An Overview of Pericoronitis

Pericoronitis (also called operculitis) is a condition involving inflammation and swelling of the soft tissue that surrounds a tooth that is partially erupted. Eruption is the process of tooth development in which a tooth becomes visible as it “erupts’’ through the gingiva (gum tissue). Pericoronitis may also affect a tooth that has not yet come in.

The soft tissue that covers a tooth that is not fully erupted is called an “operculum.” One reason this soft tissue area may become easily inflamed is that it often collects food particles and debris and it can be difficult to reach when performing oral hygiene. As it collects food particles, this dark, moist area provides the perfect medium for bacteria to grow.

The tooth that is most often affected by pericoronitis is the lower third or final set of molars sometimes called wisdom teeth. In fact, it is rare that pericoronitis involves any teeth other than the bottom wisdom teeth. Pericoronitis often affects those in their late teens or early adulthood, because that is the time the lower wisdom teeth usually erupt.

Symptoms

Mild symptoms

Mild symptoms of pericoronitis may include:

• Painful, swollen gum tissue (near the tooth that is affected)
• Difficulty biting down (without hitting the swollen area)
• A discharge of pus from the inflamed area
• A bad taste in the mouth or unpleasant smell

Severe Symptoms

Severe symptoms of pericoronitis may include:

• Difficulty opening the mouth
• Swelling of the face (on the side of the face that the inflamed tooth is on)
• Swollen lymph nodes (called lymphadenitis)
• Fever
• Ludwig’s angina (a rare bacterial infection of the floor of the mouth that sometimes occurs after a tooth infection)
• Spasms of the jaw (sometimes referred to as lockjaw)

Symptoms of pericoronitis are grouped into three different categories according to their frequency and intensity, these include:

1. Acute-involves limited mouth opening and more severe symptoms
2. Sub-acute-lower intensity of symptoms without mouth opening discomfort
3. Chronic-involves low grade pain without severe symptoms

The treatment of pericoronitis is often dependent on the level (acute, sub-acute or chronic) of the disease a person is experiencing.

Causes and Risk Factors

Those at higher risk of getting pericoronitis include:

• Those in the age group of early adulthood or late adolescence
• Having wisdom teeth that have not yet erupted
• Having a developed operculum (flap surrounding the teeth, which encourages bacterial growth)
• Experiencing chewing trauma (damage to the affected tissue from an opposing tooth)
• Those with poor oral hygiene
• Engaging in smoking (regardless of the number of cigarettes smoked per day)
• Having conditions that put a strain on the immune system (such as viral recovery, severe fatigue or emotional stress)
• Being pregnant

Study

A 2019 study, performed in Greece, aimed to determine the factors that impact the prevalence of pericoronitis (including social and risk factors, demographics and more).
The study discovered several factors related to the prevalence of pericoronitis, including:

• The prevalence of pericoronitis was 4.92% of the 20 to 25-year-old study participants.
• Oral hygiene was found to be a marginally significant factor in the prevalence of the disease.
• Smokers were found to be more susceptible to pericoronitis (but the frequency of smoking was not impactful).
• The chronic type of pericoronitis was the most frequent form of the disease.
  “The use of mouthwash along with the adequate frequency of teeth-brushing appeared to be related to a statistically significant decrease of the disease [pericoronitis],” concluded the study authors.

Diagnosis

Diagnosis of pericoronitis is usually made by a dentist, by performing an oral examination, and sometimes involves taking diagnostic X-rays (to evaluate the unerupted wisdom tooth).

Treatment

Home Treatment

Although there are several home treatment modalities that the dentist may recommend, home treatment should not replace professional medical intervention. The dentist may prescribe home treatment modalities such as:

• Warm salt-water rinses (particularly after eating to remove food and debris)
• Oral water irrigation systems (using commercial equipment)
• Meticulous/regular oral hygiene (including brushing and flossing)
• Pain relievers (such as ibuprofen [Advil] or acetaminophen [Tylenol] or other over-the-counter pain relievers prescribed by the dentist).

Note: Avoid the use of hot compresses (which may increase the swelling) particularly for those with severe symptoms of pericoronitis such as fever or swelling of the neck or face)

Medical Treatment

Treatment for pericoronitis may involve:

• Dental cleaning/flushing of food and other debris from the area
• Antibiotic administration (to take by mouth)
• An antibacterial oral rinse
• Pain relief (either over-the-counter pain relievers or prescription medication may be suggested by the dentist)

Once the infection is cleared up, subsequent treatment depends on the severity and category of the pericoronitis symptoms (including acute, sub-acute or chronic categories) and may involve:

• Observing the tooth to ensure the infection doesn’t return and that the tooth will erupt normally
• Referral to an oral and maxillofacial surgeon to evaluate the need for oral surgery
• Removal of the infected wisdom tooth (if the dentist/oral surgeon deems that it may not erupt normally)
• Removal of both the lower and upper wisdom teeth on the affected side (to prevent the upper tooth from biting into the inflamed lower gum and causing subsequent infection).
• Performing a procedure called an operculum (minor oral surgery to remove the flap of skin over the affected tooth

Sometimes the flap will grow back after it is removed, and the operculum procedure will need to be performed again.

Aftercare

If the wisdom tooth has been removed, it usually results in complete healing, and pericoronitis symptoms may subside within one to two weeks after surgery. Follow up treatment may include:

• Follow up appointments with the dentist or oral surgeon to monitor the rate of healing and level of tooth pain, if present
• Adhering strictly to aftercare instructions if a wisdom tooth was extracted (such as abstaining from smoking, eating soft foods, etc.)
• Home treatments (such as antibiotic oral rinsing, over-the-counter pain medication and more)
• Meticulous oral hygiene (including regular brushing and flossing)
• Quitting smoking (for those who smoke)

Prevention

Preventative care and regular dental visits may lower the risk of getting pericoronitis because the dentist can keep a close eye on your wisdom teeth and intervene before infection occurs when the third molars do not appear to be erupting normally.

Regular dental cleanings may also help to prevent pericoronitis because they help to keep the teeth clean and free of food and debris.  Prevention of pericoronitis may be possible with regular oral hygiene practices involving brushing, flossing and using an antibiotic oral rinse; but despite such interventions, some people will still develop the condition.