Wisdom tooth surgery – a walk in the park or a trek up Everest?

Today, I removed the four wisdom teeth of the son of my first ever wisdom tooth patient. His father was my first ever wisdom tooth surgery patient thirty years ago. I was in final year dental school then and removal of that one tooth took two hours. It was a most traumatic experience, not just for the patient, but for me as well. He was bleeding and I was sweating. It was an arduous climb up Mount Everest. Post-operatively, the swelling was tremendous and the corner of the mouth was thoroughly bruised and abraded with all the tugging and pulling. Thirty years later, he sent his son to me for wisdom teeth removal.

Wisdom tooth extraction is one of the most commonly done oral surgical procedures. With improvement in dental public health and oral hygiene, most people are able to maintain their full set of dentition throughout childhood and their adolescence. When the wisdom teeth, also known as third molars, begin to erupt at late teens, there is often insufficient space in the mouth for them and they get stuck, i.e. impacted. This gives rise to a myriad of problems like dental decay, gum infection, etc. Wisdom teeth surgery is part of the undergraduate curriculum in Singapore’s sole dental school. Students are taught how to do the surgery and  the potential complications of wisdom tooth surgery. They also have to complete at least one case on their own before they graduate.

As with all surgeries, there is a learning curve to negotiate. Whether the surgery is easy or not depends on both patient factors as well as the dentist. Some are easier to remove, some are more difficult and then there are those that are strictly for experts only.

 Patient factors:

1. Age

Younger patients tend to have softer bone which makes tooth removal easier. Extraction of teeth is possible largely due to softer nature of the bone holding the tooth. Pressure applied to the tooth results in compression of the bone, thereby creating a gap between the tooth and the bone which when then allows the tooth to be removed. As the young patient matures, the density of the bone increases and it becomes less pliable, making extraction more difficult

2. Race

There are obvious racial differences in our facial skeleton. The Chinese mandible is generally wider from side to side and shallower in depth from front to back. This makes the third molars more accessible and hence facilitate the surgery. Conversely, Caucasian and Indian mandibles are narrower and deeper, and the surgery is correspondingly more difficult due to poorer access to the back of the jaw.

3. Gender

Gender differences are related to bone density. Females tend to have lower bone density than males. As such, the teeth are relatively easier to remove.

4. Personality

A patient who is very nervous and apprehensive will require a more skillful dentist than one who is calm and indifferent.

5. Degree of impaction

If a third molar is completely impacted within bone, removal will required drilling deep into the jaw which is a lot more difficult than removing one that is partially erupted. The deeply impacted tooth is also closely related to a nerve inside the jaw and the need to avoid injury to the nerve also raises the difficulty level of the surgery.

Dentist Factor

1. Experience

Experience is obviously important but is sometimes over-rated. Experience is having performed an act many times before. However, it is only useful if that act has been correctly performed. Doing something wrong many times is still experience but is of little benefit to anyone. Experience need to be complemented with a proper data collection so that a cause and effect relationship between and action and reaction can be recorded so that actions that result in good outcomes are repeated and those that result in complications are eliminated. Without such a conscientious approach to practice, experience counts for little.

2. Training

Training is formalized and structured experience. Within the undergraduate curriculum, there is insufficient time to train a dental student to a proficient level for third molar surgery. In that structured milieu of a university faculty, teaching in the theoretical aspects is rigorous. Students will graduate knowing the when, why and how of wisdom tooth surgery. Upon graduation, it is the duty of the dentist to formulate his own training, be it in the form of a formal residency, short courses and preceptorships or be guided by a senior colleague.

While both factors are important, proper training trumps experience any day. A good training program can compress decades of experience into a few short years.

Today, the son of my first wisdom tooth patient had his four wisdom teeth removed in half an hour. Compared with what the father had to go through, it was a walk in the park alright. The difference was thirty years of training and experience. When the father asked about the cost of the surgery, I said it was paid in full thirty years ago, with blood and sweat.