To extract or not to extract? The controversy of impacted third molars: between scientific evidence, market interests, and challenges for the Unified Health System

Extrair ou não extrair? A polêmica dos terceiros molares inclusos: entre evidências científicas, interesses de mercado e desafios para o Sistema Único de Saúde

ABSTRACT

The preventive extraction of impacted and asymptomatic third molars remains a controversial practice in dentistry, with divergences between interventional and conservative approaches. This review critically analyzed scientific evidence and international protocols regarding the management of these teeth, contextualizing the implications for the Brazilian healthcare system. The methodology consisted of an integrative literature review, with searches in electronic databases using descriptors in three languages, resulting in the analysis of 13 relevant studies out of 832 initially identified. The results demonstrate that organized international healthcare systems advocate active surveillance as the preferred strategy for asymptomatic third molars, based on evidence that does not support prophylactic removal. In the Brazilian context, this conservative approach proves particularly appropriate, aligning with the principles of the Unified Health System and the integration of oral health into Primary Care. The adoption of evidence-based protocols allows for resource optimization, avoidance of unnecessary procedures, and reduction of postoperative complications, thereby contributing to equity in access to dental services. The study concludes that periodic clinical and radiographic monitoring represents the most suitable strategy for managing asymptomatic third molars and should be prioritized in Unified Health System oral health guidelines. This approach not only respects current scientific evidence but also strengthens the principles of comprehensiveness and universality in the public health system, promoting more rational and less unequal dental care for the Brazilian population.

Indexing terms
Public Health Dentistry; Tooth Extraction; Oral Health

RESUMO

A extração preventiva de terceiros molares impactados e assintomáticos permanece uma prática controversa na odontologia, com divergências entre a abordagem intervencionista e a conduta conservadora. Esta revisão analisou criticamente as evidências científicas e protocolos internacionais sobre o manejo desses dentes, contextualizando as implicações para o sistema de saúde brasileiro. A metodologia consistiu em uma revisão integrativa da literatura, com busca em bases de dados eletrônicas utilizando descritores em três idiomas, resultando na análise de 13 estudos relevantes dentre 832 identificados inicialmente. Os resultados demonstram que sistemas de saúde organizados internacionalmente preconizam o acompanhamento periódico como estratégia preferencial para terceiros molares assintomáticos, fundamentados em evidências que não sustentam a remoção profilática. No cenário brasileiro, esta abordagem conservadora mostra-se particularmente adequada, alinhando-se aos princípios do Sistema Único de Saúde e à integração da saúde bucal na Atenção Primária. A adoção de protocolos baseados em evidências permite otimizar recursos, evitar procedimentos desnecessários e reduzir complicações pós-operatórias, contribuindo para a equidade no acesso aos serviços odontológicos. O estudo conclui que o monitoramento clínico e radiográfico periódico representa a estratégia mais adequada para o manejo de terceiros molares assintomáticos, devendo ser priorizado nas diretrizes de saúde bucal do Sistema Único de Saúde. Tal abordagem não apenas respeita as evidências científicas atuais, mas também fortalece os princípios de integralidade e universalidade do sistema público de saúde, promovendo um cuidado odontológico mais racional e menos desigual para a população brasileira.

Termos de indexação
Odontologia em Saúde Pública; Extração dentária; Saúde Bucal

INTRODUCTION

Third molars (3Ms), also known as wisdom teeth, are located in the posterior region of the dental arch and exhibit the greatest variation in terms of developmental stage, crown anatomy, position, and internal anatomy [¹]. An impacted wisdom tooth is considered asymptomatic in the absence of clinical symptoms and is classified as “disease-free” when no associated pathology or symptoms of pain or discomfort are present [²,³]. However, the absence of symptoms in a third molar does not necessarily indicate the absence of disease, as pathological processes may precede clinical manifestations and progress silently [⁴].

The global prevalence of impacted wisdom teeth varies across populations and has been estimated at approximately 24.4%. Mandibular third molars have a 57.58% higher likelihood of impaction than maxillary third molars, with no significant differences observed between sexes. With regard to impaction angulation, the mesioangular position is the most frequent (41.17%), followed by vertical (25.55%), distoangular (12.17%), and horizontal (11.06%) positions. The impaction of one (42.71%) or two (29.64%) third molars is more common than the impaction of three (12.04%) or four (8.74%) teeth. In Brazil, a population-based study conducted in the city of Bauru, São Paulo, reported a prevalence of impacted third molars of 3.85% in the maxilla and 21.05% in the mandible [⁵].

When pathologies associated with third molar impaction are present, the recommended clinical management is extraction of the affected tooth [³,⁶]. This approach, however, becomes controversial when the impacted third molar is asymptomatic and disease-free. In such cases, removal is performed prophylactically – that is, in the absence of established pathology – with the aim of preventing potential future complications. Third molar surgeries constitute a highly lucrative segment of dental practice and generate substantial income for the profession, particularly for Oral and Maxillofacial Surgeons (OMFS) [⁷].

In the United States and Australia, prophylactic removal of third molars has historically been widely supported among oral and maxillofacial surgeons and general dentists. In the United States, approximately US$3 billion is spent annually on third molar extractions [⁸]. In Australia, extractions are frequently performed in hospital settings under general anesthesia, which entails increased use of time, resources, and personnel, resulting in higher procedural costs. Hospitalization rates for impacted third molar removal in Australia are among the highest worldwide. Consequently, millions of third molars are extracted prophylactically, including in young patients whose teeth may be developing normally. In this context, the cumulative financial burden of treatment and procedure-related complications, combined with constraints on public health funding, highlights the role of socioeconomic resources in shaping policies for the management of asymptomatic, disease-free third molars and underscores the need for extraction decisions to be grounded in robust scientific evidence [⁹].

From 2003 onward, oral health was formally consolidated within the Sistema Único de Saúde (SUS, Unified Health System) through the implementation of the National Oral Health Policy (PNSB), known as the Brasil Sorridente Program. This initiative represented a landmark in the expansion of dental services within the Brazilian public health system, in accordance with SUS principles and guidelines. Key developments included the expansion of Oral Health Team (OHT) coverage, the structuring of an integrated service network, and the assurance of continuity of oral health care across all levels of care [¹⁰].

Oral Health Teams (OHTs), a core component of the Brasil Sorridente National Oral Health Policy, are based in Primary Health Care Units. In 2023, more than 30,000 OHTs were operating across approximately 92% of Brazilian municipalities. As the main entry point for users of the SUS, these teams are expected to address a substantial proportion of the population’s oral health needs within the Oral Health Care Network [¹⁰]. Primary care dental surgeons are responsible for identifying cases that require referral to specialized outpatient services, such as Dental Specialty Centers (CEOs), as part of their routine duties. These referrals must be coordinated with specialized care professionals and guided by established clinical protocols. To support municipalities in developing referral and counter-referral pathways, the Ministry of Health issued guidance within the framework of the Health Care Network, aiming to strengthen the organization and operationalization of the Oral Health Care Network by defining which conditions may be referred to CEOs according to specialty [¹⁰].

Guided by its constitutional principles, the SUS seeks to ensure comprehensive and universal health care. In this context, SUS principles converge with those of quaternary prevention, which emphasizes the avoidance of unnecessary medical interventions while safeguarding patient autonomy and promoting ethically grounded care. By prioritizing primary care and patient-centered approaches, the SUS encourages practices that prevent overtreatment and respect individual needs [¹¹]. Within Primary Health Care, quaternary prevention may contribute to reducing unnecessary procedures by identifying situations of medical overuse and supporting appropriate, evidence-based decision-making [¹¹].

Against this backdrop, and in light of the limited evidence supporting prophylactic extraction of impacted, asymptomatic third molars, conservative management protocols have increasingly been adopted to guide clinical decision-making, with the aim of minimizing patient risk and avoiding unnecessary costs to health systems. In this regard, the Ministry of Health has developed Clinical Protocols and Therapeutic Guidelines (PCDTs) to standardize health care practices nationally based on the best available evidence. Although these guidelines seek to enhance the effectiveness and efficiency of health interventions, limited progress has been made in the organization of dental services within the SUS, and to date no specific guidance has been issued to direct the oral health care network regarding the management of third molars.

Considering that impacted and asymptomatic third molars are commonly referred for extraction at Dental Specialty Centers (CEOs), along with the financial burden imposed on the SUS by procedures of questionable clinical benefit and the potential exacerbation of oral health inequities in a system that still does not ensure universal coverage, this study aimed to review the literature to identify recommendations for the monitoring and management of impacted, asymptomatic third molars and to examine how other countries have addressed this issue within their health care networks.

METHODS

The present study is a literature review conducted through searches in the electronic databases Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (Lilacs), Medical Literature Analysis and Retrieval System Online (MedLine/PubMed), and Web of Science (WoS). Chart 1 presents the search terms used in each database.

Chart 1
Search terms used in the different databases.

Medical Literature Analysis and Retrieval System Online (Medline/PubMed)

(“Third Molar” OR “Third Molars” OR “Wisdom Tooth” OR “Wisdom Teeth”) AND (“Disease Prevention” OR “Prophylactic Surgical Procedures” OR “Prophylactic Surgical Procedure” OR “Preventive Surgical Procedures” OR “Preventive Surgical Procedure” OR “Oral Surgery” OR “Maxillofacial Surgery” OR “Exodontics”) AND (“Unerupted Tooth” OR “Unerupted Teeth” OR “Impacted Tooth” OR “Impacted Teeth”)

Web of Science (WOS)

(“Molar, Third” [MeSH] OR “Third Molar” OR “Third Molars” OR “Wisdom Tooth” OR “Wisdom Teeth”) AND (“Disease Prevention” OR “Prophylactic Surgical Procedures” [MeSH] OR “Prophylactic Surgical Procedures” OR “Prophylactic Surgical Procedure” OR “Preventive Surgical Procedures” OR “Preventive Surgical Procedure” OR “Surgery, Oral”[MeSH] OR “Oral Surgery” OR “Maxillofacial Surgery” OR “Exodontics”) AND (“Tooth, Unerupted”[MeSH] OR “Unerupted Tooth” OR “Unerupted Teeth” OR “Tooth, Impacted”[MeSH] OR “Impacted Tooth” OR “Impacted Teeth”)

Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS)

(“Third Molar” OR “Third Molars” OR “Wisdom Tooth” OR “Wisdom Teeth” OR “Dente Serotino” OR “Dente de Siso” OR “Dente do Juízo” OR “Dente do Siso” OR “Terceiro Dente Molar” OR “Terceiro Molar” OR “Tercer Molar” OR “muela del juicio”) AND (“Disease Prevention” OR “Prophylactic Surgical Procedures” OR “Prophylactic Surgical Procedure” OR “Preventive Surgical Procedures” OR “Preventive Surgical Procedure” OR “Oral Surgery” OR “Maxillofacial Surgery” OR “Exodontics” OR “Prevenção de Doenças” OR “Prevenção” OR “Procedimentos Preventivos contra Doenças” OR “Cirurgia Bucal” OR “Cirurgia Maxilofacial” OR “Exodontia” OR “Prevención de Enfermedades” OR “Prevención” OR “Procedimientos Quirúrgicos Profilácticos” OR “cirugía oral” OR “exodoncia”) AND (“Unerupted Tooth” OR “Unerupted Teeth” OR “Impacted Tooth” OR “Impacted Teeth” OR “Dente não Eruptionado” OR “Dente Incluso” OR “Dente Impactado” OR “Diente no Erupcionado” OR “diente incluido” OR “Diente Impactado” OR “diente enclavado” OR “diente retenido”)”Profilaxia” OR “Procedimentos Cirúrgicos Profiláticos” OR “Cirurgia Profilática” OR

Scientific Electronic Library Online (SciELO)

(“Third Molar” OR “Third Molars” OR “Wisdom Tooth” OR “Wisdom Teeth” OR “Dente Serotino” OR “Dente de Siso” OR “Dente do Juízo” OR “Dente do Siso” OR “Terceiro Dente Molar” OR “Terceiro Molar” OR “Tercer Molar” OR “muela del juicio”) AND (“Disease Prevention” OR “Prophylactic Surgical Procedures” OR “Prophylactic Surgical Procedure” OR “Preventive Surgical Procedures” OR “Preventive Surgical Procedure” OR “Oral Surgery” OR “Maxillofacial Surgery” OR “Exodontics” OR “Prevenção de Doenças” OR “Prevenção” OR “Procedimentos Profiláticos Cirúrgicos” OR “Profilaxia” OR “Cirurgia Profilática” OR “Cirurgia Bucal” OR “Cirurgia Maxilofacial” OR “Exodontia” OR “Prevención de Enfermedades” OR “Prevención” OR “Procedimientos Quirúrgicos Profilácticos” OR “cirugía oral” OR “exodoncia”) AND (“Unerupted Tooth” OR “Unerupted Teeth” OR “Impacted Tooth” OR “Impacted Teeth” OR “Dente não Eruptionado” OR “Dente Incluso” OR “Dente Impactado” OR “Diente no Erupcionado” OR “diente incluido” OR “Diente Impactado” OR “diente enclavado” OR “diente retenido”)

A 10-year time frame was considered. Eligible studies were those addressing the provision of third molar management within different health care systems. Articles focusing exclusively on surgical techniques or clinical surgical management, studies addressing pharmacological aspects of pre- or postoperative care, and clinical reports related to intraoperative or postoperative complications associated with third molar removal were excluded from the analysis.

Database searches were conducted between July and August 2023 and subsequently updated in 2024. Following the initial screening stage, a citation chaining strategy (snowball sampling) was applied, whereby reference lists of previously selected articles were reviewed to identify additional relevant studies [¹²]. Titles and abstracts of all retrieved records were screened to assess thematic relevance, after which full-text versions of eligible articles were reviewed in detail.

Study selection was independently performed by a second reviewer (IR, Independent Reviewer) using the same eligibility criteria. The results of both selection processes were compared to minimize the risk of selection bias. Any discrepancies were discussed and resolved by consensus, and studies were subsequently included or excluded from the final analysis.

RESULTS

Based on the search strategy, 832 records were identified across the databases, as shown in figure 1. After screening titles and abstracts according to the inclusion criteria, 24 articles remained and were assessed in full text. Of these, 12 studies met the eligibility criteria and were included in the review. Through citation chaining (snowball sampling), one additional article was identified and included in the analysis. Consequently, a total of 13 articles comprised the final sample.

Figure 1
Flowchart illustrating the identification of studies, screening process, and inclusion and exclusion criteria.

The selected articles were organized using Microsoft Office Excel 2010, sorted by year of publication, authorship, and title, and summarized with a brief description of their main findings, as presented in chart 2 in the appendices.

Chart 2
Organization and synthesis of articles included after full-text reading.

Article Name	Authors	Year	Journal	Database	Summary
(A1) Impacted wisdom teeth.	Dodson TB, Susarla SM [3]	2014	BMJ Clin Evid.	PubMed	A systematic review was conducted to evaluate the efficacy and safety of various interventions, including prophylactic extraction, periodic consultations, and different surgical techniques, in the context of removing impacted wisdom teeth. In summary, no direct information or prospective cohort studies with a control group were found that met clinical evidence inclusion criteria regarding complications or adverse effects of early extraction of impacted, asymptomatic, disease-free wisdom teeth compared to no extraction and no monitoring. Available evidence does not support the efficacy of prophylactic extraction of impacted wisdom teeth compared to retaining them.
(A2) Managing Impacted Third Molars	Rafetto L.K [4]	2015	Oral Maxillofac Surg Clin North Am	PubMed	OMFS professionals possess knowledge about 3Ms, including risks of future removal in initially asymptomatic teeth. Although the annual risk is low, the cumulative lifetime risk is considerably higher. In the absence of conclusive evidence, available evidence must be interpreted for patients, considering short- and long-term consequences. An organized approach based on patient symptoms and disease status simplifies treatment recommendations.
(A3) Guidance on the Extraction of Wisdom Teeth	National Institute for Health and Care Excellence [6]	2000	National Institute for Health and Care Excellence	PubMed	The National Institute for Health and Care Excellence (NICE) in the UK provides evidence-based guidance for the NHS and patients on medicines, equipment, and clinical procedures. According to NICE recommendations, impacted wisdom teeth should not be removed for two reasons: the lack of reliable evidence of benefit to patients and the risks associated with surgery, which include nerve damage, damage to other teeth, infection, bleeding, and even death. Patients with impacted wisdom teeth that cause no problems should undergo regular check-ups with their dentist. Wisdom tooth removal is intended for patients when they cause oral problems, such as intractable tooth decay, abscesses, cysts, tumors, or diseases.
(A4) Cost effectiveness modeling of a “watchful monitoring strategy” for impacted third molars vs prophylactic removal under GA: An Australian perspective.	Anjrini AA, Kruger E, Tennant M [12]	2015	Br Dent J	PubMed	This study addresses the issue of cost-effectiveness involved in the removal of impacted 3Ms in Australia. It investigates the advantages and disadvantages of adopting a careful monitoring strategy compared to prophylactic removal performed under general anesthesia. The research analyzes direct and indirect costs associated with the removal of impacted wisdom teeth, concluding that the existence of guidelines in Australia contributes to savings by avoiding significant and unnecessary spending for society. Given the lack of evidence supporting prophylactic removal of asymptomatic 3Ms, it is suggested that periodic follow-up is a more cost-effective alternative in the Australian context.
(A5) Third molars: To extract or not to extract?	Normando D [13]	2015	Dental Press J Orthod	Lilacs	There is a discussion surrounding 3M extraction, arguments for and against prophylactic extraction. The work highlights the lack of scientific evidence supporting the prophylactic extraction of asymptomatic 3Ms and emphasizes the importance of evaluating each case individually before deciding on extraction.
(A6) Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth.	Ghaeminia H, Nienhuijs ME, Toedtling V, Perry J, Tummers M, Hoppenreijs TJ, Van der Sanden WJ, Mettes TG [14]	2020	Cochrane Database Syst Rev	PubMed	Given the lack of evidence from scientific studies on the management of asymptomatic and disease-free 3Ms, patient values must be considered, and clinical experience and local and national guidelines used to guide shared decision-making. If the decision is made to retain impacted, asymptomatic, and disease-free wisdom teeth, clinical evaluation at regular intervals is advisable to prevent unwanted outcomes.
(A7) Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth.	Ghaeminia H, Perry J, Nienhuijs MEL, Toedtling V, Tummers M, Hoppenreijs TJM, Van der Sanden WJM, Mettes TG [15]	2016	Cochrane Database Syst Rev	PubMed	There is insufficient evidence available to support whether impacted, asymptomatic, and disease-free 3Ms should be removed or not. Although some evidence suggests that retaining impacted, asymptomatic, and disease-free wisdom teeth may increase the risk of periodontitis associated with adjacent second molars in the long term, this evidence is of very low quality. In light of the lack of available evidence, patient choice and clinical experience used to guide shared decision-making with patients should be considered. If the decision is made to retain impacted, asymptomatic, and disease-free wisdom teeth, clinical evaluation at regular intervals is advisable to prevent unwanted outcomes.
(A8) French good practice guidelines regarding third molar removal Indications, techniques, methods	Ruhin B [16]	2020	J Stomatol Oral Maxillofac Surg	PubMed	The French guidelines were developed by a group of experts in oral and maxillofacial surgery, radiology, and other oral health-related fields. The document provides information on indications for 3M removal, recommended techniques and methods for removal, as well as guidelines for managing post-operative complications. According to the guidelines, prophylactic removal of asymptomatic 3Ms is not routinely recommended. However, removal may be considered in specific cases, when there is a risk of damage to adjacent teeth, risk of cyst or tumor development, or risk of infection. The decision to remove an asymptomatic 3M or not should be based on an individualized assessment of each case, considering the risks and benefits of removal.
(A9) A retrospective cohort study on reasons to retain third molars.	De Bruyn L, Vranckx M, Jacobs R, Politis C [17]	2019	Int J Oral Maxillofac Surg	PubMed	This retrospective study included 1,682 patients (818 men, 864 women; mean age 31 years) who were referred to the University Hospitals of Leuven for 3M removal. Eight reasons for retaining wisdom teeth were identified: (1) risk of damaging adjacent structures, (2) compromised health status, (3) adequate space for eruption, (4) 3M serves as an abutment tooth, (5) orthodontic reasons, (6) eruption in proper occlusion, (7) asymptomatic 3Ms in patients over 30 years of age, and (8) patient preference. A total of 1,149 3Ms in 548 patients were not extracted. The most frequent reasons for retaining them were: eruption in proper occlusion (31.9%), patient preference (31.5%), and asymptomatic 3Ms in patients >30 years of age (17.5%). This study identified several reasons to retain 3Ms; eruption in proper occlusion was the most frequent reason, followed by the preference of patients over 30 years old to refuse removal.
(A10) Mandibular third molars: ‘naughty’ or NICE?	Donnell CC, Clark MV [18]	2020	Br Dental J	PubMed	Since the implementation of NICE [guidelines], the impaction of erupted or partially erupted mandibular 3Ms and the associated increased risk of caries in second molars has been a widely debated topic in both general practice and hospital settings. Radiographic examination of carious second molars with an associated impacted 3M is not routine and is commonly a finding after a routine examination in a healthy mouth without symptoms. Caries in mandibular second molars is a clear oversight in the NICE guidelines, with management decisions influenced by personal philosophy, clinical judgment, and experience. NICE guidance is exactly that; guidance, an aid to assist our decision-making and that of the patient. Caries risk assessment and the judicious use of radiographs should be considered, as well as clinical experience, taking into account patient choices on a case-by-case basis when deciding whether teeth should be retained or removed.
(A11) The contemporary management of third molars.	Hyam DM [19]	2018	Atlas Oral Maxillofac Surg Clin North Am	PubMed	The article provides the practitioner with the tools, the matrix, and the confidence to guide patients through the process of 3M assessment and treatment. The decision matrix for 3M removal must always begin with an indication: according to disease status and symptom status. Once the indication is identified, the decision to proceed with surgery will be modified by surgical difficulty along with the procedural risk of a transient or permanent complication. Other subsequently influencing factors are: social support mechanisms and the patient’s financial capabilities. If the surgical matrix has been followed and there are reasons to avoid or postpone surgery, the patient should not be discharged from care. Patients with 3Ms should be regularly evaluated and considered for regular radiological assessment. The degree of symptomatology and the type of contraindication to surgery should be considered when deciding between a review interval of 2, 5, or 10 years.
(A12) International benchmarking of hospitalisations for impacted teeth: a 10-year retrospective study from the United Kingdom, France and Australia.	Anjrini AA, Kruger E, Tennant M [20]	2014	Br Dent J	PubMed	The United Kingdom and its national health system represent a unique comparison for many other developed countries (such as Australia and France), since the practice of prophylactic removal of third molars in the UK has been discouraged for nearly two decades, with clear guidelines issued by NICE in 2000 to limit third molar removal only to pathological situations. There are no such guidelines in Australia or France. The health systems of England, France, and Australia use the International Classification of Diseases (ICD) coding system for diagnostic categorization of all hospital admissions. The study relied on the opportunity of a universal coding system and semi-open access data to complete the first comparative study on an international scale of hospitalizations for impacted tooth removal (between 1999/2000 and 2008/2009). The international comparison revealed significant differences in admission rates, with England showing rates approximately five times lower than France and seven times lower than Australia. These results can be explained by the implementation of guidelines in the UK and the absence of similar guidelines in France and Australia.
(A13) Hospitalisations for removal of impacted teeth in Australia: A national geographic modeling approach.	George R, Tennant M, Kruger E [21]	2012	Rural and Remote Health	PubMed	The study projected hospitalization rates for surgical removal of impacted teeth throughout Australia, based on statistics from Western Australia. Population data were obtained from the Australian Bureau of Statistics and were divided across Australia by local statistical area and related to a validated socioeconomic index. All discharge episodes from all hospitals in Western Australia for the financial years 1999/2000 to 2008/2009 indicating an impacted tooth removal as the principal oral condition, per ICD-10, were included in the study. Hospitalization data were obtained from the Western Australia Hospital Morbidity Data System. Variables of age, place of residence, and health insurance status were used to project rates across Australia. Results showed a rural/urban divide, and age-adjusted estimated rates were almost three times higher in higher socioeconomic areas compared to their poorer areas. Procedure costs were estimated at approximately US$60 million per year across Australia.

Overall, there was unanimous agreement across studies, irrespective of the health care system or regulatory context, regarding the indication for extraction of third molars associated with pathological conditions. In contrast, for impacted, asymptomatic, and disease-free third molars, substantial divergence was observed among authors. Most studies did not support prophylactic removal of teeth with these characteristics. Instead, the prevailing recommendation was to retain the third molars, accompanied by periodic clinical and radiographic monitoring to ensure ongoing surveillance and follow-up over time.

DISCUSSION

Several studies, including systematic reviews aimed at supporting clinical decision-making by dental surgeons, have contraindicated the extraction of impacted, disease-free third molars in both younger and older individuals [³,⁶,¹²,¹⁵]. In this regard, health authorities in countries such as the United Kingdom, Australia, and France do not endorse prophylactic extraction of third molars in the absence of documented pathology [¹³,¹⁶,²²]. Similarly, the 2012 Belgian report, the 1999 Scottish national clinical guidelines, and the 2010 Swedish health technology assessment reports reinforce this conservative approach, recommending periodic monitoring and extraction only when clinically indicated [²³-²⁵]. The rationale underlying this strategy is primarily to avoid surgical complications, including pain, bleeding, swelling, alveolitis, trismus, and injury to the inferior alveolar nerve or temporomandibular joint, with reported complication rates ranging from 4.6% to 21% [¹²].

In contrast, and adopting a less conservative stance, the American Association of Oral and Maxillofacial Surgeons (AAOMS) considers all third molars – whether impacted or erupted – as posing a potential and significant risk for disease development and therefore supports their extraction, even in contexts where the prevalence of associated lesions is relatively low [²⁶,²⁷].

With respect to the cost-effectiveness of retaining third molars versus extracting them prophylactically to prevent future complications, the available evidence remains limited, and further research is warranted. While some authors advocate a more conservative approach to extraction [³,¹²,²²], others argue in favor of prophylactic removal, suggesting that although extraction entails an immediate cost, the cumulative costs of long-term monitoring and treatment of potential complications may ultimately exceed those of early removal [²⁸,²⁹].

There has been increasing pressure to re-evaluate the NICE guidelines in light of evidence indicating that impacted, asymptomatic, disease-free third molars in a mesioangular position may increase the risk of caries in adjacent second molars, potentially leading to additional treatment needs and tooth loss [²⁸,²⁹]. In response to the reported rise in caries affecting adjacent teeth, more targeted surveillance of third molars has been proposed [³⁰]. These recommendations align with the strategy of watchful monitoring of pathology-free impacted third molars advocated in Cochrane Database systematic reviews [¹⁵]. However, for individuals at higher risk of caries – due to poor oral health status, inadequate diet, previous caries experience, or increased susceptibility to periodontitis – this approach requires active clinical and radiographic follow-up at regular intervals to prevent unfavorable outcomes [¹⁴-¹⁶].

When a monitoring strategy is adopted, a reasonable interval between follow-up appointments is two years, with shorter intervals recommended if signs or symptoms become evident [⁴]. Supporting this approach, authors emphasize that when there are reasons to avoid or postpone surgery, patients should not be discharged from care. Rather, the specific contraindication to surgery should guide the choice of imaging follow-up intervals – typically every 2, 5, or 10 years – to ensure continuity of care [¹⁷]. In cases where there is clinically significant evidence of periodontal disease progression in the region, shorter intervals are advised, such as semiannual evaluations. Another relevant consideration in this context is the increase in morbidity with advancing age, which is associated with longer postoperative recovery periods [²]. Accordingly, different follow-up intervals may be recommended depending on the patient’s clinical condition.

In this context, monitoring should be prescribed as a structured and planned therapeutic strategy, encompassing a thorough review of the patient’s clinical history and a comprehensive clinical and radiographic examination. Patients who opt for active surveillance must be committed to adhering to a scheduled program of follow-up visits [³].

It is well recognized that third molar surgeries constitute a lucrative segment of dental practice and that clinicians, in partnership with patients, retain autonomy in defining treatment plans by weighing potential risks and benefits [⁷]. It is important to note, however, that relatively few countries provide dental care within publicly funded health systems, even in a limited capacity. Consequently, service provision in many contexts is strongly influenced by market-oriented models of private dental care [⁸]. Furthermore, several longstanding assumptions regarding third molar management continue to be reproduced despite reported surgical complication rates reaching up to 21% [²²].

As a universal health system, the SUS serves as the primary source of health care for approximately 80% of the Brazilian population [³¹]. Changes observed in recent decades – including declining private-sector profitability for dental professionals, the expansion of dental insurance plans, the rapid and unregulated growth of dental schools, and technological advancements not fully absorbed by the market – reflect the exhaustion of what has been described as a “golden age” of Brazilian dentistry. Currently, Brazil has approximately 175,000 dental surgeons; however, analyses by sector reveal a marked imbalance in workforce distribution, with high population-to-provider ratios in the public sector and the opposite pattern in the private sector [³²].

This scenario underscores that meaningful improvements in access, utilization, resolution of care, and population oral health outcomes depend on the combined availability of services and the quality of care delivered, grounded in the best available scientific evidence. Across the studies identified in this review that addressed third molar management within different health systems, there was consensus that care protocols should prioritize periodic monitoring, except when extraction is clinically justified due to associated pathology or pain. Protocols supporting conservative management of asymptomatic, disease-free third molars should therefore incorporate patient age, clinical findings, radiographic assessment, and medical and dental history into decision-making processes [³].

Waiting lists represent a significant challenge within the SUS, arising from multiple contributing factors. Procedures involving asymptomatic third molars are often considered lower priority, and the absence of more refined prioritization mechanisms may delay care for patients with greater clinical needs, thereby exacerbating existing health disparities.

Overall, there is broad consensus in favor of periodic monitoring for asymptomatic, disease-free third molars. These recommendations are based on evidence that does not support early or prophylactic removal of these teeth. When considered within the context of the Brazilian oral health care network, periodic monitoring emerges as a particularly appropriate strategy. First, surveillance and follow-up approaches are aligned with the foundational principles of the SUS. Second, the integration of dental care within Primary Health Care enhances the system’s capacity to implement longitudinal monitoring. Third, because Primary Health Care functions as the coordinator of care within the SUS, access bottlenecks to specialized services may occur, contributing to waiting lists and, consequently, to health inequities. Finally, analyses grounded in preventive models – particularly quaternary prevention – highlight the importance of minimizing unnecessary interventions. To ensure comprehensiveness and universality with equity as a guiding principle, health systems must critically assess oral health care practices within their specific contexts and prioritize cost-effective interventions supported by robust evidence, especially in a country that already invests one of the lowest proportions of GDP in health among nations with universal health systems.

CONCLUSION

The literature recommends periodic monitoring of asymptomatic third molars, avoiding prophylactic extractions without clinical indication. This conservative approach, aligned with the principles of the SUS, optimizes resources, reduces surgical risks, and prioritizes equity, grounded in scientific evidence and the efficiency of the public health system.

• Article aligned with the Good Health and well-being goal of the Sustainable Development Goals (SDGs).
• How to cite this article
  Souza LS, Araújo PG, Costa Junior S. To extract or not to extract? The controversy of impacted third molars: between scientific evidence, market interests, and challenges for the Unified Health System. RGO, Rev Gaúch Odontol. 2026;74:e20260016. http://dx.doi.org/10.1590/1981-86372026001620250033

Data Availability

The research data are available in the body of the document.

REFERENCES

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Edited by

• Assistant editor
  Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  27 July 2026
• Date of issue
  2026

History

• Received
  08 July 2025
• Accepted
  23 Dec 2025