Pericoronitis

). The definition of pericoronitis is inflammation in the soft tissues surrounding the crown of a tooth. This encompasses a wide spectrum of severity, making no distinction to the extent of the inflammation into adjacent tissues or whether there is associated active infection (pericoronal infection caused by micro-organisms sometimes leading to a pus filled pericoronal abscess or cellulitis). Typically cases involve acute pericoronitis of lower third molar teeth. During "teething" in young children, pericoronitis can occur immediately preceding eruption of the deciduous teeth (baby or milk teeth). The International Classification of Diseases entry for pericoronitis lists acute and chronic forms. Acute Acute pericoronitis (i.e. sudden onset and short lived, but significant, symptoms) is defined as "varying degrees of inflammatory involvement of the pericoronal flap and adjacent structures, as well as by systemic complications." Systemic complications refers to signs and symptoms occurring outside of the mouth, such as fever, malaise or swollen lymph nodes in the neck. Chronic Pericoronitis may also be chronic or recurrent, with repeated episodes of acute pericoronitis occurring periodically. Chronic pericoronitis may cause few if any symptoms, but some signs are usually visible when the mouth is examined. ==Signs and symptoms==

The signs and symptoms of pericoronitis depend upon the severity, and are variable: • Pain, which gets worse as the condition develops and becomes severe. The pain may be throbbing and radiate to the ear, throat, temporomandibular joint, posterior submandibular region and floor of the mouth. • Trismus (difficulty opening the mouth). • Dysphagia (difficulty swallowing). • Loss of appetite. • The radiographic appearance of the local bone can become more radiopaque in chronic pericoronitis. ==Causes==

Pericoronitis occurs because the operculum (the soft tissue directly overlying the partially erupted tooth) creates a "plaque stagnation area", Sometimes pericoronal infection can spread into adjacent potential spaces (including the sublingual space, submandibular space, parapharyngeal space, pterygomandibular space, infratemporal space, submasseteric space and buccal space This can result in abscess formation. Left untreated, the abscess can spontaneously drain into the mouth from beneath the operculum. In chronic pericoronitis, drainage may happen through an approximal sinus tract. The chronically inflamed soft tissues around the tooth may give few if any symptoms. This can suddenly become symptomatic if new debris becomes trapped or if the host immune system becomes compromised and fails to keep the chronic infection in check (e.g. during influenza or upper respiratory tract infections, or a period of stress). Tooth position • When an opposing tooth bites into the operculum, it can initiate or exacerbate pericoronitis resulting in a spiraling cycle of inflammation and trauma. • Over-eruption of the opposing tooth into the unoccupied space left by the stalled eruption of a tooth is a risk factor to operculum trauma from biting. • Teeth that fail to erupt completely (commonly the lower mandibular third molars) are often the result of limited space for eruption, or a non-ideal angle of tooth eruption causing tooth impaction. • The presence of supernumerary teeth (extra teeth) makes pericoronitis more likely. ==Diagnosis==

The presence of dental plaque or infection beneath an inflamed operculum without other obvious causes of pain will often lead to a pericoronitis diagnosis; therefore, elimination of other pain and inflammation causes is essential. For pericoronal infection to occur, the affected tooth must be exposed to the oral cavity, which can be difficult to detect if the exposure is hidden beneath thick tissue or behind an adjacent tooth. Severe swelling and restricted mouth opening may limit examination of the area. Radiographs can be used to rule out other causes of pain and to properly assess the prognosis for further eruption of the affected tooth. Sometimes a "migratory abscess" of the buccal sulcus occurs with pericoronal infection, where pus from the lower third molar region tracks forwards in the submucosal plane, between the body of the mandible and the attachment of the buccinator muscle to the mandible. In this scenario, pus may spontaneously discharge via an intra-oral sinus located over the mandibular second or first molar, or even the second premolar. Similar causes of pain, some which can occur in conjunction with pericoronitis may include: • Dental caries (tooth decay) of the wisdom tooth and of the distal surface of the second molar is common. Tooth decay may cause pulpitis (toothache) to occur in the same region, and this may cause pulp necrosis and the formation of a periapical abscess associated with either tooth. • Food can also become stuck between the wisdom tooth and the tooth in front, termed food packing, and cause acute inflammation in a periodontal pocket when the bacteria become trapped. A periodontal abscess may even form by this mechanism. • Pain associated with temporomandibular joint disorder and myofascial pain also often occurs in the same region as pericoronitis. J are easily missed diagnoses in the presence of mild and chronic pericoronitis, and the latter may not be contributing greatly to the individual's pain (see table). It is rare for pericoronitis to occur in association with both lower third molars at the same time, despite the fact that many young people will have both lower wisdom teeth partially erupted. Therefore, bilateral pain from the lower third molar region is unlikely to be caused by pericoronitis and more likely to be muscular in origin. ==Prevention==

Prevention of pericoronitis can be achieved by removing impacted third molars before they erupt into the mouth, Advocates for retaining wisdom teeth cite the risk and costs of unnecessary operations and the ability to monitor the disease through clinical exam and radiographs. ==Management==

Since pericoronitis is a result of inflammation of the pericoronal tissues of a partially erupted tooth, management can include applying pain management gels for the mouth consisting of Lignocaine, a numbing agent. Definitive treatment can only be through preventing the source of inflammation. This is either through improved oral hygiene or by removal of the plaque stagnation areas through tooth extraction or gingival resection, which can be done with diode lasers atraumatically. Also immediate treatment avoids overuse of antibiotics (preventing antibiotic resistance). However, surgery is sometimes delayed in an area of acute infection, with the help of pain relief and antibiotics, for the following reasons: • Reduces the risk of causing an infected surgical site with delayed healing (e.g. osteomyelitis or cellulitis). • Avoids reduced efficiency of local anesthetics caused by the acidic environment of infected tissues. • Resolves the limited mouth opening, making oral surgery easier. • Patients may better cope with the dental treatment when free from pain. • Allows for adequate planning with correctly allocated procedure time. Firstly, the area underneath the operculum is gently irrigated to remove debris and inflammatory exudate. Irrigation may be assisted in conjunction with debridement (removal of plaque, calculus and food debris) with periodontal instruments. Irrigation may be enough to relieve any associated pericoronal abscess; otherwise a small incision can be made to allow drainage. Smoothing an opposing tooth which bites into the affected operculum can eliminate this source of trauma. Following treatment, if there are systemic signs and symptoms, such as facial or neck swelling, cervical lymphadenitis, fever or malaise, a course of oral antibiotics is often prescribed,. clindamycin or, historically, with caustic agents (trichloracetic acid) ==Prognosis==

Once the plaque stagnation area is removed either through further complete tooth eruption or tooth removal then pericoronitis will likely never return. A non-impacted tooth may continue to erupt, reaching a position which eliminates the operculum. A transient and mild pericoronal inflammation often continues while this tooth eruption completes. With adequate space for sustained improved oral hygiene methods, pericoronitis may never return. However, when relying on just oral hygiene for impacted and partially erupted teeth, chronic pericoronitis with occasional acute exacerbation can be expected. Dental infections such as a pericoronal abscess can develop into sepsis and be life-threatening in persons who have neutropenia. Even in people with normal immune function, pericoronitis may cause a spreading infection into the potential spaces of the head and neck. Rarely, the spread of infection from pericoronitis may compress the airway and require hospital treatment (e.g. Ludwig's angina), although the majority of cases of pericoronitis are localized to the tooth. Other potential complications of a spreading pericoronal abscess include peritonsillar abscess formation or cellulitis. Chronic pericoronitis may be the etiology for the development of paradental cyst, an inflammatory odontogenic cyst. ==Epidemiology==

Pericoronitis usually occurs in young adults, around the time when wisdom teeth are erupting into the mouth. If the individual has reached their twenties without any attack of pericoronitis, it becomes substantially less likely one will occur thereafter. ==References==