Management of Unerupted and Impacted Third Molar Teeth
Section 4: Assessment and referral

4.1 Clinical assessment

Patients suffering from symptoms which relate to a third molar tooth may present to a General Dental Practitioner (GDP), a General Medical Practitioner (GMP), or to a hospital Accident & Emergency department.

Initial assessment should include a full medical and dental history, extra-oral and intra-oral clinical examination. Positive findings from this examination which suggest that treatment of the third molar or related structures may be indicated, require that a more detailed examination is carried out. This should determine whether removal is indicated and/or advisable (see sections 2 and 3), and should include radiological assessment.

4.2 Radiological assessment


Radiographic examination should provide the information necessary for adequate assessment of all third molar teeth.

Prior to the age of 13, radiographic examination is not normally indicated for the assessment of third molars62 and films taken from the age of 20 are most useful in assessing the likelihood of eruption.63 When more than one third molar requires to be assessed, the radiographic examination of choice is a panoramic radiograph as the radiation dose of a panoramic radiograph is lower than from four periapical views and the diagnostic yield higher.62, 64, 65 Doses from panoramic radiography can be further limited by using field size limitation to prevent exposing areas not required in the field of view.66 Periapical or oblique lateral radiographs may be taken as an alternative. All radiographs should be of a diagnostically acceptable standard.67 Evidence level III and IV


The purpose of a careful radiological evaluation is to complement the clinical examination by providing additional information about the third molar, the related teeth and anatomical features, and the surrounding bone. This is necessary in order to make a sound decision about the proposed surgical procedure, the most appropriate location for this to take place, and to highlight aspects of management which may require specific mention to the patient.

The following signs have been demonstrated to be associated with a significantly increased risk of nerve injury during third molar surgery:22

4.3 Referral

Once it has been decided that a third molar should be removed, consideration should be given as to the appropriate treatment setting. GMPs are encouraged to refer to a GDP, although this does not preclude direct referral to a department of Oral and Maxillofacial Surgery or specialist practitioner.

The basis of this decision should take account of the general suitability of the facilities for operative procedures and recovery, the competence of support staff, and the training of the practitioner. In addition, each case should be assessed with regard to the patient's medical history and the expected degree of difficulty of surgical treatment (see section 5).

The surgeon should by letter confirm receipt of the referral, and outline the treatment plan, specific information provided to the patient, the form of anaesthesia and what follow-up arrangements are required.

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