Pericoronitis
   HOME

TheInfoList



OR:

Pericoronitis is
inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
of the
soft tissue Soft tissue connective tissue, connects and surrounds or supports internal organs and bones, and includes muscle, tendons, ligaments, Adipose tissue, fat, fibrous tissue, Lymphatic vessel, lymph and blood vessels, fasciae, and synovial membranes. ...
s surrounding the crown of a partially erupted tooth, including the
gingiva The gums or gingiva (: gingivae) consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lining of the ...
(gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an ''operculum'', an area which can be difficult to access with normal
oral hygiene Oral hygiene is the practice of keeping one's oral cavity clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and adopting good hygiene habits. It is important that oral hygiene be carr ...
methods. The
hyponym Hypernymy and hyponymy are the wikt:Wiktionary:Semantic relations, semantic relations between a generic term (''hypernym'') and a more specific term (''hyponym''). The hypernym is also called a ''supertype'', ''umbrella term'', or ''blanket term ...
''operculitis'' technically refers to inflammation of the operculum alone. Pericoronitis is caused by an accumulation of
bacteria Bacteria (; : bacterium) are ubiquitous, mostly free-living organisms often consisting of one Cell (biology), biological cell. They constitute a large domain (biology), domain of Prokaryote, prokaryotic microorganisms. Typically a few micr ...
and debris beneath the operculum, or by mechanical trauma (e.g. biting the operculum with the opposing tooth). Pericoronitis is often associated with partially erupted and impacted mandibular
third molar The third molar, commonly called wisdom tooth, is the most posterior of the three molars in each quadrant of the human dentition. The age at which wisdom teeth come through ( erupt) is variable, but this generally occurs between late teens a ...
s (lower wisdom teeth), often occurring at the age of wisdom tooth eruption (15-26). Other common causes of similar pain from the third molar region are food impaction causing periodontal pain, pulpitis from
dental caries Tooth decay, also known as caries,The word 'caries' is a mass noun, and is not a plural of 'carie'.'' is the breakdown of teeth due to acids produced by bacteria. The resulting cavities may be a number of different colors, from yellow to black ...
(tooth decay), and acute myofascial pain in temporomandibular joint disorder. Pericoronitis is classified into ''chronic'' and ''acute''. Chronic pericoronitis can present with no or only mild symptoms and long remissions between any escalations to acute pericoronitis. Acute pericoronitis is associated with a wide range of symptoms including severe pain, swelling and fever. Sometimes there is an associated pericoronal
abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...
(an accumulation of pus). This infection can spread to the cheeks,
orbit In celestial mechanics, an orbit (also known as orbital revolution) is the curved trajectory of an object such as the trajectory of a planet around a star, or of a natural satellite around a planet, or of an artificial satellite around an ...
s/ periorbits, and other parts of the face or neck, and occasionally can lead to airway compromise (e.g. Ludwig's angina) requiring emergency hospital treatment. The treatment of pericoronitis is through pain management and by resolving the inflammation. The inflammation can be resolved by flushing the debris or infection from the pericoronal tissues or by removing the associated tooth or operculum. Retaining the tooth requires improved oral hygiene in the area to prevent further acute pericoronitis episodes. Tooth removal is often indicated in cases of recurrent pericoronitis. The term is from the Greek '' peri'', "around", Latin '' corona'' "crown" and ''
-itis Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
'', "inflammation".


Classification

The definition of pericoronitis is inflammation in the soft tissues surrounding the crown of a tooth. This encompasses a wide spectrum of severity, making no distinction to the extent of the inflammation into adjacent tissues or whether there is associated active infection (''pericoronal infection'' caused by micro-organisms sometimes leading to a pus filled ''pericoronal
abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...
'' or
cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of ...
). Typically cases involve acute pericoronitis of lower third molar teeth. During "
teething Teething is the process by which an infant's first teeth (the deciduous teeth, often called "baby teeth" or "milk teeth") appear by emerging through the gums, typically arriving in pairs. The mandibular central incisors are the first primary te ...
" in young children, pericoronitis can occur immediately preceding eruption of the deciduous teeth (baby or milk teeth). The
International Classification of Diseases The International Classification of Diseases (ICD) is a globally used medical classification that is used in epidemiology, health management and clinical diagnosis. The ICD is maintained by the World Health Organization (WHO), which is the dir ...
entry for pericoronitis lists acute and chronic forms.


Acute

Acute pericoronitis (i.e. sudden onset and short lived, but significant, symptoms) is defined as "varying degrees of inflammatory involvement of the pericoronal flap and adjacent structures, as well as by systemic complications." Systemic complications refers to signs and symptoms occurring outside of the mouth, such as fever, malaise or swollen lymph nodes in the neck.


Chronic

Pericoronitis may also be chronic or recurrent, with repeated episodes of acute pericoronitis occurring periodically. Chronic pericoronitis may cause few if any symptoms, but some signs are usually visible when the mouth is examined.


Signs and symptoms

The signs and symptoms of pericoronitis depend upon the severity, and are variable: * Pain, which gets worse as the condition develops and becomes severe. The pain may be throbbing and radiate to the ear, throat,
temporomandibular joint In anatomy, the temporomandibular joints (TMJ) are the two joints connecting the jawbone to the skull. It is a bilateral Synovial joint, synovial articulation between the temporal bone of the skull above and the condylar process of mandible be ...
, posterior submandibular region and floor of the mouth. There may also be pain when biting. Sometimes the pain disturbs sleep. * Tenderness,
erythema Erythema (, ) is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Examples of erythema not associated with pathology inc ...
(redness) and
edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...
(swelling) of the tissues around the involved tooth, which is usually partially erupted into the mouth. The operculum is characteristically very painful when pressure is applied. *Halitosis resulting from the bacteria
putrefaction Putrefaction is the fifth stage of death, following pallor mortis, livor mortis, algor mortis, and rigor mortis. This process references the breaking down of a body of an animal Post-mortem interval, post-mortem. In broad terms, it can be view ...
of
protein Proteins are large biomolecules and macromolecules that comprise one or more long chains of amino acid residue (biochemistry), residues. Proteins perform a vast array of functions within organisms, including Enzyme catalysis, catalysing metab ...
s in this environment releasing malodorous volatile sulfur compounds. * Bad taste or sour taste in the mouth from exudation of pus. * Intra-oral halitosis. * Formation of pus, which can be seen exuding from beneath the operculum (i.e. a pericoronal
abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...
), especially when pressure is applied to the operculum. * Signs of trauma on the operculum, such as indentations of the cusps of the upper teeth, or
ulceration An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected Organ (biology), organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caus ...
. Rarely, the soft tissue around the crown of the involved tooth may show a similar appearance to necrotizing ulcerative gingivitis. * Trismus (difficulty opening the mouth). resulting from inflammation/infection of the
muscles of mastication The four classical muscles of mastication elevate the mandible (closing the jaw) and move it forward/backward and laterally, facilitating biting and chewing. Other muscles are responsible for opening the jaw, namely the geniohyoid, mylohyoid, an ...
. *
Dysphagia Dysphagia is difficulty in swallowing. Although classified under " symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right. It may be a sensation that suggests difficulty in the passage of solids or l ...
(difficulty swallowing). * Cervical
lymphadenitis Lymphadenopathy or adenopathy is a disease of the lymph nodes, in which they are abnormal in size or consistency. Lymphadenopathy of an inflammatory type (the most common type) is lymphadenitis, producing swollen or enlarged lymph nodes. In cl ...
(inflammation and swelling of the
lymph node A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that includ ...
s in the neck), especially of the submandibular nodes. * Facial swelling, and rubor, often of the cheek that overlies the angle of the jaw. * Pyrexia (fever). * Leukocytosis (increased white blood cell count). *
Malaise In medicine, malaise is a feeling of general discomfort, uneasiness or lack of wellbeing and often the first sign of an infection or other disease. It is considered a vague termdescribing the state of simply not feeling well. The word has exist ...
(general feeling of being unwell). * Loss of appetite. * The radiographic appearance of the local bone can become more radiopaque in chronic pericoronitis.


Causes

Pericoronitis occurs because the operculum (the soft tissue directly overlying the partially erupted tooth) creates a "plaque stagnation area", which can accumulate food debris and micro-organisms (particularly plaque). This leads to an inflammatory response in the adjacent soft tissues. Sometimes pericoronal infection can spread into adjacent potential spaces (including the sublingual space, submandibular space, parapharyngeal space, pterygomandibular space, infratemporal space, submasseteric space and buccal space) to areas of the neck or face resulting in facial swelling, or even airway compromise (called Ludwig's angina).


Bacteria

Inadequate cleaning of the operculum space allows stagnation of bacteria and any accumulated debris. This can be a result of poor access due to limited room in the case of the 3rd molars. Pericoronal infection is normally caused by a mixture of bacterial species present in the mouth, such as Streptococci and particularly various anaerobic species. This can result in abscess formation. Left untreated, the abscess can spontaneously drain into the mouth from beneath the operculum. In chronic pericoronitis, drainage may happen through an approximal sinus tract. The chronically inflamed soft tissues around the tooth may give few if any symptoms. This can suddenly become symptomatic if new debris becomes trapped or if the host immune system becomes compromised and fails to keep the chronic infection in check (e.g. during
influenza Influenza, commonly known as the flu, is an infectious disease caused by influenza viruses. Symptoms range from mild to severe and often include fever, runny nose, sore throat, muscle pain, headache, coughing, and fatigue. These sympto ...
or
upper respiratory tract infection An upper respiratory tract infection (URTI) is an illness caused by an acute infection, which involves the upper respiratory tract, including the nose, sinuses, pharynx, larynx or trachea. This commonly includes nasal obstruction, sore throat ...
s, or a period of stress).


Tooth position

*When an opposing tooth bites into the operculum, it can initiate or exacerbate pericoronitis resulting in a spiraling cycle of inflammation and trauma. *Over-eruption of the opposing tooth into the unoccupied space left by the stalled eruption of a tooth is a risk factor to operculum trauma from biting. *Teeth that fail to erupt completely (commonly the lower mandibular third molars) are often the result of limited space for eruption, or a non-ideal angle of tooth eruption causing tooth impaction. *The presence of supernumerary teeth (extra teeth) makes pericoronitis more likely.


Diagnosis

The presence of
dental plaque Dental plaque is a biofilm of microorganisms (mostly bacteria, but also fungi) that grows on surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms Calculus (dental), tartar, it is often brown or pale yellow. It is ...
or infection beneath an inflamed operculum without other obvious causes of pain will often lead to a pericoronitis diagnosis; therefore, elimination of other pain and inflammation causes is essential. For pericoronal infection to occur, the affected tooth must be exposed to the oral cavity, which can be difficult to detect if the exposure is hidden beneath thick tissue or behind an adjacent tooth. Severe swelling and restricted mouth opening may limit examination of the area.
Radiographs Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical ("diagnostic" radiography and "therapeu ...
can be used to rule out other causes of pain and to properly assess the prognosis for further eruption of the affected tooth. Sometimes a "migratory abscess" of the buccal sulcus occurs with pericoronal infection, where pus from the lower third molar region tracks forwards in the submucosal plane, between the body of the mandible and the attachment of the
buccinator muscle The bucinator () is a thin quadrilateral muscle occupying the interval between the maxilla and the Human mandible, mandible at the side of the face. It forms the anterior part of the cheek or the lateral wall of the oral cavity.Illustrated Anatom ...
to the mandible. In this scenario, pus may spontaneously discharge via an intra-oral sinus located over the mandibular second or first molar, or even the second premolar. Similar causes of pain, some which can occur in conjunction with pericoronitis may include: *
Dental caries Tooth decay, also known as caries,The word 'caries' is a mass noun, and is not a plural of 'carie'.'' is the breakdown of teeth due to acids produced by bacteria. The resulting cavities may be a number of different colors, from yellow to black ...
(tooth decay) of the wisdom tooth and of the distal surface of the second molar is common. Tooth decay may cause pulpitis (toothache) to occur in the same region, and this may cause pulp necrosis and the formation of a periapical abscess associated with either tooth. *Food can also become stuck between the wisdom tooth and the tooth in front, termed food packing, and cause acute inflammation in a periodontal pocket when the bacteria become trapped. A periodontal abscess may even form by this mechanism. *Pain associated with temporomandibular joint disorder and myofascial pain also often occurs in the same region as pericoronitis. J are easily missed diagnoses in the presence of mild and chronic pericoronitis, and the latter may not be contributing greatly to the individual's pain (see table). It is rare for pericoronitis to occur in association with both lower third molars at the same time, despite the fact that many young people will have both lower wisdom teeth partially erupted. Therefore, bilateral pain from the lower third molar region is unlikely to be caused by pericoronitis and more likely to be muscular in origin.


Prevention

Prevention of pericoronitis can be achieved by removing impacted third molars before they erupt into the mouth, or through preemptive operculectomy. A treatment controversy exists about the necessity and timing of the removal of asymptomatic, disease-free impacted wisdom teeth which prevents pericoronitis. Proponents of early extraction cite the cumulative risk for extraction over time, the high probability that wisdom teeth will eventually decay or develop gum disease and costs of monitoring to retained wisdom teeth. Advocates for retaining wisdom teeth cite the risk and costs of unnecessary operations and the ability to monitor the disease through clinical exam and radiographs.


Management

Since pericoronitis is a result of inflammation of the pericoronal tissues of a partially erupted tooth, management can include applying pain management gels for the mouth consisting of Lignocaine, a numbing agent. Definitive treatment can only be through preventing the source of inflammation. This is either through improved oral hygiene or by removal of the plaque stagnation areas through tooth extraction or gingival resection, which can be done with diode lasers atraumatically. Often acute symptoms of pericoronitis are treated before the underlying cause is addressed.


Acute pericoronitis

When possible, immediate definitive treatment of acute pericoronitis is recommended because surgical treatment has been shown to resolve the spread of the infection and pain, with a quicker return of function. Also immediate treatment avoids overuse of antibiotics (preventing
antibiotic resistance Antimicrobial resistance (AMR or AR) occurs when microbes evolve mechanisms that protect them from antimicrobials, which are drugs used to treat infections. This resistance affects all classes of microbes, including bacteria (antibiotic resis ...
). However, surgery is sometimes delayed in an area of acute infection, with the help of pain relief and antibiotics, for the following reasons: * Reduces the risk of causing an infected surgical site with delayed healing (e.g.
osteomyelitis Osteomyelitis (OM) is the infectious inflammation of bone marrow. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The feet, spine, and hips are the most commonly involved bones in adults. The cause is ...
or cellulitis). * Avoids reduced efficiency of local anesthetics caused by the acidic environment of infected tissues. * Resolves the limited mouth opening, making oral surgery easier. * Patients may better cope with the dental treatment when free from pain. * Allows for adequate planning with correctly allocated procedure time. Firstly, the area underneath the operculum is gently irrigated to remove debris and inflammatory exudate. Often warm saline is used but other solutions may contain
hydrogen peroxide Hydrogen peroxide is a chemical compound with the formula . In its pure form, it is a very pale blue liquid that is slightly more viscosity, viscous than Properties of water, water. It is used as an oxidizer, bleaching agent, and antiseptic, usua ...
,
chlorhexidine Chlorhexidine is a disinfectant and antiseptic which is used for skin disinfection before surgery and to disinfect surgical instruments. It is also used for cleaning wounds, preventing dental plaque, treating yeast infections of the mouth, and ...
or other
antiseptic An antiseptic ( and ) is an antimicrobial substance or compound that is applied to living tissue to reduce the possibility of sepsis, infection, or putrefaction. Antiseptics are generally distinguished from ''antibiotics'' by the latter's abil ...
s. Irrigation may be assisted in conjunction with Debridement (removal of plaque, calculus and food debris) with periodontal instruments. Irrigation may be enough to relieve any associated pericoronal abscess; otherwise a small incision can be made to allow drainage. Smoothing an opposing tooth which bites into the affected operculum can eliminate this source of trauma. Home care may involve regular use of warm salt water mouthwashes/mouth baths. A randomized clinical trial found green tea mouth rinse effective in controlling pain and trismus in acute cases of pericoronitis. Following treatment, if there are systemic signs and symptoms, such as facial or neck swelling, cervical lymphadenitis, fever or malaise, a course of oral
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
s is often prescribed,. Common antibiotics used are from the β-lactam antibiotic group, clindamycin and
metronidazole Metronidazole, sold under the brand name Flagyl and Metrogyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vagino ...
. If there is
dysphagia Dysphagia is difficulty in swallowing. Although classified under " symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right. It may be a sensation that suggests difficulty in the passage of solids or l ...
or dyspnoea (difficulty swallowing or breathing), then this usually means there is a severe infection and an emergency admission to hospital is appropriate so that
intravenous Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutr ...
medications and fluids can be administered and the threat to the airway monitored. Sometimes semi-emergency surgery may be arranged to drain a swelling that is threatening the airway.


Definitive treatment

If the tooth will not continue to erupt completely, definitive treatment involves either sustained oral hygiene improvements or removal of the offending tooth or operculum. The latter surgical treatment options are usually chosen in the case of impacted teeth with no further eruption potential, or in the case of recurrent episodes of acute pericoronitis despite oral hygiene instruction.


Oral hygiene

In some cases, removal of the tooth may not be necessary with meticulous oral hygiene to prevent buildup of plaque in the area. Long term maintenance is needed to keep the operculum clean in order to prevent further acute episodes of inflammation. A variety of specialized oral hygiene methods are available to deal with hard to reach areas of the mouth, including small headed tooth brushes, interdental brushes, electronic irrigators and dental floss.


Operculectomy

This is a minor surgical procedure where the affected soft tissue covering and surrounding the tooth is removed. This leaves an area that is easy to keep clean, preventing plaque buildup and subsequent inflammation. Sometimes operculectomy is not an effective treatment. Typically operculectomy is done with a surgical scalpel, electrocautery, with lasers or, historically, with caustic agents ( trichloracetic acid)


Tooth extraction

Removal of the associated tooth will eliminate the plaque stagnation area, and thus eliminate any further episodes of pericoronitis. Removal is indicated when the involved tooth will not erupt any further due to impaction or ankylosis; if extensive work would be required to restore structural damage; or to allow improved oral hygiene. Sometimes the opposing tooth is also extracted if no longer required. Extraction of teeth which are involved in pericoronitis carries a higher risk of
dry socket Alveolar osteitis, also known as dry socket, is inflammation of the alveolar bone (i.e., the alveolar process of the maxilla or mandible). Classically, this occurs as a postoperative complication of tooth extraction. Alveolar osteitis usually o ...
, a painful complication which results in delayed healing.


Prognosis

Once the plaque stagnation area is removed either through further complete tooth eruption or tooth removal then pericoronitis will likely never return. A non-impacted tooth may continue to erupt, reaching a position which eliminates the operculum. A transient and mild pericoronal inflammation often continues while this tooth eruption completes. With adequate space for sustained improved oral hygiene methods, pericoronitis may never return. However, when relying on just oral hygiene for impacted and partially erupted teeth, chronic pericoronitis with occasional acute exacerbation can be expected. Dental infections such as a pericoronal abscess can develop into
sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...
and be life-threatening in persons who have neutropenia. Even in people with normal immune function, pericoronitis may cause a spreading infection into the potential spaces of the head and neck. Rarely, the spread of infection from pericoronitis may compress the airway and require hospital treatment (e.g. Ludwig's angina), although the majority of cases of pericoronitis are localized to the tooth. Other potential complications of a spreading pericoronal abscess include peritonsillar abscess formation or
cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of ...
. Chronic pericoronitis may be the etiology for the development of paradental cyst, an inflammatory odontogenic cyst.


Epidemiology

Pericoronitis usually occurs in young adults, around the time when wisdom teeth are erupting into the mouth. If the individual has reached their twenties without any attack of pericoronitis, it becomes substantially less likely one will occur thereafter.


References

20. Professional Dental University education, both Cosmetic Dentists, Dr. David Nguyen and Dr. Benjamin Golik (2009)
Pericoronitis
dentist.


External links

{{Oral pathology Periodontal disorders