Dr. Jay Friedman relishes his role as dental outcast. Like a pesky younger brother who enjoys watching his siblings squirm, the 86-year-old dentist and public health advocate has for decades been poking and prodding at the oral health community over his personal obsession: wisdom teeth.
Friedman has argued for more than 30 years that removing a young person's healthy wisdom teeth -- called "third molars" by professionals -- is an unnecessary and irresponsible practice. While many dentists and oral surgeons have dismissed him as a traitor and a zealot, in 2007, people in the public health arena began to listen.
That's when Friedman published an article in the American Journal of Public Health claiming at least two-thirds of the millions of wisdom teeth extracted each year at a cost of billions of dollars were removed for no good reason. In pointed terms, Friedman accused his colleagues of ignoring the lack of evidence supporting the need for such surgery in order to line their own pockets.
Friedman has compared the practice to prophylactic tonsillectomies, which were routinely performed on healthy children to prevent future throat problems in the first part of the 20th century, before the medical community denounced them as unnecessary.
"There can be no excuse for tolerating so many unnecessary extractions on millions of unsuspecting and misled people and putting them at risk of so much ... nerve injury. This is a public health hazard," Friedman wrote.
The next year, the American Public Health Association adopted a recommendation opposing the prophylactic removal of wisdom teeth and a few insurance plans decided they would no longer cover such extractions.
It's hard to overstate how much these developments have angered oral surgeons.
Dr. Lou Rafetto, a practitioner in Delaware, paused during a phone interview to apologize as he wound down a tirade. "Sometimes I get emotional when it comes to Jay Friedman," Rafetto said.
Many surgeons have been similarly angered by Friedman over the years and have questioned his qualifications since he is not a trained oral surgeon. Practitioners insist wisdom teeth cause many people problems later in life, and say it's prudent to remove them early rather than wait for trouble.
One surgeon said he recently had to remove an infected wisdom tooth in a 93-year-old man, who should have had it out when he was a teenager, when the surgery would have entailed a quick recovery.
"It's sort of a thorn in the side of people who actually treat patients with third molars that this guy gets so much traction," Rafetto said of Friedman.
Yet despite the maverick dentist's unpopularity, Friedman has sparked some soul searching within the profession and even prompted a change in policy.
Earlier this year, the official oral surgeons' group, the American Association of Oral and Maxillofacial Surgeons (AAOMS), adopted a new recommendation on wisdom teeth removal. For the first time, the group said surgeons should consider retaining young patients' wisdom teeth if they do not show signs of disease. For decades, the accepted wisdom was that all wisdom teeth should be removed.
"The retention part is new," said Dr. Thomas Dodson, a member of AAOMS's task force on wisdom teeth.
Dodson, an oral surgeon at Massachusetts General Hospital, sees himself as one of the few people in the middle of the acrimonious wisdom tooth debate. He argues that Friedman is ignoring the problems associated with keeping wisdom teeth while some oral surgeons are minimizing the risks of subjecting so many people to the surgery.
And there are risks. About 1 percent of people whose wisdom teeth are removed experience nerve damage -- usually temporary numbness of the lips, mouth, or tongue. Sometimes, that damage is permanent, leading to "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," Friedman wrote. Complications from anesthesia can lead to death in very rare instances.
There's no long-term research, however, on the risks of retaining healthy wisdom teeth.
Some studies suggest that about 30 percent of wisdom teeth removed each year created some kind of problem for the patient, ranging from gum disease to cysts to painful infections. And oral surgeons point to research that shows gums are more likely to be infected around wisdom teeth than other teeth, which can lead to other health problems.
Friedman argues that dental professionals should wait until they actually see signs of disease before removing a patient's wisdom teeth, saying it's not worth subjecting people to potential complications on a hunch that their wisdom teeth might cause problems later. (That's the official policy of Britain's National Health Service, which won't pay for prophylactic procedures.) The cost is also something to consider, since without insurance, wisdom teeth extractions can cost a patient several thousand dollars.
So when Dodson is treating a young patient whose wisdom teeth seem normal, he says he's not really sure what to tell them.
"The reality is the science is insufficient at this point to demonstrate that taking them out or leaving them is the right thing to do," Dodson said.
Friedman says in these situations, oral surgeons should tell their patients to come back if they or their dentist ever notice a problem. Dodson, however, leaves the decision up to the patient after warning them of the risks of both courses of action. He says about 60 percent of these patients opt for surgery.
Friedman calls the new AAOMS policy "a big sea change" from the days when retaining healthy wisdom teeth was not even an option, and happily takes credit for it. But he's not satisfied. Though he agrees that any wisdom teeth that are causing problems should be removed, he thinks oral surgeons are overhyping the risks of retaining teeth that don't show any symptoms.
Friedman has some reason to be skeptical of AAOMS policies.
A pamphlet on the group's website once stated that 80 percent of people who retained their third molars would experience problems with them within 10 years. After Friedman pointed out that the number did not seem to be based on any scientific research, AAOMS removed the figure.
Friedman, who once reviewed medical claims for self-insured companies, introduced his theory that most wisdom teeth extractions were unnecessary in a fiery speech to a California dental association in 1976. The editor of a local dentistry journal published the speech, prompting a wave of outraged letters from California dentists. To this day, oral surgeons say Friedman is biased against wisdom teeth extractions because his aim is to save the insurance industry money.
Friedman has taken out hundreds of wisdom teeth in his own right, including those belonging to his only child. When his daughter was 18 she began to complain of pain and discomfort from her wisdom teeth and Friedman was unable to dissuade her from taking a wait-and-see approach. He says he took her to his office, removed all four teeth in 15 minutes, and then flew the next day to a dental association meeting in Las Vegas to lecture oral surgeons on their overzealous extraction policies.
"I didn't tell them that the day before I had taken out my daughter's wisdom teeth," Friedman said mischievously.
Dodson, for one, said Friedman's crusade has made him consider his own practices more carefully, despite their difference in opinion.
"He made me think about why we were doing what we're doing," Dodson said.