The hazards of wisdom tooth extraction: From patient to plaintiff

Is it really necessary to pull out those wisdom teeth? A little sage advice from someone who knows

2008 August

Ten million “impacted” wisdom teeth are extracted each year from 3.8 million people, 94 percent by oral and maxillofacial surgeons. Studies indicate that one-third of a percent (0.33 percent) to one percent of the patients (12,500 to 38,000) suffer permanent injury, mostly damage to the mandibular or lower jaw nerve, resulting in varying degrees of numbness (paresthesia) of the lip and chin, distortion of speech and smiling, cheek biting, difficulty chewing, and, in some cases, severe shooting neuralgic pain. Tens of thousands of people may also suffer lingual (tongue) nerve and TMJ or temporomandibular (jaw) joint injury.

Most of the third molar extractions are not impacted teeth. They will grow into normal position if left alone. The oral surgeons contend that early extraction, before the teeth are erupted and fully formed, reduces the pain of surgery and the risk of injury. This contention is not “evidence-based.” On average, patients suffer over two days of pain and disability, loss of school and work, following uncomplicated extraction of wisdom teeth, at least two-thirds of which is unnecessary.

If all third molar extractions were necessary, no one would fault the oral surgeons. However, at most only one-third of these teeth cause chronic pain, infection, as apart from natural teething discomfort during eruption, cysts, or damage to adjacent teeth and, therefore, should be removed. But the idea that all wisdom teeth should be removed in the absence of any recognizable pathology, whether or not impacted, or while they are still in the developmental stage, is a myth perpetrated by oral surgeons in private practice, which, coincidentally, provides as much as three-fourths of their income, averaging nearly three-quarters of $1 million gross income for the 6,000 oral surgeons in the United States. They also promote unnecessary general anesthesia, which has its own inherent risks of injury and death, even though most extractions can be done easily and more safely with a local anesthetic injection.

The American Association of Oral and Maxillofacial Surgeons argues that periodontal (gum) disease may originate with wisdom teeth, possibly leading to heart disease and other maladies; they should be removed at an early age. If that was a valid argument, all teeth with periodontal disease would be removed and there would be no need for periodontists and dental hygienists who treat and retain these teeth. The oral surgeons contend that because one cannot tell which wisdom teeth will become pathological, all wisdom teeth should be extracted. But the same unpredictability applies to the tonsils, the appendix, the gall bladder, the uterus, and female breasts. Yet, no responsible person suggests removing these structures because a small percentage of them might become diseased in the future. Surgery to prevent future pathology is irresponsible and tantamount to malpractice, particularly when removal of nonpathological, asymptomatic structures, in this case, third molars, results in iatrogenic injury.

It is likely that most patients, or their surrogate parents, sign a consent form that does not provide sufficient information, even if they read it, to make a truly informed decision. They are not told that evidence-based practice – the gold standard of ethical medical/dental practice – does not support prophylactic removal of nonpathologic, asymptomatic wisdom teeth, whether unerupted, erupted, partially or fully impacted. They are told that because one tooth is causing a problem, the other third molars need to be removed to prevent future problems, even though the risk of injury from the surgery is as great, or greater, than the risk of pathological developments. They are told that failure to extract the wisdom teeth might lead to gum and jaw disease, as well as crooked front teeth. In other words, prospective patients are fed false or misleading information to coerce them into extraction of all their wisdom teeth. When the consequence of misinformed consent results in permanent injury to sensory nerves that diminishes the quality of life, the injured patient may well become a plaintiff.

(Adapted by the author from: Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J Public Health 2007; 97:1554-1559)