Impacted Wisdom Teeth

[Mike09]

I had a panoramic X-ray done a week ago.

As you can see, the two lower wisdom teeth are problematic. They sometimes cause bleeding.
The dentist who took the photo said that I don't need to get them removed as long as I clean them properly and that there is a high risk of alveolar nerve damage from the extraction. She offered treatment for periodontal disease instead, and it includes root scaling, laser sessions, and injectable stem cells.

Since then I asked a few dentists online and they all said that the teeth should be removed. One of them explained that the lower wisdom tooth on the left (right on the picture) has already caused significant bone loss and its roots are not close to the alveolar nerve so it should be extracted as soon as possible. The right one (left on the picture) on the other hand, might be risky to extract and the surgeon might want to take CBCT to see where the nerve passes.

I have an appointment with another dentist tomorrow and she will probably recommend an oral surgeon.
I am worried that the surgeon might suggest extraction regardless of how risky it might be.

So here are my questions:
1) Do you think that both teeth should be extracted or do you think that both (or one of them) could be left and it/they wouldn't cause serious issues in the future?
2) How risky is the extraction of each one of them, in your opinion?
3) Is the extraction currently more urgent than the periodontal disease treatment offered by my dentist?
4) How much can the extractions and the periodontal disease treatment be postponed without developing serious problems? Both procedures are very expensive and I will have to choose one of them and put off the other one.
5) What could happen if the wisdom teeth are not extracted? Could this lead to a jaw infection? How would it be treated?
6) What would happen if the alveolar nerve is damaged during the surgery? And would it require expensive treatment afterwards (which I probably wouldn't be able to afford)?

 

[Dr M]

Good day

1) Yes both teeth needs removal, since the bone loss can affect the teeth adjacent to them and lead to further problems. Impacted 3rd molars can also lead to dentigerous cysts and then this can also affect the adjacent teeth. If they are partially erupted in the mouth, they can lead to continuous episodes of pericoronitis, which is very painful and also lead to abscesses.

2) Both of the teeth appear to be in close proximity to the nerve. This is a 2 dimensional image however. An oral surgeon can take a 3 dimensional scan that can give a better evaluation.

3) I would prioritize the extractions and then continue with periodontal treatment afterwards.

4) It all depends. Everyone is different and an exact timeline can't be given. Based on the amount of bone loss, I would not wait too long and definitely would prioritize the extractions.

5) If the teeth are not extracted, it could lead to cyst formation or additional bone loss, affecting the adjacent teeth, which might be lost as well, with or without additional bone loss of the cysts have to undergo additional debridement. Abscess formation is also a possibility and this infection could spread to additional spaces in the face, and can become life threatening if left untreated.

6) If the nerve gets damaged, it all depends on the type of damage. If the nerve is completely severed, you could lose all sensation on the affected lower side from the back up until the front, with possible neuropathic pain. If the nerve is only bruised, the numbing sensation could be prolonged for a period from a few days up until a few months/years and then gradually return to normal. This can also be accompanied by neuropathic pain such as a burning or tingling pain.
Usually the symptoms area treated with medications, and there have been some new studies done on laser therapies and Vitamins that can speed along nerve regeneration, but in my experience thus far, the main thing is to watch and wait and be patient.

Hope this answers some questions.

 

[Dr M]

An oral surgeon will definitely suggest extraction. An experienced oral surgeon can remove these teeth without any complications. I have seen a lot worse impacted molars than the ones you have. 90% of them were removed without any complications, and permanent nerve damage is rare.
Also remember that the image you have is 2 dimensional. In reality there might not be any nerve involvement. There are certain signs that we look for when evaluating risk of nerve involvement on a panoramic x-ray. And it doesn't look like you have many, so it might be that the nerve is not involved, in my opinion.
It would also be best to keep the adjacent teeth and remove the wisdoms. You will have to have some sort of periodontal treatment afterwards, to attend to the bone loss surrounding the adjacent molars, but this can be postponed for a while if money is an issue.

 

[Mike09]

Good day

1) Yes both teeth needs removal, since the bone loss can affect the teeth adjacent to them and lead to further problems. Impacted 3rd molars can also lead to dentigerous cysts and then this can also affect the adjacent teeth. If they are partially erupted in the mouth, they can lead to continuous episodes of pericoronitis, which is very painful and also lead to abscesses.

2) Both of the teeth appear to be in close proximity to the nerve. This is a 2 dimensional image however. An oral surgeon can take a 3 dimensional scan that can give a better evaluation.

3) I would prioritize the extractions and then continue with periodontal treatment afterwards.

4) It all depends. Everyone is different and an exact timeline can't be given. Based on the amount of bone loss, I would not wait too long and definitely would prioritize the extractions.

5) If the teeth are not extracted, it could lead to cyst formation or additional bone loss, affecting the adjacent teeth, which might be lost as well, with or without additional bone loss of the cysts have to undergo additional debridement. Abscess formation is also a possibility and this infection could spread to additional spaces in the face, and can become life threatening if left untreated.

6) If the nerve gets damaged, it all depends on the type of damage. If the nerve is completely severed, you could lose all sensation on the affected lower side from the back up until the front, with possible neuropathic pain. If the nerve is only bruised, the numbing sensation could be prolonged for a period from a few days up until a few months/years and then gradually return to normal. This can also be accompanied by neuropathic pain such as a burning or tingling pain.
Usually the symptoms area treated with medications, and there have been some new studies done on laser therapies and Vitamins that can speed along nerve regeneration, but in my experience thus far, the main thing is to watch and wait and be patient.

Hope this answers some questions.

Thanks for the thorough response, Dr M. I really appreciate it.
I have another question. What if the molars next to the wisdom teeth are extracted instead? That would allow me and my dental hygienist to clean the wisdom teeth properly, right? Would this be less risky? Does that even make any sense? No dentist has suggested that, I just came up with it the other day, so it's probably nonsense.

Also, how common is it for the wisdom teeth to be in close proximity to the nerve? And how common is it for such nerve damage to occur during extraction in cases similar to mine? I would like to have a better idea of the risk of removing the teeth vs. the risk of not removing them. Does the risk-reward ratio in a case like mine seem like a no brainer to a dentist like you? I am somewhat worried that when I go to an oral surgeon he will suggest extraction anyway, since it's his job and he will get very good money for it (especially considering the crisis that we are living in right now). So I'm not sure how objective his/her opinion would be in this case. I hope you don't find this offensive as a dental professional.

 

[Mike09]

An oral surgeon will definitely suggest extraction. An experienced oral surgeon can remove these teeth without any complications. I have seen a lot worse impacted molars than the ones you have. 90% of them were removed without any complications, and permanent nerve damage is rare.
Also remember that the image you have is 2 dimensional. In reality there might not be any nerve involvement. There are certain signs that we look for when evaluating risk of nerve involvement on a panoramic x-ray. And it doesn't look like you have many, so it might be that the nerve is not involved, in my opinion.
It would also be best to keep the adjacent teeth and remove the wisdoms. You will have to have some sort of periodontal treatment afterwards, to attend to the bone loss surrounding the adjacent molars, but this can be postponed for a while if money is an issue.

Thanks for the quick response.