January 22, 2007

Impacted Wisdom Teeth


What's so smart about wisdom teeth if it seems like they're nothing but trouble in the long run?

Indeed, impacted wisdom teeth can cause a variety of problems, from nuisance pain to serious dental disorders. They often must be surgically removed.

Wisdom teeth are your third molars, stuck way in the back of your mouth. Most people have four wisdom teeth, one in each corner of the mouth — two on top, two on bottom. Wisdom teeth are the last of your teeth to come in, or erupt through the gums. They normally emerge between ages 17 and 21.

Oftentimes, wisdom teeth aren't able to emerge normally and instead become impacted, or trapped within your jaw. Understanding more about impacted wisdom teeth can help you decide how and when to treat them and how to prevent related complications.

Signs and symptoms
Some people never experience problems with their wisdom teeth. Your wisdom teeth may emerge normally and be trouble-free for the rest of your life. Or, you may have impacted wisdom teeth but remain blissfully unaware, since they don't always cause signs and symptoms.

Common signs and symptoms of impacted wisdom teeth include:

Pain or tenderness around your gums
Swelling around your jaw
Red or swollen gums around the impacted tooth
Jaw pain
Bad breath
Unpleasant taste when biting down on or near the area
Prolonged headache or jaw ache

Early humans needed wisdom teeth and larger jaws to handle a tougher diet. Today's humans typically have smaller jaws and little use for wisdom teeth. And that often means people wind up experiencing problems. Having pesky wisdom teeth surgically extracted seems almost a rite of passage — and something to swap stories about later.

Wisdom teeth develop like your other teeth. But they take the longest to develop and are the last teeth to emerge. Any tooth can become impacted. Because wisdom teeth must fight for space with teeth that have already emerged, they're the teeth most likely to become impacted.

At about age 9, the crown of a wisdom tooth begins to form in a small sac inside your jaw. Over time, the tooth grows and the roots become more firmly planted in the jawbone. By your early 20s, the crown of a wisdom tooth should fully emerge from your gum. By your 40s, the roots of your wisdom teeth are solidly planted within the dense bone of the jaw.

For many people, wisdom teeth don't follow this normal development pattern. Today's smaller jaws simply may not have room for this last set of molars to grow properly. So the wisdom teeth become impacted.

The cramped wisdom teeth struggle for a path to grow and emerge. They grow at various angles in the jaw, sometimes even horizontally. Sometimes, a wisdom tooth partially emerges through the gums. Other times, it remains completely hidden

Risk factors
Having a small jawbone may make you more prone to having impacted wisdom teeth. But otherwise, there are no particular biological or environmental risk factors that make you more likely than someone else to have impacted wisdom teeth

When to seek medical advice
If you notice pain or swelling in your mouth, teeth, gums or jaw, contact your dentist right away. Also contact your dentist if you notice any changes in your teeth, such as shifting of position, discoloration or changes in sensitivity.

Screening and diagnosis
Your dentist can evaluate your teeth and mouth to determine if you have impacted wisdom teeth or if another condition is causing your problems. Such evaluations typically include:

Your dental and medical history
A dental exam
Dental X-rays

Impacted wisdom teeth that aren't removed can cause numerous problems. These problems include:

Gum disease. Bacteria and food can get trapped under a flap of gum that can grow over wisdom teeth, creating infections. Gum disease may be initially mild (gingivitis) or progress to a more severe form (periodontitis).
Crowding. A wisdom tooth can push on other teeth, damaging them or moving them out of position.

Decay. Because they're hard to reach, wisdom teeth may not get fully cleaned during brushing, making them vulnerable to decay and cavities.
Cysts. The crown of a wisdom tooth grows in a sac. If the sac remains in the jawbone, it can fill with fluid, forming a cyst that can damage the jawbone, teeth and nerves. Very rarely a tumor, usually benign, also may develop, which may require removal of tissue and bone.

Impacted wisdom teeth don't automatically need to be surgically removed. You have two main treatment options, depending on the severity of your situation and other factors. They are:

Conservative treatment
Surgical extraction

Conservative treatment
If impacted widsom teeth aren't causing problems, you and your dentist may choose to simply monitor them. People who can't have their teeth removed because of certain health problems may also need to choose conservative treatment.

Under guidance from your dentist or oral surgeon, you may be able to care for your impacted wisdom teeth and minor problems using mouthwashes, saltwater rinses and over-the-counter pain relievers. If complications arise or worsen, surgery might become an option.

Surgical extraction
Experts agree that when an impacted wisdom tooth causes complications, it should be extracted to prevent further problems.

Some experts say that impacted wisdom teeth should always be removed, even if they aren't causing problems. The belief is that the impacted tooth will probably eventually cause problems, and that it's better to remove it when someone is younger and more likely to recover better and faster from surgery. This is why many high-school children or young adults have their wisdom teeth extracted even before the teeth start causing problems. In addition, if a child might require braces, his or her dentist may recommend extraction of the wisdom teeth first.

There's no scientific evidence to recommend for or against extracting impacted wisdom teeth in adults or adolescents if the teeth aren't causing complications. You and your dentist can evaluate your situation to see which treatment option is best for you or your child.

Extracting an impacted wisdom tooth
Extraction of impacted wisdom teeth often can be done in your dentist's office with local anesthesia. However, if the tooth is deeply impacted or if the extraction may be difficult, your dentist may suggest that you consult with an oral surgeon. Sometimes extractions are done in the hospital. You may need general anesthesia for more complicated extractions.

To reach the impacted tooth, an incision is made in your gum. The incision creates a flap of gum, which can be peeled back to expose the impacted tooth and jawbone.

An impacted wisdom tooth that has partially emerged may be removed with forceps. But if the tooth is fully impacted or if the roots reach deep into the jawbone, the tooth may have to be broken into pieces for removal. In more severe cases, portions of jawbone may need to be removed.

You may need stitches to close the gap in your gum. The socket where your tooth was located is packed with gauze to control bleeding and to help a clot form, which promotes healing.

Care after surgery
Your dentist or oral surgeon gives you specific instructions about caring for your mouth after extraction of an impacted wisdom tooth. Here are general tips about care after oral surgery:

Activity. Plan to rest for the remainder of the day after surgery. Don't engage in rough play or ride a bike. Don't smoke for at least the first day after surgery, as doing this may disrupt the blood clot in the socket.

Diet. Drink lots of clear liquids and eat only soft foods for the first 12 hours. If you had several teeth removed, stick to a diet of soft foods for the first few days. Don't use straws, as doing so can dislodge the clot that forms in the tooth socket. Avoid hard or crunchy foods, such as popcorn, for two weeks after surgery.

Pain management. Some people may need prescription pain medication during the first few days after surgery. Others may be able to manage their pain with over-the-counter pain relievers. Applying ice packs — a bag of frozen peas or corn works nicely —also may help control pain, as well as swelling.

Bleeding. Some oozing of blood is normal for the first day after removal of your impacted wisdom tooth. Swallow blood-tinged saliva instead of spitting it out, to avoid dislodging the socket clot. Get instructions from your dentist or surgeon about replacing the gauze packing. Remember that when blood mixes with saliva, the amount of blood loss can look worse than it actually is.

Swelling and bruising. Swelling of your cheeks and jaw is normal after surgery. You can use ice packs to help control swelling. Swelling normally begins to subside by the third day. Some dentists give an injection of a steroid during the surgery to help minimize swelling. Swelling may make it a bit difficult to open your mouth fully, but this normally improves on its own. You may also have some bruising around your jaw or upper neck.

Cleaning your mouth. The day after surgery, rinse your mouth gently with warm salt water at least six times a day. Mix 1/2 teaspoon of table salt in an 8-ounce glass of water. Brush your teeth, but be very gentle in the area around your surgery.

Complications of extraction
Most people recover quickly and without problems after removal of an impacted wisdom tooth. However, complications can arise. Your dentist or surgeon advises you about signs and symptoms to watch for, such as fever and increasing pain.

Other complications can include:

Numbness, usually temporary, of your teeth, gums, tongue and chin
Dry socket when the socket clot dislodges, exposing underlying bone
Infection from bacteria or trapped food particles
Sinus problems if teeth near the sinuses were removed
Weakening of the jawbone from bone removal or damage

Coping skills
For some people, a visit to the dentist causes so much anxiety they can't get themselves to go, even if they're in pain. The thought of having a tooth extracted may be overwhelming. But if you're having problems related to an impacted wisdom tooth, delaying care could lead to serious and permanent problems.

Make sure you have a dentist who is sympathetic and willing to help relieve your fears. Talk to your dentist about your concerns. Don't be embarrassed about your anxiety — it's common, especially when you must have a dental procedure that can be uncomfortable.

Many dentists offer ways to ease your anxiety, such as listening to music or watching videos. You may be able to bring along a supportive family member or friend. You can also learn relaxation techniques, such as deep breathing and imagery. If you have severe anxiety, talk to your doctor about medications that may help. And of course, you may be able to opt for full sedation during the procedure itself, so you're asleep through it all.

Adapted from: Mayo Foundation for Medical Education and Research