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Problems with erupting wisdom teeth: Signs, symptoms, and management

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Many patients, in particular those with a fear of dentistry, or fear of the possible cost of dental treatment, consult their GP when they develop a dental problem, in particular dental pain.1 A very common cause of dental pain is erupting wisdom teeth. This article presents and describes the management of painful and infected erupting wisdom teeth. Wisdom teeth or third molars (M3s) are the last, most posteriorly placed permanent teeth to erupt. They usually erupt into the mouth between 17 and 25 years of age. They can, however, erupt many years later. Most adults have four M3s; however, 8% of the UK population have missing or no M3s.2 Mandibular M3s often get impacted in a partially erupted, non-functional position (Figure 1). Eighty per cent of M3s require extraction before 70 years of age. National Institute for Health and Care Excellence (NICE) guidance has discouraged interceptive extraction resulting in later morbidity in many patients.3 Figure 1. Radiograph showing a full set of 32 permanent teeth. In three quadrants, the third permanent molars (M3s) have erupted into a normal position. The lower right M3 (circled) became impacted into the adjacent second permanent molar tooth, which, as a consequence, has …
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Problems with erupting wisdom teeth:
signs, symptoms, and management
Tara Renton and Nairn H F Wilson
Clinical Intelligence
British Journal of General Practice, August 2016 e606
INTRODUCTION
Many patients, in particular those with a fear
of dentistry, or fear of the possible cost of
dental treatment, consult their GP when they
develop a dental problem, in particular dental
pain.1 A very common cause of dental pain is
erupting wisdom teeth. This article presents
and describes the management of painful
and infected erupting wisdom teeth.
WISDOM TEETH
Wisdom teeth or third molars (M3s) are the
last, most posteriorly placed permanent
teeth to erupt. They usually erupt into the
mouth between 17 and 25 years of age.
They can, however, erupt many years later.
Most adults have four M3s; however, 8%
of the UK population have missing or no
M3s.2 Mandibular M3s often get impacted in
a partially erupted, non-functional position
(Figure 1). Eighty per cent of M3s require
extraction before 70 years of age. National
Institute for Health and Care Excellence
(NICE) guidance has discouraged interceptive
extraction resulting in later morbidity in many
patients.3
PERICORONITIS
Pericoronitis — inflammation and infection
of the soft tissues around a partially erupted
tooth (Figure 2) — is often associated with
impacted M3s. Other associated conditions
include dental caries (Figure 1), resorption of
the roots of the adjacent tooth (Figure 1), and
rarely cyst formation and tumours.
The prevalence of pericoronitis is
reported to be 81% in the 20–29 year age
group. The general health of the patient is
not a predisposing factor, other than upper
respiratory tract infection, which precedes
the occurrence of pericoronitis in 43% of
cases. Several studies have shown that the
microflora of pericoronitis is predominantly
anaerobic, including streptococci,
Actinomyces
, and
Propionibacterium
.2
MANAGEMENT OF PERICORONITIS TYPES
Acute pericoronitis is usually a single
event of relatively short duration (3–4 days)
associated with normal eruption. Improved
local oral hygiene by toothbrushing with
toothpaste, interdental cleaning, or the use
of a chlorhexidine-containing mouthwash
can reverse the symptoms. Paracetamol
or ibuprofen may be prescribed to relieve
the pain. Analgesic tablets should always
be swallowed. Under no circumstances
should analgesic tablets be placed adjacent
to the pericoronitis; a relatively common,
ill-informed mistake by patients. If the
pain persists for more than 3–4 days, or
intensifies, a dentist should be consulted. If
the symptoms persist extraction of the tooth
is recommended.2
Acute spreading pericoronitis is an acute
spreading infection, often stemming from a
recurrence of acute pericoronitis. Surgical
removal of the erupting M3 is preferred to
the prescription of antibiotics. Antibiotics
should only be prescribed when immediate
surgical removal is impossible; for example,
when there is associated trismus, or systemic
infection with lymphadenopathy and pyrexia,
possibly requiring hospitalisation. When
antibiotics are indicated, Faculty of General
Dental Practice (UK) guidance for pericoronitis
recommends metronadizole 200 mg TDS
for 3 days plus tooth removal.3 Spread of
infection into local tissue spaces (Figure 3a
and 3b) can cause significant morbidity. Such
spread of infection, in particular if it involves
the upper respiratory tract, requires referral
for immediate care.
Chronic recurrent pericoronitis presents
with relatively mild episodes of recurrent
infection and pain associated with an erupting
M3. The preferred treatment is early extraction
of the M3, rather than the prescription of
analgesics, let alone antibiotics.4 Improved
oral hygiene and the use of an antimicrobial
mouthwash are at best palliative.
Failure to treat chronic recurrent
pericoronitis by means of extraction may lead
to dental caries and possible subsequent
abscess formation in the adjacent second
molar tooth (M2) (Figure 1). This situation
Tara Renton, PhD, FRACDS(OMS), professor of
oral surgery; Nairn HF Wilson, PhD, MSc, FDS,
FFGDP, FFD, DRD, professor of dentistry, King’s
College London Dental Institute, King’s College
London, London, UK.
Address for correspondence
King’s College London Dental Institute,
King’s College London,Denmark Hill, London
SE5 9RS, UK.
E-mail: nairn.wilson@btinternet.com
Submitted: 15 February 2016; final acceptance:
30 March 2016.
©British Journal of General Practice 2016
This is the full-length article (published online
29 Jul 2016) of an abridged version published in
print. Cite this article as: Br J Gen Pract 2016;
DOI: 10.3399/bjgp16X686509
may result in the need to extract both the
affected teeth.
EXTRACTION AND POSTOPERATIVE
PROBLEMS
Current NICE guidelines2 advocate no
prophylactic surgery; however, it is widely
considered to be indicated in patients with
planned medical procedures including
transplant and heart valve surgery, chemo-,
and radiotherapy, in particular radiotherapy
of the jaws, and the prescription of
bisphosphonates or other bone resorption
modifiers. Prophylactic surgery may be
indicated also in individuals such as armed
forces personnel who may experience
periods of limited access to dental services.
Because M3s are often largely contained
in bone, surgical extraction, including the
removal of some bone, is normally required.
Postoperatively, paracetamol or ibuprofen
pain relief is typically indicated.
The risks of M3 extraction (<5%)
include postoperative infection or a painful
dry socket and temporary or permanent
sensory neuropathy of the lingual (tongue)
and inferior alveolar (lip) nerves (0.1–2%).
Individuals presenting with any of these
problems should be encouraged to return
to their dentist for reassurance, irrigation of
the socket, and analgesia. No antibiotics are
required for this condition.
In summary, pericoronitis associated
with an erupting wisdom tooth is common.
The preferred management is patient
reassurance, improved oral hygiene,
adjunctive mouthwash, analgesia and
referral. If an individual presents with
swollen face, lymphadenopathy, trismus,
together with additional signs of spreading
systemic infection, including pyrexia, difficulty
swallowing, or airway impingement, an
urgent referral is required for immediate
extraction, drainage of infection, and, if
required, parenteral antibiotics if tooth
extraction is delayed or pus drainage is
incomplete.
Patient consent
The patient consented to the publication of
these images.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing
interests.
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Figure 1. Radiograph showing a full set of 32 permanent teeth. In three quadrants, the third permanent molars
(M3s) have erupted into a normal position. The lower right M3 (circled) became impacted into the adjacent second
permanent molar tooth, which, as a consequence, has suffered extensive dental caries (the radiolucent area in the
crown of the tooth) resulting in a dental abscess (the radiolucent area around the apices of the roots of the tooth).
Figure 2. Clinical picture and cartoon of infection in the soft tissues overlying a partially erupted lower right M3,
better known as pericoronitis. The white patches in the clinical picture are ‘scarring’ caused by trauma from the
opposing, fully erupted upper left M3.
Figure 3. Left: clinical picture of a patient presenting with acute spreading infection, stemming from a right
mandibular M3 pericoronitis. Given the risk of significant morbidity, this patient requires referral to an oral-
maxillofacial surgeon for urgent care. Right: illustrates potential tissue spaces where infection can spread from
an M3 pericoronitis.
e607 British Journal of General Practice, August 2016
REFERENCES
1. Renton T, Wilson NH. Understanding and
managing dental and orofacial pain in
general practice.
Br J Gen Pract
2016; DOI:
10.3399/bjgp16X684901.
2. National Institute for Health and Care
Excellence.
Guidance on the extraction of
wisdom teeth
.
TA1.
London: NICE, 2000.
https://www.nice.org.uk/guidance/ta1
(accessed 24 Jun 2016).
3. Faculty of Dental Surgery, Royal College of
Surgeons of England.
The management of
patients with third molar (syn: wisdom) teeth
.
London: FDS, 1997. https://www.rcseng.
ac.uk/fds/publications-clinical-guidelines/
clinical_guidelines/documents/3rdmolar.pdf
(accessed 1 Jul 2016).
4. Pogrel MA. What are the risks of operative
intervention?
J Oral Maxillofac Surg
, 2012;
70(9 Suppl 1): S33–S36.
British Journal of General Practice, August 2016 e608
... (95% confidence interval [95% CI]: 18.97% to 30.80% based on a systematic review and meta-analysis [3]. Despite usual eruption of mandibular third molars at ages ranging from 16 to 24-years, could be partially or completely impacted according to literature [5]. Consequently, pathological changes comprising infection, pain, caries and root resorption could occur indicating surgical removal of mandibular third molars [4]. ...
... Consequently, pathological changes comprising infection, pain, caries and root resorption could occur indicating surgical removal of mandibular third molars [4]. Therefore, majority of patients accessing Oral & Maxillofacial Surgery practices for wisdom tooth surgeries across the globe comprise of late adolescents and young adults [5]. However, symptomatic impacted mandibular third molars could bother middle aged adults as well [6]. ...
... Postoperative swelling denotes a common complication of third molar surgeries having biological and social impact [5,22]. Therefore, prediction of postoperative facial swelling subsequent to mandibular third molar extractions received attention of researchers. ...
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Background: Mandibular third molar surgeries garnered recognition as one of the common treatment procedures provided by Oral & Maxillofacial practices across the globe. Mandibular third molars are not only impacted, often giving rise to bothering issues to patients ranging from pain to difficulty in opening mouth but create challenges in their surgical removal. Postoperative complications of those surgeries such as pain, swelling, trismus and alveolar osteitis (dry socket) could be prevented and controlled by meticulous preoperative assessment of tooth-related and patient-related factors. Pattern of root morphology could be one important tooth-related factor connected to difficulties and subsequent postoperative complications of mandibular third molar surgeries. Aim: Against this backdrop, the aim of this study was to explore the patterns of root morphology of mandibular third molars and to elucidate their associations with selected attributes of the surgeries, self-reported preoperative pain and selected postoperative complications among a cohort of Sri Lankan patients. Materials & Methods: A hospital based, descriptive cross-sectional study was conducted among 715 patients (represented wider age range from adolescents to older adults) who underwent surgical removal of mandibular third molars at the Lanka. Of extensive socio-demographic, clinical and radiological investigation data collected, those data on root morphology and numbers of roots, inferior dental canal relationship, self-reported preoperative pain, duration of the surgery, flap design, tooth sectioning and postoperative pain and swelling complications were used for the present analysis. Data entry and analysis was done using SPSS-21 Statistical Software Package. Results: Based on our findings on patterns of root morphology, straight two roots were the most common (34.4%) across all age groups, followed by convergent two-roots (19.3%) fused straight-roots (16.3%) and distally curved two-roots (13.8) among Sri Lankan patients. Almost half (46.8%), of patients had inferior dental nerve canal placed away from mandibular third molar roots. Moreover, root morphology was significantly associated with presence of preoperative pain, duration of the surgery as well as occurrence of postoperative swelling (p<0.05). Conclusions: Patterns of root morphology of mandibular third molars may implicate on certain processes of their surgical removal and its outcomes. Therefore, careful preoperative assessment of root morphology and related factors of those teeth becomes useful in tailored patient care for minimal postoperative complications, better patient experience and quality-of-life.
... Pericoronitis is usually treated by extraction the partially-impacted tooth, which leads in the condition being completely resolved [2] . Pericoronitis that isn't infected normally doesn't require antibiotic treatment [4] . ...
... While using a population-based rather than clinical design has natural advantages, it also has the disadvantage that the data were self-reported and will include both over-and under-reporting of outcomes. To try and reduce error from recall bias, data was collected at age 23, which is likely to be near the peak age for wisdom tooth problems 46 . To minimize error, the question stems needed to be simple, and this means the questions did not attempt to distinguish between different types of non-surgical treatment such as analgesic advice, mechanical cleaning of the operculum or removal of the operculum. ...
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