When should i have my wisdom teeth removed

Wisdom teeth, also known as third molars, are the last set of permanent teeth to erupt, usually between the ages of 18 and 21. Although known as the “wisdom teeth”, these teeth are unfortunately not very smart; because of their tendency to grow in the wrong direction, they become impacted and cause a lot of problems in the process.

In recent years, it has been observed that more and more young adults are presenting with at least one impacted wisdom tooth, and although the exact cause is not known, it has been speculated that our modern diet has resulted in smaller jaws which cannot accommodate all our teeth. Consequently, the wisdom teeth do not have enough space to erupt properly and will become impacted. In Singapore, one study showed that almost 70% young adults between the ages of 20 and 40 have at least one impacted wisdom tooth1.

Types of Wisdom Teeth Impaction

Problems of Impacted Wisdom Teeth

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  Food trapping and difficulty in cleaning.
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  Bad breath.
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  Gum pain and infection.
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  In severe cases, facial swelling or swelling of the throat (potentially life-threatening condition known as Ludwig’s angina).
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  Decay and subsequently pain. The decay can form on the wisdom tooth itself, the tooth next to it (second molar), or both.
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  Cheek biting and ulcer formation.
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  Resorption of the second molar.
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  Cyst formation.

Partially-erupted wisdom tooth with an inflammed gum flap, known as pericoronitis.

Decayed impacted wisdom tooth.

An X-ray of an impacted wisdom tooth causing a large decay (which appears darker) on the second molar, highlighted by the red circle.

This X-ray of our patient shows a root resorption of the second molar, as outlined in red, which was caused by an impacted wisdom tooth.

An X-ray image of another patient, showing severe resorption of the second molar. The second molar cannot be saved and has to be removed together with the offending wisdom tooth.

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To Remove or Not To Remove? That Is the Question

It’s always best to see a dentist for an examination first before deciding if your wisdom teeth need removal. Radiographs or X-rays are also necessary as sometimes the wisdom teeth lie just beneath the gums and cannot be seen in the mouth.

The panoramic radiograph above shows a patient with 4 wisdom teeth, 3 of them impacted. The upper right wisdom tooth with the red circle is not visible in the mouth, while the lower right and left (green arrows) are partially erupted. All 3 impacted wisdom teeth will need surgical removal.

If your wisdom tooth is partially erupted, it will remain stuck in that position and is at high risk of developing symptoms such as gum and facial swelling; hence, it is recommended that you have it removed sooner rather than wait for it to become painful.

Impacted, partially erupted or decayed wisdom teeth need to be removed due to the risk of pain and swelling.

Impacted wisdom tooth which traps food and should be removed as soon as possible.

If you are one of those lucky few whose wisdom teeth are all fully erupted and at the correct angulation, then there is no need for you to have any of them removed unless they are decayed or difficult to maintain.

Fully-erupted wisdom teeth which do not require removal.

Fully erupted and properly positioned wisdom teeth do not need to removed unless they are decayed or challenging to clean.

If your wisdom tooth is deeply buried (fully encased in bone), it may not be necessary to remove it since it will not cause food trapping. However, due to its potential to turn into a cyst (an expanding fluid-filled pathology which erodes into the neighbouring bone and teeth), it is recommended that the tooth be monitored with regular X-rays.

Can I Wait Until My Wisdom Teeth Hurts? Or Should I Remove Them Earlier?

Waiting for the wisdom teeth to start bothering you is actually NOT a good idea. Sometimes the pain can be intense enough to cause you sleepless nights, and when the infection becomes significant, you may end up with a big painful swelling not just on the gums, but on your face!

Let’s talk about the image above, showing 2 radiographs taken almost exactly 2 years apart. In 2020, patient had no symptoms (no pain, no gum swelling) and did not remove his horizontally-impacted lower right wisdom tooth. There was already a shallow decay on the adjacent second molar, confined to the enamel (indicated by the green arrow). If the wisdom tooth had been removed then, a filling may not even be necessary on the second molar.

Fast forward 2 years later, when patient returned after suffering a few sleepless nights. Now, the decay has progressed deep into the pulp of the second molar (highlighted in pink), and patient has to undergo root canal treatment and eventually crowning of the affected second molar, to retain the tooth. Alternatively, the affected second molar can be extracted together with the wisdom tooth, but this would mean losing 2 teeth in one go, and the patient will now have one molar less to chew his food on.

Read more: What is a Root Canal Treatment?

Additionally, there are two very good reasons to justify early, prophylactic removal of wisdom teeth:

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  Removal when you are younger usually means an easier surgery (as younger patients have softer bone) and faster recovery (better healing thanks to the power of youth).
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  When there is infection and swelling, removal becomes very painful as the tissues are very sensitive and sometimes anaesthesia does not work as effectively in the presence of infection and pus.

Should you decide to remove a lower impacted wisdom tooth, we sometimes recommend that the upper wisdom tooth is extracted at the same time, even if it is not impacted. Leaving the upper wisdom tooth alone may cause it to eventually over-erupt and come into contact with the lower gums when you bite, leading to ulcers, cheek biting and pain. Also, since the tooth is non-functional (as it does not have an opposing tooth to bite on), and may be challenging to brush (because of the difficult access at the back of your mouth), you may be better off without said tooth.

Image showing an upper wisdom tooth biting onto the swollen lower gums, causing pain.

Even after removing the lower wisdom tooth, the upper wisdom tooth may still erupt further and cause ulcers on the lower gums.

An X-ray image of a patient whose upper wisdom tooth has over-erupted and is impinging on the lower jaw, causing painful ulcers. The lower wisdom tooth has been removed a few years earlier.

Another example of an over-erupted upper wisdom tooth. The lower wisdom tooth is still present, but because it never erupted, the upper counterpart did not have a tooth to bite on and in turn over-erupted.

Removal under Local Anaesthesia vs General Anaesthesia

Most wisdom teeth surgery can be done under local anaesthesia. This means a chair-side procedure where the surgical area is first numbed up and the tooth removed while the patient is awake. After the surgery, the patient does not need to be accompanied home as there are no drowsy side-effects. If you are having the lower wisdom tooth removed under local anaesthesia, you can consider removing the upper wisdom tooth at the same time. That way, you can still chew on the unaffected side while you recover.

However, if you have 2 to 4 impacted wisdom teeth and you are very nervous about the surgery, you can opt for general anaesthesia, where you will be put to sleep for the entire duration of the surgery (technically, one is not asleep during general anaesthesia but unconscious). However, you can only have this done at facilities equipped with life support and resuscitation devices, and that would mainly be at hospitals. Additionally, be prepared to pay an additional $800 to $1000 on top of the surgical fees, in order to cover for the anaesthetist and operating theatre fees; you will also need to be accompanied home as you will be suffering from drowsiness and sometime nausea after the surgery.

Generally speaking, normally only 1 to 2 wisdom teeth on the same side is removed under local anaesthesia, whereas under general anaesthesia, all wisdom teeth should be removed at the same time. So do expect a longer downtime of around 8 days of medical leave after general anaesthesia, as opposed to 5 to 7 days medical leave for local anaesthesia, and a longer period on a soft diet as both sides would be sore and swollen after the surgery.

Can I Utilise Medisave for Wisdom Tooth Surgery?

If your wisdom tooth is fully erupted and can be removed without any surgical intervention, then this is considered an extraction and you cannot use your Medisave funds to pay for the extraction.

Medisave funds can only used for wisdom tooth surgery, but NOT for extraction of fully-erupted wisdom teeth.

However, if your wisdom tooth is not fully-erupted, or is positioned underneath the gum or in the wrong direction (considered impacted), where surgery is required to expose the tooth completely and to remove the tooth, then yes, you may utilise your Medisave funds (or that of your spouse’s, parent’s, child’s or sibling’s, with their consent) to pay for the surgery, as well as any medications, consumables and radiographs taken on the day of the surgery.

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