Treatment in the acute stage and remission period
The main goal of therapy for pronounced inflammatory phenomena is to relieve the exacerbation. During this period, it is strictly not recommended to extract the causative third molar.
The physician's tactics boil down to establishing an outflow for the exudate:
- The space beneath the gingival "hood" is abundantly irrigated with warm antiseptic solutions.
- If necessary, a releasing longitudinal incision of the "hood" is performed to expose the crown and release pus.
- Concurrently, the patient is prescribed a course of broad-spectrum antibiotics.
When acute symptoms subside, a final decision is made. If there is sufficient space in the dental arch for the tooth and it is positioned anatomically correctly, a complete excision of the "hood" is performed. The wound surface is tamponade-packed with an iodoform gauze strip for 5–7 days. However, if dystopia (malposition) is diagnosed or there is no room for eruption, the tooth is subject to extraction using a dental bur.
Retromolar periostitis
This severe complication occurs if the outflow of inflammatory exudate is disrupted during pericoronitis. The infection spreads from beneath the "hood" and marginal periodontium deeper — beneath the periosteum of the retromolar fossa and into the surrounding cellular tissue, where an abscess forms.
The clinical picture is characterized by a sharp deterioration in condition:
- Intense pain occurs when opening the mouth and swallowing.
- Intoxication syndrome increases (weakness, malaise, fever up to 38.0–38.5 °C).
- Pronounced trismus appears — the patient can barely open their mouth by just 0.5 cm.
- External examination reveals minor edema in the posterior submandibular region; painful enlarged lymph nodes (lymphadenitis) are palpable.
In the oral cavity (Status localis), a painful inflammatory infiltrate is determined behind the molars, extending to the outer (or inner) surface of the alveolar part of the jaw. A blood test records moderate leukocytosis with a shift to the left and an ESR increase up to 25–30 mm/h.
Treatment is performed mainly on an outpatient basis. The surgeon makes an incision in the mucosa from the base of the pterygomandibular fold down to the lower vestibule of the oral cavity, mandatory placing a rubber drain. Daily dressings, antibiotic therapy, and physiotherapy (UHF, laser therapy) are indicated. As with uncomplicated pericoronitis, the tooth is extracted only after the inflammation subsides.
Eruption cysts
Difficult eruption is accompanied by the development of follicular cysts in 30% of cases. It is believed that they form either due to chronic inflammatory detachment of the mucosa from the crown or from encapsulated remnants of embryonic epithelium. Histologically, their wall consists of fibrous connective tissue lined with stratified squamous epithelium (the picture is identical to radicular cysts).
During cyst exacerbation, the symptomatology completely mimics acute pericoronitis. The main diagnostic method is radiography (including the lateral projection of the mandibular ramus), which shows an area of bone tissue destruction with clear borders around the impacted tooth.
If the cyst is small, it is removed on an outpatient basis along with the tooth. However, extensive formations projecting onto the mandibular canal and extending into the body or ramus of the jaw are operated on strictly in an inpatient setting.
Features of the extraction of impacted and dystopic teeth
Surgical extraction of problematic teeth requires careful preparation and adherence to the protocol to minimize bone tissue trauma.
Key intervention stages:
- Anesthesia and premedication: Local conduction anesthesia is used. 40 minutes before surgery, the patient takes broad-spectrum antibiotics, and immediately before the intervention, rinses the mouth with antiseptics.
- Surgical access: Most often performed from the vestibular side, but if the tooth is localized closer to the palate, a palatal access is chosen. An angle-shaped, trapezoidal, or linear incision is formed for sufficient tissue skeletonization.
- Bone management: After reflecting the mucoperiosteal flap, the bone tissue over the tooth is drilled out with a bur. Here, mandatory continuous cooling with saline solution is used. The goal of this stage is to free the crown and root as much as possible for safe extraction.
Briefly: answers to topical questions
What clinical forms (classification) of acute and chronic pericoronitis exist?
The classification of forms of difficult eruption of the wisdom tooth distinguishes the following clinical forms of pericoronitis:
- Acute catarrhal pericoronitis
- Acute purulent pericoronitis
- Chronic pericoronitis
The chronic form can proceed as chronic marginal granulating periodontitis, and with limited proliferation of granulation tissue, limited granulomatous marginal periodontitis is formed.
Which specific nerves need to be blocked during conduction anesthesia for mandibular third molar extraction?
For adequate pain control during surgical interventions in the lateral mandibular teeth region, the following nerves must be blocked:
- Inferior alveolar nerve (inferior dental nerve)
- Lingual nerve
- Buccal nerve (n. buccalis)
Blockade of the inferior alveolar and lingual nerves is achieved via mandibular anesthesia, but blockade of the buccal nerve is also mandatory. Simultaneous blockade of all three specified nerves occurs when performing the Gow-Gates conduction anesthesia technique.
Which maxillofacial region diseases are used for the differential diagnosis of acute pericoronitis?
Sources indicate that during the exacerbation of a follicular cyst, the clinical presentation is analogous to acute or chronic pericoronitis, and inflammation during the eruption of an odontoma can mimic mandibular third molar pericoronitis. A complete list of diseases for the differential diagnosis of acute pericoronitis specifically is not provided in the sources.
Which microorganisms form the basis of the pathogenic microflora in purulent pericoronitis?
The basis of the pathogenic microflora in the development of acute pericoronitis is the resident (normal) microflora of the oral cavity. The inflammatory process arises due to its activation under favorable conditions (optimal temperature, humid environment, lack of light) that form beneath the gingival "hood". Anaerobic and facultatively anaerobic bacterial species predominate in the spectrum of causative agents. Exact species names of microorganisms are not specified in the sources.
PPP in acute pericoronitis: Irrigate the hood, Perform a releasing incision, Prescribe antibiotics. Extraction — only after the process cools down.
Class and exam questions
Can a wisdom tooth be extracted in the presence of severe pain and purulent pericoronitis?
No, extracting a third molar during pronounced acute inflammatory symptoms is not recommended, as this can lead to the generalization of the infection. The exacerbation must be managed first.
How to distinguish retromolar periostitis from ordinary pericoronitis?
Periostitis is characterized by a more severe picture: pronounced intoxication with fever up to 38.5 °C, sharp pain upon swallowing, severe restriction of mouth opening (up to 0.5 cm), and the spread of inflammatory infiltrate to the surface of the alveolar part of the jaw.
When should eruption cyst removal surgery be performed in an inpatient setting?
Hospitalization is mandatory if the follicular cyst is extensive in size, projects onto the mandibular canal, and extends anteriorly to the body and ramus of the jaw.
What else to study on this topic
- Methodology for performing angle-shaped and trapezoidal incisions during extraction
- Differential diagnosis of periostitis with peritonsillar and pterygomandibular space abscesses
- Radiological criteria for distinguishing follicular cysts from odontogenic tumors
- Complications of difficult eruption of premolars and canines (maxillary sinusitis, osteomyelitis)
- Physiotherapeutic rehabilitation methods after opening a retromolar abscess
Master the entire topic in the course "Surgical Dentistry"
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Pericoronitis" and another 866 pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 28 video lessons on the subject
Other topics in the section "Chapter 6. Retention, dystopia, tooth eruption disorders (A.M. Panin)"
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.