Pericoronitis

Pericoronitis refers to inflammation and infection of the soft tissues (operculum) surrounding the crown of a partially erupted tooth. It occurs most commonly in association with mandibular third molars (wisdom teeth) during eruption.

Food debris, plaque accumulation, and bacteria become trapped beneath the gingival flap covering the erupting tooth, creating an anaerobic environment favorable for bacterial proliferation. Trauma caused by occlusion from the opposing tooth further worsens inflammation and infection.

Pericoronitis is one of the most common causes of acute dental pain and odontogenic infection in young adults.

Pathophysiology

Pericoronitis develops through the following mechanism:

• Partial eruption of tooth creates a gingival flap (operculum)

• Food particles and plaque accumulate beneath the flap

• Limited oxygen supply promotes anaerobic bacterial growth

• Local inflammatory response develops

• Trauma from opposing tooth causes ulceration

• Secondary bacterial invasion leads to suppuration

• Infection may spread into adjacent fascial spaces if untreated

Common microorganisms involved include:

• Streptococcus species

• Fusobacterium species

• Prevotella species

• Actinomyces species

• Mixed anaerobic oral flora

Severe untreated infection may progress to cellulitis or deep neck space infection.

Risk Factors

• Partially erupted mandibular third molars

• Poor oral hygiene

• Food impaction

• Trauma from opposing tooth

• Young adults (18–30 years)

• Upper respiratory infections

• Stress

• Immunosuppression

• Pregnancy

• Diabetes mellitus

• Smoking

Classification

Acute Pericoronitis

• Sudden onset pain

• Swelling and active infection

• Possible systemic symptoms

Chronic Pericoronitis

• Recurrent mild discomfort

• Persistent inflammation

• Intermittent swelling

Signs and Symptoms

• Severe pain in posterior mandibular region

• Swollen gum tissue around erupting tooth

• Pain during chewing or swallowing

• Pus discharge

• Bad taste in mouth

• Halitosis (foetor-ex-oris)

• Trismus (limited mouth opening)

• Fever

• Facial swelling

• Difficulty swallowing (odynophagia)

Diagnostic Criteria

Diagnosis is mainly clinical and includes:

• Elevated body temperature

• Malaise

• Localized dull throbbing pain

• Inflamed, swollen and tender operculum

• Partially erupted or impacted third molar

• Possible pus discharge beneath flap

• Foetor-ex-oris (offensive mouth odor)

• Trismus

• Enlarged and tender regional lymph nodes

• Pain on mastication or swallowing

Investigations

Usually not required for uncomplicated cases.

Radiographic Examination (When Indicated)

• Orthopantomogram (OPG)

• Periapical X-ray

Indications:

• Recurrent infection

• Suspected impaction pattern

• Rule out dental abscess

• Evaluation before extraction

• Suspected bone involvement

Management

Management aims to:

• Control infection

• Relieve pain

• Eliminate causative factors

• Prevent recurrence

Non-Pharmacological Management

• Irrigation beneath operculum using saline or antiseptic solution

• Removal of trapped food debris

• Improvement of oral hygiene

• Operculectomy (excision of flap) under local anesthesia

• Extraction of associated third molar after acute phase subsides

• Grinding or extraction of traumatizing opposing tooth

• Warm saline mouth rinses

• Adequate hydration and nutrition

Definitive treatment is usually removal of the offending tooth.

Pharmacological Management

(According to Tanzania Standard Treatment Guidelines – 2022)

Antiseptic Mouth Care

• Hydrogen peroxide mouthwash 3% every 6 hours for 5 daysOR

• Warm saline mouth rinses

Antibiotic Therapy

(Indicated when systemic involvement is present)

• Amoxicillin 500 mg orally every 6–8 hours for 5 daysAND

• Metronidazole 400 mg orally every 8 hours for 5 days

Penicillin Allergy

• Metronidazole 400 mg orally every 8 hoursOR

• Clindamycin 300 mg orally every 6–8 hours

Pain Control

• Paracetamol 1 g orally every 8 hoursOR

• Ibuprofen 400 mg orally every 8 hoursOR

• Diclofenac 50 mg orally every 8 hours

Severe Infection

If spreading infection occurs:

• Refer urgently for management of odontogenic infection or dental abscess

• Hospital admission may be required

Complications

• Peritonsillar infection

• Facial cellulitis

• Ludwig’s angina

• Deep neck space infection

• Osteomyelitis

• Airway compromise

• Sepsis

Prevention

• Early dental assessment of erupting wisdom teeth

• Good oral hygiene practices

• Regular dental check-ups

• Removal of impacted third molars when indicated

• Proper brushing of posterior teeth

• Antiseptic mouth rinses during eruption phase

• Avoid food impaction

Patient Education

• Maintain meticulous oral hygiene

• Rinse mouth after meals

• Avoid chewing on affected side

• Complete prescribed antibiotic course

• Seek dental care early if pain recurs

• Avoid self-medication

• Attend follow-up for definitive treatment

Prognosis

With early treatment, prognosis is excellent. However, recurrence is common if the impacted tooth is not definitively managed through operculectomy or extraction.