LONG-TERM OUTCOME OF RETAINED THIRD MOLARS IS UNKNOWN

Lee D. Pollan, DMD and M. Anthony Pogrel, DDS, MD

In his essay, Friedman asserted that there is compelling evidence that prophylactic extraction of third molars is a significant public health hazard. This is a very strong statement, based on an apparently limited review of the literature. Many of Friedman’s references could be considered selective and do not necessarily reflect current thinking.

A white paper recently commissioned by the American Association of Oral and Maxillofacial Surgeons provided a comprehensive review of the scientific literature on third molars. The literature provided no reliable evidence for predicting which third molars will cause problems in the future (including infections, caries, damage to the second molars, and periodontal disease) and which will not.

The dilemma for the oral and maxillofacial surgeon is the inability to predict future morbidity with retention of asymptomatic third molars. Recent literature on the microflora around unerupted third molars has shown a predominance of organisms implicated in periodontal disease, suggesting that periodontal disease may originate around the third molars and spread forward.

Friedman cited the policy of the United Kingdom’s National Institute for Clinical Excellence (NICE)and suggested that such policy may be appropriate for US government-funded health services. However, we note that the assessment report on which the guidance is based concluded that trials comparing prophylactic removal with management of deliberate retention are needed. It was also noted that the outcomes of third molar removal are mainly short-term events, whereas the outcomes associated with retention occur later in life and can only be fully measured with long-term follow-up.

We submit that the implementation of the NICE guidance may serve as a population-based experiment to evaluate the long-term outcome of retention of asymptomatic third molars. While we await the results of this experiment, in the United States, the establishment of a similar policy is unjustified and could potentially increase oral health morbidity, and possibly systemic morbidity.

FRIEDMAN RESPONDS

Jay W. Friedman, DDS, MPH

Jay W. Friedman is a retired general dentist and a consultant and writer living in Los Angeles, Calif.

The "current thinking" Pollan and Pogrel refer to is almost exclusively that of the American Association of Oral and Maxillofacial Surgeons (AAOMS), reflecting studies sponsored by AAOMS and published almost exclusively in its own journal. It is particularly noteworthy that periodontists, specialists in the treatment of gum disease, have not singled out third molars for extraction.

The unpredictability of morbidity stressed by Pollan and Pogrel is not limited to wisdom teeth. It applies to the appendix, gall bladder, tonsils, uterus, prostate, and female breasts. No responsible person would suggest removing these structures in adolescence, or at any age, to prevent future disease in a small percentage of the population, as AAOMS recommends for third molars. Their conjectural suggestion that "periodontal disease may originate around third molars and spread forward" will come as a surprise to those who develop periodontal disease after removal of their third molars.

Dodson refers to a study in which 25% of participants had periodontal pathology around third molars, consisting of 1 or more pockets with depths of 5 mm or greater. Is that reason to extract all third molars? By logical extension, all teeth with 5 mm or greater pockets should be extracted, and we wouldn’t need periodontists or dental hygienists, whose specialty is to treat and save those teeth in the event of disease.

I wrote that "early removal of third molars is actually more traumatic than leaving asymptomatic, nonpathologic teeth in situ." The total trauma to millions of young people having unnecessary extractions far exceeds any possible increase in trauma suffered by the few older people requiring third molar extraction for a real disease condition.

According to Dodson, few oral and maxillofacial surgeons would agree that "there is little risk of harm in the removal of third molars," and they do not consider it "a trivial operation to be undertaken lightly." If, then, it is a serious operation, why did AAOMS place a 4-page advertising supplement in USA Today urging the extraction of wisdom teeth with no mention of risk of potential injury or negative outcome? Is that truth in advertising?

Dodson writes that, following third molar extraction, " . . . periodontal health of . . . adjacent teeth remained stable or improved 90% of the time." However, his own journal article states, "Given healthy periodontal status preoperatively, 48% [of adjacent second molars] had worsening of their periodontal measures."

Dodson recommends lifetime monitoring by an oral surgeon of everyone with retained third molars. It would be much safer to have an examination every 12 to 18 months by a general dentist who is less likely to subject patients to unnecessary extractions and the corollary risk of iatrogenic injury.

This article is courtesy of The American Journal of Public Health

Original Article

Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J. Public Health 2007;97:1554-1559.

L. D. Pollan and M. A. Pogrel. LONG-TERM OUTCOME OF RETAINED THIRD MOLARS IS UNKNOWN Am J Public Health, April 1, 2008; 98(4): 580 - 581.

J. W. Friedman FRIEDMAN RESPONDS Am J Public Health, April 1, 2008; 98(4): 582 - 582.