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Pericoronitis

Wisdom teeth really hurt

Summary

Wisdom tooth pain is usually caused by pericoronitis - a very common (around 6-10% of all dental emergencies) inflammation of the gum around, and on top of,  a tooth that has not fully come through into the mouth. In theory pericoronitis can occur around any tooth must in reality it is nearly always associated with wisdom teeth. 

Because of this it is really common in 16-30 year old as this is the most likely time for wisdom teeth to be coming through. Often there is a flap of skin, or operculum, over the wisdom tooth and food and debris get stuck under this flap this creates a wonderful place for bacteria to flourish and an infection starts to take hold.

Key Features

  • Pain - can be severe
  • Swelling around the tooth
  • Swelling spreading to the face and jaw
  • Lymph glands swollen and painful
  • Difficult to open mouth
  • Bad taste

Home care advice

Pericoronitis is a very painful condition and pain relief through over the counter painkillers is likely to be required until the inflammation/infection is reduced. 

  • Regular hot salty water rinsing, making particular attention to the inflamed area.
  • A Chlorhexidine Digluconate 1.0% w/w gel applied to the area with either your finger or a tooth brush twice a day is also very effective in mild and moderate cases.
  • Thorough cleaning of the area with your toothbrush will also help clean out the bacteria which are causing the infection. Even if it is painful try to clean the area as well as you possibly can. Additional benefit may be gained by using a good electric toothbrush in the area.
  • Pain can be usually best be relieved in Over 16 year olds by a combination of paracetamol and a non steroidal anti-inflammatory drug (NSAID).

CARE MUST BE TAKEN TO CHECK FOR ANY CONTRAINDICATIONS DUE TO EXISTING CONDITIONS, MEDICATIONS OR ALLERGIES. 

There has been a suggestion that the use of NSAIDs in patients with Covid19 could worsen the symptoms. Current evidence suggest this could be the case especially with longterm use and severe symptoms. However the current guidelines (as of April 23rd 2020) are that they can be used to manage other causes of pain. 

If any of the following is true then you WILL need to contact a dentist for antibiotics:

  • Swelling is worsening or going into your neck
  • High temperature/fever
  • It is becoming harder and harder to open your mouth

In these situations a short course of Metronidazole or Amoxycillin is generally indicated. To get this you will need to contact a dentist or doctor.

Once lockdown is finished then do get the area checked and see whether you are likely to need the tooth taking out.

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Causes

A slowly erupting tooth partially covered with gum nestled right at the back of our mouths are a great place for a wide range bacterial flora to settle and proliferate. This mainly consists of anaerobic pyogenic bacteria such as Streptococcus milleri, Actinomyces, Prevotella and many others. The severity of flare up will often occur when we are feeling run down and tired. Our immune response may not be on top form and we are more likely to be less vigilant in our brushing. Other factors such as other teeth (typically an upper wisdom tooth) biting on the infected area, smoking, dental decay and depth of impaction of the tooth can exacerbate the problem.

Pericoronitis is often described by patients as an ‘impacted wisdom tooth’ however this merely describes the position of the tooth rather than any clinical symptoms.

Treatment

  • Local measures as listed in section above - warm saline rinse, topical antibacterial gels
  • Antibiotic therapy if required
  • Excision (cutting) of the operculum - this can be done with a scalpel or with electrosurgery
  • Extraction of the opposing tooth - if it is biting on the area
  • Consider extraction - routine or surgical of the affected tooth and possibly other wisdom teeth.
  • Consider Coronectomy - when nerve damage (See below) is a significant risk. This is when the crown of the tooth is removed leaving the roots in place and allowing the gum to heal over them.

There are risks involved in extraction especially of lower wisdom teeth. The inferior dental nerve and the lingual nerve travel near the lower wisdom tooth and occasionally go through the teeth. There is therefore a risk of numbness of the teeth, lip and tongue following surgery which can in some cases be permanent depending on the level of trauma to the nerve. A literature review in 2014 suggested the risk of inferior dental nerve damage was 0.35 - 8.4%.

As well as the risk of nerve damage as with any surgical procedure there is also the risk of infection, bleeding and anaesthetic complications.

The National Institute for Health and Care Excellence (NICE) recommendations state that one episode of pericoronitis is not considered to be a reason to extract the wisdom tooth:

Surgical removal of impacted third molars should be limited to patients with evidence of pathology. Such pathology includes unrestorable caries, nontreatable pulpal and/or periapical pathology, cellulitis, abscess and osteomyelitis, internal/external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumour, tooth/teeth impeding surgery or reconstructive jaw surgery, and when a tooth is involved in or within the field of tumour resection.

Specific attention is drawn to plaque formation and pericoronitis. Plaque formation is a risk factor but is not in itself an indication for surgery. The degree to which the severity or recurrence rate of pericoronitis should influence the decision for surgical removal of a third molar remains unclear. The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery.

References

An Insight into Acute Pericoronitis and the Need for an Evidence-Based Standard of Care C Wehr, G Cruz, S Young and W Fakhouri, Dentistry Journal (Basel) 2019 Sep; 7(3): 88.

Guidance on the Extraction of Wisdom Teeth Technology appraisal guidance NICE Published: 27 March 2000

Inferior Alveolar Nerve Injury after Mandibular Third Molar Extraction: a Literature Review R Sarikov, G Juodzbalys J Oral Maxillofac Res. 2014 Oct-Dec; 5(4): e1.

Written by Andrew Bain BDS MJDF (RCS Eng)
Apr 27, 2020