Is it wise to pull wisdom teeth?
Posted September 21, 2016
For many teens, the extraction of four healthy teeth is a ritual of high school, much like getting a driver’s license or going to the prom. But some people question the wisdom of pulling wisdom teeth, saying that it’s a traumatic procedure that may be unnecessary.
Most oral surgeons recommend the procedure to prevent future problems, but ultimately it’s parents and teens who decide what to do about the molars that erupt at the back of the mouth between the ages of 17 and 24. And deciding whether to subject their child to surgery can be an especially tricky dilemma for people of faith who reject the reason dentists give for the need: the shrinkage of the jaw through evolution over millions of years.
Of course, many people believe in both God and evolution (Pope Francis among them), but still question why surgery is necessary to remove teeth that aren't giving their children trouble, and in many cases, can't even be seen. While serious complications are rare, teens have died after having the procedure. A 17-year-old died during a procedure in Eden Prairie, Minnesota, in 2015, and there were three deaths in Georgia in 2012.
Even when extractions go well, people often need prescription pain medication and have to rest and eat soft foods for a couple of days, their jaws are sore and swollen, and while rare, serious infections can occur.
But people can get sick from wisdom teeth that aren't removed, too. When there isn't room for them, they can become impacted, leading to pain, ulcers and, in some cases, tumors. And dentists say it's more painful to have wisdom teeth removed when you're older than in your teens, when they're just coming in.
The American Association of Oral and Maxillofacial Surgeons recommends removing wisdom teeth if they are diseased or "at high risk" for developing disease. The American Public Health Association says wisdom teeth should be extracted only in cases of "diagnosed pathology or demonstrable need."
Dr. Thomas Dodson, professor and chairman of the Department of Oral and Maxillofacial Surgery at the University of Washington School of Dentistry, said oral surgeons are open to criticism about their recommendations since they make money by pulling wisdom teeth. "You sometimes have to wonder if there's a conflict of interest. These conflicts are common in medicine and dentistry and inherent in the circumstance when the treating clinician is making the decision about treatment," he said.
Regardless, "Wisdom teeth need to be managed, and they need to be managed by people who have expertise in the area. Just waiting until you have a problem is probably not reasonable. That's one extreme," Dodson said.
"The other extreme is to have wisdom teeth removed to prevent problems that may or may not ever be manifest. Either can be readily defended, but it's up to the family to make the decision."
A second opinion is important, said Dr. Louis K. Rafetto, an oral surgeon in Wilmington, Delaware, and president of the American Association of Oral and Maxillofacial Surgeons. So is knowing the risks of both choices.
Third one's the harm
As children, most of us have 20 baby teeth that fall out by the time we’re 12. As baby teeth fall out, they’re replaced with permanent teeth, of which we will eventually have 32.
It's the last four that are problematic, at least in the modern jaw. By the time the last molars start to erupt, for most people, there's no more room in the mouth. They can grow crookedly, pushing against the second molar, or grow sideways. Some remain trapped under the gum.
Scientists say that's because our jaws are significantly smaller than those of our ancestors, largely because of what we eat. The transition from diets of meat and roughage to refined grain removed a lot of work our teeth and jaws used to have to do. This affects not only wisdom teeth, but our teeth's alignment (meaning orthodontists have jobs because we started cultivating grain).
For people who believe in the Bible's account of creation, changes due to diet offer a plausible explanation for the wisdom-tooth dilemma, since they reject the idea of macroevolution.
"Creation science says, God doesn't make junk," said Frank Sherwin, a zoologist and researcher with the Institute for Creation Research and co-author of "The Human Body: An Intelligent Design" and other books.
"There's a perfectly good reason for those teeth coming in, and it's to grind the groceries, as it were," he said.
"When individuals who are maturing into adulthood have a diet that stimulates mandible development, they chew on material that stimulates the jaw to become more robust. Maybe the most robust thing we eat today is a Big Mac," Sherwin said.
Sherwin's own wisdom teeth were pulled by a Navy surgeon on a ship off the coast of Vietnam; he was 20 and it was Thanksgiving Day, so his feast that day was eggnog and lidocaine. He had no complications, however.
Dodson, the University of Washington oral surgeon and professor, still has all four of his wisdom teeth. This puts him in the minority of people whose third molars grow in without any issues.
Finnish researchers followed a group of 20-year-olds who retained their wisdom teeth. Within 18 years, about 60 percent had one or more removed because of problems. "The data suggest that there's a 40 percent chance that you'll do okay. But nobody knows if you're on the 60 percent or the 40 percent side," Dodson said.
When teenagers teethe
When babies teethe, parents know it, from the crying and fussiness that ensues when baby teeth come in. Teenagers teethe, too, but with considerably less drama; in fact, they may not even know that their third set of molars are erupting until a dentist points them out during a cleaning.
Dentists typically refer teens with emerging wisdom teeth to an oral surgeon for evaluation. Dentists can remove wisdom teeth, too, but oral surgeons may have more specialized equipment and options for pain management.
Dr. J. Crystal Baxter, a retired prosthodontist who has served as an expert witness in malpractice and personal injury lawsuits, said in most cases where there have been serious problems, a general dentist was involved, not a surgeon. "General dentists do most extractions in the U.S. and they do just fine, but oral surgeons have specialized equipment to do it faster and not traumatize the bone as much," she said.
And any surgery should be postponed if the patient is feeling unwell on the day the procedure is scheduled, Baxter notes.
In Britain, the National Institute for Health and Care Excellence said in 2000 that healthy wisdom teeth should not be removed. A decade later, a study found that while initially the number of extractions fell, they eventually reached previous levels. The only thing that changed was the age of the patient, said Rafetto, the oral surgeon in Delaware. The same percentage of people still had to have the teeth removed, but they were older when they had it done.
That said, Rafetto said he doesn't recommend removal for everyone he sees. Those who do opt for surgery are often surprised that it's not as bad as they expected. The extraction of all four molars often only takes about a half-hour for the procedure itself, and half of Rafetto's patients don't use prescription drugs for pain. "The recovery isn't as overwhelming as people may think," he said.
But it's still surgery that is sometimes covered by medical insurance, if not dental insurance.
The muscles have to be stretched or pulled away, and the tooth may be covered in bone, which has to be drilled through. Sometimes the tooth has to be cut into pieces to be removed, and often stitches are necessary.
Typically, patients are unaware of any of this, since they've been numbed by local or general anesthesia (an experience that sometimes shows up on YouTube).
Ironically, it's our generally excellent dental health that contributes to the need for surgery, Rafetto said. Centuries ago, people would lose teeth and so there was plenty of room (and need) for an additional four teeth. Technology has made extraction better, but still hasn't figured out a way to make it pain-free.
Dodson said some researchers have looked into procedures to remove or destroy the buds of developing teeth, but that would involve treating children around ages 9 or 10, which he finds disconcerting. For now, his mantra, like most of his colleagues, is "evaluate and manage."
Which is what Dodson's daughter decided to do when her wisdom teeth started coming in at age 19. With her father's support, she decided over the summer to leave them in. But when she started having problems a few months later, she had to have them pulled — during her Christmas vacation.