Worth the Risk?

Clinicians are often faced with the choice to remove third molars without the presence of pathology or to leave them in place knowing this creates potential risk. Sales reps can learn from a discussion of both sides of the story.

Clinicians are faced with many decisions when it comes to managing the oral health of their patients. Oral health professionals, specifically dental hygienists, are trained to exercise great proficiency in the clinical and radiographic evaluation of many presentations, including third molars — most of which are extracted. However, clinicians will encounter patients who present with special circumstances surrounding their third molars, such as jaw structures that cannot support wisdom teeth or a high risk for developing caries on neighboring teeth. For this reason, third molar prophylactic extraction has been on the increase in many dental offices. Many young, healthy people are having their impacted wisdom teeth removed when there is no sign of pain or irritation.1 Whether removing impacted teeth is necessary is a controversial subject, and dental sales reps can benefit from learning more about the issues their clients face so that they are poised to offer a host of solutions.2

There is no evidence of widespread third-molar infection and pathology or of medical necessity to justify surgery.1 On the other hand, a 2011 white paper from the American Association of Oral and Maxillofacial Surgeons states impacted third molars should be removed — even if they are asymptomatic — when there is a risk for pathology.3

Typically, the four third molars at the back of the jaw will start to erupt between the ages of 17 and 25.2 Extraction is often performed in preparation for orthodontic treatment or orthognathic surgery, or to prevent complications that may arise in the future.4 According to the dental profession, there is a list of therapeutic reasons for extracting impacted third molars, including periodontal problems, presence of cysts, acute or chronic pericoronitis, destruction of adjacent periodontal tissues, and the presence of carious lesions.4,5 However, complications may arise, such as swelling, secondary infection, hemorrhage, alveolar osteitis, paresthesia of the inferior alveolar nerve, and impaired healing in older patients.1,3–5

A study revealed impacted third molars in patients older than 50 were likely to develop cysts or tumors, especially in men.5 Most oral health professionals agree that third molars should be extracted in the presence of recurrent gingival infection or pericoronitis, irreparable tooth decay, abscess, cysts, tumors, damage to nearby teeth and bone, or pathological conditions.6


Point of Sale | Alternative Solutions

  • Sales reps can callout the importance of alternate views of radiographs: two-dimensional panoramic and three-dimensional cone-beam computed tomography to aide in the interpretation and to diagnose a patient’s condition to help determine course of treatment.
  • Imaging tools play an instrumental role in third molar removal to help prevent paresthesia and further destruction of the alveolar bone.
  • Oral health professionals must be on alert and ready to make customized recommendations because each patient has different risk factors that can occur before, during, and after surgery.

CASE STUDY

The authors present a case study for deeper understanding of this complex topic. In this case, a 62-year-old patient (“Mr. Smith‘‘) sought advice from his oral health care professional after noticing a sore left jaw, limitation of opening, and difficulty swallowing. Upon further swelling on the left side of his face and progression to an inability to eat, he sought medical attention at a local urgent care center. A steroid injection provided temporary relief, but the patient sought further medical attention at his local emergency department (ED) the very next day. The ED staff took cone-beam computed tomography (CBCT) images (Figure 1) and informed Mr. Smith of a possible infected pocket in his left tonsil area. As he was having difficulty swallowing, he was admitted to the hospital and placed on intravenous pain medications and antibiotics.

The swelling was controlled with the use of steroids and antibiotics within 24 hours, and a specialist suggested the issue was related to the patient’s dental status. Utilizing interprofessional collaboration, the specialist worked with an oral surgeon for further evaluation.

Within the week, the patient was released from the hospital and advised to follow up with the oral surgeon. Panaromic radiographs were captured and revealed decay and infection and an extraction was scheduled. Due to a relapse of the previously mentioned conditions, the patient underwent emergency tooth extraction. His condition improved gradually following the surgery.

A follow-up appointment, complete with new radiographs, took place approximately one week later. Nearly two weeks later, a panoramic image and three-dimensional (3D) CBCT scan revealed residual root fragments present at the tooth extraction site.

Upon review of the patient’s dental and health histories, the oral health professional expressed some obvious concerns, including difficulty swallowing, elevated temperature, and high white blood cell count (<20,000). Additionally, the patient was experiencing difficulty healing and less bone regeneration potential due to his age and the amount of infection present in the mandibular left region.

In this situation, sales reps can callout the importance of alternate views of radiographs (two-dimensional panoramic and 3D CBCT) — both of which aided clinicians in the interpretation and diagnosis of Mr. Smith‘s condition and helped determine his course of treatment.

The imaging tools utilized played an instrumental role in this surgery — helping to prevent paresthesia and further destruction of the alveolar bone. Furthermore, the resulting images helped aid the oral health professional with the patient‘s healing process and the drainage of infection from the extraction site. In addition, the oral surgeon was able to monitor the remaining root fragments to ensure no further infection or cysts/abscesses appear.

CONCLUSION

Sales reps must understand the dynamic and challenging situations encountered by their clients on a daily basis. By familiarizing themselves with the risks and rewards of the many courses of treatment available, sales reps can arm themselves with invaluable knowledge that can be shared casually or under pressure.

Because each patient has different risk factors that can occur before, during, and after surgery, oral health professionals must be on alert and ready to make customized recommendations. Third molarremoval surgery is specific to each individual, and the procedure is not to be entered into lightly. Each patient can present with a variety of risks and implications to consider when treatment planning for removal of third molars, and sales reps should be on standby to offer supplemental solutions during these moments of need.

The use of quality radiographs and supplemental extraoral projections (such as CBCT) will aid clinicians in both quality of the diagnosis and long-term patient success.


Lexicon

  • Third molars: The four upper and lower third molars located at the very back of the mouth. Also referred to as wisdom teeth, these molars are often the last ones to erupt.
  • Prophylactic extraction: A preventive measure intended to avoid future complications.
  • Orthognathic: Corrective jaw surgery.
  • Pericoronitis: Inflammation of the soft tissue surrounding the crown portion of a partially erupted third molar.
  • Carious lesions: Caries, cavities, or tooth decay, occur in an area of demineralized enamel on the surface of the tooth if the demineralization process is not interrupted or reversed.
  • Alveolar osteitis: Dry socket, is a complication that occurs at the site of tooth extraction. This condition results in inflammation of the alveolar bone causing severe pain to the patient.
  • Paresthesia: A feeling of numbness or tingling that may present after removal of lower third molars due to nerve damage.

This article is adapted from one previously published in Dimensions of Dental Hygiene.

References

  1. Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J Public Health. 2007:97:1554–1559.
  2. Oberliesen E. Dentists debate need to extract wisdom teeth. Los Angeles Times. January 2, 2015.
  3. Singh YK, Adamo AK, Parikh N, Buchbinder D. Transcervical removal of an impacted third molar: an uncommon indication. J Oral Maxillofac Surg. 2014;72:470–473.
  4. Blondeau F, Daniel N. Extraction of impacted mandibular third molars: postoperative complications and their risk factors. J Can Dent Assoc. 2007;73:325.
  5. Shin SM, Choi EJ, Moon SY. Prevalence of pathologies related to impacted mandibular third molars. Springerplus. 2016;5:915.
  6. Macdonald, F. Evidence is mounting that routine wisdom teeth removal is a waste of time. 2016. Available at: sciencealert.com/no-you-probably-don-t-needto-get-your-wisdom-teeth-removed-ever. Accessed January 9, 2018.

Featured image by SERPEBLU/ISTOCK/GETTY IMAGES PLUS

From MENTOR. May 2018;9(5): 28-30,32.

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