The prevention and management of distal cervical caries of the mandibular second molar

Since the introduction of NICE's guidance on the extraction of wisdom teeth in 2000, the mean age of patients having third molars removed has risen from 28 to 32 years of age.^{1, 2} In addition, there has been a notable change in the spectrum of disease affecting third molars, with a significant increase in caries-related disease associated with them.² Distal cervical caries (DCC) of the mandibular second molar (Md2M) has become a more common feature associated with partially erupted mandibular third molar teeth (Md3M) (Figure 1).^{3, 4, 5, 6, 7, 8} Its occurrence will commonly indicate the surgical removal of the Md3M, not only to allow restoration of the Md2M but also to prevent recurrence of DCC. Md2M DCC is not seen in isolation, it only occurs in the presence of a partially erupted impacted third molar, predominantly mesio-angular impacted Md3M and, less commonly, with horizontally impacted Md3M.^{3, 4} Reflection and common-sense would invariably question why the Md3M was not removed before DCC could form on the second molar, as this would have prevented additional and preventable treatment. NICE's guidance on the management of impacted third molars proscribes the removal of asymptomatic or disease-free third molars.¹ As a consequence, the removal of the Md3M before DCC forms on the second molar is ostensibly contra-indicated, although arguably the prophylactic removal of the Md3M would appear to have a strong indication in this instance. This paradox and the resultant conflict that NICE's guidance creates, namely DCC of the second molar, challenges NICE's orthodoxy and how dentists should manage the potential for this disease.⁹