Management of Third Molar Cheek Biting
For a patient experiencing cheek biting from a third molar (wisdom tooth), extraction of the offending third molar is the definitive treatment to prevent ongoing soft tissue trauma and potential complications. 1
Clinical Assessment
When evaluating third molar-related cheek biting, examine for:
- Visible trauma to the buccal mucosa including white keratotic lesions, ulcerations, or chronic irritation patterns 1
- Malpositioned third molar with sharp cusps or abnormal angulation causing repetitive cheek trauma 2
- Signs of infection or swelling from chronic tissue injury 3
- Occlusal interference when the patient closes their bite 2
Diagnostic Imaging
Begin with orthopantomography (panoramic radiograph) as the first-line imaging study to assess third molar position, angulation, and relationship to adjacent structures 2. This Level I investigation provides sufficient information for treatment planning in most cases 2.
Upgrade to CBCT imaging if:
- The panoramic view shows the third molar in close proximity to the mandibular canal (for lower molars) 2
- The tooth is near the maxillary sinus floor (for upper molars) 2
- Complex anatomical relationships require 3D assessment before extraction 2
Treatment Algorithm
Immediate Management
- Remove the source of trauma by extracting the offending third molar 3
- Provide oral hygiene instructions including gentle brushing with a soft toothbrush and mild fluoride toothpaste 3, 4
- Recommend alcohol-free antimicrobial mouth rinses such as 0.2% chlorhexidine to reduce bacterial load in the traumatized tissue 3, 4
- Advise warm saline rinses 4-6 times daily to promote healing of the injured buccal mucosa 3, 4
Extraction Planning
- For lower third molars: Panoramic imaging is sufficient for treatment planning in non-critical cases where nerve injury risk is low 2
- For upper third molars: Panoramic imaging may be appropriate for assessment and treatment planning 2
- Refer to oral surgery if CBCT reveals high-risk anatomical relationships requiring specialized extraction techniques 2
Important Caveats
Avoid prophylactic extraction of asymptomatic third molars that are not causing cheek biting or other pathology, as this creates unnecessary morbidity 5. However, when a third molar is actively causing soft tissue trauma through cheek biting, this represents a clear indication for removal 1.
Monitor for complications if the patient has a pre-existing cheek biting habit, as local anesthesia (inferior alveolar nerve block) can exacerbate self-inflicted injury during the numb period following dental procedures 1. Warn patients explicitly not to bite their cheek while numb.
Ensure proper post-extraction care including: