The Prophylactic Extraction of Third Molars: A Public Health Hazard

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. In addition, more than 11 million patient days of “standard discomfort or disability”— pain, swelling, bruising, and malaise—result postoperatively, and more than 11000 people suffer permanent paresthesia— numbness of the lip, tongue, and cheek—as a consequence of nerve injury during the surgery. At least two thirds of these extractions, associated costs, and injuries are unnecessary, constituting a silent epidemic of iatrogenic injury that afflicts tens of thousands of people with lifelong discomfort and disability. Avoidance of prophylactic extraction of third molars can prevent this public health hazard. (Am J Public Health. 2007; 97:1554–1559. doi:10.2105/AJPH. 2006.100271) IN THE UNITED STATES, prophylactic removal of third molars (wisdom teeth) is advocated by almost all oral and maxillofacial surgeons and many general dentists. According to the American Association of Oral and Maxillofacial Surgeons, “if there is insufficient anatomical space to accommodate normal eruption . . . removal of such teeth at an early age is a valid and scientifically sound treatment rationale based on medical necessity.” As a result, 10 million teeth classified as impactions (teeth that fail to erupt into normal position but remain fully or partially embedded and covered by jawbone or gum tissue) are removed every year from mostly healthy young people. There is no evidence of widespread third-molar infection and pathology or of medical necessity to justify so much surgery. In fact, 50% of upper third molars classified as impactions are normally developing teeth, most of which will erupt with minimal discomfort if not extracted prematurely. Only 12% of truly impacted teeth are associated with pathological conditions such as cysts and damage to adjacent teeth. Most discomfort of erupting wisdom teeth is equivalent to teething and disappears on full eruption. Most infection of the gum tissue around the erupting or partially erupted teeth can be prevented by good oral hygiene, including toothbrushing. Infection occurs in fewer than 10% of third molars, most of which can be cured with antibiotics, oral rinsing, or removal of excess tissue (the hyperculum) around the tooth, without requiring removal of the tooth itself. Most of the pain and illness attributed to third molars is caused by the surgery, not the teeth. Third-molar surgery is a multibillion-dollar industry that generates significant income for the dental profession, particularly oral and maxillofacial surgeons. It is driven by misinformation and myths that have been exposed before but that continue to be promulgated by the profession.