The wisdom tooth, also known as the third molar, is the last tooth to erupt (grow out from the gum). The average age of eruption for a wisdom tooth is said to be between 17 years old and 21 years old. [1]
Not everyone has wisdom teeth. Some teeth can be missing naturally. However, if wisdom teeth are present (usually 4 in total), they are the most commonly impacted teeth.
Impacted teeth mean that the teeth fail to erupt into the mouth at the expected time. [2] This happens because there is no space for eruption or there is a blockage from the bone or the other tooth.
Therefore, if you are not seeing the wisdom teeth in the mouth, it does not mean that they are absent. They could be impacted underneath the gums or the bone.
Pain from wisdom tooth: what could be the cause?
A proper erupting wisdom tooth does not cause pain, although you may feel a little discomfort. However, an infected wisdom tooth or an infected gum surrounding it can cause pain to you. [3]
The wisdom tooth can be infected due to tooth decay. On the other hand, the surrounding gum can be infected or inflamed due to the bacteria, and this condition is called pericoronitis.
Pericoronitis can happen if oral hygiene care is not effective. It is often associated with impacted third molar with the prevalence of 81%. [3] Patients with pericoronitis may have pain, swelling with pus, fever, and find it hard to open the mouth wide. This problem could have been minimized if the wisdom teeth are taken care of properly. Otherwise, treatment is required.
Below are the treatment options when dealing with the acute condition of pericoronitis (when it is causing pain). The dental surgeon may perform more than one procedure depending on the condition [4]:
- irrigation (flush the area gently)
- operculectomy (a surgical procedure to remove the gum covering the wisdom tooth)
- slight trimming of the upper tooth that is biting on the operculum (operculum is the gum covering the wisdom tooth)
- drainage in the presence of abscess (drain the pus if there is swelling)
- antibiotic prescription if the symptoms of pericoronitis are severe.
After the pain subsides, the decision will be made whether or not to keep the wisdom tooth. One of the deciding factors to keep the wisdom tooth is the possibility of the tooth erupting into a proper position. [4] Usually, the wisdom tooth will be kept under monitor after the first occurrence of pericoronitis. Whereas recurrent (repeatedly happening) pericoronitis may require the extraction of the wisdom tooth. [5]
Wisdom tooth impaction
There are different types of wisdom tooth impaction as shown in the pictures above.
Should you worry about the wisdom teeth?
It is less of a concern if the wisdom tooth is not impacted. It can be kept in the mouth with proper hygiene care which will be described later.
However, if the wisdom tooth is impacted, there is one thing that we as dentists are very concerned about: can the area be cleaned properly?
Being the tooth that is furthest inside the mouth and often impacted, it can be difficult to keep the wisdom tooth area clean.
Taking care of wisdom tooth
Below are the few ways you can do to take care of your impacted wisdom tooth:
#1 Effective brushing
Here is the tip for effective brushing for the wisdom teeth: brush like how you should brush for the other teeth, which is to brush twice daily with fluoridated toothpaste.
You have to pay attention to remove any food lodgement around your teeth, especially the area between the wisdom tooth and the second molar (the tooth that is immediately in front of the wisdom tooth). So, make sure you extend your brushing to where the wisdom teeth are. You may go for a smaller head toothbrush (or kids toothbrush) if you find it hard to reach the furthest end.
A soft bristle toothbrush is preferable to avoid hurting the gums. It is not about how hard you brush. It is about cleaning every surface of your teeth with the right technique. Brushing too hard can wear the tooth and injure the gums.
You may visit this article for simple guide on choosing the best toothbrush bristle.
This video shows you the technique for toothbrushing. While this technique can be used for most people, it may differ according to your gum condition. You may discuss more this technique with your dentist.
#2 Flossing
Flossing is helpful to remove the food lodgement between the teeth where the toothbrush could not reach. By removing the food stuck in between the wisdom tooth and the second molar, we are removing the source of infection. Remember, flossing is an add-on to toothbrushing, and it should not replace toothbrushing.
#3 Rinsing with mouthrinse
The same rule for flossing applies to rinsing: it should not replace our daily toothbrushing. Food debris and dental plaque cannot be removed by rinsing, and they need to be brushed away mechanically.
Fluoride mouthrinse has a benefit of strengthening the tooth against tooth decay. Some mouthrinses also contain substances that reduce gum inflammation which can help to reduce pericoronitis.
Visit here for more information on when and how to use mouthwash.
#4 Regular dental visit
Many people assume that the wisdom teeth are perfectly alright if they are not causing pain. However, early cavity and early bone loss can happen without any symptoms at all. By the time the pain is felt, the infection might have reached the deeper part of a tooth or bone. At this point, the treatment needed may be more than just a regular cleaning of the area.
The best way to prevent this is to attend regular dental visits. The dentist can examine the wisdom tooth to see if there is an ongoing infection or inflammation. If required, a dental radiograph (X-ray) will be taken to see any developing disease.
It is advised to follow-up on your wisdom teeth every ten or twelve months. [6] Since it is also recommended to have dental check-ups and scaling regularly, the monitoring of wisdom teeth can be carried out together.
Consequences if the wisdom tooth is not cleaned properly
As mentioned earlier, a wisdom tooth can be left in the mouth if it can be taken care of by cleaning.
If it is not taken care of well, it can lead to some bad outcomes. These include tooth decay, bone loss, pericoronitis, or swelling due to infection
The damage may even extend beyond the wisdom tooth to the neighbouring teeth. Moreover, tooth decay and gum disease can cause infection which can be dangerous to our life if it is left untreated. [7]
If any of the above occurs, seek professional help immediately! Do not wait until it is too late, as dental infection can lead to a more life-threatening condition!
Should I remove my wisdom tooth?
The current recommendation is that the disease-free impacted wisdom tooth should not be removed, and it should be monitored periodically. [8]
Wisdom tooth removal has its own risk (for example, nerve injury) that varies from person to person. If the tooth is verified by the dentist that it is disease-free, there is no need to take the risk to undergo the surgery to remove the wisdom tooth.
The main indications for the removal of impacted wisdom teeth are tooth decay and wisdom tooth-associated infections. However, there are some other situations where the dentist will advise removing the symptomless wisdom tooth. For example, when placing the denture or dental implant near the impacted wisdom tooth area, presence of cyst and tumour, and presence of bone fracture near the impact teeth. [8]
In sum, the decision for removal of impacted wisdom tooth is based on the balance between the benefits and the risks of removal. If an infection is already taking place in the wisdom tooth, removal is necessary. Leaving an ongoing infection is more harmful than the risk of surgical complications like nerve injuries. Remember that an untreated infection can turn into a life-threatening condition!
Procedure of wisdom tooth removal
Impacted wisdom teeth are often removed through a small surgery since most of the tooth structures are hidden underneath the gum or even the bone. To remove the tooth completely, a small cut of the gum and some trimming of bone have to be made. [8]
When the tooth is taken out (usually cut into pieces), sutures (stitches) will be placed to close the wound.
After the surgery, it is normal for you to experience some discomfort, slight bleeding, and swelling which can be managed by the medication. An ice pack could help to relieve the swelling. These symptoms usually disappear within a week.
However, some complications (unwanted consequences) are possible to happen as listed below [8]:
| Complications | Chance of happening |
|---|---|
| Dry socket (the wound is not healing after extraction) | 0.3% – 35% |
| Wound infection | 1% – 16% |
| Temporary nerve injuries | 0.06% – 11.5% |
| Permanent nerve injuries | 0.2% – 1% |
Bear in mind that the above complications are possible but it does not mean that they will happen. Proper case assessment and careful surgical technique done by the dental surgeon can prevent unwanted complications. [8] Even if the complications happen, they can be managed accordingly.
Conclusion
Regular follow-up of wisdom teeth should be part of our overall oral hygiene care. Proper self-care and monitoring of wisdom teeth can prevent infection. When necessary, timely removal of wisdom teeth can stop the infection before more damage takes place.
References
- American Dental Association. Tooth eruption: The permanent teeth. Journal of the American Dental Association. 2006;137(1):127. doi: 10.14219/jada.archive.2006.0031. (Link)
- Alfadil L, Almajed E. Prevalence of impacted third molars and the reason for extraction in Saudi Arabia. The Saudi Dental Journal. 2020 Jul 1;32(5):262-8. (Link)
- Renton T, Wilson NH. Problems with erupting wisdom teeth: signs, symptoms, and management. British Journal of General Practice. 2016 Aug 1;66(649):e606-8. (Link)
- Dhonge RP, Zade RM, Gopinath V, Amirisetty R. An Insight into Pericoronitis. Journal of International Dental and Medical Research. 2015;1(6):172-175.
- Subedi S, Koirala U, Shrestha B. Indications for removal of impacted mandibular third molars and associated pathologies. Journal of Gandaki Medical College-Nepal. 2020 Dec 25;13(2):134-9.
- de Lima Stevao EL, Bath MS. Are Impacted Third Molars Always Necessary to be Removed? Part I-A Literature Review. Advances in Dentistry & Oral Health. 2016;2(3):555593.
- Wehr C, Cruz G, Young S, Fakhouri WD. An insight into acute pericoronitis and the need for an evidence-based standard of care. Dentistry journal. 2019 Sep;7(3):88. (Link)
- Ministry of Health Malaysia (MoH). Management of Unerupted and Impacted Third Molar Teeth. Putrajaya: Ministry of Health Malaysia. (Link)
