Wisdom teeth and removing them

Wisdom teeth are the last of the adult teeth that emerge from the gums in your late teens or early twenties. These large grinding teeth, also known as the third molars, sometimes never develop in certain people, while in others, up to 4 teeth are seen, one at each end of the upper and lower gums.

When your wisdom teeth causes problems – the impacted wisdom tooth

Though wisdom teeth generally do not cause problems, sometimes they may not come through the gums properly when there is not enough space for them at the back of the mouth. As a result, they do not grow in a straight line and instead emerge at an angle to fill the available space. These are known as impacted wisdom teeth, and though they cause no problems in most people, some people are vulnerable to the following as a result:

• Swollen gums around the wisdom tooth leading to stiffness and soreness of jaw.
• Bad breath and a bad taste as a result of infection at the back of the mouth.
• Pain, swelling, infection, a higher risk of tooth decay, gum disease in other teeth.

What are the reasons leading to impacted wisdom tooth?

Impacted wisdom teeth occur as a result of the following factors

• A lack of space for the new teeth to come in.
• Crowding of teeth due to the other teeth in the way of emerging wisdom teeth.

What are the types of impacted wisdom tooth?

Based on the manner in which the wisdom tooth grows through, the types of impacted teeth are as follows:

• Mesial impaction - the most common type seen, whereby the teeth grow at an angle facing towards the front of the mouth.
• Vertical impaction - teeth grow straight down but get stuck against the neighboring teeth.
• Horizontal impaction - the teeth grow horizontally and push against the neighboring teeth.
• Distal impaction - the wisdom tooth turns away from the tooth next to it and becomes lodged in that position.

Do all impacted wisdom tooth cause problems and require treatment?

No, in most cases, impacted wisdom teeth are harmless and do not require treatment.

When does an impacted wisdom tooth require treatment?

Since impacted wisdom teeth as well as wisdom teeth that have emerged only partially through the gum are difficult to clean, they are highly susceptible to dental problems such as:

• Pericoronitis – the infection of the soft tissue surrounding the tooth occurring when plaque, the sticky white substance that contains bacteria, builds between the gums and top of the impacted wisdom tooth.
• Cavities - since impacted teeth are difficult to clean, it can cause plaque accumulation on the surface of the tooth, which results in the formation of holes or cavities in the teeth. Over time, this can also spread and affect the neighboring second molars.
• Periodontal disease or gum disease – occurs as a result of plaque accumulated that cannot be cleaned through normal brushing and flossing, causing infection and swelling of gums. Over time, this can spread and affect the first and second molars and the bone surrounding the tooth.
• Cysts and tumours – in rare cases, the tissue surrounding the impacted wisdom tooth can become infected, increasing the risk of a cyst or tumour development.

Treatment options for impacted wisdom teeth (in accordance with the NICE guidelines for wisdom teeth removal)

Treatment is required only when the impacted teeth are shown to cause serious dental health issues and pain through dental investigation and patient symptoms. Impacted wisdom teeth that do not cause problems are not removed, as there is no credible evidence pointing towards any benefits, and at the same time, this eliminates the unnecessary risks of an operation. The treatment options specified for problem causing impacted teeth are as follows

• No treatment – for impacted teeth causing no problems.
• Antibiotics – for temporary relief only.
• The surgical removal or extraction of the impacted wisdom tooth – most common treatment, especially when dental problems such as infection, cysts, tooth decay or gum disease occur around the wisdom tooth.
• Cutting back the surrounding gum tissue – if pain is caused as a result of the impacted teeth pressing into the surrounding gum, an operation to cut back the gum is sufficient.

What are the NICE guidelines regarding removal of wisdom tooth?

The National Institute for Clinical Excellence (NICE) is a part of the NHS and consists of a team of experts that produces guidance for both the NHS and patients on medicines, medial equipment and clinical procedures. As per the research, study and evidence gathered by NICE, the guidelines laid down for wisdom teeth removal are as follows:

1. Impacted wisdom teeth that are free from disease should not be operated on since:

• There is no reliable research suggesting the benefits for patients by the same.
• It exposes patients to the unwanted risks of surgery unnecessarily, such as nerve damage, damage to other teeth, infection, bleeding, and, in rare cases, death. Also, after surgery to remove wisdom teeth, patients may have swelling, pain and be unable to open their mouth fully.
• It exposes patients to the post-operative side effects of surgery unnecessarily, such as swelling, pain and inability to open their mouth fully.

2. Patients with healthy impacted wisdom teeth must visit their dentist for regular check-ups.
3. Only patients having wisdom teeth that cause dental problems, or have other problems with their mouth, must undergo wisdom teeth removal. Your dentist or oral surgeon will evaluate your dental health, disease and other conditions and ascertain the need for surgery on noticing:

• untreatable tooth decay.
• abscesses, cysts or tumours.
• disease of the tissues around the tooth.
• an impacted tooth is in the way of other oral surgery.

What happens during the initial consultation with the dentist?

• The dentist will make a thorough dental examination, studying the teeth, gums and jaw of the patient.
• An X-ray of the mouth is taken to identify the nature and extent of problem.
• Based on the findings, the dentist will advise the patient on the type of treatment required, procedure preparation, risks and complications and other relevant issues.

How is the patient prepared for the wisdom tooth removal/treatment?

The patient is put under local or general anaesthesia.

• In case of local anaesthesia, the area to be injected is rubbed with a numbing gel. The local anaesthesia is then injected in order to numb the teeth and the surrounding area.A sedative may also be given along with the anaesthesia to help the patient relax.
• In case of general anaesthesia, the patient is instructed to abstain from eating or drinking for about six hours prior to the procedure.

What happens during wisdom tooth removal/treatment?

• A small cut is made in the gum over the wisdom tooth in order to access the tooth if it has not come out through the gum. This incision is not required if the tooth has partially or fully emerged.
• A small piece of bone covering the teeth may be then removed.
• The tooth is broken into smaller parts so that it can be easily extracted through the opening.
• Self-dissolving stitches are used to suture the incisions (if any) in the gum.

What can be expected following the treatment?

• The patient is instructed to take rest for a while, after which they can return home, but only if a family member or other aide is there to help them.
• If the patient was administered general anaesthesia, they are advised not to drive, drink alcohol, operate machinery or sign legal documents for 48 hours afterwards.
• The patient may experience stiffness and soreness in the jaw, and will be prescribed medications to relieve any such discomfort
• The patient is also given antibiotics and mouthwash solutions to use as per instructions once they return home.

Life after wisdom tooth removal/treatment

• Take the painkillers and other medications as instructed by the dentist
• The patient may
• experience varying degrees of pain depending upon the type of extraction, and swelling or stiffness for 2 or 3 days after the operation, which will gradually improve in 7 to 10 days.
• be able to feel small fragments of bone with their tongue, which are in fact the edges of the tooth socket that will soon disappear as the gum heals.
• a feeling of comfort and a less crowded mouth.
• a dirty taste in mouth.
• tingling or numbness of the face, lips or tongue, in rare cases.
• To bring down swelling, gently apply a cold compress, using a cloth on the face around site of swelling,
• In case of bleeding of the gums:
• Fold a clean handkerchief or piece of gauze and place it on the bleeding gum and bite on it for at least 20 minutes.
• Avoid rinsing the mouth out or lying down until the bleeding has stopped.
• Avoid strenuous activity for a few days.
• For extra comfort at night, use an extra pillow to support your head.

Brushing and rinsing

• Avoid rinsing the mouth vigorously during the first 24 hours to prevent dislodging of the blood clots that aid the healing process.
• Rinse the mouth gently after meals with warm salt water ( one teaspoon of table salt to a glass of water).
• Avoid brushing the area for the first couple of days even as you continue to brush the rest of your teeth normally.

Stitches

• Dissolving stitches will usually disappear in 7 to 10 days.
• Removable stitches are removed a week after the procedure during the follow-up appointment with the dentist.

Diet

• Eat soft foods for a few days.
• Return to a normal diet once the stiffness in the jaw lessens.
• Avoid alcohol and hot fluids such as tea or coffee.
• Avoid spicy food.
• Avoid smoking until the gum has fully healed, as smoking delays healing by causing the wound to bleed.

Dentist checkups

• Follow-up - go to the dentist for the follow-up visit to check the progress of the treatment.
• Emergency visits – contact your dentist immediately if you experience any of the following symptoms:
• bleeding that does not stop after applying pressure.
• bleeding that lasts for more than half an hour.
• difficulty in breathing or swallowing.
• severe pain that is not helped by painkillers.
• high temperature.
• facial swelling even after three days following surgery.

Risks and complications associated with wisdom-tooth removal

Any surgery is subject to risks or complications during or after the procedure, though only in rare cases.

Common complications associated with any surgery:

• Excessive bleeding during or soon after the operation, requiring another operation to stop the bleeding.
• Infection, requiring antibiotics to treat it.
• Unexpected reaction to the anaesthetic.

Complications specific to wisdom-teeth removal:

• Dry socket – a very common complication that occurs when a blood clot over the wound fails to develop or is dislodged, thereby exposing the bones and nerves to air, food and fluids. It is noted by a dull aching sensation in the gum or jaw three to four days after surgery, accompanied by a bad smell, and can last about 5 to 7 days. In such a cases, the dentist covers the socket with a medicated dressing that will be removed and replaced frequently until the socket has completely healed. Smokers are usually highly vulnerable to this complication.

• Paresthesia - at times, nerves in the jaw that are closest to the tooth roots are damaged during surgery or as a result of swelling following surgery. This can result in temporary numbness or “pins and needles” in the tongue, lower lip or lower jaw. The condition is known as paresthesia, with older patients being at higher risk in contracting the condition as their tooth roots are longer and closer to the nerve. There is also risk of the sensation becoming permanent in certain rare cases.

• Accidental damage to other teeth during the extraction.