wisdom teeth removal

This information on the controversy of wisdom teeth removal is based on authoritative medical resources and guidelines, articles found in medical journals, information provided by dental professionals, and information provided by dental professional organizations. See the References below for a complete list of sources.

 

 

 

Wisdom Teeth Removal Controversy

The information presented on this site is of personal opinion and consequently is slanted and biased and not based on proper scientific research. The information presented is NOT written by a dental expert. Further the information presented has NOT been subjected to peer review by experts to verify accuracy and data integrity.

There are conditions when it is generally agreed that a wisdom tooth should be extracted and also conditions when it is generally agreed that a wisdom tooth should be retained. It is agreed in the medical and dental communities that the removal of wisdom teeth is always medically necessary where there is evidence of pathological changes which include periodontal disease, non-restorable carious lessions, infections, cysts, tumors, and damage to adjacent teeth. These conditions that can arise from wisdom teeth are discussed more on the risks of keeping wisdom teeth page. On the other side, it is agreed that wisdom teeth that are completely erupted and functional, painless, free of caries, and that have no pathological conditions can be retained and monitored over time. [28]

There are essentially three different stances one can take on whether or not to extract healthy impacted wisdom teeth.

  1. Extract all healthy wisdom teeth.
  2. Never extract any healthy wisdom teeth.
  3. Extract some healthy wisdom teeth and don't extract other healthy wisdom teeth.

Clearly it is most likely the case that option 3 is the best treatment choice. However, a lot of the debate centers around where to draw the line and research is always being done to help better understand this.

There are no reliable studies or data to support the removal of trouble free healthy impacted wisdom teeth. There are numerous problems with accurately collecting data and conducting scientific research as it relates to third molars (along with securing funding). Due to this controversy exists.

As suggested in [31] the following trial could be very beneficial in removing some of the controversy surrounding wisdom teeth : "..a clinical trial that enrolls a sample of subjects with asymptomatic, disease-free M3 [third molars] and randomizing them to 1 of the 3 primary treatment options: retention with active surveillance, retention with follow-up as needed when symptomatic, and extraction."

Some dentists and oral surgeons tend to fire arguments back and forth and the debate becomes heated.

Watchful monitoring of asymptomatic wisdom teeth may be a more appropriate strategy, suggests one of the review authors from the Cochrane Collaboration review led by Dr. Dirk Mettes of Radboud University Medical Centre Nijmegen in the Netherlands. Furthermore, the authors add, health risks and cost-effectiveness of surgery deserve greater consideration. [1, 5]

controversy

A now retired former California dentist has been arguing against removing healthy wisdom teeth since atleast the early 1970s. One article states "his work influenced many critics back in the early 1970s to label wisdom teeth extraction as the “Blue Plate Special” because the procedure was covered by Blue Shield of Pennsylvania and because so many wisdom teeth were extracted, driven more by insurance coverage and the profit motive than by dental or medical necessity. " At one point the California dentist said, "...the idea that all wisdom teeth should be removed in the absence of any recognizabled pathology, whether impacted or while they are still in the development stage, is a fraud perpetrated by oral surgeons in private practice, which coincidentally, provides three-fourths of their income." [21, 25, 26]

In 1999, the Scottish Intercollegiate Guidelines Network (SIGN) issued guidelines on unerupted and impacted wisdom teeth which said "it is self evident that there is no strong indication for removing third molars which are completely asymptomatic and disease free except under special circumstances as the risks of intervention may lead to complications both minor and major." [2]

In 2000, the National Institute for Clinical Excellence (NICE) issued guidance on the extraction of wisdom teeth which said "the practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS [National Health Service]". They further stated "there is no reliable evidence to suggest that operating on impacted wisdom teeth that are not causing problems has any benefit for the patient." [3] The policy that impacted wisdom teeth that are healthy should not be operated on continues to be recommended by NICE. [4] This policy is summed up quite nicely by Andrew Dillon: "if they are not causing a specific problem then they should not be removed." [23]

Both SIGN and NICE concluded that due to the risks and the costs of wisdom teeth extractions that disease free healthy wisdom teeth should not be removed. [2, 3]

In 2005, the Cochrane Collaboration published a systematic review of randomized controlled trials in order to evaluate the effect of preventative removal of disease free wisdom teeth. The authors of the review "found no evidence 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 impacted third molars in adolescents to reduce or prevent late incisor crowding cannot be justified." "Such removal neither reduces or prevents late incisor crowding". The authors of the review suggested that the number of surgical procedures could be reduced by 60% or more. They further stated "clinicians should make it clear to adult patients with asymptomatic third molars that there is no evidence one way or the other about the benefits or otherwise of removing these molars." [5]

Similarly, Clinical Evidence published a summary in 2006, largely based on the Cochrane review, that concluded prophylactic extraction is likely to be ineffective or harmful. Clinical Evidence suggested while it is clear that symptomatic impacted wisdom teeth should be surgically removed, it appears that extracting asymptomatic, disease-free wisdom teeth is not advisable due to the risk of damage to the inferior alveolar nerve. [6]

The American Associaton of Oral and Maxillofacial Surgeons (AAOMS) published a white paper on wisdom teeth in 2007. They stated that "the presence of visible third molars is associated with overall elevated levels of periodontitis and that of immediately adjacent teeth." AAOMS went on to say "third molar periodontal pathology and resultant inflammation may have a negative systemic impact" [on your overall health]. [10] At the time (2007) they also offered guidance on their website which "recommends that wisdom teeth be removed by the time the patient is a young adult in order to prevent future problems and to ensure optimal healing." [11] AAOMS further recommended removal of wisdom teeth at younger age since the roots of wisdom teeth are not completely formed and having fully formed roots at a later age can lead to a more complicated surgical procedure. [11]

In a 2010 third molar press conference, AAOMS defined an asymptomatic, disease free wisdom tooth to be 1 of the following options upon clinical examination: [18, 31]

• A wisdom tooth that is erupting which with examination appears to have adequate room to erupt into a functional and hygienic position.
• A wisdom tooth that is not visible, cannot be probed with a dental probe, and has a periodontal probing depth of less than 4 mm.
• A wisdom tooth that has a periodontal probing depth of less than 4 mm and is completey erupted into a functional and hygienic position and does not have a cavitiy or if it does have a cavity it can be filled (restored). Further at least 1 mm of attached gingiva tissue surrounds the tooth.

In addition, the patient has no symptoms or vague symptoms that are not readily attributable to any wisdom teeth and there is no evidence of disease in a radiographic examination. [31]

Hence based on information provided by AAOMS in 2010, if a wisdom tooth has a periodontal probing depth of greater than or equal 4 mm they feel that wisdom tooth should be extracted due to the increased risk of developing periodontal pockets. This includes those patients who experience no symptoms. AAOMS likes to use the phrase the "absence of clinical symptoms (asymptomatic) does not indicate absence of disease or pathology". See the risks of keeping wisdom teeth / reasons for their removal for further information on periodontal disease. [18]

According to the California dentist, AAOMS placed a full-page advertisement in 1981 in Time, Newsweek, and other national magazines with the following quotation "Love can make your ears ring, your heart sick, leave you breathless and wreck your health. So can wisdom teeth. . . . Because most wisdom teeth are like little time bombs. The question isn't will they go off, it's when." [21] AAOMS in September, 2007, placed a 4-page advertisement supplement in USA Today urging the extraction of wisdom teeth without mentioning any possible risks and complications that could occur from their removal. [22] Not all wisdom teeth develop problems in the future and complications can certainly happen from their removal.

The American Association of Public Health (APHA) issued a policy in 2008 in which they "recommend that public education about the removal of ...wisdom teeth, like the removal of any teeth, should be based on evidence of diagnosed pathology or demonstrable need." They "oppose prophylactic removal of third molars, which subjects individuals and society to unnecessary costs, avoidable morbidity, and the risks of permanent injury." Further the APHA "urges all public health agencies and dental professional organizations to disseminate information explaining why prophylactic removal of third molars is not recommended, in keeping with their dedication to improving the health literacy of the public and its consequent ability to make informed health care decisions." [9]

A California dentist says (2007, 2008) "...[the] prophylactic extraction of third molars is a significant public health hazard." [12] He says the idea that all wisdom teeth should be removed in the absence of any recognizable pathology, whether or not impacted, or while they are still in the developmental stage, is a myth perpetrated by oral surgeons in private practice, which, coincidentally, provides an estimated $518,636 of their average annual income. In response to AAOMS's argument regarding periodontitis as a reason to remove a wisdom tooth while a patient is a young adult he says "if that was a valid argument, all teeth with periodontal disease would be removed and there would be no need for periodontists and dental hygienists who treat and retain these teeth." He further says "surgery to prevent future pathology is irresponsible and tantamount to malpractice, particularly when removal of nonpathological, asymptomatic structures, in this case, third molars, results in iatrogenic injury." "He believes "...prospective patients are fed false or misleading information to coerce them into extraction of all their wisdom teeth." (Note this California dentist is associated with APHA) [12, 13, 19]

A systematic review in the Australian Dental Journal in 2009, reviewed literature surrounding wisdom teeth extractions with a focus on formulating evidence-based decisions. The review concludes "with regard to asymptomatic impacted third molars either partially or fully encased in bone, it would seem sound clinical practice to leave them and monitor them periodically based on the available evidence. Studies have all demonstrated that these teeth improve in angulation and vertical position with time, especially in the first three decades of life and beyond, but to a lesser degree." The authors go on to say "as health care providers, we are involved in treating patients who exhibit large biologic variation which deems the rigid adherence to individual biases or practice philosophies that extend to all patients as not only not evidence-based but unethical." In regards to asymptomatic partially or fully erupted wisdom teeth with periodontal probing depth greater than or equal to 4 mm that have bleeding on probing or attachment loss the authors suggest "..a conservative approach involving periodontal maintenance...". "However, there is indication to remove them once signs of periodontal pocketing are detected, especially if patient compliance with oral hygiene measures are average or if periodontal maintenance is not feasible." [14]

Both the review in the Australian Dental Journal and a California dentist's publications discuss how in the past few decades changes in the medical profession has occured and the removal of organs such as tonsils and appendices only occurs after taking into account numerous factors. It is suggested removing organs such as tonsils and appendices for preventative reasons when they are healthy, have no pathology, and cause no symptoms would be irresponsible, unethical, and negligent and wisdom teeth should be in that category of organs. [13, 14]

In 2009, Clinical Evidence, under new authors - one who has used too small of a sample size in a prior publication, changed the previous recommendation of extracting asymptomatic, disease-free wisdom teeth from "likely to be ineffective or harmful" to "unknown effectiveness". This was with stating in the systematic review that "guidelines based on non-randomized controlled trials evidence suggest that extraction is not advisable in people with deeply impacted wisdom teeth who have no history of pertinent local or systemic pathology" while citing the risk of permanent nerve damage. [7] This change reflects a category of effectivness change which means that their is currently insufficient data or data of inadequate quality to support or refute removing healthy wisdom teeth. [8]

A 2010 systematic review by authors from the University of Toronto's dental school stated "prophylactic extraction to prevent the development of periodontal disease would seem to be an extreme intervention and more reasonable approaches should first be explored such as improvement of oral hygiene, routine maintenance, antibiotic therapy, and periodontal treatment." In regards to the Journal of Oral and Maxillofacial Surgery the authors stated, "while this is a reputed journal, the main area of interest of the contributors to this journal is surgical intervention and thus, there may be an underlying personal interest to justify third molar [wisdom teeth] extractions." [20]

One author's view on asymptomatic wisdom teeth appearing in the American Journal of Orthodontics and Dentofacial Orthopedics in July 2011 says " ... AAOMS's self-serving arbitrary definition of disease... is misleading and inappropriate." Futher the author states "There are clear indications for the removal of third molars associated with symptoms and pathology as well as guidelines for when the removal of asymptomatic pathology-free third molars is justified .... the strategy of routine asymptomatic third molar extraction .... betrays our primary obligation as doctors to first 'do no harm.' " [24]

Due to previous criticisms and the controversy surrounding the medical necessity for removal of erupted, partially impacted, or fully impacted wisdom teeth, AAOMS issued a 6 page white paper in November 2011 which is located at http://www.aaoms.org/docs/evidence_based_third_molar_surgery.pdf. In it it states "There is no pat answer, cookbook recipe, or flow chart that is universally accepted regarding the decision making process. The presence of the third molar teeth, their position within the jaws and or dental arches, the condition of the teeth and associated teeth and structures, the presence or potential for pathology associated with the third molar teeth must be considered carefully. The risks of complications involved with early treatment of third molar teeth that are likely to cause problems versus the morbidity caused by retained third molar teeth and subsequent treatment in an older patient must be weighed." [28] In this white paper, AAOMS supports the elective removal of wisdom teeth in cases where pathology is likely to occur as a result of instead retaining those wisdom teeth regardless of whether or not those wisdom teeth cause symptoms. [28]

Around 2011/2012, AAOMS also modified their website on wisdom teeth. No longer do they necessarily recommend removal of wisdom teeth in younger age. They added language on their website to say "wisdom teeth that are completely erupted and functional, painless, cavity-free, in a hygienic environment with healthy gum tissue, and are disease-free may not require extraction." In addition, they recommend that wisdom teeth are evaluated by an oral surgeon to suggest management options ranging from removal to a monitored retention plan. [30]

In 2012, the Cochrane Collaboration published a systematic review and found insufficient evidence to support or refute routine prophylactic removal of asymptomatic impacted wisdom teeth. The authors found no randomized controlled trials that compared the removal of asymptomatic wisdom teeth with retention and reported quality of life. Only 1 trial was included in the review which found no evidence that extraction of wisdom teeth had an effect on lower incisor crowding over 5 years. [29]

It should also be mentioned that a study published in 2010 suggested possible publication bias present in oral and maxillofacial surgery (OMS) literature. The journals reviewed in the study were were the International Journal of Oral and Maxillofacial Surgery (IJOMS), Journal of Cranio-Maxillofacial Surgery (JCMS), Journal of Oral and Maxillofacial Surgery (JOMS), and British Journal of Oral and Maxillofacial Surgery (BJOMS). The Journal of Oral and Maxillofacial Surgery is published on behalf of the American Associaton of Oral and Maxillofacial Surgeons. [16]

The results of this study on publication bias over a one year period showed a substantial number of the controlled trials presented positive outcomes (77.4%), were based on low sample size (n<100; 69.8%) and from a single location (86.8%). This means "...4 leading OMS journals [may] have a preference to publish controlled trials with a positive outcome" and hence may have positive outcome bias or pipeline bias which is a form of publication bias. Low sample size of studies typically suffer from inadequate and a lack of statistical power to detect real differences in treatment (type II error). Even so it is important to know that non statistically significant findings do not prove that there is no difference between the studied interventions and instead show an absence of evidence of a difference between the groups. The bottom line is journals should not have a preference to publish only studies with positive results as this introduces bias into 'scientific evidence' and is unethical. [16, 17]

The California Dental Association (CDA) have on their website a quote by Dr. Robert Boyd who is an orthodontist and periodontist, "...the trend today is to leave healthy, stable, wisdom teeth alone, monitoring them over the years to make sure they stay healthy and stable." [15]

One dentist in the U.S. says (in 2011): [27]

"There is uncertainty as to how a wisdom tooth is going to eventually position itself. If it's clearly impacted, doesn't show evidence of pathology and looks like it will be super difficult to remove, I think it's best to leave it alone. If a wisdom tooth is erupting at an angle or is partially erupted, I think it is a good idea to remove because these often develop gum problems. I've seen partially erupted wisdom teeth cause severe resorption (the tooth eating itself), decay and gum disease that resulted in the removal of the wisdom tooth as well as the second molar."

"Even if you have room and your wisdom teeth are erupted, very often the tissue around them is loose and susceptible to gum issues and people often bite their cheeks. They are hard to clean and often develop decay that is very difficult to impossible to restore. Sometimes I'll see the writing on the wall, that a patient isn't doing a good job keeping the wisdom teeth clean and they have decay or gum issues starting, and I'll recommend removal. They'll say,"Geez, what's with you dentists, you're all wisdom tooth haters", and they want me to fix the decay or fix the gum problem instead of removing the tooth. But again, because they can't clean well back there, new decay develops or gum problems never improve, and they ultimately have to have the tooth removed anyway."

Updated August 25, 2013

References
1. Laura Kennedy, Medical News Today. No Wisdom in Routinely Pulling Wisdom Teeth, Study Says. Accessed July, 2008. http://www.medicalnewstoday.com/articles/23618.php
2. Scottish Intercollegiate Guidelines Network. Management of Unerupted and Impacted Third Molar Teeth. September 1999. http://www.sign.ac.uk/pdf/sign43.pdf
3. National Institute For Health and Clinical Evidence. Guidance of the Extraction of Wisdom Teeth. March 2000. http://www.nice.org.uk/nicemedia/live/11385/31993/31993.pdf
4. National Institute For Health and Clinical Evidence. Wisdom teeth - removal. December 13, 2010. http://guidance.nice.org.uk/TA1 Accessed January 23, 2011.
5. Mettes DTG, Nienhuijs MMEL, van der Sanded WMJ, Verdonschot EH, and Plasschaert A. Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. Cochrane Database of Systematic Reviews. 2005, Issue 2. http://www.cochrane.org/reviews/en/ab003879.html
6. Esposito M. Impacted Wisdom Teeth. Clinical Evidence. June 15, 2006. pages 1868-1870.
7. Thomas B. Dodson and Srinivas M. Susarla. Impacted Wisdom Teeth. Search date July 2009. Clinical Evidence. 2010. 04:1302. pages 1- 17. http://clinicalevidence.bmj.com/ceweb/conditions/orh/1302/1302_I1205750731260.jsp
Mirror: http://www.teethremoval.com/Clinical_Evidence_Impacted_Wisdom_Teeth_2010_BMJ.pdf
8. Clinical Evidence. http://clinicalevidence.bmj.com/ceweb/about/guide.jsp Accessed January 23, 2010.
9. American Public Health Association. Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth). Policy Date 10/28/2008. Policy Number 20085. http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1371
10. American Association of Oral and Maxillofacial Surgeons. White Paper on Third Molar Data.
Written March 2007. http://www.aaoms.org/docs/third_molar_white_paper.pdf
11. American Association of Oral and Maxillofacial Surgeons. Wisdom Teeth. http://www.aaoms.org/wisdom_teeth.php Accessed August 11, 2011.
12. Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J. Public Health 2007;97:1554-1559. http://www.ajph.org/cgi/content/full/97/9/1554
Mirror: http://www.teethremoval.com/the_prophylactic_extraction_of_third_molars.pdf
13. Friedman Jay W. The hazards of wisdom tooth extraction: From patient to plaintiff. Is it really necessary to pull out those wisdom teeth? A little sage advice from someone who knows. Plaintiff Magazine. August 2008.
http://www.plaintiffmagazine.com/Aug08/Friedman_The%20hazards%20of%20wisdom%20tooth%20extraction%20-%20From%20patient%20to%20plaintiff.pdf
14. S Kandasamy and DJ Rinchuse. The wisdom behind third molar extractions. Australian Dental Journal. 54. pages 284-292. 2009. http://onlinelibrary.wiley.com/doi/10.1111/j.1834-7819.2009.01152.x/abstract
15. California Dental Association. Wisdom Teeth. http://www.cda.org/popup/wisdom_teeth Accessed February 7, 2011.
16. Poramate Pitak-Arnnop and et al. Publication bias in oral and maxillofacial surgery journals: An observation on published controlled trials. Journal of Cranio-Maxillofacial Surgery. vol. 38, 4-10. 2010.
17. Douglas G. Altman and J Martin Bland. Statistics notes: Absence of evidence is not evidence of absence. BMJ. 1995. 311. 485. 1995.
18. American Association of Oral and Maxillofacial Surgeons. Third Molar Multidiscplinary Conference. October 19, 2010.
19. Jay W. Friedman and Scott M. Presson. Wisdom tooth extraction in perspective. Dental Abstracts. vol. 55. issue 5. pages 228-229. 2010.
20. Bertha Luk and et al. Prophylactic Extraction of Asymptomatic Third Molars to Prevent Periondontal Pathology: An Evidence Based Study. Community Dentistry DEN207Y. University of Toronto. April 8, 2010.
21. Jay W. Friedman. Containing the Cost of Third-Molar Extractions: A Dielmma for Health Insurance. Public Health Reports. vol. 98. issue 4. pages 376- 384. July-August 1983.
22. J. W. Friedman. Friedman Responds. Am J Public Health. vol. 98. issue 4. pages 582 - 582. April 1, 2008.
23. BBC News. Leave wisdom teeth in, dentists told. March 27, 2000. http://news.bbc.co.uk/2/hi/health/689856.stm Accessed July 7, 2011.
24. Sanjivan Kandasamy. Evaluation and management of asymptomatic third molars: Watchful monitoring is a low-risk alternative to extraction. American Journal of Orthodontics and Dentofacial Orthopedics. Vol. 140. Issue 1. pages 11-17. July 2011.
25. Herb Deneberg. Many decisions about caring for teeth made with profit, not need, in mind. Reading Eagle. Thursday, October 7, 2004. B16.
26. Herb Denenberg. The Deneberg Report. On myths relating to extraction of wisdom teeth and using body mass index to determine healthy weight: on the lack of wisdom of those extracting wisdom teeth and the defects of the BMI, body mass index. March 06, 2006. http://www.thedenenbergreport.org/article.php?index=792 Accessed August 18, 2011.
27. Is it "healthier" to remove wisdom teeth even if they are not bothering you? September 27, 2011. http://www.reddit.com/r/askscience/comments/ktto5/is_it_healthier_to_remove_your_wisdom_teeth_even/
28. AAOMS. Advocacy White Paper on Evidence
Based Third Molar Surgery. http://www.aaoms.org/docs/evidence_based_third_molar_surgery.pdf November 11, 2011.
29. Mettes DTG, Ghaeminia H, Nienhuijs MMEL, Perry J, van der Sanded WMJ, and Plasschaert A. Surgical removal versus retention for the management of asymptomatic impacted wisdom teeth. Cochrane Database of Systematic Reviews. 2012, Issue 6.
30. American Association of Oral and Maxillofacial Surgeons. Wisdom Teeth. http://www.aaoms.org/wisdom_teeth.php Accessed August 25, 2013.
31. Thomas B. Dodson, Ira D. Cheifetz, William J. Nelson, and Louis K. Rafetto, "Summary of hte Proceedings of the Third Molar Multidisciplinary Conference," Journal of Oral and Maxillofacial Surgery, vol. 70, pp. 66-69, 2012, supplement 1.

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