Writing blog posts is an exercise in discovery. I start with an idea and a few thoughts and then the finished post barely resembles what I set out to write.
My last post started off about wisdom teeth and ended up being about over diagnosis, over treatment and cancer. This week I want to get back to wisdom teeth.
Dr. H. Gilbert Welch, the Dartmouth epidemiologist and author of the book Less Medicine More Health, referenced oral cancer and wisdom teeth in his book, as examples of over-diagnosis and over-treatment. The last blog post discussed the oral cancer issues.
Just to give you an idea about how he feels, at one point he writes, “But I’m not a dentist. If you’re one, you already know that the topic of too much dentistry could fill a whole book. Write it.”
Well I’m not going to write a whole book about over-treatment…my last post garnered enough interest to send me numerous articles about that topic.
His point referring to wisdom teeth is that way too many wisdom teeth are removed in this country for prophylactic reasons. Most of these extractions are on asymptomatic patients. He claims that there is no data that supports the removal of wisdom teeth prophylactically and that the “UK’s National Institute for Health and Care Excellence and the American Public Health Association – recommend that wisdom teeth not be removed propylactically and should only be removed in patienbts who are experiencing problems.”
After over forty years of practice it’s difficult for me to believe such hard and fast rules—in other words I believe I can exercise a bit more judgement than that. But I do agree that we take out too many wisdom teeth.
Why? Well that’s a deep discussion…but dogma may have something to do with it.
For the patient the major concern is risk assessment. The pros and cons of the procedure. Whether the procedure is wisdom tooth extraction or placement of veneers or implants, risks should be discussed. Let’s face it all surgery has risks…believe me I know.
In the last post I referred to my mother’s wisdom tooth…at her age and even way before she passed, surgery would have been risky business. Then again risk is part of life…everytime I get in my car I am taking a risk, but people don’t usually see it that way.
“Can’t get your wisdom teeth out Lisa? Stop texting and driving.”
Welch writes about levels of risk in his book:
- Patient Autonomy. As dentists we see a lot of this. All patients have the right to refuse treatment and accept no risk. Most dentistry, unlike medicine, is not life-mandated. We have all seen patients refuse treatment and live long happy lives. In my history I have seen patients refuse to take medications and also refuse treatment for oral cancer.
- Baseline Risk. This is the old Ben Franklin saw about assessing pros and cons. Know exactly what the benefits are compared to the possible complications. How many teeth through the years have been mutilated (not my word—but one used by a very prominent and highly ethical dentist) for the sake of cosmetic dentistry—or foregoing orthodontics for aggressive restorative dentistry (instant ortho anyone?)
- Certainty of Benefit. This is where most of our dentistry should fall. Our examinations should reveal the obvious benefits and then should be discussed with the patient. In many cases the patient doesn’t understand the benefits and the doctor’s role is to open that discussion because of his or her experience.
- Certainty of Harm. Now this is the discussion that usually doesn’t get done. I divide my treatment options into Phase I and Phase II. Phase II options are irreversible…that could mean more risk. Sometimes dentists get into heroics without full disclosure to the patient…and real; trouble comes.
My suggestion is to use wise clinical judgement and openly discuss all options and risks with patients. I am amazed at how many of the “smartest dentists in the world” I meet everyday. There is very little humility in dentistry – medicine and dentistry could use a bit more humility – or else we will never improve…individually or collectively. And maybe those articles about over-diagnosis and over-treatment will go away.