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Wisdom Tooth

Discussion in 'Dental' started by turtleboard, Apr 25, 2001.

  1. turtleboard

    turtleboard SDN Advisor
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    Hey dentists and dental students,

    I've got a question: When is extraction of a wisdom tooth indicated? Please be as specific as possible. Thanks.



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    Tim Wu.
     
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  3. Sterichind

    Sterichind Member
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    Hello Tim,

    From what I've seen and read, I would say that extraction of the 3rd molars or wisdom teeth is necessary when they cause orthodontic problems (crowding teeth),which can lead to an unsightly looking smile and possibly improper bite. An improper bite can lead to tooth decay. When a wisdom tooth erupts at an improper angle, it can possibly rub against the 2nd molar and cause interproximal smooth surface cavities or a cavity on the smooth surface of the tooth next to the wisdom tooth and on the wisdom tooth itself. I hope that helps. This is all I can think of for now, but if I come up with another idea, I will tell you.

    Sterichind
     
  4. turtleboard

    turtleboard SDN Advisor
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    What's the chance of a wisdom tooth that has erupted in an improper orientation becoming a problem? Are wisdom teeth ever extracted on a prophylactic basis?

    Thanks Sterichind.



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    Tim Wu.
     
  5. Sterichind

    Sterichind Member
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    Hello Tim,

    I don't know the exact percentages. If a 3rd molar comes in sideways under the gingiva or gums and erupts into the 2nd molar, it must be removed. I believe if the tooth turns horizontal, it will probably run into the 2nd molar in most cases. Please clarify prophylactic? I'm not exactly sure what you may be referring to, but if the tooth is being absorbed or decayed under the gums, I would say it probably is wise to remove it. A decaying tooth is grounds for an abscess because of the availability of the pulp nutrients to bacteria. An abscess is grounds for a bacteria party. That party will lead to gum disease and tooth loss. I'm not a dentist yet, but that's my best guess.

    Sterichind

    P.S. Thanks for listening!
     
  6. DrDMD05

    DrDMD05 Senior Member
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    Yes, often wisdom teeth are removed on a prophylactic basis. Often dentist will x-ray a prewisdom toothed individual and will come to the conclusion that the wisdom teeth must be removed or else they might cause the others to shift. A really smart dentist will of course not removed these wisdom teeth, but let them grow on their merry way allowing the dentist to not only bill for wisdom teeth removal but also for braces.

    DMD
     
  7. turtleboard

    turtleboard SDN Advisor
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    Final question on the wisdom tooth extraction: About how painful is it compared to other, more common, dental procedures?
     
  8. DrDMD05

    DrDMD05 Senior Member
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    Recovery time and pain intensity would be directly dependent on how invasive the surgery was, and of course, ones level of tolerance for pain. For example, my wife's wisdom teeth were completely compacted (showing no crown) and her recovery time was 5-6 days. She had a great deal of pain requiring Tylenol and codeine every four hours. Then there are other patients who will experience only a slight discomfort. Lucky for them the doctor didn't have to be too invasive to remove these teeth and their pain can be easily resolved with just a few Tylenol.

    DMD

    :D ;) :confused: :p :(
     
  9. turtleboard

    turtleboard SDN Advisor
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    So what characteristics would make the extraction more complicated? DMD mentioned "impacted" tooth...
     
  10. Sterichind

    Sterichind Member
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    Hello Tim,

    How are you? I will say that impacted teeth can be somewhat troublesome because they are still under the gums and are not exposed. This requires the dentist to remove the gum tissue to expose the tooth for elevation from near the roots to the surface. If an impacted tooth is decayed or just plain breaks on extraction, this makes it difficult too for the dentist and possibly the patient. It is important to remove all of the tooth fragments. In addition, there can also be exposure of the sinuses in an extraction leading to inflammation in the sinuses. The procedure also has a minimal chance of a jaw fracture or nerve damage.
    Hope this helps! If you are having this procedure, I wouldn't worry that much. It's pretty quick, maybe 10 mins per tooth.

    Sterichind
     
  11. turtleboard

    turtleboard SDN Advisor
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    Gosh, no, not me. :)

    They'd have to give me a general anesthetic to get me to undergo one of those deals!

    Last (perhaps) question on the subject: Are these procedures always performed by an oral surgeon (someone who's done an OMS program), or can a GD do it? Ortho? Perio?

    Oh, and I just thought of something... If there's a chance for nerve damage by going into the mandible to get that sucker out or exposure of the sinuses (accidental, I suppose), why not just let the tooth grow out a bit more before actually going for it? Sounds like it's more trouble than it's worth especially if you injure the alveolar nerves or fracture the mandible.

    You dentists... :)
     
  12. Sterichind

    Sterichind Member
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    Hello Tim,

    You should have joined us to become a dentist. I know this stuff intrigues you. You joke about us behind our backs, but I know you like us. Tim join the dark side. Forget about the force.

    Any dentist can perform an extraction. However, your general dentist is appropriate for the front teeth with 1 or 2 roots, and an oral surgeon is better for larger molar extractions. The oral surgeon has 4-6 years of residency and is the most appropriate for
    extractions.

    Furthermore, I do not recommend leaving the wisdom teeth to erupt through your gums so that you can have an easier extraction. They are pretty large. They will probably cause crowding. You will not only be faced with the oral surgeon but also the orthodontist. It's difficult! The risk of nerve damage versus ordontic problems. However, I believe the risk for nerve damage being permanent are minimal to nonexistant.


    Take it easy!
    Sterichind
     
  13. Sterichind

    Sterichind Member
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    Hello Again!

    Sorry, I spelled orthodontic wrong by accident. Check out the Jerky Boys "Dental Malpractice" on Napster. It's hilarious!

    Sterichind :p
     
  14. DrJeff

    DrJeff Senior Member
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    Here's some further info on criteria for wisdom tooth extraction/surgery times/post operative pain/healing time/who should do the extractions that I provide my patients with everyday.
    1st: criteria for removal, I break it down as simply as this, is the tooth fully errupted and in function with an opposing tooth, can the patient keep the tooth clean, is the periodontal condition around the wisdom tooth the same as around adjacent teeth. If any of these questions are answered "no" then I recommend extraction.
    As for the comment that errupting wisdom teeth promote anterior crowding, thats one of the biggest misconceptions in dentistry. The medial force that the wisdom tooth places on the errupted 2nd molars isn't anywhere near enough force to move and tip the roots of the 7 teeth that are infront of it. Ask an orthodontist sometime about it. True though that over time, without retention, the errupted dentition will as a whole move medially for most folks, and thats what will cause alot of post orthodontically treated folks to have anterior crowding when they reach their late 20's/30's.
    Surgery times: For an errupted wisdom tooth, any practictioner who is comfortable with extractions should take no more than 3 to 4 minutes a tooth. If the tooth is impacted requiring elevation of a flap and either removal of bone and/or sectioning of the tooth, it can take upto 30 minutes per tooth depending on the tooths angulation, bone density, sinus and inferior alvelor nerve proximity. Healing time for most folks will take on average 5 to 20 days for soft tissue depending on the number of incisions(if any), whether primary closure was needed/achieved, tissue management, and suture placement(if any).
    Post operative pain varies tremendously. First off, if your someone who gets a paper cut and needs a Vicodin, then, its going to hurt a bit. If your the type that could get hit by a bus, take 2 motrin, and feel fine, then you'll have no problems. For extractions without have to lay an incison or remove any bone, then figure a couple of days of mild/moderate dull, achy sensations. For any incisions/bone removal then 3 to 7 days of moderate pain may be anticipated. MOST docs will get you a script for a narcotic (Vicodin or the like) and sometimes either a tapering steroid(solumedrol dose pack) and/or an antibiotic depending on the difficulty of the extractions.
    As for who should do the extractions, ask, ask, ask. True, most 3rd molar cases are done by oral surgeons, its their bread and butter money winners(1500-2500 billing for in most cases less than 30 minutes of work), but alot of that also has to do with the ability to administer IV conscious sedation. Due to extremely large increases in mal-practice insurance fees and a relatively small(read as non cost effective need) to use this on a regular basis, most GP's aren't IV certified. Alot of GP just aren't comfortable at taking out teeth, and don't have alot of experience at it. In my residency, we didn't have an oral surgery program affiliated with the hospital I was at, hence I got to take out alot of teeth during my residency(over 4000, 175 OR cases, and 275 IV sedation cases). I feel very comfortable at extraction almoost any tooth. My partners never had such extensive training at extractions, and hence rarely take any teeth out. I still though send alot of my 3rd molar cases to the oral surgeon, simply because I want to keep my patients as comfortable as possible, and having the IV in the AC fossa with some Versed and Fentanyl flowing helps a ton! Hope that helps a bit.
     
  15. turtleboard

    turtleboard SDN Advisor
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    Well, that's what I'm worried about.

    If any dentist is qualified by his state to do any extraction, whether it's of a front tooth or of a wisdom tooth, then how do you know which guy to choose?

    Ask a dentist, and being that many professionals are very confident in their abilities (or perhaps don't want to let on that they don't know what they're doing), he'll more than likely respond with "sure." I'm more confident in having an oral surgeon or someone who's had a lot of experience in doing these types of procedures -- only because it sounds rather complicated to tack out a tooth that hasn't fully erupted (note: I'm not a dentist) and the administration of anesthetics (especially of something like fentanyl) is not something I'd be comfortable with having a GD do. How many times in his career would a GD EVER have to use an IV anesthetic?

    Is there a national website to find which dentists are oral surgeons?

    Would a GD residency include a lot of wisdom tooth extractions?

    Thanks everyone for the great answers!
     
  16. Mikado

    Mikado Senior Member
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    If you teeth don't hurt then leave them where they are.
     
  17. turtleboard

    turtleboard SDN Advisor
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    Not much of a dentist/dental student, are you Mikado? :)
     
  18. Sterichind

    Sterichind Member
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    Hello Tim,

    I'm a volunteer Dental Assistant in a dental clinic with many new graduates of dental school in a general practice residency, and the dentists have oral surgery practice every Thursday. I would say they probably have two wisdom teeth extractions each Thursday ranging from 1 to 4 wisdom teeth in each case. This is problem the normal amount for most general dentists in general practice residency. This will give you an idea of their abilities to perform this procedure. Personally, I would prefer an oral surgeon. Although, it does cost a little bit more to go to a specialist, but I would pay for the procedure and confidence.

    Sterichind
     
  19. Mikado

    Mikado Senior Member
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    No turtleboard I'm not. The truth is that not having had dental coverage for many years and at the same time needing dental work done (I have had a temporary filling in one of my back teeth now for almost two years) has made me kind of hostile toward dentists.
    Financially, I just made it through pre-med and the application process by the seat of my pants and there is no way I can pay the super high costs of having dental work done.
    So I know it is irrational to take this out on the dentists themselves but I just can't help it.
     
  20. DrJeff

    DrJeff Senior Member
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    Here's a little trick to figure out of the general practitioner is comfortable at taking out teeth. When you call the office, ask the receptionist if the Doc commonly takes out teeth themselves, or if they commonly refer to a surgeon. I know its not scientific, but trust me, if a Doc doesn't feel very comfortable at taking teeth out, then they will refer alot, rather than dealing with potential post op problems, and the front desk staff knows the trends of the office.

    The experience that dental residents get in their residencies varies alot. If the hospital that the residency is at has an oral surgery program affiliated with it, then the O.S. residents will do the majority of the extractions. If there isn't an O.S. program, then the residents will get alot of experience at extractions.

    Last thing, the IV Versed and Fentanyl that I was referring to is in conjunction with the traditional intra-oral local anesthestic. Not much different(the IV meds) than you'd use of the floors for doing simple, bedside proceedures(tapping a lung, relocating a dislocated joint, etc.), with proper monitoring(and any dental provider who administers IV sedation is fully ACLS certified with a fully trained staff and full monitoring) its really quite a safe procedure.
     
  21. mtg

    mtg Junior Member
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    I had a wisdom tooth removed about a year ago by my family dentist. Under the nitrous and lidocaine local injection it was no sweat. He did upper and lower in the same sitting and had to section the lower. The upper broke into pieces as he was extracting it and he had to nab all the little bone chips out... I highly recommend the nitrous... with enough lidocaine, you feel only pressure sensations and with the nitrous, you DON'T CARE. :D I was prescribed vicoprofen afterwards and I think it took about a week before I really felt halfway decent again. For the first 8 hours or so after the procedure, that side of my face was puffed up like George Foreman slugged me a few times.

    Overall, it was a completely manageable experience under only local anesthesia and I think he did a great job. No dry socket or infection. It takes a while for the socket to fill in, but otherwise I'd have no qualms about letting a GP do this procedure to me again if necessary.

    Hope this helps.
    Mike
     
  22. Wasabi

    Wasabi Senior Member
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    OUCH.

    Reading the above post makes me want to avoid my dentist like the plague.
     
  23. No2thDk

    No2thDk Junior Member
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    Here's just a few thoughts that came to my mind when reading the above posts.

    Almost all dentists will be honest about their abilities. As a dental assistant of about 6 years, I've heard the phrase "This one's out of my league" uttered by many Dr.s many times.

    As far as the actual procedure of 3rds removal, mine went fine. 30 minutes on my lunch break to remove all 4 and I assisted on myself! No post op problems even though all 4 were impacted. Most of the post op trauma that I see in patients comes from IV, meds or dry socket.

    Don't even comment on the cost of dental care until you order supplies for a clinic! That's where the high cost starts.


    I don't think it would be considered "smart" to wait to remove 3rds just so you can bill for surgery and ortho. I hope you were kidding. If not, then that is unethical, not smart.
     

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