Dr. Jeff Hersh: A little wisdom on pulling teeth
Q: My wife's dentist told her she should have her wisdom teeth removed, but the oral surgeon they sent her to said it was not necessary. When should wisdom teeth be removed?
A: Wisdom teeth are actually a third set of molars. They may be a remnant of the days when humans had a bigger jaw, and they helped grind certain foods.
Most people have four wisdom teeth that come in (erupt) between the ages of 16 and 25, but not everyone gets them. If they erupt straight and completely, there is no problem.
However, impacted wisdom teeth, ones that do not erupt normally but instead come in "sideways," are very common. More than 70 percent of the Swedish population has at least one impacted wisdom tooth (I could not find data on the United States).
Sometimes wisdom teeth erupt oriented normally but do not break all the way through the gums. The operculum (the thin layer of gum covering the tooth) can make the tooth difficult to clean, so debris and/or bacteria get under it and infection is more likely.
What should be done about an impacted wisdom tooth? The answer to this is not clear.
Most dental experts agree that removal of impacted wisdom teeth is indicated for certain complications such as:
- Infections such as pericoronitis (inflammation/infection around the top of the tooth), cellulitis (infection in the tissues) or abscess (formation of a pocket of bacteria and pus).
- Cavities that are not easily treated.
- Pocketing (formation of a space between the tissue and the tooth where debris and/or bacteria can accumulate to cause infection), which may also affect the second molar.
- Cyst (a sack-like structure) formation which can affect the bone.
- Other bone problems (e.g. fracture, weakening of the bone).
- Pain (which is actually not so common from impacted wisdom teeth).
Interestingly, several research articles I found noted that crowding of teeth is not improved by removal of wisdom teeth, so this is not felt to be an indication for removal.
This is quite a long list, so you may be wondering why not just remove them?
Removal of wisdom teeth is not without risk. Possible complications include infections, persistent bleeding, formation of a dry socket (the hole where the tooth was has the clot fall out, becoming painful and possibly infected), damage to one of the nerves in the mouth and more.
Since many of the complications of impacted wisdom teeth listed above, as well as some of the complications of removal, are more common in older people or those with certain medical conditions (e.g., bacteria from an infected wisdom tooth can cause an infection of a heart valve in people at risk for this), some experts recommend routine removal of all impacted wisdom teeth at an early age.
But is this approach beneficial?
A study in the British Journal of Medicine concluded that extraction of asymptomatic wisdom teeth (those causing no complications) was "likely to be ineffective or harmful" and argued against such a practice.
The journal Evidence Based Dental Practice had an article noting that about 50 percent of people who had no pocketing prior to removal of asymptomatic wisdom teeth actually got worse, although 50 percent of those with pocketing before removal improved.
In 2006, the Cochrane Collaboration carried out a review of all available studies done to address this issue. Unfortunately, there was limited data to review. The conclusion was that there is not enough evidence to either support or refute the practice of removing asymptomatic impacted wisdom teeth.
Since the available data does not give a clear answer as to whether removal of asymptomatic impacted wisdom teeth is indicated for everyone, many experts recommend the decision be made on a case-by-case basis, specifically looking at the risks and benefits for the individual patient.
If you are considering having your wisdom teeth removed, it is best to sit with a dental specialist and discuss the risks and benefits and how they apply to you, so you can make the best-informed decision possible.
Jeff Hersh, Ph.D., M.D., F.A.A.P., F.A.C.P., F.A.A.E.P., can be reached at DrHersh@juno.com.