An Eighteenth Century Extraction

In reading Robert Massie’s fascinating biography of Catherine the Great, I came across the following account of a toothache and high fever that persisted for months.  It got unbearable when the Princess was traveling in an open sleigh from Moscow to St. Petersburg during a brutal Russian winter.  In her diaries she describes the agony she felt.  Of course at this time there were no antibiotics and no analgesics.

When the entourage arrived at their destination, the Empress’s chief physician was finally called in to extract the offending tooth.  The chief surgeon was French – apparently there were no dentists so medical surgeons filled in as needed.  He sat on floor with another surgeon, and both held the Princess down.   He wrenched and pulled until she could feel her jaw bone breaking.  He had extracted the tooth and with it, a piece of lower jaw.  She was confined to bed and was in pain for 4 weeks, her jaw exhibiting blue and yellow bruises from the physician’s fingers.

She survived the ordeal – but aren’t we lucky to have the benefits of modern dental medicine!

Yesterday I wrote a response to the New York Times article that claimed that too many wisdom teeth were being unnecessarily extracted in the U.S.   So this morning I got to the office and what do you think I see in my first two patients? Wisdom teeth dilemmas.

The first patient, a 40 year old mom, had all of her wisdom teeth, but one was severely decayed.  The only option was extraction.  She was not doing an adequate job of keeping the teeth free of plaque.  The second patient was a younger woman, also with retained wisdom teeth.  Her home care is good, but her wisdom teeth are semi-impacted in the soft tissue and difficult to reach.  These teeth were coated with plaque.  Extraction is certainly a viable option but I left the choice to her.

If the teeth are problematic, it is better to do the extractions while a person is younger because the healing capacity is better in younger people and as people age, other health problems have the potential to complicate any extractions.  So this is another factor weighing in on early extraction.  Again, experience and judgment as well as patient communication are key.

Are wisdom teeth expendable? – that is the question.  Pros and cons appeared in an article “Prudence of Having That Tooth Removed” in the September 6, 2011 New York Times at http://www.nytimes.com/2011/09/06/health/06consumer.html.  The article advises against routine extraction of wisdom teeth (third molars) as scientific evidence supporting routine preventive extraction is lacking.  The author notes that “Each year, despite the risks of any surgical procedure, millions of healthy, asymptomatic wisdom teeth are extracted from young patients in the United States, often as they prepare to leave for college.”  I don’t know how she came up with the figure of “millions” but it seems excessive.  I don’t know of any oral surgeon who routinely extracts “healthy, asymptomatic” wisdom teeth nor would I routinely refer such teeth to a surgeon for extraction.  I only recommend extraction if there is a reason to do so.

However I think that the author underestimates the percentage of problems we see related to wisdom teeth.  If I see a problematic tooth then I would discuss extraction with the patient and guardian.  Sometimes there is a problem that is not obvious to the untrained eye.  There might be pathology evident on a radiograph but not visible to the patient.  The tooth might be decayed.  It might be impinging on the second molar, affecting the  prognosis of the second molar.  The tooth might have soft tissue impaction and recurring infections.  These are all good reasons for extraction, and all of the above do occur quite frequently.  People are often concerned that their third molars are causing crowding of the lower front teeth – but there is no evidence that this is the case.

An issue not discussed in the article is the prevalence of periodontal disease among adults, possibly affecting 60% or more of the adult population in the U.S.  If the patient is not adept at removing plaque from hard to reach third molars, it might be prudent to extract them, for the health of the rest of the dentition.

Nevertheless, surgery always carries a risk, including possible nerve damage and complications from the anesthesia.  If you do opt for extraction, ask for local anesthesia, which is generally safer than general anesthesia.  Follow post-op instructions: soft food for a couple of days, ice on the area, and analgesics if necessary.

Whether or not to extract wisdom teeth, like everything else in dentistry,  is a matter of judgment.  Your dentist needs to have good judgment and experience and have your best interest at heart.

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Check out the ads for the new comedy film “The Hangover.” What do you notice?  Right in the center of the ad is a guy who is missing a tooth (the right later incisor, to be exact).   If that photo doesn’t convince everyone to take care of their teeth, then I don’t know what will!  So I checked out the trailer.

The film is about some friends who get together for a raucous bachelor party.  The next morning they all have headaches but remember nothing of the night before. “ I lost a tooth,” says our hero, as he looks at himself in the mirror.  You’d think it would have hurt!  Well if you need a tooth extracted, it’s better to come to our Long Island dental office for the procedure, and don’t be afraid – I promise it won’t hurt and we won’t let you go home without a replacement tooth!

 

Cover of "The Hangover (Unrated Edition) ...

The Hangover

 

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David came into my East Setauket, Long Island dental office today and insisted that we take out all of his few remaining teeth. “Pull them all out – I don’t want any more tooth problems!” he said. But don’t do it!!! You will regret it. We always try to save any teeth that we can. Even if the tooth has a limited life expectancy, it is better to keep it as long as you can then to have it extracted. If you think you have problems with your teeth, just wait until you have denture problems.

Even the best dentures – or implant dentures – are not like having your own teeth. Even in the worst of situations we can often salvage the lower front teeth or at least the lower canines so we can use the teeth for a partial denture clasp. This is so much better than a full lower denture. You can be sure that I always discuss all of the pros and cons of “pulling them all” for my Long Island patients before I consider extractions.

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