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Having wisdom teeth pulled has long been a rite of passage for many teens and young adults.
For decades, dentists routinely warned teens and their parents that pesky wisdom teeth below the surface of the gums could not only harm other teeth, but they could also lead to infections, cysts and tooth decay.
Unsurprisingly, many opted to extract those un-erupted teeth to avoid problems down the line.
But, more are now questioning having their wisdom teeth removed when there’s nothing wrong with them. A recent article in Fusion challenged the policy of removing millions of apparently healthy teeth annually.
It's uncertain exactly how many wisdom teeth are removed each year in the U.S., but there are widely cited estimates (without clear attribution) of nine million extractions, at a cost of approximately $3 billion.
Oral surgeons once justified the extraction of third molars — the technical name for wisdom teeth —to avoid damaging the teeth in front of them. Allowing them to erupt could affect the alignment and even the integrity of other teeth, they said.
But orthodontists now know that lower teeth have a tendency to crowd together regardless of whether or not wisdom teeth have been removed, said Dr. Greg Huang, a professor and chair of the department of orthodontics at the University of Washington. "There's no good evidence that having third molars removed either helps or hurts the crowding situation," says Huang.
Huang said he does recommend wisdom tooth removal if it looks like there won't be enough room for them.
In 2016 guidelines from the American Association of Oral and Maxillofacial Surgeons (AAOMS) members are advised:
"Given that we cannot confidently predict what the future holds for all patients with asymptomatic, disease-free teeth, we must rely on the clinician’s experience and expertise in recognizing the likelihood that pathology will develop and his or her ability to communicate this in realistic terms to the patient."
The patient pamphlet the organization offers on its website is more ominous, noting that pain-free doesn't mean "disease or problem free," even if wisdom teeth come in normally. Only teeth that are "completely erupted and functional, painless, cavity-free, in a hygenic environment with healthy gum tissue, and are disease-free may not require extraction."
Not a disease
Dentist and public health expert Dr. Jay Friedman started the argument against the procedure four decades ago in an article published in the Journal of the California Dental Association:
“The third molar is not a disease. It is not even a vestigial appendage like the appendix without function," Friedman wrote. "Ironically named the ‘wisdom tooth,’ the third molar is blamed for a variety of ills with a degree of vehemence that reflects more on the wisdom of dentists and especially on the self-serving interests of the specialty of oral surgeons, which derives a major portion of its income from their sacrifice.”
In the following decades, more experts have joined Friedman's side.
Lack of evidence
The prestigious Cochrane Review took on the topic in 2012 and, after scrutinizing available studies, found no evidence to support the practice of removing third molars as a preventative, reporting that a “general agreement exists that removal of wisdom teeth is appropriate if symptoms of pain or pathological conditions related to the wisdom teeth are present.”
Without evidence proving wisdom teeth could damage other teeth or the mouth's alignment, the AAOMS changed its justification for routine removal during the teen years.
Dr. Louis K. Rafetto, president of AAOMS, told TODAY that there are studies showing retained third molars lead to an increased risk of periodontal disease. One of those studies found that the risk of developing gum disease in the neighboring second molar rose by a factor of 1.5, or 50 percent, if the third molar had not been removed.
But that risk must be weighed against the possible risks of the surgery, Friedman said.
Risks of removal
A 2014 study co-authored by Huang found that, among those who had wisdom teeth removed, the rate of paresthesia —numbness and tingling —in the lips and/or tongue was nine times greater than in people who did not have the surgery. The rate of temporomandibular disorder — jaw pain upon wide opening and pain in the temples, jaw joint or jaw muscles —was nearly four times greater.
There is also a very rare risk of death, which is generally tied to general anesthesia.
Rafetto suggests patients talk to an oral surgeon.
“It’s really important to have informed consent on the current situation, as well as the consequences of not removing them," said Rafetto. “There are people who have third molars who can maintain them.”
Wait and see
Wisdom teeth are easier to remove when the patient is younger because the roots aren't completely formed, according to the AAOMS.
And there was the issue of teens being removed from their parents' insurance policies at age 18. But with the passage of the Affordable Care Act, insurance companies are required to offer coverage up to age 26.
“Now parents aren’t under the gun so much to take out the wisdom teeth at 18, " says Huang. "So you can wait and see how they develop. Most of the time, if they’re going to erupt, they’ll do so by the time you’re in your mid-20s.”