As a parsimonious young adult with what I thought was a pretty decent set of choppers, I once let a decade elapse between visits to the dentist. I brush. I floss. I figured everything was more or less cool.
I've still never had a cavity, even after bowing to pressures from The Man and becoming a dutiful twice-a-year visitor to the dentist's chair.
But ever since my wisdom teeth erupted in my early 20s — during my oral health hiatus — every dentist I've visited has at one point talked about how I really ought to have them removed.
Wisdom tooth, or third molar, extraction is a common procedure. It's practically a rite of passage for folks in their late teens or early 20s. I'm a few weeks shy of 39 and I still have all four, which makes me something of a rarity.
Why, I've always thought, would I voluntarily have a perfectly healthy part of my skeletal system removed? No thanks.
At my most recent checkup, the hygienist said she wouldn't be able to fully de-gunk the back of my mouth without causing me major pain and bleeding because of my half-in, half-out third molars — a new problem for me. So I had to go back a few weeks later for an extra-deep clean, excruciating despite two syringes of anaesthetic.
In the back of an Uber after that awesome procedure, tasting my own blood and trying to respond to the driver's attempted small talk with an immobile face, I started reconsidering my lifelong stance against having my wisdom teeth out. After all, my theory that they never cause problems had just been disproved.
Common as it is, the procedure isn't entirely without controversy — and not just from conspiracy theorists like me. And the longer you put it off, the riskier it gets.
At least, in the US, all those surgeries cost $US3 ($4) billion a year and lead to 11 million patient days of discomfort or disability, the American Journal of Public Health study reports. More than 11,000 people, the study found, wind up with permanent numbness in the lip, tongue, or cheek from the surgery.
That's not many people, statistically speaking — less than a quarter of a per cent. But the scariness of the potential mishaps — having parts of your face permanently numbed — is unpleasant enough to cause some patients (me) to fixate on the risk, however small.
And another estimate, reported in British Dental Journal, says that the risk of permanent problems is more like 20 per cent in high risk cases — such as for people with impacted teeth or a few grey hairs and wrinkles.
And there are those who say the risks outweigh the benefits — that the procedure is a solution in search of a problem.
To Yoink ...
Those in the pro-extraction camp say since the teeth are so likely to cause trouble eventually, it's best to just complete the low-risk surgery before they do — and before those risks increase, which they are bound to do with age.
A white paper by the American Association of Oral and Maxillofacial Surgeons makes the case for having them removed before you're old enough to easily rent a car.
Adverse reactions to the surgery occurred twice as often in patients older than 25 in the literature cited by the white paper and the risks keep going up with age.
"We generally recommend that teeth be removed during adolescence before the roots of the wisdom teeth are completely formed", says Thomas B. Dodson, Professor and Chairman of the Department of Oral and Maxillofacial Surgery, Interim Chair of the Department of Pediatric Dentistry and Associate Dean of Hospital Affairs at the University of Washington School of Dentistry in Seattle. Dodson is also the associate editor of the Journal of Oral and Maxillofacial Surgery.
"For younger patients, recovery is faster and the risk for postoperative complications is lower than in older patients", Dodson says.
Third molars are not like other teeth, says Louis K. Rafetto, an oral surgeon in private practice in Wilmington, Del. He's also the director of Surgical Implantology and Alveolar Reconstruction for the oral and maxillofacial residency program at Christiana Care Health Systems and a past president of the American Association of Oral and Maxillofacial Surgeons.
He says these teeth are more susceptible to disease than other teeth and we don't need them for eating or anything else, really. And since they're the last to erupt, they're squeezing into a tighter space than any of the other teeth, he explains, which can cause crowding. So no matter what, they need to be monitored.
Typically, we seek medical care for our bodies when something is bothering us. But this approach doesn't really work for wisdom teeth. "Asymptomatic does not indicate the absence of disease", says Rafetto, "rather merely the absence of symptoms". Meaning you can't rely on the ouch factor to be sure your wisdom teeth are a-OK.
In fact, by the time they're bothering you, things might be in bad shape indeed.
Dodson says that of patients over age 20 who choose to keep their third molars, more than 60 per cent of them will need to have at least one removed in the next two decades. Given that the teeth "frequently and unpredictably" move around, Rafetto says, if you do keep them, your dentist will need to keep an eye on them.
Wisdom teeth present an elevated risk for cavities and gum disease. But we keep problems like that at bay with brushing and flossing pretty well in the rest of our mouths, after all. Isn't keeping our wisdom teeth clean something we civilians can manage on our own?
"Not usually", says Dodson. "It is difficult to access the back of the mouth to clean the wisdom teeth. And if access is feasible, it can be almost impossible to clear well partially erupted teeth".
... Or Not to Yoink
That American Journal of Public Health study, even as it says how small the risks are, contains a pretty full-throated condemnation of the practice of removing wisdom teeth as a matter of course, as opposed to in response to trouble.
It calls the practice a public health hazard and says that fully two-thirds of the annual surgeries are unnecessary.
"Most of the pain and illness attributed to third molars is caused by the surgery, not the teeth", it says. Its author, Dr. Jay W. Freidman, has been on a crusade against routine removal for decades. In an interview with a dental blog in 2013, he said the surgery is meant to generate funds at the risk of patient health.
I don't want to face nerve damage and lengthy recovery time and given my age, I'm at risk for both. But I don't want to end up like Lisa Simpson's projected future without braces, either. And while my teeth don't hurt me, that horrible scraping session certainly did — and the hygienist made it clear that more are in my future if the landscape of my mouth doesn't change.
My reluctance has put me in a bind, of course. By not having them out as an undergrad, I've placed myself firmly in the high-risk category — avoiding the risks when they were comparatively unlikely has aged me into the population where they are much more likely to occur.
How to Decide
Treatment isn't always a simple binary: to pull or not to pull. Rafetto points out several treatment options that may seem more palatable to folks that aren't eager to part with their choppers.
Coronectomy — partial removal — could keep your mouth healthy. In that procedure, the crown of the tooth is sawed away but the root remains, keeping the crown from crowding other teeth but avoiding the possibility of nerve damage that occurs with root contact. Sounds fun.
There's also frequent repetition of the heinous deep-cleaning I underwent. Or your dentist may just want to keep a close eye on them during exams and with more-frequent X-rays. I can have mine out now as a high-risk patient. I can keep rolling the dice and maybe (probably, per the docs) start to have problems with impaction or cavities as I get even older and the surgery is even riskier.
Or I can just totally stop thinking about it for six months until my next date with the hygienist's pointy arsenal.