In our article in the July issue on advising orthodontic patients about third molars, we believe that we gave a reasonable discussion based on the current data of the new findings about third molars and chronic oral inflammation, with its potential to affect health more generally (White RP Jr, Proffit WR. Evaluation and management of asymptomatic third molars: lack of symptoms does not equate to lack of pathology. Am J Orthod Dentofacial Orthop 2011;140:10-6).
The response by Dr Kandasamy printed alongside it is remarkably data free (Kandasamy S. Evaluation and management of asymptomatic third molars: watchful monitoring is a low-risk alternative to extraction. Am J Orthod Dentofacial Orthop 2011;140:11-7).
The only data that are cited have to do only with third molars and crowding of incisors; this is irrelevant—it has nothing to do with the development of pathology. There are numerous inaccuracies, and the conclusions are based only on unsupported opinions. To be more specific:
Neither our article nor the key findings from the third molar interdisciplinary conference held in Washington last year, which Dr Kandasamy referenced with the implication that it recommended routine removal of wisdom teeth, said that. The first key finding from the interdisciplinary conference says “Not all wisdom teeth need to be extracted, but all of them need to be managed.” Our discussion follows up that recommendation. We said that 30 of 70 third molars could be retained in the long term without the development of pathology. We do suggest, however, that each patient should weigh the options based the data that led to those numbers.
Dr Kandasamy cited 2 articles on obstetric patients to suggest no association between adverse obstetric outcomes and periodontal disease. In both articles, the principal aims were to assess periodontal treatment during pregnancy as a predictor of an adverse outcome, not the relationship between periodontal disease and adverse outcomes. In fact, obstetric patients with periodontal disease do have more adverse outcomes, as the article from the University of Western Australia that he cited specifically acknowledged.
Dr Kandasamy questioned the entire currently accepted biologic basis of periodontal disease, without offering data or references, and said of our article that “Little consideration has been given to other well-established guidelines and studies around the world that differ in their recommendations for the management of these teeth,” with no reference to what those are. In fact, there are only 2 such sets of guidelines in English, both from the United Kingdom: National Institute for Health and Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN). The NICE guidelines are brief but say that soft-tissue disease around wisdom teeth indicates removal. The SIGN guidelines are comprehensive, and their indications for third molar removal are similar to those from last year’s interdisciplinary conference and to our recommendations. Neither NICE nor SIGN reference any data reported from third molar clinical trials, and we did not refer to them for that reason—but they support our position, not his.
He suggested that only 30% of third molars have pathology, again without supporting data, but he referenced Friedman, who has never conducted clinical studies but has offered opinions on this subject. In the article he cited, Friedman suggested, with no data, that 50% of patients might have third molar pathology. It is not clear where Dr Kandasamy got the 30% figure. Clearly, it is incorrect.
Dr Kandasamy dismissed delayed quality of life recovery in older patients who have third molars as “minor.” The delay is at least 1 day for lifestyle and oral function, and 2+ days for pain. Whether that is minor is a judgment only patients can make, after they have considered the facts.
Both ethical and informed consent considerations now require counseling potential patients that they have a choice about third molars. They need to know that some “symptom-free and pathology-free” third molars will remain so. Exactly which will stay that way requires monitoring for pathology (not just waiting for symptoms), a step that often is ignored until the effects of chronic disease over time become more severe, both locally and systemically. The 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.