This is the story of how I (Dr David Chen) ended up doing the wisdom tooth extraction for a tooth that I had already referred out. You read that correctly. It was a tooth that I referred out to the specialist but it came back into my lap.
It was like a boomerang where I threw it and it came all the way back to me.
The Story
It was the summer of 2020 and the COVID lock down was starting to be lifted. Businesses were reopening and so were dental offices! Quite amazing how we managed to not go under during that time but that’s a story for another day.
Anyway, this really sweet girl comes in as a new patient for her very first visit. In regards to her periodontal health, she needed a deep teeth cleaning. As for her teeth, she had a big cavity on the side of her lower left wisdom tooth #17. The cavitation was so big that you could stick your finger nail into it and feel the hole.
I looked at the x-ray of the wisdom tooth and just had a feeling that I shouldn’t attempt to extract it. It was probably better to give her a referral to the oral surgeon and that is exactly what I did.
She comes back 3 weeks later and tells me that it was too expensive to have the wisdom tooth removed with the surgeon. Apparently it was going to cost her close to $800 to have it extracted even though she had dental insurance.
She even shows me the panoramic x-ray that she had taken at the consultation appointment.
The x-ray seemed fine in that the tooth wasn’t on top of the inferior alveolar nerve. That means there was a low risk for nerve injury during the procedure. That’s a relief.
I decided, I was going to help her out since she seemed really sweet and had been a good patient thus far. We scheduled her to come back next week for the deep cleaning as well as the wisdom tooth extraction at the same visit.
Day of the extraction
The procedure started as envisioned. I dried the injection site with gauze and then placed some benzocaine, topical numbing gel which is the main ingredient in orajel (Yes, orajel does work). I waited two minutes before going in with the syringe that was loaded with 2% lidocaine with 1:100k epinephrine.
For the injection, I had to give her 1.5 carpules of lidocaine via an inferior alveolar nerve block. The last half a carpule was given as a long buccal. This is currently the standard technique for numbing a lower molar which includes the wisdom tooth for an extraction.
After about 5 minutes or so, she was numb enough for me to begin the procedure. As with all extractions and not just wisdom teeth removals, you must begin by severing the PDL fibers.
Essentially you take a sharp instrument and cut apically into the gums along the direction of the roots and go all around the tooth. This releases the periodontal ligaments that are attaching the gums to the crown of the tooth. If you don’t do this, when you go take out the tooth, the gums will often get ripped off while still being attached to the crown. That just creates more work at the end of the procedure which you can easily avoid by doing this step.
The next step was to start elevating the tooth with a spade elevator, which is my favorite one for all extractions. It is heart shaped or rather it looks like a spade from playing cards. Some of our colleagues also call it the “sweetheart”.
How you use the elevator is by wedging it into the PDL space. Then you start twisting clockwise as you apply apical pressure. With each twist and push you try to go more apically each time.
Unfortunately since this wisdom tooth had a big cavity on the buccal surface, the entire crown fractures off! That wasn’t unexpected but certainly not something that I wanted to happen. Once the tooth fractures down to the gum line, it makes the extraction significantly more difficult.
Reasons a broken tooth down to gum line is infinitely more difficult to remove:
- There is no crown to grab with a forcep.
- You lose the purchase point.
- Will require drilling away bone to complete procedure.
I keep trying with the elevator and it is not budging. The next thing to try was to start drilling away bone around the tooth. I trough mesially, buccally, and a little distally. Then I try the elevator again. It is still not working. I had to move to the next step which was to try sectioning the tooth into multiple pieces. I try the elevator again and it is not working.
Long story short, I had to keep repeating the process of drilling away bone and trying the elevator again. After about an hour I finally managed to remove each piece of the wisdom tooth root… It turns out that one of the roots was curved which was what was making it difficult.
The recovery
I was expecting the patient to experience some difficulty during the healing process. However I was proven wrong about that since she healed without a hitch.
As a rule of thumb, usually the faster the tooth gets extracted the less pain there is afterwards. Consequently the more you’re forced to dig around and drill around in the socket, the more post-operative pain they would feel. There is sort of a direct correlation with the amount of time spent on the procedure and the pain afterwards.
I usually like to tell my patients, “If you see me start sweating you should probably expect the healing to be a little rougher.”
Reflections
The first thing that came to my mind was… I told you so. Or rather, I sort of knew that it would be difficult which is why I had the initial hunch to give the patient a referral to the oral surgeon.
This is one of those cases where you don’t like being right!
Anyway that took far too much time for that wisdom tooth extraction. Cases like these make you question why you’re doing the extraction. They definitely aren’t worth it because they cause an immense amount of stress and at the end of the hour struggle, your hands are numb. It makes it difficult to treat the next patient to be quite honest.
It is certainly considered a difficult case because most routine wisdom tooth removals only take about 5-30 minutes at most. Some of the upper teeth will and can be extracted within 5 minutes. The lower ones tend to be more stubborn due to their root shape. Then there is also the fact that the bone for the lower jaw is denser than the upper jaw.
I guess the lesson for this story was that you should follow your gut feeling. Sometimes you just know but aren’t consciously aware of the reason why. After doing this for a while you just sort of develop this sixth clinical sense for dentistry.
Half the battle in being successful as a clinician is knowing which battles to fight. It is equally important to complete the procedure as it is to know which ones to avoid. It is good to challenge yourself once in awhile but it is not good to be permanently stressed.
If you know that the procedure will take you an hour but for the specialist it would only be 30 minutes… Perhaps the patient would be better off seeing the specialist. Unfortunately I tried to step in to help the patient out financially.
She was grateful but it was still too much sweating for me to attempt that again.