When is it best to remove wisdom teeth?

Image of birthday cake-when to remove wisdom teeth

Birthday cake-Best age to remove wisdom teeth
courtesy http://www.flickr.com/photos/pyxopotamus/9275577509/

The prospect of having wisdom teeth removed is not on anyone’s top ten list of fun things to do.  So, if it appears that you have no other options, then do it before they begin causing strong pain and their roots are fully developed.

If you are seeing a dentist on a regular basis you will receive guidance as to if and when they should be removed. A deep pain in the lower jaw that persists for several days and then disappears for several weeks only to return again may prompt you to seek advice.

If you are younger, you will do better with recovery than an older patient  after wisdom tooth removal so generally the earlier you have them removed the better. That is because the ease of removing wisdom teeth depends upon their location and position at the time of removal.

What I mean by that is, if a wisdom tooth has come in completely, (is fully erupted) and in the proper orientation, with fully formed roots it generally will have a number of potential surgical complications. Wisdom teeth with longer length roots or roots with severe bends or hooks will pose more problems for your dentist and you.

If there is a best age for the fewest number of potential complications it’s probably in the middle to late teens.  If it is clear that it is inevitable, the longer you wait the more difficult it can be.  So the moral of the story is the fewer the candles on your birthday cake the better when it comes to wisdom tooth removal.

Image of Wisdom Tooth X-Ray Incomplete Root Formation

Wisdom Tooth X-Ray Incomplete Root Formation
courtesy Craig Sommer DDS www.springsdentist.com

Your dentist may use X-rays or radiographs to reveal buried wisdom teeth.  If you are younger, you will see incompletely formed roots located closer to the nerve in the lower jaw.

Removal may be a little more surgically demanding at this time, but may have fewer long term side effects. The teeth with incompletely formed roots may require a small window be made through the gums and overlying bone to facilitate removal. Afterwards, the window in the bone is closed with the gum tissue and the jawbone is allowed to heal. There will be some swelling and tenderness after the procedure but usually an uneventful outcome. In a very low percentage of wisdom tooth removal surgeries some temporary nerve damage can occur that results in a tingling or numbness of the lower lip. Usually it is the more deeply placed wisdom teeth that are closer to the nerve initially that have this complication. Rarely it is permanent.

Image of Wisdom Tooth X-Ray Showing Blocked Eruption Path

Wisdom Tooth X-Ray Showing Blocked Eruption Path
Courtesy of Craig Sommer DDS www.springsdentist.com

A more mature wisdom tooth (with more complete root formation), buried under gums or bone, and blocked from erupting by another tooth, is an impacted wisdom tooth. The more significant the root development the more potential difficulty in removal. The wisdom tooth may require separation into several pieces to allow a segmented removal process that is safer for you and results in fewer complications. Or it may require a larger window be made in the bone to allow removal. With more bone removal the greater your chances of swelling and tenderness.

A wayward wisdom tooth pointing in the wrong direction for eruption and in an unfavorable surgical position has the highest potential for complications during surgery. In this situation you and your dentist must weigh the potential complications carefully. In some cases with no clinical symptoms you may decide that the best course of action is to leave it alone. When there is no choice, your surgeons skill and patience will provide you with the best outcome possible.

Now let’s discuss a little bit of what goes on during the process of removing a tooth.

One of the first considerations that your doctor will observe is whether there is a path or direction along which the tooth can be moved in order to bring the root out of the bone.

Do you remember the last time you or a friend had to relocate households? Do you remember moving a piece of large furniture all of the way into a back bedroom. Planning is everything. Will the table fit through the front door, all of the openings and around the corners? Will it’s legs have to be removed and be put back on later after it is in the destination location? Will a door have to be taken off it’s hinges to allow the table to be brought into the room?

Removing teeth is sometimes similar to moving day. With tooth removal there has to be a clear path for moving the tooth that is not blocked by another tooth. And if the teeth involved are in good position it makes life much easier. If not, some trimming or tooth division may be required to remove individual pieces in a controlled fashion.

If the tooth is pointing in the proper direction, in a favorable orientation, what’s next?

First, you have a topical numbing agent applied on the gum tissue to prepare for an injection of local anesthetic. Our goal is to make this as comfortable as possible. Second, your dentist will get you numb, using an optimum amount of  local anesthetic.

Yes, unfortunately, injections are necessary to remove most teeth. I am all in favor of being numb during my dental procedures. I have had enough dental work done over the years myself that I know I would rather be comfortable and not feel much if at all possible.

Your experienced dentist will try to make the injections as painless as possible for you. But you will probably feel a little discomfort during the process. This is where I encourage you to use hand signals.  I ask my patients to raise their hand if they are having difficulty during and after the numbing process. I agree to stop for a moment and assess the situation. In most cases, because the nerves that run to the teeth come from different directions and sides of the teeth, multiple injections are necessary.

After waiting a sufficient amount of time for the local anesthetic to take effect, your dentist will evaluate whether or not the tooth and the gum tissue surrounding it are numb enough to proceed. After the testing process, your dentist will assess how easily your tooth can be moved. He will try to wiggle the tooth in different directions using a variety of different instruments. The wiggling process allows your dentist to determine the next step he will use in the process of removing your tooth.

If you have a single root on your tooth, or if multiple roots are fused together like a large single root it may simplify the removal process. Your dentist may grasp onto your tooth after loosening with an instrument that I call a wiggler. The technical term is forcep.  But forcep is a scary term so I use terms that sound less scary. The forcep is used to hold onto the tooth during the wiggling process. As the wiggling and lifting process continues, your dentist will be able to see the tooth begin moving out of the bone.

Once the tooth is lifted completely out of the bone, your dentist will verify that all of the root or roots are removed and that there are no pieces left behind. Sometimes, during the lifting and wiggling process, one or more of the tips of the roots may separate from the body of the root, and require your dentist use smaller instruments to gently remove the tips of the roots remaining in the hole where the tooth was removed. The hole is called the socket.

Once the tooth and root tips have been removed from the socket your dentist will remove any infected tissue and may gently scrape the socket to remove a layer of tissue that is called the periodontal ligament. This speeds along healing and prevent future complications.

There will always be some seepage of blood from the socket and your dentist will attempt to control that seepage in several different possible ways. In most cases, moist gauze is placed over the socket and you will be asked to maintain light pressure on the gauze with your opposing teeth. If the gauze stays steady and holds the seeping blood in place until a blood clot forms, you will usually have minimal discomfort and a more rapid healing process. That’s why your dentist will tell you not to talk while the gauze is in place, or to talk while keeping your teeth together.

It sounds funny, but if you can keep the blood clot stable, you minimize bleeding, provide for good healing and make for a much better outcome for you. He will probably also tell you that you cannot smoke, rinse, spit, and or drink liquids through a straw. Because all of those can potentially loosen the blood clot which can result in extended bleeding time.  Sometimes, in spite of your best efforts and careful following of instructions, part or all of the blood clot is lost from the socket creating something called a dry socket.

You may have heard of the term dry socket from friends, coworkers or family. In essence, it means that the blood clot that formed in the socket got washed out and the boney socket walls are no longer protected, exposing naked bone. That usually happens three or four days after your surgery and can be quite painful unless your dentist places protective medication or medicated gauze in the socket for the next several days. This is one of those things that your dentist wants to hear about from you so he can help you. It doesn’t happen real often, but when it does it’s very uncomfortable. So you need to really follow the instructions that are given to you by your dentist after surgery.

In most cases, if appropriate, your dentist will recommend the short-term use of an anti-inflammatory medication and a pain medication. These are usually required only for a few days.

In some situations an antibiotic will also be recommended, but not always. Follow your dentist’s instructions as to how this can best be done to maximize your comfort, and minimize the interruption to your normal activities. Your dentist my encourage you to use probiotics along with your antibiotics to avoid intestinal bacterial disruption leading to diarrhea or yeast overgrowth.

It may take several days or even weeks before the area where the tooth was removed becomes comfortable enough to allow brushing and eating near the socket. As soon as you can resume maintaining your teeth normally in that area. The cleaner your mouth is the faster healing will be complete.

In some situations, your dentist may also consider the use of a special type of material that will help to form a good blood clot and reduce your chances of a dry socket. He places this into the socket before the moist gauze is placed over it. Or he may decide that it would be best to place a couple of small sutures or stitches to hold that material in place and to position loose gum tissue so that it will hold the blood clot in place and speed along the healing process. This is done on a case by case basis.

Thinking ahead, your dentist may also suggest, if appropriate, a bone graft be placed to minimize your chances of bone shrinkage that could affect surrounding teeth. This also improves your chances of tooth replacement using dental implants. It is important for teeth closer to the front of your mouth than wisdom teeth. You may want to bring this up during your discussion with your dentist while planning your tooth removal procedures.

I’ve described what’s done for most every tooth removal. Some are straight forward, others are more difficult. Your dentist will prepare you with information for your individual situation, but it is important to ask the questions on your mind. Get those concerns out in the open.

Look for more articles in the series- Questions You Must Ask Your Dentist Before Having Your Wisdom Teeth Removed.