Pericoronaritis

Such odontogenic inflammatory disease as pericoronaritis occurs when teething. Basically, this applies to the third molars, which erupt the very last - after 17 years, and for many this process goes through with various complications. Pericoronitis - inflammation and infection of the soft tissues around a partially cut tooth - is often associated with affected third permanent molars. Other concomitant conditions include dental caries, resorption of the roots of an adjacent tooth, and rarely the formation of cysts and tumors. 

Epidemiology

The prevalence of pericoronaritis at the age of 20-29 years, according to statistics of European dental surgeons, reaches 80%, and in 67% of patients with this disease, a deep infectious lesion of the teeth is revealed with spread to the cervical lymph nodes and even the paranasal sinuses. [1]

At least one wisdom tooth that has not erupted or partially erupted is detected by dentists in 90% of 20-year-old patients.  [2]By the way, almost 2% of people do not cut third molars at all. Women (62.7%) are more likely to suffer from pericoronitis compared to men (37.3%).  [3], [4]

About 40% of all extracted teeth are wisdom teeth, the eruption of which led to pericoronaritis.

Causes of the pericoronarite

The main causes of inflammation of the gum tissue around the crown of a partially erupted “wisdom tooth” - pericoronitis or  pericoronitis  - infection, the focus of which is formed in the pericoronary space during retention of the tooth (delayed eruption), its dystopia - when it is completely or partially covered with mucous tissue of the gum (the so-called hood - dental operculum), as well as if the tooth germ is initially improperly located inside the gums and cannot take its place in the dentition.

Pericoronaritis of the wisdom tooth usually develops in adults when teething third molars of the lower jaw, which can grow at an acute and right angle to the second molar and other teeth, in the direction of the cheek or back of the oral cavity. Very often there is occlusion of the tissues surrounding the third lower molar, chewing teeth of the upper jaw.

It is clear that pericoronaritis in children cannot be associated with wisdom teeth, and, as clinical practice shows, inflammation of the tissues surrounding any teething tooth in a child is a rather rare occurrence. Most often (about 36% of cases), inflammation accompanies teething in children after 10-11 years of second lower permanent molars.

Risk factors

The main risk factors are poor oral hygiene and the difficulty of cleaning partially erupted teeth. This leads to the accumulation of plaque, food debris and bacteria under the gingival hood covering the tooth, creating the conditions for the development of painful inflammation.

Anomalies in the development of teeth , as well as the presence of acute or chronic infections of the upper respiratory tract, which, according to some reports, are present in more than 40% of cases of pericoronaritis, are considered a predisposing factor . [5]

Pathogenesis

In all cases, the pathogenesis of inflammation of the gum tissue around the crown of the erupting tooth is due to the microbial flora, mainly anaerobic, which develops in the distal pericoronary space - an ideal place for the active growth and reproduction of bacteria. [6]

As a rule, bacteria (including obligate bacteria) such as Prevotella melaninogenica, Capnocytophaga spp., Peptostreptococcus spp., Veillonella spp., Fusobacterium mucleatum, Streptococcus mitis are directly related to the inflammatory process and alteration of the teeth. Bacteroides oralis, Propionibacterium spp., Actinomycetales odontolyticus and Actinomycetales pyogenes. [7], [8]

Moreover, the morphological picture of pericoronaritis does not depend on the type of infection, but on the characteristics of the inflammatory process, which can be either superficial (catarrhal) or deeper (involving soft tissues) - purulent as well as ulcerative (with mucosal erosion).

Symptoms of the pericoronarite

Symptoms of periocoronitis are not manifested all at once. The first signs are the development of inflammatory edema and the appearance of painful sensations in the jaw, which are quite rapidly amplified and can spread to the ear region and submandibular zone.

The range of symptoms can range from mild, mild pain to acute or throbbing pain, redness, swelling, pus, limited mouth opening, fever, lymphadenopathy, halitosis, pharyngeal damage, and systemic toxemia. [9]

According to a study conducted by Jirapun and Aurasa, symptoms associated with pericoronitis were classified as pain, 35.3%; edema 21.7%; discomfort from eating food - 3.6%; pus excretion 3.0%; and other symptoms, 1.3% (such as trismus, sore throat, and lymphadenitis).

Swelling leads to a partial blockage of the temporomandibular joint, causing difficulty in opening the mouth completely (trismus) and pain when chewing.

Inflammation can be acute, subacute, and chronic; in many, the inflammatory process is accompanied by the formation of purulent-necrotic exudate, released from under the mucosa covering the tooth crown, and this is purulent pericoronitis.

Acute pericoronaritis is manifested by redness and swelling of the tissues surrounding the tooth, as well as the palate and partially the pharynx); fever; acute throbbing pain (worse when chewing); dysphagia (difficulty swallowing). Acute purulent periocoronaritis is characterized by severe hyperthermia; bleeding of the mucous membrane of the affected area; halitosis (putrid breath) and the release of pus from the pericoronary sac; the spread of pain throughout the jaw and throat. There may be an increase and inflammation of the cervical lymph nodes.

Subacute pericoronaritis differs from the acute form in the absence of trismus and more localized pain.

Chronic pericoronitis causes localized swelling of the tissues and their hyperemia; periodic dull (aching) pain; maceration of the portion of the mucous membrane of the cheek closest to the erupting tooth; halitosis and unpleasant taste in the mouth; tenderness of the submandibular lymph nodes (with palpation).

Complications and consequences

You should be aware that periocoronitis can cause serious consequences and complications, including:

• tonsillitis; [10]
• periglottal abscess;
• peritonsillar abscess;
• flux on the right ;
• regional lymphadenopathy (inflammation of the submandibular and cervical lymph nodes);
• phlegmon of the pharyngeal space and the bottom of the oral cavity (Ludwig's tonsillitis);
• periodontal inflammation;
• the spread of inflammation to the periosteum of the gums with the development of periostitis.

Diagnostics of the pericoronarite

For dentists, the diagnosis of periocoronaritis is not difficult when examining the oral cavity: teeth and gums.

And for visualization of non-cut teeth and determination of treatment tactics, instrumental diagnostics are performed: X-ray or orthopantomography with  orthopantomograms  - a panoramic picture of all teeth and peri-tooth structures.

Differential diagnosis

Differential diagnosis helps to clarify the diagnosis in cases where the patient has a follicular cyst or exostosis of the jaw, swelling of the gums or salivary gland.

Treatment of the pericoronarite

The results of treatment of patients with pericoronaritis depend on the form of the disease and the method of treatment. [11] Treatment of pericoronaritis includes purification of the pericoronary space, drainage of pus, draining the affected area, treatment with antiseptics, photodynamic therapy with methylene blue. [12]

To relieve inflammation, β-lactam antibiotics are prescribed (Amoxicillin, Clavamitin, etc.) or Metronidazole; NSAIDs, for example, Ketonal or Ibuprofen, help with pain and inflammation  . 

The results of tests for sensitivity to antibiotics show that amoxicillin and pristinamycin are the most effective drugs against the tested strains and, in particular, against strains classified as aerobic. Metronidazole alone or in combination with spiramycin, amoxicillin at a dose of 4 mg / liter and pristinamycin are the most effective drugs against obligate anaerobic bacteria. The effectiveness of the latter drug confirms its value in acute cases and after abandonment of other antibiotics. [13], [14] 

Dentists take into account not only the degree of inflammation and the severity of the infection, but also the position of the erupting tooth. And after the end of the acute phase of the inflammatory process, one of the dental surgical procedures is performed. If the position of the tooth is normal, then for the release of its crown and complete eruption, excision of pericoronaritis is necessary, that is, an operectomy (conventional or laser), in which a flap of the gingival mucosa above a partially cut tooth is removed.

Pericoronarotomy (pericoronarectomy) is also performed - excision of the hood during pericoronaritis with antiseptic treatment of the wound and its drainage. In both cases, antibiotics of a wide spectrum of action are prescribed in the postoperative period.

And when the position of the tooth is abnormal, resort to extraction - the  removal of the wisdom tooth . [15]

The treatment of pericoronaritis at home is carried out by rinsing the mouth with a warm solution of table salt, a decoction of sage, oak bark, peppermint, flowers of a pharmaceutical chamomile, ginger root, as well as a solution with the addition of a few drops of 10% alcohol tincture of propolis. [16]

Prevention

Thorough toothbrushing and compliance with the rules of oral hygiene, as well as timely access to medical care are key factors in the prevention of dental inflammatory diseases. [17]

Forecast

Pericoronaritis is cured, but the prognosis regarding the duration of its treatment largely depends on the severity of the infectious inflammation and the patient’s immune system.

With minor inflammation and proper treatment, it may take several days or a week to completely stop it. In severe cases or with the development of complications of pericoronaritis, recovery may take longer and require additional therapy.