# Presentation: 557065

## Considerations in the Treatment of Third Molars Emerson Robinson, DDS, MPHRegional Dental Consultant Regions II & VJob Corps National Health and Wellness ConferenceApril 25, 2007Denver, Colorado

## What is an Impacted Tooth?

- When a tooth develops it travels to its appropriate position in the arch. If the path to eruption through the gum is prevented due to the size of the jaw, the tooth will become partially or totally blocked (IMPACTED).

## Slide 3

## What are Wisdom Teeth?

- Third molars or your wisdom teeth will appear during the late teens or early twenties – supposedly the onset of the “age of wisdom” hence the name.
- Complications arise because our jaw is normally equipped to handle 28 teeth and not the additional four – two in the upper jaw, and two in the lower.
- They are the last teeth to come in and the least needed for good oral health.

## Slide 5

## What are Wisdom Teeth?

- Most often, they are impacted, or trapped in the jawbone and gums. Usually there is not enough room for them in your mouth.
- They cause more problems than any other tooth in the mouth.
- They will either partially break the gum tissue and grow in crooked or remain underneath the gum.
- In 9 out of 10 people, at least one tooth remains underneath the gum – referred to as an impacted tooth.

## Slide 7

## Common Signs of Wisdom Teeth Problems

- Swelling
- Infection
- Headaches
- Earaches
- Restricted mouth openings

## Slide 9

## How Serious is an Impacted Tooth?

- Serious problems, such as infection and possible crowding of and damage to adjacent teeth, can develop from partially blocked teeth.
- More serious complications can develop when the sac that surrounds the impacted tooth fills with fluid and enlarges to form a cyst, causing an enlargement that hollows out the jaw and can cause permanent damage to an adjacent tooth, jawbone, and nerves.

## Slide 11

## Must the Tooth Come Out if it Hasn’t Caused any Problems Yet?

- No one can tell you when your impacted molar will cause trouble, but trouble will probably arise in the future. When it does, the circumstances can be much more painful and the teeth can be more complicated to treat.

## Slide 13

## Types of Impacted Third Molars

- Impacted Third Molars can be classified as:
- Symptomatic – the patient is obviously experiencing acute pain and needs immediate treatment.
- Asymptomatic – patient is not experiencing any problems, may have been made aware that they have impacted teeth.

## Slide 15

## Management of Symptomatic or Asymptomatic Third Molars

- There is no clearly defined consensus on how to manage compromised third molars.
- Third molars may be in a variety of partially or completely unerupted states, ranging from soft tissue impactions to full bony impactions.
- General agreement exists that removal is appropriate in case of symptoms of pain or pathological conditions.

## Slide 17

## Management of Symptomatic or Asymptomatic Third Molars

- Controversy exists with regard to the prophylactic removal of asymptomatic or disease-free impacted third molars.
- There is no evidence to support or refute routine prophylactic removal of asymptomatic impacted third molars in adults.
- However, there is some reliable evidence that the prophylactic removal of impacted third molars in adolescents to result or prevent late anterior crowding cannot be justified.

## Slide 19

## When Should Impacted Teeth be Removed?

- The key is periodic x-rays of the third molar areas.
- With these pictures, the dentist can frequently predict if the third molars are going to cause problems, either in the near future or later in life.
- If so, the dentist will recommend their removal rather than wait for trouble to occur.
- Removal is easier in younger patients. Roots are not yet fully developed and the bone is less dense.
- In older patients, removal before complications develop is key to shorter recovery and healing time and minimizing discomfort after surgery.

## Slide 21

## Pericoronitis

- Pericoronitis is a dental disorder in which the gum tissue around the molar teeth become swollen and infected.
- Pericoronitis can develop when third molars only partially erupt (break through the gum) which allows an opening for bacteria to enter around the tooth and cause an infection.
- Food or plaque (a bacterial film that remains on the teeth after eating) may get caught underneath a flap of gum tissue around the tooth.

## Slide 23

## Pericoronitis

- Pericoronitis is most common in teens and young adults, and can cause severe pain and swelling.
- In severe cases, pericoronitis can cause intense pain, fever, an increase in the number of white blood cells, and overall fatigue.
- The infection is capable of spreading into surrounding tissue resulting in cellulitis.
- Cellulitis is a very serious, often life-threatening infection that must be treated quickly to prevent further spread of the infection and possible swelling of the airway.

## Slide 25

## Slide 26

## Deciding Whether to Authorize Specialized Care

*Four factors will influence decisions for approval of services:*
- Priority rankings of other students
- Likelihood that the special treatment will enhance employability
- Cost
- Scope of the procedure - some oral care is to complex
- Examples of procedures that are too expensive or complex including "routine extraction of symptomatic impacted third molars, general anesthesia for exodontia, and use of nitrous oxide."