What are wisdom teeth?
Wisdom teeth are also called third molars and are the last teeth to develop in the mouth.  They generally develop and appear in the late teen years (questionably called the age of wisdom).  The first molars are the 6 year molars, the second molars are the 12 year molars and the third molars (wisdom teeth) develop behind the second molars.

What is an impacted tooth?
A tooth becomes impacted when there is a lack of space in the dental arch and its growth and eruption are prevented by overlying gum, bone or another tooth.  A tooth may be partially impacted, which means that a portion of it has broken through the gum, or totally impacted and unable to break through the gum at all.

What problems do wisdom teeth cause and why should they be evaluated?
Wisdom teeth can cause a variety of problems for patients.  Impacted and partially impacted teeth can be painful and lead to infection.  They may also damage adjacent teeth or roots or cause decay on the adjacent second molars.  The most common long term problem with wisdom teeth is that they cause chronic inflammation in the mouth (periodontal or gum disease) which increases the risk of inflammation throughout the body.  Inflammation causes a variety of adverse effects on the body including increased risk of coronary artery disease (heart attack), stroke, renal vascular disease (kidney disease), diabetes, and low birth weight infants.  The effect of periodontal disease on babies is equal to the effect of smoking during pregnancy.

Wisdom teeth can also develop disease if the sac around the impacted tooth becomes fluid filled and enlarges to form a cyst.  As the cyst grows it enlarges and hollows out the bone and damages adjacent teeth, bone and nerves.  Rarely, a tumor develops in the wall of the cyst and a more serious surgical procedure is required to remove it.

What percentage of wisdom teeth need to be removed?
It is estimated that 85% of wisdom teeth need to be removed.  Even wisdom teeth that are erupted tend to be hard to access for cleaning. Restorations, including fillings and crowns, are often difficult to place and maintain.  In these instances, it is often necessary to replace the fillings several times during the patient's lifetime.  In these cases, removal of the third molars may be the most prudent option.  Periodontal pathology (gum disease), once established in the third molars region is difficult to treat successfully.  Once bacteria are established, it is hard or impossible to eliminate the bacteria even with repetitive treatments.

When should wisdom teeth be evaluated?
An evaluation of wisdom teeth should be carried out in the late teenage years.  Evaluation is performed by clinical exam and xray exam.  Generally, the wisdom teeth can be assessed for eruptive potential when 1/2 to 2/3 of the root of the third molar has developed.  It is generally best to remove the third molars by the 25 th birthday to allow a faster recovery period and more predictable bone healing.

How are wisdom teeth removed?
Removal of wisdom teeth is a surgical procedure that involves making incisions in the gum tissue.  The gum tissue is reflected aside and bone removal around the tooth may need to be carried out.  Lower wisdom teeth are frequently divided and taken out in pieces.  Upper wisdom teeth often can be removed intact.  Stitches are sometimes placed in the area of the extractions.  Gauze pads are placed over the extraction sites the first hour or so after the procedure to provide pressure to control bleeding.  Local anesthetic (Novocaine) is used to control pain during the procedure and either IV sedation or general anesthesia is utilized for the procedure.  An IV sedation is a state of deep relaxation produced by medications delivered into an intravenous catheter.  A general anesthetic is a state in which the patient is asleep for the procedure using a combination of IV medications and inhalational (gas) anesthetics.  In most cases the procedure is carried out in the office but in some cases the hospital may be utilized if the patient is not in good health or has extreme obesity.

What are the risks with wisdom tooth removal?
Like all surgical procedures, wisdom tooth removal carries some risks.  The patient will need to arrange time for recuperation of 3-4 days to recover from typical wisdom tooth surgery.  Pain and anti-swelling medications are prescribed to make the patient comfortable in the post op period.  Generally a 1-2 weeks period of time is needed to be able to return to a normal diet of crunchy hard foods.  For the first several weeks after the procedure, it is difficult to open the mouth widely due to inflammation in the muscles that move the jaws (trismus).  Rarely damage to adjacent teeth or fillings can occur with removal of wisdom teeth.

A “dry socket” sometimes occurs the first week after surgery which can result in intense discomfort.  A “dry socket” is thought to be early loss of the blood clot in the socket causing inflammation in the bone.  The exact cause is not know but thought to be related to bacterial action.  The chance for a dry socket is increased in smokers, patients taking birth control medications and patients older the 25 years of age.  Medicated “dressings” are placed into the socket to relieve the discomfort and manage the “dry socket”. 

Infection can occur as with any surgical procedure but is a low risk in most cases.  Most routine third molar patients do not require antibiotics during their care. There are several sensory nerves that are at risk during lower wisdom tooth removal.  There is a 1-5% chance of injury to a sensory (feeling) nerve to the lower lip and chin.  If this nerve is injured, the lip and chin on the affected side can feel numb, tingly, or fat.  Most of the time the numbness in the lower lip slowly returns over a period of 3-6 months.  In rare cases, the nerve injury is permanent.  There is also about a 0.5% chance of injury to a nerve that provides taste and feeling the anterior 2/3 of the tongue on one side.  This nerve is less likely to return to normal over time.  If permanent injury occurs to either of these nerves and is bothersome to the patient, nerve repair can be attempted by specialists but results in terms of complete recovery are unpredicatable. Upper wisdom teeth can have roots that extend into the sinus resulting in an opening. Between the sinus and the mouth.  This rare complication can result in the need for a procedure to close this opening.

What are typical post op instructions after wisdom tooth removal?
It is generally recommended to have 3-4 days to recuperate after third molar removal.  Generally a prescription pain medication in conjunction with medicine like motrin as used for pain control.  Generally an additional medication to help control swelling and trismus (stiffness in the jaw muscles) is also prescribed.  Ice packs are recommended for 3-4 days to help control swelling and discomfort.  Usually, the swelling after the procedure peaks at about the 3 rd or 4 th day.  Contact sports and heavy exertion need to be avoided during the first week after the procedure.  Soft foods are recommended for the first 7-14 days after the procedure.  Smoking should be eliminated if at all possible during recovery from the procedure.  The patient is usually seen 1 week after the procedure to evaluate the healing and review post op instructions.