Pericoronitis - Management - Management Following Acute Phase - Tooth Extraction

Tooth Extraction

If the tooth is to be extracted, this can be carried out under local anesthetic and with the person awake, or under sedation, or under general anesthetic. Depending on the position of the tooth, this may be a straightforward or more complex procedure, where an incision is placed in the mouth and surgical burs are used to remove portions bone that is holding the tooth in, and also to divide the tooth into sections so it can be removed more easily. The latter scenario involves sutures (stitches) to replace the soft tissues in a position for healing, and the area where the tooth was and the bone removed eventually fills in with bone during the healing. Extraction of teeth which are involved in pericoronitis carries a higher risk of dry socket, a painful complication which results in delayed healing. The anxiety of the individual towards oral surgery is a common reason for carrying this procedure out under general anesthetic. If a general anesthetic is required, in order to reduce the overall number of general anesthetics used, each of which carries its own risk, then other teeth which are likely to require extraction in the future are often extracted during the same procedure. This especially applies to cases where there is a similarly impacted and partially erupted wisdom tooth on the other side of the mouth which has yet to cause any acute problems.

Historically many lower wisdom teeth that were not in an ideal position were surgically removed in order to prevent problems like pericoronitis. It became apparent that the majority of impacted lower third molars would cause little or no problems during the individual's lifetime. In modern practice, oral surgeons tend to only remove wisdom teeth that develop problems, or those that are likely to develop problems, in cases where the benefits of removing the tooth outweigh the potential risks of leaving it in place or the possible complications associated with the procedure. However, removal of impacted wisdom teeth remains one of most common surgical procedures, and recurrent episodes of significant pericoronitis is the most common reason it is undertaken. In the UK, the National Institute for Health and Clinical Excellence (the body which advises best practice for the National Health Service) published guidelines for the removal of wisdom teeth in 2000. These guidelines advised that the routine prophylactic removal of pathology free third molars should be discontinued, and that a single episode of acute pericoronitis, unless especially severe, did not constitute an indication for tooth extraction, but that a second episode was an indication. This was intended to avoid the unnecessary removal of wisdom teeth that may only cause a single instance of acute pericoronitis, and then erupt further and/or be manageable with oral hygiene methods. A systematic review in 2012 investigating the possible preventative benefits of removal of symptom-free, impacted wisdom teeth in adults found no evidence for this practise. The review also concluded that prevention of late lower incisor tooth crowding, a commonly cited reason for removing symptom free and impacted wisdom teeth, also had no evidence.

However, many mainstream dental textbooks state that impacted wisdom teeth should generally be removed unless otherwise contraindicated, and this should be done earlier rather than later because their removal may become more difficult with advancing age. Research has also shown that there is a significant geographic variation in the views of both dentists and patients as to whether wisdom teeth should be removed.