The Evidence Base for Third Molar (Wisdom Teeth) Decisions

An excellent editorial appears in the Journal of Oral and Maxillofacial Surgery in the August 2012 edition titled “Those Who Ignore the Evidence Are Doomed to Misuse It” by Dr. Thomas B. Dodson (70, pages 1765-1767).

Dr. Dodson explains how the debate regarding whether or not to either 1) remove asymptomatic, disease-free third molars, or 2) retain asymptomatic, disease-free third molars has become highly controversial. He argues that there are an assortment of viewpoints that play a role here.

A) Payer-based clinical decision making:

“The payer is the invisible hand in the operatory, influencing the treatment plan with a bold line that determines whether a service is covered or not. With PBCD, there is little regard or sympathy for what the OMS perceives about the individual patients and their circumstances. Thus, PBCD risks moral hazard by pre-empting services that the OMS or patient believe to be necessary to enhance the bottom line.”

B) Surgeon-based clinical decision-making

“SBCD integrates the best current literature with the clinician’s experiences and expertise. Detractors argue that maximizing revenue, rather than patient safety, is the OMS’s motivation for M3 removal. Publications that recommend the prophylactic removal of M3s add fuel to this fire. Here, the perceived moral hazard is that patients may be pressured into receiving unnecessary procedures.”

An example of such a group is the American Public Health Association. Dr. Dodson says:

“A case in point is the American Public Health Association (APHA), which recommends against prophylactic removal of asymptomatic M3s. This policy is based on published systematic reviews that conclude that the current evidence is insufficient to support or refute extraction to prevent future problems. They conclude, argumentum ad ignorantium, that the prophylactic operative intervention must be worse than the nonoperative intervention. The absence of evidence supporting extraction, however, is not evidence affirming retention as the preferred treatment.”

Dr. Dodson goes on to say

“In the case of M3 management, there are mountains of data on costs and outcomes of removing M3s, while there is a dearth of data regarding outcomes and costs associated with M3 retention. Despite evidence of adverse outcomes associated with retention, advocates for nonremoval conveniently ignore these corresponding risks and costs, including the persistent risk of removal, escalating symptoms, disease progression, spread of disease to adjacent structures, and age-related risks for complications.”

Dr. Dodson than goes on to address how NICE issued a recommendation in 2000 which said only diseased wisdom teeth should be removed. He then argues that the NHS did not seek to assess the outcomes of their recommendation. Further he says that in 2008 the APHA issued a recommendation against the removal of nonpathological wisdom teeth and again did not assess the consequences of this recommendation. (See the controversy page here for some additional details on these recommendations

C) Evidence-based clinical decision-making

“EBCD is distinguished from the other approaches in that it integrates the best information from the literature, the clinician’s expertise and experience, and the patient’s preferences and desires into the decision calculus.”

Dr. Dodson goes go on to say:

“In the absence of clear indicators for surgery, the EBCD clinician reviews with the patient with [asymptomatic, disease-free third molars] all the risks and benefits of operative and nonoperative treatments. It should be clear that nonoperative treatment is not a pass; there are costs and risks—a point conveniently ignored by the “wisdom tooth deniers.” It demands regular follow-up and includes associated costs for office visits, imaging, plus the persistent risk for extraction and the known risks associated with extraction at an older age.”

Dr. Dodson ends the piece by saying

“In the end, the choice of whether to remove or retain [asymptomatic, disease-free third molars] belongs to the patient. The responsibility to forge better evidence and apply EBCD belongs to us.”

I agree with Dr. Dodson on this point and hopefully one day additional data and evidence will be available to help patients better make a decision.

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