Wisdom Teeth Removal (What’s Involved?)

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Dr. Matthew Hannan | My Dental Advocate
Matt Hannan, DDS
Updated: July 5, 2023
Impacted Wisdom Teeth X-ray | My Dental Advocate

Wisdom teeth removal is a daunting procedure that most people fret about in their early years. According to a recent study, 10 million wisdom teeth are removed from 5 million patients every year. It’s stressful to think about being put to sleep, having teeth extracted, and managing the pain after; while bedridden for days.

Understanding the wisdom teeth removal process from start to finish will help eliminate fear, anxiety, and worry before surgery. In addition, it’s essential to learn about common signs and symptoms of wisdom teeth pain and learn how to manage post-operative complications.

 Recommended Reading: Wisdom Teeth | The Ultimate Guide

What are wisdom teeth?

Wisdom teeth or third molars are the last adult teeth to erupt and are located in the back of the mouth. They come in between the ages of 17 and 25, but their eruption time is variable. Most people have four wisdom teeth (two on top and two on the bottom); however, it’s possible to have one, two, three, or more than four; the extra teeth are called supernumerary teeth.

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They are called wisdom teeth because they come in when you are more mature in age. Because wisdom teeth are the last teeth to erupt, there is minimal room left in the mouth for them to fit. Occasionally they can fit without any issues; often, they need to be removed because of lack of space, impaction (poor tooth position), gum issues, or cavities.

Is it necessary to remove wisdom teeth?

No, it’s not necessary to remove all wisdom teeth. This question has been debated for many years within the dental community whether or not wisdom teeth should be prophylactically removed, referring to the removal of wisdom teeth to prevent future problems.

Although wisdom teeth removal is highly successful, potential adverse effects can occur, such as pain, soreness, prolonged numbness, or permanent numbness (paresthesia).

The risk of future disease requiring the removal of wisdom teeth in patients who don’t have them removed exceeds 70% after 18 years.

Often, a toothache in the back of the mouth or lower jaw is the first sign of wisdom teeth eruption. Earaches and headaches may also occur due to insufficient space for the wisdom teeth to erupt. This sensation is called referred pain because the pain triggers a response away from the actual pain source.

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Wisdom teeth symptoms

  • Toothache
  • Gum inflammation
  • Cheek biting
  • Jaw tenderness
  • Difficulty opening and closing
  • Food-trap behind 2nd molars

When wisdom teeth erupt and push through the gums, small holes develop and allow food to pack in hard-to-clean areas. If the food is not cleared away, cavity-causing bacteria will congregate and cause tooth decay. In addition, gum inflammation will occur, and gum disease and bone loss will occur if left untreated.

 Recommended Reading: Wisdom Teeth Pain: Symptoms, Causes, Relief & Home Remedies (Helpful Tips)

Although wisdom teeth pain closely resembles TMJ pain or pain caused by a cavity, there are distinct differences. Your dentist will evaluate your teeth and take x-rays; however, these are the most common symptoms of cavity-causing pain.

Cavity symptoms

  • Sensitivity to hot and cold
  • Pain when biting down
  • Pain caused by a stimulus
  • Tooth discoloration
  • Visible hole in tooth

What are impacted wisdom teeth?

Third molars are impacted when they don’t have enough room to erupt correctly. These teeth are “stuck” below the bone or gum line and are often positioned sideways toward the adjacent teeth. Impacted wisdom teeth should be extracted before the roots have fully formed, between the ages of 15 and 25.

 Recommended Reading: Impacted Wisdom Teeth: Symptoms, Causes, Removal & Recovery

Untreated impacted wisdom teeth will harbor bad bacteria. Oral bacteria can travel from your mouth through the gum tissue and into the bloodstream leading to systemic infections affecting the heart, kidneys, and other organs. Diabetes, heart disease, and kidney disease are common systemic health conditions associated with oral bacteria invasion.

In addition, problems can occur when the roots are fully grown and cause difficulties for the surgeon during the procedure.

9 out of 10 people have at least one impacted wisdom tooth.

Problems associated with impacted wisdom teeth

  1. Infection – Lack of adequate room to erupt will irritate the gum tissue, resulting in recurrent pain and infection (pericoronitis). Patients often begin inadvertently biting on the inflamed gum tissue, intensifying the problem. Smokers are more susceptible to pericoronitis. A recent study showed that 72.4% of patients between 20 and 25 presented with pericoronitis before wisdom teeth removal.
  2. Crowding – According to a recent study, some dentists believe that lower third molars cause teeth crowding, whereas others deny this theory. Retained impacted wisdom teeth may be a contributing factor in teeth crowding; however, there are other factors to consider, including gum health, tooth shape, size, and patient’s age.
  3. Tooth decay – Malposed (crooked) wisdom teeth can be difficult clean, and this encourages cavity-causing bacteria growth. In addition, cavities can form deep below the gum line and are nearly impossible for the dentist to manage.
  4. Cyst formation – Cysts are fluid-filled “sacs” within the jaw that can develop due to impacted wisdom teeth. Cysts are challenging to manage and can destroy adjacent teeth, gums and bone. In addition, cysts can expand into essential elements, including the IAN (Inferior alveolar nerve) and various blood vessels.
  5. Damage to adjacent teeth – Impacted wisdom teeth angled toward the adjacent teeth can inadvertently grow into the tooth roots and cause tooth resorption. This irreversible process can affect both teeth and requires tooth extraction. Unfortunately, tooth resorption cannot be repaired or prevented.
  6. Bone loss/periodontal disease – Impacted wisdom teeth can resorb bone tissue supporting the adjacent teeth. The disease process results in moderate to severe bone loss around the “healthy” second molar and may require removal if inadequate bone support is present.

Studies have found that periodontal disease in expectant mothers may be associated with a greater likelihood of preterm and low birthrate babies.

How to know when you need your wisdom teeth removed?

Patients are first evaluated by their dentist or orthodontist in their mid-teenage years using oral examination and x-rays to monitor the eruption status of wisdom teeth. Studies show that early detection and treatment intervention provides the best opportunity for success.

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Third molars can be retained if they meet these conditions:

  • Completely erupted
  • Functional
  • Painless
  • Cavity-free
  • Disease-free
  • Healthy & clean

Wisdom teeth are easier to remove when the patient is younger because the roots haven’t fully formed, the bone is softer, and the wisdom teeth are away from nearby nerves and other structures. In addition, younger patients can recover faster compared to older patients.

Morbidity associated with wisdom teeth extraction and the risk of complications has been shown to increase with age.

On the other hand, wisdom teeth are more difficult to remove the more senior the patient becomes; bone is thicker and denser, and tooth roots extend toward the nerve and other vital structures. In rare situations, the tooth roots can wrap around the nerve.

First signs of wisdom teeth

  • Inadvertent cheek biting
  • Dull ache in the lower jaw
  • Jaw is warm to the touch
  • Gum tissue is red and inflamed
  • White spots on gums

What is evidence-based management of third molars?

Evidence-based clinical decision-making (EBCD) is a systemic approach utilized by clinicians that considers the best available scientific evidence, clinical expertise, and patient values to solve a clinical problem (wisdom teeth extraction).

Evaluating third molars surgery using (EBCD)

  • Every patient & treatment case is unique
  • Consider patients’ medical & dental history
  • Intraoral & extraoral evaluation
  • Radiographic (x-ray) evaluation
  • Consultation between dentist, orthodontist, and oral surgeon
  • Evaluate pros & cons

Third molar treatment options

According to the American Association of Oral and Maxillofacial Surgeons (AAOMS), “…third molar teeth [with] disease, or are at high risk of developing disease, should be surgically managed. Active clinical and radiographic surveillance is indicated in the absence of disease or significant risk of disease.”

Extraction of third molars reduces the risk for periodontal disease in young adults.

Even though most patients will need their third molars extracted, some patients are able to maintain these teeth for a lifetime with no issues. Yearly intraoral, extraoral, and radiographic (x-ray) observation is recommended for patients with healthy, asymptomatic, disease-free wisdom teeth.

Depending on the consultation results and patient examination, the oral surgeon may extract the tooth, partially remove the tooth or monitor the tooth over time (active surveillance). It’s important to remember that an absence of symptoms does not equate to a lack of disease.

  1. Extract tooth – Requires removal of the entire tooth, including the roots. Complete tooth removal is indicated when there is unobstructed access to remove the tooth, and the roots are away from the nerve and other tissue structures.
  2. Partially extract tooth – Requires the removal of the crown portion of the tooth, whereas the roots are left within the jaw. This procedure is known as a coronectomy. It’s indicated when wisdom tooth roots are dangerously close to the nerve, wrapped around the nerve, or within the nerve chamber. After the tooth crown is removed, the roots are safely housed within the bone; however, yearly x-rays are recommended to confirm health.
  3. Active surveillance – Requires yearly observance of wisdom teeth to observe any changes that may occur over time. Active surveillance is indicated when patients have asymptomatic, healthy, and disease-free wisdom teeth with enough room to erupt. No surgery is needed at the time; however, issues such as tooth decay, bone loss or infection will lead to intervention.

Wisdom teeth classifications

Wisdom teeth classifications are used to predict surgical difficulties and potential complications. In addition to evaluating the position of the third molars, your oral surgeon will factor your age, sex, systemic health, dental health, current medications, and cardiovascular health.

Although there are various classification methods, the most common method is based on the nature of the overlying tissue.

  • Erupted – The third molar has fully erupted above the bone and gum tissue. Complete eruption only occurs if there is adequate space for the tooth and it erupts in an upright position.
  • Soft tissue impaction – Requires the wisdom tooth to be above the bone level but below the gum tissue level. The wisdom tooth is not visible in the mouth; however, the patient may note a significant bump under the gums. This is the most accessible type of tooth impaction to remove surgically.
  • Hard tissue (bony) impaction – This occurs when the wisdom tooth is below the bone level and is obstructed (blocked) from erupting. Bony impaction is divided into two categories; partial bony and complete bony impaction.
  • Partial bony impaction – Involves a portion of the wisdom tooth above the bone level but below the gum tissue level. Partial bony impaction may require sectioning the tooth to remove in pieces.
  • Complete bony impaction – Involves the complete obstruction of the wisdom tooth due to tooth angulation or encased within the bone. These are the most difficult teeth to remove and involve removing large portions of bone and sectioning the wisdom tooth to pieces.

Wisdom teeth pain relief

If you are dealing with wisdom tooth pain there are various methods to help alleviate the pain; however, it’s best to contact your dentist as soon as possible for an evaluation. In the meantime, over-the-counter medication such as Ibuprofen or Tylenol will help alleviate pain and inflammation.

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Other pain relief methods include:

  • Saltwater rinse
  • Topical benzocaine
  • Clove oil
  • Cold compress
  • Antibiotics
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Sedation options for wisdom teeth removal

Most patients and clinicians prefer sedation during third molar extractions to relieve patient anxiety and minimize unexpected movements that could compromise the surgical procedure. In addition, sedation will supress the patient’s stress level, preventing a spike in blood pressure that may lead to a cardiovascular event (heart attack).

 Recommended Reading: Sedation Options for Wisdom Teeth Removal (Read this FIRST)

If the wisdom teeth are erupted and easily accessible to the surgeon, local anesthesia can be administered without sedation for surgical extractions. However, sedation dentistry is advised for most wisdom teeth if the patient is between the ages of 15 and 25 because the teeth are impacted and require more extensive surgical treatment.

Aside from nitrous oxide (laughing gas), the two most common sedation methods are conscious sedation and general anesthesia (deep sedation).

  • Nitrous oxide – Laughing gas is a safe and effective gas that is rapidly inhaled and exhaled, leading to a quick response and recovery after treatment. The patient is awake, aware and able to respond to cues and questions; however, their body will feel calm, heavy, and comfortable for treatment. Unlike conscious sedation and general anesthesia, they do not need a designated driver.
  • Oral conscious sedation – Valium (diazepam) is the most common form of oral conscious sedation and involves taking medication 30-60 minutes before the procedure. Often, your clinician will have you take the medication in the office and monitor your vitals before the procedure. You will need a designated driver to take you home after the procedure, and you may not recall your experience at the dentist.
  • IV conscious sedation – IV conscious sedation is more potent than oral sedation, with a quicker onset into the bloodstream. Often you can still respond to cues and questions; however, you will not recall your visit. Like oral conscious sedation, you will need a designated driver to take you home after the procedure.
  • General anesthesia – This is the most common sedation method for third molars and essentially “makes you sleep” during the procedure. The anesthesiologist or oral surgeon will monitor your vitals during the procedure. In addition, this is the preferred method as you wake up after the procedure without realizing you even went to the dentist.

What’s involved BEFORE wisdom teeth extractions?

If your dentist or orthodontist recommends removing your wisdom teeth, they will refer you to an oral surgeon (OMS) for the procedure. The surgeon will review your medical and dental history, current medications, and other information during your consultation appointment.

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In addition, the surgeon will review your x-rays and discuss the treatment plan and what to expect. This is a great time to ask any question you believe is helpful before the procedure. Ultimately, your surgeon desires you to be comfortable and understand what’s involved.

What’s involved DURING wisdom teeth extractions?

On the day of your surgery, it’s essential that you don’t eat or drink 8 hours before the procedure, although the dentist will advise you to take medication you generally take (unless it interferes with the procedure – your surgeon will discuss this with you).

Generally, wisdom teeth can be extracted with little to no pain, and the procedure will take 30-60 minutes to complete. Plan accordingly, as you and your driver will be in the office for approximately 90 minutes. Wisdom teeth extractions are considered an outpatient procedure, so you can go home afterward.

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Procedure steps

  1. The oral surgeon or anesthesiologist will administer anesthesia/sedation. General anesthesia is the most common method, allowing you to “fall asleep” and not recall the procedure. In addition, the dentist will monitor your vitals, including blood pressure, heart rhythms, pulse, and blood oxygen.
  2. Local anesthesia will be administered to numb the teeth adequately. In addition, the dental assistants will support your head, neck, and jaw as you cannot actively support them.
  3. An incision will be made behind the second molars to allow access to the bone and wisdom teeth.
  4. After the gums are retracted, a surgical handpiece will be used to remove bone above and around the tooth. The surgeon will carefully cut bone to access the teeth without disturbing the nerve and other vital elements.
  5. The tooth is “sectioned” (split into pieces) to allow easier removal within the small, confined space.
  6. The tooth is then carefully elevated (rocked back and forth) and extracted.
  7. The tooth socket is rinsed with sterile saline (salt water) to remove any tooth or bone particles that may be left behind.
  8. Sutures/stitches will be placed over the tooth socket to allow a blood clot to form and prevent food debris from entering the space. Dissolvable stitches will be placed and will last for 3-5 days before dissolving.
  9. Medication will be administered to reverse the general anesthesia and cause you to wake up from the sedation. In addition, you will be sleepy for most of the day, so be sure to rest and recover.
  10. Gauze packs will be placed and keep firm pressure for 30-60 minutes to encourage blood clot formation.

What’s involved AFTER wisdom teeth extractions?

After the procedure, the dental team will discuss post-operative instructions with your driver before heading home. The local anesthesia will wear off soon after, so take OTC Ibupfron and Tylenol (400 mg IBU + 1000 mg Tylenol) unless the surgeon prescribes prescription pain medication.

Be sure your pharmacy fills the pain medication before your procedure so you can take the medication BEFORE the local anesthesia wears off.

You may experience swelling, oozing, and mild discomfort for a few days after the procedure. Use a cold pack and anti-inflammatory OTC medications to minimize swelling. Also, you may have difficulties opening and closing your jaw as the muscles have been stretched during the procedure. In addition, expect bleeding and oozing to occur for up to 24 hours.

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Your surgeon will provide you with more detailed instructions, including changing the gauze if bleeding persists, avoiding physical activities for 3-5 days, and sticking with a soft-food diet for two weeks. Wisdom teeth extractions take two weeks to heal; however, call your doctor with any questions or concerns.

If antibiotics are prescribed and you are taking birth control pills, consider alternative birth control methods as birth control pills may be ineffective.

What to eat after wisdom teeth removal

Adequate nutrition after wisdom teeth surgery is essential to replenish your body with nutrients, vitamins and minerals to aid recovery. Your body spent many calories during the surgery and will continue spending calories for the next 1-2 weeks during the healing process.

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Dairy products such as yogurt, ice cream or milkshakes are not recommended soon after surgery, as nausea and vomiting may develop in conjunction with the anesthetic and pain medication.

Stick to foods such as mac & cheese, applesauce, scrambled eggs, soups, oatmeal and mashed potatoes. In addition, protein drinks provide a great source of nutrients in an easy-to-consume liquid formula.

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Most common complications after wisdom tooth removal

Although every effort is made to minimize complications, 4.3% to 9.1% of cases result in some degree of complications.

According to a recent study, the most frequent complication was alveolar osteitis (dry socket), occurring in 3.9% of cases. The second most common complication in 1.5% of cases was a post-operative temporary or permanent sensation disorder. Managing post-operative complications becomes more challenging if immediate care is not taken. When in doubt, call your dentist if you have any questions or concerns.

How to manage surgical complications

  • Dry socket (alveolar osteitis) – Dry socket is the most common complication and occurs when the blood clot falls out, exposing infected bone. This condition is excruciating and most often occurs around days 3 and 4. Dry socket is managed with dry socket paste (eugenol + cloves) at the oral surgeon or irrigated with sterile saline to initiate a new blood clot formation.
  • Temporary/permanent numbness (paresthesia) – This complication can occur from trauma to the inferior alveolar nerve (IAN) that runs adjacent to lower wisdom teeth. According to a recent study, inferior alveolar nerve (IAN) paresthesia occurs 0.35% to 8.4% of the time. Although these figures are relatively low, they are still significant for patients and clinicians.

Complete recovery of inferior alveolar nerve injury (IANI) occurs 6 to 8 weeks after the trauma, although it may take up to 24 months.

  • Excessive bleeding – Bleeding and oozing are expected up to 24 hours after surgery; however, if you are actively bleeding after 24 hours, call your dentist as soon as possible. Patients taking blood thinners or other platelet management medications may experience this complication. Bite on a tea bag until your dentist can see you.
  • Damage to adjacent teeth – During the surgery, the oral surgeon uses great force to pry and loosen the wisdom teeth from the bone. It’s not uncommon for the surgeon to inadvertently damage adjacent teeth, specifically crowns or fillings. However, most complications can be quickly resolved by your dentist.
  • TMJ damage/clicking/popping -The TMJ can be stretched and traumatized during the procedure as the surgeon and assistants access the wisdom teeth. Although it’s uncommon, clicking or popping after your wisdom teeth have been removed may occur and if there is no pain, there is no cause for concern.
  • Jaw muscle strain – Similar to TMJ trauma, the muscles that support the jaw will be stretched during the procedure. As a result, sore, stiff or tender muscles are common for 1-2 weeks after the surgery. Use a cold compress for the first 36 hours to minimize swelling, followed by alternating cold and warm packs afterward. In addition, it’s not uncommon to have limited jaw opening after surgery because of jaw muscle strain.
  • Swelling & infection – Swelling and bruising are expected after wisdom teeth removal; however, if you notice signs of infection, including an elevated temperature, contact your surgeon as this may be a sign that you need antibiotics. In addition, use OTC anti-inflammatory medications (Ibuprofen, Motrin, Advil) as is necessary to minimize inflammation and pain.
  • Poor nutrition – It’s essential to stay hydrated after the surgery and consume adequate carbohydrates, protein, vitamins and minerals. Stick to a soft food diet for 1-2 weeks. Consume foods such as mac & cheese, applesauce and protein shakes. Poor nutrition will lead to poor healing and immune response. In addition, be sure to get enough sleep to allow your body to recover after surgery.

A dry socket occurs when the blood clot fails to form or falls out of the socket. As a result, the exposed bone becomes inflamed and causes severe pain, predominantly in the lower extraction sites. Dry sockets commonly occur around day 3 or 4 and are highly unlikely to occur after one week. According to the literature, the dry socket pain can last 7-14 days after surgery and the total healing time is increased.

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How to prevent dry socket

  1. Avoid using a straw, spitting or swishing vigorously up to 48 hours after surgery
  2. Allow warm salt water to pour out of your mouth when rinsing
  3. Avoid smoking & chewing tobacco up to 48 hours after surgery
  4. Avoid brushing the extraction site for 3-4 days
  5. Avoid crunchy, hot and spicy foods
  6. Consume a soft-food diet for 1-2 weeks after surgery

What does a dry socket look like?

Dry sockets appear red, pink, or white. The red and pink coloration is the blood clot remnants left behind. The white coloration is the infected bone surface that triggers the pain response. The tooth socket will be visible with minimal or no active bleeding.

Although there is a dry socket paste available (eugenol + cloves) that provides immediate relief, most clinicians will avoid applying it to the socket because it delays healing time and increases the chances of infection.

An alternative treatment method includes rinsing the tooth socket with sterile saline and curating (scraping) the socket walls to stimulate a new blood clot.

Increased risk of post-operative complications

According to literature, post-operative complications are rare; however, they do occur. Many factors increase your chances of complications, including medical conditions, age, immune response and oral health.

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Other factors include

  • Diabetes
  • Heart Disease
  • Immunocompromised (HIV/AIDS, Cancer)
  • Blood thinners
  • Certain medications
  • Poor oral health
  • Poor surgical technique
  • Incompetent surgeon

Is top or bottom wisdom teeth removal worse?

Generally, upper wisdom teeth are less challenging to remove because they are easier to access, and the upper jaw bone is thinner than the lower jaw bone. In addition, the oral surgeon can remove the upper teeth without worrying about invading any major nerves or blood vessels in the area.

Lower wisdom teeth are more challenging to remove because the lower jaw bone is thick cortical bone, and impacted wisdom teeth can face many directions. In addition, the oral surgeon has to be extremely careful not to damage the lower nerve (inferior alveolar nerve) as that may cause permanent lip numbness (paresthesia).

Oral surgeons are some of the most skilled and respected dentists because of their surgical expertise and technical abilities. Periodontists are also trained to remove wisdom teeth; however, they primarily focus on managing periodontal disease and placing implants.

Recovery after wisdom teeth removal

Wisdom teeth removal is a standard outpatient procedure for patients between the ages of 15 and 25. Recovery after wisdom teeth removal takes 3-4 days, but it can take 1-2 weeks for symptoms to subside. Your oral surgeon will provide detailed post-op instructions, including contact information. In addition, you must follow the at-home care instructions that your surgeon gives you to prevent complications and to improve healing.

Your mouth is designed for optimal healing and regeneration; however, expect the tooth socket to take 3-6 months to heal completely.

Follow these steps to minimize complications and recover quicker:

  1. Take prescribed medication before the local anesthesia wears off
  2. Rest and recover for the first 3-4 days to allow the mouth to heal
  3. Avoid sucking, spitting, smoking or vigorously swishing to prevent dry socket.
  4. Use cold compress up to 36 hours after surgery to reduce inflammation, pain and swelling
  5. Alternate between hot and cold packs after that to stimulate healing
  6. Gently rinse mouth out with warm salt water 2-3x/day
  7. Gently massage TMJ and jaw muscles to decrease soreness
  8. Keep head elevated up to 72 hours after surgery to minimize pain and swelling
  9. Sleep often and stay off of your feet
  10. Avoid physical activity for 3-4 days
  11. Consume adequate amounts of fluid and electrolytes (Gatorade)
  12. Consume sufficient amounts of nutrients (soft-food diet)

Can you work after wisdom teeth removal?

Talk to your surgeon about their recommendations to return to work; however, most clinicians will encourage you to take 2-4 days off work after surgery. Consider having your wisdom teeth removed over a holiday break, weekend or when you have time off of work to allow your body to rest and recover.

If you return to work, avoid physical activity or exertion, including bending, lifting or straining, as this will increase blood pressure, disturb the developing blood clot, and delay healing.

My Experience & Expertise

Wisdom teeth removal is a standard procedure to help you maintain oral health and minimize complications. By understanding what’s involved in the surgery, including the recovery process, you’ll be better prepared for your surgery and know what to expect. If you have any questions or concerns, speak with your dentist.

Knowledge is power when cultivating healthy dental habits. The more informed you are, the better positioned you’ll be to prevent avoidable and potentially costly dental procedures for you and your family. Watch for future blog posts, where we’ll continue sharing important information, product reviews and practical advice!