Wisdom teeth removal

What is it?

Wisdom teeth are the last molar teeth to develop which usually grow at the very back of the upper and lower jaw bones, one at each back 'corner' of the mouth. They usually appear when people are aged 18 to 21 years old, and they are called wisdom teeth because by that age people become 'more mature and wise'. Wisdom teeth can be as good and useful as any other teeth provided that, as they develop, they can penetrate the gums and emerge or erupt into the mouth completely and properly. Unfortunately, this is not always the case. Frequently wisdom teeth erupt only partly or they don’t erupt at all. They are then called impacted wisdom teeth and they are usually a cause of many problems that makes it necessary for them to be removed. The wisdom teeth usually need to be

removed because of one or more of the following:

• severe pain and swelling caused by the wisdom teeth themselves

• recurrent infection of the gum around the tooth

• serious decay of the wisdom teeth which cannot be repaired

• helping to reduce crowding of other teeth before straightening with a 'brace' (orthodontic appliance).

Very rarely, the tissues around the wisdom teeth can develop cysts or tumours and this can be one more reason for removing them.

The operation

In some cases a wisdom tooth can be removed under local anaesthetic. In this situation, the area around the tooth is made numb with an injection of local anaesthetic. Sometimes the local anaesthetic is combined with sedation to help you relax and allow you to go through the operation. Having sedation means that you will be conscious during the operation, but will not be aware of what is going on.

Finally, the operation can also be done under general anaesthetic. Having a general anaesthetic means that you will be completely asleep during the operation and you will not feel any pain. The choice of anaesthetic depends partly on which you prefer, and partly on what your surgeon thinks is best. It is generally better to have local anaesthetic and sedation or a general anaesthetic if it is anticipated that the operation will be difficult; for example when a wisdom tooth hasn’t erupted at all and lies deep in your gum.

Your wisdom teeth will be removed from inside the mouth. The gum may need to be cut slightly at the back of the mouth and a small amount of bone removed to loosen the wisdom tooth. The tooth may need to be cut into one or more pieces to help its removal. The gum will be stitched after the tooth is removed, often with a type of stitch that is designed to dissolve. Most patients are allowed to go home in the early evening after the operation. If you have had local anaesthesia with or without sedation you will normally go home about three to four hours after your operation.

Before the operation

Stop smoking and try to get your weight down if you are overweight. (See Healthy Living). If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control. Check the hospital's advice about taking the Pill or hormone replacement therapy (HRT). Check you have a relative or friend who can come with you to the hospital and take you home. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to the hospital with you. On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the operation as safely as possible. Please tell the doctors and nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form. Many hospitals now run special preadmission clinics, where you visit for an hour or two, a few weeks or so before the operation for these checks.

After - in hospital

Your mouth will feel bruised and swollen, the jaw will be slightly stiff and usually there is some mild to moderate discomfort. Your cheeks will usually swell a little with slight bruising of the skin. You will be given painkillers to help with any discomfort. The swelling, bruising and stiffness of the jaw will disappear over a week to 10 days. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. The same can happen with sedation but to a lesser degree. The nurses will help you with everything you need until you are able to do things for yourself. Do not make important decisions, drive a car, use machinery, or even boil a kettle during this time. You will be able to drink two to three hours after the operation but eating may not be possible for a few hours. It may be hard to chew normally for a while so you should eat a softer diet and initially avoid very 'spicy' or 'vinegary' foods. A little extra daily fibre in the form of porridge or 'Ready Brek' often helps to prevent constipation whilst your diet is temporarily altered. The stitches which may have been put in usually dissolve, but you are normally asked to attend for a short outpatient visit to check healing about two weeks after your operation. The stitches may be removed if required. An after surgery –X-ray may be taken at that visit. Occasionally further visits may be arranged to monitor your progress. Some hospitals arrange a check-up about one month after you leave hospital. Others leave check-ups to the general practitioner. You will be given a 'summary discharge letter' for your doctor or dentist to let him or her know what has been done for you in hospital. The nurses will advise about sick notes, certificates etc.

After - at home

You will be given a small 'take home drug pack' containing an antiseptic mouthwash, some painkillers and some antibiotics. It is important to keep your mouth cleaner than normal to prevent infection of your wounds. A warm salt water mouth bath, three times a day (a pinch of salt to half a pint of warm water), used for one minute each side of the mouth after tooth-brushing often helps soothe the mouth. The antiseptic mouthwash given to you should also be used after the salt water for one minute. You should finish the full course of antibiotics but only take painkillers as directed. Antibiotics can affect function of the contraceptive pill and alternative precautions are advisable whilst taking the antibiotics and for about a week after finishing the antibiotics.

Possible complications

If you have this operation under general anaesthetic, there is a very small risk of complications related to your heart and lungs. The same is true for sedation but to a lesser degree. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will bring the risk for such complications very close to zero.
It is generally recommended that you have the operation for wisdom teeth removal sooner rather than later because as you get older the chance of complications after this operation increases.
Bleeding after the operation occurs rarely and usually stops when the surgeon applies some pressure with a sponge on the area of the operation. Extremely rarely you will need another operation to stop the bleeding.

If you experience increasing pain at the area of the operation, you feel that it is getting more swollen and you have a temperature, it most probably means that the antibiotics that you were given to prevent an infection were not adequate and that the area of the operation has become infected. This happens relatively rarely and taking antibiotics (most likely different to the ones you were given to prevent the infection) for another week or two usually solves the problem. In a very small number of patients the infection can be very and lead to a collection of infected fluid or pus (abscess) at the area of the operation. In this situation you will need another operation to drain the infected fluid or pus.

The lower wisdom teeth are usually very close to a nerve which supplies the tongue and lip for touch sensation. There is a separate nerve like this on each side. The nerve(s) may be affected by bruising and swelling around the wound(s). This may cause some numbness of the lower lip and tongue on one or both sides. It happens in 1 to 3% of patients who are up to 21 years old but in about 10% of patients who are over 35 years old. Normal feeling usually returns but in some very rare instances permanent numbness may persist.

In 5 to 10% of cases you can have experience a problem called a “dry socket”. This happens because following the removal of the wisdom tooth a clot was not formed in the area or socket where the tooth used to be or it did form but was then dislodged. This can be painful, and often causes foul bad breath and it is something you usually experience four to five days after the operation. The socket needs to be packed with some medicated gauze for a few days to relief the symptoms until the healing process progresses and starts to fill the socket. The gauze needs to be changed every other day and most patients don’t need more than two to three changes until they feel much better and packing of the socket is no longer required. It is believed that patients who smoke or women who use contraceptive pills experience this problem more frequently. Although a “dry socket” can be very annoying, with proper care it settles completely, relatively quickly.
If you have any problems relating to your surgery whilst at home and are not sure what to do, ring your hospital and ask to speak to the senior nurse responsible for oral surgery. You may feel quite tired for one to two weeks after your operation.

General advice

You will be aware of the 'hole(s)' left after removal of your teeth for several weeks, but the bone and gum will reshape and after six months it will be hard to tell you have had surgery there. These notes should help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.