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Impacted Wisdom Teeth

Nearly everyone knows someone who has had to deal with the consequences of an impacted wisdom tooth. Being on the receiving end of this notoriously problematic dental condition can be a memorably unpleasant experience.

Indeed, there is nothing good to be said about them. Impacted wisdom teeth can cause a great deal of pain and misery, and they can be the source of serious infections. Consequently, those unfortunate enough to have them must deal with them—preferably sooner, rather than later.

Fortunately, managing the complications of impacted wisdom teeth does not have to be a horrible experience. The key is knowing what to do and when to do it.

What are Wisdom Teeth?

Wisdom teeth—also known as third molars—are the rearmost teeth and the last to come into the mouth. They may have acquired their common name from the fact that a person is old enough to have gained some wisdom by the time these teeth appear.

There are normally four wisdom teeth—one in each of the upper and lower, left and right dental arches. Although some people do not form one or more third molars, most do. For those who do, these teeth generally make their appearance during the late teens or early twenties.

Third molars can be perfectly normal and functional teeth when they come in completely and in proper position. When this happens, they typically do not cause patients any problems and they require no treatment. Because of their location, they can be somewhat challenging to access for brushing and flossing, but with some effort, most patients can maintain them adequately.

The Problems with Wisdom Teeth

It is when these teeth fail to come in completely that they cause problems. A third molar that remains either partially or completely imbedded in the jaw bone is said to be impacted.

Unfortunately, impacted third molars are more the rule than the exception. Retrospective studies have revealed that more than half of the population has at least one impacted third molar. Most of these occur in the lower jaw.

The reason so many third molars are impacted may relate to the decreased size of the human jaw that has occurred over the ages. Thousands of years ago, larger jaws with fully erupted third molars may have been necessary for chewing raw meats and grains. With a progressively softer diet, the jaws have gradually become too small to accommodate third molars. For this reason, many wisdom teeth simply do not have the space to erupt fully, so they remain imbedded below the gum line. Impacted third molars can be either partially or fully impacted.

Partially impacted wisdom teeth can and do cause many problems. When they are partially impacted, they are in contact with the mouth and all the bacteria and debris present there. However, they are not erupted enough to allow cleaning and debridement. This often results in an infection called pericoronitis. It is characterized by soreness and localized swelling of the gum tissue overlaying the partially erupted tooth.

The infection can usually be successfully treated with rinses and by cleaning the area with a cotton swab soaked with hydrogen peroxide or similar disinfectant. If the pericoronitis persists, it can progress into a much more serious infection, known as cellulitis, that causes fever and swelling. If this is not managed aggressively, it can be fatal.

Partially impacted wisdom teeth are also prone to decay because they cannot be adequately cleaned. Such cavities are usually impossible to treat and if allowed to progress, can lead to tooth abscess and infection.

Additionally, impacted wisdom teeth can cause damage to the adjacent second molar. They can tilt forward and put pressure on its neighbor, causing it to resorb, or melt away. They can also put the second molar at great risk of decay and/or gum disease.

Fully impacted wisdom teeth are, likewise, a potential source of problems. Teeth that are fully impacted can develop fluid-filled cysts and other pathological tumors, such as odontomas, ameloblastomas, and cancerous lesions. These can sometimes grow aggressively and destroy a large portion of the jaw. In rare cases, they can even lead to death.

Impacted wisdom teeth can cause a great deal of pain and misery, and they can be the source of serious infections. Consequently, those unfortunate enough to have them must deal with them—preferably sooner, rather than later.

When and When Not to Extract

Clearly, impacted and partially impacted third molars should not be taken lightly. Some clinicians advocate the extraction of all third molars, but there is little justification for this. Those that are fully erupted and functional should be maintained and treated like any other molar.

Likewise, fully impacted third molars exhibiting no pathological changes should probably be left alone. This is especially true in older patients. In these cases, the risks associated with the removal of the impacted but presumably healthy tooth probably exceed the risk of leaving it in place and developing future pathology. Certainly, these teeth should be monitored radiographically in the future for possible pathological changes.

There are, however, some valid reasons to remove impacted third molars.

  • Risk of Infection – Certainly, those that are subject to infection or decay, should be taken out as soon as possible.
  • Causing Damage to Adjacent Tooth –Surgical extraction is indicated for a wisdom tooth that is jeopardizing the health of the adjacent second molar.
  • Radiographic Pathology – An impacted third molar that shows evidence of pathological changes on an x-ray should be extracted.
  • Orthodontic Expediency – Dental providers my also recommend the removal of third molars, impacted or otherwise, for orthodontic reasons. Orthodontists about to put braces on a patient to straighten their teeth may first want their wisdom teeth removed. This is to create more jaw space into which the crowded tooth can be moved. Other teeth, besides third molars, may need to be removed, as well.
  • Symptomatic – Perhaps the most compelling reason to remove impacted third molars is if they are causing problems. Patients who are having any of the symptoms of an infected wisdom tooth—pain or swelling in the posterior jaw, uncharacteristically bad breath, unexplained head or jaw ache, jaw stiffness, or tender lymph nodes in the neck or beneath the lower jaw—should see their dentist without any delay. These symptoms can progress into a full infection very quickly and can require extreme measures to control.

What is the Best Age?

If third molars are to be removed, the ideal time for surgery is before the teeth have had the time to develop roots. Therefore, patients in their late teens are the best candidates for impacted third molar removal.

Patients of any age can have their wisdom teeth removed, but older patients have more developed roots that complicate extraction. They also have increased bone density and a greater likelihood of having complicating health issues. Finally, their extraction sites often do not heal as completely as in younger patients and can leave a bony defect.

It is for all these reasons that the American Dental Association and the American Association of Oral and Maxillofacial Surgeons recommend that patients aged 16 to 19 routinely have their wisdom teeth evaluated, and if indicated, extracted.

Either a dentist or an oral surgeon can extract impacted third molars, depending on the anticipated difficulty of the procedure. However, most dentists refer these cases to the oral surgeon, who is well equipped, both in skill and instrumentation, to surgically extract wisdom teeth.

Surgical Extraction

The procedure is generally accomplished using local anesthesia and intravenous (IV) sedation. In most cases, patients have all four impacted third molars removed at one time. This one procedure alleviates any future problems and avoids additional oral surgical procedures.

Wisdom teeth removal generally takes an hour or so, and since patients are usually sedated and anesthetized, they feel no pain and retain no memory of the procedure. Afterward, the surgeon prescribes them pain medications and advises to go home, keep an ice pack on their face, and rest for the next few days.

Patients can expect some pain and swelling, but it usually subsides within a week or less. Occasionally, they experience a painful sequalae of tooth extraction, known as dry socket, a few days after the surgery. This occurs if the blood clot sealing off the bony socket is lost. If it occurs, patients need to contact the surgeon and return to have the socket treated. In any event, the surgeon will usually want to see patients at least one time post-operatively to ensure that they are healing properly.

There are some risks to the removal of impacted wisdom teeth. These include post-operative infection, damage to the inferior alveolar nerve, which passes near the roots of the lower third molar, and damage to the adjacent second molar. Fortunately, these rarely occur, and the benefits of third molar removal nearly always outweigh the risks.

Be Informed

Patients should ask their dentist about their third molars. They need to know if they are present and whether they are fully erupted and functional or impacted. Often, wisdom teeth need no treatment at all, but if they are causing problems—which may or may not be symptomatic—or if they are likely to cause problems in the future, patients should make an appointment to see an oral surgeon.

Patients should bear in mind that the preferred time to remove potentially troublesome wisdom teeth is at a young age, before they can cause problems. Any competent oral surgeon can extract them painlessly and safely. Only then can patients experience the peace of mind that comes with knowing that they have eliminated the possibility of future problems.

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