Review of the Wisdom Behind Third Molar Extractions

Back in 2009, an article titled  The wisdom behind third molar extractions” by “S Kandasamy and DJ Rinchuse appeared in the Australian Dental Journal (54. pages 284-292. 2009) I discussed some of the provocative comments in this article in the post Bringing About Healthcare Change. To reiterate he states

“…in the 21st century, the routine removal of asymptomatic pathology- free third molars has become a dated practice that is rapidly running out of valid excuses, and it has no justification in contemporary dentistry and medicine.”

Earlier this year an article titled “Patient Specific Variables are a Consideration in the Decision to Extract Asymptomatic Third Molars” by Katerine W. L. Vig appeared in the J Evid Base Dent Pract. (2012 12 pp. 92-94)

The conclusion of this article is

“The removal of third molars to avoid lower incisor crowding is not justified. Clear indications exist for removal of third molars associated with pathology. Asymptomatic partially or fully erupted third molars are best retained and monitored regularly for periodontal maintenance, especially those with associated pockets greater than 4mm. Risks with retaining third molars should be put in the context of the overall medical condition of the patient with the potential for systemic involvement.”

The author describes how in the article by Kandasamy he discusses how there is lack of evidence to support the association between lower incisor crowding and third molars. He also discuses the 2008 Cochrane review on asymptomatic wisdom teeth.

The author of this article Patient Specific Variables are a Consideration in the Decision to Extract Asymptomatic Third Molars says:

“The issue of lower incisor crowding is not a pathological event and is somewhat irrelevant, but its association with the eruption of the wisdom teeth has been a contentious and mythical concept in orthodontics. As crowding of the lower incisors occurs coincidentally at the same chronological age that third molars erupt, a causal relationship seems intuitive, and prophylactic third molar extraction should be a logical preventive measure.”

Well in a recent article which I discussed here Hows Jaws Shrink with Age and Does This Affect Wisdom Teeth Crowding the authors state:

“The dentoalveolar processes continue to undergo physiological changes throughout adult life. Of particular clinical relevance is the finding that decreases in arch length and depth result in a decrease in intercanine width and increased crowding of the anterior teeth. These findings have important clinical implications in orthodontic practice, particularly in treatment planning and long-term post-treatment stability/retention…We can also eliminate wisdom teeth as the cause, because even people who have no wisdom teeth have crowded front teeth.”

The author of the article in Patient Specific Variables are a Consideration in the Decision to Extract Asymptomatic Third Molars then goes on to state that since 2011 new data has emerged from North Carolina and the University of Kentucky “confirming that ‘‘symptom-free’’ third molars do not equate to ‘‘pathology-free’’ third molars.” Dr. Vig then states that based on this study

“approximately 70% of young adults with symptom-free third molars will either have pathology or develop pathology with age. That leaves 30% of young adults who will not have associated pathology with asymptomatic third molars. This is an important probability estimate when counseling patients on the options of extraction of third molars.”

Frankly I find statistics such as this to be misleading and not helpful at all. Back in 2006, when I was researching wisdom teeth removal after being told I should have them removed I came across a statement on the AAOMS website which said back then that research shows that 85% of all third molars will need to be removed. If these numbers come about from just one study, I want to know the sample size, origin of the study, and other pertinent factors.

Dr. Vig goes on to say

“As the strength of evidence has moved higher up the pyramid, clinical standards and best practices need to change as new evidence emerges. Kandasamy relates this to the previous medical practice of prophylactic removal of tonsils and adenoids, which has now been revised as new evidence has emerged, resulting in fewer children routinely undergoing ‘‘prophylactic’’ tonsillectomy and adenoidectomy. In spite of the continuing controversy as the higher level of evidence emerges, it becomes more difficult to defend personal beliefs and biases on compelling rhetoric alone. As with most controversies, they are based on weak evidence, plausible theory, and strong advocacy. Regarding the review of the 2009 Kandasamy et al article, the study design (a comprehensive literature review) is insufficiently robust, which produces weak evidence to support a favorable recommendation. We now have newer evidence emerging to translate into clinical and best practice for advising patients on their wisdom teeth with an emphasis on quality of life outcomes.”

Unfortunately, I do not quite understand how the strength of evidence has moved that much higher up the pyramid from one additional study. Dr. Vig essentially accuses Kandasamy of basing his opinions based on personal beliefs and rhetoric.

I am sorry but I find this article in a so called Evidence-Based Journal to be ridiculous. As indicated on the controversy page there is no strong evidence either way to retain or extract healthy trouble free wisdom teeth.

However, there is evidence and reports of serious and life altering complications occurring in young healthy patients who receive no compensation and no health insurance such as to myself and on the complications page.

If you want to improve quality of life outcomes there needs to be a serious shift in thinking. What I am concerned about is if I get injured can I get compensation? There is evidence to suggest that many patients who are injured do not receive compensation. Clearly there is no universal health care system in the U.S. so if you get injured by a doctor and get no compensation then you are PERSONALLY responsible for the healthcare bills for the rest of your life.

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