The wisdom tooth dilemma: to extract or not to extract?

Wisdom teeth are the last teeth to arrive, usually between the late teens and mid-twenties. They are also the teeth most likely to cause trouble — largely because the modern jaw frequently has no room left for them by the time they turn up.

The question is not whether wisdom teeth are a problem in general. It is whether yours are.

This page is about making that decision. For the clinical detail — types of impaction, what the procedure involves, recovery — see signs you may need your wisdom teeth removed.

What can go wrong

Impaction. The tooth has no room to erupt and stays partly or completely trapped in the bone or under the gum. Impacted teeth can push against the second molars, damaging them, and can occasionally form cysts.

Partial eruption. Arguably the worst outcome, because it creates a flap of gum over part of the tooth that traps food and bacteria and cannot be cleaned. This causes pericoronitis — recurring infection, swelling, difficulty opening and a bad taste — which tends to recur.

Decay. Wisdom teeth sit at the very back where brushing is awkward, so both the wisdom tooth and the second molar in front of it are at raised risk. Decay on the back of a second molar caused by a wisdom tooth is a common and avoidable loss.

Crowding. Often blamed for front teeth becoming crooked, though the evidence for wisdom teeth being the cause of late crowding is weaker than commonly assumed.

When removal is usually recommended

• Recurrent pericoronitis — repeated infection around a partly erupted tooth
• Decay in the wisdom tooth, or in the second molar because of it, that cannot be restored
• Damage to the adjacent tooth from the angle of impaction
• Cyst or pathology identified on a radiograph
• Gum disease localised around the tooth that cannot be controlled

When it is not

This is the part worth stating clearly, because attitudes have shifted.

A wisdom tooth that is fully erupted, functional, cleanable and causing no problems does not automatically need removing. Nor does an impacted tooth that is completely buried, symptom-free and not causing pathology — monitoring is often the appropriate course.

Routine removal of every wisdom tooth simply because it exists is no longer standard practice. Surgery carries risk; leaving a healthy asymptomatic tooth alone does not.

Some people also never develop wisdom teeth at all, which is entirely normal.

The decision, in short

Notice that two of the strongest arguments for removal are about protecting the second molar rather than the wisdom tooth itself. That tooth does real work; the wisdom tooth often does not.

What "monitoring" actually means

If the recommendation is to leave them, that is an active plan rather than a shrug, and it should look like this:

• Looked at every check-up — the gum around a partly erupted tooth, and whether food is packing behind the second molar
• A radiograph at intervals — often an OPG every few years, to check the angle, the second molar, and that no cyst is developing
• A record of symptoms. Tell us about every episode of soreness, even one that settled by itself. Two episodes in a year change the picture
• A clear trigger. Ask what would make the answer change, so you know what you are watching for

Monitoring is not the same as forgetting. If nobody has looked at yours on a radiograph in a decade, that is worth raising.

What to ask before you consent

The single most useful thing you can do, and every one of these is a fair question:

1. Which specific tooth, and what exactly is wrong with it?
2. What happens if I do nothing? Including how likely, and how soon
3. Can I see the radiograph? And where does the nerve sit relative to the roots
4. What are the risks for my anatomy, not risks in general
5. Is this straightforward here, or should it be a specialist?
6. All four, or one at a time?
7. What will it cost, with item numbers, and what will my fund pay
8. How long will I need off work?
9. Is there a reason to do it now rather than in two years?

A practitioner who welcomes those questions is giving you a better sign than any answer to them.

The risks, stated plainly

Any surgical procedure carries risk, and you should hear these before consenting rather than after:

• Swelling, bruising and limited opening for several days — expected rather than a complication
• Dry socket, where the clot is lost and the site becomes painful several days later
• Infection
• Nerve involvement. Lower wisdom teeth can sit close to the nerve supplying sensation to the lip, chin and tongue. Altered sensation is usually temporary, but can occasionally be prolonged or permanent. A radiograph is taken specifically to assess this relationship, and it is a key reason some cases are referred to an oral and maxillofacial surgeon.
• Sinus involvement, for upper wisdom teeth sitting close to the sinus floor

Before proceeding you should seek a second opinion from an appropriately qualified health practitioner if you want one.

A coronectomy — removing the crown and deliberately leaving the roots where they lie against the nerve — is an established option in selected high-risk lower cases. It trades a small chance of needing further treatment later for a lower risk of nerve injury now. It is a specialist decision, and worth knowing it exists.

What the procedure and recovery actually involve

Most removals here are done under local anaesthetic — you are awake and the area is numb. You will feel firm pressure and hear sounds conducted through the bones of your skull, which are louder to you than to anyone else in the room. Pressure is normal; sharpness is not, and more anaesthetic can be given.

A surgical removal usually involves a small incision, sometimes removing a little bone, and often sectioning the tooth so each root comes out along its own path. Sectioning is routine and gentler on the surrounding bone than forcing a multi-rooted tooth out whole. Dissolving stitches typically disappear within one to two weeks.

Contact us if bleeding will not settle with firm pressure, pain worsens sharply after day three (often dry socket), swelling increases rather than decreases after day three, or you develop a fever. Go to a hospital emergency department for spreading facial swelling, or difficulty breathing or swallowing.

Do not smoke. It substantially raises the risk of dry socket and slows healing.

Most people need the day itself and take it easy for two to three days, avoiding heavy lifting and exercise. Plan around exams, weddings and travel rather than hoping.

Preparing for the day

• Eat beforehand, unless you have been told otherwise for sedation or a general anaesthetic
• Arrange a lift if you are having anything beyond local anaesthetic
• Stock soft food — yoghurt, soup (not hot), scrambled egg, mashed potato, smoothies eaten with a spoon rather than a straw
• Have gauze, a cold pack and pain relief in the house before you go
• Clear two or three days of anything strenuous
• Tell us your medications, particularly blood thinners, bisphosphonates or denosumab, and anything for diabetes or immune conditions. Do not stop anything yourself
• Tell us if you are pregnant, or might be

What it costs

Fees depend on how straightforward the tooth is — a fully erupted upper wisdom tooth and a horizontally impacted lower one are very different procedures, and they carry different item numbers.

You will be given a written quote with item numbers before anything is booked. Most extras policies contribute under major dental, subject to waiting periods and annual limits; a hospital case under general anaesthetic adds separate hospital and anaesthetist fees, which are worth checking with your fund before you commit. See private health insurance.

If cost is the constraint, say so. Staging treatment, or doing the tooth that is actually causing trouble and monitoring the rest, is often a legitimate plan.

Assessment at Victorian Dental Group

We offer comprehensive examination and assessment of wisdom teeth, including on-site OPG imaging — so the X-ray happens during your appointment rather than at a separate radiography centre.

The radiograph shows the position and angle of each tooth, how much room there is, the relationship to the nerve, and whether the adjacent teeth are being affected. From there your practitioner will explain whether removal is indicated, whether monitoring is reasonable, and what the specific risks are for your anatomy.

In many cases wisdom teeth can be removed under local anaesthetic at the clinic. Complex cases — deep impactions, close nerve proximity, or where general anaesthetic is preferable — are referred to an oral and maxillofacial surgeon. We are a general dental practice and hold no specialist registration.

Timing

Where removal is indicated, it is generally more straightforward in younger patients, because roots are less fully formed and bone is less dense. That is a reason to have them assessed in the late teens — not a reason to remove them automatically.

Two timing considerations that come up often:

Before orthodontic treatment. Sometimes the orthodontist wants them out as part of the plan; often they do not. This should be a coordinated decision rather than two practitioners each assuming the other has it covered.

Before pregnancy, or before travel. Elective removal is better done when there is time to recover and access to care. A wisdom tooth with a history of infection is not a good thing to take on a long trip.

Questions we are asked

Do all four have to come out at once? No. Sometimes all four are done together, sometimes one side at a time so you can chew on the other. It depends on the case and on what you would prefer.

Will removing them stop my front teeth crowding? The evidence for wisdom teeth causing late crowding is weaker than the folklore suggests. It is not on its own a good reason to remove them.

Do I need a general anaesthetic? Usually not. Where it is appropriate, it is done in a hospital or a facility set up for it, and we refer.

Can I drive afterwards? After local anaesthetic, yes. After sedation or general anaesthetic, no — arrange a lift.

What if I just leave them? For a symptom-free, cleanable tooth, often nothing happens and monitoring is reasonable. For a partly erupted one with a gum flap, infection tends to recur. Your practitioner will tell you which you have.

Does the gap need filling afterwards? No. A wisdom tooth is not replaced.

I am 45 and mine have never bothered me. Then the case for removing them is weak. Have them looked at on a radiograph; if there is no pathology, monitoring is usually right.

Someone told me they should all come out before I turn 25. That was the prevailing approach a generation ago. Current practice is to remove teeth that have a problem or a clear trajectory towards one, not teeth that merely exist.

Can I have them out while pregnant? Urgent treatment, yes, whenever it is needed. Elective removal is usually deferred.

Book an assessment

Victorian Dental Group — 291 Wattletree Road, Malvern East VIC 3145

Phone (03) 9088 5808 · book online at any hour. See also dental surgery and wisdom teeth.

This page is general information and does not replace advice from a registered dental practitioner. Any surgical or invasive procedure carries risks. Please see our Disclaimer.