Patient information and consent to Surgical Removal of Impacted Wisdom Teeth

Key messages

• Please read your admission letter carefully. It is important to follow the instructions we give you about not eating or drinking or we may have to postpone or cancel your operation.
• Please read this information carefully, you and your health professional will sign it to document your consent.
• It is important that you bring the consent form with you when you are admitted for surgery. You will have an opportunity to ask any questions from the surgeon or anaesthetist when you are admitted. You may sign the consent form either before you come or when you are admitted.
• Please bring with you all of your medications and its packaging (including inhalers, injections, creams, eye drops, patches, insulin and herbal remedies), a current repeat prescription from your GP, any cards about your treatment and any information that you have been given relevant to your care in hospital, such as x rays or test results.
• Take your medications as normal on the day of the procedure unless you have been specifically told not to take a drug or drugs before or on the day by a member of your medical team. If your procedure is being performed under general anaesthesia or sedation, do not take any medications used to treat diabetes on the day of surgery. However if you are being treated as an outpatient under local anaesthesia take your diabetic medicines as normal and eat and drink normally.
• Please call the Department of Oral and Maxillofacial Surgery, Clinic 8, on 01223 216635 if you have any questions or concerns about this procedure or your appointment.

After the procedure we will file the consent form in your medical notes and you may take this information leaflet home with you.

Important things you need to know

Patient choice is an important part of your care. You have the right to change your mind at any time, even after you have given consent and the procedure has started (as long as it is safe and practical to do so). If you are having an anaesthetic you will have the opportunity to discuss this with the anaesthetist, unless the urgency of your treatment prevents this.

We will also only carry out the procedure on your consent form unless, in the opinion of the health professional responsible for your care, a further procedure is needed in order to save your life or prevent serious harm to your health. However, there may be procedures you do not wish us to carry out and these can be recorded on the consent form. We are unable to guarantee that a particular person will perform the procedure. However the person undertaking the procedure will have the relevant experience.

All information we hold about you is stored according to the Data Protection Act 1998.

About surgical removal of impacted wisdom teeth

The wisdom tooth (or third molar) is usually the last tooth to erupt into the mouth, this can happen anytime after about 16 years of age. Frequently, there is not enough room in the mouth to accommodate the erupting wisdom teeth, and therefore, they might not always come into the mouth normally. When this happens, the wisdom teeth are said to be ‘impacted’. Wisdom teeth are usually either impacted forwards into the tooth in front or backwards into the jaw bone.

Why do I need treatment?

An impacted wisdom tooth can cause a number of problems if not removed:

• repeated attacks of infection in the gum surrounding the tooth, leading to pain and swelling
• food packing, which causes decay in either the wisdom tooth or the tooth in front
• cysts can form around the wisdom tooth if it does not come into the mouth properly. A cyst occurs when fluid fills the sack that normally surrounds a developing wisdom tooth.

Intended benefits

To prevent any problems that can occur from an impacted wisdom tooth, most commonly being infection.

Who will perform my procedure?

This procedure will be performed by a suitably qualified and experienced surgeon, or a trainee surgeon under the direct supervision of a suitably qualified and experienced surgeon.

Before your procedure

Most patients attend a pre-admission consultation, when you will meet members of the maxillofacial surgery team. At this clinic, we will ask you for details of your medical history and carry out any necessary clinical examinations and investigations including X-rays. This is a good opportunity for you to ask us any questions about the procedure, but please feel free to discuss any concerns you might have at any time.

You will be asked if you are taking any tablets or other types of medication - these might have been prescribed by a doctor or bought over the counter in a pharmacy. It helps us if you bring details with you of anything you are taking (please bring the packaging or a list of medicines with you). Please tell us if you have a prescription for Warfarin, Aspirin, Rivaroxaban, Dabigatran, Apixaban, Edoxaban or Clopidogrel, Ticagrelor or blood thinning medication.

The type of anaesthetic will be discussed with you before the operation, together with any possible complications of the surgery. A number of options are available and depend on how difficult the wisdom tooth is to remove.

Local anaesthetic

This is an injection into the gum surrounding the wisdom tooth, rather similar to the injection you might have had at your dentist for a filling. The injection takes a couple of minutes to numb the area and means that you will feel no pain while the wisdom tooth is removed. For wisdom teeth that are simple to remove, this is the best option.

Local anaesthetic and intravenous sedation

In addition to a local anaesthetic injection, you can be given an injection into your arm or back of your hand. This makes you feel relaxed and less aware of the procedure.

Please note - IV Sedation is not offered at present.

General anaesthetic

It is usually possible to remove wisdom teeth as a day case under general anaesthetic, i.e. although you are asleep during the procedure, you will be able to go home on the same day as the surgery. You will find out more about general anaesthesia at the end of this leaflet.

During the procedure

Because the wisdom tooth has not fully erupted into the mouth it is often necessary to make a cut in the gum over the tooth. Sometimes it is also necessary to remove some bone surrounding the wisdom tooth and/or section the tooth into two or three pieces to remove it. Once the wisdom tooth has been removed the gum is put back together with stitches. In the majority of cases these stitches are dissolvable and take around two weeks to disappear.

Some wisdom teeth can take a few minutes to remove. More difficult wisdom teeth that need to be cut into pieces to remove can take around 20 minutes to remove.

After the procedure

How you will feel after the removal of your wisdom teeth will depend on what has been done, whether you had a local or general anaesthetic and how well you heal.

It is likely that there will be some discomfort and swelling both on the inside and outside of your mouth after surgery. This is usually worse for the first three days but it can take up to two weeks before all the soreness disappears. You might also find that your jaw is stiff and you might need to eat a soft diet for a week or so. If it is likely to be sore, your surgeon will arrange painkillers for you. It might also be necessary for you to have a course of antibiotics after the extraction. There can be some bruising of the skin of your face that can take up to a fortnight to fade away.

Significant, unavoidable or frequently occurring risks of this procedure

You might have swelling and stiffness of the jaw which can last for about one week.

Although there might be a little bleeding at the time of the extraction this usually stops very quickly and is unlikely to be a problem if the wound is stitched. Should the area bleed again when you get home this can usually be stopped by applying pressure over the area for at least 10 minutes with a rolled up handkerchief or swab. If the bleeding does not stop, please contact the department of oral and maxillofacial surgery.

Pain and discomfort after surgery can usually be well controlled by regular pain killers like Paracetamol or Ibuprofen. If you require stronger pain killers these would be prescribed by the surgeon.

Infection is uncommon, particularly if good oral hygiene is maintained after surgery.

There are two nerves that lie very close to the roots of the lower wisdom teeth. One of these nerves supplies feeling to your lower lip, chin and lower teeth. The other supplies feeling to your tongue and helps with taste. Sometimes, when a wisdom tooth is taken out, these nerves can be bruised. This causes tingling or numbness in your lip, chin or tongue, and more rarely can alter taste. About one in 10 people will have some tingling or numbness that can last several weeks.

Less than one in 100 people will have problems that last more than a year. These risks can be higher if your tooth is in a difficult position. The surgeon will tell you if you are considered to be at an increased risk.

A dry socket (alveolitis) can lead to a persistently painful tooth socket which can be slow to heal. The socket then needs to be cleaned and a dressing is usually placed in the socket by the surgeon.

Damage to adjacent teeth and fractures of the mandible (lower jaw or jaw bone) are very rare complications and you will be advised if this risk applies to you.

Alternative procedures that are available

Asymptomatic (not showing any symptoms of disease) wisdom teeth are usually best left alone.

Coronectomy may be offered if the roots of the wisdom teeth are deemed to be intimately related to the nerve in the jaw bone.

In the coronectomy technique the crown of the wisdom tooth is removed (decoronation) leaving the tooth roots behind in an attempt to minimise the risk of nerve damage.

• Lower wisdom teeth can lie close to the nerve inside the jawbone which supplies the feeling but not the movement to the lower lip and chin. We can see this nerve on a normal X-Ray radiograph but sometimes a special cross sectional scan called a cone beam CT is also taken to give a 3D picture of the relationship of the nerve to the tooth roots.
• If the roots of your lower wisdom tooth are judged to be particularly close to the adjacent sensory nerve nerves, then you may be offered a coronectomy instead of complete removal of the whole tooth. Intentionally leaving the roots behind reduces the risk of bruising or stretching of the nerve. This can significantly reduce the risk of permanent lip, chin, cheek, gums and tongue numbness or tingling that can happen after wisdom tooth removal. There are only certain situations where this procedure is recommended. If the tooth is decayed or has a nerve present which has died, the roots will not be healthy and cannot be left behind.

It is possible that the wisdom tooth roots will have to be removed at the time of surgery if they are mobile. The roots may also become infected in the future and need removing. If this happens they usually rise upwards, away from the nerve, reducing the risk of numbness that may occur. Studies suggest that migration of the retained root or delayed healing happens in about 15% of cases, resulting in a need for further surgery.

Whether or not to take out wisdom teeth that are not (yet) causing problems remains debatable. Most dentists will recommend that impacted wisdom teeth are removed particularly if there have already been infections.

If the teeth are only partially erupted teeth, they are more likely to become decayed and infected. Gum disease might develop and the next tooth in the row can become decayed.

Information and support

For general enquiries please contact the department of Oral and Maxillofacial Surgery, Clinic 8 on 01223 216635.

Anaesthesia

This section is relevant to patients who require removal of impacted wisdom teeth under general anaesthesia.

Before your operation

Before your operation you will meet an anaesthetist who will discuss with you the most appropriate type of anaesthetic for your operation, and pain relief after your surgery. To inform this decision, he/she will need to know about:

• your general health, including previous and current health problems
• whether you or anyone in your family has had problems with anaesthetics
• any medicines or drugs you use
• whether you smoke
• whether you have had any abnormal reactions to any drugs or have any other allergies
• your teeth, whether you wear dentures, or have caps or crowns.

Your anaesthetist may need to listen to your heart and lungs, ask you to open your mouth and move your neck and will review your test results.

Pre-medication

You may be prescribed a ‘premed’ prior to your operation. This a drug or combination of drugs which may be used to make you sleepy and relaxed before surgery, provide pain relief, reduce the risk of you being sick, or have effects specific for the procedure that you are going to have or for any medical conditions that you may have. Not all patients will be given a premed or will require one and the anaesthetist will often use drugs in the operating theatre to produce the same effects.

Moving to the operating room or theatre

You will usually change into a gown before your operation and we will take you to the operating suite.

When you arrive in the theatre or anaesthetic room, monitoring devices may be attached to you, such as a blood pressure cuff, heart monitor (ECG) and a monitor to check your oxygen levels (a pulse oximeter). An intravenous line (drip) may be inserted and you may be asked to breathe oxygen through a face mask.

It is common practice nowadays to allow a parent into the anaesthetic room with children; as the child goes unconscious, the parent will be asked to leave.

Before starting your anaesthesia the medical team will perform a check of your name, personal details and confirm the operation you are expecting.

General anaesthesia

During general anaesthesia you are put into a state of unconsciousness and you will be unaware of anything during the time of your operation. Your anaesthetist achieves this by giving you a combination of drugs.

While you are unconscious and unaware your anaesthetist remains with you at all times. He or she monitors your condition and administers the right amount of anaesthetic drugs to maintain you at the correct level of unconsciousness for the period of the surgery. Your anaesthetist will be monitoring such factors as heart rate, blood pressure, heart rhythm, body temperature and breathing. He or she will also constantly watch your need for fluid or blood replacement.

What will I feel like afterwards?

How you will feel will depend on the type of anaesthetic and operation you have had, how much pain relieving medicine you need and your general health.

Most people will feel fine after their operation. Some people may feel dizzy, sick or have general aches and pains. Others may experience some blurred vision, drowsiness, a sore throat, headache or breathing difficulties.

You may have fewer of these effects after local or regional anaesthesia although when the effects of the anaesthesia wear off you may need pain relieving medicines.

What are the risks of anaesthesia?

In modern anaesthesia, serious problems are uncommon. Risks cannot be removed completely, but modern equipment, training and drugs have made it a much safer procedure in recent years. The risk to you as an individual will depend on whether you have any other illness, personal factors (such as smoking or being overweight) or surgery which is complicated, long or performed in an emergency.

Very common (1 in 10 people) and common side effects (1 in 100 people)

• Feeling sick and vomiting after surgery
• Sore throat
• Dizziness, blurred vision
• Headache
• Bladder problems
• Damage to lips or tongue (usually minor)
• Itching
• Aches, pains and backache
• Pain during injection of drugs
• Bruising and soreness
• Confusion or memory loss

Uncommon side effects and complications (1 in 1000 people)

• Chest infection
• Muscle pains
• Slow breathing (depressed respiration)
• Damage to teeth
• An existing medical condition getting worse
• Awareness (becoming conscious during your operation)

Rare (1 in 10,000 people) and very rare (1 in 100,000 people) complications

• Damage to the eyes
• Heart attack or stroke
• Serious allergy to drugs
• Nerve damage
• Death
• Equipment failure
• Deaths caused by anaesthesia are very rare. There are probably about five deaths for every million anaesthetics in the UK.

For more information about anaesthesia, please visit the Royal College of Anaesthetists’ (opens in a new tab) website

Information about important questions on the consent form

Creutzfeldt Jakob Disease (‘CJD’)

We must take special measures with hospital instruments if there is a possibility you have been at risk of CJD or variant CJD disease. We therefore ask all patients undergoing any surgical procedure if they have been told that they are at increased risk of either of these forms of CJD. This helps prevent the spread of CJD to the wider public. A positive answer will not stop your procedure taking place, but enables us to plan your operation to minimise any risk of transmission to other patients.

Photography, Audio or Visual Recordings

As a leading teaching hospital we take great pride in our research and staff training. We ask for your permission to use images and recordings for your diagnosis and treatment, they will form part of your medical record. We also ask for your permission to use these images for audit and in training medical and other healthcare staff and UK medical students; you do not have to agree and if you prefer not to, this will not affect the care and treatment we provide. We will ask for your separate written permission to use any images or recordings in publications or research.

Students in training

Training doctors and other health professionals is essential to the NHS. Your treatment may provide an important opportunity for such training, where necessary under the careful supervision of a registered professional. You may, however, prefer not to take part in the formal training of medical and other students without this affecting your care and treatment.

Use of Tissue

As a leading bio-medical research centre and teaching hospital, we may be able to use tissue not needed for your treatment or diagnosis to carry out research, for quality control or to train medical staff for the future. Any such research, or storage or disposal of tissue, will be carried out in accordance with ethical, legal and professional standards. In order to carry out such research we need your consent. Any research will only be carried out if it has received ethical approval from a Research Ethics Committee. You do not have to agree and if you prefer not to, this will not in any way affect the care and treatment we provide. The leaflet ‘Donating tissue or cells for research’ gives more detailed information. Please ask for a copy.

If you wish to withdraw your consent on the use of tissue (including blood) for research, please contact our Patient Advice and Liaison Service (PALS), on 01223 216756.

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