Omfs questions/skepticism

[Mocizzle]

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Hi guys I am a dental student right now and wanted to pursue omfs, what's bothering me is as I conduct more and more research Im noticing a lot of third molar extractions are plain unneseccary at best. From my understanding omfs private practice is predicated on chucking thirds, I have no problem with that in fact thats why I liked omfs, extractions are fun! but i only want to do them when the patient *needs* it. Abscesses, pain, irritation, infection, etc and not just because they turned 16.

Is this going to limit my production potential? Are there other omfs who feel the same way? I obviously like the more complex surgeries but this is like the bread and butter and i'm just curious if this is possible? the idea of only pulling molars of ppl who actually need it (in private practice)? Or am I just going to be forced to be stuck in the hospital doing the big procedures

 

[pookatooth]

https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/management_third_molar_white_paper.pdf

 

[doktorinprogres]

The Prophylactic Extraction of Third Molars: A Public Health Hazard - PMC

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 ...

www.ncbi.nlm.nih.gov

The risk for associated pathology seems exceedingly low to me as well. I've struggled with this exact issue too

 

[Mocizzle]

The Prophylactic Extraction of Third Molars: A Public Health Hazard - PMC

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 ...

www.ncbi.nlm.nih.gov

The risk for associated pathology seems exceedingly low to me as well. I've struggled with this exact issue too

It seems that our concerns are picking up popularity with the public no?

 

[setdoc7]

Liking extractions is not a reason to go into OMFS. It is an extremely time consuming program which is much more than dento alveolar surgery. Not worth it just to "chuck thirds" as you put it.

 

[lemoncurry]

I feel like some days I do more extractions than our local OMFS. I'm pretty darn good at them although I leave the really impacted ones for them. People often ask why I don't go into oral surgery and it's precisely because of the extra time, money, schooling and all that just so I can learn how to do something that I already know how to do well, plus a few other things that I won't do quite as often.

I say that if you really like extractions but can do without the other stuff, go into public health/FQHC or Indian Health.

 

[Racquetball3r]

I feel like some days I do more extractions than our local OMFS. I'm pretty darn good at them although I leave the really impacted ones for them. People often ask why I don't go into oral surgery and it's precisely because of the extra time, money, schooling and all that just so I can learn how to do something that I already know how to do well, plus a few other things that I won't do quite as often.

I say that if you really like extractions but can do without the other stuff, go into public health/FQHC or Indian Health.

“A few other things”, ie the full gamut of facial surgery ranging from pediatric craniofacial to head and neck oncology and everything in between

 

[lemoncurry]

“A few other things”, ie the full gamut of facial surgery ranging from pediatric craniofacial to head and neck oncology and everything in between

Of course. I didn't mean to imply that you don't learn a whole ton of stuff, I just don't anticipate using the vast majority of it on a regular basis in private practice.

 

[setdoc7]

TMJ surgery, pathology, anesthesiology, orthognathics, trauma surgery, salivary gland surgery,......just to name a few things other than third molars. It's a lot of training. I see it every day. Count in Med School for the 6 year programs, and it is a lot to just extract some teeth. You better like the rest of it if you go in to OMFS.

 

[2TH MVR]

Hasn't been mentioned, but OMFS expose and attach button/chains to impacted cuspids for ortho traction. Pretty critical that the attachment is placed on the labial aspect of the cuspid. TAD placement.

 

[BlackThought]

Just saw that this was posted here as well. I'm copy/pasting my reply from the resident forum from May 8th here, just in case people missed it


Some stuff to look at:

White Paper on Third Molar Data

AAMOS Clinical Paper

AAMOS Position Statement
"Predicated on the best evidence-based data, third molar teeth that are associated with disease, or are at high risk of developing disease, should be surgically managed. In the absence of disease or significant risk of disease, active clinical and radiographic surveillance is indicated."

Evaluation and management of asymptomatic third molars: Lack of symptoms does not equate to lack of pathology (White & Proffit, 2011)
"It is appropriate to tell adolescents and young adults that, based on recent data, at least 70 of 100 young adults with third molars that are “symptom free” already have pathology or will experience pathology with time. Conversely then, 30 or possibly fewer of 100 young adults will not experience pathology with retained asymptomatic third molars. No current data can be more specific about the odds for any patient. In this circumstance, patients must decide about management of their third molars, with either removal or retention with periodic monitoring. No decision is a decision to retain third molars and accept the risks associated with that decision."

...what's bothering me is as I conduct more and more research Im noticing a lot of third molar extractions are plain unneseccary at best.

Do better research. See above. Do an externship.

...thats why I liked omfs, extractions are fun!

If extractions are what interest you the most about OMFS you will have a bad time in residency. Do an externship.

...but i only want to do them when the patient *needs* it. Abscesses, pain, irritation, infection, etc

Don't be a hero. Do an externship.

...am I just going to be forced to be stuck in the hospital doing the big procedures

If this is your mindset you will have a bad time in residency. Do an externship.

Is this going to limit my production potential?

Don't understand the question.

It seems that our concerns are picking up popularity with the public no?

No. Its your job to inform the public. What is popular with "the public" should be a non-factor when it comes to making clinical decisions.
Being a dental student and future professional, you best get out of the habit of being a pigeon.


Bottom line: Do an externship. Ask questions. Don't be misinformed. Be a good person. Adopt a cat.

 

[Charcot-Marie-Tooth]

I dig the @BlackThought no-nonsense approach

 

[GoDental101]

For some reason the group of people who think that 3rd molar extractions are unnecessary remind me of the same group of people that think vaccines are bad. I think you just need to do better resource. Don’t forget the importance of having credible sources.

 

[setdoc7]

Although I am familiar with the AAOMS position and the White paper, I prefer to cite NIH/NIDR findings which have no unintentional bias attached to it. No offense to the OMFS crew out in SDN land, but a paper expounding on the positive factors of third molar extraction by the people that do them seems self serving. Just my opinion. Not fact. And for the record, I believe the AAOMS paper is correct.

 

[2TH MVR]

To offer some anecdotal, non-evidence based opinion from years as an orthodontist. 😉 Here is my take.

1. I usually evaluate 3rd molars at age 16,17. If there is no obvious room in the mandible for the 3rds .... I prefer to have them out. From an evolutionary stand point .... our mandibles have become smaller. The foods we eat are processed and less abrasive. Studies of early man and women have shown that malocclusions rarely existed due to their abrasive diet. Fast forward today. In-And-Burgers. McDonalds. Taco Bell. Etc. Etc. Etc. Less abrasive foods. Smaller mandibles. Not alot of room for the 3rds.

2. If I treat a malocclusion with extractions. I LIKE TO KEEP the 3rds if they are not impacted. Upper bis extracted? Keep the upper 3rds and exo the lower 3rds. All four bis extracted .... keep all the 3rds. No real need to have them extracted. It always burns my a** when some dentists are in such a hurry to extract the 3rds. If the patient is under my care .... I like to complete the ortho ... then decide on the 3rds.

3. I've witnessed 3rd molars completely disrupt the positions of the 2nd molars. If so ..... prefer to have the 3rds extracted.

4. Hyperdivergent growth pattern ..... best to get the 3rds out at the appropriate time.

5. Missing 2nd molars ..... keep the 3rds.

6. Impacting 2nd molars .... get the 3rds out.

7. Orthognathic case. Get the 3rds out.

So many situations requiring where the patient is from a growth and occlusion standpoint.

If I'm on the fence on whether to have the 3rds extracted or not. I will have them removed age 16,17.

 

[Mocizzle]

To offer some anecdotal, non-evidence based opinion from years as an orthodontist. 😉 Here is my take.

1. I usually evaluate 3rd molars at age 16,17. If there is no obvious room in the mandible for the 3rds .... I prefer to have them out. From an evolutionary stand point .... our mandibles have become smaller. The foods we eat are processed and less abrasive. Studies of early man and women have shown that malocclusions rarely existed due to their abrasive diet. Fast forward today. In-And-Burgers. McDonalds. Taco Bell. Etc. Etc. Etc. Less abrasive foods. Smaller mandibles. Not alot of room for the 3rds.

2. If I treat a malocclusion with extractions. I LIKE TO KEEP the 3rds if they are not impacted. Upper bis extracted? Keep the upper 3rds and exo the lower 3rds. All four bis extracted .... keep all the 3rds. No real need to have them extracted. It always burns my a** when some dentists are in such a hurry to extract the 3rds. If the patient is under my care .... I like to complete the ortho ... then decide on the 3rds.

3. I've witnessed 3rd molars completely disrupt the positions of the 2nd molars. If so ..... prefer to have the 3rds extracted.

4. Hyperdivergent growth pattern ..... best to get the 3rds out at the appropriate time.

5. Missing 2nd molars ..... keep the 3rds.

6. Impacting 2nd molars .... get the 3rds out.

7. Orthognathic case. Get the 3rds out.

So many situations requiring where the patient is from a growth and occlusion standpoint.

If I'm on the fence on whether to have the 3rds extracted or not. I will have them removed age 16,17.

thanks this was really helpful, so do you feel Its definitely possible to be an oral surgeon who does 3rd molar extractions only when theyre neccessary, its just these corporate chains have me worried seems theyll pull anything for a quick buck and just dont want to have a guilty conscious

 

[2TH MVR]

thanks this was really helpful, so do you feel Its definitely possible to be an oral surgeon who does 3rd molar extractions only when theyre neccessary, its just these corporate chains have me worried seems theyll pull anything for a quick buck and just dont want to have a guilty conscious

It's tricky in Corp. Technically GPs diagnose and tx plan the patients. Specialists are called in to carry out the GPs tx plan. I will make my case on the 3rds, but ultimately .... I defer to the GP. Once you develop a working relationship with the GPs and they understand your wisdom teeth extraction rationale....then the tx plans can be agreeable by both GP and Specialist.

 

[Mocizzle]

It's tricky in Corp. Technically GPs diagnose and tx plan the patients. Specialists are called in to carry out the GPs tx plan. I will make my case on the 3rds, but ultimately .... I defer to the GP. Once you develop a working relationship with the GPs and they understand your wisdom teeth extraction rationale....then the tx plans can be agreeable by both GP and Specialist.

Seems the solution i am looking for is found in working for like minded individuals or starting your own practice, thanks for the clarification