Management of pericorinitis

Question 1

Pericorinitis

Answer 1

Inflammation of soft tissues around crown of partially erupted tooth

• most commonly lower 3rd molars
• following upper respiratory infection, when generally down or stressed
• plaque & food debris accumulate beneath gum flap. mixed flora including anaerobes

Question 2

Clinical features

Answer 2

Vary in intensity and include:

• pain and swelling (usually localised to tissues around crown, can be more widespread)
• trauma from opposing tooth
• bad breath
• trismus
• presence of pus
• lympadenopathy
• pyrexia (fever)

Question 3

Patient complaint

Answer 3

Establish main problem and degree of discomfort

-in most cases swelling will be localised but remember can spread and endanger airway/ lead to trismus

Question 4

PMH

Answer 4

Debilitated pxs e.g. those on steroids, anti-metabolites, those with poorly controlled diabetes, leukaemia, HIV etc more at risk of spreading infection
Pxs with bleeding problems including on warfarin will need careful management, possibly in liason with haematologist if surgery needed

Question 5

S/H

Answer 5

More likely to have post-op complications e.g. dry socket

Work & domestic commitments may limit pxs’ availability for treatment

Question 6

Extra-oral examination

Answer 6

Palpate neck nodes – if palpable indicates > just local inflammation, assess opening, trismus indicates spreading infection
Look for facial asymmetry & swelling as well as signs of spreading infection / abscess formation

Question 7

Intra-oral examination

Answer 7

Assess OH, look at teeth in quadrant and opposing teeth, presence of localised inflammation, swelling, pus, occlusal trauma from opposing tooth
Also look for presence of caries, non-vital teeth, periodontal problems that might account for symptoms

Question 8

Special tests

Answer 8

Percussion testing, vitality testing if in doubt
Pericoronitis usually obvious, if you can’t see inflammation in soft tissues around partially erupted tooth look for another diagnosis for px’s symptoms e.g. pulpitis, apical periodontitis, TMJ problems

Question 9

Initial treatment

Answer 9

Aimed at relieving acute problems, always the same
-local measures sufficient in most cases & include: irrigation beneath gum flap with sterile saline, chlorhexidine mouthwash or even LA soln; if opposing 3rd molar occluding with gum flap this tooth can be extracted or cusps reduced
Pxs should be advised of need for careful OH and to use HSMW or Corsodyl mouthwash, they should be advised to use one of the simple analgesics listed

Question 10

Analgesics

Answer 10

Aspirin 300 – 900 mg every 4 – 6 hours (avoid in patients allergic to aspirin, those with gastric or bleeding problems)
Paracetamol 500mg – 1gram every 4 – 6 hours (no more than 8 tablets, 4g, per day).
Ibuprofen 200 – 400mg three times daily
Co-codamol 500/8 mg every 4 -6 hours (no more than 8 tablets per day)

Question 11

If abscess present

Answer 11

Pus should be incised and drained

Question 12

If signs of spreading infection

Answer 12

Antibiotics indicated in addition to above measures, including
Metronidazole 200mg three times daily for 5 days – avoid alcohol
Penicillin V 250mg four times daily for 5 days – remember to ask about allergy to penicillin before prescribing

Question 13

Patients with severe trismus, pyrexia and who have difficulty eating/drinking

Answer 13

May need admitting to hospital for airway management, fluid replacement, IV antibiotics and drainage of abscess if present
If in general practice phone local maxfax unit and give full details to on-call SHO or registrar; alternatively patients could attend local A&E where staff would contact maxfaxl team, but this may take a long time!

Question 14

At review

Answer 14

If this was first episode of pericoronitis or if intermittent but v mild, may not need to do anything more at this stage, though px should be advised of presence of 3rd molar & potential for further problems. Review situation at normal check ups
If px has had recurrent problems take radiograph & assess potential for eruption into useful function
-if likely that tooth will erupt further and pericoronitis not severe do not plan to remove tooth but reassure px that problems will resolve as tooth erupts and manage further episodes as indicated above
If tooth unlikely to become functional and pericoronitis was severe or is recurrent consider extraction

Question 15

Operculectomy

Answer 15

Can be considered if there is well defined operculum over occlusal surface however, warn px that extraction may be necessary if this procedure fails to resolve problems

Question 16

Whenever extraction is considered

Answer 16

Benefits must outweigh risks

Risks should be explained to pxs and consent given - record this in notes