Wisdom Tooth Removal

A wisdom tooth can have problems without causing any symptoms, which is why it is checked at check-ups. When it does cause symptoms, a common reason is inflammation of the gum around it.

Pericoronitis is inflammation of the gum² that covers a partly erupted tooth. It is most common around wisdom teeth. The signs are:

• pain at the back of the mouth and swelling of the gum
• a bad taste or smell in the mouth
• difficulty opening the mouth, discomfort when swallowing
• sometimes a fever, feeling unwell and swelling that spreads to the face

An inflamed tooth can cause pain to spread³ to the face or head. However, a large population study found no link⁴ between wisdom teeth and migraine or other headaches. See our article on whether wisdom teeth can cause a headache for details. Problems with the jaw joint can also cause signs similar² to pericoronitis; this is one reason an examination is needed.

When removal is usually discussed

• There is disease in or around the tooth. The UK's NICE guidance recommends limiting surgical removal to patients with evidence of disease⁵. Examples are decay that cannot be repaired and disease of the nerve or around the root tip that cannot be treated. Others are an abscess, a cyst and resorption of the tooth. This guidance was published in 2000 and is now being updated.
• Gum inflammation keeps coming back. According to NICE, a first episode of pericoronitis is not in itself a reason for removal unless it is very severe. Second and later episodes are⁵. The Scottish dental guidance (SDCEP) also recommends removal in severe cases or with repeated episodes in the same tooth².

When watching the tooth is usually reasonable

• An impacted tooth that is not painful and shows no disease. NICE recommends that routine preventive removal should be discontinued⁵. These teeth are watched at regular check-ups. The evidence on this is not certain (see “What happens to a tooth left in place?” below).
• Only to prevent crowding. In the only randomised trial on this question, removal had no clinically meaningful effect⁶ on the alignment of the teeth. The trial is small and at high risk of bias.
• Headache alone. If there is no problem with the tooth, a headache is not in itself a reason for removal.

Tell your dentist before an extraction if

• You take a blood thinner. Do not stop or change these medicines⁷ for dental treatment unless your doctor, specialist or dentist tells you to.
• You take, or have taken, a medicine for osteoporosis or for cancer. Our page on tooth extraction explains why these medicines matter.
• You are pregnant. According to UK guidance, dental X-rays, including panoramic and three-dimensional X-rays, do not need to wait until after the birth⁸. You may also choose to postpone an X-ray that is not urgent.
• You take other medicines regularly, or have a condition that weakens your immune system.

Not everyone has four wisdom teeth. According to an analysis that combined 92 studies, at least one wisdom tooth is missing from birth in about 23 in every 100 people⁹. That is more than one in five. The rate varies widely from study to study.

• Watching without removal: no treatment, regular check-ups. This is the usual course for a tooth that causes no problems. At the check-up, the area around the tooth and the neighbouring tooth is examined for decay and gum problems. If there is no sign of disease, waiting is a choice, not a failure to act.
• Treating the gum inflammation without removal. For adults with pericoronitis, the Scottish guidance recommends pain relief and rinsing with salt water or a chlorhexidine mouthwash². Antibiotics are not recommended; they are considered only if the infection is spreading, affects the whole body, or the immune system is weak.
• Removal. A fully erupted wisdom tooth is often taken out like other teeth. An impacted or partly impacted tooth needs more. The gum is opened, sometimes some of the bone is removed, and the tooth is cut into pieces. Our general page on tooth extraction may also help.

For impacted teeth without disease, it is not certain which course is better. A Cochrane review found insufficient evidence⁶ to decide whether these teeth should be removed or kept. The review recommends that the patient and the dentist decide together and that teeth left in place are checked regularly. So neither “every wisdom tooth should come out” nor “none should” is correct.

The steps below are for removing an impacted or partly impacted wisdom tooth; for a fully erupted tooth the procedure is simpler. Your dentist will tell you after the examination how many appointments are needed and how long the procedure will take.

According to UK guidance, X-rays are chosen for you after your history has been taken and you have been examined⁸. Most removals are done under local anaesthetic. Sedation or a general anaesthetic may be discussed if you feel anxious, or if more than one impacted tooth is to be removed. See our page on conscious sedation.

Risks

• Removal cannot be undone. No new tooth grows in place of the one removed. Removing a tooth without disease means choosing the risks of removal instead of the risks of keeping it.
• Pain and swelling. According to the NHS, there may be some pain and swelling for up to 2 weeks¹ after the removal. These are expected to start improving after 1 or 2 days.
• Dry socket. A painful condition that develops when the protective blood clot in the socket is lost. According to a Cochrane review, it occurs after 1 to 5 in every 100 routine extractions, and after 30 or more in every 100 surgically removed wisdom teeth¹⁰. This is a general range given by the review, not a pooled estimate. In a review that pooled observational studies, dry socket occurred in about 13 in every 100 smokers and about 4 in every 100 non-smokers¹¹. Those studies included both simple and surgical extractions.
• Infection. Whether preventive antibiotics are given with the removal is decided patient by patient. Most of the trials were done in healthy people having wisdom teeth removed. In this group, antibiotics may slightly reduce infection: on average, 19 people need to be treated to prevent one infection¹². The certainty of the evidence is low. Because of side effects and antibiotic resistance, the review asks for each patient to be assessed individually.
• Numbness of the lower lip and chin. The roots of a lower wisdom tooth can lie close to the nerve that supplies feeling to the lip and chin. In a review of 23 studies of the removal of impacted lower wisdom teeth, numbness occurred temporarily after about 12 in every 1,000 removals and permanently after fewer than 3 in every 1,000¹³. These rates do not apply to upper wisdom teeth or to simple extractions. Your own risk depends on how close the tooth is to the nerve and how difficult the procedure is. According to the NHS, nerve damage usually gets better but can take a few weeks or months¹.
• Bleeding. Some oozing for a while after the removal is normal. What to do if the bleeding does not stop is explained below.

Benefits

• Removing a diseased tooth removes the cause of the pain, inflammation or abscess coming from that tooth.
• Removal may help prevent further episodes of pericoronitis.

Two reviews look at different questions and put the emphasis in different places.

• A review of 37 studies reported that wisdom teeth without symptoms that are left in the mouth rarely remain free of disease over time¹⁴. The most common problems are decay and gum problems, especially in partly erupted lower teeth that tilt forward. The studies differ in design, and the authors describe the evidence as of medium to fair quality.
• This finding does not on its own show that removing a tooth without disease at the outset is better than watching it. The Cochrane review found insufficient evidence⁶ to decide whether removal or keeping the tooth is better. Evidence that a retained tooth may be linked to gum disease at the neighbouring molar rests on a single study. Its certainty is very low.

Taken together, the two findings say this: a wisdom tooth left in place should not be forgotten. It should be watched at regular check-ups. If disease is found at a check-up, removal is discussed again.

We cover the first night in detail in our article on the first night after a tooth extraction. In short:

• Bleeding. If the socket keeps bleeding, the Scottish guidance recommends biting firmly on a damp gauze pad for 20 minutes¹⁵. If you do not take a blood thinner and the bleeding has not stopped, repeat the pressure once more. If it still does not stop, get urgent care.
• If you take a blood thinner. The Scottish leaflet for people taking these medicines recommends pressing on the bleeding area for 30 minutes¹⁶. If the bleeding does not stop, or starts again later, contact your dentist straight away or get urgent care¹⁵.
• Do not rinse your mouth on the first day. Guidance advises not rinsing on the day of the extraction¹⁷, and on the following days rinsing gently¹ with warm salt water or mouthwash.
• The first 24 hours. Once the bleeding has stopped, avoid alcohol, smoking and exercise for 24 hours¹⁵. If you can, keep your head raised and do not disturb the clot.
• Smoking. The studies in a review of smoking and dry socket did not test¹¹ when it is safe to start smoking again. This may be a good time to stop.
• Pain relief. The usual over-the-counter options are paracetamol or ibuprofen. A Cochrane overview, based mostly on trials after wisdom tooth removal, found taking the two together¹⁸ among the options that worked well. Follow the instructions on the pack. For people taking blood thinners, the Scottish leaflet recommends avoiding medicines such as ibuprofen and using paracetamol¹⁶. If you are pregnant, the NHS says to avoid ibuprofen¹⁹ unless a doctor or pharmacist recommends it. It adds that paracetamol is usually the best painkiller to take in pregnancy. If you have a long-term condition such as asthma or a stomach problem, or take other medicines, ask your pharmacist which painkiller is suitable.
• Cold packs. Applying cold to the cheek may slightly reduce pain on day 3²⁰. No effect on swelling has been shown, and the certainty of the evidence is low. Wrap the cold pack in a cloth.
• Food. Do not eat until the numbness has worn off. The NHS recommends soft or liquid food¹; avoid hard and crunchy food, nuts and seeds, and very hot drinks.
• Dairy. Two randomised trials in Germany did not find that dairy products harmed healing. One was done in healthy young people having wisdom teeth removed²¹, the other in a broader group having oral surgery²². This does not prove that dairy is safe for everyone. See our article on dairy after a tooth extraction for details.
• Driving and work. The NHS advises not driving for 24 hours after a sedative injection and 48 hours after a general anaesthetic¹. After a difficult removal you may need 1 to 3 days off work¹. If sedation is planned, see our page on conscious sedation for the rules on an escort and preparation.

Daily care

Keep brushing your other teeth twice a day with fluoride toothpaste. For the first few days, keep the toothbrush away from the socket.

See your dentist if you have any of the following:

• Pain at the back of the mouth, or swollen or tender gum around a wisdom tooth
• A bad taste or smell in the mouth

Get seen the same day if you have swelling in your face or jaw, or a fever. The same applies if it becomes harder and harder to open your mouth. The Scottish guidance counts facial swelling and limited mouth opening as signs of a spreading infection².

After the removal, call your dentist without delay if you have:

• Bleeding that does not stop despite pressure
• Severe or increasing pain that painkillers do not relieve
• A bad taste, a high temperature or feeling unwell together with pain; the NHS lists these among the signs that need urgent help¹
• Pain that starts 24 to 48 hours after the removal, a socket that looks empty, and a bad taste or smell. These can be signs of dry socket; the Scottish guidance recommends getting urgent dental care¹⁷
• Numbness or tingling in the lower lip or chin that continues after the anaesthetic has worn off

Emergencies. Difficulty breathing, noisy breathing, difficulty swallowing or a muffled voice need emergency medical help². Do not wait for a dental appointment; call 112 or go to the nearest emergency department.

This page carries no prices. A plan is prepared for you after an examination and X-rays. The main factors that shape it are:

• Whether the tooth is fully erupted, partly impacted or fully impacted
• How many teeth are taken out, and whether at the same visit
• The imaging needed (X-rays, and a cone-beam CT scan if needed)
• Local anaesthetic, sedation or a general anaesthetic
• Check-up and stitch-removal appointments

Ask for your plan in writing, including what it covers.