In July, I was given the opportunity to provide the “Counterpoint” response to White and Proffit’s “Point” article regarding the management of third molars. Drs White and Proffit have now responded to that and concluded that their “data show that most ‘symptom-free and pathology-free’ third molars will not remain pathology free over time. The bottom line: one can indeed do harm by doing nothing.”
Who said do nothing . . . ever? We should definitely do nothing if there is nothing to do; however, when something emerges (including pathology associated with third molars), then by all means assess it, discuss it, and then apprise the patient of the various options. Therein lies the rub. Extraction is not the only treatment available. It might be indicated in some patients, but certainly not all. Where and by whom is the line to be drawn? What is the prospective medical disutility of the proposed 4-mm periodontal pocket compared with the well-documented hazards of extraction?
Third molar extraction is not a benign procedure. Until recently, the decision-theory recommendation was to “let sleeping dogs lie.” Has the standard of care in relation to third molars changed from a concern for stability to now medical prophylaxis? Interestingly, the Cochrane review on treating asymptomatic third molars suggests “Prudent decision-making, with adherence to specified indicators for removal, may reduce the number of surgical procedures by 60% or more. It has been suggested that watchful monitoring of asymptomatic wisdom teeth may be an appropriate strategy” (Mettes TG, Nienhuijs MEL, van der Sanden WJM, Verdonschot EH, Plasschaert AJM. Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003879. DOI: 10.1002/14651858.CD003879.pub2 ).
For an orthodontist, the risk of future crowding is real and relevant; however, according to the literature, third molars are innocent bystanders. The question, therefore, reduces to a simple one: are there molar-related medical events hidden in the mists of future time that are so certain and so obvious that they should be within the purview of today’s clinician? Has it been shown that the “choices” presented by Drs White and Proffit now offer the patient an enhanced expected gain?
I do not want to encourage a frivolous back-and-forth banter. This is not about Kandasamy vs White and Proffit. It is about an influential point of view that unfortunately seems to advise and guide clinicians to extract most, if not all, third molars on the basis of the probability of future periodontal disease, resulting systemic implications, and presumed complications when the teeth are extracted later rather than earlier in life. Stated simply, I remain unconvinced.
In the end, there is nothing I can say in this response that I haven’t said better in my “Counterpoint.” Please give it some thought as you try to do the right thing by your patients.