Wis-Dumb Teeth

Wisdom Teeth.

This seems to be one of the most common things "friends" ask about. Mostly in the form of "oh I have a friend of a friend who has been having problems from their wisdom teeth (I believe they call this "giving them jip" in local lingo) and they think they need them ripping out (another of my favourite expressions) but they're really scared so wanted me to ask you about it"

My usual response is, "let me see" to which they look around as if this friend of a friend has magically appeared, realise I have cottoned onto their game, and promptly show me. 99% of the time I can't see a thing (those lights and mirrors on sticks have their uses from time to time) and generally nod in agreement that they need to come out. Perhaps in future I shall direct them to this blog post.

What are they?

God bless NHS Choices.

"The wisdom teeth grow at the back of your gums and are the last teeth to come through. Most people have four wisdom teeth, one in each corner."

I would add that they are not always the last teeth to come through. So stick that in your pipe and smoke it nhs.uk. (Of course I do not in any way promote smoking and you will perhaps realise this in my next blog post).

Some people have no wisdom teeth, some have up to 4. It is likely in most people that 4 wisdom teeth will have formed but just not "come through". 

Dental Glossary:

Wisdom teeth are also referred to as "8's" as they are the 8th tooth along from the mid line. They can also be called 3rd molars. 

See the particularly helpful picture below, the man is even so kind as to point to said tooth. I have also rather patronisingly added numbers to the teeth. 

We refer to teeth "coming through" as erupting. So unerupted, means the tooth/teeth are not yet in the mouth. That is to say, they are lying somewhere under the gums. Partially erupted means the tooth is just poking through and usually covered by a flap of gum, and erupted means that the tooth is fully through in the mouth and we are able to see all of the top part of the tooth (the crown)

Here are another slightly condescending picture to explain:

I will explain partially erupted teeth and problems associated with them a little bit later on. 

It was in fact very difficult for me to find a picture of an "unerupted" wisdom tooth as they are all labelled "impacted" and there is a certain amount of confusion between the 2 terms even within the dental world. I used the incorrect nomenclature the other day at work and received a telling off so thus am bypassing the damage it caused to my perfectionist nature by writing it in this blog post as if its a mistake everyone makes. 

Unerupted means as above, that the tooth simply has not erupted, i.e. has not come through into the mouth. This can be for several reasons. As a child, when you lose a baby tooth and then there is a period of time before the adult teeth come through, this is usually because they are lying under the gum waiting for the appropriate time to come through which is most likely when your parents need to travel in a car with you for several hours, or board a plane, or sleep. This can occur with wisdom teeth. 

Sadly, because we are generally evolving (although some human beings seen at the Dental Hospital lead me to rethink the idea that this scientific process is ongoing in our society) to have smaller jaws, we mostly don't have room for wisdom teeth. Therefore they often struggle to come through, or erupt, normally. They may be tilted, lie sideways, or simply be wedged in against the next door tooth. This is when they are termed impacted. The tooth can be completely under the gumline – so you cannot see any of it, or it may have managed to poke through the gum slightly but then realise it’s stuck and cannot erupt any further (a bit like when you stick your head through a gap in the railings only to find you can’t then get out)

It is worth noting that is impossible to know which case you have – unerupted or impacted wisdom teeth - unless you take an x ray. Similarly, a tooth can simply be partially erupted because it is just too lazy to make a proper effort to erupt, or it can be because it is impacted and cannot move any more.

When it all goes wrong

When teeth are impacted the future can progress in a number of separate, or in fact a combination of, ways:

1) The teeth never attempt to come through because it’s just not worth their time or energy trying to push their way past an unmoveable blockage i.e. jaw bone, the adjacent tooth. In this situation the impacted wisdom tooth just stays where it is below the bone and you experience no problems at all.

2) The wisdom teeth cannot erupt for the reasons explained above, but instead remain positioned very very close to the 2nd molars (the number 7 teeth). For this explanation I require you to “suspend disbelief” (that English A level didn’t all go to waste) and imagine being on the Tube, or a nice ram-packed bus in rush hour. Picture the overweight sweaty man that you are just about managing to keep a safe distance from. Now imagine that it is no longer possible to maintain the space between you and his sweaty armpit and the two of you become wedged together.  This is a similar sort of thing to when wisdom teeth cannot erupt. You would of course be fine for a while, despite feeling a deep feeling of mortification, however say if you had to stay like that for months or years on end. Eventually things are going to get, shall we say, stagnant. In this way, going back to what I was meant to be discussing rather than my nightmare commute to work, it is not necessarily the wisdom tooth itself (in today’s production played by the sweaty man) that suffers from damage, but the adjacent tooth.

This can occur in a number of ways,

•  If the tooth has managed to come slightly through the gum, as shown below, then it becomes almost impossible to clean around the back surface of the adjacent tooth, and so you can develop tooth decay in the second molar

Here is the same thing shown on an x ray -  which is often the only way we can detect a problem going on due to the close proximity of the molar teeth and our tooth worker abilities being limited to human only skills (although some like to believe otherwise).

•  If the tooth is completely impacted i.e. it has not come through the gum/erupted into the mouth at all, the most common problem is that the wisdom tooth causes resorption of the second molar. (which is where the tooth or more importantly the tooth of the tooth, is eaten away, much like in those awful horror films where the busty blonde one gets attacked by some sort of flesh-eating bug – whilst I may add, her make-up and hair stays in pristine condition).

Apologies for the unclear quality of this x ray – it turns out that there is pretty much no visual evidence of this “resorption” being caused by wisdom teeth despite seeing it at the hospital on a weekly basis. The x ray shows a typical appearance of a second molar suffering from this resorption. Of course the wisdom tooth has been removed at this point because it was causing said resorption.

Partially erupted teeth

Whilst the above circumstances of decay or resorption due to wisdom teeth happen on a fairly regular basis, the most common problem with said intelligence-increasing teeth is something called pericoronitis. I have decided to give my good friends at nhs.net a break and have (perhaps blasphemously) borrowed this definition from medicinenet.com

“Pericoronitis is a dental disorder in which the gum tissue around the (3^rd) molar teeth becomes swollen and infected” To break the word down:

• “peri” means “around"
• The “coron” bit is a shortened version of coronal(ly) which refers to the crown of the tooth (the top bit that you see above the gum)
• “itis” means inflammation/swelling (which is a good common bit of information, anything with “itis” after it means inflammation or swelling e.g. sinusitis, bronchitis)

So the word pericoronitis means, inflammation or swelling around the crown of a tooth. This therefore can occur with teeth other than 8’s – for example when children are teething, however it tends to occur most with wisdom teeth because they are so hard to get at anyway.

For pericoronitis to occur there has to be a certain set of circumstances:

1. Your wisdom tooth should be PARTIALLY erupted. If the tooth is in its final position in the mouth i.e. has come through fully, then you cannot get pericoronitis and any problems or symptoms you are experiencing will be due to something else.
2. For the reason above, the tooth will therefore be covered by a flap of gum
3. Due to the flap of gum, it becomes very difficult to clean around the wisdom tooth effectively. It’s a bit like trying to hoover under the sofa. It’s doable but it takes effort.

        Here is a picture.

How you know you have it.

Your dentist will be able to tell you immediately but the signs and symptoms of periocoronitis are:

      1)    Pain from around the wisdom tooth – it can be upper or lower

a.    You will often be able to feel with your tongue that there is a flap of gum over the tooth and that pressing on this triggers the pain or feels sore

      2)    You may feel like you have pain in the jaw particularly if you try to stretch wide for example when yawning

      3)    Bad breath. I don’t mean morning breath I mean actual people-walk-out-the-room-when-you-come-in bad.

      4)    Accompanying the bad breath is often a foul taste

      5)    Sometimes you can also get swollen glands (because they are reacting to the infection/inflammation) or a generally swelling around the area of the wisdom tooth for example a lower left wisdom tooth with pericoronitis may present with a swelling of the lower left part of the face if it is left untreated

How to deal with it

Ideally, you should go and see your local toothworker as a lot of the above symptoms can also be caused by a lot of other things from the mundane tooth decay to something more sinister. However, if they are fully booked (i.e. have a rep coming at 12pm and they’re bringing free lunch so all emergency slots are cancelled) or if you cannot get to a dentist then there are a number of things that you can try first to relieve the pain. If these work then it will save you a visit to the dentist and the accompanying cost and time etc.

Having a partially erupted wisdom tooth alone will not lead to pericoronitis. There has to be the build-up of plaque under the flap of gum. Unfortunately this does not spare even those of us with a toothbrushing addiction or the possession of the “they should know better” degree. I had a nasty bout of it last week. Sadly you don’t realise you’re not cleaning effectively enough until it hits you.

Therefore, the action plan is as follows:

     1.    Clean the hell out of the area. (Pardon my French). Get your toothbrush round there, but more importantly you need to get under the flap of gum (which just for completeness is called the operculum).The best way to do this is with either a single tufted toothbrush – you may have one lying around, if not they are readily available to purchase from supermarkets or chemists – or if you cannot get out to get one, a cotton bud will do a good job

 

2.    Use chlorhexidine mouthwash. This is most commonly called “Corsodyl” mouthwash, because after university we tend to lose all concept of chemistry and medicine and just call everything by its brand name.

a.    Use this as a rinse whenever you can be bothered, but at least after eating. As a side note, do not do this for more than a week. This is for several reasons, the first being that if there is no improvement after a few days then it is unlikely using a mouthwash for a week is going to help. Also, chlorhexidine causes staining of the teeth if used continuously for longer than 7 day periods. This staining is easily removed via a scale and polish but it is best to avoid it if possible.

b.    It is also very helpful to dip the aforementioned single tufted brush or cotton bud in some chlorhexidine prior to cleaning under the gum flap

     3.    If this does not improve the situation then you really do need to go to your dentist. They will wash out under the gum more effectively than you can manage at home, and if deemed necessary i.e. if you have swollen glands, severe pain, pain that hasn’t resided, any difficulties opening or closing the mouth, then they can prescribe you some antibiotics. Generally we will give a drug called Metronidazole. As a prior warning, if you’re planning to go to the dentist on a Friday and then drink away your sorrows at the weekend, think again. Metronidazole blocks the production of a certain chemical/enzyme required for breaking down alcohol. Therefore should you choose to indulge in an alcoholic beverage or 2, you will be violently ill. I don’t mean standard-end-of-a-night-out ill, or even Freshers-week ill, I mean wanting to murder-the-person-who-discovered-alcohol-I-promise-I’ll-never-drink-again sick.

     This nicely leads into the wondrous and very much mistaken taking out of wisdom teeth. Sadly one bout of pericoronitis is not an adequate reason for extracting wisdom teeth. Nor is “well they just don’t do anything useful do they?”. In my next post I will go into the reasons for and against extracting 3^rd molars/8’s/wisdom teeth, as well as the process itself and a few pointers to follow as I feel I have waffled on quite enough for one sitting.
     
     As always questions are more than welcome, as are corrections of blatant mistakes. General rudeness however will result in an internet-transmitted slap. 

    Bye for now!!

Where I “borrowed” info from

http://www.nhs.uk/Conditions/Wisdom-tooth-removal/Pages/Introduction.aspx

http://www.drvenmar.com/Impacted_Teeth

http://www.drjohnschmitz.com/images/wisdomTeeth_adjacent.jpg

http://www.thenextdds.com/uploadedImages/The_Next_DDS/Clinical_Images/02b%20Laskin.jpg

http://www.medicinenet.com/pericoronitis/article.htm

http://www.juniordentist.com/wp-content/uploads/2012/09/pericoronitis-pericoronal-pouch-or-operculum1.gif

http://blog.dentist.net/wp-content/uploads/2011/12/tepe-compact-tuft-toothbrush.jpg