What Is Pericoronitis

Pericoronitis is a local infection and inflammation of the soft tissue that covers the erupting third molars or wisdom teeth.³ Pericoronitis commonly occurs in individuals in their 20s, although any individual with an unerupted or partially erupted wisdom tooth complicated further poor oral hygiene may be at high risk of developing pericoronitis. Pericoronitis can often cause severe pain, discomfort and swelling, which may adversely impact the quality of life of the individual suffering from it and may progress into severe head and neck infection, which, if untreated, may lead to airway obstruction; thus, some individuals may require urgent medical attention.^1,5

Overview

Erupting third or last molars/wisdom teeth may often have difficulties in eruption (coming out) due to insufficient space inside the mouth, causing the molar tooth to become completely or partially impacted (stuck).¹ This impacted wisdom tooth creates an area inside the mouth that is often difficult to clean, causing food particles and food debris to accumulate between the tooth and the gum flap covering it.² Over a period of time, this accumulation can cause a local increase in the growth of microorganisms and localised infection, causing irritation to the gum tissue in and around the tooth, resulting in inflammation of the gum flap covering the wisdom tooth.³

This inflammation of the local gum flap covering the wisdom tooth is called pericoronitis.^2,3 It affects the mandibular (lower) wisdom teeth more commonly and is seen more commonly in partially erupted wisdom tooth cases.² Individuals between the ages of 16 and 30 years of age are at maximum risk of developing pericoronitis, with the highest chances at 21-25 years of age.³

Pericoronitis can be acute – severe symptoms such as difficulty opening the mouth developing suddenly, sub-acute – following a similar pattern as the acute variant with lower intensity without any difficulty in mouth opening and chronic – short-lasting low-grade pain and non-significant symptoms over a long duration of time.⁴ Severe pericoronitis is often quite intense, with very extreme symptoms that can adversely compromise the patient’s quality of life.⁵

Causes of pericoronitis

As discussed above, the leading cause of pericoronitis is the accumulation of food debris or particles in the space between the partially erupted or impacted wisdom tooth and the gum flap covering it.³ When this difficult-to-clean previously sterile space is exposed to the constantly changing and complex external conditions inside the mouth, this accumulation causes an increase in the growth of many different types of bacteria that subsequently cause infection of the surrounding soft tissue.³ This infection causes a reaction by the immune system of the body, which is known as inflammation.^2,3

While there is only a single cause of pericoronitis, there are other factors that may increase the severity of the condition, such as physical trauma from teeth in the opposite jaw, which can cause ulcers which further worsen the symptoms.³ Systemic factors that can increase the severity of symptoms include patients with compromised immune systems, such as patients with uncontrolled diabetes or immunodeficiency disorders. Furthermore, conditions that compromise the immune system temporarily such as stress, upper respiratory infection, or menstruation in females, may also trigger or worsen symptoms of pericoronitis.³

Signs and symptoms of pericoronitis

Some common signs and symptoms of pericoronitis include:³

• Redness and swelling (can be local or diffused in patients with widespread involvement)
• Pain and discomfort (can vary from being very severe and radiating to just mild achiness in the lower wisdom tooth area)
• Pus collection or drainage
• Difficulty opening and closing the mouth or locked jaw (trismus)
• Swollen lymph nodes in the neck
• Bad breath (halitosis)
• Bad taste
• Difficulty swallowing, speaking, or sleeping on that side
• Fever

As discussed earlier, patient presentation may differ in every individual, given that acute pericoronitis and chronic pericoronitis may have differing severity and onset of symptoms.

Management and treatment for pericoronitis

Management and treatment for pericoronitis vary significantly based on the individual patient presentation and choice and/or experience of the dental care professional or dentist.^2,3 Early recognition of the signs and symptoms is key here to successful management with the minimal requirement of invasive procedures.³ Following are some options for the treatment of pericoronitis:

Non-Surgical Management

• Professionally cleaning/debridement of the locally affected area to improve oral hygiene – can be done using solutions such as normal saline, plain water/ warm salt water, chlorhexidine, hydrogen peroxide, or mechanically by a trained and qualified dental professional using periodontal (gum-related) instruments.³ Following this, maintaining oral hygiene is of paramount importance.^2,3
• Pain management – This can be done by prescribing pain relievers or via local injections or topical creams.⁶
• Oral antibiotics – The use of antibiotics in pericoronitis depends on the spread and severity of the infection.³
• Patient Education – Providing patient information leaflets and educating patients about the condition has been shown to be very helpful in maintaining good oral hygiene practices that in turn help in managing pericoronitis.³

Surgical management

• Soft tissue surgery – A procedure in which the gum flap covering the affected tooth is surgically removed to resolve the local infection.
• Tooth Extraction – Wisdom tooth removal is the most permanent and effective way of treating pericoronitis in certain cases.⁷ Removal may also be needed in some patients where wisdom tooth decay might have started due to the accumulation of food debris.⁷ This procedure is commonly performed by specialist oral surgeons, and the complexity of the procedure may vary highly on a case-to-case basis.⁷   

The above-mentioned options may be used individually or in combination and are dependent purely on the findings of the assessment of the patient by a professional.^3,6,7

Diagnosis

1. History and Examination: Oral history and physical examination inside the mouth or in some very severe cases, externally is generally key to finding the above-mentioned signs and symptoms for diagnosing pericoronitis.³
2. Radiological examination: Various X-rays, such as localised X-rays inside the mouth or panoramic imaging, may aid in diagnosing pericoronitis. These may also be very helpful in determining the spread of the infection, the position of the tooth, and tooth decay, which in combination with other factors, are also helpful in planning treatment for patients suffering from pericoronitis.³

Some common differential diagnosis of pericoronitis is Periodontitis (gum disease), localised tooth decay, foreign body impaction, and benign tumours such as Pyogenic granuloma, and Peripheral ossifying fibroma.³

Risk factors

Some common risk factors for pericoronitis are :

• Age - Individuals in their 20s have a higher risk
• Non-erupted or partially erupted lower wisdom teeth
• Stress
• Excess gum tissue
• Pregnancy or menstruation
• Poor oral hygiene
• Diabetes³

Complications

It is commonly not a life-threatening infection in itself, but the spread of local infection in pericoronitis to the various areas in the head and neck can cause serious and fatal space infections, which if not diagnosed and treated at the earliest, could lead to airway compromise or obstruction which significantly increases the risk for death.^3,8  

FAQs

How can I prevent pericoronitis

Pericoronitis, in certain cases, may be difficult to prevent completely, but maintaining good oral hygiene regularly by brushing thoroughly at least 2 times a day and using a mouthwash regularly can help significantly reduce the risk of developing an infection. Additionally, visiting a dental care professional frequently for professional cleaning and check-ups helps reduce the risk of infection.

How common is pericoronitis

Pericoronitis is very common globally and affects all individuals equally.³ Individuals in their 20s or anyone with unerupted or partially erupted wisdom teeth are at high risk of developing it. Certain other factors, such as uncontrolled diabetes, stress, or poor oral hygiene, may also increase the risk of developing pericoronitis.^2,3

When should I see a doctor?

If you develop any of the above-mentioned signs and symptoms, such as fever, locked jaw, or pain/swelling/redness inside the mouth near the wisdom teeth area (especially in the lower jaw), you must visit your dentist for treatment and advice. More importantly, if you feel severely unwell and develop any severe symptoms, you must seek emergency medical or dental attention to avoid the risk of severe infection.^3,8

Summary

Pericoronitis is a fairly common localised infection of the soft tissue/gum flap that covers the third molar or the wisdom tooth.^2,3 It is more commonly seen in cases of unerupted or partially erupted lower wisdom teeth due to the accumulation of food debris in the difficult-to-clean space between the wisdom tooth and the flap covering it.³ It may be exacerbated by factors such as poor oral hygiene, stress, etc.^3,4 Some common signs and symptoms include pain, swelling and redness in the lower wisdom tooth area, difficulty opening and closing the mouth, bad breath, pus discharge from the affected area, fever, swollen lymph nodes and difficulty swallowing or speaking.³ Symptom onset may be acute or chronic with varying presentations.³ Pericoronitis can be diagnosed by history and examination, although certain cases may require additional examination via X-rays. Common treatment options include professional cleaning of the affected area, use of a medicated mouthwash, pain management, oral antibiotics, surgical removal of soft tissue flap or wisdom tooth removal.^1,2 Pericoronitis must be treated and monitored professionally to reduce the risk of progression to fatal space infections that may risk airway compromise or obstruction.^3,8