Should One Remove Wisdom Teeth?
Wisdom of Having That Tooth Removed
By RONI CARYN RABIN
Published: September 5, 2011
We had still not found the perfect duvet cover for my daughter Emma’s college dorm room when she went for a routine dental checkup and was told that her wisdom teeth had to come out, A.S.A.P.
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She wasn’t having any problems now, but our dentist said trouble could flare up unexpectedly in the middle of the semester, perhaps in the middle of exams, and then she would probably have to leave school to get the teeth pulled. Better to do it now, he said.
Each year, 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 prepare to leave for college. Many dental plans cover the removal of these teeth, which have partly grown in or are impacted below the gum.
But scientific evidence supporting the routine prophylactic extraction of wisdom teeth is surprisingly scant, and in some countries the practice has been abandoned. “Everybody is at risk for appendicitis, but do you take out everyone’s appendix?” said Dr. Greg J. Huang, chairman of orthodontics at the University of Washington in Seattle. “I’m not against removing wisdom teeth, but you should do an assessment and have a good clinical reason.”
Oral surgeons have long argued that if you don’t have your wisdom teeth removed at a young age, you are simply postponing the inevitable.
“It’s hard to get a percentage, but probably 75 to 80 percent of people do not meet the criteria of being able to successfully maintain their wisdom teeth,” said Dr. Louis K. Rafetto of Wilmington, Del., who headed the American Association of Oral and Maxillofacial Surgeons’ task force on wisdom teeth.
Another expert, Dr. Raymond P. White Jr., a professor of surgery at the University of North Carolina School of Dentistry, said that roughly 60 to 70 percent of patients with wisdom teeth will eventually have trouble with them, but he acknowledged that data is limited. “We’re making decisions based on the best data we have,” he said.
Those persuasive numbers are used repeatedly by dentists and oral surgeons to justify routine removal of wisdom teeth. Just last year, the surgeons’ association issued a 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.”
The association said that 80 percent of young adults who retained previously healthy wisdom teeth developed problems within seven years, and that retained wisdom teeth are extracted up to 70 percent of the time.
Yet when asked, the association was not able to produce the evidence for these figures. “We were not able to locate the reference for it, and subsequently deleted the statement from our Web site,” Janice Teplitz, the group’s associate executive director of communications, said last week.
As of Monday, however, the association’s Web site still said that “between 25 percent and almost 70 percent” of the time, retained, asymptomatic wisdom teeth “are eventually extracted.”
Many studies suggest that the actual number of people who have trouble with their wisdom teeth is far lower.
Oral surgeons warn that even when young people are not experiencing pain or discomfort, they may have infection or inflammation; numerous studies have found that adults who keep their wisdom teeth tend to have more such problems over time than those who have them removed. But there does not appear to be a single randomized clinical trial — the gold standard for scientific proof — comparing similar patients who have and have not undergone prophylactic wisdom teeth removal.
Our dentist warned us that cysts and tumors could grow around impacted wisdom teeth. But a new study of more than 6,000 patients in Greece found that only 2.7 percent of the teeth had a cyst or tumor. An older study, often cited by critics of routine extraction, found that only 12 percent of 1,756 middle-aged people who had not had impacted wisdom teeth removed experienced a complication.
Numerous comprehensive reviews of research, conducted by independent bodies not affiliated with oral surgeons, have concluded that there was no evidence to support routine prophylactic extraction of impacted but healthy wisdom teeth.
Britain’s National Health Service stopped paying for the procedure if there was no good reason for it 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.”
In 2005, a review by the respected Cochrane Collaboration said the number of extractions could be reduced by 60 percent if they were done only when patients were in pain or developed a condition related to wisdom teeth. The group also said there is “reliable evidence” that suggests that removing wisdom teeth does not prevent or reduce crowding of front teeth.
In 2008, the American Public Health Association dismissed arguments typically made for removing wisdom teeth: that adjacent teeth might be damaged, or that the teeth may harbor 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.
“The few studies of long-term retention of impacted teeth have shown little risk of harm,” the association concluded.
So given what all agree is a lack of good evidence, how should consumers proceed when a dentist suggests removing healthy wisdom teeth?
IF EXTRACTION IS RECOMMENDED All surgery carries risks, and you should try to ensure that there is something to be gained from having your wisdom teeth removed. Ask what the reason is in your case. Is there a chance the wisdom teeth will grow in successfully? If you see a dentist on a regular basis, is watchful waiting an option?
If you have an infection or inflammation, ask about less-invasive treatment.
The general consensus among critics of routine extraction is that recurrent gum infection, or pericoronitis; irreparable tooth decay; an abscess; cysts; tumors; damage to nearby teeth and bone; or other pathological conditions justify the procedure.
IF YOU CHOOSE SURGERY Most dental plans cover at least some of the costs of extraction. If you don’t have dental insurance, pulling all four teeth may cost several thousand dollars.
Ask if you can have local anesthesia, which is considered safer than general anesthesia.
Follow postoperative instructions carefully. Avoid being very active or eating solid food for three to four days (instead try noodles and milkshakes). Keeping ice on the jaw may help with pain and swelling. Painkillers may be needed. Young patients tend to recover sooner than older patients.
IF YOU DECIDE AGAINST EXTRACTION Good dental hygiene will be even more important for you. The teeth in the back of the mouth are often harder to reach and clean well. Get frequent cleanings, and X-rays if necessary.
Smoking increases the risk of periodontal disease, as does diabetes. If you have cavities in your back molars, you may be at greater risk for problems with the wisdom teeth.
As for my daughter Emma, we have opted for watchful waiting. She went off to college last month, wisdom teeth and all.
A version of this article appeared in print on September 6, 2011, on page D5 of the New York edition with the headline: Prudence Of Having That Tooth Removed.
article accessed Sept.13th, 2011 http://www.nytimes.com/2011/09/06/health/06consumer.html?_r=2