Third Molar Surgery a Review of Current Controversies in Prophylactic Removal of Wisdom Teeth
Am J Public Wellness. 2007 September; 97(9): 1554–1559.
The Prophylactic Extraction of Third Molars: A Public Health Hazard
Jay W. Friedman
Jay Westward. Friedman is a retired general dentist and a consultant and author living in Los Angeles, Calif.
Accepted September 20, 2006.
Abstract
Ten million tertiary molars (wisdom teeth) are extracted from approximately 5 million people in the Us each year at an annual cost of over $3 billion.
In addition, more than 11 million patient days of "standard discomfort or disability"—pain, swelling, bruising, and malaise—result postoperatively, and more than 11000 people suffer permanent paresthesia—numbness of the lip, natural language, and cheek—as a issue of nervus injury during the surgery. At least two thirds of these extractions, associated costs, and injuries are unnecessary, constituting a silent epidemic of iatrogenic injury that afflicts tens of thousands of people with lifelong discomfort and disability.
Abstention of prophylactic extraction of third molars tin can prevent this public health hazard.
IN THE UNITED STATES, prophylactic removal of third molars (wisdom teeth) is advocated by most all oral and maxillofacial surgeons and many full general dentists. According to the American Clan of Oral and Maxillofacial Surgeons, "if in that location is insufficient anatomical infinite to accommodate normal eruption. . . removal of such teeth at an early age is a valid and scientifically sound treatment rationale based on medical necessity."ane As a result, 10 one thousand thousand teeth classified equally impactions (teeth that neglect to erupt into normal position but remain fully or partially embedded and covered by jawbone or gum tissue) are removed every yr from mostly healthy young people.2
There is no evidence of widespread tertiary-tooth infection and pathology or of medical necessity to justify so much surgery. In fact, 50% of upper third molars classified equally impactions are unremarkably developing teeth, nigh of which will erupt with minimal discomfort if not extracted prematurely. Only 12% of truly impacted teeth are associated with pathological weather such equally cysts and damage to adjacent teeth.3,four Most discomfort of erupting wisdom teeth is equivalent to teething and disappears on full eruption. Most infection of the gum tissue around the erupting or partially erupted teeth tin can exist prevented past skilful oral hygiene, including toothbrushing. Infection occurs in fewer than 10% of third molars, most of which can be cured with antibiotics, oral rinsing, or removal of excess tissue (the hyperculum) around the tooth, without requiring removal of the molar itself.5 Most of the pain and illness attributed to third molars is caused by the surgery, non the teeth.
Third-molar surgery is a multibillion-dollar industry that generates pregnant income for the dental profession, particularly oral and maxillofacial surgeons. It is driven past misinformation and myths that have been exposed earlier but that proceed to exist promulgated by the profession.6
THE MYTHOLOGY OF WISDOM TEETH
Myth Number 1—Third Molars Have a High Incidence of Pathology
Not more than than 12% of impacted teeth have associated pathology (Table 1 ▶). This incidence is the same every bit for appendicitis (10%) and cholecystitis (12%), withal prophylactic appendectomies and cholecystectomies are not the standard of care.4 Why then prophylactic third-molar extractions?
i
Pathologies and Pericoronitis Associated With Impacted Third Molars
| Per centum | |
| Pathology | Affected |
| Internal resorption | 0.85 |
| Cysts | one.65 |
| Periodontal os loss | iv.72 |
| Resorption on distal surface of 2d molar | 4.78 |
| Pericoronitis | 8 |
| Full | 20 |
Source. Run across references 3, 5, 7, and 8.
What about pericoronitis, the pain and infection of the gum tissue surrounding a partially erupted or erupted tertiary tooth? Excluding the normal discomfort of teething as the tooth erupts, the incidence of inflammation and infection of the glue tissue ranges from half dozen% to 10%.5,7,eight Adding an boilerplate of 8% incidence of pericoronitis to the 12% pathology listed in Table 1 ▶ brings the maximum pathology associated with tertiary molars to xx%. However, a unmarried episode of pericoronitis is not a reason to remove a third molar; this should be considered only if the problem fails to respond to conservative treatment or recurs.nine
Many dentists confuse the incidence of pathology every bit information technology shows up in their offices with its prevalence in the population. Advocacy of prophylactic extractions that is based on anecdotal feel (i.e., patients with diseased tertiary molars who make dental appointments) exaggerates the problem and exposes millions of people to the risk of iatrogenic injury. Because the low prevalence of third-molar pathology in the population, removal of asymptomatic, nonpathologic third molars does not meet the standard of evidence-based practice.
Myth Number ii—Early Removal of Third Molars Is Less Traumatic
The American Association of Oral and Maxillofacial Surgeons states that "about 85% of third molars will somewhen need to be removed."10(p3) The clan recommends extraction of all 4 third molars by young adulthood—preferably in boyhood, before the roots are fully formed—to minimize complications such equally postextraction pain and infection.
Early removal of third molars is actually more traumatic and painful than leaving asymptomatic, nonpathologic teeth in situ. Tulloch et al. estimate that patients endure an average of 2.27 days of standard discomfort or disability, divers as "the disability commonly associated with an uncomplicated surgical extraction of a mandibular third molar: namely, pain, swelling, bruising and angst."xi(p507) Furthermore, dry socket, secondary infection, and paresthesia are less likely to occur in persons anile 35 to 83 years than in those aged 12 to 24 years, who experience more than third-molar extractions. The highest risk of complication is in persons anile 25 to 34 years.7
When a lower third molar is removed, usually the opposing upper third molar is also removed. Assuming an average of 2 extractions per episode, the 10 million third molars extracted annually involve 5 million people and 11.36 million days of standard discomfort or inability (Table 2 ▶). If merely the 20% of wisdom teeth with pathology were extracted, four 1000000 people would be spared hurting, swelling, bruising, malaise, and consistent absence from school or piece of work—an aggregate decrease of nine million days of discomfort and disability each year. Allowing for some margin of error and for the fact that one third of tertiary molars are reported to cause some symptoms in the past or nowadays, if only 33% were extracted, iii.34 million people would still be spared an average of 2.27 days of discomfort and disability each, or 7.6 million days of discomfort and inability in the aggregate (Table 3 ▶).
two
Estimated Third-Molar Extractions Per Year, past Dr. Performing Extraction: Us
| No. of Extractions | Toll,a $ | No. of Patients | No. of Lower Third-Molar Extractions | Patient Days of Standard Discomfort or Inabilityb | |
| Oral and maxillofacial surgeons | 7 000 000 | two 852 500 000 | 3 500 000 | 3 500 000 | 7 950 000 |
| Full general practitioners | 3 000 000 | 450 000 000 | 1 500 000 | 1 500 000 | 3 410 000 |
| Total | ten 000 000 | 3 302 500 000 | v 000 000 | v 000 000 | 11 360 000 |
3
Estimated Annual Reduction of Toll and Disability From Performing Only Needed Third-Molar Extractions: U.s.a.
| No. of Extractions | Cost, $ | Savings, $a | No. of Patients | Patient Days of Standard Discomfort or Disability | Reduction of Patient Days of Standard Discomfort or Inability | |
| Oral and maxillofacial surgeons | 2 310 000 | 941 325 000 | 1 911 175 000 | 1 160 000 | ii 630 000 | 5 320 000 |
| General practitioners | 1 000 000 | 150 000 000 | 300 000 000 | 500 000 | 1 130 000 | 2 280 000 |
| Total | 3 310 000 | 1 091 325 000 | two 211 175 000 | 1 660 000 | 3 760 000 | seven 600 000 |
Myth Number 3—Pressure level of Erupting Third Molars Causes Crowding of Inductive Teeth
It is not possible for lower third molars, which develop in the spongy interior cancellous tissue of bone with no house support, to button 14 other teeth with roots implanted vertically like the pegs of a picket contend so that the incisors in the middle twist and overlap. Yet that is the reason often given for removal of 3rd molars, even though studies have produced contrary evidence.12–14 Third molars practice not possess sufficient forcefulness to move other teeth. They cannot cause crowding and overlapping of the incisors, and any such association is non causation.
Myth Number 4—The Risk of Pathology in Impacted Tertiary Molars Increases With Historic period
The American Association of Oral and Maxillofacial Surgeons states, without substantiation, "Pathologic conditions [of impacted tertiary molars] are generally more common with an increase in age."1(p2) A study of more than than 1756 patients who had retained more than 2000 mandibular impactions for an average of 27 years found that just 0.81% experienced cystic formation. There is no evidence of a significant increase in third-tooth pathology with age.3 Of form, teeth that become repeatedly symptomatic or develop associated pathology should be removed.15,16
Myth Number 5—There is Little Adventure of Impairment in the Removal of Third Molars
Given the low incidence of pathology, it is specious to contend that less than 3 days of temporary discomfort or disability is a small-scale toll to pay to avert the hereafter risks of root resorption, serious infections, and cysts. Besides ignored is the risk of incidental injury such as broken jaws, fractured teeth, damage to the temporomandibular joints, temporary and, especially, permanent paresthesia or dysthesia (numbness and dysfunction of the lower lip and the natural language). The box
Data on the number of fractured jaws and damaged teeth are lacking. Fractures occur but are uncommon. There is lilliputian data on temporary and permanent temporomandibular joint injury after third-tooth surgery, although a recent study of patients anile 15 to 20 years reported an incidence of 1.6%, which translates to thousands of such injuries each twelvemonth.17 However, mandibular and lingual nerve injury resulting from tertiary-molar surgery has been more than widely reported. Because the percentages of incidental (unavoidable) and iatrogenic (avoidable) injury are small, no i has previously performed the elementary chore of applying these figures to the entire population exposed to surgery.
Reports on the incidence of mandibular (lower jaw) nerve paresthesia vary from a depression of ane.3% for temporary and 0.33% for permanent paresthesia to a high of four.4% for temporary and ane% for permanent paresthesia.xviii,nineteen Pocket-size figures, indeed! But if 3.5 meg lower third molars are removed from 3.5 million persons past oral and maxillofacial surgeons (Table 2 ▶), the incidence of permanent paresthesia ranges from a depression of more than 11500 to a high of 35000. Two thirds of these patients had no nowadays or previous symptoms to warrant extraction.20,21 If 67% of the surgery is unnecessary, then between 7739 and 23450 people are afflicted with permanent paresthesia unnecessarily each year (Table 4 ▶).
four
Estimated Annual Incidence of Paresthesia of the Mandibular Nerve Post-obit Tertiary-Molar Extractions by Oral and Maxillofacial Surgeons: Usa
| Persons with Paresthesia | Minimum No | Maximum No. |
| Extraction of three.5 1000000 lower third molars | ||
| Temporary | 45 500 | 154 000 |
| Permanent | 11 550 | 35 000 |
| Extraction of the 33% of 3rd molars with symptoms or pathology | ||
| Temporary | 15 015 | 50 820 |
| Permanent | 3 811 | 11 550 |
| Incidence of iatrogenic paresthesia if 67% of the extractions are unnecessary | ||
| Temporary | 30 485 | 103 180 |
| Permanent | 7 739 | 23 450 |
| Incidence of iatrogenic paresthesia if 50% of the extractions are unnecessary | ||
| Temporary | 22 750 | 77 000 |
| Permanent | 5 775 | 17 500 |
Notation. Paresthesia is numbness of the lips, natural language, and cheek.The estimated minimum per centum of temporary cases of paresthesia is i.3% and of permanent cases is 0.33%—the maximum is 4.4% temporary and one% permanent.
These figures are based on simple extrapolations from studies by independent researchers, many of whom are oral and maxillofacial surgeons and therefore should be credible. Nigh of the paresthesias derive from third-molar surgery performed by oral and maxillofacial surgeons because they perform nearly third-molar extractions, including those at a high gamble of nerve injury.
A contempo written report reported that 25% of erupted third molars may take deep periodontal pockets that are considered an indicator of periodontal disease.22 Many of these are pseudopockets consisting of backlog gum tissue that can be treated conservatively or reduced surgically, rather than extracted, every bit is done for other teeth with this condition. However, allow usa assume that the incidence of 3rd-tooth pathology has been underrepresented in the other cited studies and that l% of third-molar extractions, including those with deep periodontal pockets, are justified. In that case, among the other 50% there would be 5775 to 17 500 individuals with permanent mandibular paresthesia every yr. And this does not include lingual (tongue) nerve paresthesia, which may occur as frequently as once in 10 000 mandibular extractions, adding another 350 to 500 paresthesia cases a yr.23 At this rate, between 57 000 and 175 000 persons in the United States accept been afflicted with permanent paresthesia over the past 10 years as a consequence of unnecessary safety third-tooth extractions.
PARESTHESIA
How is it possible that so much harm is done and so little is heard of it? The answer is that paresthesia of the lips and tongue is not deadly. Although information technology is one of the almost mutual reasons that patients sue oral and maxillofacial surgeons, most judges and jurors do not fault the surgeons, because the patients consented to surgery, thereby bold the hazard. That patients are given unsubstantiated information that would, in just circumstances, invalidate their informed consent is rarely disarming to a court.24,25 Patients who might have avoided the surgery in the absence of confirmed pathology are consigned to a numb jaw or lip or tongue for the remainder of their lives. Symptoms include frequent drooling, bitter of the lip or the inside of the cheek or the side of the tongue, and paralytic disfigurement or drooping of the lip. The gustation, the facility of speech, and the sensory pleasance of kissing are diminished. When bilateral paresthesia occurs, the anguish, discomfort, and disability are more than doubled. To be certain, the caste of paresthesia varies, from mild to severe. Abiding tingling numbness is the nigh common feature, just some patients experience frequent shooting pains much like neuralgia. Those suffering from severe paresthesia may be driven to about hysteria by a loss of sensory functions that affects all aspects of their lives.
The risk of paresthesia is non the same for all extractions. It is highest for the mesioangular impaction, in which the molar is positioned at a thirty–45° angle toward or really confronting the distal, or dorsum, surface of the second molar (Figure 1 ▶).
A mesioangular impaction, with the roots in shut proximity to or saddling the mandibular canal containing the mandibular nerve.
When fully formed, the roots frequently lie close to the right and left mandibular nerves, which run along the jaw beneath or between the roots. The gamble of permanent paresthesia following extraction of a mesioangular impaction is equally loftier as half dozen.8%, much higher than for other types of unerupted or impacted teeth.6 More than than 95% of these teeth will never cause any problem. As many every bit iii fourths of the developing third molars classified equally mesioangular impactions at the fourth dimension of extraction are not impacted at all, but would continue to erupt into normal position in the oral cavity if left alone.26 There can exist no alibi for tolerating so many unnecessary extractions on millions of unsuspecting and misled people and putting them at take a chance of then much iatrogenic nerve injury. This is a public health risk.
THE Economic science OF THIRD-Tooth SURGERY
Each of the approximately 5500 oral and maxillofacial surgeons in individual practice averages nearly 53 third-molar cases a month, accounting for the removal of at least 7 of the 10 million "impacted" third molars extracted annually.27 Most of these teeth are not impacted. One-half are upper third molars, most of which can erupt normally, every bit will many, if not most, of the lower third molars (Effigy 2 ▶). Removing these teeth while they are still developing in the jaw bone results in a higher fee: extraction when the molar is embedded in soft tissue or bone is a more complex surgical procedure than a uncomplicated extraction later on the tooth erupts. Yet, information technology seldom takes an oral and maxillofacial surgeon more than 8 minutes to extract an impacted tooth once the patient is anesthetized.28
Panographic radiograph of four unremarkably developing wisdom teeth, classified as total bony impactions at the time of extraction.
The boilerplate annual income of oral and maxillofacial surgeons from tertiary-molar extractions alone is estimated at $518 636 (see footnote, Table 2 ▶). Even though only 20% of third molars have associated pathology or tissue inflammation, allowance should be made for the 33% that may crusade some discomfort (Tabular array 3 ▶), even if the condition might resolve after on without surgery. Two thirds of all third-molar extractions are unnecessary. Eliminating these extractions would reduce the oral and maxillofacial surgeon's almanac income by $347 486, resulting in an annual savings to patients of more than $one.nine billion, or $2.2 billion if extractions by general practitioners are included (Tabular array iii ▶).
A RATIONAL POLICY
The British National Institute for Clinical Excellence is unequivocal in its recommendation, adopted by the National Health Service: "The exercise of safety removal of pathology-costless impacted third molars should be discontinued. . . . There is no reliable bear witness to support a health benefit to patients from the condom removal of pathology-gratis impacted teeth."nine(p1–2) The conditions for which extraction is justified include nonrestorable dental caries, pulpal infection, cellulitis, recurrent pericoronitis, abscesses, cysts, and fractures.
Authorities-funded programs in the Us are beginning to prefer like policies; an example is the Salubrious Kids Dental Programme administered by Delta Dental of Michigan. Also needed is ameliorate educational activity of dentists, first in dental school, and of the public on the reasons to avoid unnecessary extractions.
THE FALLACY OF Ii SCHOOLS OF Thought
One school of thought is endorsed by oral and maxillofacial surgeons who contend that most third molars are potentially pathologic and should exist removed. The other holds that simply 3rd molars with associated pathology should be removed. The legal organization, in which decisions are mostly based on norms of exercise or local or regional standards of care, credits each school of thought as having equal merit, ignoring the scientific evidence base. That is why oral and maxillofacial surgeons usually prevail in malpractice suits when patients are injured during elective surgery. After all, if the skilful oral and maxillofacial surgeon says the surgery is necessary, then it is necessary. The fact that near third molars, impacted or not, practice non become diseased and that the risk of iatrogenic injury from such surgery is greater than the gamble of leaving asymptomatic, nonpathologic teeth lone does not override the expert opinion of oral and maxillofacial surgeons. Thus, the prevalent practice of prophylactic third-molar extractions is ordained as the standard of care, even though that standard is based on an erroneous evaluation of all outcomes and costs.
Malpractice in dentistry is more common than is best-selling, but the victim's recourse to redress the physical and financial injury is severely express.25 The recovery amounts involved are usually too small to encompass an attorney'due south expenses. However, in that location is something the legal profession could practice to protect the public: abolish the fallacy of the standard of care and two schools of idea, which ignores testify-based science and perpetuates and forgives malpractice.
The evidence is compelling that prophylactic extraction of third molars is a significant public wellness hazard. It is a silent epidemic of iatrogenic injury that warrants avoidance of the extraction of whatever third tooth in the absenteeism of a pathologic condition or a specific problem.
Notes
Peer Reviewed
Homo Participation Protection
No protocol approval was needed for this report.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1963310/
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