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There are many good reasons for
removing wisdom teeth also known as third molars, there are also some
risks and complications that are possible when extracting these teeth and
sometimes there are some good reasons for leaving them alone. The decision
on a specific course of action must be determined by a well informed
doctor and patient working together.
Is it necessary to remove wisdom teeth?
Wisdom teeth are a valuable asset to the mouth when they are healthy
and properly positioned. Often, however, problems develop that require
their removal. When the jaw isn't large enough to accommodate wisdom
teeth, they can become impacted (unable to come in or misaligned) Wisdom
teeth may grow sideways, emerge only part way through the gum or remain
trapped beneath the gum and bone.
Extraction of third molars is generally recommended:
When wisdom teeth only partially erupt;
When there is a chance that poorly aligned wisdom teeth will damage
adjacent teeth;
When a cyst (fluid-filled sac) forms, destroying surrounding
structures such as bone tooth roots.
Consider first the many reasons that people choose to have their third
molars extracted. By far one of the most common findings is that the mouth
is just too small for these teeth to fully erupt into a good functional
position. This leads to one of several situations.
1. The teeth remain completely buried in the bone of the upper and
lower jaws in which they developed, a condition known as impaction. In
the case of the fully impacted tooth, it may continue to sit in the
bone, surrounded by the normal cyst in which all teeth develop. It may
also happen that the normal cyst, later in life, enlarges and may even
develop changes in the cells that line the cyst. When such cysts get
large enough, they should be removed and examined by a pathologist.
2. The teeth begin to erupt but are not able to assume their correct
upright position. Most commonly the upper third molars will tend to face
out towards the cheeks while the lower third molars will lean forward
with just a small portion of the crown protruding through the gum. Teeth
that are partially erupted lead to two problems.
A) First they make hygiene of the second molars difficult leading
to increased possiblity of decay and gum disease (periodontal
disease) around these important teeth.
B) Second the pink flap of gum tissue which partially covers the
erupting tooth creates a warm, moist and dark pocket where bacteria
which normally live in the mouth can use the food you eat to
flourish, multiply and cause an infection known as pericoronitis. In
fortunate cases, the swelling and pain of this condition will be
relieved when the infection drains back into the mouth. In those
less fortunate, the swelling persists, does not drain back into the
mouth but rather extends laterally and if not treated can become a
very serious infection. The treatment of choice for pericoronitis is
extraction of the offending tooth. Antibiotics, operculectomies and
other adjuncitve treatments may be helpful from time to time but the
problem has a propensity to return as long as the conditions which
allowed it to develop in the first place continue to exist.
It is easy to understand why many people choose to hedge their bets
and have their wisdom teeth extracted while they are young and healthy
and the teeth are surrounded only by a small normal developmental cyst
rather than have to undergo a more extensive surgical procedure later in
life when their recovery may not be as easy and their general state of
health may not be as good.
Finally, some dentists subscribe to the theory that wisdom teeth may
push the other teeth in the mouth forward and cause crowding and
misalignment. You should be aware however, that not all oral surgeons
believe this to be the case.
Now however, it is important to consider the possible risks and
complications involved in the removal of third molars. There are some
risks/potential complications which are common to all surgical
procedures however major or minor they might be. These are:
PAIN
Removal of third molars is a surgical
procedure and some discomfort should be expected. It is also reasonable
to expect that this discomfort will be taken care of by the pain
medication prescribed.
INFECTION
In the absence of preexisting
infection it is uncommon to see an infection resulting from the removal
of third molars however, there are more bacteria per square inch in the
oral cavity than anywhere else in the human body and so often patients
are placed on antibiotics prophylactically during the initial healing
period.
SWELLING
Post operative swelling and bruising
are both within the spectrum of normal. The exact amount of each of
these varies from patient to patient as does the time required for
complete resolution of these symptoms. Surgical edema is a normal
consequence of surgery and also normally resolves without extraordinary
measures.
BLEEDING
It is not possible to do surgery
without some bleeding but when you leave your surgeon's office you
should expect that the minimal oozing you are experiencing can be easily
controlled by biting on clean gauze or a tea bag. Bleeding that cannot
be controlled in such a fashion warrants an immediate call to the
surgeon.
and the risk of the ANESTHETIC
itself.
Most wisdom teeth COULD be removed
without any anesthesia at all...but that would make for a very unhappy
patient and an equally unhappy doctor. For patients whose medical
condition contraindicates general anesthesia, third molars can safely
and effectively be removed with local anesthetic only. Local
anesthestics as used in the oral surgeon's office are among the safest
of drugs around and true allergic reaction to a properly administered
local anesthetic is so rare as to be worthy of publication in scientific
journals. Most persons prefer, however, to be "asleep" for the
removal of their third molars. There
is a somewhat greater risk for this
than for the use of local anesthetic alone and if this is your desire,
your oral surgeon should discuss your medical history and your
particular risks with you prior to your procedure. You should be aware
that in the young healthy individual, those risks are often minimal and
acceptable but they do exist and should be discussed with the doctor.
Finally there are some risks/complications that are unique to the
removal of third molars.
The upper third molars have roots which often are separated from the
maxillary sinuses by only a very thin layer of bone. Occasionally, a
small communication is established between the sinus and the oral cavity
when one of the upper third molars is removed. If this is the case, the
normal procedure is for the area to be sutured closed, the patient to be
informed of the finding, appropriate antibiotics and decongestants to be
prescribed, the patient to be instructed to avoid Valsalva maneuvers
(tasks which build up pressure in the sinus like nose blowing and
bearing down forcefully) and the patient reappointed for followup. Most
often this results in an uneventful healing period with no further
treatment being required. Occasionally, the area will heal open rather
than closed in which case an additional small surgical procedure will be
required to close the communication.
The lower third molars often have roots that lie very near or even
wrapped around the inferior alveolar nerve. This is the nerve that
supplies feeling to the lip, teeth and tongue on each side of the mouth.
Occasionaly, when a lower third molar is removed, that nerve will be
bumped or bruised and if so a change in sensation may be noted on that
side. It is important to understand that this is a sensory nerve and
does not affect the ability to move the parts of the oral cavity to
which it gives sensation (feeling). In most cases, the nerve heals
itself but, because nerves heal slowly, it may take six months to one
year before return of normal sensation. Very rarely, the damage to the
nerve is permanent.
Finally, the normal precautions, risks and benefits of extraction of
any tooth (which are beyond the scope of this discussion) also apply
here and should be discussed with the dentist prior to beginning any
procedure.
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