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Wisdom Teeth FAQs
Nine out of 10 people have at least one impacted wisdom tooth, making wisdom tooth extraction a common outpatient surgery. It’s normal to have questions before and after wisdom tooth removal, and Dr. Stuart Lieblich discusses these frequently asked questions about wisdom teeth.
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The James Q. Swift Professorship Endowment was founded and funded at the University of Minnesota in 2016. He received his dental degree from the University of Iowa and his oral and maxillofacial surgery training from the University of Oklahoma College of Medicine. He is also a practicing oral and maxillofacial surgeon at the University of Minnesota. He served the American Board of Oral and Maxillofacial Surgery as President and as a Director for six years. He served the American Dental Education Association as President in 2007-08 and on the Board of Directors. Dr. Swift served as a Director of the OMS Foundation from 2009-12.
He has served the AAOMS on numerous committees including service as an officer and chair of the Faculty Section. He received AAOMS’s Daniel M. Laskin Award for the most outstanding Journal of Oral and Maxillofacial Surgery article published in 1998. In 2011, Dr. Swift received the William J. Gies Foundation Award for oral and maxillofacial surgery. He was given the ADEA Distinguished Service Award in 2009. He received the R.V. Walker Distinguished Service Award in 2015. He is a Fellow of the American College of Surgeons. Dr. Swift has been a Director of OMSNIC since 2006, served as Vice Chair from 2011 to 2013 and as Chair since 2014.
Dr. Lieblich graduated from the University of Pennsylvania School of Dental Medicine and completed his residency in oral and maxillofacial surgery at Kings County/Downstate Medical Center in New York. He was full-time faculty of the University of Connecticut from 1984-88. Currently, he is in private practice in Avon, Conn., and maintains a part-time teaching appointment at the university as Clinical Professor, where he lectures to the medical and dental students on head and neck anatomy (with special focus on the temporomandibular joint and the anatomy of orthognathic surgery) and also to the various postgraduate residency programs.
In 2019, he was appointed Medical Director for Oral and Maxillofacial Surgery/Pediatric Dentistry at the Connecticut Childrens Medical Center in Hartford.
Dr. Lieblich has been a contributor to over 20 textbooks and recently co-authored the textbook Anesthesia Complications in the Dental Office. He has published over 45 peer-reviewed papers and abstracts. He is an invited speaker at conferences throughout the United States and has presented his research at international scientific meetings with focuses on ambulatory anesthesia, dental implants, dentoalveolar surgery and periapical surgery.
Previously, he has served as President of the American Dental Society of Anesthesiology and as a Director on the American Board of Oral and Maxillofacial Surgery. (Dr. Lieblich is on the editorial boards of three journals, including the Journal of Oral and Maxillofacial Surgery (section editor, Anesthesia/Temporomandibular Joint Surgery). His recently published research includes a national multicenter study on the use of antibiotics for elective oral surgical procedures as well as opioid reduction strategies for oral surgical procedures.
James Q. Swift, DDS, FACS | Stuart Lieblich, DMD
Dr. James Swift is a tenured Professor and was Director of the Division of Oral and Maxillofacial Surgery at the University of Minnesota School of Dentistry. He was named the University of Minnesota School of Dentistry Century Club Professor of the Year in 2001. Dr. Swift has authored over 100 manuscripts, articles, abstracts and book chapters. He has procured funding from the NIDH as a Principal Investigator, securing RO1 support for his scientific work.The James Q. Swift Professorship Endowment was founded and funded at the University of Minnesota in 2016. He received his dental degree from the University of Iowa and his oral and maxillofacial surgery training from the University of Oklahoma College of Medicine. He is also a practicing oral and maxillofacial surgeon at the University of Minnesota. He served the American Board of Oral and Maxillofacial Surgery as President and as a Director for six years. He served the American Dental Education Association as President in 2007-08 and on the Board of Directors. Dr. Swift served as a Director of the OMS Foundation from 2009-12.
He has served the AAOMS on numerous committees including service as an officer and chair of the Faculty Section. He received AAOMS’s Daniel M. Laskin Award for the most outstanding Journal of Oral and Maxillofacial Surgery article published in 1998. In 2011, Dr. Swift received the William J. Gies Foundation Award for oral and maxillofacial surgery. He was given the ADEA Distinguished Service Award in 2009. He received the R.V. Walker Distinguished Service Award in 2015. He is a Fellow of the American College of Surgeons. Dr. Swift has been a Director of OMSNIC since 2006, served as Vice Chair from 2011 to 2013 and as Chair since 2014.
Dr. Lieblich graduated from the University of Pennsylvania School of Dental Medicine and completed his residency in oral and maxillofacial surgery at Kings County/Downstate Medical Center in New York. He was full-time faculty of the University of Connecticut from 1984-88. Currently, he is in private practice in Avon, Conn., and maintains a part-time teaching appointment at the university as Clinical Professor, where he lectures to the medical and dental students on head and neck anatomy (with special focus on the temporomandibular joint and the anatomy of orthognathic surgery) and also to the various postgraduate residency programs.
In 2019, he was appointed Medical Director for Oral and Maxillofacial Surgery/Pediatric Dentistry at the Connecticut Childrens Medical Center in Hartford.
Dr. Lieblich has been a contributor to over 20 textbooks and recently co-authored the textbook Anesthesia Complications in the Dental Office. He has published over 45 peer-reviewed papers and abstracts. He is an invited speaker at conferences throughout the United States and has presented his research at international scientific meetings with focuses on ambulatory anesthesia, dental implants, dentoalveolar surgery and periapical surgery.
Previously, he has served as President of the American Dental Society of Anesthesiology and as a Director on the American Board of Oral and Maxillofacial Surgery. (Dr. Lieblich is on the editorial boards of three journals, including the Journal of Oral and Maxillofacial Surgery (section editor, Anesthesia/Temporomandibular Joint Surgery). His recently published research includes a national multicenter study on the use of antibiotics for elective oral surgical procedures as well as opioid reduction strategies for oral surgical procedures.
Transcription:
Wisdom Teeth FAQs
Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth and with me is Dr. Jim Swift. Dr. Swift, great to see you.
Dr. James Swift: Great to be with you, Bill.
Bill Klaproth (host): Absolutely. And we also have Dr. Stu Lieblich. Dr. Lieblich, great to see you as well.
Dr. Stuart Lieblich: Thanks. Well, great to be here.
Bill Klaproth (host): Thank you both for your time. Looking forward to this. We're going to be talking about wisdom teeth and answering FAQs. So, thank you both for being here again. Dr. Lieblich, let me start with you. So, basic question, what are wisdom teeth and why do people have them?
Dr. Stuart Lieblich: Well, that's always the question. We do also call them third molars. So, we think about the first molar being your six-year molar that comes in; the second, twelve-year molar; and then, the wisdom teeth come in after that.
Interestingly, in most cases now, we don't have quite enough room in our mouths for all the teeth plus the wisdom tooth. And previous times, you know, it may not have been unusual to lose your first molar that came in at six. And perhaps through lack of good dental care, fluoride and all the advances that we have now in dentistry and medicine, now those teeth are maintained. But in the past, those teeth might've been lost. And as the person grew, everything could slide forward. So, teeth will move towards the front of the mouth. So, that's a theory. Hard to prove, but that's our working theory as far as why we have wisdom teeth.
Bill Klaproth (host): Right. And Dr. Lieblich, without the room, then wisdom teeth often get impacted. Is that right?
Dr. Stuart Lieblich: Correct. So, impacted meaning they're stuck, caught under the gum, caught under the bone or some combination thereof. And when they're half in and half out, they can create some significant dental issues and medical issues for our patients.
Bill Klaproth (host): Absolutely. And Dr. Swift, does everyone have wisdom teeth? And when do they generally come in?
Dr. James Swift: Most people have wisdom teeth, but not all of them have all four of them. There's typically two in the upper jaw and two in the lower jaw. The last teeth back on both the upper jaw and the lower jaw. And there's a variability as to when they come in. Some of it's based upon how crowded they are. If in fact there's no space for them to erupt, it may take longer. But what gives the tooth the energy to come into the oral cavity is the development of the tooth roots themselves. And so, as these teeth grow and develop, they create the eruptive force that they have to come into the mouth to be functional.
Bill Klaproth (host): You know, when I think of teeth, I don't often think about eruptive force. Is that right, Dr. Lieblich? You're going to add something.
Dr. Stuart Lieblich: Yeah, exactly. And interestingly about the variability, both my children only had upper wisdom teeth. So, it's variable from one person to another, one family. So, there's a genetic composition. But Jim, I'm sure you've seen in your practice extra wisdom teeth too. So, sometimes people have a fourth molar.
Bill Klaproth (host): Yeah. So, we talked about the wisdom teeth getting impacted. So, I think I kind of know the answer why, but why remove the wisdom teeth? I think it seems kind of obvious, but I'm sure there's probably a real definition on why it's important they come out.
Dr. James Swift: Bill, can I make a point about that?
Bill Klaproth (host): Yeah.
Dr. James Swift: Actually, the wisdom teeth don't get impacted. They're prevented from erupting by the lack of space and that creates the absence of eruption. They don't have anywhere to go. So, the other teeth that are in front of it or perhaps the back part of the jawbone holds them in position and they can't come in because there's not any space for them. And then, you call them impacted at that point in time.
Bill Klaproth (host): Okay. Good distinction. I'm glad you said that. So, there's no room for them to come out. And so then, obviously, that's why we have to have them out. Does everybody always have them out?
Dr. Stuart Lieblich: Not at all. So, the oral surgeon in conjunction with the patient's dentist will evaluate the case based on clinical examination, based on radiographs or X-rays. Typically, the problem we see is when the tooth is kind of half in and half out because the gum tissue won't attach or adhere to the enamel or crown structure of the tooth. So, there's a space between the tooth and the gum where food and bacteria gets caught and creates localized infections.
Bill Klaproth (host): Okay. Got it. So then, Dr. Swift, when it comes to removing wisdom teeth, how long does it generally take?
Dr. James Swift: To relate what Stu just said, the fact is that you can't predict the eruption of these teeth. I mean, you can see them on an X-ray, but just seeing them there, you're guessing as to whether they may or not erupt into the mouth. And so, it's unpredictable to some degree. And so, it's hard to determine at an earlier age, say we have a patient that's 12 or 13 years old, and you can see that there's a portion of the tooth developing in the area where the third molar would be. It's hard to predict if in fact they will come into the mouth. Scientists and clinicians have been looking for years to try to make that prediction, so that it could determine advice that you would give to someone to determine when they should come out or if they should come out. And if we were better at predicting whether they would be functional teeth and without disease, then likely we wouldn't have to take out as many. Because before they're fully formed, they're easier to remove.
Bill Klaproth (host): Okay. So then when is it time for them to come out? Or when do we know if they have to come out?
Dr. James Swift: Well, from that perspective, it's dependent upon, again, the things that I already mentioned. We use imaging to try to determine the location of the teeth and how they're developed and if in fact the structures around it are preventing them from erupting. But there's variability, as Stu said earlier. They come in at various different points in time. And so most people start looking as to the potential for eruption around the mid-teen years, trying to see if in fact there's anything else in the way; if the teeth are crowded in some way, shape or form, and there's not going to be enough space, then you can start talking about if in fact you can predict that those teeth will not be functional. And as a result, then you could make a decision to have them removed at that point or later.
Bill Klaproth (host): So, Dr. Lieblich, if someone puts this off, is there something symptomatic where, "Oh God, my mouth hurts. It's time for them to come out." Is that the other telltale sign?
Dr. Stuart Lieblich: That's a great point because once pain develops, sometimes it's too late. So, an example could be if the wisdom tooth is coming in sideways, growing up against the side of the tooth in front of it. That space then gets created where food and bacteria gets caught and creates decay, not only on the wisdom tooth, but on the side of the tooth directly in front of it. And that's typically against the root surface, which is much softer. So, if pain develops in that tooth, usually that tooth is now so compromised, it needs to be extracted as well.
So, we try and make a decision radiographically and on examination from around the age of 15, up through around 25, to determine if it's recommended for the wisdom tooth to come out. But as you asked earlier, we can observe wisdom teeth if we feel they're not going to create problems for the patient. A great test is just to use what's called a probe, a little blunt tip to go behind that molar tooth and see if you can feel the wisdom tooth under the gum. And if you can feel it with a blunt probe, then, you know, the bacteria can get in there and very likely that individual will sustain some infection of the gum around the wisdom tooth called pericoronitis. Interestingly, it often affects people in college age. So, many times they're away from home. And it's difficult for the family to arrange for care, difficult for the person to take time away from the activity. So, again, an ideal way if we could predict the problematic ones, but we have to use our clinical judgment in many cases.
Bill Klaproth (host): And then, Dr. Swift, through consultation, you'll determine, "Okay. We're just going to remove this one or we're going to remove two" or "All four need to come out." Is that right?
Dr. James Swift: Well, it depends upon the condition of all four. I will tell you that in the military, in the U.S. Military, before soldiers are put out to deploy, most services recommend removal of their third molars, Because if they have a challenge with an infection in the field, when they're fighting perhaps, then they create a loss of that presence on the battlefield and there's not accessibility. And so, that's just one way that one entity managed the situation. They don't really wait for them to hurt. The concept of waiting for pain is not realistic. If I say to a patient, "You need to have your wisdom teeth removed," they might say, "Well, why? They don't hurt." Well, the challenge is that if the longer you wait, the more challenging it might be to remove them." In addition, the longer they're subjected to an infectious process, because infections don't always hurt to the point where they can have a fairly aggressive bacteria that's forming around the teeth that they're adjacent to causing significant challenges with those bacteria getting into the bloodstream and going to other places. And so, it's not a matter of doing it when it hurts. It's when it's anticipated that you need to remove it to prevent future disease process.
Bill Klaproth (host): Yeah. Dr. Lieblich?
Dr. Stuart Lieblich: Yeah. And we try and make that decision by age 25, because if we can get the wisdom teeth out prior to that age, the healing potential of the gum and the bone is much better. Whereas, if you wait until they're 25 and later, there's not as good resolution of the healing of the extraction socket or the space where the wisdom tooth was.
Bill Klaproth (host): So, this works great for people to go to the dentist regularly. But for people that don't, that's when you run into the problems. Is all right, Dr. Lieblich?
Dr. Stuart Lieblich: Exactly. And occasionally, they can be fairly significant acute infections that can spread into their throat or down into their neck. Both of our practices and hospital settings do have to occasionally admit patients in fairly serious distress. In significant cases, that can cross and actually block off the airway and create life-threatening complications. So obviously, that's rare, but it is something that we see in our practices all the time.
Bill Klaproth (host): Absolutely. So, when it comes time to take the tooth out, what is involved with that, Dr. Swift?
Dr. James Swift: Well, a determination by the doc as to what needs to be done, how that needs to be approached, there has to be imaging obtained, X-rays, to be able to determine where that tooth is in relationship to adjacent structures and where the incisions may need to be made to remove it. And that really dictates the surgical plan to the surgeon, the oral and maxillofacial surgeon, which typically does this procedure.
Bill Klaproth (host): Right. Dr. Lieblich, you want to add something?
Dr. Stuart Lieblich: Yeah. And then, the conversation will then go with the patient, the doctor, and the family members as to the type of anesthetic, whether it's just local anesthetic, often known as Novocain or perhaps nitrous oxide, laughing gas and Novocain. Many patients, due to complexity the surgery, will have it done with intravenous sedation or anesthesia in the oral and maxillofacial surgeon's office.
Bill Klaproth (host): And then, when we talk about healing from wisdom teeth surgery, how long does that generally take, Dr. Swift?
Dr. James Swift: Bill, it's somewhat dependent upon the difficulty of the surgery and what type of tissue needs to be moved to be able to extract the tooth from its site. I tell my patients that having your third molars out is like having four separate operations in a small space, because they are independent of each other and that typically will generate a desire to have some type of sedation in addition to just the local anesthetic to remove a tooth because we use handpieces or to be able to remove components of the tooth, perhaps sectioning it into two pieces or more or to remove some bone to provide release so that the teeth can be removed.
Bill Klaproth (host): Right. So, let me continue with you, Dr. Swift, or both of you. Are there challenges to this? Do people put this off? "Because I don't want to deal with anesthesia. I don't want to deal with that stuff. So, I'm going to try to put it off." Is that a challenge facing, you know, an OMS?
Dr. James Swift: Most definitely. Because if they get to be older, then the challenge of removal is increased. And it's likely that the surgery is more invasive. And as a result, then, the wound is just larger. And that by itself will create more discomfort.
Bill Klaproth (host): Yeah.
Dr. Stuart Lieblich: And you do have to anticipate three to five days of healing in a typical case of a young adult. And scheduling that at a time electively when they're home from summer break or away from school or other major activities is often beneficial. If you wait until it becomes infected, then many times we have to clear the infection up first perhaps with antibiotics, then have the patient in for the procedure. So, it takes a three to five-day process into a 10- to 12-day process or even longer.
Bill Klaproth (host): So, Dr. Lieblich, since we're doing wisdom teeth FAQs, what question do you get asked the most when it comes to wisdom teeth?
Dr. Stuart Lieblich: Well, the big concerns are pain and swelling. And fortunately, in many of our cases, they're young, healthy individuals that never have had surgery before. So, the anxiety or anxiousness that we have about having an operation is certainly there. Again, the oral and maxillofacial surgeon will spend time to discuss the actual surgical process, the anesthetic plan and what to expect during recovery. There've been great advances with the use of longer acting local anesthetics that can provide, you know, six to eight hours of pain relief afterwards so that the patient go home.
We're also finding that we can avoid opioids and narcotics in many of our patients. And that's certainly a concern. And oral and maxillofacial surgery has really addressed that as part of society issues of opioid abuse. And we're able to now, in most cases, have opioid-free procedures for our patients.
Bill Klaproth (host): Absolutely. What about nausea and vomiting? Is that another question that comes up?
Dr. Stuart Lieblich: Absolutely. And anesthesia in general, that's usually more concerning to patients than pain. They'd rather have pain, than have nausea and vomiting. And one of the medications that we're able to give patients, which reduces swelling, also reduces nausea and vomiting. One of the anesthetic agents that many people are aware of called Propofol is an antiemetic or that reduces the tendency towards nausea. And then, additional agents are available. And that's one other thing that doctor will do, is screen the patients for their risk factors of nausea and vomiting.
Bill Klaproth (host): And again, non-opioid, you're able to prescribe non-opioid medication as well, which I would imagine would be beneficial and people like to hear that. Is that right?
Dr. Stuart Lieblich: They do. And it's a conversation to have. We will oftentimes send in a backup prescription for, say, a small amount of an opioid if need be. We tell the family only to pick that up, if necessary, but this is what we want you to do as far as pain control. And in about 85 percent of our cases, we find that they don't need to pick up the opioids at all.
Bill Klaproth (host): Which is very good news. And Dr. Swift, what is the question you get asked most often?
Dr. James Swift: How long it will take to heal? What do I need to expect during the next few days? What can I do or not do? And, many times they think, "Well, this is just in my mouth. This is just dentistry. So, I don't really need to lay down and recover" and we see patients go out and exercise or do something strenuous, or they have a job that's high risk that they have to have attention to be able to execute what they do. They need to recover, and they need to take time to recover. And when I get a patient that says, "I'm going to go run a marathon tomorrow," I just say, "Well, then, get ready for additional pain and discomfort because that's not going to work." This is a surgery, albeit a minor one. If I told them I would make two cuts in their forearm in each side and drill a hole in the bone, they would probably not do something so crazy. But they think of it as dentistry and they say, "Well, gee, that's no big deal. It's just my teeth. So, why should I worry about that?"
Bill Klaproth (host): Well, you mentioned what they can and cannot do. What can they do and what can't they do?
Dr. James Swift: Well, as far as strenuous exercise, I say stay away from that. And obviously, if opioids or medications, then they should be precluded from operating a motor vehicle or machinery and anything that takes concentration. In some situations, if they feel lightheaded, then they're operating machinery in such a way that could be harmful to other, it's just not a wise thing for them to do normal activity. So, I typically tell my patients that it's going to be at least three or four days before they can recover to a great enough degree to be able to do that. And some of it's dependent upon how they feel. Everyone takes it little bit differently.
Bill Klaproth (host): Right. So, good to set those expectations right upfront. Well, thank you both. This has been a great discussion. Last question before we wrap up. Dr. Swift, I'll start with you. Anything else you want to add when it comes to wisdom teeth and frequently asked questions?
Dr. James Swift: I think that it is an essential procedure for most people. But there is an undertow out there by various different agencies that say that there's not a necessity to remove wisdom teeth, that it is of no value to do it early or prophylactically so that you can prevent problems. I totally disagree with that discussion. Because when we see these individuals at age 50 or 60, and they have an infection around their third molar, at that point in time, the risk of complications is greatly increased. Although there are people that would say that they're not, but the data shows that they are greatly increased. And so, in that particular situation, it's reasonable to do it on the front end and try to anticipate what might happen by doing this earlier when someone's youthful and healthier and not having to deal with other conditions or medical conditions that for which they may be taking medications.
Bill Klaproth (host): Yeah, that makes sense. And Dr. Lieblich, final thoughts from you.
Dr. Stuart Lieblich: Yeah. Kind of echoing what Dr. Swift said, don't wait for it to hurt. That's usually a sign it's too late. See your dentist regularly for your six-month visits. If they make a referral to an oral and maxillofacial surgeon, understanding it's a consultation. The oral surgeon will also look at your exam and your X-rays and help make a combined decision with your other healthcare providers, whether they should be removed or not.
Bill Klaproth (host): Absolutely. Dr. Swift, thank you for being here.
Dr. James Swift: Thank you. My pleasure.
Bill Klaproth (host): And Dr. Lieblich.
Dr. Stuart Lieblich: Thank you, Bill. And a pleasure to be with my esteemed colleague, Dr. Swift. Thank you.
Dr. James Swift: Yes, and same for me, Dr. Lieblich.
Bill Klaproth (host): Absolutely a great discussion. Thank you both. And for more information and the full podcast library, please visit MYOMS.org. And if you found this podcast interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.
Wisdom Teeth FAQs
Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth and with me is Dr. Jim Swift. Dr. Swift, great to see you.
Dr. James Swift: Great to be with you, Bill.
Bill Klaproth (host): Absolutely. And we also have Dr. Stu Lieblich. Dr. Lieblich, great to see you as well.
Dr. Stuart Lieblich: Thanks. Well, great to be here.
Bill Klaproth (host): Thank you both for your time. Looking forward to this. We're going to be talking about wisdom teeth and answering FAQs. So, thank you both for being here again. Dr. Lieblich, let me start with you. So, basic question, what are wisdom teeth and why do people have them?
Dr. Stuart Lieblich: Well, that's always the question. We do also call them third molars. So, we think about the first molar being your six-year molar that comes in; the second, twelve-year molar; and then, the wisdom teeth come in after that.
Interestingly, in most cases now, we don't have quite enough room in our mouths for all the teeth plus the wisdom tooth. And previous times, you know, it may not have been unusual to lose your first molar that came in at six. And perhaps through lack of good dental care, fluoride and all the advances that we have now in dentistry and medicine, now those teeth are maintained. But in the past, those teeth might've been lost. And as the person grew, everything could slide forward. So, teeth will move towards the front of the mouth. So, that's a theory. Hard to prove, but that's our working theory as far as why we have wisdom teeth.
Bill Klaproth (host): Right. And Dr. Lieblich, without the room, then wisdom teeth often get impacted. Is that right?
Dr. Stuart Lieblich: Correct. So, impacted meaning they're stuck, caught under the gum, caught under the bone or some combination thereof. And when they're half in and half out, they can create some significant dental issues and medical issues for our patients.
Bill Klaproth (host): Absolutely. And Dr. Swift, does everyone have wisdom teeth? And when do they generally come in?
Dr. James Swift: Most people have wisdom teeth, but not all of them have all four of them. There's typically two in the upper jaw and two in the lower jaw. The last teeth back on both the upper jaw and the lower jaw. And there's a variability as to when they come in. Some of it's based upon how crowded they are. If in fact there's no space for them to erupt, it may take longer. But what gives the tooth the energy to come into the oral cavity is the development of the tooth roots themselves. And so, as these teeth grow and develop, they create the eruptive force that they have to come into the mouth to be functional.
Bill Klaproth (host): You know, when I think of teeth, I don't often think about eruptive force. Is that right, Dr. Lieblich? You're going to add something.
Dr. Stuart Lieblich: Yeah, exactly. And interestingly about the variability, both my children only had upper wisdom teeth. So, it's variable from one person to another, one family. So, there's a genetic composition. But Jim, I'm sure you've seen in your practice extra wisdom teeth too. So, sometimes people have a fourth molar.
Bill Klaproth (host): Yeah. So, we talked about the wisdom teeth getting impacted. So, I think I kind of know the answer why, but why remove the wisdom teeth? I think it seems kind of obvious, but I'm sure there's probably a real definition on why it's important they come out.
Dr. James Swift: Bill, can I make a point about that?
Bill Klaproth (host): Yeah.
Dr. James Swift: Actually, the wisdom teeth don't get impacted. They're prevented from erupting by the lack of space and that creates the absence of eruption. They don't have anywhere to go. So, the other teeth that are in front of it or perhaps the back part of the jawbone holds them in position and they can't come in because there's not any space for them. And then, you call them impacted at that point in time.
Bill Klaproth (host): Okay. Good distinction. I'm glad you said that. So, there's no room for them to come out. And so then, obviously, that's why we have to have them out. Does everybody always have them out?
Dr. Stuart Lieblich: Not at all. So, the oral surgeon in conjunction with the patient's dentist will evaluate the case based on clinical examination, based on radiographs or X-rays. Typically, the problem we see is when the tooth is kind of half in and half out because the gum tissue won't attach or adhere to the enamel or crown structure of the tooth. So, there's a space between the tooth and the gum where food and bacteria gets caught and creates localized infections.
Bill Klaproth (host): Okay. Got it. So then, Dr. Swift, when it comes to removing wisdom teeth, how long does it generally take?
Dr. James Swift: To relate what Stu just said, the fact is that you can't predict the eruption of these teeth. I mean, you can see them on an X-ray, but just seeing them there, you're guessing as to whether they may or not erupt into the mouth. And so, it's unpredictable to some degree. And so, it's hard to determine at an earlier age, say we have a patient that's 12 or 13 years old, and you can see that there's a portion of the tooth developing in the area where the third molar would be. It's hard to predict if in fact they will come into the mouth. Scientists and clinicians have been looking for years to try to make that prediction, so that it could determine advice that you would give to someone to determine when they should come out or if they should come out. And if we were better at predicting whether they would be functional teeth and without disease, then likely we wouldn't have to take out as many. Because before they're fully formed, they're easier to remove.
Bill Klaproth (host): Okay. So then when is it time for them to come out? Or when do we know if they have to come out?
Dr. James Swift: Well, from that perspective, it's dependent upon, again, the things that I already mentioned. We use imaging to try to determine the location of the teeth and how they're developed and if in fact the structures around it are preventing them from erupting. But there's variability, as Stu said earlier. They come in at various different points in time. And so most people start looking as to the potential for eruption around the mid-teen years, trying to see if in fact there's anything else in the way; if the teeth are crowded in some way, shape or form, and there's not going to be enough space, then you can start talking about if in fact you can predict that those teeth will not be functional. And as a result, then you could make a decision to have them removed at that point or later.
Bill Klaproth (host): So, Dr. Lieblich, if someone puts this off, is there something symptomatic where, "Oh God, my mouth hurts. It's time for them to come out." Is that the other telltale sign?
Dr. Stuart Lieblich: That's a great point because once pain develops, sometimes it's too late. So, an example could be if the wisdom tooth is coming in sideways, growing up against the side of the tooth in front of it. That space then gets created where food and bacteria gets caught and creates decay, not only on the wisdom tooth, but on the side of the tooth directly in front of it. And that's typically against the root surface, which is much softer. So, if pain develops in that tooth, usually that tooth is now so compromised, it needs to be extracted as well.
So, we try and make a decision radiographically and on examination from around the age of 15, up through around 25, to determine if it's recommended for the wisdom tooth to come out. But as you asked earlier, we can observe wisdom teeth if we feel they're not going to create problems for the patient. A great test is just to use what's called a probe, a little blunt tip to go behind that molar tooth and see if you can feel the wisdom tooth under the gum. And if you can feel it with a blunt probe, then, you know, the bacteria can get in there and very likely that individual will sustain some infection of the gum around the wisdom tooth called pericoronitis. Interestingly, it often affects people in college age. So, many times they're away from home. And it's difficult for the family to arrange for care, difficult for the person to take time away from the activity. So, again, an ideal way if we could predict the problematic ones, but we have to use our clinical judgment in many cases.
Bill Klaproth (host): And then, Dr. Swift, through consultation, you'll determine, "Okay. We're just going to remove this one or we're going to remove two" or "All four need to come out." Is that right?
Dr. James Swift: Well, it depends upon the condition of all four. I will tell you that in the military, in the U.S. Military, before soldiers are put out to deploy, most services recommend removal of their third molars, Because if they have a challenge with an infection in the field, when they're fighting perhaps, then they create a loss of that presence on the battlefield and there's not accessibility. And so, that's just one way that one entity managed the situation. They don't really wait for them to hurt. The concept of waiting for pain is not realistic. If I say to a patient, "You need to have your wisdom teeth removed," they might say, "Well, why? They don't hurt." Well, the challenge is that if the longer you wait, the more challenging it might be to remove them." In addition, the longer they're subjected to an infectious process, because infections don't always hurt to the point where they can have a fairly aggressive bacteria that's forming around the teeth that they're adjacent to causing significant challenges with those bacteria getting into the bloodstream and going to other places. And so, it's not a matter of doing it when it hurts. It's when it's anticipated that you need to remove it to prevent future disease process.
Bill Klaproth (host): Yeah. Dr. Lieblich?
Dr. Stuart Lieblich: Yeah. And we try and make that decision by age 25, because if we can get the wisdom teeth out prior to that age, the healing potential of the gum and the bone is much better. Whereas, if you wait until they're 25 and later, there's not as good resolution of the healing of the extraction socket or the space where the wisdom tooth was.
Bill Klaproth (host): So, this works great for people to go to the dentist regularly. But for people that don't, that's when you run into the problems. Is all right, Dr. Lieblich?
Dr. Stuart Lieblich: Exactly. And occasionally, they can be fairly significant acute infections that can spread into their throat or down into their neck. Both of our practices and hospital settings do have to occasionally admit patients in fairly serious distress. In significant cases, that can cross and actually block off the airway and create life-threatening complications. So obviously, that's rare, but it is something that we see in our practices all the time.
Bill Klaproth (host): Absolutely. So, when it comes time to take the tooth out, what is involved with that, Dr. Swift?
Dr. James Swift: Well, a determination by the doc as to what needs to be done, how that needs to be approached, there has to be imaging obtained, X-rays, to be able to determine where that tooth is in relationship to adjacent structures and where the incisions may need to be made to remove it. And that really dictates the surgical plan to the surgeon, the oral and maxillofacial surgeon, which typically does this procedure.
Bill Klaproth (host): Right. Dr. Lieblich, you want to add something?
Dr. Stuart Lieblich: Yeah. And then, the conversation will then go with the patient, the doctor, and the family members as to the type of anesthetic, whether it's just local anesthetic, often known as Novocain or perhaps nitrous oxide, laughing gas and Novocain. Many patients, due to complexity the surgery, will have it done with intravenous sedation or anesthesia in the oral and maxillofacial surgeon's office.
Bill Klaproth (host): And then, when we talk about healing from wisdom teeth surgery, how long does that generally take, Dr. Swift?
Dr. James Swift: Bill, it's somewhat dependent upon the difficulty of the surgery and what type of tissue needs to be moved to be able to extract the tooth from its site. I tell my patients that having your third molars out is like having four separate operations in a small space, because they are independent of each other and that typically will generate a desire to have some type of sedation in addition to just the local anesthetic to remove a tooth because we use handpieces or to be able to remove components of the tooth, perhaps sectioning it into two pieces or more or to remove some bone to provide release so that the teeth can be removed.
Bill Klaproth (host): Right. So, let me continue with you, Dr. Swift, or both of you. Are there challenges to this? Do people put this off? "Because I don't want to deal with anesthesia. I don't want to deal with that stuff. So, I'm going to try to put it off." Is that a challenge facing, you know, an OMS?
Dr. James Swift: Most definitely. Because if they get to be older, then the challenge of removal is increased. And it's likely that the surgery is more invasive. And as a result, then, the wound is just larger. And that by itself will create more discomfort.
Bill Klaproth (host): Yeah.
Dr. Stuart Lieblich: And you do have to anticipate three to five days of healing in a typical case of a young adult. And scheduling that at a time electively when they're home from summer break or away from school or other major activities is often beneficial. If you wait until it becomes infected, then many times we have to clear the infection up first perhaps with antibiotics, then have the patient in for the procedure. So, it takes a three to five-day process into a 10- to 12-day process or even longer.
Bill Klaproth (host): So, Dr. Lieblich, since we're doing wisdom teeth FAQs, what question do you get asked the most when it comes to wisdom teeth?
Dr. Stuart Lieblich: Well, the big concerns are pain and swelling. And fortunately, in many of our cases, they're young, healthy individuals that never have had surgery before. So, the anxiety or anxiousness that we have about having an operation is certainly there. Again, the oral and maxillofacial surgeon will spend time to discuss the actual surgical process, the anesthetic plan and what to expect during recovery. There've been great advances with the use of longer acting local anesthetics that can provide, you know, six to eight hours of pain relief afterwards so that the patient go home.
We're also finding that we can avoid opioids and narcotics in many of our patients. And that's certainly a concern. And oral and maxillofacial surgery has really addressed that as part of society issues of opioid abuse. And we're able to now, in most cases, have opioid-free procedures for our patients.
Bill Klaproth (host): Absolutely. What about nausea and vomiting? Is that another question that comes up?
Dr. Stuart Lieblich: Absolutely. And anesthesia in general, that's usually more concerning to patients than pain. They'd rather have pain, than have nausea and vomiting. And one of the medications that we're able to give patients, which reduces swelling, also reduces nausea and vomiting. One of the anesthetic agents that many people are aware of called Propofol is an antiemetic or that reduces the tendency towards nausea. And then, additional agents are available. And that's one other thing that doctor will do, is screen the patients for their risk factors of nausea and vomiting.
Bill Klaproth (host): And again, non-opioid, you're able to prescribe non-opioid medication as well, which I would imagine would be beneficial and people like to hear that. Is that right?
Dr. Stuart Lieblich: They do. And it's a conversation to have. We will oftentimes send in a backup prescription for, say, a small amount of an opioid if need be. We tell the family only to pick that up, if necessary, but this is what we want you to do as far as pain control. And in about 85 percent of our cases, we find that they don't need to pick up the opioids at all.
Bill Klaproth (host): Which is very good news. And Dr. Swift, what is the question you get asked most often?
Dr. James Swift: How long it will take to heal? What do I need to expect during the next few days? What can I do or not do? And, many times they think, "Well, this is just in my mouth. This is just dentistry. So, I don't really need to lay down and recover" and we see patients go out and exercise or do something strenuous, or they have a job that's high risk that they have to have attention to be able to execute what they do. They need to recover, and they need to take time to recover. And when I get a patient that says, "I'm going to go run a marathon tomorrow," I just say, "Well, then, get ready for additional pain and discomfort because that's not going to work." This is a surgery, albeit a minor one. If I told them I would make two cuts in their forearm in each side and drill a hole in the bone, they would probably not do something so crazy. But they think of it as dentistry and they say, "Well, gee, that's no big deal. It's just my teeth. So, why should I worry about that?"
Bill Klaproth (host): Well, you mentioned what they can and cannot do. What can they do and what can't they do?
Dr. James Swift: Well, as far as strenuous exercise, I say stay away from that. And obviously, if opioids or medications, then they should be precluded from operating a motor vehicle or machinery and anything that takes concentration. In some situations, if they feel lightheaded, then they're operating machinery in such a way that could be harmful to other, it's just not a wise thing for them to do normal activity. So, I typically tell my patients that it's going to be at least three or four days before they can recover to a great enough degree to be able to do that. And some of it's dependent upon how they feel. Everyone takes it little bit differently.
Bill Klaproth (host): Right. So, good to set those expectations right upfront. Well, thank you both. This has been a great discussion. Last question before we wrap up. Dr. Swift, I'll start with you. Anything else you want to add when it comes to wisdom teeth and frequently asked questions?
Dr. James Swift: I think that it is an essential procedure for most people. But there is an undertow out there by various different agencies that say that there's not a necessity to remove wisdom teeth, that it is of no value to do it early or prophylactically so that you can prevent problems. I totally disagree with that discussion. Because when we see these individuals at age 50 or 60, and they have an infection around their third molar, at that point in time, the risk of complications is greatly increased. Although there are people that would say that they're not, but the data shows that they are greatly increased. And so, in that particular situation, it's reasonable to do it on the front end and try to anticipate what might happen by doing this earlier when someone's youthful and healthier and not having to deal with other conditions or medical conditions that for which they may be taking medications.
Bill Klaproth (host): Yeah, that makes sense. And Dr. Lieblich, final thoughts from you.
Dr. Stuart Lieblich: Yeah. Kind of echoing what Dr. Swift said, don't wait for it to hurt. That's usually a sign it's too late. See your dentist regularly for your six-month visits. If they make a referral to an oral and maxillofacial surgeon, understanding it's a consultation. The oral surgeon will also look at your exam and your X-rays and help make a combined decision with your other healthcare providers, whether they should be removed or not.
Bill Klaproth (host): Absolutely. Dr. Swift, thank you for being here.
Dr. James Swift: Thank you. My pleasure.
Bill Klaproth (host): And Dr. Lieblich.
Dr. Stuart Lieblich: Thank you, Bill. And a pleasure to be with my esteemed colleague, Dr. Swift. Thank you.
Dr. James Swift: Yes, and same for me, Dr. Lieblich.
Bill Klaproth (host): Absolutely a great discussion. Thank you both. And for more information and the full podcast library, please visit MYOMS.org. And if you found this podcast interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.