A Disturbing Question for all OMFS

[Expert]

To any and all OMFS, OMFS residents, dentists and dental students. This is an extremely important, highly relevant question and I would sincerely appreciate your honest answer. I want to ask you about the ethics of OMFS private practice. Specifically, the ethics of wisdom teeth removal. Wisdom teeth are normally removed in teenagers because there is not enough space for them to grow. So the OS remove them prophylaxis to prevent problems in the future. However, I have come across some VERY disturbing information regarding how most wisdom teeth are removed for no medically valid reason and they are mostly removed because the removal procedure is so profitable. This is further discussed in the following articles.

http://www.webmd.com/oral-health/news/20050505/wisdom-teeth-removal-often-unnecessary
http://www.thehealthyhomeeconomist.com/skip-that-surgery-most-wisdom-tooth-extractions-unnecessary/
http://news.yahoo.com/blogs/the-loo...e-against-wisdom-teeth-removal-105243007.html

They make a strong case that most 3rd molar extractions are painful and unnecessary, providing no useful benefit to the patient. What are your thoughts on this?? Do y'all feel that this is a huge ethical dilemna confronting OMFS. I will be the first to admit that this is extremely unpleasant to hear and read. I hope that there is an answer to this issue. Please share your expert opinion in this matter. It is of crucial importance - as the future of OMFS may be at stake here.

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[yappy]

I have not yet seen wisdom teeth extracted by an OS, or general dentist, that didn't need to be per some well established dental-health reason. Most of the time it was related to the third molar beginning to destroy the posterior side of the second molar.

BTW - the last link made my brain hurt lol... references to Weston Price Foundation & Mercola, refuting legit-peer-reviewed research because of perceived "bias", "holistic dentistry", reliance/overtrust in all that is "natural". These are the kind of people you hope you never have as patients.

 

[chill45]

Have you ever seen a 50, 60, or even 70 year old patient come into the clinic for 3rd molar extractions and the cysts that usually accompany them? I agree that I think a lot of times it is just a routine thing that we do and is usually a preventative measure but taking out a set of 3rds on a 17 year old can take 8-10 minutes (of actual surgery time) and up to 30+ minutes for someone in their 30's or older. A few days of hurting for a teenager vs a couple weeks for someone older. Usually have better insurance when younger and under parent's plan vs an older person who may have limited benefits. To me there is just a lot of reasons to go ahead and get them out when you're young and not have to worry about it when it becomes a problem. (ps I did not read the articles because I don't start school until August so no need to read more than I'm gonna have to anyways lol) I've easily seen over 100 3rd molar extraction cases and from what I've learned it's just better to get them out when you're young than deal with the complications that arise when you get older.

 

[Totori]

To any and all OMFS, OMFS residents, dentists and dental students. This is an extremely important, highly relevant question and I would sincerely appreciate your honest answer. I want to ask you about the ethics of OMFS private practice. Specifically, the ethics of wisdom teeth removal. Wisdom teeth are normally removed in teenagers because there is not enough space for them to grow. So the OS remove them prophylaxis to prevent problems in the future. However, I have come across some VERY disturbing information regarding how most wisdom teeth are removed for no medically valid reason and they are mostly removed because the removal procedure is so profitable. This is further discussed in the following articles.

http://www.webmd.com/oral-health/news/20050505/wisdom-teeth-removal-often-unnecessary
http://www.thehealthyhomeeconomist.com/skip-that-surgery-most-wisdom-tooth-extractions-unnecessary/
http://news.yahoo.com/blogs/the-loo...e-against-wisdom-teeth-removal-105243007.html

They make a strong case that most 3rd molar extractions are painful and unnecessary, providing no useful benefit to the patient. What are your thoughts on this?? Do y'all feel that this is a huge ethical dilemna confronting OMFS. I will be the first to admit that this is extremely unpleasant to hear and read. I hope that there is an answer to this issue. Please share your expert opinion in this matter. It is of crucial importance - as the future of OMFS may be at stake here.

Painful? Of course. It is 'Surgery' for god's sake!! Is there Any Surgery that is Not Painful?
Unnecessary? Well, I have not seen any wisdom teeth extractions that are not medically(dentally) indicated. I tell my patients not to remove wisdom teeth if they are not associated with present disease process or are not at risk of future disease process.

 

[Silent Cool]

Ireland abandoned prophylactic wisdom tooth extraction because they decided it was unnecessary. Likewise, the US abandoned prophylactic tonsillectomy many years ago. Re: cysts developing in older adults--about 12-15% of adults develop appendicitis, but we don't remove appendices prophylactically. My parents never had their wisdom teeth out and they have no problems. About 12-15% of people will develop serious problems with wisdom teeth, but the question is: should we be taking out all asymptomatic wisdom teeth, or wait until a problem develops (ie, appendicitis)?

 

[chill45]

Some good points by @Totori and @Silent Cool but I would still venture to say I would prefer my future children get theirs out in high school. 12-15% is still a pretty high number for what I consider a pretty routine surgery. When it becomes "non-routine" is when the patient is 40+ and the roots have wrapped themselves around a nerve or created a cyst that eats jaw bone away and starts creating problems with the 2nd molars. Is the risk of being permanently numb on one side of your jaw worth it just because you didn't get them out when you were younger? Again I have a lot to learn about all this but I've worked full time at a very productive oral surgery private practice for the past year and have had the opportunity to see some extreme cases. One (older) patient even drove all the way from Illinois to get his or her wisdom teeth out by one of our docs because the oral surgeon up there said he wouldn't touch them with the nerve associated with them.

Do the appendix and tonsils get exponentially more difficult to remove from an adult than an adolescent like 3rd molars do?

 

[osteotomy01]

I'm assuming that the OP read the white paper on third molar extractions

 

[Sublimazing]

Have you ever seen a 50, 60, or even 70 year old patient come into the clinic for 3rd molar extractions and the cysts that usually accompany them? I agree that I think a lot of times it is just a routine thing that we do and is usually a preventative measure but taking out a set of 3rds on a 17 year old can take 8-10 minutes (of actual surgery time) and up to 30+ minutes for someone in their 30's or older. A few days of hurting for a teenager vs a couple weeks for someone older. Usually have better insurance when younger and under parent's plan vs an older person who may have limited benefits. To me there is just a lot of reasons to go ahead and get them out when you're young and not have to worry about it when it becomes a problem. (ps I did not read the articles because I don't start school until August so no need to read more than I'm gonna have to anyways lol) I've easily seen over 100 3rd molar extraction cases and from what I've learned it's just better to get them out when you're young than deal with the complications that arise when you get older.

Agreed. Had to do this a handful of times. They come in at 60-70 with a bevy of health problems, can't afford the OS...and now they gotta sit there awake at a free clinic to get surgery....once or twice we had to take them to the OR for MACs bc they were sick and scared...when you get to be that age your risk/comorbidities just start to climb and climb.

Get them out when you're young and healthy and hard to kill.

 

[DaleDoback]

To any and all OMFS, OMFS residents, dentists and dental students. This is an extremely important, highly relevant question and I would sincerely appreciate your honest answer. I want to ask you about the ethics of OMFS private practice. Specifically, the ethics of wisdom teeth removal. Wisdom teeth are normally removed in teenagers because there is not enough space for them to grow. So the OS remove them prophylaxis to prevent problems in the future. However, I have come across some VERY disturbing information regarding how most wisdom teeth are removed for no medically valid reason and they are mostly removed because the removal procedure is so profitable. This is further discussed in the following articles.

http://www.webmd.com/oral-health/news/20050505/wisdom-teeth-removal-often-unnecessary
http://www.thehealthyhomeeconomist.com/skip-that-surgery-most-wisdom-tooth-extractions-unnecessary/
http://news.yahoo.com/blogs/the-loo...e-against-wisdom-teeth-removal-105243007.html

They make a strong case that most 3rd molar extractions are painful and unnecessary, providing no useful benefit to the patient. What are your thoughts on this?? Do y'all feel that this is a huge ethical dilemna confronting OMFS. I will be the first to admit that this is extremely unpleasant to hear and read. I hope that there is an answer to this issue. Please share your expert opinion in this matter. It is of crucial importance - as the future of OMFS may be at stake here.

Troll. Google aaoms white paper.

Friedman has been around for years. Trust me, the future of OMFS is not at stake by you posting links to blogs.

 

[chill45]

@Sublimazing We had a gentlement in his 50's come in with cysts around 17 and 32 that had destroyed so much mandibular bone that our doctor told us to be prepared to take him to the hospital in case his jaw broke. Definitely one of the craziest x-rays I've ever seen. Probably about 4-5 mm of bone left below the cyst, which isn't much considering how much pressure we exert on our jaws.

 

[Pleonasm]

Some good points by @Totori and @Silent Cool but I would still venture to say I would prefer my future children get theirs out in high school. 12-15% is still a pretty high number for what I consider a pretty routine surgery. When it becomes "non-routine" is when the patient is 40+ and the roots have wrapped themselves around a nerve or created a cyst that eats jaw bone away and starts creating problems with the 2nd molars. Is the risk of being permanently numb on one side of your jaw worth it just because you didn't get them out when you were younger? Again I have a lot to learn about all this but I've worked full time at a very productive oral surgery private practice for the past year and have had the opportunity to see some extreme cases. One (older) patient even drove all the way from Illinois to get his or her wisdom teeth out by one of our docs because the oral surgeon up there said he wouldn't touch them with the nerve associated with them.

Do the appendix and tonsils get exponentially more difficult to remove from an adult than an adolescent like 3rd molars do?

There are 2 types of risks associated with surgery. The risk posed by the type of of surgery ranging from high risk to minimal (ie major vessel surgery-aortic repair as compared to superficial lipoma excision). Then there's risk posed by the physical status of the patient(ASA l patient with no major health issues as compared with an ASA lV patient who has coronary artery disease w/ recent MI w/ severe COPD and pulmonary HTN and is winded after walking 10 feet). The assumption is that the older someone gets, the more likely they are to suffer from chronic illnesses that increase the risk of doing the surgery in the first place.

 

[chill45]

There are 2 types of risks associated with surgery. The risk posed by the type of of surgery ranging from high risk to minimal (ie major vessel surgery-aortic repair as compared to superficial lipoma excision). Then there's risk posed by the physical status of the patient(ASA l patient with no major health issues as compared with an ASA lV patient who has coronary artery disease w/ recent MI w/ severe COPD and pulmonary HTN and is winded after walking 10 feet). The assumption is that the older someone gets, the more likely they are to suffer from chronic illnesses that increase the risk of doing the surgery in the first place.

Interesting to know. I guess I was assuming that the physical status of a patient was noncontributory when comparing fully impacted 3rd molars to tonsils on a 50 year old patient, but if a patient is an ASA IV then are the risks exponentially increased for the more difficult 3rd molar extractions compared to the tonsils? I've never seen tonsils removed so I don't know how difficult it is or the risks posed. If you did not take the physical status into account it is still well known that 3rds are more difficult to remove the older the patient gets, so I am curious if this is the same for tonsils or an appendix?

 

[IHO]

the comparison of 3rds to prophylactic appendectomy is flawed. Appy would be much more invasive since it involves opening the abdomen. Incidentally, if a general surgeon or ob/gyn or urologist is in the abdomen for a different procedure, they very well might also snip the appendix "prophylactically".

As with any surgery, the decision to operate or not is based on risk assessment...there are benefits and risks to doing a surgery and there are benefits and risks to not doing a surgery.

In addition to all benefits/risks mentioned in earlier comments, there is also the added financial burden/radiation risk of having to obtain screening panorex every 2-3 years if you elect NOT to remove 3rds and instead "follow them".

for me and mine, the 3rds go in early years unless there is a compelling reason not to do so.

 

[Silent Cool]

Just for some light-heartedness.....

Lady GaGa-Gat her wizzies out....

http://www.dailymail.co.uk/tvshowbi...ing-wisdom-teeth-yanked-ahead-major-tour.html

 

[DDSMD2018]

To any and all OMFS, OMFS residents, dentists and dental students. This is an extremely important, highly relevant question and I would sincerely appreciate your honest answer. I want to ask you about the ethics of OMFS private practice. Specifically, the ethics of wisdom teeth removal. Wisdom teeth are normally removed in teenagers because there is not enough space for them to grow. So the OS remove them prophylaxis to prevent problems in the future. However, I have come across some VERY disturbing information regarding how most wisdom teeth are removed for no medically valid reason and they are mostly removed because the removal procedure is so profitable. This is further discussed in the following articles.

http://www.webmd.com/oral-health/news/20050505/wisdom-teeth-removal-often-unnecessary
http://www.thehealthyhomeeconomist.com/skip-that-surgery-most-wisdom-tooth-extractions-unnecessary/
http://news.yahoo.com/blogs/the-loo...e-against-wisdom-teeth-removal-105243007.html

They make a strong case that most 3rd molar extractions are painful and unnecessary, providing no useful benefit to the patient. What are your thoughts on this?? Do y'all feel that this is a huge ethical dilemna confronting OMFS. I will be the first to admit that this is extremely unpleasant to hear and read. I hope that there is an answer to this issue. Please share your expert opinion in this matter. It is of crucial importance - as the future of OMFS may be at stake here.

This has been a debate for over 50 years. You'll find just as much research FOR and AGAINST prophylactic removal of 3rd molars. I would like to think as dentists and doctors we are doing the right thing by extracting impacted 3rd molars and I have seen several cases where patients had bad outcomes later in life by leaving in impacted 3rd molars. I will say, it is very case dependent. I have seen people with completely erupted 3rd molars that are in occlusion and functioning. For them, it would be ridiculous to extract their 3rd molars. If the 3rd molars are completely impacted in the bone and have NO chance of ever reaching the oral cavity whatsoever, then you MAY make an argument to leave those as well. If they are impacted and DO disrupt the gingiva or created a perio pocket behind the 2nd molar, then they should be extracted. Those will cause problems later in life. However, with the way health care is going, our professional opinions are counting less and less. The INSURANCE companies will soon be the ones to determine if 3rd molars need to come out. I think this is wrong, but it's the way healthcare is going in general for everything. So, what you're asking is to predict the future. If you can do that, then you should go to Vegas and gamble. You will make more money than anyone else in this world. But the real question is, will insurance every stop paying for extracting 3rd molars? I hope not. There are several cases that there are clear indications for extractions. All that we can do as professionals is argue our professional opinions and do the right thing. I know this doesn't answer your question, but what I stated is the truth. In my personal opinion if you want it, I think extraction of 3rd molars is completely dependent case by case. I use my own professional training and common sense on whether or not a 3rd molar is indicated for extraction or not.

 

[vellnueve]

All I know is that I had to deal with some British military - in the UK they do not extract unless symptomatic - and as a result several of their guys were deployed and not mission-ready because I had to do emergency surgeries on them.

 

[AU07DMD]

Seriously this is a troll thread. OP needs to read White paper and stay off blogger websites.