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To Keep or Not to Keep: Wisdom Teeth
Wisdom teeth, also known as third molars are the last teeth to erupt. This occurs usually between the ages of 17 and 25. There remains a great deal of controversy regarding whether or not these teeth need to be removed. It is generally suggested that teeth that remain completely buried or un-erupted in a normal position are unlikely to cause harm. However, if these impacted teeth are in an abnormal position (a dentist can show you this on an x-ray), their potential for harm should be assessed.
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What is an Impacted Wisdom Tooth ?
A tooth becomes impacted due to lack of space in the dental arch and its eruption is therefore prevented by gum, bone, another tooth or all three. Lack of space occurs because our jaws have become smaller (through evolution), we do not loose teeth through decay as frequently as in the past, and our diet is such that our teeth do not wear down as much.
 
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What are the Indications for Removing Wisdom Teeth ?
Wisdom teeth generally cause problems when they erupt partially through the gum. The most common reasons for removing them are:
 
Decay
 
Saliva, bacteria and food particles can collect around an impacted wisdom tooth, causing it, or the next tooth to decay. It is very difficult to remove such decay. Pain and infection will usually follow.
 
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Gum Infection (Pericoronitis)
When a wisdom tooth is partially erupted, food and bacteria collect under the gum causing a local infection. This may result in bad breath, pain, swelling and trismus (inability to open the mouth fully). The infection can spread to involve the cheek and neck. Once the initial episode occurs, each subsequent attack becomes more frequent and more severe.

Pressure Pain
Pain may also come from the pressure of the erupting wisdom tooth against other teeth. In some cases this pressure may cause the erosion of these teeth.

Orthodontic Reasons
Many younger patients have had prolonged orthodontic treatment to straighten teeth. Wisdom teeth may cause movement of teeth (particularly the front teeth) when they try to erupt and this will compromise the orthodontic result.

Prosthetic Reasons
Patients who are to have dentures constructed should have any wisdom tooth removed. If a wisdom tooth erupts beneath a denture it will cause severe irritation and if removed, the patient will need to have a new denture constructed as the shape of the gum will have changed.

Cyst Formation
A cyst (fluid filled sac) can develop from the soft tissue around an impacted wisdom tooth. Cysts cause bone destruction, jaw expansion and displacement or damage to nearby teeth. The removal of the tooth and cyst is necessary to prevent further bone loss. Rarely, tumors may develop within these cysts or the jaw may fracture spontaneously if the cyst grows very large.
 
Why Should an Impacted Wisdom Tooth be Removed if it Hasn't Caused any Trouble?
Impacted wisdom teeth are almost certain to cause problems if left in place. This is particularly true of the lower wisdom teeth. Such problems may occur suddenly, and often at the most inconvenient times.

When is the Best Time to Have my Wisdom Teeth Removed?
It is now recommended by specialists that impacted wisdom teeth be removed between the ages of 14 and 22 years whether they are causing problems or not. Surgery is technically easier and patients recover much more quickly when they are younger. What is a relatively minor operation at 20 can become quiet difficult in patients over 40. Also the risk of complications increases with age, and the healing process is slower.

Travel to Inaccessible Places
If you are going to an area where specialist dental services are not available and your wisdom teeth are impacted, it may be advisable to have them removed beforehand.

Should a Wisdom Tooth be Removed When an Acute Infection (Pericoronitis) is Present?
Generally, no. Surgery in the presence of infection can cause infection to spread and become more serious. Firstly, the infection must be controlled by local oral hygiene, antibiotics and sometimes the extraction of the opposing wisdom tooth.
 
The Pro's and Con's of Wisdom Tooth Removal
 
Some Pro's of Removing a Wisdom Tooth:
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Wisdom teeth may be hard to access with your toothbrush or floss. Over time, the accumulation of bacteria, sugars and acids may cause a cavity to form in the tooth. If it is not restored with a filling, the cavity may spread and destroy more tooth structure causing severe consequences to the tooth and surrounding supportive structures.
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Due to the difficulty of keeping these teeth clean with your daily home care (brushing and flossing), bacteria and food debris remaining on the wisdom teeth may present a foul smell-causing bad breath.
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A wisdom tooth that is still under the gums in a horizontal position (rather than a vertical position) may exert pressure to the surrounding teeth, causing crowding and crooked teeth. This also may occur if there is not enough space in the mouth for the wisdom tooth. This may warrant braces to repair the damage.
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A wisdom tooth that is still under the gums may become irritated. The gum tissue that lays over the tooth may harbor food debris and bacteria that gets trapped under the gum, resulting in an infection in the gums.
 
Some Con's of Removing the Wisdom Teeth:
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Depending on the size shape and position of the tooth, removal can vary from a simple extraction to a more complex extraction. With a simple extraction, there is usually little swelling, bruising and/or bleeding. More complex extraction will require special treatment which may result in more bruising, swelling and bleeding. However, your dental professional will provide you with post treatment instructions to minimize these side effects.
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Following an extraction, a condition called "dry socket" may occur. If the blood clot that formed in the extraction area becomes dislodged, it exposes the underlying bone. This condition is very painful, but resolves after a few days. It is preventable by following the post treatment instructions provided by your dental professional.
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The longer you wait and the older you get, there is the potential for more problems to occur. This is because as you get older, the bone surrounding the tooth becomes more dense, making the tooth more difficult to remove. The healing process may also be slower.
 
Post Operative Care
Do Not Disturb the Wound
In doing so you may invite irritation, infection and/or bleeding. Chew on the opposite side for the first 24 hours.

Do Not Smoke for 12 Hours
Smoking will promote bleeding and interfere with healing.

Do Not Spit or Suck Through a Straw
This will promote bleeding and may dislodge the blood clot, which could result in a dry socket.

Control of Bleeding
If the area is not closed with stitches, a pressure pack made of folded sterile gauze pads will be placed over the socket. It is important that this pack stay in place to control bleeding and to encourage clot formation. The gauze is usually kept in place for 30 minutes. If the bleeding has not stopped once the original pack is removed, place a new gauze pad over the extraction site.

Control of Swelling
After surgery, some swelling is to be expected. This can be controlled through the use of  cold packs, which slow the circulation. A cold pack is usually placed at the site of swelling during the first 24 hours in a cycle of 20 minutes on and 20 minutes off.

After the first 24 hours, it is advisable to rinse with warm saltwater every two hours to promote healing. (one teaspoon of salt to eight ounces of warm water).

Medication for Pain Control
Anti-inflammatory medication such as Aspirin or Ibuprofen are used to control minor discomfort following oral surgery. Stronger analgesics may be prescribed by the dentist if the patient is in extreme discomfort.

Diet and Nutrition
A soft diet may be prescribed for the patient for a few days following surgery.
 
Following the removal of your wisdom teeth it is important that you call your dentist if any unusual bleeding, swelling or pain occurs. The first 6-8 hours after the extraction are typically the worst, but are manageable with ice packs and non-prescription pain medication. You should also plan to see your dentist approximately one week later to ensure everything is healing well.

It is very important to talk to your dentist about extraction procedure, risks, possible complications and outcomes of the removal of these teeth. The actual extraction may be done by a dentist or it may be referred to an oral surgeon, who is a specialist. This decision is based on the dentist's preference and the unique features of each individual case. If you are unsure about whether or not to proceed  with the treatment suggested by your dental professional, it is a good idea to get a second opinion. If you decide after consulting with a dentist to not have any teeth extracted, they should be monitored at every dental visit.
 
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