Driver’s license, dancing, ridding the body of tooth residue. All rites for American teenagers.
So things went well when, after a routine visit to the dentist during my oldest child’s high school years, he left the office clutching a referral note to an oral surgeon.
According to the dentist, my son’s two lower wisdom teeth were partially knocked out. They came in vertically, as teeth should, but had stopped on their upward journey through the gums. They would remain stuck there forever, posing a risk of future infection. The two upper wisdom teeth had grown in normally, but they would have had nothing to bite on if the lower teeth were gone. If we were going for the removal of the two lower wisdom teeth, all four would have to be removed.
I trust our family dentist. He is thorough, listens well and is conservative in his treatment recommendations. A guy who waits carefully. In this case, his take on the potential surgery was, “It’s a little bit borderline, but, yeah, I’d say it’s worth doing.”
However, the word “borderline” left a little room for doubt, so I wanted to think about it. Even minor surgery has risks and the fact that wisdom tooth extraction seems to be the default made me want to push back a bit.
I am well aware that the fee-for-service health care system tends to provide many medical procedures, including surgeries, that later turn out to be unnecessary. For part of the 20u century, tonsillectomy it was the most executed operation in the countrywith tonsils once seen as “portals of infection.” Now, how many kids do you know who have had their tonsils removed? It turned out that it wasn’t as helpful for most children as doctors thought, and it may even bring long term risks.
There are other examples. Spinal surgery was once a good treatment for persistent low back pain. But these operations made things worse as often as they made them better, and even led to a brand new diagnosis.failed back surgery syndrome”, with millions experiencing prolonged suffering. Surgery is now rarely recommended for chronic lower back pain. Heart stents were thought to be useful for clearing arteries, until a rigorous study showed this in many cases it is not.
At some point before each of these procedures was performed, a doctor looked a patient or family member in the eye and said that surgery was the best way to do it, or at least a reasonable option.
These doctors believed they were doing the right thing. Standards of care evolve as new evidence supports—or fails to support—the use of a particular treatment. However, this system does not work perfectly. Sometimes things are done a certain way simply because they are done that way, regardless of the state of the evidence. In fact, because we’re all creatures of habit, it often is harder to stop old health care practices rather than implementing new ones.
I called the number on my son’s referral card and made an appointment to see the oral surgeon in a few weeks. The receptionist also suggested I go ahead and book a surgery date a few days after the consultation, which I did. In the meantime, I decided to take a look at the medical literature to see what kind of evidence there was for wisdom teeth removal for preventative purposes.
I went to the precious ones first Cochrane Collaboration, an open access hub for systematic reviews of healthcare treatments. Systematic reviews are collections of findings from studies of a particular treatment, taking into account the quality of each study (for example, results from randomized trials are given more weight than studies without a control group). But the review on the impact of wisdom tooth removal, published in May 2020, was based on two previous studies. He concluded that “the available evidence is insufficient to tell us whether or not affected wisdom teeth without symptoms of asymptomatic disease should be removed”—the scientific equivalent of the Magic 8-Ball’s “Cannot predict now.”
I then typed “NHS wisdom teeth” into the search bar. The UK NHS lacks the profit motive of the US system, and so tends to provide less unnecessary care (although what is ‘necessary’ and ‘unnecessary’ is often far from clear). I learned that the NHS does not generally recommend wisdom teeth removal unless a patient is experiencing symptoms such as severe pain. The NHS policy was combined with an (admittedly old) 2008 statement issued by the American Public Health Association against wisdom tooth removal for preventive purposes.
Clearly, wisdom teeth have never been a hot research topic. But research could be done right now, so my last stop was the public access databases NIH Reporter and clinicaltrials.gov for review for ongoing studies. While I found records of studies comparing approaches to pain relief after wisdom tooth extraction and others comparing surgical techniques, there were no ongoing research programs that would inform if and when surgery should be performed.
Back to my son’s teeth. The oral surgeon’s recommendation was to remove all four teeth, under general anesthesia. We were given information about the risks of surgery: swelling and pain, infection. Rarely, it can lead to more permanent damage. And of course general anesthesia always carries a small risk of death. (Not mentioned at all was the not insignificant risk of addiction to opioid painkillers after wisdom tooth extraction in adolescents and young adults.) Overall, however, the potential for serious harm from this surgery appeared to be small. If I felt sure it was necessary to avoid future suffering and trouble for my son, I wouldn’t think twice. But was it?
After weighing the scant information we had and going back and forth a few times, we made the kind of decision we can best make when neither option is appealing: We decided to decide later. He could have the surgery over the summer when, if something went wrong, at least there wouldn’t be school to worry about. Soon, my son would be an adult and would be able to decide for himself whether or not to have the surgery (until now, he wasn’t sure either). And of course, if he developed symptoms or signs of disease around his wisdom teeth, then the case for surgery would be clearer.
For the record, no one ever forced us to do it. Not our dentist. Not the oral surgeon or his receptionist who was kind and understanding when we canceled the surgery. But our experience left me wanting more data. Should we be pulling wisdom teeth without symptoms as often as we do in this country? Based on my own look at the evidence, maybe not. But how do you know if your child is one of the people who will benefit from this procedure? Wisdom teeth are removed from thousands of healthy young mouths in this country every day. This procedure is not without risk and, for families without dental insurance, it is costly. Seems like we should know a little more about it than we do I am doing.
