Driver’s license, prom, ridding the body of vestigial teeth. All rites of passage for American adolescents.
So things were right on track when, after a routine dentist visit during my oldest child’s senior year of high school, he left the office clutching a referral slip to an oral surgeon.
According to the dentist, my son’s bottom two wisdom teeth were partially impacted. They were coming in vertically, as teeth should, but had stalled on their journey up through the gums. They would remain stuck there forever, posing a risk of future infection. The upper two wisdom teeth had grown in normally, but would have nothing to bite against if the lower teeth were no longer there. If we went for the removal of the bottom two wisdom teeth, all four would have to be yanked.
I trust our family dentist. He’s thorough, listens well, and is conservative in his treatment recommendations. A watchful-waiting kind of guy. In this case, his take on the potential surgery was: “It’s a little borderline but, yeah, I’d say it’s worth doing.”
The word “borderline” left a little space for doubt, though, so I wanted to mull it over. Even minor surgery has risks, and the fact that wisdom tooth extraction seems to be the default made me want to push back a little.
I’m well aware that our fee-for-service health care system tends to provide lots of medical procedures, including surgeries, that have later turned out to be unnecessary. For part of the 20th century, tonsillectomies were the country’s most-performed operation, with tonsils once seen as “portals of infection.” Now, how many kids do you know who have had their tonsils out? Turned out it wasn’t as helpful for most kids as doctors thought, and it might even carry long-term risks.
There are other examples. Spinal surgery was once a go-to remedy for stubborn lower back pain. But these operations made things worse as often as they made them better, and even gave rise to a brand-new diagnosis, “failed back surgery syndrome,” with millions experiencing prolonged suffering. Surgery is now seldom recommended for chronic lower back pain. Cardiac stents were considered helpful for clearing arteries, until a rigorous study showed that in many cases they aren’t.
At some point before each and every one of these operations were performed, a doctor looked a patient or family member in the eye and said that surgery was the best way to go, or at least a reasonable option.
These doctors believed they were doing the right thing. Standards of care evolve as new evidence supports—or fails to support—use of a particular treatment. Yet this system does not work perfectly. Sometimes things are done in a certain way simply because they are done that way, regardless of the state of the evidence. In fact, because we are all creatures of habit, it’s often harder to stop old health care practices than to implement new ones.
I called the number on my son’s referral slip and made an appointment for him to see the oral surgeon in a couple of weeks. The receptionist suggested that I also go ahead and book a date for the surgery a few days after the consultation, which I did. In the meantime, I decided to peek at the medical literature to see what kind of evidence there was for the removal of wisdom teeth for preventative purposes.
I went first to the highly regarded Cochrane Collaboration, an open-access hub for systematic reviews of health care treatments. Systematic reviews are compilations of findings from studies on a particular treatment, taking into account the quality of each study (for example, results from randomized trials are given more weight than studies that lack a control group). But the review about the impact of wisdom teeth removal, published in May 2020, was based on a measly two prior studies. It concluded that the “available evidence is insufficient to tell us whether or not asymptomatic disease-free impacted wisdom teeth should be removed”—the scientific equivalent of the Magic 8-Ball’s “Cannot predict now.”
Next, I typed “NHS wisdom teeth” into the search bar. The U.K.’s National Health System lacks the baked-in profit motive of the U.S. system, and thus tends to provide less unnecessary care (although what is “necessary” and “unnecessary” is often far from clear-cut). I learned that the NHS does not generally recommend removal of wisdom teeth unless a patient is experiencing symptoms like severe pain. The NHS policy jibed with an (admittedly old) 2008 statement issued by the American Public Health Association against removal of wisdom teeth for preventive purposes.
Clearly, wisdom teeth have never been a hot research topic. But there could be investigations underway right now, so my final stop was the public-access databases NIH Reporter and Clinicaltrials.gov to check for ongoing studies. While I found records for studies comparing approaches to pain relief following wisdom tooth extraction, and others comparing surgical techniques, there were no ongoing research projects that would give insight into whether and when the operation should be performed at all.
Back to my son’s teeth. The oral surgeon’s recommendation was to have all four teeth removed, under general anesthesia. We were given information about risks from the surgery: swelling and pain, infection. Rarely, it could lead to more permanent damage. And of course general anesthesia always carries a teensy-tiny risk of death. (Not mentioned at all was the not-insignificant risk of addiction to opioid painkillers following wisdom tooth extraction in adolescents and young adults.) All in all, though, the chance of serious harm from this surgery appeared to be slim. If I felt certain that it was necessary to avoid future suffering and trouble for my son, I wouldn’t think twice. But was it?
After weighing the meager information at hand and going back and forth a few times, we made the type of decision we are best at making when neither choice is appealing: We decided to decide later. He could have the operation done over the summer, when, if something went wrong, at least there wouldn’t be school to worry about. Soon, my son would be an adult and could decide for himself whether or not to have the surgery (so far, he was unsure, too). And of course, if he developed any symptoms or signs of disease around his wisdom teeth, then the case for surgery would be more clear-cut.
For the record, no one ever pressured us to do it. Not our dentist. Not the oral surgeon, or his receptionist, who was kind and understanding when we canceled the operation. But our experience left me wanting more data. Should we be pulling out symptom-free wisdom teeth as often as we do in this country? Based on my own look at the evidence, maybe not. But how do you know if your kid is one of the people who would benefit from this procedure? Wisdom teeth are removed from thousands of healthy young mouths every day in this country. This surgery is not risk-free and, for families who lack dental insurance, it is costly. Seems like we should know a little more about it than we do.