I was having serious trouble with a painful tooth that was painful even after a root canal (twice). I was sent to the oral surgeon to check if the impacted wisdom tooth behind the problem molar was leaning on it hard enough to be causing the ongoing pain. Oral surgeon decided that not only that one but the wisdom tooth on the other side needed to come out, and by the way I also have an impacted bicuspid in the upper jaw that we really ought to have out as well while we're about it...

Um. Yes. I've known about that impacted bicuspid for over twenty years. Nobody else has ever seen fit to suggest that it ought to come out "just in case". Since I've moved around a bit, that's several dentists. This did not endear him to me, as it raised just the tiniest suspicion in my mind that he might be more concerned with his bank balance than clinical necessity. Both in that, and in suggesting that the other wisdom tooth should be removed.

An implant got added to the the list of potential surgery after it turned out that a molar near the impacted bicuspid was so badly decayed under a filling that it wasn't salvageable. When I went for the assessment on taking that molar out (it was a general anaesthetic and drill it out job, so back to the oral surgeon), he had another go at me about let's take out the bicuspid while he was rummaging around in that quadrant anyway. I objected, because there was a distinct possibility that yet another tooth was going to have to come out, and the bicuspid might be useful as a replacement. At which point there was chatting back and forth between practices, and it was decided to leave it alone until they were quite sure they'd cleared up the rest of the mess.

So I trotted along to the Australian dentist, told him what had been happening since he'd seen me as an emergency patient a year before, and asked him what he thought about the proposed extractions and implant.

The impacted bicuspid - if ain't broke, don't fix it. Taking it out is serious invasive surgery, with a lot of pain and discomfort for several weeks, and small but serious risk of things going wrong. On balance, if it's not causing a problem (which it's not), leave it alone and check it regularly by X-ray, rather than taking it out simply as a precautionary measure.

The impacted wisdom tooth - yes, removal is justified, but it has to be balanced against the risk of nerve damage. If the roots are wrapped around the nerve (which needs to be decided by an oral surgeon with full X-ray), it's less risky to leave it alone unless there's serious bone damage.

Having an end-of-row implant will be expensive, invasive, painful surgery with all the attendant risks and ongoing discomfort, for a small amount of cosmetic benefit, and almost no real practical benefit at the moment given that I still have adequate chewing function on that side, and full chewing function on the other side.

Which is pretty much what I thought, but it was nice to have it confirmed. The proposed work can all be clinically justified, but not all of it is necessary and even the item that is needs to have the risks weighed.

[This message has been edited by Julia (edited 05-16-2003).]