What to do when your wisdom tooth is touching the nerve in the jaw?

The wisdom tooth removal is probably the most commonly removed anatomical part of the body. No doubt it is a rudimentary structure that does not serve much function. In fact, more often than not, it fails to erupt properly and ends up causing trouble to the adjacent teeth. As such, not only do problematic wisdom teeth gets removed, even the non problematic ones are often extracted to prevent possible future problems. Herein lies the one of the major controversies around wisdom tooth surgery. Should non-problematic wisdom teeth be remove? I’ll illustrate the complexities with a case.

A general dentist referred me a patient for a wisdom tooth consult. This was a 20 year old female of Indian descent who is a British citizen but lives in America and happened to be visiting her parents who are working in Singapore. She does not have a problem with her wisdom teeth but her dentist in America has indicated for them to be removed “because they might cause trouble later.” As she was alone in America, her parents had wanted her to do the surgery in Singapore so that they could be with her for the surgery. She had lived in Singapore during her high school years and has been visiting this colleague of mine for general checkups and routine dentistry for most of her teenage years.

Her lower wisdom teeth are partially erupted but there is no sign of any decay or gum infection. Adjacent teeth are also healthy and intact. However, the x-rays showed that the roots of her wisdom teeth are tightly pressed against the nerve in the lower jaw. This nerve provides sensation to the lips and surgery to remove her lower wisdom teeth will carry a high risk of injury to the nerve which may, in the worst case scenario, result in a permanent numbness of the lower lips. As such, I recommended that she leave the wisdom teeth alone and only remove them if they cause trouble.

The parents were really upset to hear that and asked if the risk could have been less if the wisdom teeth were removed earlier, before the roots were formed. They were upset that my colleague did not refer their daughter for wisdom teeth surgery when she was under his care during her teenage years. My answer was that theoretically it was possible that the risk could be lower. Remembering that she’s British, I quoted the British guidelines which basically states that wisdom teeth that are not causing trouble should be left alone. At this point, the mother countered that they lived in America and all their friends’ kids have had their wisdom teeth removed when they were teenagers.

As we can’t turn back the clock, there is no point talking about what could have been. At that point in time, the risks of surgery outweighed the benefits and the best thing to do is to keep the wisdom teeth and maintain good oral hygiene to prevent future problems. They were still unhappy but they accept that that was probably the best course of action.

There is one other treatment option other than removal and observation. This third option is not very commonly done but is a viable option for cases where the wisdom tooth is very close to the nerve and is painful. The crown can be cut off, leaving the root in the bone. This procedure, known as coronectomy, is gaining in popularity as the complication rate was found to be low. A study following 612 wisdom teeth that underwent coronectomy over five years found a complication rate of less than 1%. For patients with wisdom teeth that are pressed against the nerve, coronectomy is a viable option.

There is no one standard for management of asymptomatic wisdom teeth. In the above case, the patient and her parents do have a point that if the wisdom teeth were taken out before root formation, it would have been a less risky procedure where the nerve in concern. However, it is impossible to predict which patient will have the roots developing against the nerve and which will not. Doing the surgery at a young age would have entails a general anesthetic as some kids are too apprehensive to keep still. That has it own set of risks. I suspect that funding the cost of wisdom tooth surgery  play a role in the decision making process. In the UK, the National Health Service funds the surgery with taxpayers money and perhaps that is why their guidelines stated to only remove the problematic ones. In the USA, wisdom teeth surgery is usually funded by private insurance. As such, preventive removal is more often practiced than in the UK. One practice is not more right than the other. So long as the patient understands the pros and cons of each option, he can make his own decision.