Pericoronitis

Pericoronitis is a condition often marked by the gum growing over a wisdom tooth.

Pericoronitis is inflammation of the gum tissue surrounding the crown portion of a tooth. Pericoronitis usually affects the lower third molar (wisdom tooth) where gum tissue overlaps the chewing surface of the tooth. Pericoronitis can be either chronic or acute.

• Chronic pericoronitis is a mild persistent inflammation of the area.
• Acute pericoronitis is when the symptoms intensify to fever, swelling, and pain, which indicate a spreading infection.

Pericoronitis is differentiated from periodontal disease (or periodontitis) in that it occurs specifically around a partially erupted tooth where the tooth has not completely emerged from the gum overlying it.

The primary cause of pericoronitis is accumulation of bacteria. Usually, the tooth is only partially exposed (soft tissue impaction) and has excess gum tissue that overlaps the tooth. Bacteria and food debris get trapped in the space between the tooth and the overlapping gingiva. This overlapping gum flap is called an "operculum." Initially, inflammation of the operculum (operculate) takes place. A pericoronal infection can develop by forming an abscess under the operculum. If left unattended, the infection can spread to other soft tissue spaces.

Most commonly, pericoronitis affects young adults in their mid-20s who are experiencing poorly erupting wisdom teeth (third molars). Pericoronitis is essentially a "wisdom tooth infection."

Risk factors for pericoronitis include:

• The presence of excess gum tissue (operculum) overlying the wisdom tooth
• Difficult access to the wisdom teeth for proper cleaning
• Poor oral hygiene

Signs and symptoms of pericoronitis can range from mild to severe and include:

• Pain
• Swelling of the gums
• Tenderness
• Redness of gum tissue
• Bad breath (halitosis)
• Bad taste from pus
• Difficulty opening the jaw (trismus)
• Difficulty swallowing (dysphagia)
• Swollen submandibular lymph nodes
• Fever
• Loss of appetite
• Feeling unwell

Any licensed dentist can treat pericoronitis. In situations where surgery is required or if it is a severe and complicated case, dental specialists such as an oral surgeon or a periodontist (gum surgeon) can provide treatment. In rare instances, should the infection become more general, emergency services with physician care might be needed.

Diagnosis of pericoronitis is based on symptoms and appearance during a clinical evaluation with a health care professional such as a dentist or oral surgeon. A dental X-ray is used to assess the area and rule out other possible causes of pain, such as dental decay. Once all the information from the patient and facts are gathered, the diagnosis of pericoronitis can be made.

There are three methods for the treatment of pericoronitis depending on the severity of the condition:

1. Management of pain and resolving the pericoronal inflammation and/or infection
2. Minor oral surgery to remove the overlapping gingival tissue (operculectomy)
3. Removal of the wisdom tooth

To manage the pain of acute pericoronitis, use over-the-counter medications such as acetaminophen (Tylenol) or ibuprofen (Advil). If it is localized to the tooth and there has been no spread of the infection, a dentist thoroughly cleans out the area under local anesthesia. A dentist may prescribe an oral rinse containing chlorhexidine to keep the site clean. Otherwise, warm salt water or diluted hydrogen peroxide can be used as an oral rinse. If there is swelling or fever, a dentist may prescribe oral antibiotics such as amoxicillin or erythromycin.

When the molar can be useful for chewing and wants to keep the tooth, minor oral surgery can be performed to remove the operculum. This will allow better access to properly clean the area and prevent bacteria and food debris accumulation. Unfortunately, the gum tissue may grow back and create the same problem.

Removal (extraction) of the tooth is the most common treatment method since wisdom teeth often are poorly positioned and do not erupt completely. This method eliminates any future occurrences of a wisdom tooth infection. It also helps prevent other issues related to wisdom tooth malposition.

In rare instances, the symptoms become so severe that an individual needs to go to the hospital emergency room to seek care due to the rapid spread of a pericoronal abscess. This is especially the case if there is swelling of the lymph nodes.

Sometimes, mild symptoms of pericoronitis can be treated at home through meticulous oral hygiene without antibiotics. Thorough and gentle brushing of the area with a small-headed toothbrush may help break up the plaque or trapped food. Oral water irrigators can be effective in clearing out the debris trapped under the operculum, as well. Rinsing with warm salt water can help to soothe the area. Additionally, diluted hydrogen peroxide can be used as a rinse or irrigating solution to help reduce the bacteria in the area. Be careful not to swallow the rinse.

Home treatments are not advised for severe pericoronitis where swelling and fever are present and proper care should be sought with the appropriate healthcare professional.

The prognosis for pericoronitis is usually very good. With timely care and treatment, pericoronitis can properly be managed or eliminated. Symptoms of pericoronitis can last for days to weeks depending on the severity. The condition should resolve in approximately one to two weeks with treatment. If the initial cause of the infection is not treated, the condition will likely return.

Complications can occur with pericoronitis. Although rare, the infection can spread from the mouth into the head and neck and cause a serious complication called "Ludwig's angina." This can be a life-threatening condition where the airway could be blocked. Another life-threatening concern is the spread of the infection to the bloodstream (sepsis). Symptoms are to be addressed as soon as possible to avoid any possible complications and will include intravenous antibiotic treatment and possible surgery.

Prevention of pericoronitis may be achieved with conscientious oral hygiene, regular dental visits, and preemptive care. The dentist can aid in keeping these potential problem areas clean and determine the need to remove the operculum. Alternatively, the dentist can also monitor the eruption of the third molars and determine the need for early extraction of these teeth. Removal of the wisdom teeth before an eruption can prevent pericoronitis.