Pericoronitis, Distal pocket and Third Molar

Dental, pericoronitis, third molar, distal pocket

1. TOPIC- PERICORONITIS DEPARTMENT OF PERIODONTOLOGY AND ORAL IMPLANTOLOGY PRESENTED BY- DR.TANYA PG 1 ST YR

2. content INTRODUCTION INCIDENCE CLASSIFICATION CLINICAL FEATURES PATHOGENESIS THERAPY COMPLICATION PERICORONAL ABSCESS DEPARTMENTAL CASE REFRENCES

3. INTRODUCTION Pericoronitis is a term referring to inflammation of the soft tissues around the crown of an erupting tooth or a tooth with an incomplete eruption. The term pericoronitis refers to inflammation of the gingiva in relation to the crown of an incompletely erupted tooth (Carranza 13 th edition) Douglass, A.B.; Douglass, J.M. Common dental emergencies. Am. Fam. Physician 2003, 67, 511–516 . The term Pericoronitis was first introduced to dental literature by BLOCH in 1921

4. INTRODUCTION After the tooth has partially erupted into the oral cavity, the integrity of the dental follicle is breached, and the space between the tooth and the follicle is colonized by oral microflora . This newly formed ‘pocket like’ area is difficult to keep clean, and bacterial plaque and debris tend to accumulate underneath the soft tissue cap. Such a confined space is predisposed to the development of inflammatory complications Douglass, A.B.; Douglass, J.M. Common dental emergencies. Am. Fam. Physician 2003, 67, 511–516

5. INCIDENCE The incidence of pericoronitis is 4.92%. 95% of cases occur with the lower third molar. Although incomplete eruption can occur with any tooth, lower third molars are affected most frequently due to their localization . Nitzan , D.; Tal, O.; Sela , M.; Shteyer , A. Pericoronitis : A reappraisal of its clinical and microbiologic aspects. J. Oral Maxillofac . Surg. 1985, 43, 510–516.

6. INCIDENCE The highest incidence is in vicenarians (20–29 years old), corresponding with the average age of third molar eruption A Several studies have reported the distribution of pericoronitis between the sexes to be insignificant with a slight female predominance. Kay, L. Investigations into the nature of pericoronitis . Br. J. Oral Surg 1966, 3, 188–205

7. Abstract   An inflammation of the soft tissue surrounding of the partial eruption impacted mandibular third molars. The  clinical appearance are edema , redness, pain in the left lower thirds and bad oral hygiene with halitosis. It's a  regular round in shape, its well-defined margins, measuring 2.5mm It was covered with thin mucosal tissue. The  Pericoronitis occurrence in the female more than male Case situation: Partial impacted teeth and inflammation of the surrounding soft tissue in the mouth of a 23  years. Conclusion: The Pericoronitis occurrence in the female more than male because the jaw of the female  is a smaller therefore haven't space for eruption of the third molar . 

8. ETIOLOGY MICROORGANISM VARIOUS SYSTEMIC DISEASE POSITION OF 3 RD MOLAR

9.   CONCLUSION Actinomyces   oris ,  Eikenella   corrodens ,  Eubacterium   nodatum ,  Fusobacterium   nucleatum ,  Treponema   denticola ,and   Eubacterium   saburreum  were present in high levels in case of pericoronitis .

10. Pell and Gregory Classification Illustration (1933)

11. Winter Classification of Third Molar Angulation (1926)

12. ETIOLOGY

13. CLASSIFICATION Pericoronitis can be classified as transient or non-transient In relation to tooth eruption process. Transient pericoronitis occurs during the tooth eruption and may be considered a complication of the teething process . . . Non-transient pericoronitis occurs after the end of tooth eruption Moloney , J.; Stassen, L. Pericoronitis : Treatment and a clinical dilemma. J. Ir. Dent. Assoc. 2009, 55, 190–192

14. CLASSIFICATION Pericoronitis can be classified as acute or chronic.(In relation to development) Chronic pericoronitis displays as mild and protracted, while the manifestation of inflammation signs may be present but subclinical Chronic pericoronitis is one of the predispositions for acute form, and its shift from chronic to acute is referred to as acute exacerbation of chronic pericoronitis . Acute pericoronitis manifests as a sudden and severe expression of inflammation signs—heat, pain, redness, swelling, and loss of function. Moloney , J.; Stassen, L. Pericoronitis : Treatment and a clinical dilemma. J. Ir. Dent. Assoc. 2009, 55, 190–192

15. Clinical features of Acute pericoronitis Operculitis Severe redness + soreness Continuous severe pain Localised intra-oral swelling Trismus Fœtor ex ora (bad breath) Lymphadenitis ++ Malaise Leucocytosis Dysphagia (problems eating) Pyrexia (fever) associated with tachycardia (increased heart rate) if neglected

16. Chronic Pericoronitis – Clinical Features: Localised tissue swelling & redness Soreness Continuous dull pain Localised rise in temperature Lymphadenitis +

17. ETIOPATHOGENESIS Microorganisms involved are mostly obligatory and facultative anaerobes, such as Actinomyces , Prevotella , Veillonella , Micromonas , or Propionibacterium however, aerobic species, like Streptococcus or Staphylococcus, are usually present as well The problem is not simply the presence of these bacteria but their accumulation, overgrowth, and poor hygiene management in the confined space between the soft tissue and the tooth Sixou , J.-L.; Magaud , C.; Jolivet-Gougeon , A.; Cormier, M.; Bonnaure -Mallet, M. Evaluation of the mandibular third molar pericoronitis flora and its susceptibility to different antibiotics prescribed in France. J. Clin . Microbiol . 2003, 41, 5794–5797 .

18. Pericoronitis may be considered a plaque-induced complication of tooth eruption .

19. THERAPY The first phase of treatment focuses on the elimination of bacterial overgrowth and pain management. Infection Management - Most cases of pericoronitis are resolved with local intervention, including debridement and irrigation of stagnation areas. Antibiotics are reserved only for severe cases and when systemic symptoms are present. Avery, B.; Brown, J.; Carter, J.; Corrigan, A.; Haskell, R.; Leopard, P.; Williams, J.; Loukota , R.; Lowry, J.; McManners , J. Management of pericoronitis . In National Clinical Guidelines 1997, 2nd ed.; Gregg, T.A., Ed.; The Faculty of Dental Surgery of the Royal College of Surgeons of England: London, UK, 2004; pp. 19–21.

20. THERAPY a.Irrigation of pericoronal space with a sterile solution ( saline, antiseptics for mucosa, e.g., hydrogen peroxide or chlorhexidine ). b. Mechanical removal of plaque and debris (debridement) from the pocket using periodontal instruments and swabs gently. c. Irrigation and debridement may be combined to achieve better results. d. Any collection of pus should be drained. Avery, B.; Brown, J.; Carter, J.; Corrigan, A.; Haskell, R.; Leopard, P.; Williams, J.; Loukota , R.; Lowry, J.; McManners , J. Management of pericoronitis . In National Clinical Guidelines 1997, 2nd ed.; Gregg, T.A., Ed.; The Faculty of Dental Surgery of the Royal College of Surgeons of England: London, UK, 2004; pp. 19–21.

21. THERAPY e. Traumatic occlusion, if present, should be prevented by soft tissue or occlusal adjustment. Extraction of antagonist tooth may be considered. f. The patient should be instructed in oral hygiene involving gentle and careful mechanical cleaning of the affected area and mouth rinsing with antiseptics (e.g., 0.12–0.2% chlorhexidine two times daily for 1 min). Avery, B.; Brown, J.; Carter, J.; Corrigan, A.; Haskell, R.; Leopard, P.; Williams, J.; Loukota , R.; Lowry, J.; McManners , J. Management of pericoronitis . In National Clinical Guidelines 1997, 2nd ed.; Gregg, T.A., Ed.; The Faculty of Dental Surgery of the Royal College of Surgeons of England: London, UK, 2004; pp. 19–21.

22. B. Antibiotics Indication: Adjunct to local treatment in infection spread or systemic involvement Prescription: Principles of appropriate antibiotic prescribing based on guidance by the Faculty of General Dental Practice in the United Kingdom issued in 2020

23. C. Antimicrobial photodynamic therapy ( apdt ) Cytotoxic non-invasive treatment option with a low tendency to induce drug resistance, this method includes an application of a photosensitizing agent in the target tissue and its activation by laser light of a specific wavelength in the presence of oxygen . Upon irradiation, the photosensitizer molecules undergo excitation transferring energy to the oxygen molecule that consequently forms oxygen free radicals These free radicals are highly cytotoxic and help to eliminate bacteria .

24. Surgical Treatment Options Soft tissue surgery: Removing the infected soft tissue can resolve pericoronitis , as it is the soft tissue disease overlying an erupting third molar. The operculum, soft tissue covering erupting third molar, can be removed to eliminate the deep pocket formed between the gingiva and the tooth. This surgery is also known as operculectomy , and laser, electrocautery , radiofrequency ablation, or scalpel can be used . Abate A, Cavagnetto D, Fama A, Matarese M, Bellincioni F, Assandri F. Efficacy of Operculectomy in the Treatment of 145 Cases with Unerupted Second Molars: A Retrospective Case-Control Study. Dent J (Basel). 2020 Jul 01;8(3

25. Surgical operculectomy using the scalpel technique Surgical operculectomy using the scalpel technique is the gold standard and a traditional technique. Operculectomy is performed using blade No. 15, and it is inexpensive and easy to perform. The healing process was gone well, compared to operculectomy using electrosurgery and laser. However, the pain response is more on the surgical operculectomy than electrosurgery and laser .

26. OPERCULECTOMY USING ELECTROCAUTERY Electrosurgery uses an electrode that can generate heat. It involves the intentional passage of high-frequency waveforms or currents through the body's tissues to achieve a controllable surgical effect. The advantages of using electrosurgery are coagulation and plugging of micro-diameter blood vessels, creating an operation area that is free of blood and minimal post-operative edema .

27. OPERCULECTOMY USING ELECTROCAUTERY Electrosurgery can expedite hemostasis , self-disinfecting tip, reduce edema , and less scarring According to Eisenmann et al. (1970), there were no differences in the wound healing process at the cellular level under an electron microscope between the scalpel technique and electrosurgery .

28. OPERCULECTOMY USING LASER The most common laser types are diode laser, Er:YAG , CO2 laser, and Nd:YAG . The laser technique has effectively excised gingival tissue, providing adequate hemostasis , less patient discomfort, less chair-side time, reduced bacteremia , reduced healing time and edema . In the use of a laser, there is a reduction in the acute inflammatory response compared to the use of a scalpel, causing the disintegration of cells in the wound tissue without releasing chemical mediators.

29. SURGICAL TREATMENT OPTIONS Pericoronal ostectomy If a tooth is in a favorable position to erupt into functional occlusion with adequate space, removing the bone that is covering the coronal portion of the erupting tooth can help accelerate the eruption Len Tolstunov , Bahram Javid , Lance Keyes, Anders Nattestad,Pericoronal Ostectomy : An Alternative Surgical Technique for Management of Mandibular Third Molars in Close Proximity to the Inferior Alveolar Nerve,Journal of Oral and Maxillofacial Surgery,Vol 69, Issue 7,2011, 1858-66 .

30. EXTRACTION Extraction of the opposing tooth : If there is an opposing tooth that is exacerbating pericoronitis by causing mechanical trauma, extraction of the opposing tooth may be considered to help address pericoronitis . Removing the source of mechanical insult can significantly reduce the symptoms of pericoronitis . Johri A, Piecuch JF. Should teeth be extracted immediately in the presence of acute infection? Oral Maxillofac Surg Clin North Am. 2011 Nov;23(4):507-11

31. EXTRACTION Extraction of the involved tooth : Extraction of a tooth is the most permanent solution to pericoronitis when the tooth does not have a favorable eruption position For example, if a tooth is horizontally impacted, it is not possible to completely irrigate and debride the infected pericoronal space. Removing the third molar will resolve pericoronitis by removing the unreachable, uncleansable space. Johri A, Piecuch JF. Should teeth be extracted immediately in the presence of acute infection? Oral Maxillofac Surg Clin North Am. 2011 Nov;23(4):507-11

32. Johri A, Piecuch JF. Should teeth be extracted immediately in the presence of acute infection? Oral Maxillofac Surg Clin North Am. 2011 Nov;23(4):507-11

33. Complication Pericoronitis is associated with the production of pus. If not evacuated, it accumulates, and an abscess is formed in the pericoronal space Local tissue structures, such as ligaments and preformed anatomical spaces, facilitate the progression of the infection into the surrounding areas like the sublingual space, submandibular space, parapharyngeal space, pterygomandibular space, infratemporal space, submasseteric space, and buccal space.

34. Involvement of submandibular, sublingual, and submental spaces may lead to a life-threatening condition called Ludwig's angina Pus collection behind the tonsil leads to the formation of the peritonsillar abscess, also known as quinsy.

35. PERIOCORONAL ABSCESS A localized purulent infection within the tissue surrounding (operculum) the crown of a partially erupted tooth. Most commonly seen in relation to mandibular third molars The etiology may be attributed to food impaction along with microbial plaque retention or sometimes trauma . Parameter on acute periodontal diseases. American Academy of Periodontology. J Periodontol . 2000;71 (5 suppl ):863-866 .

36. CLINICAL FEATURES localized red, swollen, lesion around incompletely erupted 3rd molar that is painful to touch. Radiating pain to the ear, throat and floor of the mouth and inability to properly masticate food. Also evident may be foul breath, purulent exudate, trismus , lymphadenopathy, fever, and malaise Kulkarni , Devi G., Reddy K., Kurra U et al. Abscesses 0f Periodontium : A Review. 2014

37. DIAGNOSIS Diagnosis is mainly by clinical examination of the intraoral swelling in the third molar area which may reveal inflamed swollen operculum, and inability of the patient to open mouth due to spread infection around the muscles of mastication. An IOPA may reveal whether the tooth is in soft tissue covering or is embedded partially in the bone. Kulkarni , Devi G., Reddy K., Kurra U et al. Abscesses 0f Periodontium : A Review. 2014

38. TREATMENT Drainage of abscess by gently lifting the operculum with periodontal probe or curette. If the tissue permits instrumentation, debridement and irrigation of the under-surface of the pericoronal flap should be done along with the use of antimicrobials and later Tissue recontouring can be considered, or extraction of the involved and/or opposing tooth. Kulkarni , Devi ., Reddy K., Kurra U et al. Abscesses 0f Periodontium : A Review. 2014

39. TREATMENT Patients should be instructed to rinse with warm salt water every 2 hours. Analgesics and muscle relaxants may be considered depending on the need. Antibiotics are helpful in conditions with infectious focus around the tooth. Kulkarni , Devi G., Reddy K., Kurra U et al. Abscesses 0f Periodontium : A Review. 2014

40. Ahad A, Tandon S, Lamba AK, Faraz F. Minimally Invasive Management of Pericoronal Abscess using 810 nm GaAlAs Diode Laser. Int J Laser Dent 2014;4(3):79-82.

41. prognosis The amount of dental plaque is positively associated with pericoronitis . If the third molars have adequate space to erupt into a cleansable position, pericoronitis  may resolve once the eruption is complete. However, pericoronitis may persist or recur if a tooth is unlikely to erupt into a favorable position. Dicus -Brookes C, Partrick M, Blakey GH, Faulk-Eggleston J, Offenbacher S, Phillips C, White RP. Removal of symptomatic third molars may improve periodontal status of remaining dentition. J Oral Maxillofac Surg. 2013 Oct;71(10):1639-46

42. DEPARTMENTAL CASE PRE-OPERATIVE IMMEDIATE POST-OPERATIVE EXCISED TISSUE POST- OPERATIVE

43. conclusion Despite the fact that pericoronitis around the third molar appears to be a minor illness, its possible implications cannot be ignored. If left unmanaged, this minor infection can extend into nearby soft tissue areas or develop into a localized abscess, both of which can result in fatal complications. On the basis of a complete case history, physical assessment, and imaging, an accurate diagnosis should be determined. The best course of action should be started at once, based on the assessment.

44. references Douglass, A.B.; Douglass, J.M. Common dental emergencies. Am. Fam. Physician 2003, 67, 511–516 Nitzan , D.; Tal, O.; Sela , M.; Shteyer , A. Pericoronitis : A reappraisal of its clinical and microbiologic aspects. J. Oral Maxillofac . Surg. 1985, 43, 510–516. Kay, L. Investigations into the nature of pericoronitis . Br. J. Oral Surg 1966, 3, 188–205 Moloney , J.; Stassen, L. Pericoronitis : Treatment and a clinical dilemma. J. Ir. Dent. Assoc. 2009, 55, 190–192 Sixou , J.-L.; Magaud , C.; Jolivet-Gougeon , A.; Cormier, M.; Bonnaure -Mallet, M. Evaluation of the mandibular third molar pericoronitis flora and its susceptibility to different antibiotics prescribed in France. J. Clin . Microbiol . 2003, 41, 5794–5797

45. references Parameter on acute periodontal diseases. American Academy of Periodontology. J Periodontol . 2000;71 (5 suppl ):863- Kulkarni , Devi G., Reddy K., Kurra U et al. Abscesses 0f Periodontium : A Review. 2014 866 . Avery, B.; Brown, J.; Carter, J.; Corrigan, A.; Haskell, R.; Leopard, P.; Williams, J.; Loukota , R.; Lowry, J.; McManners , J. Management of pericoronitis . In National Clinical Guidelines 1997, 2nd ed.; Gregg, T.A., Ed.; The Faculty of Dental Surgery of the Royal College of Surgeons of England: London, UK, 2004; pp. 19–21.