Wisdom teeth: are we removing them more often than needed?

They say the evidence suggests it’s best to leave them in unless they are causing problems.

But others argue such calls are driven by economic considerations rather than what’s best for the patient.

Researchers writing recently in the British Dental Journal argue dentists shouldn’t remove impacted wisdom teeth that are not giving any symptoms.

They say this approach, taken in the UK, is based on the best available evidence and saves money by leaving alone wisdom teeth that were never going to cause a problem in the first place.

“The core message is using evidence to drive healthcare reform,” says Professor Marc Tennant of the University of Western Australia, who worked for 20 years in public health dentistry.

“In Britain when they started to apply some evidence-based criteria, the number of teeth they needed to remove dropped, and has remained relatively low over the past 10 years or so.”

Wisdom teeth are the last of our teeth to emerge — starting to appear by age 17.

In a large proportion of cases the teeth become impacted, remaining hidden under the gums or pushing into other teeth.

Dentists often remove impacted wisdom teeth to avoid the risk of problems such as pain, gum inflammation and decay.

But Tennant points to guidelines from the UK National Institute for Health and Care Excellence (NICE) that say only patients who have diseased wisdom teeth or other problems should have their wisdom teeth removed.

The UK guidelines say there is no evidence that taking out asymptomatic teeth as a precaution benefits patients. Instead, they advise dentists keep a close eye on the teeth to see if they develop problems.

Indeed, the NICE guidelines point out, surgery itself can lead to complications such as nerve damage, damage to other teeth, infection, swelling, bleeding, pain or affect a patient’s ability to open their mouth fully.
Rates of removal

Tennant and colleagues, including graduate student Abed Anjrini, previously found 527 per 100,000 Australians were admitted to hospital for impacted wisdom teeth removal in 2008/09 — a rate seven times higher than in the UK and continuing to increase.

In the new paper, the team calculate the savings that would result if Australia took a similar approach to the UK.

However they included an even more stringent monitoring regime than that recommended by the NICE guidelines, including dental x-rays every two years.

The researchers say a ‘watchful monitoring strategy’ would save Australians between $420-513 million a year, including indirect costs (for example time off work).

Most of the costs involved in wisdom tooth removal in Australia are borne by individuals, usually drawing on their private health insurance.
Economic driver

But Dr Rick Olive, president of the Australian Dental Association, argues the approach taken by the UK, and recommended by Tennant and colleagues, is just a cost-saving exercise.

“This is the argument that is used by those who seek to ration healthcare,” says Olive, who is currently involved in researching the impact of wisdom tooth removal himself.

He says there is not enough research to back evidence-based guidelines for impacted wisdom teeth removal, so it should be up to patients, advised by their dentists, to decide whether they want to take the risk of keeping their impacted wisdom teeth.

An important thing to consider, says Olive, is that the older you are when you have your wisdom teeth out the more likely you will suffer complications from the surgery, which affects 5 to 21 per cent of people.

Watchful monitoring also means you will also receive extra radiation from dental x-rays in the meantime, he says.

Olive believes the UK approach just defers problems arising from wisdom teeth and will result in an increasing rate of surgical complications.

Although, he adds, we won’t know if this is the case for another 15 years.

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