A normal adult mouth will contain 32 teeth. Each quarter of a mouth has eight teeth. The molar at the back has become known as the ‘wisdom tooth’. Often they need to be removed and because of their position they can present unique problems both before and after surgery.
Wisdom teeth are often short of space and therefore do not fully grow (erupt) into the mouth. They often have a piece of gum over the back part of their biting surface; this makes them vulnerable to infection (pericoronitis). Lower wisdom teeth are very commonly infected. Such infections give symptoms such as swelling over the back part of the jaw, inability to open the mouth (trismus), pain especially to bite on the area, and a bad taste.
The infection can be prevented by good oral hygiene and stopping smoking. If the infection becomes established then hot salty water mouth rinses can be very helpful. The upper third molar often bites on the gum overlying the tooth and so the dentist may suggest that the upper wisdom tooth be removed or ground down. Antibiotics, commonly metronidazole or a penicillin, are given to help combat this illness.
Wisdom teeth are also susceptible to dental decay and gum disease (periodontal disease) and their presence may contribute to decay or gum disease in the adjacent molar tooth. There are other more unusual reasons why wisdom teeth are removed in hospitals such as cysts, tumours, and fractures of the jaw in this region.
Not all wisdom teeth will need to be removed. There are now national guidelines issued by the National Institute for Clinical Excellence, which stipulate the conditions for their removal. Most symptomless wisdom teeth should be left unless there is evidence that they are going to give rise to symptoms in the near future.
Although infections are unusual in upper wisdom teeth (unless they are decayed), they often grow in such a way that they rub the cheek. If the lower wisdom teeth are to be removed then most surgeons would consider removing the upper on the same side to prevent it growing too far down (over-erupting) in the future.
Every patient about to have their wisdom teeth removed will have heard horror stories or had friends who have suffered greatly. Whilst a minority of patients do have problems, most patients do not. Upper wisdom teeth are usually very straightforward to remove unless badly decayed. Lower wisdom teeth are often removed under a local anaesthetic with or without sedation. After the area is numbed, gently cutting the gum and moving it to one side exposes the tooth. Some teeth require a little piece of bone to be removed and this is done with a drill. Just as when a filling is done the drill requires water irrigation and so the nurse will suction around the wound to enable the dentist to see the tooth. Sometimes the tooth will be cut into pieces to aid its removal. Following the removal the wound is washed and the gum stitched into place.
There is no doubt that the surgery is easier for the dentist if the area is healthy. If the patient takes steps to keep the tooth as clean as possible with good toothbrushing and rinsing the area with hot salt water mouth rinses or Corsodyl mouth wash, then this will reduce gum swelling (gingivitis) and make it easier for the dentist to operate. Reducing or stopping smoking reduces the chances of problems after the teeth have been taken out.
The dentist may use dissolvable stitches. Some dentists prefer to use non-dissolving stitches and will make an appointment to remove them, usually between 1 and 2 weeks later. If they do need to be removed then this is usually straightforward and painless.
Patients may experience symptoms after surgery, which may resemble those of an infection. Swelling and discomfort together with an inability to open the mouth fully may be worrying especially when these reach their peak, usually three days after surgery. Most dentists would prescribe antibiotics for difficult lower wisdom teeth extractions in order to avoid any potential infection.
There are many ways in which the patient can help the wound to heal. The medication prescribed should be taken in the manner directed. Hot salt water mouth rinses should be used regularly for five minutes four times a day for a week. The water should be tepid but not too hot as to burn. A tablespoon full of salt should be allowed to dissolve in a coffee mug sized amount of this water. The mouthwash is then held over the wisdom teeth socket until it is cooled and then spat out.
Discomfort is common following any operation on the body. Most patients find that any pain is easily treated by painkillers such as paracetamol or ibuprofen (assuming that there are no reasons why they may not take this medication, eg stomach ulcer). However, if the pain becomes severe then it may be that a dry socket is developing. A return to the dentist will be necessary.
A dry socket is when the clot in the socket gets broken down leaving exposed raw bone. The pain usually comes on seven days after the operation. The pain is deep-seated and described as throbbing. Risk factors include difficult extractions, smokers, poor oral hygiene and ladies on the oral contraceptive pill. It is treated by washing the socket out thoroughly and placing a dressing in the wound. The discomfort typically lasts 7-10 days and may require a further appointment during this time.
All patients will be numb in the lower lip or tongue for a few hours afterwards. If this persists it may be that the surgery has stretched or damaged one of two nerves in the area. The nerve to the lower lip runs in a bony canal in the lower jaw. The roots of the wisdom tooth may be intimately involved with the nerve and may cause temporary or permanent damage. The nerve to the tongue runs alongside the roots of the lower wisdom tooth in the gum. If the numbness persists for more than a week then the dentist who removed the tooth should be consulted. About one percent of patients will have some numbness post-surgery although the vast majority would expect a rapid full recovery. About one percent of the one percent can expect a slower recovery. Rarely, the numbness can be permanent.
If the socket continues to bleed, the most important thing is to stay calm. The amount of blood loss appears greater because of all the saliva that is mixed with it. Remove all of the clots in the mouth, if necessary with fingers. Take a swab or clean hankie and put it under the hot tap. Wring the gauze dry and place it directly over the wound and bite hard. The swab should be kept inside the mouth for at least 15 minutes. This will stop 90 percent of all bleeding sockets. If the bleeding persists, contact the dental surgery immediately.