Many, if not most removals of wisdom teeth are unjustified. This is something that appears very obvious to me as a dentist. And I often ask myself: why?

Why is this even an issue? Routine tonsil removal ceased to be common practice a long time ago, and no ENT doctor performs it anymore unless it is clearly justified. We don’t see digestive doctors removing gallbladders and appendices prophylactically. We don’t see nephrologists removing perfectly healthy kidneys “just in case”. We don’t see pediatricians ignoring evidence and guidelines to become anti-vaxxers.

However, the prophylactic removal of healthy and asymptomatic wisdom teeth is a terrifyingly common thing, with plenty of dentists or surgeons advocating for it. This sometimes includes the removal of perfectly positioned or normally developing wisdom teeth: an outrageous practice that I am not shy to call mutilation.

Wisdom teeth are the only body part whose removal is ever suggested in healthy patients with no risk factors. Well. Almost the only one. But this project is controversial enough as it is, so I will stick to my topic.

There is little to no evidence to back such an invasive approach to wisdom teeth. In fact, it even goes directly against the official clinical guidelines set by multiple health authorities around the world. You heard me right: you don’t need to take my word on this.

I am not some eccentric weirdo trying to fight “the establishment” like Don Quixote fought against the windmills in La Mancha. The opinions I express on this website are not just my personal ideas: they go in line with what is recommended by multiple, competent authorities. You can consult it on the Resources section. Remember that I am no friend of pseudoscience or any kind of “alternative” approach. To me, a dentist that believes that perfect wisdom teeth should still be removed is not all that different from a pediatrician that opposes children’s vaccines.

Despite the lack of evidence, dentists keep removing healthy wisdom teeth. In some countries more than in others, with the USA and my adoptive country of France being clearly among the worst. But still, it is a problem that happens more or less universally.

And again, the question pops up: why?

I have various ideas as to why this is an issue. Before diving into them, let me make it clear that this is just my opinion. And just like Laura Gallego is not a better writer than Lemony Snicket, I am not a better dentist than yours.

But in my opinion, a very important reason stems from the fact that dentistry is a very particular health discipline. Unlike in other areas of medicine, dental treatment decisions are highly subjective. This is basically what I mean when I call dentistry an art. A dentist is free to plan and decide his treatments. And we dentists have such a wide arsenal of materials and procedures to use in our practice, that the possibilities of what we can do are endless.

In oncology, there would be no discussion about the convenience of removing a malignant tumor (feasibility would be the issue, if anything). In traumatology, nobody would question the need to use a splint to treat a broken bone. But in dentistry, decisions aren’t usually this straightforward. Why reconstruct a tooth using an onlay instead of a regular filling? Or why use a crown instead of an onlay? Why ceramic instead of resin or zircon? Why an implant instead of a bridge for a missing tooth?

The wide range of possible choices also includes what we can do to deal with wisdom teeth, of course. In a nutshell: many dentists are, subjectively, making wrong (or at least, sub-optimal) choices. The free and “artistic” nature of dental care allows for this.

Another key different between dentistry and other branches of medicine lies in the manual nature of dentistry. There are multiple medical specialties where doctors barely touch their patients. Think of endocrinology, where many treatments are basically just pharmacological. Think of going to the emergency room with pus in your throat and a fever: the general doctor will kindly give you a prescription for good auld antibiotics, but they will not bother to drain the throat abscesses. Think of a radiologist!

Dentistry is the extreme opposite. Dentistry is a very manual discipline. When people ask me whether a certain treatment is “forever”, I often reply that what we dentists do is simple “do-it-yourself”, compared to what nature does. Dentists shouldn’t be expected to perform miracles where nature failed!

But that is the thing: we do “DIY”. We modify stuff all the time. We build and remove things. We intervene, on soft or hard tissue, on a daily basis. I’ve told myself that if I were seeing patients at an emergency room, I would drain any pus patch I saw on patients’ tonsils with pharyngitis. We just can’t resist. A dentist is a proactive “manual worker” by nature.

And this can very easily result in excessive treatment. Such as excessive wisdom teeth removals.

Another reason is probably related to something called the Semmelweis effect: the tendency of people to reject evidence that contradicts established customs or beliefs. Ignaz Semmelweis himself found out in the 1800s that something as basic as proper hand hygiene saved lives. And he was rejected by his fellow colleagues! When other dentists mock my philosophy towards wisdom teeth, that includes things as basic as not removing teeth that are fine, I can’t but feel identified with him.

So, maybe you’re seeing a not-so-serious orthodontist. Maybe he recommends everybody to get their wisdom teeth removed when braces are over “to prevent crowding”. Or maybe before them, “to improve crowding”. Maybe this is an experienced orthodontist that has been doing it like this since he began working. Maybe this is what he was taught during his training as an orthodontist.

Well, let me tell you something: despite his experience and training, your orthodontist is wrong. Miserably wrong. He believes in an urban legend. Whatever their position, wisdom teeth cause no crowding, and removing them doesn’t improve crowded teeth. But even if he was confronted with evidence and guidelines, do you think he would change his mind… and his way of working, after so many years of doing the same, and so many beliefs built around this wrong idea? Obviously, no, he wouldn’t. I don’t need to imagine it: I have seen it in real life. And it is a perfect example of the Semmelweis effect.

This nonsense of wisdom teeth pushing and crowding teeth, or ruining orthodontic treatments, used to be particularly popular in French schools of orthodontics. This resulted in legions of orthodontists that, up to this day, continue to recommend the removal of healthy and normal third molars for no reason. In fact, orthodontists are arguably responsible for more unjustified wisdom tooth removals than general dentists, so wherever you are, beware of this, if you have or going to get an orthodontic treatment.

Another reason that’s closely related to the previous one is probably that dentists usually don’t bother to be up to date about removals. Removals are kind of taken for granted as a very basic procedure. They are indeed very basic: removing a tooth is the most primitive and elemental dental care act. Think of how ancient barbers, or healers, or whatever, were already able to remove teeth.

So, dentists past their university years will spend almost no time learning more about dental extractions. I mean, compare that with the time they (we) will spend on accessory training about… implantology? Periodontics? Orthodontics? Endodontics? You name it.

And this means, not getting to know the guidelines that advise against removing asymptomatic and healthy wisdom teeth, for instance. I am actually convinced that many of the dentists that hate me didn’t even know those guidelines existed… until they found me, and they decided to begin hating Jay Friedman, the NICE and the APHA too.

Also linking with the previous reason, I can think of a final one: a simple lack of knowledge and proper training by many dentists. In my particular case, I swear dental school never taught me when it is OK to remove a wisdom tooth. When we studied the indications of removals in orthodontics, my Orthodontics professor deliberately skipped the third molars. I will never understand why. And in the three Orthodontics subjects we had, we were never clearly taught that wisdom teeth causing crowding is a myth.

In Surgery, we were forced to memorize a huge awful list of pathology related to third molars, but we were never taught how rare the incidence of such pathology is, or even more in general, what the proper indications for the removal are! Sure, the removal is only fine when those rare cases of pathology show up, as you probably already know at this point, my dear reader. But we were never taught this! I only discovered the guidelines advising against unnecessary wisdom teeth removals while doing research on my own.

I am sure I am not the only dentist that received such poor training. For starters, this was the case of the tens of dentists that were graduating each year from the University of Granada (often said to be the second best dental school in Spain). Tens of dentists each year, that need to deal with wisdom teeth, having been taught so many things about wisdom tooth pathology, but nothing about their myths and the removal contraindications. I can subsequently imagine them, seeing scary panoramic x-rays of horizontally impacted wisdom teeth for the first time, and applying some flawed “common sense” to deal with them: because if they look so oddly positioned on the x-ray, it only makes sense to get them removed before they cause a problem, right? Well, no!

Lastly, I would like to make it clear that there is something I do not believe: I don’t think economic incentives are the reason as to why so many wisdom teeth get removed without necessity. At least, they are not the main reason. Believing this would be like believing your pediatrician tells you to vaccinate your kids because the big evil pharma companies are bribing them: pseudoscientific crack pottery! I invite you to read the corresponding article for more insight.

For now, know this: unnecessary wisdom tooth removal is also a thing in places where it is not all that profitable, including France, where I work. This proves that the economic part is not all that relevant to the problem. Most of us dentists or oral surgeons do our best to work ethically.

So, I will bid farewell by quoting the Hanlon’s razor with no further comment. Its origin is not clearly known, so I will take the freedom to quote it bilingually, as usual: Nunca atribuyas a la maldad lo que se explica adecuadamente por la estupidez. Meaning: Never attribute to malice that which is adequately explained by stupidity.

Saludos cordales.