Wisdom Teeth Extraction

Wisdom Tooth Extraction

Wisdom tooth extraction is also known as third molar extraction. These teeth consist of the mandibular and maxillary third molars; they usually appear between the ages of 17 and 25.They are called wisdom teeth because they usually come in when a person is between age 17 and 25 or older – old enough to have supposedly gained some wisdom. Preventative extractions of them could prevent some potential dental problems later in life. The decision should be made between you and your dentist.

Some of the guidelines to determine if or not you need to have them removed are:

  1. They are partially or fully erupted that causes discomfort, pain or difficulty to keep them clean.
  2. You are still young, say less than 25 years old.
  3. There is some pathology associated with it (this needs to be determined by your dentist).

They can be left alone if:

  1. They are not in your mouth at all
  2. You are over 25 years of age.
  3. They have never bothered you.
  4. There is no pathology associated with it.

Medical assessment before wisdom teeth extraction or any dental surgery in general

(Adapted from Clinicial’s Manual of Oral and Maxillofacial Surgery, 3rd Edition, by Paul H. Kwon and Daniel M. Lashin)

Before your dentist provides wisdom teeth extraction for you, he/she needs to do a preoperative medical evaluation. Particular attention should be paid to your heart, lung, liver, and kidney diseases if applicable. Blood clotting disorder is also important to be evaluated.

Taking Blood Thinner: If you are put on blood thinner by your medical doctor such as daily dose of aspirin and Coumadin (warfarin), your dentist may need to check your ability to form blood clot because dental surgery will involve certain extent of bleeding. You will be sent for blood work to check an INR value. If that number is more than 4, your dentist may need to coordinate with your physician to adjust your medication prior to a dental surgery procedure.

High Blood Pressure: If your blood pressure is more than 100 (in diastolic pressure), it is contra-indicative to proceed with wisdom teeth extraction. Your dentist will need to refer you for definitive medical management of the hypertensive disorder prior to any dental surgery.

Steroid Therapy: If you are currently taking or has within the prior 2 years taken large dose of steroids, you may require supplemental administration of steroids prior to wisdom teeth extraction. Patients taking exogenous steroids may experience acute adrenal insufficiency when subject to the stress associated with dental surgery. A patient who is taking prescribed steroid therapy equivalent to 20mg/day or more of cortisol may not be able to respond appropriately with more endogenous steroid when stressed by the dental surgery. Steroid therapy is common among patients with autoimmune diseases such as Lupus, rheumatoid arthritis and multiple sclerosis.

Orthopedic Joint Replacement: If you have total joint replacement in the past 2 years, your dentist may need to prescribe you antibiotic prophylaxis prior to teeth extraction or any dental procedure involving moderate bleeding. This should include regular hygiene appointments. On the other hand, antibiotic prophylaxis is not indicated for dental patients with pins, plates, or screws.

Antibiotic Prophylaxis: Regimens: 4 caps of Amoxil 500mg 1hour prior to procedure or if you are allergic to penicillin, then 4 caps of Clindamycin 150mg. No second dose is recommended in any of these regimens. It is needed in heart Conditions such as prosthetic heart valves, previous bacterial endocarditis, complex cyanotic congenital heart disease, surgically constructed systemic pulmonary shunts, most congenital heart malformations, acquired valvular dysfunction, hypertrophic cardiomyopathy, mitral valve prolapse with regurgitation (presented as heart murmur).

Post-irradiation tooth extractions: If you have radiation therapy in the oral facial area before, make sure to let your dentist know. Because radiation may have caused decreased blood supply to the oral and dental tissues, healing after surgery can present a very difficult situation, with no satisfactory result. If teeth must be removed, antibiotics are recommended along with pre- and post-operative rinses with chlorhexidine mouthrinse. If available, hyperbaric oxygen administered pre- and post-extraction may help diminish the likelihood of osteoradionecrosis.

Common Complications for Wisdom Teeth Extraction

Aspiration of foreign objects: wisdom tooth are particularly vulnerable to being swallowed or aspirated. A gauze screen placed lightly in the oropharynx should be used during the procedure to minimize the risk.

Temporomandibular Joint (TMJ) pain: post-operative TMJ pain is often caused by prolonged mouth opening, stretching, or pressure on the joint contralateral to the side where lower jaw surgery is performed. Stabilizing the joint with a mouth prop or providing intraoperative mandibular support will help minimize postoperative joint discomfort. If it happens, it can be managed with moist heat application to the affected side, a soft diet, resting the joint, and nonsteroidal anti-inflammatory analgesics such as advil, motrin or ibuprofen.

Trismus (limited mouth opening): It can be caused by infection, muscle spasm, or from injection of a local anesthetic. If it is from infection, antibiotics should be administered. If it is due to muscle spasm, it can be managed similarly like TMJ pain described above.

Root Fracture: It is not necessary to regard all root fragments as foreign bodies. Vital root tips measuring 0.5mm or less can very often be left in place provided there is no associated pathosis: If large amounts of healthy bone must be sacrificed to gain access to the root fragment, it may be better to leave it in place.

Displaced Roots and Root Fragments into vital spaces such as submandibular space, mandibular canal, maxillary sinus etc.

Oral-Antral Communication

Bleeding

Dry Socket: most often develops on the 2nd to the 5th postoperative day. Chief complaint is pain. Patient may also complain of odor or a bad taste.