I love panoramic x-rays. Let that be clear beforehand.

Panoramic x-rays are the kind of images that allow us to see all the teeth (and much of their surroundings) in one go. To me, they are an indispensable tool. I take them almost systematically when I see a new patient. Not generally in subsequent check-ups, but when I see the patient for the first time? Absolutely.

They provide a lot of information. They really help to better understand and plan the case we’re dealing with. A metaphor I like is that if working inside the mouth was a strategy or city building videogame, the panoramic x-ray would be the minimap: it allows you to see where you are and what you have around you, in a fast and easy way. And they allow you to detect problems that would otherwise go unseen. Cavities between teeth come to mind.

However, I personally have the suspicion that this awesome kind of dental imagery comes with a downside: I believe there is a strong correlation between unnecessary wisdom tooth removals and the widespread use of panoramic x-rays.

I always say that on this website I only give my opinion, which is not supposed to be taken as universal truth. And in this article, where I am just sharing a random thought, this is truer than ever. Let’s say that just like Félix Rodríguez de la Fuente was not a better documentary maker than Jacques Cousteau, I am not a better dentist than yours.

However, here’s the thing: in France, where I work, almost every patient gets at least one panoramic x-ray taken, at some point, more or less systematically. The reason? The French reimbursement system works in a way so that dentists earn money for taking them, while patients don’t need to pay for them (directly). For most dentists in France, myself included, a patient’s first consultation and his or her panoramic x-ray go together.

At the same time, France is a country where wisdom tooth removal is extremely common. Among certain age and social groups, the people that underwent the removal outnumber those that kept their wisdom teeth. With the removals being indiscriminate (all four wisdom teeth), sometimes at terrifyingly young ages (I know multiple cases under 15), and for no valid reason that the patients can recall. When I ask them why, they will almost invariably answer “because I had no place”, or the ever popular urban legend: “to prevent crowding”. Reasons that do not justify the removal of wisdom teeth. No more serious than believing that most dentists are scammers, that vaccines cause autism, that fluoride in dental care products is bad, or that chemtrails turn frogs gay.

On the other hand, things are different in my motherland Spain, where I also studied. First consultations are often expected by patients to be completely free. So, when seeing a patient for the first time, in general, no panoramic x-ray will be taken, because if taken, the patient will have to pay for it. And later on, many dentists will resort to working and following the treatment they have planned without taking a panoramic x-ray in any moment. In fact, my own dentist in Spain had never taken a panoramic x-ray of my mouth. They only did when I specifically requested it. And I had been seeing them regularly since I was 7 years old! I still remember getting my first permanent molars sealed at their place.

Being an afrancesado, like I unavoidably am at this point, I frown at the Spanish way of doing it. The idea of working for free when seeing a patient for the first time sounds bad enough to me, but I also have no doubt that not taking panoramic x-rays means leaving undiagnosed cavities, infections and other problems.

However, no matter what an afrancesado expat like me thinks, dentistry in Spain is top quality, affordable, efficient and cutting-edge. And this includes, of course, fewer unjustified wisdom tooth removals.

Unnecessary wisdom tooth removal is, of course, a thing in Spain. I know it very well. It is indeed a thing everywhere, to some extent, because the flawed “common sense” that pushes dentists and surgeons towards doing it is universal. But even if wisdom teeth get removed in Spain without a real need too, this happens a lot less frequently than in France. And I believe that at least a part of the reason for this difference is that panoramic x-rays get taken a lot less frequently in Spain than in France.

And why? Why would taking panoramic x-rays more frequently lead to more wisdom teeth being removed without a real need? Simple: it is about impacted wisdom teeth, the ones that have no space to come in, or their position is not favorable for a complete eruption. Wisdom teeth in this situation rarely cause problems (if yours did, you are an exception to the rule). However, they do appear as extremely obvious on x-rays.

Nobody would even think about these impacted wisdom teeth if no x-ray was taken. However, it does get taken and… they are there. And everybody panics. And everybody wants to remove them. Not because there is any particular problem, but just because they look “bad” on the x-ray, so “common sense” tells that they need to go.

A whole molar, bent, horizontal, that looks so extremely wrong? How awful, isn’t it? Your dentist tells you that you need to get it out. You look at the x-ray, and you need no more proof. You don’t need to be a dentist to see that something is odd. You fear for the future, you are afraid it may cause problems someday, even if you have never felt anything. And so, you agree to removing a tooth you didn’t even know was there.

Well, this, my dear reader, is a mistake. Just think about it: you have no problems or pathology at all. If you didn’t have the x-ray taken, you would go on with your life without even realizing you have an impacted tooth (or more than one), just like you never realized it before. Just how absurd is that?

I see this frequently, because even if so many wisdom teeth get removed in France, it is not all of them, thankfully. And I frequently see patients in their 60s, or older, that have impacted wisdom teeth, and have never even felt them. This is actually the norm for impacted wisdom teeth, not the exception. If you have no symptoms or infections, you can totally rest assured, my dear reader, and expect this to be your case too. Just like you don’t remove your appendix “just in case”, there is no reason to remove an impacted wisdom tooth “just in case” either.

Let the takeaway be: impacted wisdom teeth get removed without a real need because they look too obvious on the x-rays. And this is something that should change. And I don’t mean we should take panoramic x-rays less frequently, God forbid! I mean that we dentists should be respectful and minimally invasive when dealing with dental issues, and be aware that the prophylactic removal of wisdom teeth is a bad idea.

I will close the article with a very famous and internationally known phrase, attributed to different sources, William Lamb and Winston Churchill among others: With great power comes great responsibility. And indeed, the panoramic x-ray is a very powerful tool for us dentists, oral surgeons and the like. So, we better use it wisely!

I dream of a world where it only helps us take responsible, respectful and ethical decisions for our treatments.

Saludos cordales.

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