Is it necessary to get your wisdom tooth extracted?
In today's world, most practicing oral and maxillofacial surgeons routinely perform prophylactic removal of impacted third molars. Ten million third molars (wisdom teeth) are extracted from approximately 5 million people in the United States each year at an annual cost of over $3 billion (source:ncbi.nlm.nih.gov). The indications for removal of asymptomatic third molars have been challenged. This controversy indicated the search for evidence based data to justify or dispute the practice.
Do the risks and costs involved for the extraction of 3rd molars outweigh the life long benefits obtained from their removal?
Decisions regarding this question not only consider the presence of ongoing symptoms or pathology but also anticipate future complications and morbidity associated with retention of third molars and possibly increases the risk of extraction at an older age.
Two major professional organizations i.e. AAOMS (The American Association of Oral and Maxillofacial Surgeons) AND National Health Service of Great Britain(NHS) have made contradictory recommendations towards prophylactic removal of impacted third molars.
EVIDENCE AGAINGST PROPHYLACTIC REMOVAL OF THIRD MOLAR
Lida and colleagues (2004) and Zhu and colleagues (2005) studied relationship between presence of impacted mandible third molars and fracture of condyle. Significant relationship has been found between removal of third impacted third molars and mandible condylar fractures. The conclusion was finally drawn that the absence of an impacted third molar may increase the risk of condylar fractures and decrease the prevalence of mandibular angle fractures.(source:www.ncbi.nlm.nih.gov)
Extraction of third molar is also associated with risk of injury to inferior alveolar nerve and lingual nerve (source:www.ncbi.nlm.nih.gov). The incidence of nerve injury is statistically associated with age of patient which is related to chronology of third molar development. Roots of third molar are not usually formed until age of 21. Subsequently extraction of 3rd molar in teenage is associated with lower risk of inferior alveolar nerve injury.
Possible link between extraction of 3rd molar and internal derangement of TMJ has also been suggested. Here is more resources on Opposition to Prophylactic Removal of Third Molars by American Public Health Association.
EVIDENCE IN FAVOUR OF PROPHYLACTIC REMOVAL OF THIRD MOLAR
In addition to the AAOMS third molar clinical trials, the current literature was reviewed regarding the evidence of supporting the prophylactic extraction of third molars in early childhood.
It has been seen that young adults experience anterior mandibular incisor crowding usually coinciding with emergence of third molars. Crowding occurs due to pressure from posterior arch.
HAUG and colleagues conducted a well designed prospective study in which he evaluated 3760 patients aged 25 years who were undergoing removal of 3rd molar. (source:www.centreoms.com)
They found that third molar surgery in patients aged 25 years or older is associated with minimal morbidity, low incidence of post operative complications, and minimum impact on the patient's quality of life.
Extensive evidence also supports that removing 3rd molars reduces the incidence of mandibular angle fractures which is said to be caused by decreased cross sectional area of bone at angle with retained 3rd molars.
More importantly the benefits of early extraction in regards to future complications (such as periodontal disease, systemic inflammation, mandibular fracture, development of cysts and tumors, odontogenic infections, anterior crowding) and complications associated with extraction with advancing age should be considered.
Studies have confirmed the high proportion of soft tissue pathologic conditions for asymptomatic third molar in absence of radiographic signs of pathology. Incidence of dentigerous cyst is 51%, chronic non specific inflammation by 4.8% and odontogenic keratocyst by 1.9% is more in the patients with impacted third molars then the ones getting removed. Early extraction of third molars eliminates need for future more extensive surgical treatments at an older age. Also the oral bacteria associated with periodontal disease provides a portal of entry for pathogenic bacteria in blood stream and can cause serious health problems such as coronary artery disease, stroke, renal vascular disease, diabetes and obstetric complications.
So all these trials suggest that 3rd molars even those that are asymptomatic and display no current signs of disease should be considered for removal in young childhood.
In ideal world cost would not carry any significant weight for health care decision. Though in some regions of world, socioeconomic and available resources play a greater role in determining of guidelines for 3rd molar (wisdom tooth) extraction, the current evidence remains unchanged. Cumulative financial costs of treating health complications of retained 3rd molar in older population should be accounted.
Although it is clear that extraction of third molar pose some risk to patients, determination of extraction vs. non extraction of asymptomatic 3rd molar should compare the costs and risks of surgical extraction to the life time health and cost benefits from prevention and elimination of any pathological process associated with retention of third molar.
Written By: Dr. Aastha, Mohali, Punjab, India
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Edited by: Rajesh Bihani ( Find me on Google+ )