When should wisdom teeth be removed, and when can they stay?

The third molars — wisdom teeth — usually erupt between 17 and 25. If there is enough room in the jaw and they are well positioned, they are used like any other tooth; in most people, however, lack of space leaves them impacted or partly erupted.

When do they cause trouble?

• Pericoronitis: Food collecting under the gum flap over a partly erupted tooth, with recurrent infection, swelling and difficulty opening the mouth.
• Damage to the neighbouring tooth: A forward-tilted impacted tooth pressing on the root of the second molar can cause decay and bone loss.
• Decay: Decay progresses fast in a tooth that cannot be cleaned because it is hard to reach.
• Cyst: Rarely, a cyst develops in the sac around an impacted tooth; it is seen on an X-ray.
• Crowding: Thought to play a part in teeth crowding again after orthodontics.

When can they stay?

Fully erupted teeth that can be cleaned, have an opposing tooth and cause no trouble are not removed; they are monitored at regular check-ups. Deeply impacted teeth very close to the nerve that cause no symptoms are also sometimes monitored; the decision rests on X-rays and examination.

The extraction

Erupted teeth are removed with a routine extraction. For impacted teeth, the gum is opened under local anaesthesia, the tooth is sectioned if necessary and removed, and sutures are placed. The procedure takes 20–45 minutes. In the lower jaw, teeth close to the nerve canal are first located with a CBCT scan.

Recovery

• First 24 hours: bite on the gauze for 30 minutes; no spitting, rinsing, hot or hard food, or smoking.
• Swelling and pain for 2–3 days are normal; cold compresses and prescribed medication.
• Sutures are removed at 7–10 days; complete healing takes a few weeks.
• Loss of the clot from the socket ("dry socket") causes severe pain; smoking and sucking (straws) raise the risk. If it happens, the dentist eases it with a dressing.

Frequently asked

Can all four be removed at once? Depending on general health and the position of the teeth, at one visit or two. Age? Extractions done young, before the roots are complete, heal more easily; they are also done safely later in life.

Four wisdom teeth in one go?

All four can be removed under general anaesthesia or sedation; under local anaesthesia the upper and lower tooth on the same side are usually removed together, the other side 1–2 weeks later, so the patient can keep chewing on one side. The decision depends on the difficulty of the teeth, the patient's anxiety and general health.

Preparing for the operation

• A panoramic X-ray; CBCT if the root tip is close to the nerve canal
• Report blood thinners, diabetes medication and allergies
• Eat breakfast (no fasting for local anaesthesia); for sedation, follow the fasting time given
• Sedation is not planned if you will be driving afterwards
• Have soft food and an ice pack ready at home

Day-by-day recovery

Warning signs

• Pain increasing rather than easing on day 3–4 and radiating to the ear → dry socket; a dressing from the dentist is needed
• Fever, growing swelling, difficulty swallowing → infection, same-day visit
• Bleeding that will not stop (active bleeding for more than an hour despite gauze)
• Lip or chin numbness lasting more than a week → check-up; most cases resolve over weeks to months

What if it is not removed?

When a troublesome wisdom tooth is left, pericoronitis attacks become more frequent, decay starts in the uncleanable part of the molar in front and that tooth may be lost too; rarely the sac around the tooth turns into a cyst. For symptom-free teeth, monitoring is an entirely reasonable option; the decision is made with the dentist. More: What is an impacted tooth? · Extractions and oral surgery