What is pericoronitis?

Pericoronitis is an inflammatory condition of the gums that occurs during tooth eruption due to infection. It leads to swelling of the soft tissues and bleeding. In many cases, pericoronitis causes severe, unbearable pain. What is the appropriate treatment for this condition?

This issue is most commonly seen in individuals aged 20-29 when wisdom teeth, also known as the “eights,” emerge. However, it can occasionally occur when the neighboring molar, the “seven,” is erupting. In children, it is rarely observed when milk teeth are replaced with permanent ones.

Causes of pericoronitis

The development of pericoronitis is linked to abnormal tooth eruption. Several theories explain the origins of this disorder. One suggests that improper tooth positioning is determined during fetal development when the dental arch is formed. If a child inherits a small jaw from one parent and large teeth from the other, the tooth buds may be misaligned. During eruption, such teeth may lack space, causing them to shift toward adjacent teeth.

Another theory attributes improper eruption to evolutionary changes in the dentition. Over time, the dental arch has narrowed by approximately 10 mm, while the number of teeth has remained the same. Since wisdom teeth emerge last, they often face space constraints.

Difficulties with wisdom tooth eruption adversely affect the surrounding soft tissues. The gum near the tooth is frequently injured while chewing, leading to inflammation and scar tissue formation, which further hinders or even halts eruption.

Additional factors influencing wisdom tooth eruption include:

• Dense bone tissue in the eruption area
• Thick gum biotype covering the emerging tooth
• A thicker cortical plate due to jaw development anomalies

If you experience these symptoms, consult a doctor. Avoid self-treatment, as it may pose risks to your health.

What are the symptoms?

The symptoms of pericoronitis vary depending on its stage. In 43% of cases, an upper respiratory tract infection—such as rhinitis, pharyngitis, sinusitis, tonsillitis, otitis media, or epiglottitis—precedes the condition. Stress is another contributing factor.

Initially, patients report a dull ache in the affected tooth area. As the condition progresses, the pain intensifies, making chewing on the affected side difficult and causing discomfort when opening the mouth.

As inflammation around the erupting tooth worsens, the following symptoms develop:

• Sharp pain that may spread to nearby areas
• Redness and swelling of the gums
• Facial asymmetry due to localized swelling

At this stage, the general health of the patient remains stable. Occasionally, a mild fever of 37-37.5°C and headaches occur.

Signs of acute pericoronitis

If left untreated, pericoronitis becomes chronic. While symptoms may seem less severe due to fluid drainage from inflamed tissues, the infection continues to spread to the surrounding soft tissues.

Chronic pericoronitis is characterized by mild gum redness. A serous or purulent discharge may be present, often causing bad breath. Inflamed lymph nodes can be felt in the submandibular area on the affected side. Pain may also occur when opening the mouth.

How to identify the condition?

Wisdom teeth typically erupt between ages 17-25, a process that can take weeks or even months. Often, the tooth fails to emerge completely, leaving part of its crown covered by a thick gum flap known as the operculum.

A gap forms between the erupting tooth and the gum flap, creating a warm pocket where food debris, fluids, and bacteria—including streptococci, actinomycetes, and propionibacteria—accumulate. Cleaning this area thoroughly with routine oral hygiene is difficult, leading to inflammation and swelling. Due to this, wisdom teeth frequently erupt with dental issues such as cavities, pulpitis, or periodontal cysts.

In severe cases, untreated cavities can extend to the root of the adjacent tooth. If the bone structure between the wisdom tooth and the second molar deteriorates completely, removal of the wisdom tooth may expose part of the root of the neighboring tooth, leading to gum recession.

Aside from bacterial buildup, the gum covering the emerging tooth is frequently traumatized by the opposing tooth during chewing. This constant irritation leads to chronic gum erosion and reduced local immunity. Repeated inflammation episodes result in scar tissue formation around the impacted tooth.

This condition follows a cyclical pattern: inflammation causes swelling, which leads to trauma, resulting in erosion and further inflammation—ultimately producing intense pain.

As the infection spreads, the inflammation progresses similarly to marginal chronic periodontitis. The gum surrounding not only the crown but also the entire root becomes affected. In this area, bone loss occurs, soft tissues become swollen or hypertrophic, and nearby lymph nodes may enlarge.

So, is pericoronitis always an emergency? Not necessarily, but in some cases, it can escalate into one.

Is Pericoronitis an emergency?

Clinically, pericoronitis is classified based on its progression and the type of surrounding tissue inflammation.

Based on progression, it is categorized as either acute or chronic:

• Acute pericoronitis develops suddenly, with rapid inflammation and severe symptoms, including sharp pain in the eruption site. The patient may struggle to open their mouth due to pain and swelling. Without timely treatment, this form can transition into chronic pericoronitis.
• Chronic pericoronitis is less aggressive, with milder symptoms. Pain is minimal, accompanied by slight gum redness and swelling. The patient’s general condition remains stable. Lymph nodes may be slightly enlarged, and bad breath may be present.

Some researchers identify an additional category known as subacute pericoronitis. This form differs from the acute stage by presenting milder symptoms and an absence of difficulty in opening the mouth.

Types of pericoronitis based on inflammation

Pericoronitis is classified into catarrhal, ulcerative, and purulent types, depending on the nature of the inflammation.

Catarrhal

This represents the earliest stage of the condition and may progress into either ulcerative or purulent pericoronitis if left untreated. Patients experience discomfort, especially while eating. The gum tissue covering the erupting tooth becomes swollen, inflamed, and painful to touch. Regional lymph nodes on the affected side may also become enlarged and tender. There is no presence of pus, and mouth opening remains unaffected. Prompt treatment can resolve symptoms quickly.

Ulcerative

This form arises when inflammation leads to the destruction of soft tissues, resulting in ulcers around the impacted tooth. Attempts to remove plaque from the area cause pain and discomfort.

Purulent

Purulent pericoronitis is considered the most severe form. The affected individual may experience severe fatigue and a significant decline in overall health, along with a persistent fever reaching up to 38.0°C. Pain becomes intense, especially when swallowing or opening the mouth, often radiating to the ear or temple.

A discharge of pus is evident from the affected area, and palpation intensifies both pain and secretion. Swelling and redness extend beyond the gum tissue, involving the palatine-lingual arch, the inner cheeks, and the soft palate. Lymph nodes in the region become swollen and mobile.

Molar

A distinct form of pericoronitis, posterior molar pericoronitis, is characterized by inflammation developing below the level of the tooth crown. Initially superficial, the infection may spread deeper, reaching the periosteum. Without timely intervention, complications such as a retromolar abscess can arise.

How is it diagnosed?

A comprehensive assessment is required for an accurate diagnosis. This involves:

1. Medical History (Anamnesis) – The dentist will ask questions to gather essential information, such as:
   • When the discomfort started.
   • Presence of fever, weakness, or pain when opening the mouth.
   • Any factors that alleviate or worsen symptoms.
   • Medications taken and their effects.
   • Previous issues with tooth eruption.
   • Any existing chronic conditions.
2. Clinical Examination – The oral cavity is inspected for signs of inflammation. Soft tissues are palpated to detect pus accumulation or confirm its absence.
3. Lymph Node Examination – Since pericoronitis often causes regional lymph node swelling, the dentist will examine the jawline and neck for abnormalities.
4. Imaging Tests – To assess the position of the affected tooth, X-rays, computed tomography (CT), or orthopantomography may be required.

X-ray and orthopantomography

During the diagnostic process, accurately identifying the clinical form of pericoronitis, the severity of its progression, and the extent of inflammation is crucial. These factors directly influence the effectiveness of the chosen treatment strategy. The classification of pericoronitis depends on the presence or absence of purulent exudate or ulcerations, the intensity of symptoms, and the duration of their manifestation.

What is a treatment?

Treatment for pericoronitis should begin immediately, except in the following situations:

• Allergic reactions to medications or materials used during treatment
• Presence of other acute inflammatory processes in the oral cavity
• Exacerbation of a chronic medical condition

The most effective approach combines both therapeutic and surgical methods. The initial phase of treatment focuses on controlling the inflammation. This involves rinsing the periodontal pocket with an antiseptic solution using a syringe or applying a specialized dressing to the affected area. If necessary, the doctor may prescribe antibiotics and anti-inflammatory medications.

Once the inflammation has subsided, the next step involves either removing the overhanging mucoperiosteal flap or extracting the problematic tooth.

The treatment plan depends on whether the erupting tooth should be preserved. To make this decision, the dentist will analyze an X-ray of the affected area and assess the patient’s current condition during the visit.

If a tooth is misaligned, causing recurrent inflammation that is difficult to manage, extraction is the best course of action after acute symptoms have been controlled. Choosing not to remove the problematic tooth in such cases may lead to complications, such as cavities or an abscess in the adjacent molar region, potentially requiring the extraction of both teeth.

Tooth extraction is performed under local anesthesia. The procedure starts with the detachment of soft tissues, followed by the removal of the tooth using forceps or elevators. In some cases, the tooth may need to be sectioned for easier removal—this decision is made by the surgeon either during the planning stage or during the actual procedure.

For two hours post-operation, patients are advised to avoid eating, consuming alcohol, and smoking. Warm compresses should not be applied. If the extraction was complicated by limited mouth opening, the patient may require a medical leave of absence until the inflammation resolves completely. During this period, physical exertion is not recommended.

Wisdom tooth extraction

A procedure called pericoronarotomy, which involves the excision of the gum flap covering the wisdom tooth, helps improve oral hygiene in the affected area and prevents further spread of inflammation. In cases of purulent pericoronitis, it facilitates the drainage of pus. This procedure is performed by an oral surgeon using a scalpel or surgical scissors under local anesthesia.

Gum hood excision

The recovery period following tooth extraction or gum flap removal typically ranges from three days to two weeks, depending on the complexity of the procedure. The day after surgery, the dentist may recommend antiseptic mouth rinses, such as chlorhexidine. If necessary, pain relief medications, antibiotic therapy, and follow-up examinations may be prescribed.

If swelling, pain, or other discomfort occurs during the recovery phase, it is essential to consult a doctor.

Can pericoronitis resolve on its own?

Acute pericoronitis carries the risk of serious complications if left untreated. Self-treatment is not advisable, as delaying professional care can lead to severe infections. Seeking prompt medical attention is essential.

Complications arising from pericoronitis during tooth eruption may include:

• Ulcerative gingivitis – Formation of ulcers along the gumline, leading to tissue necrosis.
• Peri-maxillary phlegmon – A diffuse, spreading infection of the soft tissues.
• Periostitis – Inflammation of the periosteum.
• Osteomyelitis – A severe bone infection.
• Retromolar abscess – A deep infection behind the affected tooth.

What happens if it left untreated?

If pericoronitis remains untreated, serious complications can develop, including posterior molar abscesses. These conditions can spread to surrounding structures, affecting the periosteum and jawbone, potentially extending into the submandibular space.

Severe complications may result in:

• Fever (37.1–38°C), chills, fatigue, and headaches.
• Inflamed, swollen, and painful oral tissues.
• Facial asymmetry due to jaw swelling.
• Severe difficulty or complete inability to open the mouth.

In extreme cases, these complications can pose life-threatening risks. Contributing factors include weakened immunity, older age, chronic illnesses, and existing oral infections.

Even if antibiotics provide temporary relief, they do not eliminate the root cause of the inflammation. Thus, professional dental evaluation and treatment are necessary when symptoms appear.

Should an asymptomatic wisdom tooth be removed?

If a wisdom tooth is erupting abnormally but does not show signs of pericoronitis, cavities, or other complications, opinions on extraction vary. Generally, dentists do not recommend removing such a tooth unless necessary. Regular dental check-ups and good oral hygiene are usually sufficient.

However, as a person ages, tooth extractions become more challenging due to fully developed wisdom tooth roots, changes in bone structure, and the presence of other medical conditions.

How to prevent?

To prevent pericoronitis from becoming chronic, it is crucial to see a dentist as soon as symptoms such as gum inflammation, pain in the erupting tooth, or swollen lymph nodes appear. With timely treatment, the prognosis is favorable.

If the decision is made to preserve the tooth, the patient should schedule routine dental visits every six months for check-ups and professional cleanings.

To minimize the risk of infection, using an antiseptic mouth rinse after brushing is recommended.

Preventive dental check-ups, including orthopantomography, help reduce the risk of developing pericoronitis. The early formation of tooth buds typically becomes visible around the age of 16. Based on the X-ray results, the dentist can evaluate the tooth’s positioning and predict potential eruption difficulties.

Home remedies

If the condition is in its early stages and symptoms are mild, self-care measures may help manage the inflammation. Frequent rinsing with chamomile tea, saline and baking soda solution, or furacilin can be beneficial. Cold compresses may also help reduce gum inflammation.

However, it is essential to remain vigilant. Delaying professional treatment may allow the condition to worsen, necessitating surgical intervention. If symptoms persist or intensify within a few days, consulting a dentist is imperative. Only timely medical treatment can prevent complications.

Medications for pericoronitis include broad-spectrum antimicrobial and anti-inflammatory drugs such as Amoxicillin, Amoxiclav, and Azithromycin. If the condition affects a wisdom tooth, surgical intervention usually involves excising (removing) the gum flap covering the tooth.

Popular questions and answers

Does salt water cure pericoronitis?

Salt is considered an effective remedy for gum inflammation. It promotes tissue healing and reduces inflammation by drawing out excess moisture. When in contact with the oral cavity, salt absorbs liquid from inflamed areas, depriving bacteria of their optimal environment. Sea salt is preferable for treatment due to its high iodine content.

What can a doctor do if I have pericoronitis?

A dentist can diagnose pericoronitis by assessing the patient’s symptoms and conducting an oral examination. In some cases, an X-ray may be required to determine the tooth’s position, the degree of misalignment, and whether bone structures are involved in the inflammation.

Why does it worsen at night?

Lying down with your head on a pillow increases blood flow to the head, intensifying discomfort.

Can it cause nausea?

Severe gum inflammation with pus formation can lead to nausea, weakness, and headaches due to the release of toxins into the bloodstream.

How can I tell if a tooth infection has spread to my jaw?

Severe and persistent pain that radiates into the bone is an indication of infection spread. Symptoms of an abscess—a deep infection in the tissues—include high fever, swelling, redness, and signs of systemic toxicity, such as nausea, weakness, pale skin, and cold sweats. An abscess can lead to life-threatening blood poisoning, so immediate medical attention is necessary.