Define Pericoronitis and its causes, symptoms, complications and treatments

What does pericoronitis mean?

Pericoronitis is a condition involving inflammation within the soft tissue surrounding a partially or fully-erupted tooth. The “coronitis” in pericoronitis specifically refers to inflammation occurring around the part of the tooth known as the crown. Temporally, the condition is associated with the emergence of third molars, otherwise known as wisdom teeth. These set of teeth usually emerge between the late teens and early twenties, although there is a wide-variation in actual age at emergence.

Pericoronitis if left untreated
Pericoronitis if left untreated

What causes Pericoronitis (Infection near wisdom tooth)?

As a new wisdom tooth emerges, it displaces the gingival (gum) tissue surrounding it. This would be fine, except that the growth of wisdom teeth is not always predictable, frequently leading to either a partial eruption and/or impaction due to a lack of space, obstruction or abnormal position. (6) Inflammation begins as a result of the interaction between the soft tissue and the crown now located adjacent to it. After emerging, the crown leaves a flap of gum tissue (known as the operculum) above it. The presence of this soft tissue flap, with subsequent trapping of food particles between the gum and crown causes pain and discomfort on the affected side. As food is chewed, the operculum can get caught between the new third molar and opposing teeth leading to additional swelling and occasionally, bleeding. The combination of lodged food, plaque and blood thus provides a nidus for inflammation and recurrent infections.

However, it is important to recognize that bacterial colonization is not necessary for pericoronitis to occur. In the acute form, symptoms can start abruptly with pain, fever and swelling which are signs of an underlying infection. Conversely, the disease can occur as a slow & chronic process with the food particles lodged around the crown of the tooth providing the fuel and environment for repeat episodes. Complications arise if the swelling continues, pus accumulates and the condition is not promptly managed.

Symptoms : What does Pericoronitis look and smell like?

The symptoms of pericoronitis depend on the severity of disease. Generally, a feeling of discomfort is expected to accompany the eruption of wisdom tooth, so does pain which accompanies any soft tissue infection. However, the level of pain during normal wisdom tooth emergence should be bearable, well-localized and not restrict opening the mouth or chewing. Pericoronitis can lead to additional symptoms of tenderness to touch around the tooth, localized red and swollen lesions on the gingiva around the partially erupted tooth. The swelling can extend to other areas such as the lower face, especially if the lower third molar is involved. Affected persons may also experience dyspepsia (bad taste), halitosis (bad breath) and trismus (difficulty opening the jaw/mouth). Fever, nausea, a feeling of general malaise and tiredness as seen in many infections, may be present.

Can an infected wisdom tooth kill you?
Can an infected wisdom tooth kill you?

The symptoms may vary based on the individual’s age and general health. As earlier mentioned, the emergence of wisdom teeth is almost always associated with pain. Because of this, diagnosis by a dentist will require clearly reported signs and symptoms and confirmation through a physical exam. A thorough understanding of the anatomy is required to differentiate a benign third molar from pericoronitis and any life-threatening complications that may accompany it.

Prevention : Can Pericoronitis go away on its own?

Risk factors for pericoronitis could include excess gum tissue overlying the new tooth as well as difficulty accessing the area for routine cleaning. Hence, the most important preventive steps would involve maintaining basics of dental care with good oral hygiene and regularly scheduled dental visits. This enables the dentist monitor the emergence of the third molars through physical exams and imaging. The results of surveillance will determine if early extraction of an impacted third molar is warranted. Studies have not been able to definitively show that early surgical extraction is beneficial in disease-free impacted third molars. Therefore, it may be wise to delay surgical extraction until actual symptoms arise. (6)

The diagnosis of pericoronitis is clinical – based on presenting symptoms and results of a physical exam. Imaging tests such as X-ray of the mouth and jaw can be used to rule out other causes, determine the extent of involvement and aid in treatment planning

How do you treat Pericoronitis?

The goal of therapy is to eliminate the acute signs and symptoms including the causes of irritation. (4) Treatment for pericoronitis depends on severity of the symptoms, whether the disease is localized to the teeth and surrounding tissue, or if it has spread to adjacent tissue in the mouth and neck. In the case of localized disease, initial management simply involves rinsing the mouth with a good amount of warm salt water or chlorhexidine.

Home remedies for Pericoronitis

Initial management of mild symptoms involves maintaining good oral hygiene. In the case of mild and localized disease, home remedies could prove effective. It is important when brushing the teeth to gently focus on the posterior (back) area where the wisdom teeth emerge, all while making sure food does not remain stuck between the new tooth and gum flap.

  • Use a small-headed, soft toothbrush if the affected tooth is especially hard to reach.
  • Rinse the mouth with a generous amount of warm salt water, supplementing with hydrogen peroxide or chlorhexidine where available. This will help flush debris, loose plaque and bacteria out of the area.
  • Oral irrigators can be used to reach the affected tooth as well.
  • To reduce the pain, various over the counter, topical anesthetics such as benzocaine (main ingredient in Oragel) can be applied twice a day, or as directed.
pericoronitis treatment hydrogen peroxide
Is hydrogen peroxide good for your teeth?

If pain and swelling persist or concerning symptoms of infection arise, a visit to the hospital (and dentist) may then be needed for adequate management. It is at this visit that a decision can be made on the need for antibiotic therapy and or surgery. An impacted wisdom tooth, that is stable, shows no pathology, no signs of inflammation or evidence of infection should be managed conservatively. (6)

If neck swelling is so extensive that the affected person is having difficulty breathing, emergency care is immediately prioritized. If the airway is not compromised, then analgesia with acetaminophen, ibuprofen etc. is recommended as the next step. (3) If at a primary care office, antibiotics are not initially recommended unless there are clear signs of systemic infection or the patient is immunocompromised; (3,5) If that is the case, clinical judgement should guide care of the patient and urgent dental care sought where available. Occasionally, a referral to a periodontist or oral surgeon may be necessary if infection is present or has spread beyond the affected tooth. Signs pointing towards the need for additional referrals would be swollen lymph nodes in the neck or restricted movement of the jaw.

In the event that infection is suspected and antibiotic treatment indicated, the possible initial choices include penicillin or erythromycin. Depending on the case, treatment is accompanied by cleaning with chlorhexidine, normal saline under local anesthesia. Surgery will usually involve debridement to remove pus and infected tissue under anesthesia. Incisional drainage of soft tissue swelling and any abscesses is also advised. Any drainage through the tooth is irrigated with sodium hypochlorite solution and chlorhexidine. Removal of the tooth has been successful in preventing recurrence of the condition but carries the risks of nerve damage, damage to other teeth, infection and bleeding. In the past, evidence suggested that an initial isolated case of acute pericoronitis, unless particularly severe, should not be cause for surgical removal of the tooth. Subsequent episodes or a persistent case of chronic pericoronitis would be an appropriate indication. (5) Some dental practitioners even prefer to remove all the wisdom teeth after one is affected by pericoronitis. The rationale being a significant reduction in risk of future pericoronitis as well as reduced costs to the patient. Following surgery, the patient may experience some swelling and difficulty opening the mouth. Patients should be instructed on home care.

References

  1. Nguyen, D., et al. “Common Dental Infections in the Primary Care Setting.” American Family Physician 77.6 (2008): 797-802.
  2. Web source: https://www.medicinenet.com/pericoronitis/article.htm#what_is_pericoronitis Accessed Nov 11, 2017.
  3. Management of Acute Dental Problems. Guidance for Healthcare Professionals. Scottish Dental Clinical Effectiveness Program (SDCEP), 2013.
  4. Parameter on acute periodontal diseases. American Academy of Periodontology. Journal of Periodontology 2000; 71 (5 Suppl): 863–6.
  5. National Institute for Clinical Excellence. Guidance on the extraction of wisdom teeth; 2000-2003. (www.nice.org.uk/nicemedia/pdf/wisdomteethguidance.pdf) . Accessed Nov 12, 2017.
  6. Dodson TB, Susarla SM. Impacted wisdom teeth. BMJ Clinical Evidence.2014:1302.

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