Does every wisdom tooth have to come out?

Wisdom teeth usually come through in the teenage and young adult years. The ADA says they typically erupt at around seventeen to twenty-one, while MyOMS gives a range of seventeen to twenty-five. Many people have been told, even before that age, “You’ll have to get your wisdom teeth out.” It is true that some need to be removed, but not all. This article explains what the decision is based on.

What is an impacted wisdom tooth?

The NHS writes that sometimes there is not enough room for the tooth, and the neighbouring tooth blocks it or the gum covers part of it. The ADA calls such a tooth “impacted” and writes that it is trapped in the bone or under the gum. Being impacted is not a disease in itself. Many impacted teeth stay quiet for years. Studies give different figures for how common it is. For example, a review in BMJ Clinical Evidence describes Swedes of whom about seventy-two percent had at least one impacted wisdom tooth at the age of twenty to thirty, and MyOMS also says most people have at least one impacted tooth. By contrast, a worldwide meta-analysis in the Journal of Dental Research estimated the prevalence at about 24 percent among people who had been imaged.

Which signs make removal reasonable?

The ADA, NHS and MyOMS give similar lists:

• Repeated pain or swelling, or infection of the gum around a partly erupted tooth. The NHS calls this pericoronitis, and MyOMS and the ADA also mention infection and swelling.
• Decay that cannot be repaired. The ADA says this.
• Gum disease or food repeatedly getting trapped. The NHS and MyOMS both say this.
• A cyst or tumour around the tooth. The ADA says a cyst can damage the roots of nearby teeth and the bone.
• Damage to the neighbouring tooth. MyOMS and the ADA say this.
• Part of a larger treatment plan. The ADA writes that removal is sometimes recommended alongside orthodontics or other treatment. Cochrane also names reasons such as preparing for jaw surgery, radiotherapy, or treatment of an injury to the area.

The NHS and the ADA both remind us that the decision is made after an examination and imaging. The ADA says “every patient is unique”.

What if the tooth causes no trouble?

The NHS writes that if a wisdom tooth is not causing a problem, it is usually left in place and watched at regular check-ups. MyOMS also says that a tooth that has come through fully, works properly, and has no pain, decay or gum disease may not need removal, but it still needs cleaning, a yearly examination and an occasional X-ray. The ADA says teeth that stay should be flossed, kept clean and seen at check-ups, because the risk of problems can rise with age. If you have pain, the ADA says to see a dentist right away.

What does research say about a tooth with no symptoms?

Three specialist sources have focused on this question.

The Cochrane review on impacted teeth with no disease and no symptoms found two studies: one randomised trial and one cohort study. It concluded that the evidence on removing versus keeping these teeth is only of “low to very low certainty”, and no study reported the effect on quality of life. In other words, we cannot say with confidence whether removing a symptom-free tooth is better than keeping it. Very low certainty evidence suggests that keeping these teeth may raise the long-term risk of gum disease at the neighbouring tooth. Cochrane advises that if a tooth is kept, it should be examined at regular intervals. Cochrane also notes that when removal is done in older people, the risk of complications, pain and discomfort after surgery is higher.

The UK Health Technology Assessment was about preventive removal of impacted lower wisdom teeth. Two earlier economic studies had found no evidence in favour of doing it. The review’s own exploratory model showed a small extra cost and a very small gain in quality of life, and concluded that preventive removal may be the more cost-effective strategy. In the same review, depending on the length of follow-up, about 5.5 to 31.4 percent of the teeth that were kept ended up being removed. The authors noted that there is no trial directly comparing removal with keeping the tooth, and that the assessment rests on observational data.

BMJ Clinical Evidence also followed the same question and says that an impacted wisdom tooth can be linked with pain and swelling and can damage the neighbouring tooth and bone.

Conclusion: medicine does not have a single answer for a tooth with no symptoms. For this reason, it is wise to decide with your own surgeon or dentist, based on your X-ray and the state of your mouth.

What questions should you ask?

• Does my tooth have a problem now, or is it just impacted?
• If I keep it, how often does it need to be checked, and which X-ray is needed?
• If I have it removed, what complications are possible, and what raises the risk in my case?
• Is local anaesthesia enough, or are sedation and general anaesthesia also offered? The NHS names all three.
• Where is the lower jaw nerve in relation to my tooth, and which image shows this? Guide to jaw imaging

If removal is needed

The NHS says it is usually short, and most people go home the same day. Read about preparation and aftercare in the guide to preparing for surgery and after-surgery care. If you have danger signs, such as difficulty breathing or swallowing, or swelling under the tongue, call emergency services (115). Warning signs.