An extracted wisdom tooth. (Thinkstock)Dr. Jay Friedman relishes his role as dental outcast. Like a pesky younger brother who enjoys watching his siblings squirm, the 86-year-old dentist and public health advocate has for decades been poking and prodding at the oral health community over his personal obsession: wisdom teeth.
Friedman has argued for more than
30 years that removing a young person's healthy wisdom teeth -- called
"third molars" by professionals -- is an unnecessary and irresponsible
practice. While many dentists and oral surgeons have dismissed him as a
traitor and a zealot, in 2007, people in the public health arena began
to listen.
That's when Friedman published an article in the American Journal of Public Health
claiming at least two-thirds of the millions of wisdom teeth extracted
each year at a cost of billions of dollars were removed for no good
reason. In pointed terms, Friedman accused his colleagues of ignoring
the lack of evidence supporting the need for such surgery in order to
line their own pockets.
Friedman has compared the
practice to prophylactic tonsillectomies, which were routinely performed
on healthy children to prevent future throat problems in the first part
of the 20th century, before the medical community denounced them as
unnecessary.
"There can be no excuse for tolerating so many unnecessary
extractions on millions of unsuspecting and misled people and putting
them at risk of so much ... nerve injury. This is a public health
hazard," Friedman wrote.
The next year, the American
Public Health Association adopted a recommendation opposing the
prophylactic removal of wisdom teeth and a few insurance plans decided
they would no longer cover such extractions.
It's hard to overstate how much these developments have angered oral surgeons.
Dr. Lou Rafetto, a practitioner in Delaware, paused during a phone
interview to apologize as he wound down a tirade. "Sometimes I get
emotional when it comes to Jay Friedman," Rafetto said.
Many surgeons have been similarly
angered by Friedman over the years and have questioned his
qualifications since he is not a trained oral surgeon. Practitioners
insist wisdom teeth cause many people problems later in life, and say
it's prudent to remove them early rather than wait for trouble.
One surgeon said he recently had
to remove an infected wisdom tooth in a 93-year-old man, who should have
had it out when he was a teenager, when the surgery would have entailed
a quick recovery.
"It's sort of a thorn in the side of people who actually treat
patients with third molars that this guy gets so much traction," Rafetto
said of Friedman.
Yet despite the maverick
dentist's unpopularity, Friedman has sparked some soul searching within
the profession and even prompted a change in policy.
Earlier this year, the official
oral surgeons' group, the American Association of Oral and Maxillofacial
Surgeons (AAOMS), adopted a new recommendation on wisdom teeth removal.
For the first time, the group said surgeons should consider retaining
young patients' wisdom teeth if they do not show signs of disease. For
decades, the accepted wisdom was that all wisdom teeth should be
removed.
"The retention part is new," said Dr. Thomas Dodson, a member of AAOMS's task force on wisdom teeth.
Dodson, an oral surgeon at Massachusetts General Hospital, sees
himself as one of the few people in the middle of the acrimonious wisdom
tooth debate. He argues that Friedman is ignoring the problems
associated with keeping wisdom teeth while some oral surgeons are
minimizing the risks of subjecting so many people to the surgery.
And there are risks. About 1
percent of people whose wisdom teeth are removed experience nerve damage
-- usually temporary numbness of the lips, mouth, or tongue. Sometimes,
that damage is permanent, leading to "frequent drooling, biting of the
lip or the inside of the cheek or the side of the tongue, and paralytic
disfigurement or drooping of the lip," Friedman wrote. Complications
from anesthesia can lead to death in very rare instances.
There's no long-term research, however, on the risks of retaining healthy wisdom teeth.
Some studies suggest that about
30 percent of wisdom teeth removed each year created some kind of
problem for the patient, ranging from gum disease to cysts to painful
infections. And oral surgeons point to research that shows gums are more
likely to be infected around wisdom teeth than other teeth, which can
lead to other health problems.
Friedman argues that dental professionals should wait until they
actually see signs of disease before removing a patient's wisdom teeth,
saying it's not worth subjecting people to potential complications on a
hunch that their wisdom teeth might cause problems later. (That's the
official policy of Britain's National Health Service, which won't pay
for prophylactic procedures.) The cost is also something to consider,
since without insurance, wisdom teeth extractions can cost a patient
several thousand dollars.
So when Dodson is treating a young patient whose wisdom teeth seem normal, he says he's not really sure what to tell them.
"The reality is the science is insufficient at this point to
demonstrate that taking them out or leaving them is the right thing to
do," Dodson said.
Jay FriedmanFriedman
says in these situations, oral surgeons should tell their patients to
come back if they or their dentist ever notice a problem. Dodson,
however, leaves the decision up to the patient after warning them of the
risks of both courses of action. He says about 60 percent of these
patients opt for surgery.
Friedman calls the new AAOMS
policy "a big sea change" from the days when retaining healthy wisdom
teeth was not even an option, and happily takes credit for it. But he's
not satisfied. Though he agrees that any wisdom teeth that are causing
problems should be removed, he thinks oral surgeons are overhyping the
risks of retaining teeth that don't show any symptoms.
Friedman has some reason to be skeptical of AAOMS policies.
A pamphlet on the group's website
once stated that 80 percent of people who retained their third molars
would experience problems with them within 10 years. After Friedman
pointed out that the number did not seem to be based on any scientific
research, AAOMS removed the figure.
Friedman, who once reviewed
medical claims for self-insured companies, introduced his theory that
most wisdom teeth extractions were unnecessary in a fiery speech to a
California dental association in 1976. The editor of a local dentistry
journal published the speech, prompting a wave of outraged letters from
California dentists. To this day, oral surgeons say Friedman is biased
against wisdom teeth extractions because his aim is to save the
insurance industry money.
Friedman has taken out hundreds
of wisdom teeth in his own right, including those belonging to his only
child. When his daughter was 18 she began to complain of pain and
discomfort from her wisdom teeth and Friedman was unable to dissuade her
from taking a wait-and-see approach. He says he took her to his office,
removed all four teeth in 15 minutes, and then flew the next day to a
dental association meting Las Vegas to lecture oral surgeons on their
overzealous extraction policies.
"I didn't tell them that the day before I had taken out my daughter's wisdom teeth," Friedman said mischievously.
Dodson, for one, said Friedman's
crusade has made him consider his own practices more carefully, despite
their difference in opinion.
"He made me think about why we were doing what we're doing," Dodson said.
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