Wisdom Teeth and Extraction of Teeth Wisdom teeth, or third molars, are the last teeth to develop and appear in the mouth. They are called wisdom teeth because they usually appear during a person’s late teens or early 20's, the age where we are hopefully increasing in wisdom. The upper and lower wisdom teeth develop just behind the second, or 12-year, molars. Wisdom teeth cause more problems than other teeth for two reasons. First, the jaws of the typical modern human aren't normally large enough to accommodate the four wisdom teeth. Second, since wisdom teeth are the last teeth to develop and attempt to erupt, the space available is generally already taken up by the other teeth. Wisdom teeth are simply left without a place to erupt. This is why 9 out of 10 people have at least one wisdom tooth that remains underneath the gum due to lack of space in the mouth. For those who do have enough space, and the wisdom teeth erupt normally, it is still difficult to keep the area clean since it's so far back in the mouth. Decay is a common problem for even successfully erupted wisdom teeth. When a wisdom tooth is blocked from erupting or coming into the mouth normally, it is said to be impacted. A tooth may be partially impacted, meaning it grows in crooked and only partially breaks through the gum, or it may fail to break through at all and thus remains completely impacted. Serious problems can develop from partially impacted teeth, such as pain, infection, or damage to adjacent second molar teeth. For completely impacted teeth, a painless but serious problem can occur if the sac that surrounds the impacted tooth fills with fluid and enlarges to form a cyst. This enlargement can hollow out the jaw and result in permanent damage to the adjacent teeth, jawbone, and nerves. If the cyst is not treated, a tumor may develop from the walls of the cyst and a more involved surgical procedure may be required for removal. Although less than 10 percent of people are able to avoid having any wisdom teeth extracted during their life, not all wisdom teeth require extraction. Those wisdom teeth that have fully erupted into a normal position may be checked by your general dentist to ensure that you are properly cleaning them and no problems are developing, such as decay or gum infections. It’s tempting to ignore potential problems unless pain is noticed, but many problems withwisdom teeth occur without any symptoms of pain or swelling. This is particularly true when there’s partial, even microscopic, eruption of the wisdom teeth. This condition allows a chronic bacterial infection (periodontal disease) to exist in the tiny gap between the wisdom tooth and the second molar tooth just in front. Since this area is totally inaccessible for hygiene, the result is slowly progressing gum and bone recession that affects the healthy tooth next door. Xray showing the immature roots of developing wisdom tooth Far too often, when a patient has the wisdom teeth taken out after his or her early twenties, there is significant (and usually irreversible) damage to the second molars. For these reasons, we may recommend the removal of wisdom teeth even if they aren’t yet causing obvious problems. There is significant risk to a "wait and see" approach to unerupted wisdom teeth. The Ideal Time for Wisdom Tooth Removal It’s important to know that as wisdom teeth develop, their roots become longer and the surrounding jawbone more dense. Root development usually begins at about age 12 and ends at about age 18 to 20. Once a person exceeds that age, it becomes more difficult to remove wisdom teeth, resulting in a longer recuperation and a higher likelihood of complications. In addition, the typical responsibilities at home and at work make it far less convenient for adults to take time out for a surgical recovery than for teenagers to do so. Although extraction for orthodontic patients may be as early as age 12, the ideal age for evaluation and possible extraction of wisdom teeth is about age 15 or 16. At this age, the position of the wisdom teeth and the space available for eruption can be determined, and the need for extraction can be decided upon. In addition, root development and general health conditions at this age are optimal for a smooth procedure and recovery. No matter what age you are when you come to see us, we will begin with a consultation where we can review your health and dental history, examine you and your Xrays, and discuss your diagnosis and treatment options. Occasionally, circumstances of a more urgent nature require that surgery be done the same day as the consultation. Generally, however, after a review of your medical history and a discussion regarding your needs, a second appointment is necessary to provide your actual treatment. In addition to wisdom teeth, which may never actually be visible in the mouth, a number of problems or defects in other teeth may leave them unrestorable or unusable. In these cases, extraction is necessary to prevent the spread of infection and improve the long-term outlook for adjacent teeth. Extraction of Other Problem Teeth Decayed Teeth As long as tooth decay is discovered before it becomes too large, most teeth can be repaired with restorations or crowns. Occasionally, endodontic or root canal treatment is needed if decay has reached the deeper part of the tooth and infected the nerve. Extensive decay leaves such a large cavity that the tooth is hopelessly weakened, and extraction is advisable to prevent spread of the infection. An infection that starts out as a simple cavity can spread into the surrounding jawbone. The resulting pain can be excruciating, and the infection can cause swelling and fluid to build up in the face. This condition is called an abscess, requiring prompt extraction and perhaps surgical drainage and antibiotic treatment. Periodontally Diseased Teeth The gum and bone surrounding teeth (the periodontal tissues) recede very slowly as we age. As gum and bone tissue recedes, the tooth is left with progressively less and less bone to anchor it into the jaw. This gum recession can be accelerated greatly where there is a defect in the gum tissue, from overaggressive brushing, or from chronic bacterial infections, called periodontal disease. In advanced stages, a tooth can be chronically sore, exude a foul odor, and even become loose in the socket. Although oral hygiene is a critical factor in the progression of periodontal disease, some patients with excellent hygiene still suffer from progressive periodontal disease. Certain periodontal surgeries can prolong the life of affected teeth, but extraction is the only appropriate treatment for a severely diseased tooth. On some children, deciduous, or baby teeth, do not loosen and fall out as they should. In this case, there is often pain, looseness, and bleeding gums, and it is necessary to extract the affected teeth. Cracked or Fractured Teeth A cracked or fractured tooth can result from a traumatic blow or a chewing accident, but it most often occurs as result of a cavity that has become large enough to weaken the tooth. Sometimes a tooth that has had a crown or a root canal is weakened, and a fracture occurs. A very strong bite or a habit of teeth-grinding or chewing very hard things like ice or corn nuts can increase the chance of a cracked tooth. A cracked tooth can not be adequately cleaned out, even with a root canal treatment, and must be extracted. Crowded Teeth or Extra Teeth Many people have insufficient jaw space for all of their teeth. With too little space, wisdom teeth often become impacted, but other teeth may also become crowded, malposed, or even impacted. In most cases, crowding can be resolved by orthodontic treatment. Impacted teeth that are not wisdom teeth can even be guided into proper eruption; this is commonly done on the upper canine teeth. Sometimes the crowding is so severe that 2 or 4 permanent teeth are strategically extracted in order to create enough space to properly align the others. To carry out your successful orthodontic care, we will work in close cooperation with your orthodontist, who will specify which teeth need to be removed or surgically guided into eruption. Since these extractions are often needed at about the time wisdom teeth need to be extracted, it is very common that patients will have wisdom teeth as well as other teeth removed at the same time. Most people develop a set of 20 deciduous teeth, followed by 32 permanent teeth. Although some people fail to develop all the permanent teeth, some patients actually develop too many teeth. The most common sites for extra supernumary teeth are the anterior palate just behind the upper front teeth, the lower premolar area, and the wisdom tooth area. Like wisdom teeth that are impacted, if an extra tooth is left in place, it may cause harm to nearby teeth. These teeth often prevent proper oral hygiene and cause orthodontic crowding. Extra teeth are nearly always extracted, and, like wisdom teeth, early extraction is advisable to minimize risks. The Surgical Procedure Your specific treatment will be discussed during your consultation. The removal of wisdom teeth or other teeth is a minor surgical procedure and is performed on an out-patient basis in our office surgery center. The surgical procedure usually takes 30 to 60 minutes, but it varies according to each case. Some simpler procedures can be performed using local anesthesia. The more complex or difficult procedures and surgeries are best performed in complete comfort with the aid of sedation anesthesia. On the day of surgery we’ll ask you to come in with an empty stomach and an escort driver to be here with you during the treatment and then take you home. We will bring you back to our treatment room, recline you on one of the surgical chairs, and start a small IV in your arm. Once the medicine is administered through the IV, it takes about 30 seconds to fall asleep. Once you’re asleep we’ll go ahead and begin the procedure. Sedation anesthesia allows your treatment to be free of pain and anxiety. The method used to remove your wisdom teeth will depend on various factors: the position of the teeth, the length or curvature of the roots, the thickness of the bone surrounding the teeth, and the position of nearby teeth. If the teeth have fully erupted, it’s possible to simply remove each tooth intact from its socket, using forceps or other instruments designed for this purpose. If gum tissue is covering the tooth, an incision will be required to open up the gum and expose the tooth. For an impacted tooth, after opening up the gums we’ll remove sufficient bone to expose the tooth and allow its removal. We sometimes place sutures (stitches) at the end of the procedure to hold the gum tissues together and aid healing. Sutures usually aren’t needed unless several teeth are removed at once, but for your convenience we always use dissolving sutures that don’t require removal. When we have finished your treatment, you’ll be awakened from the sedation and brought to the recovery area where your escort can keep you company as you recover. It typically takes about 30 minutes to be ready to go home. Once you’re home you’ll probably want to take a long nap and should keep your activity light for several days. Most patients experience enough discomfort to take pain medication, and we will prescribe some strong medicines to keep you comfortable. There will also be some swelling and stiffness of the jaw, which will require you to stay on a softer diet for several days. You can advance your diet to more normal foods as long as your comfort permits but most patients take close to a week before they’re back to chewing all their normal foods. At the end of this chapter, a more complete set of instructions is given for recovery and wound care. Potential Complications of Tooth Extraction The removal of wisdom teeth and other similar oral surgery and extractions are common procedures that usually produce few, if any, serious complications. However, as with any surgical procedure, you should be aware of the risks and benefits. A partial list of potential problems appears below. When you come in for a consultation, we can discuss any potential problems relating to your particular circumstances. Infection: Any time body tissues are invaded, as in surgery, there’s a slight chance of infection. Any infection should be taken seriously and brought to our attention. We may need to prescribe antibiotics to eliminate the problem. Signs to watch for include fever, prolonged swelling and pain, or a foul discharge from the wound. Problems with adjacent teeth: Damage to adjacent teeth or the fillings or crown or bridgework of adjacent teeth can occur, generally in older, weakened fillings or crowns. Neighboring teeth are often sensitive or even slightly mobile for a couple of weeks following an extraction. Discomfort: It’s common to experience discomfort after oral surgery. Sometimes the pain doesn’t reach its peak for 3 or 4 days after surgery. In some patients, healing doesn’t progress properly, and the socket heals much more slowly than usual. This condition leaves the bone within the socket exposed to air, food, and fluids, and the pain can take a week or even longer to subside. Most often, this occurs only in the wisdom teeth of the lower jaw and is nearly always associated with smoking or birth-control therapy. Some patients who clench or grind their teeth also have a more prolonged recovery because of soreness in the jaw muscles. Numbness: In some cases, sensory nerves serving the mouth are close to wisdom teeth roots, and it’s possible that one of these nerves could be irritated during surgery. If this happens, there may be numbness or a tingling sensation affecting one or more sites in the lower lip and chin, gums, teeth, and very rarely the tongue. The numbness is nearly always temporary but in rare cases can be permanent. This complication is very dependent on the age of the patient – the older the patient, the higher the risk. Sinus complications: Sometimes upper wisdom teeth or molars are near the large maxillary sinus, and the roots may even penetrate into the sinus cavity. An opening into the sinus through the extraction socket may occur following tooth removal. Although this opening generally heals itself, we’ll give you a few precautions that will assist the healing. Postoperative Instructions Discomfort: Adults should take 400 mg of ibuprofen (sold over the counter as Motrin, Advil, Nuprin) every 6 hours whether or not you’re having pain. You should fill the written prescription and have it available to treat any pain that isn’t relieved by ibuprofen. Applying ice to your face, especially during the first 2 days, can also help keep you more comfortable. Discomfort generally peaks several days after the surgery. Your pain medication can be tapered off as your comfort level improves. Smoking has been shown to greatly increase the pain and the complication rate after surgery and should be stopped during the entire healing period. Discomfort that continues after the first several days may be due to spasm of the jaw muscles. Applying moist heat for 10 minutes followed by massaging the areas for 10 minutes will help break the spasm; do this several times a day. Bleeding: Gauze packs were placed in your mouth at the surgical site to provide gentle pressure over the wounds. Replace these packs with fresh ones every 30 to 45 minutes, or until the bleeding has completely stopped. Usually several hours of gauze application are needed. It is quite normal to notice occasional bleeding or blood-tinged saliva many days after surgery. If bleeding seems to be persistent, dip the gauze in ice water and bite on it firmly for an hour or two. Keep your head elevated. Certain activities such as drinking through a straw, spitting, rinsing vigorously, or eating hot foods can all cause persistent bleeding and should be avoided during the first 24 hours. Fever, swelling and bruising: A low-grade fever (under 101? F) sometimes occurs for a few days after surgery. Swelling in the face usually peaks at 24 to 48 hours after surgery, and then resolves over the next few days. You may also notice some bruising on your face or neck. Diet and oral hygiene: You should limit your diet to soft foods for the first 24 hours. Make sure you take in plenty of fluids to avoid dehydration. After 24 hours, you may eat whatever your comfort permits. Don’t rinse vigorously the day of surgery since this may cause bleeding. To keep the wound clean, beginning on the second day, rinse your mouth with warm water. If you were given an irrigating syringe, use it to irrigate any food or debris from the sockets after meals. You can brush the teeth surrounding the surgical site with a soft toothbrush a few days after the surgery. Stitches: After extraction of teeth, dissolving stitches are sometimes placed in the area; these stitches generally work their way loose after a few days. Nausea: Narcotic pain medicines or even small amounts of swallowed blood will cause nausea for some people. You can decrease the likelihood of nausea by making sure you take the pain medicine with some food. If you do become nauseated, you can take a dose of Bonine (travel sickness medication available without a prescription) along with the pain medicine, or you can discontinue the prescription medicine and substitute a non-narcotic medication such as Aleve or Motrin. If you find that in spite of taking the measures mentioned above, your nausea is severe enough to prevent you from holding anything down, then a prescription suppository is available. Please call our office immediately at (805) 981-8144 if you encounter severe bleeding, difficult breathing, inability to swallow, or persistent vomiting. If you were given any sedating medicines for your surgery, do not operate any vehicle or other hazardous device for 24 hours.