Wisdom Teeth

Third molars or wisdom teeth are very common among the general population. If and when they erupt they can be found all the way back in every arch. They can also get impacted and become problematic. The decision to keep or extract wisdom teeth and the risks and benefits of the procedure should be discussed with your dentist. It is very likely that someone you know has had their wisdom teeth removed. Tooth removal is usually accompanied by stories of discomfort from pain and swelling.

Guide to third molar extraction

Third molar extraction
Third molars or wisdom teeth, as they are commonly known, are the last teeth in the posterior region of each arch

-Some of the common reasons for extraction of wisdom teeth are:

  • Infected tooth. This can be either a cavity within the tooth or infected supporting structures (gum tissue)
  • Insufficient space in the jaws to allow for normal tooth eruption
  • Difficult to keep clean due to positioning, size, or partial eruption. If the tooth is partially coming through the gum tissue the tooth or the supporting tissue will get infected and potentially cause swelling and severe pain.  Patient will often describe pain that is shooting back to their ear on the involved side
  • Poor oral hygiene by patient. This means that the tooth will most likely get infected in the future and will need some form of attention (a filling or deeper cleaning around the tooth). Healthy wisdom teeth are easier to extract than teeth with large cavities.

Any combination of the conditions mentioned above can compromise adjacent teeth and supporting structures, such as bone, or gum tissue. Failing to address potential problems with wisdom teeth in a timely manner can lead to loss of other teeth, loss of supporting bone, pain, swelling and inability to chew.  If the extraction of a wisdom tooth is postponed and the condition of the tooth deteriorates, the extraction can become more complex.  Sometimes removal of a badly decayed third molar involves surgical sectioning of the tooth or roots and potentially removal of the surrounding bone.  More complex procedures can lead to longer recovery time, more pain and swelling after surgery as well as possible nerve damage.  Read the consent form carefully and discuss the possible complications with your dentist before the procedure is started.

 

-Not all third molars need to be extracted. Some of the reasons for retaining wisdom teeth are:

  • Missing teeth in the posterior region. Someone that lost a back tooth or teeth might have a gap that could potentially be filled with the wisdom tooth
  • Large jaws, which provide sufficient space to accommodate extra teeth in the jaw without causing problems with existing dentition
  • Excellent oral hygiene practice. If there is sufficient space for the wisdom teeth to erupt the patient has to show the ability to maintain good oral health.
  • Unerupted, asymptomatic teeth that are completely surrounded by bone and show no potential for eruption in the future.

Choice of Anesthesia

The procedure of third molar extraction is usually done under local anesthesia. This means that the whole area around the tooth is anesthetized, the patient is awake for the entire procedure, and should not feel any discomfort. Another option for a fearful patient or someone who will undergo more than one extraction is deep sedation with local anesthesia. The patient is put to sleep and because of amnesic affect of the medication used, doesn’t remember anything about the procedure. Patient comfort is the main advantage of deep sedation. The main disadvantage is the extra cost associated with the added procedure.  The cost of deep sedation can range from 300 to 1000 dollars depending on the complexity of the procedure.

 

Sedation Dentistry
Intravenous (IV) sedation can be used to make the dental procedure more tolerable

The most popular class of medications used by dentists for in-office IV sedation are a class of drugs known as the benzodiazepines. The most commonly used drugs include midazolam (Versed), diazepam (Valium),  (lorazepam) Ativan. Midazolam is usually the drug of choice because it is quick acting and and wears off faster than some of the older benzodiazepines like diazepam and lorazepam, making it a great option for sedation.  Midazolam also has a very good amnesic affect, meaning that you do not remember much about the surgery. Diazepam is longer-acting, takes longer for its effect to wear off, and is more irritating to the veins than midazolam. Lorazepam has the benefit of being able to be used in some people who cannot tolerate midazolam or diazepam. Midazolam and diazepam are metabolized by liver enzymes therefore they should not be used by individuals with compromised liver function.  Lorazapam is metabolized in the bloodstream and not the liver.

Another common medication that is used for deeper levels of sedation and anesthesia is propofol (Diprivan). Propofol is not generally used in dental offices but more often in a hospital setting for sedation during dental care. Propofol is very fast acting and wears off very quickly (short half-life).  Well trained personnel that carefully monitor the patients vital signs and response to the administered medication and specialized equipment is required for administration of propofol.

Opioid analgesics or pain-reducing medication, such as fentanyl, can be added to the IV sedative medication. These medications contribute to the sedative effect, reducing the need for larger amounts of the other sedation medications and help with pain control during and after dental procedures. Nalbuphine (Nubain) is another opioid analgesic that some dentists prefer to Fentanyl. Ketarolac (Toradol) is a non-steroidal anti-inflammatory analgesic (non-opioid) preferred by some dentists because it does not cause respiratory depression seen with opioid analgesics.

Other medications may be administered during the procedure to minimize possible side effects of sedation, such as nausea or allergy.  Nitrous oxide is also commonly used before the procedure is started for anxiety reduction.  People with dental phobias often are afraid of needles, and the use of nitrous oxide, an anxiolytic (anxiety reducing) gas, can help them relax and get past the initial intense moments of the procedure.

Before, During, and After Surgery

In certain situations where the tooth or the supporting area around the tooth is infected, anesthesia can be difficult to obtain. Also, if the swelling is extensive it can diminish the patient’s ability to open their mouth. This can compromise the dentist’s ability to extract the problem tooth or teeth due to limited access. At that point, antibiotics are prescribed to control the infection, reduce pain and swelling and improve patient’s overall health, which will allow for easier extraction and smoother recovery after dental surgery.

Depending on the overall health of the patient, the condition of the surrounding tissue, the presence or absence of an infection and the patients pain tolerance the dentist might either recommend or prescribe medication to reduce post surgical pain. Non-steroidal anti-inflammatory and opioid medications are the drug of choice.  The dentist will determine which medication ill be beneficial to you based on the difficulty of the procedure.  Antibiotics can also be prescribed in certain situations, especially for patients with a compromised immune system, to speed up the recovery process.

Post operative Instructions
It is important to follow the recommendations of your dentist after oral surgery

-What you should expect after surgery, if you do decide to go ahead with third molar extraction (single or multiple):

  • It is normal to have pain and swelling in the first 48-72 hours.  Swelling can get worse for for the first three days
  • The pain can be controlled with prescription or over-the-counter pain medication. If deemed necessary, your dentist will provide you with pain medication
  • The swelling can me minimized with ice packs and over-the-counter anti-inflammatory medication such as ibuprofen (Motrin, Advil) or naproxen (Aleve)
  • Mild bleeding from the extraction site is normal and expected.
  • Rest is very important. It takes time for the body to recover from this traumatic episode
  • You shouldn’t do anything strenuous until about three days after surgery
  • Follow post-operative instructions provided by your dentist
  • If you encounter any problems, call your dentist
  • If you cannot reach your dentist and you are visibly swelling up after surgery, go to the emergency room.  Swelling can lead to obstruction of the airway and potentially other complications