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Why do dentists so often advise their patients to have them removed? Before you make an appointment for a wisdom tooth extraction, be sure you understand all the pros and cons of wisdom teeth removal.

What Are Your Wisdom Teeth?

The wisdom teeth are the very last teeth to emerge, usually between the ages of 17 and 25. Since a young adult is more astute than a child, these molars at the extreme left and right of your upper and lower jaws are referred to as "wisdom" teeth.[1]

The first differentiation between wisdom teeth is: 

  • erupted wisdom teeth (those that have penetrated through the gums fully)
  • impacted wisdom teeth (those that have not penetrated through the gums and are either buried in the gum tissue or even in the jawbone) 

A logical conclusion would be that the ones that have erupted are easier to extract compared to the ones that are buried deeper in the jawbone. Surgical intervention is needed for the later.  

Impacted Wisdom Teeth

A study conducted on Swedish people aged 20 to 30 years claims that the occurrence of having impacted wisdom teeth is high - up to 70% of cases having impacted third molar. What are the main reasons for having impacted wisdom teeth? Different studies claim that impacted wisdom teeth occur because of a lack of space, obstruction, or abnormal position. The problems they can cause can be serious: inflammatory dental disease manifested by pain and swelling of infected teeth and may destroy adjacent teeth and bone.[2]

The reason dentists so often recommend removal of wisdom teeth is that, more often than not, they do not come in straight. Below you will find variations in the anatomical positioning of impacted mandibular wisdom teeth and their practical implications when examining a total of 1197 wisdom teeth in 699 patients [3]: 

  • 6.7% exhibited direct contact to the mandibular canal, another 28.7% showed close proximity and 24.6% a measurable distance.
  • In 29.0% of wisdom teeth, the mandibular canal was vestibular and in 23.8% lingual to the wisdom tooth.
  • In 7.4%, it was interradicular and in 0.6% intraradicular.
  • Most teeth had one (21.3%) or two (55.3%) roots. Others had three (17.6%), four (2.0%) or five (0.2%) roots.
  • In 31.4% of the teeth, the root perforated the lingual compact bone, and in 4.3% the vestibular compact bone.
  • 44.4% of the teeth had mesial angulation, 9.7% distal angulation, 35.3% lingual and 2.9% buccal angulation. 

Here are additional facts about impacted wisdom teeth: 

  • Almost About half of all wisdom teeth come in angled forward (also known as mesioangular impaction) this malformation points the tooth toward the front of the mouth.
  • About 40% of the time, the wisdom tooth never comes completely through the gum line. This malformation is known as vertical impaction.
  • In relatively rare cases, about 6% of the time, the wisdom tooth is angled backward, toward the rear of the mouth. This phenomenon is known as distoangular impaction.
  • It is also possible for a wisdom tooth to come in sideways. This phenomenon, known as horizontal impaction, occurs in about 3% of wisdom teeth that come in growing at a 90 degree angle to neighboring teeth, growing their roots into the neighboring molar.
  • A significant minority of people, however, have wisdom teeth that come in straight. 

Easier Extractions and Harder Extractions of Wisdom Teeth

In general, here are the rules of thumbs you can expect when evaluating the difficulty of wisdom tooth extractions [4]:

  • Erupted vs. impacted wisdom teeth extractions: you can expect that teeth that have penetrated through the gums fully (erupted wisdom teeth)  will be easier to extract than those still significantly buried in the gum tissue or jawbone, aka impacted ones. 
  • Soft-tissue vs. bony tissue extractions: Soft-tissue impactions are typically less difficult than bony ones when the teeth are still substantially or completely encased in the jawbone.
  • The impact of the tooth angle on the extraction: Vertical (upright) and mesio-angular (leaning forward) impactions are typically easier to remove than disto-angular (tilted backward) or horizontal (sideways) ones. 

The dentists will also tell you that it is easier to remove a backwards-pointing wisdom tooth from the upper jaw, and it is easier to remove a forward-facing tooth from the lower jaw. The person undergoing wisdom tooth extraction, however, is not likely to report any part of the process as easy unless they are under anesthesia. And, yes, they should be always under anesthesia. 

When the dentist cannot remove the tooth with forceps, it will be necessary to remove a tiny amount of jaw bone. If a bone is not removed with a fully developed upper wisdom tooth, the jaw bone may be fractured, tearing out the floor of one of the sinuses, providing a pathway for infection throughout the face. A good dental technique is essential if you are to have your wisdom teeth removed. But is wisdom tooth removal really necessary?

The Pros of Wisdom Teeth Removal

There is no doubt that wisdom teeth pose potential problems when they do not erupt in good alignment. They can crowd adjacent teeth, or if they come in sideways, grow roots into them. When wisdom teeth lean toward adjacent molars they trap food particles, plaque, and debris that can cause tooth decay.[1,2]

It is not unusual for wisdom teeth to break an only part way through the gum. When a wisdom tooth is partially or completely trapped beneath the gum line, it is said to be "impacted.", as already mentioned. These teeth usually hurt. They make the jaws stiff. They are prone to tooth decay and they harbor the bacteria that cause gum disease. Their hard-to-reach location, or impossible-to-reach location, makes brushing and flossing difficult or impossible. The pain of an impacted wisdom tooth often sends the sufferer to the dentist looking for relief.

A study researched combined acetaminophen and ibuprofen for pain relief after oral surgery in adults since acetaminophen is often used with a non-steriodal anti-inflammatory drug for acute pain. A research proved that Maxigesic tablets (tablets that combine acetaminophen and ibuprofen) provide superior pain relief after oral surgery compared to acetaminophen or ibuprofen alone. [5]. Antibiotics can be also prescribed to prevent complications following wisdom tooth extraction.[6

Bleeding and oozing is inevitable after having wisdom teeth extracted, and rinsing out your mouth only makes it worse. That is because every time you rinse you dislodge the tiny blood clots that block the flow of blood. Bleeding can be stopped by placing a clean gauze pad over the site of the extraction and biting down, but doing this too often also makes the problem worse.

It is very important to follow the surgeon's instructions regarding smoking, spitting, drinking through a straw, or playing a musical instrument. These activities can cause the formation of a "dry socket" where blood clots either fail to form or fall out prematurely. Essentially a little hole where the wisdom tooth used to be, a dry socket can catch food and bacteria and cause severe inflammation and bad breath.[7]

In rare instances, a botched wisdom tooth removal operation can damage the inferior alveolar nerve, which serves the chin and the lower mouth, or the lingual nerve, which controls the movement of 2/3 of the tongue and the gums at the side of the mouth. Nerve injury is usually caused by accidental contact with a drill. More often than not this kind of injury is temporary, but it can be permanent.[8]

The Cons of Wisdom Teeth Removal

Even if your oral surgeon has great skills, there are still reasons you may not really want to have your wisdom teeth removed. In 2006 the Cochrane Collaboration published a review of studies of the results of removing wisdom teeth to prevent future dental problems, that is, as soon as they emerge when the patient is in her late teens or early 20's.[1]

The review found that about 60% of people who do not have their wisdom teeth removed do not develop future dental problems.

All the health issues associated with wisdom teeth, however, are not limited to dental health. In the United States, there is considerable concern that the wisdom teeth can serve as harbors for infectious bacteria that escape the gums and travel through the bloodstream. The bacteria that can cause gum infections can also infect the heart and kidneys.

The American Association of Oral and Maxillofacial Surgeons recommends that anyone who has a gum infection more than 3 mm (about 1/10 of an inch) deep have wisdom teeth removed to make sure the infection does not spread to the heart, kidneys, sinuses, or adjacent facial nerves.[9]

Over Four Million Wisdom Tooth Extractions a Year in the USA Alone

Most Americans err on the side of caution when it comes to having their wisdom teeth removed. Four million wisdom teeth extractions take out over 10 million teeth every year just in the USA. Before you have your wisdom teeth removed, however, make sure that you have an identifiable impaction, in other words, that your tooth points forward, backward, or sideways, or has not emerged above the gum line, and discuss the possibilities of keeping your wisdom teeth with your dentist.