Wisdom tooth complications - Gum disease (periodontitis). -

Why 3rd molars can be at elevated risk for periodontal disease. | How a wisdom tooth's gum health can affect adjacent molars. | Treating the gum condition vs. tooth extraction. | Correlations and incidence rates for third molar gum problems reported by dental research.

Maintaining gum health with wisdom teeth can be difficult.

Third molars can be a challenge to clean. And in cases where they are, they run a greater risk of developing periodontal problems (gum disease).

As we discuss on this page, this is an important issue because the health of the gum tissue surrounding your 3rd molars doesn't just affect them alone but potentially other teeth in your mouth as well. And for this reason, the removal of your wisdom teeth may be a needed preventive measure.

1) Why are some wisdom teeth at increased risk for developing periodontal problems?

Background.

Gum disease is caused by oral bacteria. And whenever a tooth can't be cleansed properly on a regular basis, the bacterial-laden film (dental plaque) that accumulates around it may lead to its formation.

The added problem that third molars can pose.

The positioning of some wisdom teeth can be such that it makes them exceptionally difficult (if not entirely impossible) to clean.

And when this type of added challenge exists, these teeth are at even greater risk for developing a periodontal (gum tissue) condition (either just minor [i.e. gingivitis] or advanced [i.e. periodontitis]).

Cleaning challenges unique to wisdom teeth.

a) Tooth impaction.

Diagram showing the empty space around a wisdom tooth where bacteria that cause gum disease can accumulate.

Plaque that accumulates in the space under the gums can't be removed.

In regard to its potential for developing periodontal disease, the worst case situation for a third molar is one where the tooth is locked in a position where it only sticks through the gum tissue part way. (This is referred to as a "partially erupted" tooth, see illustration).

When this type of tooth impaction exists, bacteria are able to seep down into the space between the tooth and its surrounding gum tissue. But the problem is, this area can't be effectively cleansed and therefore the bacterial colony that forms (dental plaque) is able to persist undisturbed.

That scenario makes the perfect recipe for the development of gum disease around the tooth.

b) Gum tissue flaps.

Some wisdom teeth have a flap of gum tissue that lies over their chewing surface. This "lid" overlying the tooth is referred to as an operculum (see picture).

A wisdom tooth operculum (extra flap of skin).

The extra flap of gum tissue on this tooth makes it impossible to clean.

Notes:

Just like above, this situation is a type of partial eruption. But different, what we're describing here is teeth that have emerged through the gum tissue to a greater degree.

Actually, with this scenario it's possible that the tooth isn't impacted (its eruption pathway blocked), and in fact, in all other ways it may be fully erupted (has reached its expected positioning in the jawbone).

When so, this condition can exist simply because there isn't enough length in the jawbone to accommodate both the tooth and normal gum tissue contours.

The difficulty.

As you can imagine from our picture, the extra flap of tissue extending from the back of the tooth across its chewing surface makes those portions more difficult, if not impossible, to clean.

As such, much of the dental plaque that forms in these areas will perpetually remain undisturbed, thus setting the stage for the formation of gum disease.

Section references - Hupp

c) Difficult access.

No matter what their orientation in the jawbone is, a general problem that all wisdom teeth share is that by nature they occupy a position in the rear of the mouth that is simply difficult to access with a toothbrush and floss.

That means, even fully erupted, normally positioned wisdom teeth can be extremely challenging to keep clean. And for that reason, they may be at elevated risk for developing gum disease.

2) The gum disease around a tooth is not an isolated event.

The conundrum.

For many dental patients the following statements about the need to extract their wisdom teeth may seem a little confusing. It's common that ...

  • A dentist will suggest removing a wisdom tooth so it doesn't develop advanced periodontal disease (periodontitis).
  • But if the tooth isn't extracted and ultimately does develop significant gum problems, the treatment recommended at that time will probably be the same, pull it.

With either scenario you end up loosing the tooth. So it's easy enough to see why a patient might think why not just wait to see if any problems (tooth looseness, pain, swelling) actually occur.

 

◀ Rear of mouth. | Front of mouth. ▶

Periodontal disease around the wisdom tooth impacts the 2nd molar.

Gum disease damage can impact both the 2nd and 3rd molars.

The 2nd molar may be affected too.

What must be understood is that gum disease isn't necessarily an isolated event. In fact, it usually isn't.

In the case of a wisdom tooth, that area of gum tissue and bone that serves as the support for the tooth on its front side is the exact same tissue and bone that provides the supporting foundation for the backside of the next tooth forward (the 2nd molar).

So, if damage occurs (characteristics of advanced gum disease [periodontitis] include bone destruction and gum recession), two teeth are actually affected not just one. (See illustration.)

Additional issues with the 2nd and 3rd molar relationship.

Wisdom teeth are noted for the diverse range of orientations they may have. And in some cases, the positioning/angulation of a third may be such that the amount of bone that exists between it and the 2nd molar is comparatively thin.

A thinner bone wall between the two teeth is more easily damaged by the gum disease process (a lesser volume of bone is present initially, the bone is comparatively less vascular and therefore less able to combat infection). And if that is the case, this configuration simply compounds the issue of the damaging effects of gum disease.

Section references - Koerner, Hupp

Possible symptoms.

Associated with the patient's developing condition will be chronic gum tissue inflammation, evidenced by gum tenderness, redness and bleeding that's easily provoked.

As the patient's condition worsens, the wisdom tooth might become noticeably loose (as more and more bone is lost), and acute episodes may be experienced from time to time (flareups involving pain and swelling) during periods when the infection that's present enters an especially active phase.

Outcomes -

For the wisdom tooth.

As mentioned above, tooth extraction is a common treatment solution for cases of advanced gum disease involving third molars.

While other treatment approaches are possible, the successful outcome of this therapy can be hard to predict. That's both from the standpoint of:

  • The dentist having to perform the work for a difficult location. (Access can be difficult, the dental anatomy of this region can pose challenges.)
  • And the patient having the skills and motivation to regularly and adequately clean the tooth. (A factor that's needed for long-term success.)

 

For the 2nd molar.

In cases where extensive bone destruction has occurred, there may be no realistic alternative other than extracting both the 3rd molar and 2nd molar too. However it would be the hope that treatment can provide a solution by which the tooth can be salvaged. Obviously, case specifics and the patient's wishes will be the deciding factors.

What we can state is that most people would sorely miss a second molar. And it would be a shame to lose or have one of these valuable teeth compromised simply because a wisdom tooth that was identified as not being possible to properly cleanse was not extracted before problems developed.

Other 2nd molar concerns.

It's not just gum disease that can damage the second molar in this type of situation. Tooth decay may play a role too.

The bone destruction caused by the periodontal disease can leave a deep void that traps food, plaque and debris. This mixture creates the perfect environment for the formation of tooth decay. If it does, the teeth involved may be damaged beyond repair.

[Problems with cavities is another one of the "Valid reasons to extract wisdom teeth" issues that we discuss on our pages.]


3) How likely is it that your wisdom tooth will encounter problems with gum disease?

Incidence rates.
  • An evaluation of dental literature (Pogrel) concluded that the incidence rate of experiencing periodontal complications with a wisdom tooth runs on the order of 1% to 4.5%.
  • This paper also stated that dental patients over the age of 25 years were roughly twice as likely to have an asymptomatic periodontal defect associated with a third molar, as compared to younger patients.

    - The term asymptomatic means "showing no symptoms." So in these cases, a gum problem existed even though the patients were unaware of them.

    - Additionally, this finding simply documents what dentists already know. Older people tend to have more problems with gum disease than younger ones. So, in the case where you are comparatively young and some type of marginal problem already exists with your tooth. Going ahead and having it removed may make preventive sense.

Section references - Pogrel

Correlations.

Here are some of the correlations research studies have found.

Periodontal disease has formed between the wisdom tooth and 2nd molar.
  • a) Two large scale studies found that there's a greater probability of finding deep (5mm and greater) periodontal pockets on the distal of 2nd molars (the in-between space identified in our picture) when a visible wisdom tooth is present.

    - The term "visible wisdom tooth" precisely describes the two difficult to clean situations we explain above: 1) An erupted wisdom tooth that's simply hard to access or 2) A partially erupted one, which often involves the situation where almost no below-the-gum-line cleaning can be accomplished at all. In either case, you would expect periodontal problems to exist.

  • b) Other studies have shown that having a visible 3rd molar correlates with the subject's overall level of periodontal disease severity.

    - This finding simply reinforces the fact that gum disease is not a localized event. It tends to affect other areas of the mouth as well.

  • c) Some studies have focused on the types of bacteria living below the gum line around wisdom teeth and the level of pathologic periodontal activity taking place in that person's mouth.

    - The idea associated with these findings is that non-maintainable areas around wisdom teeth can harbor the types of bacteria known to be the causative agents of gum disease. And their presence there tends to impact the health of the mouth as a whole.

Section references - Pogrel

4) If gum disease is found around wisdom teeth, what should be done?

No one can debate that it can be extremely difficult, if not impossible, for a person to effectively remove dental plaque from around their third molars. But what is debatable is exactly how this difficulty should be managed.

Should the teeth be removed?

Obviously, you'll have to rely on your dentist's judgment. Extraction is one solution but it's not always required.

Non-extraction approaches.

If the bacterial infection (gum disease) surrounding your wisdom teeth can be brought under control and subsequently managed, then there's no real reason to remove them. This might be accomplished via one of the following approaches.

  • More effective oral home care (better brushing and flossing, and possibly incorporating the use of an electric toothbrush into your cleaning routine).
  • More frequent or extensive dental cleanings (scaling and root planing).
  • The use of gum surgery to improve the tooth-gum relationship so adequate cleaning is possible.

Obviously, only your dentist can counsel you on which approach, extraction or alternative, seems to offer the most appropriate solution for your situation.

In the case where the teeth are retained, the level of home care you perform on a daily basis will likely be the deciding factor in what your long-term outcome will be. If you can't commit to keeping that level high, extraction may make the more realistic choice.

 
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Comments

Broken wisdom tooth

So my back right wisdom tooth, the farthest one back was partial erupted. I have a little him flap that I think is from it. This tooth was already broken and falling apart as soon as it broke threw my gums. Now theres only slight fragments under the flap. And a piece that seems like it shifted down my gums closer to my tongue. From what ive said is some sort of surgery my only route here?

Megann

Well yes, surgery in the sense that you need the tooth extracted. But you don't necessarily have to expect the worst with the procedure. Only your dentist, after an examination that includes x-rays, can determine what level of surgical procedure is needed (simple extraction (routine) vs. surgical extraction).

Probably the biggest thing working against you is how you describe the tooth has decayed extensively and has now started to fall apart. A dentist needs to be able to plant their tools on/against the tooth in some area where it is solid, so force can be applied to remove it. And if the dentist has no such access readily available (the fact that your tooth is only partially erupted works against you here), then yes, they will have to expose the tooth surgically somewhat (reflect gums back, possibly trim bone) so access is achieved.

But it can't be overlooked that some wisdom teeth (often due to their root configuration) can be astoundingly easy to remove. (This would be more likely with an upper 3rd rather than a lower one. You don't mention which yours is.) And therefore, just minimal force needed to remove the tooth (so no surgical exposure possibly needed).

Just go ahead and make the needed consultation appointment with your dentist. Delaying the extraction serves no purpose and will probably tend to add to the degree of difficulty of the procedure. After looking at your tooth, hopefully your dentist will be able to tell you that they expect your procedure to be less of an ordeal than you anticipate.


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