1. Wisdom Teeth – The Basics / Impaction Types

Which teeth are they? | What does the term “impacted” mean? | Impaction classifications.

1) What are wisdom teeth?

“Wisdom teeth” are a type of molar. Molars are the large chewing teeth found furthest in the back of the mouth.

Most people have 1st, 2nd and 3rd molars. A person’s third molars are their wisdom teeth. (See our graphic below.)

a) When do they come in?

For most people, the eruption process takes place during their late teens or early twenties (usually ages 18 to 24 years), although eruption outside of this age range is not uncommon.

An x-ray showing a person's upper and lower teeth on their right side.

Use the slideshow button to see examples of which teeth are a person’ wisdom teeth.

If there is not enough room for the teeth, or they are not aligned properly, they may never fully erupt. (See “Impacted Teeth” below.)

b) How many wisdom teeth does a person have?

People usually have four: upper left, upper right, lower left, and lower right.

If they don’t, it’s due to their genetic makeup. It’s been estimated that about 25% of people are lacking one or more. (Faculty, 1997)

2) What are “impacted” wisdom teeth?

In dental terminology, an “impacted” tooth refers to one that has failed to fully erupt (emerge into its expected position).

This failure to erupt properly might occur because:

  • There is not enough room in the person’s jaw to accommodate the tooth.
  • The tooth’s eruption path is obstructed by other teeth.
  • Because the angulation of the tooth is improper.

3) Types of impactions (classifications).

Dentists use a number of terms, in combination, to describe the positioning of impacted teeth. They are mesial, distal, horizontal, vertical, soft-tissue and bony.

a) Mesial, vertical, horizontal and distal.

These terms are used to refer to the general angulation (positioning) of the tooth.

Graphic showing mesial, distal, vertical and horizontal impaction types.

Mesial, distal, vertical and horizontal wisdom tooth impactions.

  • The term “Mesial” (also mesio-angular) means that the tooth is angled forward, toward the front of the mouth. This is the most common type of wisdom tooth impaction.

The other types of impactions, in order of frequency of occurrence, are the vertical, horizontal, and distal types.

  • Vertical impactions have a relatively normal orientation.
  • Horizontal (also traverse) impactions have an alignment where the tooth is lying on its side.
  • Distal (also disto-angular) impaction has an angulation that is generally directed towards the rear of the mouth.
Graphic illustrating soft tissue and bony impaction types.

Full-bony, partial-bony and soft-tissue impactions.

b) Soft-tissue and bony wisdom tooth impactions.

In combination with the classifications above, wisdom teeth are also categorized as soft tissue or bony impactions.

  • A “soft tissue” impaction is one where the upper portion of a wisdom tooth (the tooth’s crown) has penetrated through the bone but has not yet fully erupted through the gum tissue.
  • The term “bony” or “hard tissue” impaction indicates that the tooth still lies primarily within the jawbone. A full-bonyimpaction is entirely encased by bone tissue, whereas apartial-bony one has erupted through it somewhat.

 c) How likely is it that your wisdom teeth will be impacted?

Studies suggest that the incidence of having at least one that’s impacted runs on the order of 65 to 72%. (Faculty, 1997)

Lower wisdom teeth are more likely to be impacted than upper ones.

4) What causes wisdom tooth impaction?

The reason why some wisdom teeth are impacted is not an easy question to answer. A primary cause simply seems to be a condition of inadequate jawbone space behind a person’s second molar.

Why this lack of space exists is not fully understood. There does, however, seem to be a correlation between large tooth size and/or the presence of generalized tooth crowding and having impacted wisdom teeth.

The human diet has changed.

The dietary changes adopted by modern man have been theorized as playing a role in the incidence of 3rd molar impaction.

The coarse nature of stone-age man’s diet had the effect of producing extensive tooth wear (not just on the chewing surface of the teeth but also in between, where neighboring teeth touch against each other).

When this type of wear takes place, it tends to reduce the “length” of the teeth (as a set), thus creating additional jawbone space to accommodate the wisdom teeth by the time they erupt. In comparison, the diet of modern man does not usually cause a significant amount of this type of wear.

It has also been argued that the coarse nature of stone-age man’s diet, as compared to modern man’s relatively soft diet, probably required more chewing muscle activity. This activity could have stimulated greater jawbone growth, thus providing more space for wisdom teeth.

Additionally, the harsh world of the caveman no doubt often lead to the occurrence of broken teeth and tooth loss. Once a tooth (or a portion of it) is missing the teeth behind it have a tendency to shift forward. This type of movement would make more jawbone space available for wisdom teeth. In comparison, with the advent of modern dentistry there are relatively few reasons why a tooth should remain unrepaired or be lost.

2. Valid reasons why wisdom teeth should be removed

An overview of the most common justifications dentists give when recommending 3rd molar extraction (both impacted and non-impacted teeth).

Some reasons are more valid than others.

As you read through this list, take note of the fact that we have labeled a few of them as being “questionable.”

By this we mean that their validity is not universally accepted by the dental profession as a whole (despite having been used as a justification for decades).

Of course, there will always be differing opinions about the need for any type of medical treatment, and oral surgery is no different. In fact, even some the reasons we’ve categorized as being “valid” are sometimes debated.

a) Valid reasons to extract.

b) Questionable (debated) reasons given for removal.

Explanations.

For the most part, the rationales associated with each of the above reasons (to extract or not) can be explained by the following principles, events or current schools of thought.

1) Some 3rd molars are hard to properly maintain.

A partially erupted 3rd molar.

Dental plaque can accumulate underneath a partially erupted tooth’s gum line. But it is impossible to remove.

Wisdom teeth frequently have a positioning in the jaws or jawbone that makes them difficult, if not impossible, to adequately clean and maintain.

This is especially true for:

  • Teeth that have erupted but are misaligned or malpositioned.
  • Partially erupted teeth, meaning those that don’t fully stick out above the gum line as they should. (see diagram)
  • People with lax brushing habits.

If an environment exists where dental plaque tends to accumulate (for any reason, ranging from patient neglect to situations that are simply impossible to clean), both the tooth and the tissues that surround it will be at increased risk for problems.

This can include tooth decayperiodontal (gum) disease and recurring infections (pericoronitis). Additionally, areas that harbor bacteria and debris can also be a source of breath odors.

So for any of these reasons, whether a current problem or a likely one to come, your dentist may make a recommendation that your unmaintainable wisdom teeth should be removed.

Takeaways from this section.

A dentist’s concern isn’t just for the wisdom tooth itself but also the neighboring 2nd molar.

  • Any gum disease issues that develop will affect it too.
  • If the mass of dental plaque that has caused decay on the 3rd molar extends onto the surface of the 2nd, it will be at increased risk for cavity formation too.

That means waiting to remove a wisdom tooth that a patient has persistently shown an inability to clean until a point when an obvious problem has developed may also be a point when the neighboring tooth has already been damaged, possibly significantly so. In extreme cases, both teeth may need to be extracted.

2) The presence of major pathology or abnormalities.

Some very valid reasons to remove wisdom teeth involve situations where they are associated with some type of abnormality or pathology. They can include:

For the most part, the occurrence of these types of conditions are relatively rare.

A panoramic dental x-ray.
Identifying problems.

Pathology and abnormalities associated with wisdom teeth are frequently only identified when a full-mouth x-ray examination is performed.

This might take the form of a survey where 18 to 20 individual films of your teeth are taken (four of which will show the area of your 3rd molars well) or else a single panoramic radiograph (see picture).

Takeaways from this section.

The ability to identify problems that otherwise could not be detected is one reason why dentists frequently recommend that a full-mouth x-ray examination should be performed every 3 to 5 years.

Even when no pathology is noted (which of course is the hope), this type of evaluation can provide informative details such as the current stage of development, eruption and alignment of the wisdom teeth, or identify cases where one or more of them are absent.

3) Some justifications for extraction are no longer universally accepted.

As mentioned above, some of the justifications for wisdom tooth extraction given in previous decades are no longer widely accepted by the dental community as a whole, to the point that some of them are now heatedly debated.

For example, it was previously thought that the process associated with 3rd molars coming in could cause other teeth in the mouth to shift. The fact of the matter is, however, that this “tooth crowding” theory has never been definitively confirmed by research.

Additionally, the basic train of thought that all impacted 3rds must be removed is no longer universally accepted.

Takeaways from this section.

While a decision for each tooth should be made on a case-by-case basis, there seems to be growing consensus among many in the dental community that leaving impacted wisdom teeth alone and monitoring them over time may pose less of a risk than those potential complications associated with removing them needlessly. (Friedman 2007) [References page.]

A standard recommendation for the removal of asymptomatic impacted third molars (a stance still frequently taken by general dentists and oral surgeons in the USA) runs contrary to the conclusions of a Canadian health technology report, American Public Health Association policy, and health technology reports from Sweden, Belgium and the UK. (Boughner 2013)

3. Is it really necessary to have your wisdom teeth out?

A list of factors that should be considered when evaluating the importance of having (or not having) your third molars extracted (including impacted ones).

A) Do all wisdom teeth need to be removed?

No, without question a viewpoint that a tooth, just because it’s a wisdom tooth, must be extracted is not justifiable.

Despite some common myths and fallacies (like about causing tooth crowding), there’s absolutely nothing inherently bad about third molars. Just like any other type of tooth, they can be a valuable part of a person’s dentition (set of teeth).

B) Do impacted wisdom teeth need to be extracted?

It might come as a surprise to you but no, not all impacted wisdom teeth necessarily need to be removed.

It’s certainly possible that a person who has one (or even all 4) will live their entire life without ever experiencing any problems at all. And, in fact, there is a growing consensus (more so in other parts of the world as opposed to the USA) that leaving asymptomatic thirds alone makes the best choice. (see below)

Of course, problematic teeth should be removed. The trick however is determining which ones have the greatest potential to become troublesome. This is where your dentist’s experience and judgment comes into play.

What does a dentist look for?

One of the primary factors that a dentist will take into consideration when evaluating an impacted wisdom tooth is its impaction type.

A tooth’s position in the jaw hints to how troublesome it may be.

Partially erupted teeth are more troublesome.

Partially-erupted teeth are more likely to be associated with acute flare-ups (swelling, pain) than full-bony impactions.

In regards to this factor, the following guidelines typically hold true.

  • Overall, full bony impactions (a situation where the tooth is fully encased in the jawbone) are the type of impaction that’s least likely to cause problems.

    [The types of problems that might be expected would typically fall along the line of cyst or tumor formation, or the cause of damage to a neighboring tooth. These are, however, relatively low-frequency events.]

  • Partially erupted teeth (the situation where just a portion of the tooth sticks through the gums) are the type most likely to become problematic.

    [It’s their communication with the oral cavity, and the bacteria it harbors, places these teeth at greater risk for complications, especially pericoronitis (infection), periodontal disease (gum disease) and tooth decay.]

When a tooth is evaluated, it’s important to keep its normal eruption process in mind.

  • A typical time frame for third molars to come in is between the ages of 16 and 25 years.
  • For some people in this age group, it might be debated if the term “impacted” really applies to their tooth. After all, it’s quite possible that it’s still in the process of erupting and simply has not reached its final position yet.

Using a wait-and-see approach with third molars.

In those cases where available jaw space and the tooth’s alignment appear to fall within normal limits, then quite possibly the tooth should simply be given more time to progress with its eruption process.

Then, at an age lying closer to the end of the normal eruption time frame, if it appears that the tooth really won’t come in properly, it can still be extracted within that time window typically considered best for extracting wisdom teeth (the upper end of this range is age 24)

A mesially impacted tooth.

Mesially inclined teeth may still erupt properly.

There’s evidence that supports a wait-and-see approach with wisdom teeth.

One study, Hattab 1997 (references page), evaluated the change in position of mesially impacted third molars over time. (Our graphic shows the angulation of a mesial impaction.)

A group whose average age was 19.7 years was evaluated and then re-evaluated 4 years later (the time frame of normal wisdom tooth eruption).

Of these impacted teeth (whose forward tilt ranged between 5 and 30 degrees), 37% managed to successfully erupt (come into position fully) and 15% accomplished partial eruption.

[Our comment: In the case where a partially erupted tooth still needs to be removed, it’s likely that its extraction at age 24 would be less of an ordeal for the patient than removing it as a full-bony impaction at age 19.7 years.]

D) The patient’s age must be factored in.

When making a decision about what to do about an impacted wisdom tooth, it’s important to consider the patient’s age. There is no question; comparatively younger patients tend to experience fewer complications with third molar surgery than older adults.

Because of this, for those 35 years of age and beyond, if an impacted wisdom tooth exists (especially a full bony impaction) and it’s not causing problems and shows no evidence of associated pathology, it’s frequently just left alone.

E) Any retained wisdom teeth should be monitored regularly.

Over time, a wisdom tooth’s status may change. This includes both the formation of pathology (cysts, tumors, decay), or a change in its positioning (a full-bony configuration may transform into a less predictable partially-erupted one).

A panoramic dental x-ray.

Panoramic x-rays are usually used to evaluate 3rd molars.

X-ray examination will be required.

So to monitor for changes, a dentist will usually recommend that the teeth in question should be periodically re-evaluated. These examinations will almost certainly need to include the use of dental x-rays (possibly taken at an interval of every 12 to 24 months).

F) Other complications and risks must be considered.

1) All surgery involves risk.

It’s important to keep in mind that all types of surgery, including oral surgery, contain some inherent risk, no matter how minor.

For this reason, wisdom teeth should only be extracted in those cases where a reasonable case for their removal can be made. (See our page: Reasons why wisdom teeth should be extracted.)

2) The patient’s health status must be considered.

The status of a person’s health may contraindicate having an extraction. Considerations include underlying systemic disease and factors that may complicate or interfere with the healing process [diabetes, hepatic (liver) disease, blood disorders, renal (kidney) disease, steroid therapy, contraceptive medications, immunosuppression, and malnutrition].

In some cases, it may be possible to remove the wisdom tooth after the patient’s medical issues have been resolved.

3) Is there potential for damaging neighboring teeth or anatomical structures?

In some cases, the surgical procedure associated with accessing and removing an impacted wisdom tooth might be such that it’s possible that nearby teeth or anatomical structures may be damaged.

As an example, lower wisdom teeth often lie in close relationship to the mandibular nerve. Trauma to this nerve can cause postoperative lip numbness (termed paresthesia), which may be permanent.

In other cases, the neighboring second molar, surrounding bone tissue or even the jawbone itself might be damaged, fractured or otherwise compromised during the procedure.

G) Recommendations of health organizations about wisdom tooth removal.

A number of agencies and associations world-wide have evaluated the issue of prophylactically removing asymptomatic third molars.

Most of them have taken a stance that extraction is not indicated unless the teeth have created or become associated with a pathological condition. (American Public Health Association – 2008, British National Institute for Clinical Excellence – 2000, Belgian Health Care Knowledge Centre – 2012, Scottish National Clinical Guideline – 1999, Regional Health Technology Assessment Centre [Sweden] – 2011)

In contrast to this opinion, the American Association of Oral and Maxillofacial Surgeons (AAOMS) in a White Paper statement (2011) projects the stance that all third molars are inherently prone to disease and therefore make reasonable candidates for removal. Other publications issued by the AAOMS suggest that this assessment even includes those teeth that have come into normal, upright position. (Boughner 2013)

In an era where the primary focus of dentistry is one of retention of teeth via the use of preventive techniques and the early detection and repair of problems, this stance may be hard for many dentists to agree with. (It certainly runs contrary to our initial statement at the top of this page.)

4. Estimating the difficulty of wisdom tooth extractions

General guidelines and rules of thumb: Upper vs. lower. / Erupted vs. impacted. / Difficulty by impaction type. | How the expected level of difficulty will affect the planning of your extraction procedure.

How hard will your wisdom tooth extraction be?

It’s important for your dentist to have an idea.

Long before the day of your procedure, your dentist will have made an estimation about the level of difficulty they expect when they remove your teeth.

  • Their determination will influence factors about your case such as how many of your wisdom teeth should be removed per visit, the length of your appointment(s) and whether or not a recommendation for some type of sedation is made.
  • Their pre-treatment evaluation will also help with planning your procedure, so it’s performed in a manner that helps to minimize the chances for complications both during your extraction(s) and the healing process that follows.

A) Factors that influence extraction difficulty.

A panoramic x-ray is frequently used to evaluate 3rd molar positioning.

A panoramic dental x-ray.

If more detail is needed, an individual “intraoral” x-ray of each tooth may be taken too.

1) The tooth’s position in the jaw.

Much of the difficulty associated with removing a wisdom tooth will be due to the way it’s situated in the jawbone.

In general, the more normal the alignment of the tooth, and the further through the gum line it has pierced, the less involved its extraction and the healing process that follows are likely to be.

Rules of thumb.

  • You can expect that erupted wisdom teeth (those that have penetrated through the gums fully) will be easier to extract than impacted ones (those still significantly buried in the gum tissue or jawbone).
  • Soft-tissue impactions are typically less difficult than bony ones (teeth still substantially or completely encased in the jawbone). (Graphic: Soft-tissue vs. bony impactions.)
  • The tilt of the tooth will affect the ease with which it’s removed. Vertical (upright) and mesio-angular (leaning forward) impactions are typically easier to remove than disto-angular (tilted backward) or horizontal (sideways) ones. (Graphic: Impaction orientations.)
Takeaways from this section.
  • Fully erupted wisdom teeth (teeth that have come all of the way into place) are often no more difficult to extract than other molars.
  • Impacted wisdom teeth that have a pronounced tilt are more likely to need to be sectioned (cut into pieces) when extracted.

    This technique (see animation below) is used as a way of limiting the size of the wound that needs to be created. In extreme cases, sectioning might be the only way of getting the tooth out.

2) Tooth depth.

Another method that’s used to estimate extraction difficulty is to make a comparison between the impacted wisdom tooth and its neighboring 2nd molar.

The wisdom tooth’s depth is compared to the neighboring 2nd molar.

The depth of the wisdom tooth is compared to the neighboring 2nd molar.

Removing this wisdom tooth can be expected to be of “moderate” difficulty.

When making this calculation:

  • The 2nd molar’s root is marked in thirds on an x-ray.
  • A point is then identified on the 3rd molar where the forces of the dentist’s extraction instrument (an elevator) will be applied.

    This point is frequently that part of the tooth where its crown (enamel-covered portion) ends and root begins. (The white dot and arrow in our diagram.)

  • The level at which this point resides in comparison to the 2nd molar’s root gives an idea of how hard the extraction will be.
Takeaways from this section.

Obviously, the deeper the positioning of a tooth, the more bone tissue that must be removed to reach it. And generally, that means creating a larger wound.

The larger the surgical area, the more involved the extraction site’s healing process (as well as its potential for complications like a dry socket) will be.

Beyond those issues, deeply positioned teeth are more likely to be near anatomical obstacles such as nerves or sinuses. If so, the risk for surgical complications involving them is higher too.

3) Root anatomy.

Wisdom teeth have multiple roots (lower ones typically have two whereas uppers usually have three). And there can be quite a bit of variation in the way they are shaped.

In some cases, each root will be separate and distinct. In others, they may be fused together (fully or partially) or have an irregular shape or curvature.

These anatomical variations will affect the relative ease with which the tooth can be removed.

The shape of a tooth's roots affects the extraction difficulty.

Extraction difficulty is influenced by the tooth’s root form.

Rules of thumb.

If the “average” wisdom tooth is one where its roots are relatively straight, distinct and separate (see animation), in comparison:

  • Teeth with fused roots (partially or fully) are often easier to extract (this is especially true for upper third molars).
  • Teeth that have roots that are curved or irregularly shaped can be more difficult to remove. Although, in some instances the curvature may be such that it actually facilitates the extraction.
  • Teeth whose roots are just 1/3 to 2/3rd formed typically make for an easier extraction that those whose roots are fully formed.

    This factor is dependent upon the age of the patient. We discuss this and other age-related issues here: What’s the ideal age to have your wisdom teeth extracted?

B) How anticipated extraction difficulty affects treatment planning.

More so than with any other type of tooth, removing wisdom teeth routinely poses an assortment of challenges (ranging from just minor to significant). And this level of difficulty must be factored into the way your dentist plans your case.

1) Some wisdom teeth are quite easy to remove.

You don’t have to expect the worst. In the case of fully erupted 3rd molars (those that have come all of the way into place), the extraction process may be no more difficult than with any other molar, and possibly less.

Examples.
  • When compared with the molars in front of them, there’s a tendency for wisdom teeth to be slightly smaller and more likely to have fused roots. Either of these factors can help to make their removal comparatively less difficult.
  • Upper wisdom teeth that have fused roots can be astonishingly quick and easy to extract.
Takeaways from this section.

This page outlines the steps that take place during routine (simple) extractions. The type of extraction process typically used to remove erupted teeth.

The term “simple” is used because the oral surgery techniques used are straight forward and relatively uninvolved (as compared to surgical extractions, see below).

2) Some wisdom teeth will require “surgical” intervention.

With impacted third molars, the dentist will of course need to gain access to the tooth they’re removing. So in these cases, the dentist will need to perform a “surgical” extraction.

This is the type of process where gum tissue is flapped back and, if needed, bone tissue cut away, so the dentist can visualize and manipulate the tooth. Use the link above for more details.

Takeaways from this section.

You shouldn’t be overly apprehensive about the need of having a surgical extraction.

While with many cases it might be impossible to remove a tooth without taking surgical steps, even with borderline cases doing so frequently allows the patient’s whole extraction process to go more predictably, quickly and easily.

Sectioning a 3rd molar during extraction.

Less bone removal is needed when a tooth is “sectioned” into parts.

3) Sectioning wisdom teeth.

A dentist may be able to minimize the amount of bone that must be removed during the extraction process by cutting the tooth into pieces.

Since each individual part is smaller than the tooth as a whole, they can be removed through a smaller access opening. This procedure is termed “sectioning” a tooth.

C) How extraction difficulty can affect patient aftercare and the post-extraction healing process.

In general, the quicker and easier it’s been for the dentist to access and remove a wisdom tooth, the less tissue trauma that’s created and the more uneventful the extraction site’s healing process should be.

As examples:

  • The post-operative inconvenience and aftercare needs associated with the routine extraction of an easily accessed, fully-erupted third molar may be surprisingly minimal, to almost non-existent.
  • At the other extreme, the swelling and pain resulting from a difficult impaction may require several days of recuperation.

Which scenario applies to you will simply depend on how difficult your extraction process has been. And thanks to the type of indicators discussed on this page, your dentist should be able to give you an idea of what to expect even before your procedure is performed.

Aftercare guidelines and instructions.

For the most part, extraction aftercare is broken into two general time frames:

When it comes to preventing or minimizing post-operative complications, nothing is more important than following your dentist’s instructions, period. (Use the links above for more information.)

5. Conscious sedation for wisdom teeth and other tooth extractions.

Should you be sedated for your procedure? | Oral vs I.V. vs inhalation sedation. | Advantages, disadvantages, precautions. | What drugs are used? – Laughing gas (nitrous oxide), Valium (diazepam)

What is “conscious” sedation?

The term conscious sedation refers to the administration of medication (an oral, I.V. or inhaled sedative) for the purpose of placing a patient in a relaxed state for their dental procedure. In comparison to general anesthesia however, the patient remains conscious (awake).

Other names and terminology that equate with the use of conscious sedation technique (although possibly just loosely) are “moderate sedation,” “twilight anesthesia” and “sedation dentistry.”

When should sedation be used for a dental procedure?

A dentist may suggest that conscious sedation should be used in cases where:

  • The patient is exceptionally apprehensive about their procedure.
  • The procedure is expected to be difficult or require an extended period of time (such as when removing multiple teeth, or impacted wisdom teeth). In these cases the patient might become physically or emotionally taxed.

With either situation, sedating the patient helps to make their procedure more tolerable for them, which generally translates into allowing them to be a more ideal patient.

What’s having conscious sedation like? – Characteristics.

When moderate sedation is used the patient remains awake, in the sense that:

  • They remain responsive to stimuli such as verbal commands from their doctor (“open your mouth,” “close down”), or the sensation of pain.

    If the patient does happen to doze off, they are easily awaken.

  • All of the patient’s protective reflexes (breathing, coughing) remain functional.
  • The patient’s cognitive function (perception, reasoning, comprehension) may be modestly impaired.

In comparison, with general anesthesia the patient looses all sensation and consciousness.

Advantages of opting for sedation.

Procedure acceptability.

Two key benefits of utilizing conscious sedation are that:

  • It helps to reduce patient fear or concern about what’s planned or is going on.
  • It helps to make difficult or extended procedures more tolerable. (The patient is better able to cooperate with the dentist’s requests or the needs of the procedure.)

Especially in the case of a procedure like a difficult extraction, the extra degree of patient cooperation that using sedation can provide can help the process to go more smoothly and therefore quickly. This can be favorable for both what the patient experiences during their procedure and over the course of the healing process that follows.

  • Fagade (2005) reported that longer extraction procedures correlated with patients feeling higher levels of pain.
  • Malkawi (2011) determined that lengthier wisdom tooth surgeries correlated with the patient having more frequent (both immediate and late) post-extraction complications.

Alleviating a patient’s anxiety alone will help to improve their experience. A study by Tickle (2012) determined that the strongest predictor of procedure pain was dental anxiety.

Be sure to choose sedation for the right reasons.

The use of any sedative involves some risks.

The use of any type of medication places the patient at some degree of risk for complications and side effects. And for that reason, when one is administered it should be for good reason.

Generally speaking, the type of anesthesia used for a procedure should be kept to the simplest form possible. So if you’re not convinced that you need to be sedated, ask your dentist why they feel you do.

Improved patient cooperation can be a big help for your doctor during procedures such as a difficult extraction. But in some cases it may be used simply for their convenience or to create an additional billable service.

Conscious sedation is primarily used for anxiety control.

Although some types of drugs used can help to elevate the patient’s pain threshold somewhat, this technique is primarily used to help control patient anxiety.

That means when it is chosen, your dentist will still need to administer a local anesthetic (give you dental “shots”). So don’t choose sedation because you think it will allow you to avoid the use of a needle because it won’t. (See below.)

Ways dentists administer conscious sedation.

(We discuss dental fees for sedation services here.)

1) Inhalation technique.

With this method, the sedative medication that the patient is given is a gas that they breathe.

Nitrous oxide / Laughing gas

How it’s administered.

Nitrous oxide creates its effect as the patient breathes it in via a mask that’s placed over their nose. To produce conscious sedation, its mixed with pure oxygen at a concentration of 25 to 40%.

The gas’s onset is rapid (usually just a matter of 2 to 5 minutes). And once the patient stops breathing it in, its effects disappear fairly rapidly too.

It can be used alone or in combination with oral or I.V. sedation technique (see below).

Advantages

A very unique feature of inhalation technique, and one that makes it very convenient to work with, is that the patient’s level of sedation can be adjusted, almost immediately, just by changing the amount of gas being breathed in.

  • That means if you require more of an effect during your procedure, just indicate to your dentist and it can be achieved in just a few moments with their twist of a dial.
  • Likewise, if you find you would be more comfortable with less of an effect, your level of sedation can be reduced in just a matter of moments by reducing the concentration of nitrous oxide in the mixture you are breathing.

Inhalation technique is the only method where the level of the patient’s sedation can be immediately increased or decreased.

Another advantage of inhalation sedation is that minimal prior planning is required. Choosing to use laughing gas during your procedure can usually be opted for as late as at the time of your appointment.

Precautions.

Your dentist will have a set of precautions and instructions they will discuss with you. We will note that nitrous oxide sedation should not be administered to patients after a full meal, so watch your timing on that. In most cases, a patient should be capable of driving home after their procedure.

A difficulty unique to dental procedures.

Dentistry presents a special challenge in the use of laughing gas.

  • During their dental procedure, a person will have their mouth open.
  • If they breathe through their mouth, they will dilute the overall concentration of gas that reaches their lungs, thus reducing the level of sedation that’s produced.

So when inhalation technique is utilized, the patient must be sure to breathe only through their nose (the source of the gas) for their entire procedure.

2) Oral conscious sedation.

“Oral” sedatives are medications (pill or liquid form) that are taken by-mouth (swallowed).

As an example, Valium (diazepam) is one drug that’s frequently used to create sedation for oral surgery procedures.

Others include: Ativan (lorazepam), Xanax (alprazolam), Vistaril (hydroxyzine), Halcion (triazolam), Versed(midazolam), Serax (oxazepam), Ambien (zolpidem) and Sonata (zaleplon).

All of these are prescription medications.

Administering the drug.

Your dentist will discuss a specific set of instructions and precautions with you. Some are generic, others may vary depending on the specific medication chosen.

A common regimen for oral sedatives used to create conscious sedation is:

  • An initial dose in the evening before going to bed. This helps to insure that you have a good night’s sleep prior to having your procedure. (This step isn’t always included.)
  • A second dose 1 hour before your scheduled dental appointment. (Onset typically takes 30 to 60 minutes.)

You’ll require assistance.

Because oral sedatives are likely to affect both your behavior and ability to function for some hours, once they’ve been taken you must have someone tend to and assist you.

Oral sedatives.

Oral sedatives can help to put a patient at ease.

This includes prior to and while delivering you to your appointment. As well as escorting you home and monitoring your activities afterward until the effects of your medication have finally worn off.

Advantages or oral sedation.

As compared to inhalation or I.V. technique, when oral sedatives are used no special equipment is needed. The cost of the medication itself to the patient or dentist is minimal.

Disadvantages.

The use of oral sedatives does have some disadvantages as opposed to other techniques.

  • The fact that you must take your dose well before your appointment means that someone must escort you both coming and going. (Instead of just when leaving as with I.V. technique. Or possibly not at all, as with inhalation sedation.)
  • While your dentist will make calculations base on your weight, it’s hard for them to predict exactly what level of sedation will be created by the dose you have taken.

    If it’s too little, it can’t be immediately adjusted by taking more. (Using a combination of oral and inhalation technique can help to address this issue.)

  • The effect created by oral sedatives typically lasts much longer than your dental appointment itself, thus requiring a long monitoring period afterward. In comparison, I.V. medications and especially inhaled ones are typically much shorter-acting.

3) I.V. Sedatives.

Intravenous (“I.V.”) sedatives are administered by way of injecting them into a blood vein.

Using our referral links for purchases supports this website at no additional cost to you.It’s sincerely appreciated if you do.
Shop either  Amazon related productsbelow on this page, or else for any items on  Amazon.com or  Walmart.com.

What medications are used?

Your dentist has a number of drugs that they can choose from when performing I.V. conscious sedation (some may be used in combination). They include: Valium (diazepam), Halcion (triazolam), Ativan (lorazepam), Versed (midazolam), Duragesic (fentanyl) and Diprivan (propofol).

The one(s) chosen will depend on both the needs of the patient and the procedure as well as the dentist’s preference. Each drug varies by way of its duration and degree of amnesic and anesthetic effect it creates (see below).

Things to know about I.V. sedation.

  • Some sedatives create an “amnesic” effect, meaning the patient has little or no memory of the dental procedure that has taken place (from the time the medication kicks in until it has worn off). Onset can be as quick as 30 seconds or less.
  • If the fact that the medication is administered via the use of a needle is upsetting to you, ask if nitrous oxide or oral sedation can be given first.
  • Intravenous sedatives are more likely to be administered by an oral surgeon as opposed to a general dentist because they have the specialized training and monitoring equipment that’s needed when this technique is used.
  • As compared to oral sedation, I.V. technique provides a way of creating a more predictable and controlled effect.

Precautions – Before your procedure.

Your dentist will provide you with a set of precautions and instructions that must be adhered to. The following points are usually included:

  • No eating or drinking (that means anything, even water) for some hours (usually 6 to 8) prior to the administration of your medication.
  • You need to report any systemic factors you have noticed including: fever, head or chest cold, upset stomach or bowels, sore throat.

Complications with any of the factors above may mean that your procedure will need to be rescheduled.

Your instructions will also include a list of best practices:

  • Wear sensible footwear (no heels, flip-flops or sandals) so your risk of stumbling while under the influence is minimized.
  • If you need to you may wear contact lenses, jewelry, dentures, oral piercings or lipstick to your appointment but they must be removed before your procedure.
  • Wear loose, comfortable clothing. Select a shirt or blouse that has short sleeves or else sleeves that are easily rolled up above the elbows.
  • Don’t wear nail polish to your appointment. (It can interfere with some types of vital sign monitors.)

Precautions – Following your procedure.

  • You’ll need to make arrangements for someone who after the completion of your appointment can escort you out of your dentist’s office, drive and escort you home, as well as monitor your activities until your medication’s effects have worn off.
  • Don’t place yourself in a situation where you will need to operate a car or machinery, or tend to important matters, for the first 24 hours after your procedure.

Conscious vs. Deep sedation.

As a side note, we’ll mention that I.V. technique can also be used to create “deep” sedation. This differs from the conscious form by way of the fact that the patient’s responsiveness and protective reflexes are both impaired (you can’t respond in a purposeful way to questions or stimuli).

If this method is suggested to you by your dentist ask them why they feel it’s needed. With conscious sedation, your ability to communicate and respond (even if only as a reflex) helps to add a layer of safety to your procedure.

A dentist giving a dental injection.

Local anesthetic is administered via an injection.

Even when conscious sedation is used your tooth will still need numbing up.

Some of the medications used to create conscious sedation also create an anesthesia effect (raises the person’s pain threshold). Unfortunately, the extent of this effect is just minimal.

(Remember, a part of the definition of conscious sedation specifically involves the fact that you remain responsive to events, like feeling pain.)

You will get a “shot.”

That means even when conscious sedation is used your dentist will still need to numb up your tooth and the gum tissue that surrounds it using a local anesthetic (they’ll need to give you a dental “shot”). Otherwise you wouldn’t be able to tolerate having your dental work done (except for possibly some very minor procedures such as a dental cleaning).

If getting a shot is the scary part for you, you can make your experience more tolerable by requesting that it’s not given until you’re already fully under the effects of your sedation medication. (Related content: Why do/don’t some shots hurt?)

6. Risks and complications of wisdom tooth extractions

Dry socket and paresthesia (nerve damage) are two of the most common postoperative complications.

A) Dry Sockets

What are they?

A dry socket is a painful, foul smelling postoperative condition that develops during the course of the first several days after a tooth extraction. An equivalent term for a dry socket is “alveolar osteitis.”

What causes them?

Dry sockets occur when either an adequate blood clot has failed to form in the extracted tooth’s socket (the hole left in the jawbone after an extraction) or else the blood clot that did form has been dislodged and lost.

Extraction post-op x-ray.

Post-op x-ray of tooth extraction site.

Since the formation of a blood clot is an important part of the healing process, the healing of the extraction site is disrupted and delayed.

The term “dry socket” comes from the appearance of the wound. Since no blood clot is present, exposed bare bone is visible.

What are the symptoms?

A dry socket’s symptoms typically include:

  • A dull, often throbbing, pain that doesn’t first appear until three or four days after the tooth has been extracted.
  • The pain can be moderate to quite severe.
  • The socket typically has a foul odor or taste coming from it.
An impacted lower 3rd molar.

An impacted lower right 3rd molar.

How likely is it that a person will develop a dry socket?

Although there are risk factors that may predispose a dental patient to the formation of a dry socket, knowing who will actually develop one is totally unpredictable.

Rules of thumb.

  • There is a greater likelihood of their formation with the extraction of lower wisdom teeth, as opposed to upper ones.
  • Their incidence is typically greater with the removal of impacted wisdom teeth, as opposed to non-surgical extractions.

Research – Incident rates.

A literature review performed by Blondeau (2007)suggested an incidence rate for dry sockets following third molar extractions ranged between 5% and 10%. This should be viewed in light of Bui’s (2003) review of dental literature that suggested an incidence range of 1% to 3% for all tooth extractions as a whole.

Bui (2003) cited the findings of a study that reported a dry socket incidence rate as high as 30% for impacted lower wisdom teeth. Chuang (2008) found the incidence of “inflammatory postoperative complications” to be more than twice as high when full-bony wisdom teeth were removed, as compared to soft-tissue third molar impactions.

Overall, while having a dry socket is an unfortunate complication for anyone who has to experience it, the potential for one is not typically considered to be a reason not to extract a wisdom tooth. Instead, it is simply recognized as a disappointing, transient side effect.

Placing a medicated dressing in an extraction site.

The dressing is placed directly into the socket.

What is the treatment for dry sockets?

The best treatment for a dry socket comes from your dentist:

  • They will place a medicated dressing down into the socket that can soothe and moderate its pain.
  • This dressing is typically removed and replaced every 24 hours until the patient’s symptoms have subsided.
  • Depending on the level of symptoms displayed, they may feel the use of prescription pain relievers is indicated too.

We’ve created a whole topic just covering the subject of dry sockets. You can find it here: Dry Sockets / Alveolar Osteitis.

7. Tooth extraction aftercare: Instructions for the first 24 hours after having your tooth pulled.

Stopping bleeding. / Clot protection. / Smoking. / Eating. / Numbness. / Pain control. / General do’s and don’ts.

Once your tooth extraction has been completed, your dentist should provide you with two sets of aftercare instructions.

  1. One will cover things to do (and not to do) during the first 24 hours after having your tooth pulled. (The subject of this page.)
  2. The other will be recovery instructions for the days that follow. (Use the link for more information about this topic.)

Aftercare – The first 24 hours after having your tooth pulled.

This group of instructions covers topics such as:  1) Controlling bleeding.  2) Protecting the blood clot that has formed.  3) Directions for how to minimize swelling and pain.

They also address post-extraction do’s-and-don’ts for issues such as:  1) Smoking.  2) What types of physical activities are appropriate.  3) Eating and drinking.  4) Issues with numbness. 5) Cleaning your teeth.  6) If indicated, the use of antibiotics.

Remember, the care you take (or don’t take) during this first 24 hour period will set the stage for the healing process to come.

Get your dentist’s input.

While this page contains common aftercare guidelines typically used during the first 24 hours after an extraction, your specific situation may involve special circumstances. For this reason, you should discuss these instructions with your dentist so they can amend them as is needed.

Additionally, if you feel you have developed complications you should contact your dentist. It’s their obligation to address your need

A) Stopping tooth extraction bleeding.

Immediately after your tooth has been pulled, some amount of bleeding will occur, possibly for some time.

[For information about continued post-extraction bleeding beyond the initial 24 hour period, use this link.]

Closing down on gauze is a good way to control extraction site bleeding.

Animation illustrating the placement of gauze directly over the tooth's socket, then applying firm pressure.

Place firm pressure on the gauze for 45 minutes or longer.

a) Controlling bleeding with gauze.

In most cases, this bleeding can be controlled and ultimately stopped by performing the following steps:

  1. Place a piece of clean damp gauze over the empty tooth socket.

    (Roll or fold it up into a ball or square. It’s the portion that rests directly over your wound that’s important. If you don’t have any gauze, a piece of clean cloth can be used instead.)

  2. Bite firmly on the gauze for 45 minutes to an hour.

Make sure the wad of gauze is large enough and positioned so that when you bite down on it it applies pressure directly onto your extraction site. (If your teeth come fully together when you close, the gauze may not be receiving much pressure.)

Applying pressure over an extended period is the key.

It’s both creating firm pressure and maintaining continuously it over a prolonged period of time (45 minutes or so) that are important factors in getting this technique to work.

Don’t keep changing the gauze, and don’t chew on it. Just put it in place and continuously close down, for the full 45 minutes to an hour.

b) Controlling bleeding with a tea bag.

If your bleeding seems to persist, a dampened tea bag can be more effective than gauze.

One of the components of tea (black tea, the regular stuff you would use to make iced tea) is tannic acid. Tannic acid aids in the formation of blood clots, thus making this method a very effective technique. (Same instructions as above, just substitute the tea bag for the gauze.)

Repeat as needed.

If some bleeding still persists after the completion of a 45 minute application (gauze or tea bag), then repeat the process. Several applications may be needed. However, after each subsequent cycle you should notice that the amount of flow that continues is less and less.

It’s rare that this technique, expecially when a tea bag is used, doesn’t provide the needed solution. However, if heavy or prolonged discharge persists, then contact your dentist

Clotting aids.

In some cases your dentist may anticipate that post-operative bleeding will be a concern. If so, they may place some type of clotting aid in your extraction socket.

This might be an absorbable collagen or gelatin dressing (CollaPlug®, Gelfoam®), oxidized cellulose (Surgicel®), microfibrillar collagen (Avitene®), or similar-purposed product. For specific details, you’ll simply have to ask your dentist what has been placed.

(Absorb = the process where a person’s body will naturally degrade and then take up the breakdown components of an object.)

You still need to follow standard protocol.

By no means does your dentist having placed a clotting aid in your tooth’s socket lessen your need to follow standard post-op instructions.

Instead you should recognize that they consider you to be at elevated risk for complications, which makes faithfully following their directions all that more important.

What becomes of the clot?

As a socket’s healing process progresses the space occupied by its clot is gradually replaced by granulation tissue (new tissue that’s especially rich in blood vessels). During this transition the clot is broken down into components that are resorbed by your body. The whole process is usually completed within about one week following your extraction. (Cohen 2014)

B) Insuring that an adequate blood clot forms (and stays) in the tooth socket.

The blood clot that forms in the tooth’s empty socket plays an important role in supporting the healing process that follows, so be careful not to do anything that will dislodge or disrupt it.

Remember, events that occur during this first-24-hours time frame will affect the healing process for days to come. For example, it’s thought that the formation of a dry socket is related to the loss of the original blood clot.

Blood-clot Don’ts.

As a way of protecting the clot that has formed, during the first 24 hours following your extraction, you should …

  • Avoid vigorous rinsing or spitting. – These activities may dislodge the clot.
  • Don’t disturb your extraction site. – Don’t touch or poke at it with your finger. Don’t explore it with your tongue.
  • Don’t consume hot liquids and foods. – Hot items, especially liquids like soup, tea and coffee, tend to dissolve blood clots.
  • Minimize air pressure differences. – You should also avoid creating air pressure variations in your mouth, or pressure differences between your mouth and your sinuses (in the case of an upper tooth extraction) because these events may dislodge the blood clot from its socket.

    This means you should avoid smoking or using a straw (these activities create suction). Also, don’t blow your nose. And if you need to sneeze, sneeze with your mouth open. (See below for more details.)


C) Minimize activities that may make it harder to control bleeding.

During the first 24 hours after your tooth extraction, you’ll want to avoid any activities that might make it difficult to control bleeding from your extraction site, or interfere with blood clot formation and retention.

While the risk of these complications is often minimal after very simple extractions, when multiple teeth have been removed or the patient’s procedure has been difficult, they can become a substantial concern. Either way, it only makes sense to take precautions.

Activities.

It’s best to avoid strenuous work or exercise. You should also avoid bending over or lifting heavy objects. In general, it’s not a bad idea to just take it easy for the rest of the day following your surgery.

(Use this link for more details about post-extraction activities.)

Resting.

When you sleep or lie down, position yourself so your head is above the level of your heart. Doing so tends to lower your head’s blood pressure level, which when trying to control post-extraction bleeding is a favorable thing.

Toward this goal:

  • In bed, prop your head up using an extra pillow, or even 2.
  • Rest in a recliner with the head portion of your chair positioned higher than your feet.

Be careful when transitioning from a reclined to upright position. You may find you get lightheaded. Try just sitting up for a minute before slowly getting on up.

D) Swelling may occur.

It’s common and normal for some degree of swelling to occur after having a tooth pulled. The amount that ultimately forms is typically proportional to the extent of the surgery that has taken place. That means:

  • After very simple extractions you may notice very little, possibly none.
  • With more involved cases (longer, more difficult extractions or the removal of several teeth) you may notice a pronounced enlargement, possibly involving a large portion of your face.

Generally speaking, the amount of swelling that forms can be minimized via the application of ice packs on the outside of your face over the area where your surgery was performed, starting immediately upon the completion of your procedure.

This page provides in-depth details and instructions about managing this complication: Post-tooth extraction swelling.

'No Smoking' graphic.

Don’t smoke for as many days as you can.

E) Avoid smoking.

People who smoke tend to experience a higher level of complications with extraction site healing. That means if you can avoid smoking for the first 24 hours (and preferably 48 hours and longer) after having your tooth pulled, it will be to your benefit.

We explain the how’s and why’s of this effect in greater detail in our discussion of smoking as a risk factor for dry sockets (a common post-extraction complication).

F) Avoid blowing your nose.

As mentioned above, in the case where you’ve had an upper back tooth removed (molar, bicuspid) it’s best form to refrain from blowing your nose.

That’s because doing so can create a pressure difference between your mouth (via the recesses of your extracted tooth’s socket) and your sinuses that might be great enough to disrupt what in some cases may be just a paper-thin layer of bone separating the two.

Oroantral communications.

Failing to follow these directions can result in creating what’s termed an “oroantral communication” (a direct connection between your mouth and sinus). And the development of one will complicate the healing process. (The communication itself will need to be blocked off before normal healing of the socket can occur.)

Other precautions.

Actually, it’s not just avoiding blowing your nose that’s important. You should generally refrain from doing anything that might create a pressure difference, such as:

  • Sneezing. If you need to sneeze, do so with your mouth open.
  • Avoid sucking on items such as a straw or cigarette.
  • If you play a ‘wind’ musical instrument, ask your dentist when it will be OK to resume playing.

G) Controlling extraction-site pain.

The level of discomfort a patient can expect during the first 24 hours following their extraction can be quite variable. For some people, it will be a non-event. For others, it may be quite noticeable. (This page discusses managing pain that extends beyond the initial 24 hours after your procedure.)

Timing your medication.

Quiz your dentist about what to expect. If they feel it’s highly likely that you’ll need to take an analgesic (pain pill), a good plan can be to do so before the local anesthetic used for your procedure has worn off. (That will be tapering down over the next hour or two.)

If discomfort does become an issue, in terms of types of analgesics there are two general classes of medications that are typically used.

a) OTC medications.

For just minor to mild pain, your dentist will probably advise the use of an over-the-counter (non-prescription) analgesic.

Commonly used products include acetaminophen (Tylenol®) or ibuprofen (Motrin®, Advil®). You’ll need to read and follow the directions and warnings that accompany the one that’s been recommended for you.

b) Prescription medications.

If a higher level of pain relief is needed, your dentist will likely turn to the use of prescription analgesics.

Picture of prescription pain relievers.

A narcotic pain reliever may be needed after some extractions.

Narcotic medications.

The formulation of many prescription pain relievers includes the narcotic codeine (or related compounds).

  • These products tend to cause nausea (upset stomach). This effect can be minimized by taking the medication with milk or food (milk shake, soup, fruit juice, yogurt, mashed potatoes, etc…).
  • Taking a narcotic may make you dizzy, drowsy or groggy. It may also slow down your reflexes or cause you to act strangely.

    If you’re taking a narcotic medication, you should let those around you know. You should also limit your activities (driving, operating machinery, etc…).

  • Additional common side effects include nausea, vomiting and constipation.
  • You should abstain from drinking alcoholic beverages when taking a narcotic.

Other precautions.

Make sure that you read and follow all directions and precautions associated with your medication’s use. If you have any questions, you should discuss them with your dentist or pharmacist.

Remember that your product has been prescribed to you for the short-term use of controlling the pain associated with your extraction. Since some products can become habit forming, their use should be discontinued at the earliest point where pain control is no longer needed.

H) Continue on with prescribed antibiotics.

Any antibiotics prescribed by your dentist should be taken as directed, which typically means “to completion” (the endpoint where all have finally been taken according to schedule). Doing so may include continuing on with your medication even after your tooth has been removed.

I) Eating.Is it OK to eat after having a tooth pulled?

Yes, maintaining proper nutrition is important for both keeping up your strength and providing the nutrients needed for your extraction site’s healing process, so try not to skip any meals.

For the first several days, keep foods away from your surgical area by chewing on the other side. That will help to minimize any chances of disrupting its healing process or allowing debris to collect in it.

Sticking to cool, soft foods makes the right choice after simple extractions. When multiple teeth, multiple extraction sites or surgical extractions are involved, a liquid diet (supplemental nutrition drinks) may be indicated during the first 24 hours. (See our post-extraction food suggestions below.)

How soon after can you eat?

It’s best to wait until the local anesthetic used for your extraction has worn off. Trying to eat while you’re still numb could result in an accident (like biting your lip) or trauma to your surgical site.

  • Following simple single-tooth extractions, you may be able to return to fairly normal eating habits after just a few days.
  • After more involved ones (surgical extractions, the removal of multiple teeth) you may need to favor your extraction site for most of a week as its healing gradually progresses.

What kinds of foods are recommended?

As a general rule, stick to cool, soft foods as opposed to hard, crunchy or spicy ones after having a tooth pulled. You should also avoid consuming alcoholic beverages or drinking beverages with a straw (the negative pressure might draw the blood clot out of your socket).

  • Soft foodstuffs are less likely to traumatize your extraction site (this is true for both the day of your extraction as well as during the healing process that follows).
  • Hot food items (especially soup or coffee but even semi-solid ones) have the potential to dissolve the blood clot that has formed in your tooth’s socket, so they should be avoided during the first 24 hours.

Consider food items like these: pudding, yogurt, jello, mashed potatoes, oatmeal, applesauce, scrambled eggs, pancakes, noodles, (cool) soup, ice cream, milkshakes, supplemental nutrition drinks.

As the healing of your extraction site progresses, you can start to add foods that have more firmness and texture to your diet.

Drink plenty of water.

It’s important to stay well hydrated. That’s because you’ve lost some bodily fluids during your extraction procedure. You’ll also want to maintain optimal body chemistry for your socket’s healing process.

Especially after more involved extractions (difficult procedures, the removal of multiple teeth), drinking 6 to 8 glasses of water per day makes a good idea.


J) Precautions with numbness.

Picture of a dentist giving a dental injection.

The numbness from your local anesthetic will linger after your procedure.

After the completion of your procedure you’ll still have some lingering numbness. Besides just your extraction site, some aspect of your lips, cheeks or tongue are likely to be affected too.

How long will the numbness last?

You can expect to notice the effects of the anesthetic used for your extraction for some hours following your appointment. The method of injection, and type and formulation of anesthetic solution used, are primary determining factors.

Studies evaluating the effect of various anesthetic solutions commonly used in dentistry for numbing up lower molars (inferior alveolar nerve block injections) have reported duration times of:

  • 2.5 hours (Elbay 2016), 2.5 hours (Managutti 2015) and 3.8 hours (Kammerer 2012). [page references]
  • Differences in the duration of numbness among individual patients generally varied from 18 to 35 minutes (plus or minus).

As time passes, the level of numbness you notice will slowly fade as your body’s vascular system carries the anesthetic solution off to be metabolized and excreted.

What precautions should you take?

The sensory loss (pain, temperature and touch) that your postoperative numbness creates can result in accidents. For example …

  • You might unknowingly bite your lip or tongue while chewing, possibly even repeatedly.
  • You might not be able to test hot (temperature) foods and beverages adequately, which could result in burns.
  • Some patients, especially children, may find their numbness a novelty and will bite on, or chew, numbed tissues (lips, cheeks or tongue). This may result in significant damage.

In regard to this last issue, children must always be monitored during periods of numbness.

'No Mouthwash Use' graphic.

Avoid rinsing your extraction site with mouthwash.

K) Cleaning your teeth.

It’s important for you to maintain good oral hygiene over the days and weeks while your extraction site is healing.

  • On the day your tooth has been pulled, it’s best to avoid brushing those teeth that directly border your extraction site. Wherever access isn’t a problem, it’s OK to clean your other teeth.
  • During the first day after your extraction, it’s OK to let water or saline solution (1/2 teaspoon of table salt in 1 cup of warm water) roll around in your mouth but rinsing vigorously must be avoided. Doing so might dislodge the blood clot that’s formed in your tooth’s socket.
  • Avoid the use of commercial mouthwash or mouth rinse. These products may irritate your extraction site.

8. Tooth extraction healing. – How long does it take? / What can you expect? / Precautions and restrictions. / Pictures.

An overview of the time line and stages of post-extraction healing.

Once your tooth’s extraction process has been completed, you’ll no doubt want to know how long it will take for its socket to heal.

We’ve broken our discussion of this subject into the following time frames following your extraction:

Wound size matters.

The type of healing progress that’s taken place at each of the above stages will generally be the same for any extraction. But you’ll need to keep in mind that larger, more involved wounds simply take longer to fully resolve than comparative smaller ones.

So if you’ve just had a wisdom tooth surgically removed, your healing time frame will extend out longer than someone who just had a lower incisor or baby tooth out.

Related issues this page covers:

How much time will you need to take off after your extraction?

It only makes sense that as a patient you’ll need to know how long you may need to limit your activities or take time off from work or school after having your tooth removed.

While your dentist is in the best position to know, this page explains how different factors can affect the decision about “if” or “how long.”

An x-ray of a tooth socket after having its tooth pulled.

X-ray of empty tooth socket.

When can future dental work be started?

In the case where a tooth that’s been pulled will be replaced, we explain how extraction site healing affects the timing of future dental work.

A) The initial 24 hours following your tooth extraction.

What will you notice?

As far as seeing changes, during the first 24 hours after your surgery you really won’t be able to visualize all that much in terms of actual extraction site healing.

Tooth sockets immediately after the extraction process.

Picture of sockets immediately after tooth extraction.

Blood clots have begun to form.

You should, however, notice that:

Additionally …

  • You’ll probably find that the region immediately adjacent to the tooth’s empty socket is tender when touched and feels irregular and different to your tongue.
  • It’s also possible (especially in the case of a relatively involved or difficult extraction) that you’ll find some degree of swelling has formed, both in the tissues that surround your extraction site and possibly your face too.

    If so, this swelling should peak within the first 24 hours and then start to subside.

What’s taking place with the gum tissue around your extraction site at this point?

While you’ll notice nothing, the reattachment and new growth of gum tissue begins at the edges of your wound as early as 12 hours post-extraction.

What’s going on inside your tooth’s socket?

At just 24 hours after your extraction, the focus of the activity inside your socket revolves around the blood clot that’s formed.

The clot itself is composed of platelets (sticky cell fragments that initiated the clot’s formation) and red and white blood cells, all embedded together in a fibrin gel. (It’s the fibrin gel that gives the clot its semi-solid consistency.)

Starting at this point and continuing on during the days that follow, platelets in the clot and other types of cells attracted to it begin to produce chemical factors and mediators that initiate and promote the healing process.

Restrictions on activities. / How much time will you need to take off?

The amount of postoperative rest and recuperation you require will vary according to the circumstances of your extraction process.

a) With routine extractions.

Most patients are probably best served by just going on home after their tooth extraction and taking it easy.

  • Doing so will give you some privacy and adjustment time during that awkward period while your anesthetic is wearing off and your site’s bleeding is coming to an end.
  • It will also give you an opportunity to familiarize yourself and get in sync with your dentist’s all-important postoperative instructions.

Possible guidelines.

Returning to routine non-strenuous activities (going to an office job, attending class, shopping) the next day should present no problem. If you have more aggressive or involved activities in mind (including during the next several days) you should clear them with your dentist.

Generally speaking, for people who are healthy who have had the easiest, most routine kind of extraction:

  • After a short period of recuperation, you may be able to return to non-strenuous activities even the same day of your surgery.
  • With extractions involving small-sized wounds whose bleeding has been easily controlled (think small single-rooted tooth vs. large multi-rooted molar), returning to moderate physical activity the day following your extraction may be permissible too.

Ask your dentist for instructions. And of course, it always makes sense to error on the side of caution.

b) With difficult or involved extractions.

In the case of relatively involved or difficult extractions, or cases where some method of patient sedation has been used, your dentist may feel strongly that you must limit your activities during the initial 24 hour period following your surgery.

  • In regard to strenuous physical activities, their concern may extend for some days after your surgery too, you’ll need to ask.
  • As far as participating in routine non-strenuous activities (school, desk work, running errands) the following day, even with your dentist’s OK the way you feel (or look, if pronounced swelling has occurred) may factor into your decision about how active to become.

It’s important to follow their recommendation, your safety may be involved. And remember, the way you take care (or don’t take care) of your extraction site during this initial period will set the stage for the healing process that follows.

c) Taking time off / Sick leave – What research studies have found.

Here are some examples of what researchers have reported about the amount of time off patients typically require after having wisdom teeth taken out (a level of surgery that is frequently more involved than just a routine tooth extraction).

Lopes (1995)

This paper followed the healing outcomes of 522 patients that had 3rd molars removed (from the simplest to very involved surgeries). 81% of the patients took time off from work, for an average of 3 days (with a range of 0 to 10 days). 19% of the patients took no time off.

Hu (2001)

This study also evaluated patient healing outcomes associated with 3rd molar extractions (about 2000 of them). It found that on average patients missed 1.2 days of work, or were unable to perform normal daily activities.

40% of the teeth removed were erupted (had come through the gums into relatively normal position). Removing erupted teeth typically creates less surgical insult than impacted ones, thus possibly explaining the lower amount of recuperation time reported by this study.

[page reference sources]

Extraction site healing timeline.

Pictures showing progress of tooth extraction site healing over time.

B) Extraction site healing – Weeks 1 and 2.

What will you notice?

During the first two weeks following your surgery you should be able to notice that the gum tissue that surrounds your extraction site has completed a significant amount of repair.

  • In comparison to skin on the outside of your body, oral soft tissue wounds generally heal more rapidly.
  • As a point of reference, it’s usually considered that enough gum tissue healing has taken place by days 7 through 10 that stitches can be removed.

Especially towards the end of this time frame, your extraction area should look much improved and shouldn’t pose any significant problems.

How much will your socket have closed up?

The total amount of healing that’s been able to take place by this point in time (weeks 1 & 2) will be influenced by the initial size of your wound.

  • The sockets of smaller diameter, single-rooted teeth (such as lower incisors) may appear mostly healed over by the end of two weeks. The same goes for baby teeth.
  • Wider and deeper wounds left by comparatively larger teeth (canines, premolars) or multi-rooted ones (molars), or wounds resulting from surgical extractions (like needed to remove impacted wisdom teeth), will require a greater amount of time to heal over and show signs of filling in.

    So in these types of instances, the contours of the gum tissue in the region may still show quite an indentation or divot in the area of the tooth’s socket.

What’s going on inside your tooth’s socket during this time frame?

During the first week after your extraction, the blood clot that originally formed will be colonized and ultimately replaced by granulation tissue (a kind of primordial highly-vascularized collagen-rich tissue).

Then as a next stage, mesenchymal cells (“adult” stem cells) will begin to organize within this granulation tissue. They will ultimately differentiate into more specialized types of cells such as bone tissue.

Restrictions on activities.

Since the new tissues that form during this time frame are quite vascular (contain a large number of blood vessels), if you inadvertently traumatize your extraction site it’s likely to bleed easily. So be careful when eating foods or brushing.

You can also expect this newly formed tissue to be tender if accidentally touched or prodded. But other than that, at this point you’ll probably find your extraction area to be of minimal concern and does not need to be a major consideration in regard to performing routine activities.

C) Extraction site healing – Weeks 3 and 4.

What will you notice?

By the end of the 3rd to 4th weeks after your tooth extraction, most of the soft tissue healing will have taken place.

You’ll probably still be able to see at least a slight indentation in your jawbone that corresponds with the tooth’s original socket (hole).

Where large teeth have been removed (or a lot of bone was removed during the extraction process like with impacted wisdom teeth), a relatively significant indentation may still remain. It may persist, even for some months.

What’s going on inside your tooth’s socket at this point?

During this phase mesenchymal cells will continue to proliferate and organize within the socket’s granulation tissue. Many of these cells will transform into bone cells, with the first bone tissue formation occurring along side the bony walls of the tooth’s socket.

Restrictions on activities.

You may notice that the new gum tissue that has formed has some tenderness, like when jabbed by hard foods. But even this type of trauma shouldn’t result in significant amounts of bleeding.


D) Bone healing – Filling in the socket.

When you have a tooth ‘pulled,’ it’s the healing of your jaw’s bone tissue (as opposed to your gums) that takes the greatest amount of time.

Despite the fact that new bone formation begins as early as one week post-op, it may take on the order of 6 to 8 months for this process to have substantially filled in your tooth’s empty socket.

What will you notice?

During the initial weeks of the healing process that follows your extraction it will be easy for you to see and feel the pronounced ‘hole’ left in your jawbone.

In some cases it may be deep enough that it traps food and debris. (Especially large or deep sockets may require “irrigation” to keep them clean during the early weeks of healing.)

A healed extraction site.

Picture of healed extraction site showing alveolar ridge resorption.

Note the sunken appearance of the bone (in both height and thickness) due to ridge resorption.

The shape of your jawbone will change.

Your tooth’s socket will ultimately fill in and smooth over but the shape of the bone in the immediate area of your extraction site will change.

  • Some of the bone’s original height will be lost during the healing process and as a result never again lie at a level as high as where it originally abutted the tooth. (The contours of the bone in the region of the extraction space will look somewhat sunken.) (Pagni 2012)
  • There will also be a reduction in the width of the jawbone. Usually this is more pronounced on the cheek or lip side, as opposed to the palate or tongue side.

    Studies have shown that the dimensional changes associated with premolar and molar extraction healing can run as high as 50% of the bone’s width at 12 months post-op. (Walker 2017)

Collectively these changes are referred to as “resorption of the alveolar ridge” (the alveolar ridge is that portion of the jawbone intended to hold teeth). And overall the effect of this resorption process is one that results in a narrower and shorter ridge.

One long-term study (measurements were taken 2 to 3 years post-extraction) reported alveolar ridge shrinkage on the order of 40 to 60%. (Pagni 2012)

How long do these changes take?

Ultimately the amount of time it takes for healing, and thus for the “final” shape of the ridge to form, will greatly depend on the size of the original wound. Larger wounds (i.e. multi-rooted teeth like molars, surgical sites from impacted wisdom tooth removal) will take longer to heal and will result in a greater degree of alveolar ridge changes.

  • Overall, the rate of resorption (and therefore bone shape changes noticed) will be greatest during the first month post-op.
  • At 3 months, two-thirds of the changes will have occurred. By 6 to 12 months out, the bulk of the transformation will have completed.
  • Beyond that, some level of continued resorption will continue throughout the patient’s lifetime, albeit at an ever reducing rate (estimated around 0.5 to 1.0% per year).

(Schropp 2003, Van der Weijden 2009, Pagni 2012)

X-ray showing tooth socket bundle bone.

Immediately after an extraction, the outline of the socket is easily seen.

FYI: Bundle Bone

If your dentist takes an x-ray right after you’ve had your tooth pulled, it will show a whitish outline surrounding your tooth’s socket (see our graphic).

This is called “bundle bone” and it is that layer in which the fibers that anchored your tooth in place (its periodontal ligament) were embedded.

Over time as healing takes place and new bone is formed in the socket, this layer will slowly resorb (be broken down and dispersed by your body) since the tooth is now gone and it no longer has a function.

After about 18 months or so it will have totally disappeared and the outline of the socket will have been mostly lost.

Restrictions on activities.

Don’t expect to be incapacitated, or even inconvenienced, during the 6 to 8 month time period required for bone healing. It’s a slow gradual process during which you really shouldn’t notice anything going on at all.

Bits and fragments.

The exception might be the case where you discover a small piece of broken tooth or necrotic bone poking through the surface of your gums (your body’s attempt to eject the object).

In most cases these fragments are only of minor concern and are easily removed. This link: Bone and tooth fragments explains this issue in greater detail.


Treatment timing – Making plans to replace your missing tooth.

The fact that it takes as long as 6 to 12 months for the bulk of the jawbone’s healing process to take place doesn’t mean that you have to wait that long until your empty space can be filled in with a replacement tooth.

A healing period may be needed.

With some types of restorations (dental bridges, partial dentures, some kinds of dental implants) there is typically a healing ‘wait’ period that must be adhered to for best results. For many cases this may be on the order of just 1 to a few months. With others, it may be 6 months or longer before the final prosthesis should be placed.

The general idea is that the dentist wants to wait for your socket’s healing process to have progressed to a point where the changes it creates in the shape of the jawbone (see discussion above) won’t substantially adversely affect the fit, function or appearance of the replacement teeth.

But even if some sort of wait period is required, your dentist should have some type of temporary tooth or appliance that can be placed or worn until that point in time when your jawbone’s healing has advanced enough.