Hello all.
If you have returned
for the second instalment of my wisdom tooth rant then I thank you! I realise
the last one was a bit of a slog but hopefully it provided some basic
information about the problems wisdom teeth cause.
I discussed
pericoronitis last time, which is the most common problem wisdom teeth cause. I
also briefly mentioned that if you rocked up to your dentist, or worse, the
dental hospital, demanding extraction (whipping out) of your wisdom teeth
because they don’t look very nice, they are the cause of all your life problems
(failure of your marriage, loss of job etc) then sadly you will be met by a
wall of silence and handed a “bye bye” discharge letter.
Unfortunately, as
with most things, there are risks to taking out all teeth. Wisdom teeth are
particularly troublesome (to put it mildly, I would quite frankly say they are
a pain in the arse) to take out. This is
mostly because of the position right at the back of the mouth, or as mentioned
before that they are literally wedged in place often below the gum line. They
are also a bit of an anomaly. Whilst most teeth have a generally accepted
anatomy, wisdom teeth are a law unto themselves, a bit like Miley Cyrus or Lady
Gaga – you never know what you’re going to get from one day to the next. They
can have 1-3 roots of different angles, either splayed out or fused together.
They can be surrounded by bone, or even be fused to the jaw bone. Therefore, if
we can avoid taking them out – much as we enjoy getting out our pneumatic
drills and nail guns – if you don’t absolutely need them removing, you don’t
get them extracted. Especially not by me.
The most important
reason for why we are hesitant about taking wisdom teeth out however is due to
unavoidable potential side effects, the most important being nerve damage.
In order to explain
this I am sadly going to have to describe the process of extracting wisdom
teeth in some detail. If you are at all squeamish, you may wish to skim over
this bit.
Of course, if you have a fully erupted
wisdom tooth, i.e. it is fully visible in the mouth just like all the other
(normal, non-pain-in-the-arse-causing) teeth, then the procedure for taking it
out is no different to other teeth.
However when the tooth is partially
erupted, or unerupted, it is surrounded by bone and there is very little/no
tooth to grab hold of with our highly advanced sci-fi (not) forceps. In this
case we have to do something called “minor oral surgery”. As opposed to major
oral surgery which I imagine entails something similar to beheading and
fortunately not performed by any of us toothworkers. Well, not intentionally
anyway.
Minor oral surgery for wisdom teeth
As the wisdom tooth is surrounded by
bone, in order to take it out, we have to remove some of this bone, and the
only way to do this is peel back (sorry, I desperately consulted several
thesauruses for a better way of phrasing this but this genuinely is the best
way of describing what we do) the gum and then drill away some of the bone in
the same way that we drill to do a filling.
Before you go into panic mode, the
important thing to remember is that the only difference between a “normal”
extraction and this method is that we directly visualise the roots of the teeth
that we are trying to take out. In some ways this is actually easier and often
means that less “force” is required to take the teeth out as we can get a
better leverage and see exactly what we are working with – i.e. 3 roots, 2
roots, fused roots etc.
The same amount of anaesthetic (if not
slightly more because we often book longer for this minor oral surgery
appointments than we do for regular extractions) is used, and the only
difference you will actually be aware of is the noise/vibration that occurs
when removing bone, and the fact that you will have some stitches in place
afterwards.
So here goes.
How to (surgically) take out a wisdom
tooth for dummies.
1) 2 or 3 cuts are made in the gum. Again,
please remember you will be completely numb for this, so you will feel that we
are there/pressure but not pain.
2) The wisdom tooth will then be hidden
behind a layer of bone.
Sadly, Google seems to want to terrify people into never attending a
dentist ever again and thus most pictures I could locate were not appropriate
for this blog, unless I want to do myself out of employment of course.
It is at this point
that I suppose the most “risky” aspect of the extraction arises.
This nerve supplies sensation
i.e. feeling for HALF the lower lip (the half being whichever side the tooth
you are talking about is, i.e. right tooth, right half of lip), some of the
skin of the cheek, and half of the lower teeth. It is important to mention that
it does not provide motor or movement supply to these areas.
When extracting LOWER
wisdom teeth damage can occur to this nerve. The wisdom tooth can be sitting on
the nerve and when it gets wiggled out this can irritate the nerve. The roots
can be wrapped around the nerve and on taking it out more damage can occur.
Sometimes the tooth itself is not actually touching the nerve but in order to
extract the tooth, bone has to be removed and this can cause damage to the nerve.
See below. #freeadvertisingforthisguy
This means that following
the extraction it will feel like you are still numb. Like when you have an
injection before a filling for a lower tooth, that sensation will continue past
the time when the anaesthetic wears off. There are various figures in the
literature about 1) the chances of this damage happening and 2) whether or not
the sensation comes back. They estimate
that there is around a 2% risk of damage occurring to this nerve during lower wisdom
tooth extraction. Of course if you need an upper tooth out, this risk is
irrelevant. In terms of whether this sensation will return, there is again
debatable evidence. It is most common that the disturbance to feeling is temporary
i.e. it will return, usually fully, however it is estimated that 0.6 to
2.2 percent of cases of people who lose sensation after wisdom tooth extraction
will have this permanently.
What this means in terms of your daily life is that nothing will be
visibly different either whilst your face is still, or if your face is moving.
Your lip etc will move normally, it will just feel different i.e. numb or have
a pins and needles sensation. It is however important to point out that there
is a small chance that by leaving infection or pathologies (e.g. cysts) around
wisdom teeth, the same nerve damage can occur but is much less predictable so
it really is best to get them out in this case.
Whilst we will always
take an xray of the tooth to be extracted, and have a good idea of where the
nerve is positioned, radiographs (x ray images) are only a 2D image of a 3D situation
so the only really guaranteed information they can give us is “yes the tooth is
close to the nerve” or “no the tooth is miles away”. Luckily some Hungarian oral
surgeons have completed a study and summarise this nicely “radiography
[i.e. taking and interpretation of x ray pictures] is an inadequate screening
method for predicting IAN [inferior alveolar nerve] paraesthesia after
mandibular [i.e. lower] third molar removal”
Back to the surgical bit….
3) Following bone removal so that we can
see the tooth, it is then extracted. This
is done in a number of ways but for the purposes of how much you need to know
and what you will be aware of, at this point you will feel pressure and lots of
wiggling of equipment from our part.
4)
Once the tooth is out, we will then replace the flap back over the area
and place a couple of stiches to hold it in place. These will dissolve by
themselves but you will of course be aware of them.
As with any
extraction, you will be sore afterwards. As you can see, the procedure is
slightly more involved than the normal, grab-it-pull-it-out technique that we
can use on other teeth, so expect to feel a bit naf for a few days. Your
dentist will give you lots of aftercare instructions and things to expect straight
after you have gone through this and thus you won’t listen to a word so I will
summarise.
1) Pain, swelling. I have lumped these 2 together because it is
pretty much guaranteed that you will experience these. In terms of pain, the
best medication to take is paracetamol and ibuprofen. You do not require
codeine or in fact as I have been asked for on several occasions – ketamine.
Please check that you are ok to take ibuprofen. It is one of a group of drugs
called NSAID’s and can cause problems for certain asthma sufferers, people with
kidney disease, stomach problems etc. Also, if you are already taking an anti-inflammatory
medication e.g. for arthritis, back pain, then do not increase your dose.
Swelling will reach a maximum after 48 hours then begin to go down. You
may also notice some bruising if it is a particularly difficult extraction.
Expect the worse basically, then you will be pleasantly surprised.
2)
Bleeding. This is where people get confused. If you have the tooth “surgically”
removed, the wound will be stitched. This can help reduce but not eliminate
bleeding. If you do not have stitches, there will be some oozing of the area.
The small amount of blood coming from the socket where the tooth was taken
from, mixes with saliva and causes people to panic that they are bleeding out
and have seconds to left to live without a transfusion.
We will usually give you some squares of gauze to take home with you. If
you feel that the area is actually bleeding, i.e. when you spit out, it is red
not just pink, then roll one of these gauze pieces up into a sausage and bite
for 20 mins. If bleeding continues you need to return to your own dentist or go
to A+E.
3)
Infection. When you cut yourself elsewhere on the body, in order for it
to heal you want a scab to form. In the mouth it is a similar concept but you
want a blood clot rather than a scab. If you do a gym session, lift heavy
objects, raise your blood pressure in any number of ways, this will dislodge the
clot and leave a gunky mess in the socket. Gunky mess = no healing. Similarly,
if you decide to leave the dental surgery and have a fag, the same thing will
occur. You will then come back crying to us in more pain than you were with the
toothache, with something called “dry socket”.
Heat will also increase blood pressure, so don’t hold anything hot
against the side of the face to try and ease discomfort because it will just
make it worse in the long run.
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If this does occur,
go back to the dentist and we will place a dressing in. This works wonders but
it tastes repulsive so let that be a warning to you.
4) In terms of keeping the area clean,
brush the other teeth as normal. SPIT DON’T RINSE FOR 24 HOURS. As above, if
you rinse and swill around the mouth vigorously, you will dislodge the blood
clot and end up in the above situation. For 24 hours just spit out any blood
stained saliva you feel is building up. After 24 hours, start with some hot
salt water mouthwashes. Get some hot water, fill a mug or a cup, add a teaspoon
of salt, GENTLY swish this around your mouth and spit out until the cup of
water is gone. If you don’t do this, you will get nice bits of your roast
dinner, cereal etc building up in the socket which then I have to fish out.
Usually before lunch. Please save me having to do this.
5) If you have any concerns, please just
ring your dentist. They can advise you, settle worries, and recommend you come
in for a check if necessary.
Finally, just when
you are wondering why the hell anyone would choose to do this to themselves,
there are a number of myths surrounding extraction of wisdom teeth and why/when
we take them out. For this I require the assistance of the wonderful people at
the National Institute for Clinical Excellent (NICE) who provide helpful
although thoroughly not-NICE guidance on a number of clinical topics.
Because of the
aforementioned risks of taking wisdom teeth out – pain, bleeding, swelling,
infection, nerve damage etc – we will try not to do it if we can. NICE in fact
says that there is no reliable research to suggest that impacted wisdom teeth
free from disease should be operated on.
They classify “disease”
as decay which cannot be fixed by filling or root canal treatment, either
because it has gone too far or because the tooth is at such an angle that we
simply cannot treat it. Similarly, if it is causing damage to next door teeth,
this is a valid reason for removal. Wisdom teeth are also deemed to be valid
for “the bucket” if they are in the path of a cysts, tumour, or cancer which
needs removal.
In terms of the
aforementioned pericoronitis, NICE basically suggest it is a bit of an opinion
based deicision. They state that “plaque formation is a risk factor but is not
in itself an indication for surgery…The evidence suggests that a first episode
of pericoronitis, unless particularly severe, should not be considered an
indication for surgery. Second or subsequent episodes should be considered the
appropriate indication for surgery”. I.e. unless you have been back to the
dentist several times with this problem, and we can see that you have been
trying to resolve the situation yourself by keeping it clean, you will not
qualify to have the tooth taken out.
To finish, the common
myth that eruption of wisdom teeth causes crowding of the other teeth. I was
going to paraphrase this paragraph from oralhealthgroup.com but it just
summaries the absolute ludicrousy that this concept presents.
“It is
not possible for lower third molars, which develop in the…interior bone…with no
firm support, to push 14 other teeth with roots implanted vertically like the
pegs of a picket fence so that the incisors in the middle twist and overlap. Third
molars do not possess sufficient force to move other teeth. They cannot cause
crowding and overlapping of the incisors, and any such association is not
causation.
This is also
supported by a number of studies of high evidence level (i.e. they were
conducted by the highest level of boffin). I have included some of these below
with boffin-normal person translations:
1) No statistically significant third
molar presence-specific differences were recorded in the lower dental arch
crowding between the groups with erupted and unerupted third molars. i.e.
people with crowding were examined and among these people it was noted whether
or not they had wisdom teeth present. The study found that the crowding was
completely unrelated to the presence of 3rd molars.
2) The principal conclusion drawn from
this randomized prospective study is that the removal of third molars to reduce
or prevent late incisor crowding cannot be justified. Now us tooth workers love
nothing more than whipping out teeth so this is a fairly significant finding.
3)
The dental arches in the extraction group tended to be more crowded than
in the group with complete dentitions. i.e. this study found that in cases
where wisdom teeth had been extracted there was in fact MORE crowding. This is
most likely a coincidence but just goes to show the lack of importance of
wisdom teeth on crowding.
4) This study has not been able to predict
which patients should react favourably or unfavourably to removal of the third
lower molars in cases of anticipated crowding. I.e. these guys haven’t got a
clue.
In summary, if you
are in pain from your wisdom tooth, get it out. Yes there are risks but there
are also risks of leaving infection teeth in place.
As always, if I have
terrified you and you wish to tell me this, or if you want any further
explanation of any aspect, please feel free to comment on here, or follow me on
twitter @smiles__better.
Ode to the boffins:
Forsberg Tooth size,
spacing, and crowding in relation to eruption or impaction of third molars American
Journal of Orthodontics and Dentofacial Orthopedics Volume 94, Issue 1, July
1988, Pages 57–62
Friedman The Prophylactic Extraction of Third
Molars: A Public Health Hazard Am J Public
Health. 2007 September; 97(9): 1554–1559.
Harradine NW, Pearson
MH, Toth B. The effect of extraction of third molars on late lower incisor
crowding: a randomized controlled trial. Br J Orthod. 1998 May;25(2):117-22.
Lindqvist, Extraction
of third molars in cases of anticipated crowding in the lower jaw American
Journal of Orthodontics Volume 81, Issue 2, February 1982, Pages 130–139
NICE guidelines:
Guidance on the Extraction of Wisdom Teeth
Sidlauskas A, Trakiniene
G. Effect of the lower third molars on the lower dental arch crowding. Stomatologija.
2006;8(3):80-4.
Szalma J The prognostic value of panoramic
radiography of inferior alveolar nerve damage after mandibular third molar
removal: retrospective study of 400 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Feb;109(2):294-302. Epub 2009 Oct
20.
http://www.toothology.net/getmedia.asp?media_id=52
