Third molars: to remove or not to remove

By Maria Perno Goldie, RDH, MS
The New York Times had a most comprehensive report on wisdom teeth yet to appear in the public press. It is fair to the oral surgeons’ position but clear-cut in presenting the lack of objective evidence in support of it, as well as reporting the position in opposition to prophylactic extractions.

According to some, this educational article should make anyone considering third molar extractions without cause hesitate, or at least question. They said, despite the risks of any surgical procedure, millions of healthy, asymptomatic wisdom teeth are extracted from young patients in the United States, often as they get ready to leave for college. Many dental plans in the USA cover the removal discof these teeth. The article points out that scientific evidence supporting the routine prophylactic extraction of wisdom teeth is astoundingly limited and in some countries the practice has been abandoned. There was an analogy to appendicitis, and the fact that we do not take out everyone’s appendix absent a good clinical reason. (Rabin RC. Wisdom of Having That Tooth Removed. NY Times, September 5, 2011. WWW.NYTIMES.COM/2011/09/06/HEALTH/06CONSUMER.HTML.)According to the article, persuasive numbers used by dentists and oral surgeons to justify routine removal of wisdom teeth are based on the American Association of Oral and Maxillofacial Surgeons issued statement subtitled “Keeping Wisdom Teeth May Be More Harmful Than Previously Thought,” saying it was imperative that patients understood “how harmful retaining these wisdom teeth can be.” (Task Force, American Association of Oral and Maxillofacial Surgeons. White Paper on Third Molar Data. March 2007. www.aaoms.org/docs/third_molar_white_paper.pdf)On October 19, 2010, a press release was issued entitled: “Conventional Wisdom about Wisdom Teeth Confirmed - Evidence Shows Keeping Wisdom Teeth May Be More Harmful than Previously Thought.” (www.aaoms.org/third_molar_news.php) The press release states that evidence-based data confirmed what dentists have been advising for years: “having your wisdom teeth removed while you are young helps you stay healthy.” (www.aaoms.org/docs/media/third_molars/press_release.pdf). The key findings of that conference can be found at: www.aaoms.org/docs/media/third_molars/key_findings.pdf.

In the UK, Britain’s National Health Service stopped paying for removal of third molars if there was no good reason for removal. That was after an analysis by its Center for Reviews and Dissemination at the University of York concluded in 1998 that there was no solid scientific evidence to support it. Also that year, the Royal College of Physicians of Edinburgh said that for patients who do not have a condition related to third molars or whose teeth would probably grow in successfully, removal is “not advisable.” (Scottish Intercollegiate Guidelines Network. Management of Unerupted and Impacted Third Molar Teeth. A National Clinical Guideline. September 1999, 1-36. www.sign.ac.uk/pdf/sign43.pdf). In 2005, a review by the Cochrane Collaboration stated that the number of extractions could be reduced by 60 percent if they were performed only when patients were in pain or developed a condition related to wisdom teeth. The Cochrane Collaboration said there is “reliable evidence” that suggests that removing wisdom teeth does not prevent or reduce crowding of front teeth. (Mettes DTG, Nienhuijs MMEL, van der Sanden WJM, Verdonschot EH, Plasschaert A. Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003879. DOI: 10.1002/14651858.CD003879.pub2). The final conclusion was that no evidence was found to support or refute routine prophylactic removal of asymptomatic impacted wisdom teeth in adults. They found some reliable evidence that suggests that the prophylactic removal of asymptomatic impacted wisdom teeth in adolescents neither reduces nor prevents late incisor crowding. Prudent decision-making, with adherence to specified indicators for removal, and watchful monitoring of asymptomatic wisdom teeth may be an appropriate strategy.

In 2008, the American Public Health Association countered opinions for removing wisdom teeth, such that adjacent teeth might be damaged, or that the teeth may be a haven for bacteria that cause periodontal disease. The association approved a policy saying these concerns do not justify the risks of surgery, which include possible nerve damage, complications from anesthesia, loss of the sense of taste and, very rarely, death. (APHA Policy Statement Database. Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth). Policy Date: 10/28/2008, Policy Number: 20085. www.apha.org/advocacy/policy/policysearch/default.htm).