Keywords: wisdom teeth removal infection, migraine headache, facial pain, TMJ pain
Infected and impacted wisdom (third molar) teeth cause difficulties with oral hygiene in the recesses of the mouth. Awkward to floss and brush, with food debris collecting between the tooth and the jawbone and gum, tooth decay is almost inevitable.
What to do with wisdom teeth remains controversial in the circles or oral surgeons. In some countries the practice of extracting them whether healthy, impacted, infected or not is prevalent. Other countries are less proactive waiting until they create a problem. Fiery debates continue. In the chair by your dentist? Under anaesthetic by an oral surgeon only? Money and defending of turf comes also into the equation.
The problem is that the lingual nerve, which supplies taste to the tongue. and the inferior alveolar nerve lie very close to the lower wisdom tooth. Research reveals that up to about 2% of surgical cases can produce serious injury to one or other of the nerves.
Part of the problem is that the position of the lingual nerve is quite variable, and, in 10% of cases is above the "lingual plate" creating difficulties for oral surgeons.
Another is that prolonged opening of the mouth can cause "trismus" or spasm of the muscles of chewing. Over-opening of the jaw can damage the meniscus within the jaw joint.
This month has seen three women in their thirties suffering from severe facial pain, jaw
joint pain and severe migraine type headache after surgical procedures
in the mouth.
All three were treated under a general anaesthetic. Two developed the pain after wisdom tooth extractions, and one after a procedure for tonsils.
three had associated neck pain, and in one case the stiffness in the
neck raised suspicion of meningitis, resulting in a hospitilisation.
Eventually she was discharged after a negative lumbar puncture, but the
headaches and facial pain continued for some months. No one thought to examine the jaw joints, and the muscles associated with mastication.
Why do women appear to be more prone? This is purely anecdotal so I have no research to present about the sex distribution of facial pain after surgery in the mouth. But a woman has a smaller mouth, and can't open as wide, that's fact. And most dentists and oral surgeons are men, have large hands. Opening of the mouth
under anaesthetic, particularly for a prolonged period, when the patient is unable to protest, and you stand the possibility of facial pain syndrome which will mostly have associated headache and neck pain; the pain may be self limiting, and of a temporary nature, but sometimes in lasts for years.
If the wisdom teeth are not impacted then do your best to convince your dentist to pull your wisdom teeth in his office under local anaesthesia.
With human jaw bones gradually becoming smaller, there is less space for the wisdoms, or third molars as dentists call them, and they have the propensity to crowd the adjacent molars causing them to malalign, both with neighbouring teeth and the molars from the opposing jaw. These crooked teeth are both visually not pleasing but more seriously it affects chewing and the harmony of the paired TMJs.
In addition, they often impact or erupt only partially causing a host of difficulties; more information on dentistry sites. In particular they are often half covered by a flap of gum that makes wisdom teeth removal infection almost inevitable. Food particles gets trapped under the flap making it very difficult to clean the teeth properly.
Because of their location remotely in nethermost nooks of the mouth, and the fact that food particals tend to accumulate behind the wisdom tooth, brushing and flossing is usually less effective. So, infection; pain, redness, swelling affects the area locally, but the infection may also spread into the bone and the jaw joint which lies very close by; the pain and even spread to the cervical spine; the sensory nucleus of the nerve that supplies the jaw is found in the neck, so you may feel mouth related pain in the neck, strange as that may seem.
So, for dentists a frequent practice is wisdom tooth removal before infection. It's sensible, and I take no issue with the practice. Prevention is better than a cure in the mouth just as elsewhere in the body, especially as wisdoms often have smaller roots and can be easily extracted without the necessity of a general anaesthetic. In short, by your dentist in the chair in his or her clinic.
Controversy reigns about when is the optimum time. In some parts of the world wisdom tooth extraction is recommended as teenagers, even perfectly healthy wisdoms, before they inevitably cause infection; and before the jawbone becomes harder and thicker, making extraction more difficult and a greater likelihood of injuring the nerves and even the floor of the sinuses as the upper wisdom teeth come out.
In other words, before the infected wisdom, marked in the graphic above, begins to infect adjoining wisdoms as we may see happening.
The long and the short of it is that you are probably going to have all four wisdom teeth extracted, one way or another, sooner or later, if they haven't already been pulled.
There certainly is a place for infected and impacted wisdom teeth removal under a GA, especially as the Lingual and Inferior alveolar nerves may be damaged during a difficult impaction.
This however needs to be the exception, not the rule; plead with your dentist to pull your infected wisdom teeth in the chair under a local anesthetic. Quite apart from the cost, which will be much higher under a general, but more important will less likelihood of injury to your TMJ.
Noscomial infection in hospital, dangers of a general... have your dentist pull them, unless he strongly recommends in your case you attend a surgeon. Which will happen occasionally.
In most instances it's routine to have a fully erupted wisdom pulled under a local in the chair. Squeal if s/he is over opening your mouth.
Case history: Wisdom tooth extraction and headache
A 30-year old woman consulted me with R TMJ pain, facial pain and severe headache, and upper cervical pain. Three months previously she had her wisdom teeth extracted under general anaesthetic.
On examination, there was extreme tenderness of the right TMJ with associated active trigger points in the right masseter, temporalis and external pterygoid muscles.
Fortunately there were no popping or clicking sounds from the TMJs, but there was delayed opening of the left TMJ.
Rotation of the neck, in both directions was painful, with a marked fixation of C2.
There were other details that I won't bore you with. It took six treatments of her upper cervical spine, jaw joint mobilisation and deep, painful soft tissue work of the muscles, to relieve her severe facial pain and headaches.
I'm hoping her condition will now stabilise; she's had to stop chewing gum. The next step is TMJ exercises. But there is no guarantee that this will not continue, and become chronic migraine and facial pain. If often does, but fortunately she didn't wait years before consulting me.
Popping, clicking jaw joints
If the jaws are forced even wider, then the meniscus in the joint is injured, and the joint begins to develop a painful click, often associated with facial and jaw joint pain and headaches.
Prevention is the key. If at all possible, have them out in the chair.
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Interesting challenges of the day
1. Mr B has the trophy for the most acute neck in February. He has quite advanced lower neck arthritis for a forty year old, thanks to a severe fall on the head from a trampoline. But this is upper cervical pain. Right rotation is simply impossible. Luckily he is improving rapidly, eighty percent better he says after three treatments. See cervical facet syndrome.
2. Mrs C is a new patient with a long history of lower back pain, hip pain and pain in both feet. We'll see how we get on, Rome wasn't built in a day.
3. Miss U sprained her ankle two months ago, wearing high heels. She still has severe mid foot pain. Xrays and perhaps a CT scan.
4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.
5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.
6. Mrs X, a young mother has severe lower back pain, with numbness down the posterior thigh, calf and side of foot. It started after a long drive in the car. Update, she's forty percent less painful after four treatments, but the leg is still numb. Update two; she 60% better, but it's slow and is going to take the full 6 weeks to heal. Further update; a setback, after lifting her child she now has leg pain. It's going to the be difficult.
7. Mrs Y, a 70 year old woman is on maintenance care fo a nasty lumbar stenosis despite having to do everything at home. Her husband has a hospital acquired infection in the shoulder. After 4 operations he is incapacitated and going rapidly down hill.
8. Mrs Z, an 78 year old woman is doing remarkably well with a bad sciatica. But at over 200 lbs she is not losing weight, in fact gaining despite my suggestions. She's high risk for a stroke. Referral to a dietician to crack the whip.
9. Mr A, a 73 year old engineer, still working, is doing fine after a long episode of lower back pain. Some pain on the side of the hip remains after five treatments. Reassured him it's not hip arthritis.
10. Mrs B, a 64 year old woman has had Scheuermanns disease; it's left with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment, provides she come every six weeks or so for treatment.
11. Mr C, a young engineer fell off his mountain bike injuring his cervical spine and pelvis. Luckily both responded very quickly to a few chiropractic adjustments. Update: his neck is sore again. It all goes back to a whiplash injury ten years ago when he was rammed by a fully laden truck carrying a load of stone. Time for Xrays.
12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.
13. Both Mrs E and I can't believe how much better her lower back and leg pain are. Surgery for a scoliosis and spondylolysthesis three years ago helped greatly for one year. But then her leg went lame and weak. He was responded extremely well despite all expectations.
And so the day goes. Chiropractors shouldn't be treating the elderly? Bunkum.
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