Doctors Revision

Oral & Dental Health

Pericoronitis

Inflammation of the soft tissues (operculum) surrounding the crown of a partially erupted tooth, most commonly the mandibular third molar (wisdom tooth).

Also known as: Wisdom Tooth Infection (Gum)

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Referral and warning signs

When to refer

Refer to Dentist/Oral Surgeon (HC4+/RR) for: Irrigation/debridement, Consideration of operculectomy or extraction, Severe infection, Trismus, Failure to resolve with initial management.

Red flags

  • Difficulty breathing or swallowing (suggests deep space infection).
  • Significant facial or neck swelling.
  • Severe trismus.
  • High fever / Sepsis.

Signs and symptoms

  • Pain and swelling of the gum tissue overlying the partially erupted wisdom tooth.
  • Tenderness.
  • Redness (erythema) of the operculum.
  • Difficulty opening mouth (trismus).
  • Pain radiating to ear, throat, or floor of mouth.
  • Bad taste or bad breath (halitosis) due to trapped food debris/pus.
  • Pus discharge from under the operculum (may occur on pressure).
  • Fever, malaise, regional lymphadenopathy (if infection spreads).

Risk factors

  • Partially erupted mandibular third molars.
  • Food trapping under the operculum.
  • Poor oral hygiene in the area.
  • Trauma from the opposing upper wisdom tooth biting on the operculum.
  • Upper respiratory tract infections.

Diagnosis

Clinical assessment

Based on clinical findings of inflamed, swollen operculum over a partially erupted third molar, often associated with pain, trismus, and possible pus discharge.

Differential diagnosis

  • Dental abscess (from caries in the wisdom tooth or adjacent tooth).
  • Tonsillitis / Peritonsillar abscess (pain more posterior, different location of swelling).
  • Temporomandibular Joint (TMJ) disorder.
  • Cellulitis.

Investigations

  • Dental examination.
  • Dental X-ray (OPG or Periapical): Shows position/eruption status of the third molar and relationship to opposing tooth.

Diagnostic criteria

Clinical evidence of inflammation of the operculum overlying a partially erupted tooth.

Management

Non-pharmacological management

  • Local Irrigation: Gently irrigate under the operculum with warm saline solution or antiseptic mouthwash (e.g., Chlorhexidine, dilute Hydrogen Peroxide) using a syringe with a blunted needle/cannula to remove debris and pus. (LOC: HC4)
  • Improve Oral Hygiene: Instruct patient on meticulous cleaning of the area.
  • Soft Diet.

Pharmacological treatment

  • Analgesia: Paracetamol, NSAIDs (Ibuprofen, Diclofenac). (LOC: HC2+)
  • Antibiotics: Indicated if signs of spreading infection (fever, lymphadenopathy, trismus, cellulitis).
  • - Amoxicillin 500mg PO Q8H (Child: 25mg/kg Q8H) for 5-7 days. (LOC: HC4)
  • - PLUS Metronidazole 400mg PO Q8H (Child: 10-12.5mg/kg Q8H) if severe infection/anaerobes suspected. (LOC: HC4)
  • Antiseptic Mouthwashes: Chlorhexidine or Warm Salt Water rinses.
  • Application of caustic agents (Trichloracetic acid - TCA) under operculum by trained personnel (mentioned in UCG, less common standard practice elsewhere). (LOC: HC4)

Surgical Management

  • Operculectomy: Surgical removal of the overlying gum flap (operculum). May provide temporary relief but often recurs if tooth remains impacted. (LOC: HC4+)
  • Extraction of the Mandibular Third Molar: Definitive treatment if tooth is impacted, unlikely to erupt fully, or causing recurrent pericoronitis. (LOC: HC4+/RR)
  • Extraction or Grinding of Opposing Upper Third Molar: If it is traumatizing the lower operculum.

Monitoring

Follow up to ensure resolution of acute infection. Assess need for definitive surgical management (extraction/operculectomy).

Complications

  • Spread of infection (submandibular space, parapharyngeal space, Ludwig's angina - rare).
  • Cellulitis.
  • Dental abscess/cyst formation around wisdom tooth.
  • Severe trismus.
  • Damage to adjacent second molar.

Prevention

  • Maintain good oral hygiene around erupting wisdom teeth.
  • Prophylactic removal of impacted third molars prone to pericoronitis (decision based on individual assessment).

Patient education

  • Explanation of the condition (inflammation around wisdom tooth).
  • Importance of local cleaning/irrigation.
  • Need for antibiotics if prescribed.
  • Pain relief.
  • Potential need for future extraction.
  • Signs of worsening infection requiring urgent review.

Uganda-specific notes

Common problem. Irrigation and antibiotics often used. Definitive treatment (extraction) requires referral.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.2.11

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