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TheWisdomofWisdomTeethRemoval

RonaldAchong,M.D.,D.M.D.

RubenCohen,D.D.S.

�LicoPublishing

1541SouthRobertsonBlvdLosAngeles,CA90035

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TheWisdomofWisdomTeethRemovalBy:Dr.RonaldAchong&Dr.RubenCohen

Copyright2014byRonaldAchong.M.D.,D.M.D.&RubenCohen.D.D.S.

ALLRIGHTSRESERVEDunderInternationalandPan-AmericanCopyrightConventions.Exceptforbriefquotationinreviewsorarticles,nopartofthisbook

maybereproducedbyanymeans.

Inquiriesshouldbeaddressesto:LicoPublishing

1541SouthRobertsonBoulevard,LosAngeles,CA90035

FirstEdition2014Coverdesign:ChadCarpenter.

Insidedesign:ChadCarpenterandRoseMaryH.Cohen

Contacttheauthors:

Dr.RonaldAchong:rachong1@gmail.com

Dr.RubenCohen:rcohen@ParkAvenueFaces.com

ISBN:978-0-9667361-7-5

DISCLAIMER:Theinformationprovidedinthisbookisnotintendedasasubstituteforprofessionalmedicaladvice,diagnosisortreatment.Itisprovidedtohelpyoucommunicateeffectivelywhenyouseektheadviceofyouroralandmaxillofacial

surgeon.

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TableofContents

RemovalofWisdomTeeth:AWiseMove?...............................................................................4

WhyShouldWisdomTeethBeRemoved?................................................................................4

WhenShouldWisdomTeethBeRemoved?.............................................................................5

Cavities,PainandInfection.............................................................................................................7

GumDiseaseandWisdomTeeth...................................................................................................8

WisdomTeethandDentalCrowding...........................................................................................8

Pathology.................................................................................................................................................8

TheHealthoftheSecondMolar....................................................................................................10

AgeandWisdomTeeth.....................................................................................................................10

HowAreWisdomTeethRemoved?.............................................................................................10

X-rays,ImagingandOralSurgery.................................................................................................12

AnesthesiaandOralSurgery..........................................................................................................13

Bene`itsofOf`ice-BasedAnesthesia............................................................................................14

Post-OpInstructions..........................................................................................................................14

You’veMadeItthroughtheFirstDay.NowWhat?...............................................................15

ThingstoAvoidPost-Op....................................................................................................................15

RisksofRemovingWisdomTeeth.................................................................................................16

Conclusion...............................................................................................................................................17

FrequentlyAskedQuestions............................................................................................................17

AbouttheAuthors................................................................................................................................19

References................................................................................................................................................21

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RemovalofWisdomTeeth:AWiseMove?

Yourdentistprobablyhasbeentellingyouforyearstohaveyourwisdomteethremoved,butyoumaybehesitanttohavetheproceduredoneforamultitudeofreasons:youmayhaveheardhorrorstoriesfromfriendsorcolleagues,youmaybeanxiousaboutsurgery,youmaynotknowwhat’sinvolved,oryoumaythinkthatyoucancontinuetowaitsinceyourwisdomteetharenotcausingpain.

Severalfactorsneedtobeconsideredwhenevaluatingwisdomteeth:thehealthofthesecondmolar(whichsitsrightinfrontofthewisdomtooth),thepresenceofgumdisease,theageofthepatient,andtheriskofdentalcrowding.

Yourdentist’srecommendationtohaveyourwisdomteethremovedprobablyiscorrect.Inthisbook,theauthors—bothofwhomhavemanyyearsofexperienceinevaluatingandremovingwisdomteeth—willdescribewhatwisdomteethactuallyare,reasonstohavewisdomteethremoved,howtheyareremoved,andwhattoexpectaftersurgery.Inshort,thisisaguideforpatientsconsideringorplanningtohavetheirwisdomteethremoved.Theprocessisusuallyquickandeasy,andmostpatientsarepleasantlysurprisedbyhowsmooththewholeexperiencereallyis.

Why Should Wisdom Teeth Be Removed?

Onereasonfortheremovalofwisdomteethislackofspaceinthejaws.Often,ourjawsarenotwideenoughtoaccommodateallofthewisdomteeth.Thisresultsinovercrowdingandmisalignedteeth.Patientscanalsoexperienceanunpleasantsmile,ordevelopgumdisease,cavities,infectionsandpain.

Theaveragejawhasroomforonlyfourteenteeth,butmostadultshavesixteenteethonthetopjawandsixteenonthelowerjawforatotalofthirty-twoteeth.Thefouradditionalteeth,whicharethelastteethinthebackofthejaw,arethethirdmolars,commonlyknownas“wisdomteeth.”

Allfourwisdomteethdonotalwaysdevelop.Mostindividualshaveatotaloffourwisdomteethintheirmouth;however,othersmayhavefewerormorethanfour.Someluckypeoplehavenone,andsomeunluckypeoplehavemorethanfour.Lookatthex-raybelowandguesshowmanywisdomteethareinthispatient.Theanswerisseven:twoonthetopright,twoonthetopleft,oneonthelowerleft,andtwoonthelowerright.

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�Figure1:X-rayshowing7wisdomteethinapatient

Eachtoothhasaspeci`icnameandeachtoothhasaspeci`icfunction.Thefrontteeth(incisors,caninesandbicuspids)areusedtobiteintofood,whilethebackteeth,calledmolars,areusedtochewfood.Technically,wisdomteetharecalledthirdmolars;theyareusuallynon-functionalandprovidenocosmeticbene`it.Anumberofstudieshavede`inedthedevelopmentanderuptionpatternofthirdmolars.Thelowerwisdomtoothbudisusuallyvisibleonx-raybytheageofnine.Thecrownofthewisdomtoothisusuallyformedcompletelybyagefourteen,andtherootsareapproximately50percentformedbyagesixteen.

Whenatoothisunabletofullygrowthroughthegumandenterthemouth,itisreferredtoasan“impacted”tooth.Ingeneral,impactedteethareunabletobreakthroughthegumsbecausethereisnotenoughspacepresent.Themostcommonimpactedteetharewisdomteeth.

Mostwisdomteethdonoteruptintothemouthandinsteadbecomeimpacted,orunerupted.Itisimportanttorememberthattheeruptionofwisdomteethisusuallycompletebytheageoftwenty,soiftheyarenotvisiblebythatage,oneormoreoftheteethmaybeimpacted.

WhenShouldWisdomTeethBeRemoved?

Theoptimumtimetoremovewisdomteethisinyourteenageryears.Lookatthex-raysbelowthatshowthegrowthofthewisdomteethatvariousages.Wisdomteethareeasiertoremovewhenpatientsareyounger,sincetherootsarenotcompletelyformed,thesurroundingboneissofter,andthereislesschanceofdamagingnearbynervesorotherstructures.Removalofwisdomteethatalateragebecomesmorecomplicatedbecausetherootsarefullydeveloped,therootsgrowclosertothemandibularnerve,andtheresultingdefect(fromtheremovalofthewisdomtooth)maybesolargethatabonegraftingproceduremaybeneededto`ixthedefect.

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� Figure2:X-rayshowingthedevelopmentofwisdomteethona12year-oldpatient

� Figure3:X-rayshowingthedevelopmentofwisdomteethona15year-oldpatient

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� Figure4:X-rayshowingthedevelopmentofwisdomteethona23year-oldpatient

Cavities,PainandInfection

Itischallengingtomaintaingoodoralhygienenearwisdomteeth.Subsequently,foodbecomestrappedaroundthewisdomteeth.Thefoodwillattractbacteriathatcancausecavitiesinboththewisdomteethandthesecondmolars.Whenwisdomteetheruptthroughthegums,paincanbefeltinthebackofthemouth,makingitdif`iculttochewandspeak.Astheteethtrytoeruptthroughthegums,foodmaygettrappedaroundtheseeruptingteeth.Thisareabecomesamagnetforbacteria,causingthewisdomtoothandthesurroundingareatobecomeinfected.Thischronicinfectioncanleadtoanabscess.Suchanabscesscangrowsigni`icantlywithinhours,causingsevereswellingofthefaceandneck.Thissituationcanbelife-threateningifnottreatedimmediatelyandmayrequirehospitalizationforintravenousantibioticsandsurgicaldrainage.

Figure5:Illustrationshowinganinfection(green)attherootsofthewisdomtooth

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GumDiseaseandWisdomTeeth

Anotherfactortoconsiderintheremovalofwisdomteethisthedepthofthegumpocketbehindthesecondmolars.Agumpocketdepthof`ivemillimetersormorecancompromisethesecondmolars.1Thesepocketdepthshavebeenshowntoincreaseovertimeandattractbacteriathatcausegumdisease.Therefore,impactedwisdomteethcanhaveadetrimentaleffectonthehealthofthegums.2,3Notably,thebacteriacountaroundthemolarshasbeenshowntodecreaseafterremovalofwisdomteeth.4

Afterwisdomteethareremoved,theholesleftbehindinthejawbonecanhaveadetrimentaleffectonthesecondmolar,whichisrightinfrontofit.Somesurgeonsadvocatepackingboneinthatholetoimprovethehealthofthatsecondmolar.Thisprocedure,knownasbonegrafting,preventsadefectfromdevelopingbehindthesecondmolar,especiallyinadultstwenty-sixyearsofageorolderwithpre-existinggumdisease.Bonegraftingwillpreservethehealthandintegrityoftheboneandthesecondmolar.5

Itisalsoimportanttonotetheeffectofwisdomteethongumdiseaseandin`lammation.Evenpregnantwomenwhosewisdomteethshownosignsofdistresstendtoexperiencemoreproblemsthanwomenwhosewisdomteethhavebeenremoved.6Inshort,themerepresenceofwisdomteethtendstocausein`lammation,whichcannegativelyimpactphysicalhealth,includingpregnancyoutcomes.

WisdomTeethandDentalCrowding

Whilepatientsanddentistsarealwaysquicktoblamewisdomteethfordentalcrowding,ade`initiveandclearcorrelationbetweenwisdomteethanddentalcrowdingisdif`iculttodetermine.Dentalcrowdingiscausedbyavarietyofconditions,andwhilewisdomteethmayplayasigni`icantroleinsomepatients,adirecteffectisdif`iculttoestablishconclusively.Itiscommonlybelievedinthedentalcommunitythatpressurefromeruptingwisdomteethwillcauseshiftingoftheremainingteeth,whichmayeventuallydisruptthenaturalalignmentofteeth,andadverselyaffectyoursmile.

Pathology

Cystsortumorsmayformaroundanimpactedwisdomtoothcausingdestructionoftheadjacentjawboneandteeth.Removaloftheoffendingimpactedwisdomtooth

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orteethusuallyremediesthisproblem.Earlyremovalisrecommendedtoavoidfutureproblemsandtodecreasethesurgicalrisk.

Acystcanformaroundawisdomtooth,asshowninFigure6below.Thispatientisinhislate`iftiesandthiscystwasfoundonaroutinepanoramicx-ray.Thecystislargeinsizeandisaffectingthelowerrightsecondmolarandthewisdomtooth.Notealsotheamountofbonethathasbeendestroyedbythecyst,whichisrepresentedbyadarkareaaroundthecrownofthewisdomtooth.Tominimizesuchdamage,itisrecommendedthatpatientswithwisdomteethhaveanx-rayoftheupperandlowerjawstakeneveryfewyears.Thispatienthadthecystremovedalongwiththeinvolvedwisdomtoothandthesecondmolar.Sixmonthslater,theareafromwhichthecystwasremovedhashealedwellandnewbonehasformed.

� Figure6:X-rayshowingacyst(blackshadow)aroundthecrownofthelowerrightwisdomtooth

� Figure7:X-rayofthesamepatient,taken1yearafterremovalofthecystandteeth

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TheHealthoftheSecondMolar

Secondmolarsareimportantfunctioningteethusedtogrindfood.Theyarelocatedimmediatelyinfrontofthewisdomteeth.Whenevaluatingwisdomteeth,itisimportanttoevaluatethehealthofthesecondmolarstodetermineiftheyarecompromisedbythepositionofthewisdomteeth.Wisdomteethcangrowinavarietyofpositions.Sometimestheyeruptstraightupliketherestoftheteeth,butothertimestheywillgrowsidewaysortowardthesecondmolars.Researchhasshownthattheligamentsurroundingthesecondmolarsandtheirrootscanbenegativelyaffectedbywisdomteeth,especiallyasthepatientgetsolder.7

AgeandWisdomTeeth

Numerousstudieshaveshownthatolderadultswhostillhavewisdomteethhaveahigherriskofcomplications.Theyhaveahigherriskofgumdefectsaroundthesecondmolar.8Theincidenceofcavitiesonwisdomteethalsoincreaseswithage.9Theriskofcomplicationsaftersurgeryandtherecoverytimebothincreasewithage,especiallyinpatientstwenty-`iveyearsofageandolder.10

Therefore,earlyremovalofwisdomteeth(whentheteethhavehardlyanyoftherootsformed)hasbeenshowntoresultinverypredictableandsuccessfuloutcomes,withhardlyanygumpockets,drysockets,nerveinjuryorinfectionsdevelopingpost-operatively.11

Alternatively,itiswelldocumentedthatthereisincreaseddifAicultyandanincreasedriskofcomplicationswhenremovingwisdomteethlaterinlife.12

HowAreWisdomTeethRemoved?

Someofyoumaybecuriousabouthowimpactedwisdomteethareremoved.Howdoestheoralsurgeongetdownintotheboneandremoveatooththatisdeepunderthegumsandsurroundedbybone?Thefollowingdiagramswillclearlyexplaintheseprocedures.

Wisdomteethcanbepresentinvariouscon`igurations:tiltedforward,straightup,tiltedbackwards,orsideways.

1. Awisdomtooththatistiltedforward:Whenremovinganimpactedwisdomtooththatistiltedforward,asurgicaldrillisusedtocreateasmalltrougharoundthecrownofthetooth.Thisprovidesspacetoallowremovalofthetooth.Thebackpartofthetoothissectionedoffandthengentlyremoved.Thetoothisloosenedwithaninstrument.Afterwards,thetoothisthenrotatedbackandoutoftheextractionsocket.

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Figure8:Removalofawisdomtoothtiltedforward

2.Awisdomtooththatisinthestraightupposition:Whenremovinganimpactedwisdomtooththatisstraightup,asurgicaldrillisusedtocreateasmalltrougharoundthecrownofthetooth.Thisprovidesspacetoallowfortheremovalofthetooth.Thetoothisthensectionedinhalfandeachhalfisgentlyloosenedwithaninstrument.Next,thebackhalfofthetoothisremovedoutofthesocket.Thisprovidesadequateroomtoallowremovalofthefronthalfofthetooth.

Figure9:Removalofawisdomtooththatisinthestraightupposition

3.Awisdomtooththatistiltedbackwards:Whenremovinganimpactedwisdomtooththatistiltedbackwards,asurgicaldrillisusedtocreateasmalltrougharoundthecrownofthetooth.Thisprovidesspacetoallowremovalofthetooth.Thecrownofthetoothissectionedoffandthengentlyremoved.Therootsofthetoothareloosenedwithaninstrument.Therootsarethenremovedfromtheextractionsocket.

Figure10:Removalofawisdomtooththatistiltedbackwards

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4.Awisdomtooththatislyingsideways:Whenremovinganimpactedwisdomtooththatislyingsideways,asurgicaldrillisusedtocreateasmalltrougharoundthecrownofthetooth.Thisprovidesspacetoallowremovalofthetooth.Thecrownofthetoothissectionedoffandthengentlyremoved.Therootsofthetoothareloosenedwithaninstrumentandremovedoneatatime.

Figure11:Removalofawisdomtooththatislyingsideways

X-rays,ImagingandOralSurgery

Traditionally,wisdomteethhavebeenevaluatedbyobtainingapanoramicx-ray.Suchpicturesgiveanexcellentpreliminaryevaluationofsomeone’sjaws,enablingthesurgeontodetectthepresenceandpositionofwisdomteethandtodiscoveranycystsorotherpathology.However,duetodistortionspresentintheimage,panoramicx-raysdonotprovidetheamountofspeci`icityanddetailneededtoproperlyplanandprepareforanactualsurgery.Someoralandmaxillofacialsurgeonsmayorderaconebeamscan,whichissimilartoamedicalCATscaninthatitrevealsminutedetailsinaviewthatallowsthesurgeontolookathundredsofindividualslicesofthescannedarea,includingthree-dimensionalimages.

Whenplanningtheremovalofwisdomteeth,oneimportantconsiderationisthepositionofthemandibularnerve(themainnervethatispresentinsidethelowerjaw)inrelationtotherootsofthelowerwisdomteeth.Thisnerveoftenrunsincloseproximitytothelowerwisdomteeth,andinjurytoitcancausetemporaryorpermanentnumbnessofthecornerofthemouth,chinand/orlowerlip.Whileresearchsuggeststhattheimmediateriskofnumbnessaftersurgeryisbetween1and5percent,andpersistentnumbnesssixmonthsaftersurgeryislessthan1percent,itisalwaysdesirabletominimizetheriskofanycomplicationsduringsurgery.13,14

Aconebeamscanallowsthesurgeontoviewthepositionofthemandibularnervein`inedetail,evaluatethepositionofthesecondmolar,andcarefullyplanthesurgery.Justassurgeonswhospecializeinlungoperationsusebothachestx-rayandaCATscantoplanprocedures,oralandmaxillofacialsurgeonsusebothx-raysandaconebeamscantominimizetheriskofcomplicationsandtraumatothesurroundinghealthytissue.

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Whilethelevelofradiationexposureisalwaysacauseforconcernanytimesomeonegetsanx-ray,it’simportanttonotethatconebeamscanscandeliveraslittleas0.087mSvofradiation,whichiscomparabletonaturalbackgroundradiationexposureforelevendays.Incontrast,atypicalCATscanoftheheaddeliversabout0.86mSvofradiation,whichiscomparabletonaturalradiationexposureforonehundredandeightdays.15

AnesthesiaandOralSurgery

Beforeremovingawisdomtooth,thesurgeonwilladministeralocalanesthetictonumbthetoothtoberemovedandthesurroundinggum.However,mostpatientspreferfull-bodysedationsothattheyarenotawakeduringtheprocedure.Inthissection,differentlevelsofanesthesiawillbereviewed.

Oralandmaxillofacialsurgeons(OMS)aretrainedinallaspectsofanesthesiaadministration.Followingdentalschool,theycompleteatleastfouryearsoftraininginahospital-basedsurgicalresidencyprogramalongsidemedicalresidentsingeneralsurgery,anesthesiaandotherspecialties.Duringthistime,residentOMSserveonthemedicalanesthesiologyservice,wheretheyevaluatepatientsforanesthesia,delivertheanesthetics,andmonitorpatientsduringandaftersurgery.

Asaresultoftheirextensivetraining,OMSarewellpreparedtoappropriatelyadministernotonlylocalanesthesiabutallformsofsedationandgeneralanesthesiainanoutpatientsetting.Theyareexperiencedinairwaymanagement,endotrachealintubation,establishingandmaintainingintravenouslines,andmanagingcomplicationsandemergenciesthatmayariseduringtheadministrationofanesthesia.

Beforeschedulingyoursurgery,youroralsurgeonwillreviewalltypesofanestheticavailableinordertomeetyourexpectations.Thisisthetimetodiscussanyconcernsyoumayhaveaboutanyfacetoftheprocedure.

Thefollowingarevariousanestheticoptionsthatmaybeusedtocontrolapatient’spainandanxiety.Mostoftheseoptionsareusedinconjunctionwithlocalanesthesia.

LocalAnesthesia:Thepatientremainstotallyawakeandwillbefullyawareofeverythingduringtheprocedure.Alocalanesthetic(e.g.,lidocaine)isadministeredintheareawheretheteetharetoberemoved.

NitrousOxide:Thisisalsoknownaslaughinggas.Amixtureofnitrousoxideandoxygenisadministeredthroughanasalbreathingapparatus.Thepatientisawakebuttypicallyfeelsrelaxed,evengiddy,whichusuallylessenstheuncomfortablesensationsassociatedwiththeprocedure.

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IntravenousAnesthesia:Alsoknownas“twilightsleep,”thisiswhensedationmedicationsareadministeredthroughanintravenousline,causingthepatienttobecomecalmandsleepy.Thepatientislessawareoftheactualprocedureandthuslessabletorememberit.

GeneralAnesthesia:Sedationmedicationsareadministeredthroughanintravenousline.Thepatientiscompletelyasleepfortheprocedureanddoesnotremembertheprocedure.

BeneYitsofOfYice-BasedAnesthesia

Themajorityoforalandmaxillofacialsurgeryproceduresareperformedintheof`iceusingoneoftheanesthesiaoptionslistedabove.Thistreatmentapproachisconvenient,safeandcost-effective.Thecomfortable,personalizedsettingoftheOMSof`iceminimizeswaitingandrecoverytime,ascomparedtohavingthesameprocedureperformedinahospitaloutpatientsurgerycenter.Inaddition,in-of`iceproceduresandanesthesiadeliveryareusuallylessexpensivethansimilarcareinahospitaloroutpatientsurgerycenter.

OMSof`icesareoftenaccreditedbystateagenciesorindependentagencies—sometimesboth—whichalsoaccreditandinspecthospitalsandoutpatientsurgerycenters.Tocon`irmtheaccreditationofyouroralsurgeon’spractice,askthesurgeonorof`icestaffatthetimeofyourappointment.

Post-OpInstructions

Duringthe`irsthouraftertheoperation,bitedowngentlybut`irmlyonthegauzepacksthathavebeenplacedovertheextractionareas,makingsuretheyremaininplace.Donotchangethemduringthistimeunlessthebleedingisnotcontrolled.Thepacksmaybegentlyremovedafteronehour.Ifactivebleedingpersists,placeenoughnewgauzetoobtainpressureovertheextractionsitesforanotherthirtyminutes.

Donotdisturbtheareaswheretheteethwereremoved.Donotrinsevigorouslyorprobetheextractionareaswithanyobjects.Youmaybrushyourteethgently.DONOTSMOKEforatleastoneweek,sincethisisverydetrimentaltohealingandmaycauseadrysocket.

Bleeding:Intermittentbleedingoroozingovernightisnormal.Bleedingmaybecontrolledbyplacingfreshgauzeovertheareasandbitingonthegauzefortwentytothirtyminutesatatime.

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Bleedingshouldneverbesevere.Ifthereispersistentbleeding,itusuallymeansthatthegauzepacksarebeingclenchedbetweenteethonlyandarenotexertingpressureontheextractionareas.Tryrepositioningthepacks.Ifbleedingpersistsorbecomesheavy,substituteateabagthatwassoakedinveryhotwater,squeezeddamp-dry,andwrappedinmoistgauze.Ifbleedingstillremainsuncontrolled,callyouroralsurgeon’sof`iceorproceedtoyourlocalemergencyroom.

Swelling:Swellingoftenaccompaniesoralsurgery.Itcanbeminimizedbyusingacoldpack,icebag,orabagoffrozenpeaswrappedinatowelandapplied`irmlytothecheekadjacenttotheextractionarea.Applycoldcompressestothefaceforthe`irsttwenty-fourtoforty-eighthours.

Pain:Wisdom-toothremovalisnotatrivialundertaking.Mostpatientswillexperiencesomedegreeofdiscomfortaftertheprocedure.Analgesicssuchasaspirinoribuprofenmaybesuf`icienttorelievethisdiscomfort.Sometimesstrongerprescriptionpainmedicationsmaybeneeded.Youroralsurgeonwillusuallyprescribepainmedicationstouseafterthesurgery.

You’veMadeItthroughtheFirstDay.NowWhat?

MouthRinses:Keepingyourmouthcleanisessentialtohealing.Use1/4teaspoonofsaltdissolvedinaneight-ounceglassofwarmwaterandgentlyrinseoutyourmouth.Youcanrepeatthisasoftenasdesired,butdoitatleasttwicedaily.Threetimesisbetter.

Brushing:Afterthe`irstday,resumeyournormaloralhygieneroutineassoonaspossible.

Compresses:Verywarmcompressesappliedtotheskinovertheareasofswellingmaybeappliedafterthe`irstforty-eighthourstosoothetenderareasanddecreaseswellingandstiffness.

ThingstoAvoidPost-Op

Avoidspittingforatleastaweek.Spittingcanrestartbleedingandleadtopainatthesurgicalsite.Ifyoufeeltheurgetospit(suchasafterbrushingyourteeth),takeasipofwaterandgentlyrinseyourmouthandthenletthewaterfalloutofyourmouthandintothesink.

Avoidusingastrawforaweek.Justlikespitting,usingastrawcanrestartbleedingandleadtopainatthesurgicalsite(drysocket).Ifyouwanttohaveasmoothieormilkshakeaftersurgery,eatitwithaspoonordrinkitoutofacup,butavoidstraws.

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Avoidsolidfoodsforthe`irstday.Startwithclearliquidslikewater,applejuiceorvitamindrinks.Iftheseliquidsaretoleratedwell,thenadvancetosmoothies,milkshakes,proteinshakes,icecream,Jell-Oorothernutritiouscoolliquidsforthe`irsttwenty-fourhours.Fortherestoftheweek,haveasoftdiet(e.g.,mashedpotatoes,scrambledeggs,macaronietc.).Toavoidpainandbleeding,donotconsumespicyorhigh-temperaturefoods;allowahotsouporhotcoffeetocooltoroomtemperaturebeforedrinkingit.

Avoid`lossingaroundthesurgicalsite.Brushyourteethgentlywithasoftbristletoothbrush.Rinsegentlywithanalcohol-freemouthrinseorsaltwaterandthenletthewaterfalloutofyourmouthandintothesink.Over-the-counteralcohol-freemouthrinsescanbefoundatanypharmacy.

Avoidexerciseforoneweekaftersurgery,asexercisecancausepainfulthrobbingorbleedingwheretheteethwereremoved.Restisimportantaftersurgery.

Finally,torepeat,avoidsmokingforatleastaweek.Nicotinedecreasestheamountofoxygenthatblooddeliverstothehealingsurgicalsite,thusdelayingthehealingprocess.Inaddition,smokeirritatesthesurgicalsite.Smokingisadouble-barreledthreat.Itcandelayhealingandincreasepain.

RisksofRemovingWisdomTeeth

Aswithanysurgery,therearerisksassociatedwiththeremovalofwisdomteeth.Themostcommonrisksareswelling,painandbleeding.Whileuncommon,theadditionalcomplicationslistedbelowmayhappenduringoraftersurgery:

•Painandswellingatthegumsandtoothsocketwherethetoothwasremoved.

•Bleedingthatcontinuesformorethantwenty-fourhours.

•Dif`icultyandpainwhenopeningthejaw.

•Slow-healinggums.

•Damagetoexistingdentalwork,suchascrownsorbridges,ortorootsofnearbyteeth.

•Apainfulin`lammatoryprocess,calleddrysocket,whichhappensiftheprotectivebloodclotislosttoosoonordoesnotform.

•Temporarynumbnessinthemouthandlipsafterthelocalanestheticwearsoff,duetoinjuryorin`lammationofthenervesinthejaw.

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•Anopeningintothesinuscavitywhenawisdomtoothisremovedfromtheupperjaw.

Thereareotherrisksthatcanoccurwhenremovingwisdomteeth.Alwaysdiscusstherisksofyourspeci`icsurgerywithyouroralsurgeonsothatyouknowwhattoexpectafteryoursurgery.

Conclusion

Whileallpatientsdonotneedtohavetheirwisdomteethextracted,thereareclearindicationsthatwarrantremovalofwisdomteeth.Theageofthepatient,thepresenceofgumdisease,thepotentialfordentalcrowding,andthelong-termhealthofthesecondmolarsareallfactorsthatmustbeconsideredwhendecidingifwisdomteethneedtobeextracted.

FrequentlyAskedQuestions

Whycan’tmyregulardentistremovemywisdomteeth?

Atonetimealldentistswouldremovewisdomteeth.Butbecauseofthedif`icultiesassociatedwithremovingwisdomteeth,moreandmoredentistsreferwisdomteethremovaltospecialists,whointurngaveuptheirbroaderpracticetospecializeinwisdomteethextraction.

Today,whilesimpleandroutineextractionscanbeperformedsafelybygeneraldentists,impactedwisdomteetharebesttreatedbyoralandmaxillofacialsurgeons,whoremoveimpactedteethroutinely.Additionally,generaldentistsareusuallyequippedtoutilizeonlylocalanesthesiaornitrousoxide,whileoralsurgeonsarepreparedtousetwilightsleep,deepsedationorgeneralanesthesia.Thesespecialistshavetheextensivetrainingandexperiencenecessarytoperformthisproceduresafelyandwithminimaltrauma.

Howlongwillittaketorecoveraftermywisdomteethareremoved?

Somepatientscanhavewisdomteethextractedearlyinthemorningandthenperformafullday’sworkwithlittlediscomfort.However,mostpatientswillneedonetothreedaysofrestbeforegoingbacktoschoolorwork.Everyprocedureisdifferent,andsoiseverypatient,soit’sbesttoallotuptosevendaysofrestfollowingsurgery.Swellingandpainwillusuallyguideyourrecovery,butrestisalwaysrecommendedimmediatelyaftertheprocedure.

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Whatkindofanesthesiadomostpeoplechoose?

Mostpatientschoosetohavetheirwisdomteethextractedundertwilightsleep(intravenoussedationwithlocalanesthesia).Underthisformofanesthesia,patientsarerelaxed,comfortableandstress-free,andhaveminimalmemoryoftheprocedure.

AtwhatageshouldIhavemywisdomteethremoved?

Werecommendthatwisdomteethbeextractedbeforetheformationoftheroots.Thisresultsinverypredictableandsuccessfuloutcomes,withhardlyanygumpockets,drysockets,nerveinjury,orinfectionsdevelopingpost-operatively.Whiletheformationofrootswillvarybetweenpatients,werecommendthatpatientshaveaninitialscreeningx-rayperformedbyanoralsurgeonbytheageof`ifteentoevaluateteetheruption,position,anddevelopment.

Mymedicalinsurancedoesn’tcoverroutinedentalwork,butwillitpayfordentalsurgery?

Possibly.Everyplanisdifferent,andstatelawsregulatingwhatmedicalinsuranceplanscovervaryfromstatetostate.Beforeyouhavetheproceduredone,checkwithyourinsuranceagentorcompanybene`itsof`icial.Someplanswillcoversurgerythatisdeemedamedicalnecessityorthatisperformedundergeneralanesthesia.

Mostdentalinsurancepoliciescovertheremovalofwisdomteeth.Again,it’sbesttocheckpriortothesurgerysoyoucanmake`inancialplansaccordingly.

Myparentsneverhadtheirwisdomteethextracted,sodoIneedtogetmineremoved?

Whetherornoteitherparentneededtohavewisdomteethremovedhasnobearingontheirchildren’ssituation.Everyperson’sdentalmakeupisunique.Therefore,everyteenageroryoungadultshouldobtainacomprehensiveexamtodetermineifwisdomteetharepresentandiftheyneedtoberemoved.

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AbouttheAuthors

RonaldM.Achong,M.D.,D.M.D.

RonaldM.Achongisanoralandmaxillofacialsurgeonspecializingintheremovalofteethandsedationdentistry.Dr.AchongisaBoardCerti`iedOralandMaxillofacialSurgeon.AftergraduatingfromcollegeattheUniversityofTorontoinCanada,heattendedHarvardDentalSchoolwherehereceivedhisDoctorateinDentistry.HisMedicalDegreewasobtainedatLouisianaStateUniversityMedicalSchool,NewOrleans,wherehealsocompletedhisresidencyinOralandMaxillofacialSurgery.

Dr.AchonghasanactivemedicalanddentallicenseintheStateofFlorida;healsomaintainsadentallicenseinCanada.

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RonaldM.Achong,D.M.D.OralFacialSurgicalArts,P.A.3180CitrusTowerBoulevardClermont,Florida34711 (352)243-5599

10437MossParkRoad,SuiteB,Orlando,Florida32832

www.OralSurgicalArts.comwww.NoMoreWisdomTooth.com

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RubenCohen,D.D.S.

BorninFrance,RubenCohengrewupinParisandLosAngeles.Dr.CohenobtainedhisBachelor’sofArtsatBrandeisUniversity,Waltham,Massachusetts.HethenobtainedhisDoctorateofDentalSurgeryatNewYorkUniversityCollegeofDentistry.HesubsequentlycompletedaresearchfellowshipatLouisianaStateUniversityHealthSciencesCenterinNewOrleans.HecompletedhisresidencyinOralandMaxillofacialSurgeryatAlleghenyGeneralHospitalinPittsburgh,Pennsylvania.

Dr.Cohen’spracticefocusesontheremovalofteethandthedeliveryofambulatoryanesthesiaandsedationinadultandpediatricpatients.Hehasappearedontelevisionnewsprogramsdiscussingwisdomteethextractionandhaswrittenarticlesonthesafeextractionofwisdomteeth.HeisthefounderofParkAvenueOral&FacialSurgery,P.C.,Manhattan’spremieroralandmaxillofacialsurgerypractice,whichopenedin2010.Theof`iceisnewlyrenovatedwithstateoftheartequipmentandisamongthe`irstoralsurgerypracticesinManhattantobeaccreditedasanambulatorysurgeryfacilitybytheAmericanAssociationforAccreditationofAmbulatorySurgeryFacilities,Inc.

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RubenCohen,D.D.S.ParkAvenueOral&FacialSurgery,P.C.970ParkAvenueNewYork,NewYork10028 (212)988-6725

www.ParkAvenueFaces.com

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References

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2.WhiteJr.,R.P.,S.Offenbacher,G.H.Blakeyetal.:Chronicoralin`lammationandtheprogressionofperiodontalpathologyinthethirdmolarregion.JournalofOralMaxillofacialSurgery64:880,2006.

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4.Blakey,G.H.,M.T.Jacks,S.Offenbacheretal.:Progressionofperiodontaldiseaseinthesecond/thirdmolarregioninsubjectswithasymptomaticthirdmolars.JournalofOralMaxillofacialSurgery64:189,2006.

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9.Moss,K.L.,J.D.Beck,S.M.Maurielloetal.:Thirdmolarperiodontalpathologyandcariesinsenioradults.JournalofOralMaxillofacialSurgery65:103,2007;Shugars,D.A.,M.T.Jacks,R.P.White,Jr.etal.:Occlusalcariesexperienceinpatientswithasymptomaticthirdmolars.JournalofOralMaxillofacialSurgery62:973,2004;

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Shugars,D.A.,J.R.Elter,M.T.Jacksetal.:Incidenceofocclusaldentalcariesinasymptomaticthirdmolars.JournalofOralMaxillofacialSurgery63:341,2005.

10.Mercier,P.,D.Precious:Risksandbene`itsofremovalofimpactedthirdmolars:acriticalreviewoftheliterature.InternationalJournalofOralMaxillofacialSurgery21:17,1992;Bruce,R.A.,G.C.Frederickson,G.S.Small:Ageofpatientsandmorbidityassociatedwithmandibularthirdmolarsurgery.JournaloftheAmericanDentalAssociation101:240,1980;Phillips,C.,R.P.White,Jr.,D.A.Shugars,X.Zhou:Riskfactorsassociatedwithprolongedrecoveryanddelayedhealingafterthirdmolarsurgery.JournalofOralMaxillofacialSurgery61:1436,2003;Bui,C.H.,F.B.Seldin,T.B.Dodson:Types,frequencies,andriskfactorsforcomplicationsafterthirdmolarextraction.JournalofOralMaxillofacialSurgery61:1379,2003

11.Chiapasco,M.,M.Crescentini,G.Romanoni:Germectomyordelayedremovalofmandibularimpactedthirdmolars:therelationshipbetweenageandincidenceofcomplications.JournalofOralMaxillofacialSurgery53:418,1995;Chossegros,C.,L.Guyot,F.Cheynetetal.:Islingualnerveprotectionnecessaryforlowerthirdmolargermectomy?Aprospectivestudyof300procedures.InternationalJournalofOralMaxillofacialSurgery31:620,2002.

12.Chiapasco,M.,M.Crescentini,G.Romanoni:Theextractionofthelowerthirdmolars:germectomyorlateavulsion?[articleinItalian]MinervaStomatol43:191,1994;Bruce,R.A.,G.C.Frederickson,G.S.Small:Ageofpatientsandmorbidityassociatedwithmandibularthirdmolarsurgery.JournaloftheAmericanDentalAssociation101:240,1980.

13.GulicherD.,K.L.Gerlach:Sensoryimpairmentofthelingualandinferioralveolarnervesfollowingremovalofimpactedmandibularthirdmolars.InternationalJournalofOralMaxillofacialSurgery30:306,2001;Schultze-Mosgau,S.,R.H.Reich:Assessmentofinferioralveolarandlingualnervedisturbancesafterdentoalveolarsurgery,andofrecoveryofsensitivity.InternationalJournalofOralMaxillofacialSurgery22:214,1993.

14.Queral-Godoy,E.,E.Valmaseda-Castellon,L.Berini-Aytes,C.Gay-Escoda:Incidenceandevolutionofinferioralveolarnervelesionsfollowinglowerthirdmolarextraction.OralSurgery,OralMedicine,OralPathology,OralRadiology&Endodontology99:259,2005;Valmaseda-Castellon,E.,L.Berini-Aytes,C.Gay-Escoda:Interioralveolarnervedamageafterlowerthirdmolarsurgicalextraction:aprospectivestudyof1117surgicalextractions.OralSurgery,OralMedicine,OralPathology,OralRadiology&Endodontology92:377,2001.

15.ImagingSciencesInternationalletterfromHenrikRoos,datedNovember23,2010.