CHAPTER 46
Dental Pain, Pericoronitis
Presentation
The patient is between the ages of 17 and 25 and seeks help because of painful swelling and infection around an erupting or impacted third molar (wisdom tooth). There may be a bad taste caused by pus oozing from the area. The pain may be mild but is usually quite intense and may radiate to the external neck, the throat, the ear, or the oral floor. Occasionally, there is trismus (the inability to open the jaws more than a few millimeters) or pain on biting. The site appears red and swollen, with a flap that may reveal a partial tooth eruption beneath it. There may be purulent drainage when the flap is pulled open. There should be no pain on percussion of the tooth.
Even with relatively minor enlargement of the operculum (flap), the third molar region of the mandible can be very painful (Figure 46-1). Cervical lymphadenopathy, fever, and malaise may be present in the more advanced cases.
Figure 46-1 Mild pericoronitis. (From Douglass AB, Douglass JM: Common dental emergencies. Am Fam Physician 67:511-516, 2003.)
What To Do:
Irrigate with a weak (2%) hydrogen peroxide solution. Purulent material can be released by placing the catheter tip of the irrigating syringe under the tissue flap overlying the impacted molar. A syringe with an Angiocath catheter will work well to accomplish this.
Prescribe oral analgesics for comfort.
When the problem is no longer localized and there is evidence of cellulitis, prescribe penicillin to be taken over the next 10 days (penicillin V potassium, 500 mg qid). Use erythromycin, azithromycin, or clindamycin in penicillin-allergic individuals. Cefuroxime axetil is also effective in the treatment of acute dental infections.
Instruct the patient regarding the importance of cleansing away any food particles that collect beneath the gingival flap. This can be accomplished simply by using a soft toothbrush or by using water-jet irrigation. Have the patient rinse and swish with a hot, salty mouthwash after meals and at least four times per day.
A follow-up visit with a dentist should be arranged so that the resolution of the acute infection can be observed and so that the patient can be evaluated to see if symptomatic treatment can suffice until eruption is complete or if surgical therapy to remove the gum flap or underlying tooth is necessary.
What Not To Do:
Do not undertake any major blunt dissection while draining pus. This could spread a superficial infection into the deep spaces of the head and neck or follow a deep abscess posteriorly into the carotid sheath.
Discussion
Pericoronitis is a special type of acute periodontal abscess that occurs when gingival tissue (gum flap, or operculum) overlies a partially erupted or impacted tooth (usually a third molar, also known as a wisdom tooth). Recurring acute symptoms are usually initiated by trauma inflicted by the opposing tooth or by impaction of food or debris under the flap of tissue that partially covers the erupting tooth.
When dental referral is not readily available, one procedure that can relieve the pain is surgical removal of the operculum. Inject local anesthetic, such as lidocaine (Xylocaine) 1% with epinephrine, directly into the overlying tissue, and then cut it away using the outline of the tooth as a guide for the incision. Sutures are not required.
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