Part 2 Wisdom Teeth
Read our second part of Wisdom Teeth series of blogs and find out when to remove or not to remove wisdom teeth, learn about the treatment and recovery process.
When to treat, when not to?
Generally, wisdom tooth ‘treatment’ implies the removal of the tooth. In Australia, it is common for dentists to advise the removal of all four wisdom teeth in many cases, in adolescence. In the UK, the ‘official’ recommendations are those wisdom teeth only be removed if there is existing ‘pathology’ i.e. there is already some infection.
Our own approach is simply this:
Wisdom Tooth diagnosis
I would recommend removal of the wisdom tooth if:
- If there are any symptoms of pain, discomfort, swelling etc. associated with a wisdom tooth, the cause of which cannot ‘relatively’ easily be treated successfully and in such a way that the problem is very unlikely to recur.
- If part of the tooth is exposed through the oral cavity, and that tooth will never come through straight and fully functional, even if there is no pathology present at that time, should I evaluate such a tooth to be likely to experience problems in the future?
- If the tooth is functionless, almost impossible to ‘keep clean’ and prevents adequate cleaning of the back of the 2nd molar in front of it. This is more often the case with upper wisdom teeth.
Wisdom tooth treatment – removal
Not all wisdom teeth are ‘difficult’ to remove. It all depends on their position in the jaw bone, their root shape and formation, access to them ( i.e. small or large jaws/opening) and last but not least the patient’s tolerance and attitude. Generally, lower wisdom teeth are the ‘tougher’ to remove than the upper teeth.
Usually, it takes between 15 minutes and an hour and a half to remove (particularly) a lower wisdom tooth. In some cases, the whole tooth is removed quite easily; in others, one may have to cut the tooth into segments and take each one out separately. There are times , one may decide to leave part of the tooth root in the bone (where it can harmlessly remain ’for life’).
Sometimes it is appropriate to refer to a specialist Oral and Maxillofacial Surgeon, who may or may not remove the tooth/ teeth under local anaesthetic with or without sedation or even, under general anaesthetic. The surgery is sometimes done in a private clinic; sometimes in hospital (particularly if general anaesthetic is needed or required). More often than not sutures ( stitches) are placed over the tooth socket wound, which if not self resolvable, are removed after about a week. Painkillers are prescribed and antibiotics may or may not be.
Recovery from wisdom tooth removal can sometimes be a bit ‘unpredictable’ . This generally depends on a number of factors:
- The degree of ‘difficulty’ in the removal of the tooth.
- The amount of ‘trauma’ experienced during tooth removal.
- The presence or absence of existing underlying infection around the tooth (at time of removal).
- The expertise of the surgeon.
- And very significantly, the health and resilience of the patient.
Any possible post-operative ‘complications’ should obviously be explained to the patient, although in the relatively rare event one of these does occur, it is resolved within a week or two.
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Wisdom tooth extraction
Wisdom teeth have always been around and have always caused problems ( although not in every case ). Human beings have genetically evolved to have 32 teeth of which four are 3rdmolars and because they are the last to ‘come through’ after childhood and apparently when the individual has started to gain wisdom ( ha ! ha!) they are called ‘wisdom teeth’.
Where there is enough space in the jaws ( they are ‘big’ enough) to accommodate all 32 teeth, these 3rd molars will usually erupt straight, in line and be fully functional. In that event, ‘nothing’ needs to be done to them other than to keep them as clean as all the other teeth.
However, in some cases, and we don’t know why, one or more of these wisdom teeth ( more often the lower rather than upper ones), develops lying at an angle and so does not erupt ‘straight’ into the mouth, as the teeth in front of it generally would have done years earlier. Such a tooth is termed an ‘impacted’ (wisdom) tooth, simply because more often than not it impacts against the side of the 2nd molar in front of it. These impactions can be in all sorts of different angles and positions; some superficial, some deep.
When there isn’t enough space for all teeth to come through in the mouth, crowding (‘crookedness’) and overlapping of teeth ( particularly front ones) usually occurs. In this case, it is very common that the wisdom teeth don’t have enough space to come through ‘normally’. They may or may not be impacted, but they certainly aren’t ’functional’.
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When do they cause problems ?
Obviously, wisdom teeth that have erupted straight and are fully exposed through the gum ( like all other teeth) won’t cause a problem [unless decay or gum disease is allowed to develop as in other teeth].
Unerupted wisdom teeth, if deeply buried, irrespective of whether they are impacted or ‘misaligned’ and are not just fully covered by gum but also by the underlying bone, will not cause a problem and can be left ‘in place’, usually ‘for life’. In these cases, the infection does not penetrate around the tooth and they are ‘harmless’. There is a misconception that an impacted tooth that ‘looks’ as if it is pushing against the back of the 2nd molar in front can ‘cause’ the lower front teeth to start crowding. There is no scientific evidence for that inference.
Front teeth ( usually lowers) starting to crowd in adult life are a result of ‘mesial drift’ and are not related to wisdom teeth.
On the other hand, if a wisdom tooth is partially exposed to the oral cavity, that is ‘part’ of it is through the gum, then the plaque , food debris, bacteria etc. can collect under a gum flap or down the side of the tooth, often between it and the 2nd molar in front. This can result in inflammation, pain, swelling etc. Such a tooth may be lying on its side, maybe impacted ( which is why only a part of the crown is exposed in the mouth ) or even may ‘look’ straight but because the back part is covered by bone it can’t fully expose into the mouth.
Occasionally teeth can be fully and (relatively) normally erupted, but are simply covered by a flap of gum which is either ‘traumatised’ by being bitten on continuously by an erupted opposing upper wisdom tooth or because the infection has formed under that gum flap ( between it and the underlying wisdom tooth crown).
To find out more about when to remove or not to remove wisdom teeth, please read part 2.