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Wisdom tooth extraction in perspective
COMMENTARY Wisdom tooth extraction in perspective By Jay W. Friedman, DDS, MPH, and Scott M. Presson, DDS, MPH
In 2008, the American Public Health Association (APHA) adopted a policy in opposition to prophylactic removal of wisdom teeth.1 Thomas B. Dodson was critical of the APHA policy in his commentary in the January-February issue of Dental Abstracts. We would like to inform the reader about the rationale and recommendations of the policy.2 The policy, sponsored by the Oral Health Section, was adopted by the APHA Governing Council after a thorough review and deliberation by its Joint Policy Committee. The policy recommends that the removal of third molars (wisdom teeth), like the removal of any other tooth, should be on the basis of evidence obtained from diagnosed pathology or demonstrable need. The policy declares that the APHA opposes prophylactic removal of third molars that subject individuals and society to the risks of permanent injury, avoidable morbidity, and unnecessary costs. Dr. Dodson asserted that ‘‘This proposal treated all wisdom tooth extractions as unnecessary..’’ Dr. Dodson is entitled to his own opinions, but he is not entitled to his own facts, to paraphrase the late Senator Moyniham. The APHA policy clearly states, ‘‘No one questions the removal of third molars, or any other tooth, where there is evidence of pathological changes such as infections, nonrestorable carious lesions, cysts, tumors, and damage to adjacent teeth.’’ By this measure, at most only one-third of wisdom tooth extractions can be justified.3 What of the rationale for the APHA policy? Dr. Dodson uses the conclusions of the Cochrane systematic review,4 which states that ‘‘No evidence was found to support or refute the routine removal of asymptomatic impacted wisdom molar teeth in adults’’ as a criticism of the basis for the APHA policy. He asks, ‘‘Without data to support its recommendation, how did the APHA formulate its policy position?’’ Simply put, APHA agreed with the Cochrane review authors and others in concluding that there is no high quality evidence supporting the extraction of millions of pathology-free asymptomatic wisdom teeth each year. As every procedure to remove a third molar carries a risk to the patient, are we not to ‘‘first, do no harm?’’ The authors of the Cochrane review based their conclusions on the paucity of rigorous evidence that meets the inclusion criteria they established (randomized and/or controlled trials). So until such evidence becomes available,
228
Dental Abstracts
what is the clinician to do? We would posit to use the best available nonrandomized and/or controlled trials evidence, and formulate the most prudent course of action by taking into consideration the variations in the rigor and quality of that research. The APHA policy is based on research data published in peer reviewed journals by oral surgeons documenting the incidence of injuries related to removal of wisdom teeth. Accordingly, ‘‘an estimated 3.8 million people (in the United States) experience 5 million mandibular third-molar extractions each year. As a consequence, as many as 17,000 to 50,000 people have some degree of permanent mandibular nerve paresthesia and tens of thousands experience TMD/TMJ injuries, an unknown number of which also become permanent. Furthermore, patients experience an average of 2.7 days, more than 10 million days in aggregate, of discomfort and disability—pain, swelling, bruising, and malaise—and absence from school and loss of work and income after uncomplicated third-molar extractions. Other risks include inadvertent fractures of the jaws, damage to the maxillary sinus, damage to adjacent teeth, and occasional deaths attributed to general anesthesia.’’1 It can be concluded from the analyses done by Friedman3 and Song et al5 that a more conservative approach is appropriate. Song et al stated that ‘‘In the absence of good evidence to support prophylactic removal, there appears to be little justification for the removal of pathology-free impacted third-molars.’’ Guidelines issued by the British National Institute for Clinical Excellence6 and the Scottish Intercollegiate Guidelines Network7 have reached similar recommendations that surgical intervention in the absence of pathology is not indicated for pathology-free, asymptomatic impacted third molars. Parenthetically, everyone should have periodic oral examinations by general dentists, who are capable of monitoring retained third molars and who can provide appropriate treatment for diseased teeth. Predicting the development of future pathology for third molars is currently an uncertain science. Dr. Dodson suggests that the unpredictability of wisdom tooth morbidity is a reason to consider extraction. But unpredictable morbidity applies to other anatomical structures, such as the appendix, tonsils, gall bladder, uterus, and prostate, for which prophylactic removal is not advocated by any responsible organization. However, it is the recommendation of the American Association of Oral and Maxillofacial Surgeons for wisdom teeth.8
The APHA policy calls for the formation of an expert panel to review the available evidence and for more research funding to expand our knowledge base in this controversial area with high quality evidence. Dodson suggests that the APHA ‘‘would assume the role of ‘wisdom tooth police,’’’ but there is nothing in APHA’s recommendations to deny patients the choice of treatment. He urges the American Dental Association and the American Association of Oral and Maxillofacial Surgeons ‘‘to refocus the rhetoric responsibly on the evidence..’’ We can all agree on this assuming he means that the discussion should be about facts and not assertions that exaggerate the benefits of prophylactic extraction while minimizing risks of iatrogenic injury. Jay W. Friedman, DDS, MPH APHA Oral Health Section American Public Health Association Washington, DC E-mail: [email protected] Scott M. Presson, DDS, MPH Chair, APHA Oral Health Section American Public Health Association Washington, DC E-mail: [email protected]
References 1. American Public Health Association: Opposition to prophylactic removal of third molars (wisdom teeth). Policy statement no. 20085. Available at: http://www.apha.org/advocacy/policy/policy search/default.htm?id=1371. Accessed June 23, 2010. 2. Dodson TB: Wisdom tooth extractions: Goals gone wild. Dent Abstr 55:4-5, 2010. 3. Friedman JW: The prophylactic extraction of third molars: A public health hazard. Am J Public Health 97:1554-1559, 2007. 4. Mettes TG, Nienhuijs ME, van der Sanden WJ, et al: Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults [review]. Cochrane Database Syst Rev 18:CD003879, 2005. 5. Song F, Landes DP, Glenny AM, et al: Prophylactic removal of impacted third molars: An assessment of published reviews. Br Dent J 182:339-346, 1997. 6. National Institute for Clinical Excellence. Guidance on the extraction of wisdom teeth. London, United Kingdom: National Institute for Clinical Excellence; 2000. Available at: www/nice. org.uk/nicemedia/pdf/wisdomteethguidance.pdf. Accessed November 18 2008. 7. Scottish Intercollegiate Guidelines Network. Management of unerupted and impacted third molar teeth. 1999. Available at: http://www.sign.ac.uk/pdf/sign43.pdf. Accessed June 23, 2010. 8. Wisdom teeth [pamphlet]. Rosemont, Illinois: American Association of Oral and Maxillofacial Surgery; 2005.
Integrative thinking Background.—The American Dental Association (ADA) defines evidence-based dentistry (EBD) as ‘‘an approach to oral healthcare that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.’’ Although evidence-based healthcare in general is only slowly being implemented, considerable momentum is behind the move toward EBD. Tangible benefits from using research data to improve dental care are being observed. However, EBD’s greatest effects may be on the way dentists think. The ‘‘Age of Evidence’’.—Information access has increased dramatically and with it the need for professionals to develop more profound, critical, and integrative thinking behaviors. It can be tempting to use guidelines and standards developed from study data to categorize patients and treat them according to their classification. Evidence can also be used to validate preconceived ideas about treatment. Study results may be viewed as recipes for treatment. If the goal of dentistry is to provide individualized, patientfocused care, none of these approaches is appropriate. Instead dentists need to think critically about the evidence
they find and tailor treatments to each distinctive patient. Before applying guidelines to the care of a specific patient, the practitioner should assess whether the study sample is representative of that patient. The evidence is just the beginning of the integrative thinking process that considers data from many sources. Implementation.—Successful business training programs to develop ‘‘design thinking’’ or integrative thinking require that participants research problems thoroughly before coming to a conclusion. This includes considering the behavior of consumers, the influence of the environment, what methods have been successful, and what methods have failed. The results of this process lead to questioning of the assumptions that have dominated the weighing of options. Rather than focusing on skills developed for specific situations, the focus is on skills that create solutions while considering complex and multidimensional relationships between numerous variables. Applying this to dentistry, the practitioner needs to gather data about all the factors that contribute to each individual case, critically weigh the options that are presented, and choose a course of action that seems to offer the best fit for the patient who is to receive treatment.
Volume 55
Issue 5
2010
229
In 2008, the American Public Health Association (APHA) adopted a policy in opposition to prophylactic removal of wisdom teeth.1 Thomas B. Dodson was critical of the APHA policy in his commentary in the January-February issue of Dental Abstracts. We would like to inform the reader about the rationale and recommendations of the policy.2 The policy, sponsored by the Oral Health Section, was adopted by the APHA Governing Council after a thorough review and deliberation by its Joint Policy Committee. The policy recommends that the removal of third molars (wisdom teeth), like the removal of any other tooth, should be on the basis of evidence obtained from diagnosed pathology or demonstrable need. The policy declares that the APHA opposes prophylactic removal of third molars that subject individuals and society to the risks of permanent injury, avoidable morbidity, and unnecessary costs. Dr. Dodson asserted that ‘‘This proposal treated all wisdom tooth extractions as unnecessary..’’ Dr. Dodson is entitled to his own opinions, but he is not entitled to his own facts, to paraphrase the late Senator Moyniham. The APHA policy clearly states, ‘‘No one questions the removal of third molars, or any other tooth, where there is evidence of pathological changes such as infections, nonrestorable carious lesions, cysts, tumors, and damage to adjacent teeth.’’ By this measure, at most only one-third of wisdom tooth extractions can be justified.3 What of the rationale for the APHA policy? Dr. Dodson uses the conclusions of the Cochrane systematic review,4 which states that ‘‘No evidence was found to support or refute the routine removal of asymptomatic impacted wisdom molar teeth in adults’’ as a criticism of the basis for the APHA policy. He asks, ‘‘Without data to support its recommendation, how did the APHA formulate its policy position?’’ Simply put, APHA agreed with the Cochrane review authors and others in concluding that there is no high quality evidence supporting the extraction of millions of pathology-free asymptomatic wisdom teeth each year. As every procedure to remove a third molar carries a risk to the patient, are we not to ‘‘first, do no harm?’’ The authors of the Cochrane review based their conclusions on the paucity of rigorous evidence that meets the inclusion criteria they established (randomized and/or controlled trials). So until such evidence becomes available,
228
Dental Abstracts
what is the clinician to do? We would posit to use the best available nonrandomized and/or controlled trials evidence, and formulate the most prudent course of action by taking into consideration the variations in the rigor and quality of that research. The APHA policy is based on research data published in peer reviewed journals by oral surgeons documenting the incidence of injuries related to removal of wisdom teeth. Accordingly, ‘‘an estimated 3.8 million people (in the United States) experience 5 million mandibular third-molar extractions each year. As a consequence, as many as 17,000 to 50,000 people have some degree of permanent mandibular nerve paresthesia and tens of thousands experience TMD/TMJ injuries, an unknown number of which also become permanent. Furthermore, patients experience an average of 2.7 days, more than 10 million days in aggregate, of discomfort and disability—pain, swelling, bruising, and malaise—and absence from school and loss of work and income after uncomplicated third-molar extractions. Other risks include inadvertent fractures of the jaws, damage to the maxillary sinus, damage to adjacent teeth, and occasional deaths attributed to general anesthesia.’’1 It can be concluded from the analyses done by Friedman3 and Song et al5 that a more conservative approach is appropriate. Song et al stated that ‘‘In the absence of good evidence to support prophylactic removal, there appears to be little justification for the removal of pathology-free impacted third-molars.’’ Guidelines issued by the British National Institute for Clinical Excellence6 and the Scottish Intercollegiate Guidelines Network7 have reached similar recommendations that surgical intervention in the absence of pathology is not indicated for pathology-free, asymptomatic impacted third molars. Parenthetically, everyone should have periodic oral examinations by general dentists, who are capable of monitoring retained third molars and who can provide appropriate treatment for diseased teeth. Predicting the development of future pathology for third molars is currently an uncertain science. Dr. Dodson suggests that the unpredictability of wisdom tooth morbidity is a reason to consider extraction. But unpredictable morbidity applies to other anatomical structures, such as the appendix, tonsils, gall bladder, uterus, and prostate, for which prophylactic removal is not advocated by any responsible organization. However, it is the recommendation of the American Association of Oral and Maxillofacial Surgeons for wisdom teeth.8
The APHA policy calls for the formation of an expert panel to review the available evidence and for more research funding to expand our knowledge base in this controversial area with high quality evidence. Dodson suggests that the APHA ‘‘would assume the role of ‘wisdom tooth police,’’’ but there is nothing in APHA’s recommendations to deny patients the choice of treatment. He urges the American Dental Association and the American Association of Oral and Maxillofacial Surgeons ‘‘to refocus the rhetoric responsibly on the evidence..’’ We can all agree on this assuming he means that the discussion should be about facts and not assertions that exaggerate the benefits of prophylactic extraction while minimizing risks of iatrogenic injury. Jay W. Friedman, DDS, MPH APHA Oral Health Section American Public Health Association Washington, DC E-mail: [email protected] Scott M. Presson, DDS, MPH Chair, APHA Oral Health Section American Public Health Association Washington, DC E-mail: [email protected]
References 1. American Public Health Association: Opposition to prophylactic removal of third molars (wisdom teeth). Policy statement no. 20085. Available at: http://www.apha.org/advocacy/policy/policy search/default.htm?id=1371. Accessed June 23, 2010. 2. Dodson TB: Wisdom tooth extractions: Goals gone wild. Dent Abstr 55:4-5, 2010. 3. Friedman JW: The prophylactic extraction of third molars: A public health hazard. Am J Public Health 97:1554-1559, 2007. 4. Mettes TG, Nienhuijs ME, van der Sanden WJ, et al: Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults [review]. Cochrane Database Syst Rev 18:CD003879, 2005. 5. Song F, Landes DP, Glenny AM, et al: Prophylactic removal of impacted third molars: An assessment of published reviews. Br Dent J 182:339-346, 1997. 6. National Institute for Clinical Excellence. Guidance on the extraction of wisdom teeth. London, United Kingdom: National Institute for Clinical Excellence; 2000. Available at: www/nice. org.uk/nicemedia/pdf/wisdomteethguidance.pdf. Accessed November 18 2008. 7. Scottish Intercollegiate Guidelines Network. Management of unerupted and impacted third molar teeth. 1999. Available at: http://www.sign.ac.uk/pdf/sign43.pdf. Accessed June 23, 2010. 8. Wisdom teeth [pamphlet]. Rosemont, Illinois: American Association of Oral and Maxillofacial Surgery; 2005.
Integrative thinking Background.—The American Dental Association (ADA) defines evidence-based dentistry (EBD) as ‘‘an approach to oral healthcare that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.’’ Although evidence-based healthcare in general is only slowly being implemented, considerable momentum is behind the move toward EBD. Tangible benefits from using research data to improve dental care are being observed. However, EBD’s greatest effects may be on the way dentists think. The ‘‘Age of Evidence’’.—Information access has increased dramatically and with it the need for professionals to develop more profound, critical, and integrative thinking behaviors. It can be tempting to use guidelines and standards developed from study data to categorize patients and treat them according to their classification. Evidence can also be used to validate preconceived ideas about treatment. Study results may be viewed as recipes for treatment. If the goal of dentistry is to provide individualized, patientfocused care, none of these approaches is appropriate. Instead dentists need to think critically about the evidence
they find and tailor treatments to each distinctive patient. Before applying guidelines to the care of a specific patient, the practitioner should assess whether the study sample is representative of that patient. The evidence is just the beginning of the integrative thinking process that considers data from many sources. Implementation.—Successful business training programs to develop ‘‘design thinking’’ or integrative thinking require that participants research problems thoroughly before coming to a conclusion. This includes considering the behavior of consumers, the influence of the environment, what methods have been successful, and what methods have failed. The results of this process lead to questioning of the assumptions that have dominated the weighing of options. Rather than focusing on skills developed for specific situations, the focus is on skills that create solutions while considering complex and multidimensional relationships between numerous variables. Applying this to dentistry, the practitioner needs to gather data about all the factors that contribute to each individual case, critically weigh the options that are presented, and choose a course of action that seems to offer the best fit for the patient who is to receive treatment.
Volume 55
Issue 5
2010
229