More On Wisdom Teeth Removal

Wisdom teeth are a often a bothersome problem for many people. The reason for problems is that there isn't enough room for these teeth to erupt into the arches in a normal fashion. They may also  come in sideways. This causes them to become impacted, which means that they are impeded from normal eruption into the dental arch.

When twisdom teeth don't erupt normally, I ususally recommend them to be removed at your earliest convenience. Some people put this off, thinking that if their wisdom teeth aren't bothering them, that they should leave them alone. This is an unwise decision. Complications from wisdom teeth removal greatly increase the older we get. If you wait until they hurt, the extractions will be very difficult with serious risks of complications. If, however, they can be removed in the late teens or early twenties, complications are much less likely to occur.

Impacted and erupted wisdom teeth can be a source of serious, life threatening infection that can casue swelling,  close off your airway and prevent breating or can even spread to your brain. Why take those chances when wisdom tooth removal at a young age is such a routine procedure?

Wisdom Teeth Removal and Post Surgical Care

Here is some information to brief you on what it's like to have your wisdom teeth removed and how to take care of yourself afterward:
Impacted Tooth_ What Is It?

An impacted tooth is one that is prevented from erupting into the mouth normally. Impacted teeth are a risk factor for problems such as infections, abscesses, cyst formation, tumor growth, and damage to adjacent teeth.

The removal of impacted teeth is an operation. It requires incision of the overlying tissue, and often the removal of bone to be able to extract the tooth. The tooth may have to be sectioned. Take this operation seriously, and plan for a couple of days' rest afterward to promote good healing. The area around the surgery will swell considerably and will be very sore. This swelling will make it hard to open your mouth for a few days. You will probably need to take pain medications for a few days after. Plan on a soft diet for a few days as well
Your surgeon should provide you with instructions on how to cleanse the area of the surgery, how to control abnormal bleeding, and other aspects of post-operative care. Follow these instructions carefully for best healing results. If your surgeon hasn't done that, here are some instructions.

Taking care of yourself after wisdom teeth removal

Rest. Avoid any physical exertion for the rest of the day. After today, listen to your body. There are great variations in the amount of rest you will need until you heal depending on your age, the amount of bone that was removed, and your own individuality. If you begin to be active prematurely, you may experience increased pain in the area of the surgery.

Watch for bleeding. Some oozing of blood is normal for the first couple of days, and you will have blood-tinged saliva for that time. This is normal. But if there are dark red clots of blood in your mouth, that isn't normal. Your surgeon will give you gauze, use that and bite on it while you rest for about forty-five minutes or so.  If bleeding persists, call your surgeon.

Take all medications that have been prescribed. For pain medication, that should be taken as needed, in other words, take it only as often as you need it to control the pain. If you find the pain medication inadequate to control the pain in the dosage prescribed, call your surgeon.

Eat softer foods the day of the surgery. Advance your diet as your discomfort lessens. If it is hard to chew, don't push yourself, but continue to eat soft foods until you can comfortably handle normal food. And be sure that you get adequate nutrition. Make sure your diet includes protein. Ice cream, milk, and protein shakesare good sources of nutrients for healing.  AVOID STRAWS!

Keep the surgical sites clean as best as you can. But you don't want to disturb the surgical sites for a few days, so start by rinsing gently with salt water the first post op day if eating solid foods. A teaspoon of salt in a cup of warm water is all you need. Brush your teeth also, being sure you use a soft brush. After a couple of days, begin to brush the teeth furthest back, being sure not to disturb any loose tissue that has been sutured into place. Within a week, that loose tissue should be much firmer.


Possible  complications

The most common complication is dry socket. This ordinarily occurs in less than 10% of patients, and is much more common in the lower jaw. Dry socket results from dislodging the newly formed clots or premature breakdown of the clots. Symptoms include mild discomfort for three to five days, and then there is a dramatic increase in pain coming from the socket and radiating to the ear, down the neck and to other teeth. You may notice a foul taste in your mouth and foul odor. If this happens to you, call your surgeon. There is a dressing that will ease the pain; you may need additional prescriptions as well.

Sometimes sharp edges of bone may surface as the surgical sites heal. Often, this does not require surgical treatment. It occurs because, after the extraction, your body begins to work to reshape the soft tissues and bone in the area formerly occupied by the tooth. Unless these area cause major discomfort,salt water rinses should allow the gums to cover the area, and the normal healing process will prevail. If necessary, your surgeon can smooth the affected areas.

The roots of lower wisdom teeth may lie near the nerve in the lower jaw, and their crowns may be near the nerve that supplies the tongue. During the surgery, these nerves could be damaged. This happens in less than 1%  of cases. The result would be numbness in the lips, chin, and teeth and gums on the affected side, or in the side of the tongue if the lingual nerve was affected. Motion is not affected, only sensation. If this happens , call your surgeon immediately. It may also be possible that the nerves were not touched during the surgery, but there is swelling that is pressing on the nerve.  I often prescribe a low dose steroid post op to prevent this from occurring.
If you do have nerve damage, expect the symptoms to last for several weeks. The nerve may take a month or several months to repair itself. It is not very common for this numbness to be permanent, but that is a possibility. If the nerve was actually severed during the surgery, the numbness will likely be permanent unless the nerve is surgically repaired by a microsurgeon ( I happen to hold expertise in this field).

If the roots of your upper wisdom teeth lie close enough to the floor of one of your maxillary sinuses, your sinus floor could be perforated during the operation. If that happens, you may notice bleeding through your nose after the surgery, do not be alarmed, these perforations seal themselves off and heal normally without anty intervention. Call your surgeon who can advise you on how to care for it until it heals. Your surgeon may want to perform a minor post-operative surgical procedure to close the hole if it persists. In rare cases, the floor of the sinus can be so delicate that attempts at extraction cause the tooth or a piece of the tooth to be displaced into the sinus. If this happens, the piece or tooth should be surgically removed to prevent later sinus infections.

The degree of risk of complications varies from patient to patient and increases greatly with age. If you are over age 35 when the impacted teeth are removed, you have a greater chance of complications, because of  increased bone density. If you have the tooth extraction before their roots are completely formed, the risk of complications is usually minimal. The position of the teeth in the jaw and the difficulty of the surgery also affect the degree of risk.

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Wisdom Teeth...To Keep or Not to Keep?

Wisdom teeth also known as third molars are the last teeth to erupt. Wisdom teeth may become a problem for you as they grow and develop in each corner of your mouth. Problems often develop gradually since development normally spans several years. Nevertheless, these gradual changes can cause sudden and severe pain. Understanding why such things can happen may help you to deal with these problems, or better still, to encourage you to take preventive measures before they occur.
The jawbone grows to approximately its adult size by your late teens. Unfortunately, that size is often too small to hold developing wisdom teeth. This happens because our jaws are smaller than those of early humans who needed large jaws and more teeth for their tougher diet.
When there is not enough room for your wisdom teeth, they may become impacted, or partially trapped in the jawbone and gums. The crown, or top of the tooth, may erupt, or just break through the gum, or it may remain completely within the bone. The roots can grow in unusual directions and may cause a variety of problems in your mouth and with your sinus cavity or the nerve in your lower jaw. The primary preventive measure for wisdom teeth is removal, preferably at an early stage.

Impacted Wisdom Teeth
A tooth becomes impacted due to lack of space in the dental arch and its eruption is therefore prevented by gum, bone, another tooth or all three. Lack of space occurs because our jaws have become smaller through evolution. We do not lose teeth through decay as frequently as in the past and our diet does not wear down our teeth as much.
Impacted wisdom teeth can grow in a variety of directions. This is illustrated below.

A wisdom tooth may grow toward your other teeth, away from them, or even in horizontal or vertical positions. When such conditions occur, it's far simpler and less painful to have them removed early before they have a chance to firmly anchor in your jaw as the teeth grow and the roots lengthen.

Wisdom Tooth Assessment
Not everyone has problems with their wisdom teeth. Factors that determine whether you will have problems include the size of your jaw and how your wisdom teeth grow in. There may be pain and swelling, or you may have no symptoms at all even though the other teeth in your mouth may be at risk of damage. In addition to actual pain, common problems caused by wisdom teeth can include gum disease, crowding, decay, poor position, and cysts.
Since it is not practical for most people to evaluate how their wisdom teeth are developing, the best approach is to visit Dr. Dorfman or another Board Certified Oral & Maxillofacial Surgeon for an evaluation. Dr. Dorfman will review your dental history, take dental X-rays, and perform an examination to determine the general health of your mouth and the condition of your wisdom teeth. If a problem with your wisdom teeth is detected, our participating dentist may recommend surgery to remove them and eliminate or avoid any unpleasant symptoms. Early removal is best for most patients as it usually helps to avoid more serious problems later on.
It is very important to talk to Dr. Dorfman about extraction procedure, risks, possible complications and outcomes of the removal of these teeth.

Why Remove Wisdom Teeth?
Wisdom teeth generally cause problems when they erupt partially through the gum.
Below are the most common reasons for removing wisdom teeth.
1. Tooth decay
Saliva, bacteria and food particles can collect around an impacted wisdom tooth, causing it, or the next tooth to decay. It is very difficult to remove such decay. Pain and infection will usually follow.

2. Gum infection
When a wisdom tooth is partially erupted, food and bacteria collect under the gum causing a local infection. This may result in bad breath, pain, swelling and the inability to open your mouth fully. The infection can spread to involve the cheek and neck. Once the initial episode occurs, each subsequent attack becomes more frequent and more severe.
3. Pressure pain
Pain may also come from the pressure of the erupting wisdom tooth against other teeth. In some cases this pressure may cause the erosion of these teeth.
4. Orthodontic reasons
Many younger patients have had prolonged orthodontic treatment to straighten teeth. Wisdom teeth may cause movement of teeth particularly the front teeth when they try to erupt. This will compromise the orthodontic result.
5. Prosthetic reasons
Patients who are to have dentures constructed should have any wisdom tooth removed. If a wisdom tooth erupts beneath a denture it will cause severe irritation and if removed, the patient will need to have a new denture constructed as the shape of the gum will have changed.
6. Cyst formation
A cyst (fluid filled sac) can develop from the soft tissue around an impacted wisdom tooth. Cysts cause bone destruction, jaw expansion and displacement or damage to nearby teeth. The removal of the tooth and cyst is necessary to prevent further bone loss. Tumors may develop within these cysts or the jaw may fracture spontaneously if the cyst grows very large.
Why remove an impacted wisdom tooth if it hasn’t caused any trouble?
Impacted wisdom teeth are almost certain to cause problems if left in place. This is particularly true of the lower wisdom teeth. Such problems may occur suddenly and often at the most inconvenient times.

When is the best time to have my wisdom teeth removed?
It is now recommended by dentists that impacted wisdom teeth be removed between the ages of 14 and 22 years whether they are causing problems or not. Surgery is technically easier and patients recover much more quickly when they are younger. What is a relatively minor operation at 20 can become quiet difficult in patients over 40. Also the risk of complications increases with age and the healing process is slower.

Traveling to foreign places
It may be advisable to have them removed before traveling if you are going to an area where specialist dental services are not readily available and your wisdom teeth are impacted.

The ‘Pros & Cons’ of wisdom tooth removal

1. Some ‘Pros’ of removing a wisdom tooth.
Wisdom teeth may be hard to access with your toothbrush or floss. Over time, the accumulation of bacteria, sugars and acids may cause a cavity to form in the tooth. If it is not restored with a filling, the cavity may spread and destroy more tooth structure causing severe consequences to the tooth and surrounding supportive structures.
Due to the difficulty of keeping these teeth clean with your daily brushing and flossing, bacteria and food debris remaining on the wisdom teeth may present a foul smell causing bad breath.
A wisdom tooth that is still under the gums in a horizontal position rather than a vertical position may exert pressure on surrounding teeth causing crowding and crooked teeth. This also may occur if there is not enough space in the mouth for the wisdom tooth. This may warrant braces to repair the damage.
A wisdom tooth that is still under the gums may become irritated. The gum tissue that lay over the tooth may harbour food debris and bacteria that gets trapped under the gum resulting in an infection in the gums.
There is the potential for more problems to occur the longer you wait and the older you get. This is because as you get older, the bone surrounding the tooth becomes increasingly dense making the tooth more difficult to remove. The healing process may also be slower.

2. Some ‘Cons’ of removing a wisdom tooth.
Depending on the size shape and position of the tooth, removal can vary from a simple extraction to a more complex extraction. With a simple extraction, there is usually little swelling, bruising and bleeding. More complex extraction will require special treatment which may result in more bruising, swelling and bleeding. However, our participating dentists will provide you with post treatment instructions to minimise these side effects.
Following an extraction, a condition called "dry socket" may occur. If the blood clot that formed in the extraction area becomes dislodged, it exposes the underlying bone. This condition is very painful but resolves after a few days. It is preventable by following the post treatment instructions provided by your oral surgeon.

The Operation
Surgery is often done at Dr. Dorfman's rather than in a hospital in most circumstances. Dr. Dorfman will review the recommended procedure with you so that you will fully understand and be comfortable with the procedure before it is done. You will also be given information about eating, medication, rest, driving, and other considerations before surgery as well as after.
Very few people have their wisdom teeth removed under local anesthesia by their dentist. This means that they are awake but the area around the wisdom teeth is completely numb. Dr Dorfman performs the surgery with IV Sedation or General Anesthesia along with local anesthesia to allow people to sleep during the procedure and keep vital signs stable.
The operation will not start until the anesthetic has taken effect. It is often necessary to make a small cut in the gum over the wisdom tooth, and to remove some bone so that the tooth can be lifted out. Stitches are usually put in to help the gum heal.

Post operative healing
The healing process begins immediately after surgery as your body sends blood to nourish the tooth socket. Simple pressure from a piece of gause is usually all that is needed to control the bleeding and to help a blood clot to form in the socket, which promotes healing. Within a day or two, soft tissue begins to fill in the socket, aided by the blood clot. Eventually, the bone surrounding the socket begins to grow, filling in the socket completely. This is illustrated below.

As your mouth heals, you can promote faster healing and avoid complications by simply following the care instructions that our particiapting dentists will give you. While you may experience some discomfort as your mouth heals, following simple instructions will normally be all that is needed. However, you should call our participating dentists if you experience excessive bleeding or swelling, persistent and severe pain, fever, or any reaction to medications. A follow-up examination will also be scheduled to make sure that the socket is healing properly and that your mouth is returning to a normal, healthy state.

Post operative care
Following the removal of your wisdom teeth it is important that you call our participating dentists if any unusual bleeding, swelling or pain occurs. The first 6-8 hours after the extraction are typically the worst but are manageable.
At first, it may be possible to feel small fragments of bone with your tongue. These are the edges of the tooth socket and will soon disappear as the gum heals. Depending on the type of stitches used, they may need to be removed. Arrangements will be made for this to be done. If dissolvable stitches have been used, they will disappear 7 to 10 days after the operation.

Below are some tips to assist you after the operation.
1. Do not disturb the wound.
Disturbing the wound may invite irritation, infection and bleeding. Chew on the opposite side for the first 24 hours.
2. Do not smoke for 12 hours.
Smoking will promote bleeding and interfere with healing.
3. Do not spit or suck through a straw.
This will promote bleeding and may dislodge the blood clot which could result in a dry socket.
4. Control of bleeding.
If the area is not closed with stitches, a pressure pack made of folded sterile gauze pads will be placed over the socket. It is important that this pack stay in place to control bleeding and to encourage clot formation. The gauze is usually kept in place for 30 minutes. If the bleeding has not stopped once the original pack is removed, place a new gauze pad over the extraction site.
5. Control of swelling
After surgery, some swelling is to be expected. This can be controlled through the use of cold packs which slow the circulation. A cold pack is usually placed at the site of swelling during the first 24 hours in a cycle of 20 minutes on and 20 minutes off. After the first 24 hours, it is advisable to rinse with warm saltwater every two hours to promote healing (one teaspoon of salt to a glass of warm water). Do not rinse your mouth out during the first 24 hours because this disturbs the blood clots that are part of the healing process.
6. Medication for pain control
Anti-inflammatory medication such as Ibuprofen is used to control minor discomfort following oral surgery. Stronger analgesics are ususally prescribed by Dr. Dorfman for discomfort as well.
7. Diet and nutrition
A soft diet may be prescribed for the patient for a few days following surgery. You can gradually return to a normal diet once any jaw stiffness has settled. Very hot drinks and spicy food can increase pain and bleeding and should be avoided until the gum has healed. Also avoid alcohol as alcohol can increase bleeding and delay healing.
Most people do not experience any complications after having their wisdom teeth removed. Nonetheless, you should plan to see Dr. Dorfman approximately one week later to ensure everything is healing well.