The removal of “wisdom teeth” (third molars) is one of the most common procedures performed by oral and maxillofacial surgeons. While it is common, it is considered surgery. The questions of whether this is a safe surgical option and should be considered in a person living with Duchenne, comes up frequently. Recently, we asked our good friend (and orthodontist) Elizabeth Vroom, DDS, from UPPMD in the Netherlands to comment.  

 

As stressed by Elizabeth, routinely removing wisdom teeth (prophylactically – done to prevent future problems), should not be considered for every person. “Too many wisdom teeth are removed without evidence” that the procedure is necessary. Stories about the crowding of the other teeth by the wisdom teeth were not substantiated in a recent Cochrane Review1 (link)

 

How is the decision made?

Third molars may become “impacted.” This occurs when the second molars block the path of eruption of the third molars, creating a barrier and preventing eruption. This impaction may cause no pain or discomfort, and therefore is asymptomatic. In asymptomatic impaction, no intervention is necessary. The Cochrane Review above found no evidence to support, or refute, routine prophylactic removal of asymptomatic impacted third molars. A 30-year longitudinal study performed by the National Institutes for Health (NIH), as well as UK based National Health Service and the National Institute for Clinical Excellence (NICE), all indicate that there is a lack of evidence for the prophylactic removal of third molars.

 

A recent article discussed the indications for third molar extraction.Dodson developed the “Dodson classification system,” defining when third molars do need to be removed.3 This system is based on both patient symptoms (pain, periodic swelling and pain in the area of the third molar, occasional and temporary “foul taste” in the mouth) and the presence of disease (pericoronitis – inflammation of the soft tissues around the tooth), dental caries (tooth decay), or infection.  

 

There are four scenarios when considering the management of third molars:

  1. If symptoms and disease are present, the disease may be treated successfully with or without the removal of the third molars. 
  2. If symptoms are present without disease, removal of the third molars may be necessary.
  3. If there are no symptoms, but disease is present, the treatment is focused on eliminating the disease. Removal of the third molars may not be necessary.
  4. If there are no symptoms or disease present, removal of the third molars may not be necessary. This is rare (11.6% in a recent study4) and patients in this group should be monitored closely, as they may progress to one of the above groups.

 

Surgical risks

There are inherent risks with the surgical removal of wisdom teeth. These may include: pain following surgery, significant swelling of the jaw, the risk of infection to the surgical site, damage to the jaw resulting in the inability to open the jaw fully (trismus), damage to the nerves supplying sensation to the tongue and skin of the lower lip and chin (lingual or inferior alveolar nerve damage), and fracture of the jaw.

 

In addition, we know of the risks of anesthesia in Duchenne. Click here to view a list of safe and unsafe anesthetics for people with Duchenne.

 

Summary

In summary, if you are trying to make a decision regarding the removal of third molars, you may want to consider the following points:

  1. Are there symptoms of pain or discomfort in the area of the third molars? If so, can these symptoms be managed without removal of the teeth? If there are no symptoms, or management of the symptoms can be achieved, removal of the teeth may not be necessary.
  2. Is disease present? If so, can the disease be managed without removal of the teeth? If so, removal may not be necessary.
  3. If symptoms and disease cannot be managed without removal of the teeth, surgical extraction of the teeth may be necessary.
  4. If removal is necessary,
    • Where will the procedure be done? It is recommended that this procedure be done in a medical institution (not an orthodontic office) with emergency equipment available.
    • It is also recommended that there is an anesthesiologist present who will be managing the anesthesia that is familiar with Duchenne and using the above recommendations.
    • If the patient is taking daily steroids, steroid stress dosing may be necessary for this procedure.

 

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References

  1. Mettes TG, Nienhuijs ME, van der Sanden WJ, Verdonschot EH, Plasschaert AJ. Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults. Cochrane Database Syst Rev 2005;(2):CD003879. http://onlinelibrary.wiley.com/doi/10.1002/14651858.
  2. The indications for third-molar extractions.  Steed, Martin B. The Journal of the American Dental Association , Volume 145 , Issue 6 , 570 – 573. CD003879.pub2/abstract. Accessed March 18, 2014.
  3. Dodson TB. How many patients have third molars and how many have one or more asymptomatic, disease-free third molars? J Oral Maxil- lofac Surg 2012;70(9 suppl 1):S4-S7.
  4. Kinard BE, Dodson TB. Most patients with asymptomatic, disease- free third molars elect extraction over retention as their preferred treat- ment. J Oral Maxillofac Surg 2010;68(12):2935-2942. 

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