Is the NHS causing agony by telling dentists not to pull out wisdom teeth?
Asa 17- year- old, Rob Washington was relieved to hear he didn’t need his wisdom teeth removed. His dentist noted that the teeth were coming through at an angle, but said there was no point taking them out then as they weren’t causing harm.
‘He told me that the surgery would cause weeks of pain, so I was happy to wait, as he suggested, to see how they developed,’ recalls Rob, now 31.
and for years, this seemed the right approach: Rob had no pain and his dental check-ups were fine.
Yet when he saw a dentist last summer, after a few years of missing check-ups, the molars next to both the wisdom teeth in his lower jaw had decayed and needed filling, possibly removing. all his wisdom teeth needed removing, too.
‘The oral surgeon I was then referred to told me that 99 per cent of people with wisdom teeth coming through the way mine had would later develop tooth decay if they were left in,’ says Rob, a lawyer from Hampshire who recently moved to amsterdam. ‘I hadn’t realised it was inevitable, and was angry that I hadn’t just had them removed before they damaged my other teeth.’
Rob had his four wisdom teeth removed and is now getting a second opinion on whether his molars also need extracting.
His experience is far from unusual, with experts saying that delays in removing wisdom teeth are leaving many people with more serious dental problems.
Until 2000, it was routine to remove impacted wisdom teeth — ‘ impacted’ being teeth that emerge at an angle or only partly emerge due to lack of space.
Impacted wisdom teeth are actually a relatively modern problem. a couple of hundred years ago, our teeth wore away due to our rough diets, which created space at the back of the mouth for the wisdom teeth to come through (which is usually between ages 18 and 24).
softer diets have changed all this, says Louis Mcardle, consultant oral surgeon at Guy’s and st Thomas’ NHs Foundation Trust and London Bridge Hospital.
Impacted wisdom teeth are often jammed against the molar, making the space between the two teeth hard to clean, which leads to decay.
THIs
decay can progress rapidly because the teeth meet close to the pulp — the centre of the tooth which is made up of nerves, tiny blood vessels and connective tissue — says Luke Cascarini, a consultant oral and maxillofacial surgeon at the Wellington Hospital and Guy’s Hospital, London.
If the molar is badly decayed, then patients end up needing crowns, root canal treatment, or extraction — entirely needlessly, he says. The bacteria from the decay can also cause pain and infection.
Extraction of wisdom teeth became routine from the Fifties, thanks to the introduction of power drills and antibiotics. By the mid-Nineties, every year about 70,000 people in England and Wales were having their wisdom teeth removed in hospital (as inpatients or day-cases).
But in 2000, new guidelines from the National Institute for Health and Care Excellence ( NICE) changed the rules so that only wisdom teeth causing problems — such as tooth decay, abscesses or cysts — should be removed.
Extractions plummeted and by 2003 the figure had dropped to under 40,000. It saved the NHs money in the short term, but experts now believe this policy has caused patients more problems further down the line.
This happened to Melody Barzin, 24, a psychology student who lives with her family in Central London. Three years ago, her wisdom teeth started coming through and her dentist noticed one was impacted.
While he said it needed extracting, he didn’t refer her to an oral surgeon — because there was no decay.
Then, around a year ago, Melody started experiencing intermittent, intense pain in her lower jaw.
‘I put up with it for months but then it became more constant. Eating was hard, and at times the pain woke me at night.’
In January, she saw a dentist. an X-ray showed her impacted wisdom tooth had become infected and this had spread to the root of the molar beside it and near a nerve in her jaw.
This put her at high risk of nerve damage which could cause loss of sensation in her bottom lip.
stories such as these help explain why the number of wisdom teeth extractions are now as high as they were before 2000, because the problem has simply been delayed and is consequently a bigger dental job, say experts.
Indeed, official figures show that by 2010 almost 77,000 patients were having wisdom teeth removed — the highest level for 20 years. and this may be a gross underestimate, suggests Tara Renton, professor of oral surgery at King’s College Hospital. she says up to 500,000 wisdom tooth extractions are now done on the NHs each year.
Mr Cascarini says: ‘Now, instead of patients being in their early 20s, they are in their 30s or 40s, and a lot of them also need the molar tooth in front of the wisdom tooth removed, which wouldn’t have happened if they’d been removed earlier.’
Being about ten years older increases the risk of pain, nerve injury and infection because we don’t heal as well as we age, adds Professor Renton. ‘ There are fewer complications if they are removed before 25,’ she says. Mr Mcardle believes that NICE’s intention of reducing costs by cutting wisdom teeth extractions — previously one of the most common surgical procedures done on the NHs — has been a false economy. ‘It means there are now two problems to fix — the wisdom tooth and the tooth next to it.’ after considering evidence from dental experts, NICE is considering updating its guidance. a spokesman said a decision is expected in the next few months.
‘Most of the dental profession don’t think NICE got it right with the 2000 guidelines,’ says Mr Mcardle.
Professor Renton, who represents the dental arm of the Royal College of surgeons of England, says it’s vital not to introduce a blanket rule, and to consider carefully who needs the surgery because it has risks, such as pain, bleeding, infection, nerve injury, and, in rare cases, jaw fracture.
On average, it costs £ 150 on the NHs if done under local anaesthetic, and more for sedation or general anaesthetic. Privately, it costs up to £2,000.
If the dentist sees an impacted wisdom tooth, the patient should be referred to an oral surgeon. The surgeon will take X-rays to see if the tooth is crossing the trigeminal nerve which runs around the jaw.
The procedure is one of the higher risk dental surgeries for causing permanent nerve damage to the lip and tongue, she explains.
about 2 per cent of patients will experience temporary nerve injury, and 0.2 per cent will have permanent damage, but these risks increase tenfold when the tooth crosses the nerve canal.
‘Injuries to the nerve can’t always be avoided, so patients need to be well informed and find experienced surgeons,’ says Professor Renton. ‘Permanent nerve damage can ruin lives, with numbness, odd sensations and pain.’
BasEd
on X- rays and scans, the surgeon will decide whether to remove all or half of the tooth. several techniques are used. Professor Renton recommends a minimal access method, where little bits of tooth are removed using a drill, leaving most of the tooth root in the gum. she says this way minimises risks and damage, but it requires a lot of training.
some surgeons remove the whole tooth in one go or in fewer sections using a drill or chisels. People who report having wisdom teeth ‘ yanked out’ using dental forceps should be in the minority now, she says.
Melody is having her two wisdom teeth removed this week and will then need root canal treatment on her molar. ‘If I’d been told the complications that could occur from leaving wisdom teeth in, much of this could have been prevented,’ she says.
10% The proportion of people who have a phobia about
dentists