August 20, 2008
Orthodontists are often confronted with patients whose teeth are so crowded or protrude so far in front of their lips they cannot comfortably close them together. About 5% of an orthodontist’s patients present this problem. The diagnosis in orthodontic parlance is termed “bi-maxillary protrusion.” The treatment plan calls for fixed braces accompanied by the removal of four teeth, most often the removal of the upper and lower, right and left first premolars. KD came to my office with this problem. I prescribed the removal of his first premolars teeth. This experience can be very frightening. Herein KD presents his experience. We orthodontists are way too cavalier about our patient’s apprehensions and forebodings apropos of this procedure. Just imagine substituting of the word “amputation” for “removal” or “extraction”. So direct your patient’s feet to the sunny-side of the street as KD describes it.
Personal Health /Jane E. Brody
When you have finished reading this article, you can go to read an article written by Dr. Michael Florman* for dentists, dental assistants and dental hygienists.
*Dr. Florman, a general dentist for many years, decided to return to train for 2 more years at NYU’s post graduate orthodontic department. He was certified as a specialist in orthodontics in 2004.
The article is entitled: Etiology, Prevention and Management of Post Extraction Complications … just click on the title and voila you are there. You can even take the test provided. Woe to patient who gets a “DRY SOCKET” read all about it. The article is very informative, but has some dental terms which the interested reader will not find formidable.
Should wisdom teeth be pulled immediately or only if they cause trouble? Dentists disagree.
Chances are that as soon as wisdom teeth begin struggling to emerge, a dentist will recommend that they come out. But should they?
The wisdom of removing wisdom teeth before they cause trouble has long been debated. In only a small percentage of people do they grow in straight and healthy. The human jaw has been steadily decreasing in size for millenniums and few people have a jaw large enough to accommodate four more teeth in the back of the mouth.
As a result many teeth grow in sideways, emerge only part way from the gum or remain impacted, forever trapped beneath it. According to recent estimated, 80-90 percent of Americans have at least one impacted “third molar,” as dentists call a wisdom tooth.
If this were the end of the story, there would be no debate; unerupted wisdom could just sit there in the gums. Unfortunately, in many patients (exactly how many no one really knows), malpositioned or impacted wisdom teeth eventually cause trouble. They may become infected or decayed, or they may damage adjacent teeth. Cysts and even cancers can form.
The debate, then, is whether to remove improperly positioned wisdom teeth before such problems arise or wait until they do.
While some specialists say. “Don’t bother them until they bother you,” most believe it is better to get malpositioned wisdom teeth out when you are young and healthy, since they are likely to cause trouble eventually.
Both sides have food reasons for their views. The “don’t bother them” school cites the cost and discomfort of pulling teeth, some of which will never cause trouble. Those who advocate removal note that as patients age the surgery becomes more difficult, the complications more numerous and the recovery more prolonged.
In an effort to resolve the controversy the National Institute of Health held a conference in 1979. It was agreed that straight healthy wisdom teeth should be left alone and that those that are diseased or causing trouble for other teeth should be removed. But the main issue, whether impacted but otherwise healthy wisdom teeth should be pulled to prevent trouble was never resolved.
“The panel waffled on this issue.” Said Dr. Walter C. Guralnick, a co-chairman of the meeting. After long discussion the, the panel reluctantly agreed, “Impaction or malposition of a third molar is an abnormal state and may justify its removal.
Dr. Guralnick. Professor emeritus of maxillofacial surgery at the Harvard School of Medicine, recently explained, “There has never been a good prospective study done to determine what percentage of people get into trouble if impacted wisdom teeth are left in place.
No such study had begun before 1979 conference, and despite the panel’s recommendation none have been started since. Such a study would follow large numbers of people for many years to see what happens to their impacted wisdom teeth. Experts now have only on e small study from which to judge; in it, most other 60-to 70- year- olds who still had their wisdom teeth had no evident disease in their impacted teeth.
Not unexpectedly, American Association of Oral and Maxillofacial surgeons recommends early removal of impacted wisdom teeth. Dr. Guralnick, who departs from this advice unless the teeth have partly emerged, nonetheless believes that the surgeons arrived at it honestly, using years of clinical experience as their bases.
“The economics of clinical practice is not the primary reason for the surgeons’ view,” he insisted. “Oral surgeons today have enough other ways to earn a good living. They don’t depend on pulling wisdom teeth.”
Still, more than half of all Americans seem to wait until problems arise that force the issue, the oral surgeon’s report.
The potential complications associated with malpositioned wisdom teeth are not in question. The only argument is about how likely the complications are to occur, especially if the teeth have not erupted through the gum.
“If wisdom teeth are partially emerged, symptoms eventually occur in more than 80 or 90 percent of cases,” said Dr. Edwin D. Joy Jr., professor of oral and maxillofacial surgery at the Medical College of Georgia in Augusta.
These are the most common complications of leaving malpositioned or impacted wisdom teeth in place:
- Infection of the surrounding gum tissue. This condition, pericoronitis, is most likely to occur if the tooth is partly erupted or very close to the surface.
- Fluid filled cysts. These can form from remnants of tissue around the crown of the tooth, becoming large and painful. Dr. Guralnick said that if panoramic X-rays are taken every three years, there will be an ample opportunity to detect such cysts while they are small and easy to be removed.
- Decay, or dental caries. The positioning of wisdom teeth makes them hard to clean and hard to repair.
Decay is most likely if the teeth have erupted, but even unerupted wisdom teeth sometimes develop caries. Damage to the adjacent teeth through infection or destruction of the supporting bone. Dr. Joy maintains that impacted wisdom teeth “invariably” cause periodontal pockets to form behind the adjacent teeth, which can jeopardize these teeth.
If any of these conditions occurs, there is no question that the tooth must be removed.Dr. Guralnick said, however, that there is no solid evidenced to show that impacted third molars cause other teeth to shift, so potential crowding of the other teeth is not justification for removing the wisdom teeth.
Assuming that wisdom teeth are erupted or unhealthy, they are commonly removed two at a time, the upper and lower on the same side of the mouth. A general dentist can do it using local anesthesia. Oral surgeons usually use general anesthesia, which is recommended for patients who are very anxious about the procedure.
Dr. Joy said that when the surgery is done between the ages of 17 and 20, complications are minimal and short-lived: primary swelling, pain and discoloration.
Postoperative complications increase with age, Dr. Joy said. Infection, painful sockets and prolonged healing are two to seven times more frequent in patients over 20, a study of 990 patients showed. By age 25 there is a 10 percent risk of damage to facial nerve.
And as age increases, so does the risk of nerve damage, which may cause numbness in parts of the face, drooling or speech impairments. Five times as many older patients as younger ones in the study suffered nerve damage. Increasing age also brings greater likelihood that bone surgery will be needed to pull the tooth.
Such findings prompt Dr. Joy and his surgical colleagues to recommend removal of wisdom teeth in people in their late teens. But the surgeons advised against removing wisdom tooth buds in children, since it is not possible to predict with certainty how the teeth will eventually be positioned.
Dr. Joy also noted that healthy, normally positioned wisdom teeth can be “very valuable additions to a person’s mouth” and should not be removed. If nothing else, one might be used later as an implant to replace a molar that has been removed.
Dr. Victor Sendax is a specialist in implantology practicing in New York, NY