It seems that everyone in their late teens and early 20's have been urged by their dentist to have their wisdom teeth removed. Some of the rumors about wisdom teeth are true ..... many of the rumors are not. The following is a patient's guide to wisdom teeth.
Wisdom teeth appear as the last tooth in the mouth and begin to erupt around the age of 16 years. This has been called the age of wisdom although that parallelism would be questioned by many. Depending on the reference source, up to 90% of the population does not have enough room for wisdom teeth to erupt into a position which is accessible for good hygiene.
A commonly asked question is, "Why do we have wisdom teeth if there is no room in the jaws for them?". The answer has to do with diet. According to the British Journal of Oral and Maxillofacial surgery, in a article entitled, Management of Asymptomatic Impacted Wisdom Teeth, Vol. 34 October 1996, the author notes that in Neolithic man the average, highly abrasive diet caused attrition of the teeth resulting in a reduction in the size of the molars from front to back. This decrease in size from the abrasive nature of the food ingested allowed for the forward migration of the teeth and adequate space for the eruption of the wisdom teeth. With the arrival of processed foods and a reduction in the amount of chewing necessary to reduce the food for swallowing, less wear occurs. This coupled with a decrease in the loss of teeth as a result of a decrease in cavities, requires modern generations to address impacted and partially impacted wisdom teeth.
When the wisdom tooth cannot be cleaned, infection results. It is the potential for infection and the potential for this infection to spread to other teeth that usually motivates the patient to have the wisdom teeth removed. Other commonly sited justifications for the removal of wisdom teeth like the potential for them to cause cysts, tumors, or cancer or the potential for them to cause crowding and shifting of the other teeth in the mouth are highly suspect. Although many believe that wisdom teeth cause crowding, this has never been definitively proven in any well controlled scientific study. Additionally, the potential for them to cause cysts or tumors is very, very low. Although removing a wisdom tooth can weaken the jaw for a short period of time post-operatively, leaving a wisdom tooth in does not cause the jaw in the area to be inherently weak. As mentioned before, cancer occurring in wisdom teeth is a rare phenomenon.
Having dispelled the evils of leaving wisdom teeth in, it is important to reemphasize the primary reason for taking them out.
Wisdom teeth are removed primarily to eliminate the potential for infection and damage to adjacent teeth. Remember, the jaws of most individuals are not large enough to accommodate the wisdom teeth and they remain either under the gum tissue where they have a three to five percent chance of becoming cystic or they become partially exposed where they have a much, much greater potential for becoming infected. Infection causes bone loss, damage to adjacent teeth and PAIN. When the dentist determines that no room exists for the wisdom teeth to erupt into a normal position, the decision then becomes, do you wait for the infection to occur or do you remove the tooth before infection and pain begins. Study after study has been done to show that infection commonly occurs around malposed wisdom teeth. Study after study confirms that complications from the extraction of wisdom teeth increases dramatically as the patient enters their 30's. Once symptoms of pocketing, swelling, food impaction or pain begin, removal is the most prudent course since the symptoms will not abate until the teeth are removed. Should the patient have only symptomatic wisdom teeth removed and leave other asymptomatic wisdom teeth in the mouth until later? This depends on the relative position of the other wisdom teeth and whether or not the patient wants to be operated on more than once. Most dentists agree that one surgery is best and that multiple trips to the oral surgeon for the removal of wisdom teeth is not in the best interest of the patient and only raises the potential for complications from multiple anesthetics.
When a wisdom tooth is blocked
from erupting, it is termed impacted. Wisdom teeth can be
impacted in the gum tissue overlying them. These are called soft
tissue impactions and are many times removed by general dentists
rather than oral surgeons. (Unfortunately, for the patient, soft
tissue impactions end up begin more difficult than they sometimes
appear because of the curvature of the roots that are not
apparent on the x-rays. Is your general dentist trained to
perform more complicated procedures if necessary? (Be sure to
ask). Wisdom teeth more commonly are still encased in some bone.
These are called partial or full bony impactions. They are either
partially exposed in the mouth or completely under the gum
surface and identifiable only on an x-ray. Examples of impacted
teeth are shown below.
(click links below to load full color diagrams)
1 - Normal position of a wisdom tooth
Figure 2 - Mesioangular impaction
Figure 3 - Distoangular impaction
Figure 4 - Horizontal impaction
Figure 5 - Vertical impaction
Treatment of impacted wisdom teeth requires skill on the part of the dentist, a well trained staff and a surgical facility equipped for emergencies. Oral surgeons are specifically trained to perform these dentoalveolar procedures and have the knowledge and experience to handle any situation which might arise pre-operatively, intra-operatively and post-operatively. Most importantly they have the supportive staff and facility to accomplish the surgery safely and expeditiously.
The removal of wisdom teeth can be performed on an outpatient basis or can be performed in the oral surgeon's office. Where the surgery is performed is a decision that should be made by consensus of opinion between the patient and surgeon. There are many factors that must be weighed....patient's age, health, psychological makeup, difficulty of the procedure, potential for complications with surrounding anatomical structures, length of the anesthetic and most importantly, adequate access to the surgical site. Taking these variables into consideration, the oral surgeon will advise the patient on the most appropriate place to perform the surgery. By far, the majority of these procedures are performed in an office setting.
Prior to surgery, it is common to have a consultation with the oral surgeon. Although some offices do not routinely consult with their patients prior to the day of the surgery, it is customary for Dr. Lee to meet with the patient (and parents if applicable) prior to the surgery date. At that time the patient is evaluated for those contributing factors which might weigh in the decision as to the most appropriate setting for the surgery. Additionally, the meeting allows the doctor to evaluate the x-rays and discuss the surgical procedure. Meeting the doctor fact to face prior to the surgery also allows the patient to establish a comfort level with the doctor and staff which is hard to do minutes before the actual performance of the anesthesia surgery.
The following are tips to help you prepare for your surgical appointment.
Wisdom tooth surgery is usually performed with an IV anesthetic technique. After medicines are given intravenously the surgeon pushes the gum tissue out of the way thereby exposing the tooth and the bone overlying it. Since the art to the science is to remove the tooth with as little brute force as necessary, the surgeon will carefully remove any bone in the way. This is done with a high speed cutting instrument under water irrigation. After the tooth is exposed, it usually requires sectioning into pieces to be removed. Once again, the art to the science is to remove the tooth with as little force as necessary and with as little bone removal as possible. Sectioning the tooth accomplishes this goal and protects important surrounding structures (nerves and blood vessels).
After the tooth is removed, the gum tissue is repositioned back into it's proper place and sutured. Sutures are dissolvable and do not require removal.
After surgery, a 48 to 72 hour recovery is expected. Patients are reevaluated after this time to assess healing and to intercept any complications that may occur. This is very advantageous to the patient.
Bleeding is expected post operatively and can continue up to 10 hours after any procedure. Even a little blood seems like a lot in the mouth due to a mixture with saliva. Saliva can increase what appears to be high concentrations of blood by 10 times. Pressure on the surgical site is most important for bleeding control. If sutures were placed at the time of the surgery, pressure will almost always stop bleeding. A tea bag wrapped in a piece of gauze is also helpful. The tannic acid in the tea constricts tiny blood vessels in the wound and helps to form a clot.
Swelling is to be expected post operatively. Swelling can last for several days and can be significant in some patients. Ice is helpful in keeping the swelling to a minimum. Elevating the patient's head the first couple of nights while sleeping may also help. Steroids given at the time of surgery are a most effective weapon in the battle against selling. They are routinely used intravenously unless medically contraindicated. An interesting phenomena can occur when intravenous steroids are used however. Some patients experience what is called rebound swelling from the medications. in this scenario, patients will experience no swelling following the surgery or the following day but wake up two days after surgery with swelling. not to panic, it responds quickly to ice.
Another complication following wisdom tooth removal is pain in the muscles surrounding the jaws which affects the function of the jaw joint. This post operative problem may need treatment similar to treatment for TMJ patients.
Infection following the extraction of wisdom teeth is not a common complication. Natural immune mechanisms help to protect the surgical site. Antibiotics are prescribed by some oral surgeons after surgery although there is no documentation in the literature to support the use of antibiotics prophylatically. Some patients will experience localized inflammation and infection in the tooth socket 48 hours after surgery. This has commonly been called a dry socket. It is not dry, however, and the name is derived from the clinical appearance of the socket which is commonly void of a normal blood clot or granulating (healing) tissue. This post operative complication is best treated with a medicated dressing placed in the extraction site. It typically contains local anesthetic ointment that soothes the surgical site. If this is ineffective, it usually means the pain is originating in another tooth (most commonly the tooth in front of the wisdom tooth site), or from the muscles surrounding the surgical region. These muscles are used during opening and closing of the jaw and can be aggravated post operatively by overeating, grinding, and heavy chewing. Treatment of this type of pain requires not only a dressing in the surgical site but also anti-inflammatory medications, muscle relaxants and in some cases post operative physical therapy for the muscles.
For the first two days following surgery it is important to eat soft foods, soups, and plenty of fluids. The list of acceptable odds is as long as your gastronomic imagination. Some basic rules are : (figure 7 page 10)
Removal of wisdom teeth is a common procedure. Complications can occur, however. The following are potential complications that the patient should understand:
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Copyright © 1997 Michael B. Lee, D.D.S.
Last Updated on April 10, 2003
This site developed by SUPPORT CENTRAL and Dr. Michael B. Lee
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