Wisdom Tooth Pain
Out of a full set of 32 adult teeth, you have 4 wisdom teeth. Dentists commonly refer to wisdom teeth as “third molars” or “8s.” The term third molar refers to the fact that there are 3 back molars in total on each jaw and the wisdom tooth is the last molar or the third one. The term 8’s is a dentists notation. This is because, dentists have their own notation when carrying out an examination on a patient. If you look at your teeth in a mirror, the tooth right in front is called the “1” and the next one is called the “2” until you get to the very back where your wisdom teeth which have the number “8” designated to them.
Although patients think that somehow wisdom teeth are something special and if something goes wrong, it’s hells bells, the fact is that they are just like any other teeth in your mouth and just get the same problems, in theory. Wisdom teeth can get decay, infection and gum disease just in the same way as all the remaining 28 teeth but they do have their own particular set of issues.
There are however a number of reasons why wisdom teeth get such a bad name. Firstly, if they need treatment, treatment is more difficult because access right to the back of the mouth can be difficult or even impossible. Secondly, wisdom teeth can have extra roots and more curved roots in comparison to the adjacent molars. This makes certain treatments more awkward such as extractions or root canal treatments. Thirdly, the jaw bone around the wisdom teeth is thicker and harder. Once again, this makes them more difficult to extract with a greater chance of complications.
The main problems that you can get with wisdom teeth are decay, gum disease and impaction.
Wisdom Teeth Decay
Decay can occur in any tooth and this includes the wisdom teeth. Decay or dental caries is more likely in wisdom teeth because they are so far back in your mouth that it can be difficult or even impossible to reach and clean with a toothbrush let alone dental floss or an interdental toothbrush. If the dental plaque cannot be cleaned off, the bacteria feed off the dietary sugar causing acid to be produced hence starting off a dental cavity. The dental caries can form on any surface of the wisdom teeth and often goes unnoticed until there is pain or even a dental abscess. It is not unusual for even dentists to miss out dental caries in a wisdom tooth. As a dentist myself, I know how difficult it can be to examine wisdom teeth. Firstly, the patient may not be able to open their mouth wide enough or you can’t tilt the chair back sufficiently to carry out an examination. Dentists diagnose dental decay by direct visual examination but also by the routine use of screening dental xrays. All patients need to have a set of bitewing radiographs carried out every two years but these do not always detect the decay. A problem with wisdom teeth is that, the xrays can be difficult for patients to tolerate as they have to be placed really far back in the mouth which can cause the patient to start gagging and the film can cut into the patient’s palate and tongue. The result is that the dentist has to give up or even if the xray has been taken, it is of poor diagnostic quality. A dentist uses a mirror and probe to examine for dental caries but if the caries in under a gum flap or operculum, then it can be impossible to track. I remember having a patient who was in terrible agony. No one in the practice could find the cause of the pain and even 2 consultants at the dental hospital had all sorts of theory from muscle pain to atypical facial pain. Eventually, the cause of the pain was diagnosed as being dental caries in a lower third molar. The cavity was right under the gum line at the side of the tooth in a patient who could not open her mouth very wide so not surprising that it took ages to diagnose.
Another reason why wisdom teeth are more susceptible to dental caries is that often they are impacted or at an odd angle or there is an associated gum flap which makes a food trap hence ideal conditions promoting dental caries.
Treatment Of Decay In A Wisdom Tooth.
So now you know that you have decay, how can this be treated. The first thing to decide is if it can be treated at all in the first place. As stated above, often, once decay has been finally diagnosed, it is often too late to treat it as the tooth is beyond repair. What about root canal treatment? It is quite rare to do a root canal treatment on wisdom teeth because firstly, it’s difficult in the first place just to gain access with the drill and all the different files and reamers. The next difficulty is placing rubber dam for dentolegal reasons if you happen to accidently swallow a file. Then, you need to consider the root morphology of wisdom teeth. Often, the roots canals are curved and complex with lots of accessory canals. An important anatomical structure to consider is the IAN (inferior alveolar nerve) and if one is not careful, endodontic paste and irrigation bleach can easily be forced into the ID canal with the disastrous risk of causing facial numbness or parathesia for life. Even, if you get past this hurdle, you then have the problem of restoring the tooth. Often, root canal treated teeth will need a crown and we then have the same problems with access and difficulty. Then, even if you did have a beautiful root canal and crown on your tooth, there is the chance that it won’t last long because the original factors that caused the decay in the first place are still lurking. Dental caries can still occur under a root treated or crowned tooth and when it does, most of the time, it’s final curtains for the tooth.
Let’s assume, the decay in the wisdom tooth is not too deep. The options here are a normal conventional filling or a fissure sealant restoration. If the decay, can be treated, it may prove too difficult to gain access. Even, once all the caries has been removed, it may prove impossible to get moisture control to stop the new filling from becoming contaminated. If the filling has become contaminated, it will just either fall out or leak causing pulpitis and secondary caries.
Stick Or Extract
When treating wisdom teeth, it is important for the dentist to actually carefully consider if the tooth is worth saving or if it is better extracted. Wisdom teeth are not usually strategic teeth unless the patient has other teeth missing which then makes it worthwhile saving.
Pericoronitis
Pericoronitis is a very common problem with wisdom teeth. It is an inflammation of the gum around a wisdom tooth that has not fully come through. Often there will be a gum flap known as an operculum partially over the biting surface of the tooth. Food debris can easily get underneath the gum flap and the area becomes infected causing pain. Initial treatment involves local measures such as syringing with chlorhexidine. A really effective treatment for a painful lower wisdom tooth is to remove the upper wisdom tooth which is biting directly down onto the operculum. Once the upper tooth is out of the way, the reduction in pain is quite dramatic. There is now no upper tooth biting down on the operculum and causing it to get inflammed and swell up.
Pericoronitis can be acute or chronic. For the pain, suitable analgesics are paracetamol and ibuprofen. If infection has spread, metronidazole is the antibiotic of choice.
Some dentists carry out an operation where the gum flap is cut out. This is called an operculectomy. It’s carried out under a local anaesthetic but when the gum flap has been cut off, it grows back again after a few weeks so nothing has been gained.
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