What you should know before it gets too late: a simple article by Dr. Keneshia Tingson



Impacted wisdom tooth

is a tooth that fails to erupt in the oral cavity at its expected time of eruption. It could either be because of hindrances such as (1) adjacent teeth (2) dense overlying bone and (3) excessive soft tissue. Some abnormalities in eruption can also be affected by genetic abnormalities. The most common impacted teeth are: maxillary and mandibular third molars, followed by the maxillary canines and mandibular premolars.

Most common causes of impacted teeth is due to inadequate dental arch length and space that it should erupt. This is sometimes due to the length of the bone is less than the total width of the teeth in the arch. Or if put simply, there is a misfit in the proportion, teeth size is bigger than jaw size.

Adult humans have a total of 32 teeth in all arches. This consists of 3 molars per arch. The third molars (wisdom tooth), which is the last to erupt usually erupts at around 18-25 years old. This is also why it is the most common teeth to be impacted. Third molars should normally erupt easily with the same angulation as other molars and relatively should be located in the same line. At around this age, if you notice that one or more of your teeth are missing, you should probably need to have it checked of its present status.

There could also be signs that your wisdom tooth is impacted but you may not know it. Before the condition gets worse, you should probably be aware of the 



5 signs of impacted wisdom tooth


1. Pericoronitis: There is an on and off swelling of the gums on the back side of the jaw


Impacted tooth can be partially exposed in the oral cavity. This partial exposure can cause inadequate cleaning of debris and bacteria and can provide a niche in which the normal oral bacteria can thrive. When opposing tooth bites into the surrounding gingiva (operculum), this trauma can result to inflammation, stagnation of bacteria underneath, infection and aspiralling cycle.

For most patients, the normal oral bacteria can be controlled by the body’s host defenses unless the number and virulence of bacteria is too high, too virulent or the host’s immune system falls down..

This then causes what we call pericoronitis or the infection of soft tissue around the crown of a partially impacted tooth. Symptoms such as pain, swelling and fever depends on the degree of infection, whether it is chronic or acute. Sometimes, there is a draining abscess on the area of the operculum. It can also be caused when the patient unconsciously bites the operculum.

There could be signs such as redness, draining pus, and difficulty opening the mouth and even swallowing. If not properly managed, it can be worsened and can spread to the fascial spaces and could result to Ludwig’s angina, orbital cellulitis and more.


2. There is unlocalized moderate to severe pain on back side of the cheek. There is pain of unexplained origin.



Eruption of the third molars can bring about several inconveniences. The most common of this is the pain of unexplained origin. Pain, as we know, is a symptom of an underlying condition. Before the cause can be diagnosed, the possibilities should be narrowed down to a few, if not one. One of the possible causes of moderate to severe throbbing pain could be none other than your impacted wisdom tooth. Here are the reasons why:


a) Your tooth is completing its growth therefore indirectly exerting pressure on its adjacent 2ndmolar


The tooth develops from crown to roots. It increases its length as the root grows therefore pushing itself opposite the direction of root growth. This could be towards the adjacent tooth. The adjacent tooth in turn, becomes displaced of its position and it experiences pressure due to the developing, malpositioned wisdom tooth.


b) The growth of third molars causes it to impinge on the nerves


The mandibular third molar position in relation to the inferior mandibular nerve is proximate. It is relatively close to the main nerve that supplies the sensation to the whole mandible and to some areas of the tongue. Some malpositioning permits the growth of third molars to a problematic position where in if it grows, it grows towards the nerves. The crown or the root may become closer to the nerve which makes it exert pressure, this in turn manifests as dull, throbbing unlocalized pain.


c) Some third molars are associated with oral pathological lesions that could also impinge on the nerves or make the tooth impinge on the nerves


Some lesions are associated with mandibular third molars. Such examples are dentigerous cysts, ameloblastoma, radicular cysts and Odontogenic keratocysts. These cysts will be discussed in detail in the future.  But in general, some cells of these pathological lesions comes from the normal surrounding cells of the erupting third molars. But once this tooth has not erupted properly, the surrounding cells that form the normal erupting cyst remains intact underneath the bone. If this remains intact for long periods of time, the cells can transform to more aggressive and destructive lesions. Although in a relatively low statistics can also transform into a malignant lesion.

These oral lesions might go for long periods of time undetected unless destruction of surrounding structures has already begun. Some of these lesions can only be detected if lesion already has a significant size, and sometimes it is only then that they become symptomatic. The hard part is that treatment options may be already radical. This includes


3. There could be difficulty in opening the mouth or swallowing


When the surrounding mucosa of the partially erupted teeth has been infected, it causes inflammation on the surrounding structures. This can be seen as reddish, inflamed, swelling, soft, sensitivity to pressure and sometimes has contiguous pus discharge. Because there is muscle inflammation on muscles of mastication, movements can be limited as compared to normal. This is the natural response of the body to contain the increased number of bacteria, virulence and pathogenicity.

When the infection cannot be contained by the body’s immune system forerunners, it spreads in the fascial spaces (including sublingual spacesubmandibular spaceparapharyngeal spacepterygomandibular spaceinfratemporal spacesubmasseteric space and buccal space) to areas of the face and neck and causes localized disturbance to the structures. If infection is not controlled, this may cause worse symptoms such as swelling, difficulty swallowing and breathing


4. There is tooth exposure but does not seem to erupt


Some third molars are actually visible by the naked eye but only partially exposed. This is (as discussed) due to adjacent teeth, dense overlying bone and thick, excessive soft tissue. This can be observed as a window exposing the tooth through the gingiva. There is distinction due to differences in color and texture (white vs pink and soft vs hard). Although sometimes a normal occurrence, if observed for a long period of time is already unusual. It is always best to have this consulted with a professional.


5. There is unexplained swelling in the jaw


A swelling can have a few causes. Understanding the causes of swelling can help identify presence or absence of pathology and its classification if present. Here are the possible causes of third molars associated swelling:

a) The third molar is badly broken down by caries which then causes infection


This causes chronic apical periodontitis or acute apical abscess. This happens when the caries is too deep, reaches the pulp and provides a pathway of oral bacteria to supporting structures. Bacteria and inflammatory deposits then occupy the bone, gingiva and pulp. This can lie undetected and can also be exacerbated that could cause extreme pain, swelling, redness and fever.

The swelling is caused by the body’s inflammatory products to decrease the amount of bacteria and control the infection. If infection is acute, symptoms may be more prominent but if it is long standing, it could drain in the fistula or the pathologic pathway to the external environment: either inside the mouth or outside the face

b) The third molar is associated with other oral pathological lesion


As discussed above, teeth that will erupt has a cystic cavity that is lined by the epithelial cells of the reduced enamel epithelium of the tooth forming organ. This remains in the periodontium (here refers to alveolar bone) until the tooth has erupted in the oral cavity. If the impacted tooth remains inside the bone for years and lies undetected, there is an increased tendency for these normal cells to transform to cystic and tumorlike lesions which could either be benign or malignant.

What is worse is that these can only be detected if it already has a significant size (2cm and above depending on the location). Significantly sized lesions means that a large bone already has been resorbed (eaten) by the oral lesion. Whether the growth is fast or not, a lesion with a significant size has the tendency to be treated by radical means.

Some of the treatment options are marsupialization, enucleation, partial resection or complete resection. This is why regular check-up with the dentist is necessary for safe diagnosis.



The routine recommendations of any impacted wisdom teeth should be its removal unless contraindicated by factors such as


  1.  a) extremes of age
  2. b) compromised medical status
  3. c) removal may cause extreme damage to significant oral structures


The indications and contraindications of removal of impacted wisdom teeth will be discussed further in another blog. If you have observed any of these signs and symptoms, maybe it is time to consult your dentist.


 Author: Dr. Keneshia Tingson