“To treat or not to treat?” That is the question.
As another August came to an end, thousands of recent high school graduates were making ready to begin the next phase of their formal education: college. And while students and proud parents alike were preparing for this milestone with shopping sprees to department stores, electronics stores (for the requisite laptop, printer and other accoutrements), Bed, Bath and Beyond (don’t forget bedsheets, towels, laundry bag and shower caddy); another errand that is part of this coming of age ritual is a trip to the dentist and an evaluation of the soon-to-be-freshman’s wisdom teeth.
Wisdom teeth generally begin to erupt around the age of seventeen, but the process of eruption can be very gradual over several years. In fact, for many people the wisdom teeth don’t develop at all. They happen to be the most frequently missing teeth in the human dentition.
The college years, ages 18-22, are primetime for wisdom teeth problems and hence, the pre-baccalaureate conversation about Dick or Jane’s wisdom teeth (and no, there isn’t dog named Spot in this tale or if you prefer: tail).
Recent trends in both clinical practice and research over the past decade suggest that wisdom teeth need not be, and perhaps should not be, extracted merely because they are impacted or poorly aligned. This is a dramatic departure from routine removal for some 20-30 years when malposed or partially erupted wisdom teeth were viewed almost as if they were “white tumors” and they had to come out. In fact, a recent study in the British Dental Journal as well as the UK National Institute for Health and Care Excellence question the heretofore-unquestioned practice of extracting asymptomatic wisdom teeth.
Certainly, there are potential problems associated with aberrant wisdom teeth such as infection, cysts, damage to the adjacent teeth, pain, and even the rare neoplasm or tumor. But, third molar surgery is not without the risks associated with any surgical intervention (pain, swelling and infection to name a few). Plus, in rare occasions nerve damage is possible (lower wisdom teeth) or sinus damage (upper wisdom teeth).
As a general dentist I am usually the first go-to person with regards to wisdom teeth evaluation. More frequently than not I am able to make my treatment recommendation based upon clinical examination and evaluation of diagnostic x-rays. When appropriate, I will make a referral to my oral surgeon colleagues for their input and expertise as often two heads are better than one when making a proper diagnosis and treatment plan. Sometimes more advanced diagnostic imaging such as a CT-scan is warranted. This helps to me to visualize the tooth, its position in three dimensions and its proximity to vital structures such as the mandibular nerve.
Each patient must be carefully evaluated on an individual basis. While younger people tolerate wisdom tooth extractions more easily, this fact alone does not warrant automatic removal.
Sometimes, however, it makes sense to remove the tooth before the roots are fully formed which makes for both a simpler surgical procedure while also avoiding nearby vital structures like nerves and sinuses.
Coronoectomy or the removal of just the crown portion of the tooth while leaving the deeply impacted roots alone is a somewhat novel surgical approach that involves thinking “out of the box” treatment planning. It eliminates the “problem” of a malposed wisdom tooth and its threat to the adjacent second molar while minimizing the potential morbidity of more complicated and invasive surgery. My close working relationships with talented specialists is an essential resource for optimal patient care; even when the extent of that care may be the decision not to care at all.
Proper evaluation of wisdom teeth is essential to maintaining and safeguarding optimal oral health. Diagnostic imaging, be it x-rays or cone beam scans (dental cat scans) are a crucial part of thorough work-up.
I will never forget my patient Tim. When I first met Tim he was a healthy 40-year old with a full complement of completely erupted and properly-aligned wisdom teeth. One day he arrived at the office with swelling in his jaw. Conventional dental x-rays could not “reach” far enough back in his jaw to see the source of his problem. (By the way, this is a common problem when taking X-rays of wisdom teeth in a small mouth because the X-ray sensor can cause a gag reflex and even dig into the delicate tissues of the mouth.)
I referred Tim to an oral surgeon, who upon taking a panoramic x-ray and a C-T Scan, discovered an impacted wisdom tooth with what turned out to be an associated dental tumor (Odotontogenic Keratocyst, if you must know). Not only did the wisdom tooth, extra tooth and tumor need to be removed, the procedure needed to be done in a hospital (in this case, Sloan-Kettering in NYC).
Tim is fine now, but i shudder to think what might have been if his condition was not discovered. The tumor was literally eating his jaw bone. While his situation is indeed rare, it underscores the importance of a thorough evaluation of your wisdom teeth, even if they are not bothering you.
Remember, an ounce of prevention…
To all of you college students: Good Luck! Remember to brush your teeth and don’t let your books get in the way of your education. For those of you not pursuing a college education, remember that college may not be the be all and end all to a successful happy life, and it won’t spare you from those potentially pesky wisdom teeth.