Approximately ten million third molars (wisdom teeth) are extracted from approximately 5 million people each year at an annual cost of over $3 billion. And at least 2/3rd of these extractions were unnecessary, giving rise to an interesting treatment in dentistry- ‘Prophylactic Third Molar Extraction’, and giving rise to a debate- “Whether asymptomatic wisdom tooth be pulled out?”
According to the American Association of Oral and Maxillofacial Surgeons, wisdom teeth should be removed if they are suspected to be potential problem creators. In young age, impacted third molars are in the coronal development stage which is the ideal time to remove it and more important to remove if the root formation is predicted to damage the inferior alveolar nerve beneath. The Association however, recommends that a semi annual check up must be done with the general dentist to check on the progress of development of third molar and recognition of any potential problem.
At Dental Jugaad, we conducted a survey by asking dental professionals from India and abroad.
When asked about their views on prophylactic removal of an asymptomatic third molar, which can itself trigger problems such as nerve damage and injury to important adjacent structures in the oral cavity, all of them agreed that,
“If it would trigger problems such as those mentioned above, I would rather keep observing with periodic radiographs and remove it at a better time”
Taking their clinical expertise and experience in dentistry into consideration, this is undoubtedly true. However, an interesting article which we found on the site of American Association of Oral and Maxillofacial Surgeons says:
1. the general thought of third molars remaining dormant after a particular age is not completely true. Third molars that remain impacted after the age of 25, may still change in position, and therefore can cause damage.
2. asymptomatic third molars adversely affect the periodontium of the second molar causing pocket formation, root resorption and therefore attachment loss. However, interestingly, the removal of the third molar does not improve the periodontal condition, and in a few cases, has caused an adverse outcome!
3. Data on microflora states that in an asymptomatic third molar, periodontal disease does exist and progresses. Also, pathogenic bacteria are present in clinically significant numbers around asymptomatic third molars.
So, what is the solution?
Dr. Ruchir Mishra, an Oral and Maxillo Facial Surgeon, from Delhi, states that as a dental professional, it is absolutely necessary to explain your patient about potential complications caused by third molars. But he would not necessarily advise them for a removal. It seems best to extract them if there is any damage caused by them in the oral cavity.
“Educating the patient about the potential fallout of an asymptomatic third molar or for that matter without signs of problems, should be the norm we should follow. I allow the patient to take informed decision rather than advising them to go one way or the other” is what Dr. Gururaj Bhosale, an Oral surgeon, from Pune has to say.
Another point to consider is the potential crowding which can be caused by third molars, and which is another reason for some orthodontists as well as general dentists, to remove third molars before they start with the braces treatment. Dr. Shreyas Oza, an Indian dentist, currently pursuing DDS from University of California, San Francisco, states that according to new ADA guidelines, "prophylactic removal" is not supported if it is just to prevent crowding of teeth. That is, the reason of future crowding of anterior teeth is not a satisfactory rationale for extraction of third molars.
He further states that third molars may not be causing any symptoms but may be
1) grossly decayed or
2) partially erupted (with the operculum is acting like a food trap) or
3) impinging on adjacent structures or associated with other pathologies (like say, a cyst).
In such cases, "prophylactic" removal is justified but such decisions can be made only over time when the practitioner foresees any impending troubles.
A medical practitioner, when asked about the same, said that he cannot comment on this topic since it is out of his professional reach. But he has a very interesting line to tell us. He says, ‘We do not carry out appendectomy in an asymptomatic patient, even though it is a vestigial organ. This is a whole grown functional tooth, which has the potential for eruption. Then why remove it??’
Dr. Ruchir Mishra gives us the final statement on this debate:
“I am strictly against the concept of prophylactic removal of third molars. Dentists and oral surgeons should get out of the habit of such prophylactic removals just for the sake of allowing the moolahs to keep flowing in. There is no rationale for prophylactic surgical removal of any part of the human body, even if it is vestigial , unless it directly contributes to or is a part of a pathology. And, please remember, that pericoronitis (which is the most common reason or should i say excuse for removing third molars) is actually also not an indication; only recurrent pericoronitis is.”