Pulling the Truth: How Routine Wisdom Teeth Extraction Became a Public Health Crisis

25 Q&As

In the United States, a silent public health crisis was operating in plain sight within the dental care system, according to a revealing 2007 study. At that time, dental professionals were extracting 10 million third molars (wisdom teeth) from 5 million Americans at an annual cost exceeding $3 billion—yet according to the evidence presented, at least two-thirds of these procedures were entirely unnecessary. Dr. Jay W. Friedman's landmark analysis, published in the American Journal of Public Health, systematically dismantled the scientific and clinical rationale behind prophylactic wisdom teeth removal, revealing how this routine practice subjected millions to needless pain, complications, and permanent nerve damage while generating substantial revenue for the dental profession.

Through meticulous examination of 2007 clinical data, Friedman demonstrated that only 12-20% of third molars ever develop pathological conditions requiring removal, comparable to appendicitis rates—yet we don't routinely remove healthy appendixes. His analysis exposed five persistent myths driving unnecessary extractions: exaggerated pathology rates, misguided beliefs about timing, unfounded concerns about dental crowding, unsupported claims about age-related risks, and dangerous underestimation of surgical complications. Perhaps most alarming was the revelation that over 11,000 Americans annually suffered permanent paresthesia—lifelong numbness of the lips, tongue, and cheek—from procedures that were never medically necessary, representing what Friedman characterized as "a silent epidemic of iatrogenic injury that afflicts tens of thousands of people with lifelong discomfort and disability." While these findings are now over 15 years old, they raised critical questions about dental practices that may still resonate today.

With thanks to Dr Jay Freidman.

The Prophylactic Extraction of Third Molars: A Public Health Hazard - PMC

Analogy

Imagine you own a car with four specialized sensors—one in each corner. A nationwide chain of auto shops has convinced millions of car owners that these sensors should be preventively removed because they might malfunction someday, even though they're currently working perfectly fine.

The auto chain explains that "85% of these sensors will eventually need removal" and it's "better to remove them early before they become more difficult to access." They've established this as the standard practice, despite only having data showing that about 12-20% of sensors ever develop problems.

The removal process isn't simple—it costs $500-800 per sensor, requires sedation, causes 2-3 days of pain and swelling, and in some cars (especially certain models), the sensors are located dangerously close to important electrical wiring. In fact, for about 1 in 100 removals, the wiring gets permanently damaged, causing sections of your dashboard to stop working forever—no warning lights, no fuel gauge, no speedometer in that section.

Meanwhile, in the UK, their transportation authority has studied this issue and officially recommends: "Don't remove perfectly functioning sensors preventively." They've found that monitoring the sensors and only removing them if they actually develop problems is far safer. When sensors do malfunction, simple fixes like resetting them or cleaning the connections solve most issues without removal.

The American shops perform 10 million sensor removals annually, generating over $3 billion in revenue. Each technician averages over $500,000 yearly from these procedures alone. If you question the necessity, they'll explain there are "two schools of thought" on sensor maintenance, presenting it as a legitimate debate rather than acknowledging the overwhelming evidence favoring monitoring over removal.

Just as unnecessarily removing these functioning car sensors would be considered wasteful and potentially harmful, the prophylactic extraction of healthy wisdom teeth represents a similar public health concern—creating preventable suffering and disability while consuming billions in healthcare resources to "fix" what often isn't broken.

12-point summary

1. Massive scale of unnecessary surgery In the United States, approximately 10 million third molars (wisdom teeth) are extracted from 5 million people annually at a cost exceeding $3 billion. Despite this enormous volume, Friedman argues that at least two-thirds of these extractions are unnecessary, as only about 12-20% of third molars actually develop pathological conditions requiring removal. This represents a massive public health issue affecting millions of people unnecessarily.

2. Real risks versus perceived benefits The extraction of wisdom teeth carries significant risks, including over 11 million patient days of pain, swelling, bruising, and malaise annually. More seriously, more than 11,000 people suffer permanent nerve damage (paresthesia) each year, resulting in numbness of the lip, tongue, and cheek. If prophylactic extractions were eliminated, between 7,739 and 23,450 cases of iatrogenic permanent nerve damage could be prevented annually, dramatically reducing suffering from lifelong sensory loss.

3. The myth of pathology prevalence Contrary to the claim that most wisdom teeth will eventually develop problems, only 12% of truly impacted teeth are associated with pathological conditions such as cysts and damage to adjacent teeth. Approximately 8% of third molars develop pericoronitis (gum inflammation), bringing the maximum pathology rate to about 20%. This rate is comparable to appendicitis (10%) and cholecystitis (12%), yet prophylactic appendectomies and cholecystectomies are not standard practice.

4. Challenging the early extraction argument The dental profession frequently recommends early extraction in adolescence to minimize complications, but research shows this approach may actually increase harm. Dry socket, infection, and nerve damage are less common in older adults (35-83 years) than in younger patients (12-24 years). The highest complication rate occurs in patients aged 25-34 years. This evidence contradicts the rationale for early prophylactic removal of asymptomatic third molars.

5. Misclassification of normal development Half of upper third molars classified as "impactions" are actually normally developing teeth that would erupt properly if left alone. Similarly, about three-fourths of developing teeth classified as mesioangular impactions would continue to erupt into normal position if not extracted. This misclassification contributes significantly to unnecessary surgeries and complications, particularly when normal developmental processes are mistaken for pathological conditions.

6. Debunking the dental crowding myth One common justification for wisdom tooth extraction—that they cause crowding of anterior teeth—has no scientific basis. Friedman explains that it is physically impossible for third molars, which develop in spongy bone without firm support, to exert enough force to push 14 other firmly rooted teeth. Any association between wisdom teeth and dental crowding represents correlation, not causation, yet this myth persists as a reason for extraction.

7. Conservative management alternatives Most third molar issues can be managed without extraction. Normal eruption discomfort is temporary and similar to teething. Infections, which occur in fewer than 10% of third molars, can typically be treated with antibiotics, oral rinsing, or removal of excess gum tissue without extracting the tooth. Pericoronitis should only lead to extraction if it repeatedly fails to respond to conservative treatment, not after a single episode.

8. Economic drivers of unnecessary surgery Friedman argues that third-molar extraction is a multibillion-dollar industry that generates significant income for oral surgeons. Each of the approximately 5,500 oral-maxillofacial surgeons in the U.S. averages 53 cases monthly, generating about $518,636 annually from these procedures alone. If only necessary extractions were performed, their income would decrease by approximately $347,486 per surgeon, suggesting financial incentives may influence clinical recommendations.

9. High-risk cases with minimal benefit Mesioangular impactions, where the tooth is angled toward the second molar, carry the highest risk of permanent nerve damage—up to 6.8% compared to other positions. Yet more than 95% of these teeth never cause problems. Despite this elevated risk-to-benefit ratio, these extractions continue to be routinely performed, contributing disproportionately to permanent nerve injuries without corresponding health benefits.

10. Quality of life impacts from nerve damage Permanent paresthesia from nerve damage significantly affects quality of life, causing symptoms like frequent drooling, accidental self-biting of numb areas, disfigurement, diminished taste, impaired speech, and reduced sensory pleasure. Some patients experience neuralgia-like shooting pains, and those with severe cases may be "driven to near hysteria by a loss of sensory functions that affects all aspects of their lives." These permanent consequences receive inadequate attention as a public health concern.

11. International policy divergence The British National Institute for Clinical Excellence has taken a clear stance against prophylactic wisdom tooth removal, stating: "The practice of prophylactic removal of pathology-free impacted third molars should be discontinued." Some U.S. government-funded programs are beginning to adopt similar policies, but American dental associations continue to recommend routine prophylactic extraction, highlighting a significant practice gap not supported by current evidence.

12. Legal barriers to addressing harm Patients who suffer permanent nerve damage face significant legal obstacles when seeking recourse. Most courts don't fault surgeons because patients consented to surgery and assumed the risk, even though this consent is based on what the author considers "unsubstantiated information." Recovery amounts are typically too small to cover attorney expenses, and the legal concept of "two schools of thought" regarding extraction being equally valid persists despite the scientific evidence favoring more conservative approaches.

25 Questions and Answers

Question 1: What is the scale of third molar extraction in the United States, including number of extractions and associated costs?

Ten million third molars (wisdom teeth) are extracted from approximately 5 million people in the United States each year. This massive volume of extractions comes at an annual cost of over $3 billion. Friedman breaks down these numbers further, explaining that oral and maxillofacial surgeons perform about 7 million of these extractions at a cost of approximately $2.85 billion, while general practitioners perform about 3 million extractions costing around $450 million.

These extractions result in more than 11 million patient days of "standard discomfort or disability," which includes pain, swelling, bruising, and malaise. Additionally, more than 11,000 people suffer permanent paresthesia—numbness of the lip, tongue, and cheek—as a consequence of nerve injury during surgery. The author argues that at least two-thirds of these extractions, associated costs, and injuries are unnecessary.

Question 2: What evidence does Friedman present regarding the actual necessity of third molar extractions?

Friedman contends there is no evidence of widespread third-molar infection and pathology to justify so many surgeries. He states that 50% of upper third molars classified as impactions are normally developing teeth that would erupt with minimal discomfort if not extracted prematurely. Only 12% of truly impacted teeth are associated with pathological conditions such as cysts and damage to adjacent teeth. This means that even accounting for some margin of error, the vast majority of extractions are performed on teeth without pathology.

Additionally, Friedman notes that most discomfort of erupting wisdom teeth is equivalent to teething and disappears after full eruption. Infection occurs in fewer than 10% of third molars, and most of these infections can be cured with antibiotics, oral rinsing, or removal of excess tissue around the tooth, without requiring extraction of the tooth itself. The author emphasizes that most pain and illness attributed to third molars is actually caused by the surgery rather than the teeth themselves.

Question 3: What are the common post-operative complications of third molar extractions?

Post-operative complications of third molar extractions include pain, swelling, trismus (limited mouth opening), hemorrhage, and alveolar osteitis (dry socket). Patients may also experience periodontal damage, soft-tissue infection, injury to the temporomandibular joint, and general malaise. Friedman notes that patients suffer an average of 2.27 days of "standard discomfort or disability," defined as "the disability normally associated with an uncomplicated surgical extraction of a mandibular third molar: namely, pain, swelling, bruising and malaise."

More serious complications include temporary or permanent paresthesia (numbness of the lips, tongue, and cheek), fracture of adjacent teeth, fracture of the mandible or maxilla, sinus exposure or infection, and anesthetic complications. With 10 million extractions annually, these complications affect a significant number of people. Friedman calculates that if only the 20% of wisdom teeth with pathology were extracted, 4 million people would be spared unnecessary pain and complications each year.

Question 4: What is paresthesia and how significant is this complication following third molar surgery?

Paresthesia is numbness of the lips, tongue, and cheek resulting from nerve damage during surgery. It can be temporary or permanent, with symptoms including frequent drooling, biting of the lip or inside of the cheek or tongue, and paralytic disfigurement or drooping of the lip. The sense of taste, facility of speech, and sensory pleasure are diminished. When bilateral paresthesia occurs, the anguish, discomfort, and disability are more than doubled.

Friedman reports that the incidence of mandibular nerve paresthesia ranges from 1.3% to 4.4% for temporary cases and 0.33% to 1% for permanent cases. While these percentages may seem small, when applied to the 3.5 million lower third molars extracted annually, the author estimates between 11,550 and 35,000 people suffer permanent paresthesia each year. Since approximately two-thirds of these extractions are deemed unnecessary, between 7,739 and 23,450 people suffer permanent paresthesia unnecessarily each year. The risk is particularly high for mesioangular impactions, where the permanent paresthesia rate can be as high as 6.8%.

Question 5: What is the American Association of Oral and Maxillofacial Surgeons' position on prophylactic wisdom teeth removal?

The American Association of Oral and Maxillofacial Surgeons advocates for prophylactic removal of third molars. According to their statement cited in Friedman, "if there is insufficient anatomical space to accommodate normal eruption... removal of such teeth at an early age is a valid and scientifically sound treatment rationale based on medical necessity." They further state that "about 85% of third molars will eventually need to be removed."

The organization recommends extraction of all four third molars by young adulthood—preferably in adolescence, before the roots are fully formed—to minimize complications such as postextraction pain and infection. This position is what the author characterizes as one of two competing schools of thought, with the Association promoting the idea that most third molars are potentially pathologic and should be removed, regardless of current symptoms or evidence of pathology.

Question 6: What is the actual incidence of pathology in third molars according to Friedman?

According to Friedman, not more than 12% of impacted teeth have associated pathology. The breakdown of pathologies includes internal resorption (0.85%), cysts (1.65%), periodontal bone loss (4.72%), and resorption on the distal surface of the second molar (4.78%). When adding the approximate 8% incidence of pericoronitis (inflammation and infection of the gum tissue), the maximum pathology associated with third molars reaches about 20%.

Friedman compares this 12% incidence of pathology to the rates for appendicitis (10%) and cholecystitis (12%), noting that prophylactic appendectomies and cholecystectomies are not the standard of care despite similar rates of disease. He argues that many dentists confuse the incidence of pathology as it appears in their offices with its prevalence in the general population, leading to an exaggerated perception of the problem. Those with diseased third molars are more likely to make dental appointments, creating a biased sample.

Question 7: What is pericoronitis and how does it relate to the wisdom teeth extraction debate?

Pericoronitis is the pain and infection of the gum tissue surrounding a partially erupted or erupted third molar. Excluding the normal discomfort of teething as the tooth erupts, the incidence of inflammation and infection of the gum tissue ranges from 6% to 10%. Friedman notes that pericoronitis accounts for approximately 8% of pathology associated with third molars.

Importantly, Friedman argues that a single episode of pericoronitis is not sufficient reason to remove a third molar. Extraction should only be considered if the problem fails to respond to conservative treatment or recurs. Conservative management can include antibiotics, oral rinsing, or removal of excess tissue (the hyperculem) around the tooth. The author points out that most discomfort of erupting wisdom teeth is equivalent to teething and disappears on full eruption, and that good oral hygiene, including toothbrushing, can prevent most infection of the gum tissue around erupting or partially erupted teeth.

Question 8: What is the first myth about third molars addressed in Friedman?

The first myth addressed is that "Third Molars Have a High Incidence of Pathology." Friedman directly challenges this claim by presenting evidence that not more than 12% of impacted teeth have associated pathology. This incidence is comparable to appendicitis (10%) and cholecystitis (12%), yet prophylactic appendectomies and cholecystectomies are not the standard of care.

The author argues that there is no evidence of widespread third-molar infection and pathology or of medical necessity to justify so much surgery. He points out that 50% of upper third molars classified as impactions are normally developing teeth that would erupt with minimal discomfort if not extracted prematurely. Friedman states that dental professionals often confuse the incidence of pathology seen in their offices with its prevalence in the general population, leading to an exaggerated perception of the problem and exposure of millions of people to the risk of iatrogenic injury.

Question 9: What evidence contradicts the claim that early removal of third molars is less traumatic?

Friedman presents several pieces of evidence contradicting the claim that early removal of third molars is less traumatic. Friedman cites research estimating that patients suffer an average of 2.27 days of standard discomfort or disability from extraction. He argues that early removal is actually more traumatic and painful than leaving asymptomatic, nonpathologic teeth in place.

Furthermore, Friedman presents evidence that dry socket, secondary infection, and paresthesia are less likely to occur in persons aged 35 to 83 years than in those aged 12 to 24 years, who experience more third-molar extractions. The highest risk of complication is in persons aged 25 to 34 years. This contradicts the common recommendation for early removal in adolescence. Friedman calculates that if only the 20% of wisdom teeth with pathology were extracted, 4 million people would be spared unnecessary pain and complications, reducing the aggregate patient days of discomfort and disability by 9 million days each year.

Question 10: How does Friedman address the myth that erupting third molars cause crowding of anterior teeth?

Friedman categorically refutes the myth that erupting third molars cause crowding of anterior teeth. Friedman states: "It is not possible for lower third molars, which develop in the spongy interior cancellous tissue of bone with no firm support, to push 14 other teeth with roots implanted vertically like the pegs of a picket fence so that the incisors in the middle twist and overlap."

The author notes that this explanation is often given for the removal of third molars, despite studies that have produced contrary evidence. He emphasizes that third molars do not possess sufficient force to move other teeth, cannot cause crowding and overlapping of the incisors, and any such association is correlation rather than causation. This argument directly challenges a common justification given to patients for prophylactic wisdom tooth removal.

Question 11: What evidence does Friedman present regarding the myth that risk of pathology in impacted third molars increases with age?

Friedman directly challenges the American Association of Oral and Maxillofacial Surgeons' unsubstantiated claim that "Pathologic conditions [of impacted third molars] are generally more common with an increase in age." Friedman cites a study of more than 1756 patients who had retained more than 2000 mandibular impactions for an average of 27 years, which found that only 0.81% experienced cystic formation.

The author states there is no evidence of a significant increase in third-molar pathology with age. This contradicts the rationale often given for early prophylactic extraction of wisdom teeth. Friedman acknowledges that teeth that become repeatedly symptomatic or develop associated pathology should be removed, but challenges the notion that age alone is a risk factor that justifies prophylactic extraction of asymptomatic, non-pathological third molars.

Question 12: How does Friedman address the myth about low risk of harm in third molar extraction?

Friedman categorically refutes the myth of low risk of harm in third molar extraction by highlighting numerous complications. He argues that given the low incidence of pathology, it is misleading to contend that less than 3 days of temporary discomfort is a small price to pay to avoid future risks. Friedman lists multiple complications including broken jaws, fractured teeth, damage to the temporomandibular joints, and both temporary and permanent paresthesia.

The author focuses particularly on mandibular and lingual nerve injury, calculating that if 3.5 million lower third molars are removed annually, between 11,500 and 35,000 people suffer permanent paresthesia each year. Since approximately two-thirds of these extractions are unnecessary, between 7,739 and 23,450 people suffer permanent paresthesia unnecessarily annually. Friedman characterizes this as "a public health hazard" that causes "lifelong discomfort and disability" for tens of thousands of people.

Question 13: What is a mesioangular impaction and why is it significant in the context of wisdom teeth removal?

A mesioangular impaction is a specific positioning of a third molar where the tooth is angled at a 30–45° angle toward or actually against the distal (back) surface of the second molar. Friedman includes a radiographic image showing this type of impaction with the roots in close proximity to or "saddling" the mandibular canal containing the mandibular nerve.

This type of impaction is particularly significant because it carries the highest risk of nerve damage during extraction. The risk of permanent paresthesia following extraction of a mesioangular impaction is as high as 6.8%, much higher than for other types of unerupted or impacted teeth. Despite this elevated risk, Friedman notes that more than 95% of these teeth will never cause any problem. He states that as many as three-fourths of developing third molars classified as mesioangular impactions at the time of extraction are not impacted at all but would continue to erupt into normal position if left alone.

Question 14: What are the economic implications of third-molar surgery according to Friedman?

According to Friedman, third-molar surgery is a multibillion-dollar industry that generates significant income for the dental profession, particularly oral and maxillofacial surgeons. The annual cost exceeds $3 billion, with oral and maxillofacial surgeons performing around 7 million extractions at a cost of approximately $2.85 billion, and general practitioners performing about 3 million extractions costing around $450 million.

Each of the approximately 5,500 oral and maxillofacial surgeons in private practice averages nearly 53 third-molar cases a month, with an average annual income from third-molar extractions alone estimated at $518,636. If only the 33% of extractions deemed necessary were performed, the oral and maxillofacial surgeon's annual income would be reduced by $347,486, resulting in annual savings to patients of more than $1.9 billion, or $2.2 billion if extractions by general practitioners are included. Friedman suggests this economic incentive helps drive the continuation of what he considers an unnecessary and harmful practice.

Question 15: What are the conservative alternatives to extraction for managing third molar issues?

Friedman outlines several conservative alternatives to extraction for managing third molar issues. For most erupting wisdom teeth, Friedman notes that discomfort is equivalent to teething and disappears on full eruption. Good oral hygiene, including toothbrushing, can prevent most infection of the gum tissue around erupting or partially erupted teeth.

When infection does occur (in fewer than 10% of third molars), it can often be managed with antibiotics, oral rinsing, or removal of excess tissue (the hyperculem) around the tooth, without requiring removal of the tooth itself. For pericoronitis (inflammation of the gum tissue), the author recommends conservative treatment first, with extraction considered only if the problem fails to respond or recurs. For erupted third molars with deep periodontal pockets (pseudopockets), excess gum tissue can be treated conservatively or reduced surgically, rather than extracting the tooth.

Question 16: What do the British National Institute for Clinical Excellence and other authorities recommend regarding third molar extractions?

The British National Institute for Clinical Excellence makes an unequivocal recommendation, adopted by the National Health Service: "The practice of prophylactic removal of pathology-free impacted third molars should be discontinued.... There is no reliable evidence to support a health benefit to patients from the prophylactic removal of pathology-free impacted teeth." The Institute specifically outlines conditions for which extraction is justified, including nonrestorable dental caries, pulpal infection, cellulitis, recurrent pericoronitis, abscesses, cysts, and fractures.

Friedman also notes that government-funded programs in the United States are beginning to adopt similar policies. It specifically mentions the Healthy Kids Dental Program administered by Delta Dental of Michigan. Friedman suggests that better education of dentists, beginning in dental school, and of the public on the reasons to avoid unnecessary extractions is also needed to address this issue.

Question 17: How does the author characterize the "two schools of thought" regarding wisdom teeth extraction?

Friedman characterizes the "two schools of thought" as being unequal in their scientific merit, despite being treated equally in legal contexts. One school, endorsed by oral and maxillofacial surgeons, contends that most third molars are potentially pathologic and should be removed. The other school holds that only third molars with associated pathology should be removed.

The author criticizes the legal system for crediting each school of thought as having equal merit, "ignoring the scientific evidence base." He explains that this is why oral and maxillofacial surgeons usually prevail in malpractice suits when patients are injured during elective surgery. The expert testimony of oral and maxillofacial surgeons establishes the necessity of the surgery, regardless of evidence showing that most third molars do not become diseased and that the risk of iatrogenic injury from surgery is greater than the risk of leaving asymptomatic, nonpathologic teeth alone. Friedman argues this perpetuates a standard of care "based on an erroneous evaluation of all outcomes and costs."

Question 18: What legal aspects of malpractice in third-molar extractions does Friedman discuss?

Friedman discusses how patients who suffer from paresthesia following third-molar extractions face significant legal challenges when seeking redress. Friedman explains that although paresthesia is one of the most common reasons patients sue oral and maxillofacial surgeons, most judges and jurors do not fault the surgeons because the patients consented to surgery, thereby assuming the risk.

The author argues that "patients are given unsubstantiated information that would, in just circumstances, invalidate their informed consent," but this is "rarely convincing to a court." Recovery amounts for dental malpractice are usually too small to cover attorney's expenses, limiting legal recourse. Friedman suggests abolishing the fallacy of the standard of care and two schools of thought, which "ignores evidence-based science and perpetuates and forgives malpractice," as a way the legal profession could better protect the public.

Question 19: How does Friedman compare prophylactic third molar extraction to other preventive surgeries?

Friedman directly compares prophylactic third molar extraction to other preventive surgeries by examining pathology rates. Friedman notes that not more than 12% of impacted third molars have associated pathology, comparable to the incidence of appendicitis (10%) and cholecystitis (12%). However, he points out that "prophylactic appendectomies and cholecystectomies are not the standard of care" despite having similar rates of disease.

This comparison highlights the inconsistency in medical practice regarding preventive surgery. While other organs with similar rates of pathology are only removed when symptomatic or diseased, third molars are routinely extracted prophylactically. The author uses this comparison to question why third molars are treated differently and to challenge the rationale behind the widespread practice of prophylactic extraction.

Question 20: What quality of life impacts can result from permanent nerve damage following third molar surgery?

Permanent nerve damage following third molar surgery can have significant quality of life impacts. Friedman describes how patients with paresthesia experience symptoms including 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. The sense of taste, the facility of speech, and the sensory pleasure of kissing are diminished.

Friedman notes that when bilateral paresthesia occurs, the anguish, discomfort, and disability are more than doubled. While the degree of paresthesia varies from mild to severe, constant tingling numbness is the most common feature. Some patients experience frequent shooting pains much like neuralgia. Those suffering from severe paresthesia "may be driven to near hysteria by a loss of sensory functions that affects all aspects of their lives." These permanent consequences significantly impact daily functioning and quality of life, yet are rarely recognized as the public health issue the author believes they represent.

Question 21: What proportion of upper third molars classified as impactions are actually normally developing teeth?

According to Friedman, 50% of upper third molars classified as impactions are normally developing teeth. Friedman states that most of these teeth "will erupt with minimal discomfort if not extracted prematurely." This statistic directly challenges the rationale for extracting these teeth prophylactically.

The author extends this observation to mesioangular impactions as well, noting that "as many as three fourths of the developing third molars classified as mesioangular impactions at the time of extraction are not impacted at all, but would continue to erupt into normal position in the mouth if left alone." This misclassification of normally developing teeth as problematic impactions contributes significantly to what the author considers unnecessary extractions. Friedman includes a radiographic image showing four normally developing wisdom teeth that were classified as "full bony impactions" at the time of extraction.

Question 22: How does patient age correlate with the risk of complications from third molar surgery?

Contrary to the common recommendation for early removal in adolescence, Friedman cites evidence that complications are actually more common in younger patients. Friedman notes that "dry socket, secondary infection, and paresthesia are less likely to occur in persons aged 35 to 83 years than in those aged 12 to 24 years, who experience more third-molar extractions."

The highest risk of complication is in persons aged 25 to 34 years. This evidence directly contradicts the American Association of Oral and Maxillofacial Surgeons' recommendation for extraction of all four third molars by young adulthood—preferably in adolescence, before the roots are fully formed—to minimize complications. Based on this evidence, the author argues that early removal of third molars is actually more traumatic and painful than leaving asymptomatic, nonpathologic teeth in place.

Question 23: What is the estimated reduction in cost and disability if only necessary third molar extractions were performed?

If only necessary third molar extractions were performed (estimated at 33% of current extractions), Friedman projects significant reductions in both costs and disability. Friedman calculates total savings of $2,211,175,000 annually by eliminating unnecessary extractions. Specifically, this includes savings of $1,911,175,000 from oral and maxillofacial surgeons and $300,000,000 from general practitioners.

Additionally, 3.34 million people would be spared an average of 2.27 days of discomfort and disability each, representing an aggregate reduction of 7.6 million patient days of pain, swelling, bruising, and malaise. If the more conservative estimate that only 20% of wisdom teeth have pathology were used, the savings in cost and reduction in disability would be even greater. Friedman presents these figures in a detailed table showing the economic and health benefits of performing only medically necessary extractions.

Question 24: How does Friedman describe the role of dental education in addressing unnecessary extractions?

Friedman briefly mentions that "better education of dentists, beginning in dental school, and of the public on the reasons to avoid unnecessary extractions" is needed. Friedman identifies dental education as one component of a broader approach to reform current practices around third molar extraction.

The implication is that current dental education may contribute to perpetuating the practice of prophylactic extraction by teaching future dentists to recommend removal of asymptomatic wisdom teeth. The author suggests that changing educational approaches could help shift the paradigm toward more evidence-based practice. This educational reform is mentioned alongside policy changes, such as those implemented by government-funded programs that are beginning to adopt policies against prophylactic extraction of third molars.

Question 25: What constitutes a "rational policy" regarding third molar extraction according to Friedman?

A rational policy regarding third molar extraction, according to Friedman, would follow the British National Institute for Clinical Excellence's recommendation: "The practice of prophylactic removal of pathology-free impacted third molars should be discontinued." Extraction would be justified only for specific conditions, including nonrestorable dental caries, pulpal infection, cellulitis, recurrent pericoronitis, abscesses, cysts, and fractures.

Friedman asserts that the evidence is "compelling that prophylactic extraction of third molars is a significant public health hazard" and warrants "avoidance of the extraction of any third molar in the absence of a pathologic condition or a specific problem." He supports government-funded programs in the United States that are beginning to adopt similar policies limiting prophylactic extractions. The author also advocates for better education of dentists and the public on the reasons to avoid unnecessary extractions, and for abolishing the legal concept of two equally valid schools of thought regarding extraction, which he believes perpetuates and forgives malpractice.

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