MINISTRY OF HEALTH OF UKRAINE Higher medical educational institution of Ukraine "Ukrainian medical stomatological academy"

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1 MINISTRY OF HEALTH OF UKRAINE Higher medical educational institution of Ukraine "Ukrainian medical stomatological academy" Approved On the meeting chair Of Pediatric Surgical Stomatology and Propaedeutics Surgical Stomatology The Head of the Department prof. Ткаchеnко P.I. 20 Educational discipline Module 1 Content module 2 Theme lesson GUIDELINES Individual work of students During preparation for Practical classes Course 3 Faculty Stomatological Surgical stomatology Propaedeutics Surgical Stomatology Tools and techniques removal of teeth and root Complicated tooth eruption. Pericoronitis. Clinic, diagnostics of complications, medical treatment. Indication to the extraction, and method of atypical extraction. Poltava 2016

2 1. Actuality of the topic: When a tooth is partially impacted with a large amount of soft tissue over the axial and occlusal surfaces, the patient frequently has one or more episodes of pericoronitis. Pericoronitis is an infection of the soft tissue around the crown of a partially impacted tooth and is caused by the normal oral flora. Pericoronitis can lead to serious fascial space infections. Because the infection begins in the posterior mouth, it can spread rapidly into the fascial spaces of the mandibular ramus and the lateral neck. 2. The objectives of the studies: To know features of clinics of, a structure lower jaw and teeth. To be able to carry out inspection, preparation of the patient and establish diagnosis of pericoronitis. To be able to choose adequate treatment of pericironitis. 3. Basic knowledge, skills, skills necessary for study topics (interdisciplinary integration). Name of previous courses These skills Human anatomy, histology, Precisely to be guided in a structure lower jaw. physiology The pharmacology Truly to choose preparations for treatment of pericoronitis The propedeutics of internal To carry out injections illnesses General surgery The common principles of carrying out of surgical manipulations The therapeutic odontology, To find out indications to operation of an exodontia children's surgical odontology, orthopedic odontology 4. Tasks for independent work in preparation for the classes A list of key terms, parameters, characteristics that must learn the student in preparation for the lesson: Term Pericoronitis Lymphadenitis Definition inflammation of soft tissue around the tooth inflammation of the lymph node 4.2. Theoretical questions to lesson 1. Etiological factors and frequency of becoming of pericoronitis. 2. Classification of pericoronitis. 3. Clinical manifestations of pericoronitis. 4. Principles of treatment of pericoronitis Practical works (tasks) are performed in class: 1. To be able to collect an anamnesis of illness and life at the patient. 2. To examine the patient. 3. To make a diagnosis. 4. To make a treatment planning. 5. To be able to remove a tooth on the phantom. 5. Theme contents: PERICORONAL INFECTIONS (Pericoronitis; operculitis) Pericoronal infections of the gum surrounding unerupted or partially erupted teeth. They can occur through out life time; namely:

3 1. Infancy and child hood 2. Young adult hood 3. Old age. Pericoronal infection in infancy and child hood: Are associated with the eruption periods. The soft tissues overlying the tooth follicle may show acute or chronic inflammatory reactions and infection, depending on the veriolence of the organisms and the body resistance. Acute inflammatory stage: Acute pericoronitis may occur with formation of a pericoronal abscess with actual fluctuant mass of pus. Occasionally this abscess may develop a facial cellulitis by the invasion of the infection to the soft tissues, causing local and systemic reactions associated with the general constitutional symptoms of acute infections. The patient usually suffers from fever, malaise, cervical adenopathy, sore throat, dysphagia etc. Chronic inflammatory stage: Chronic pericoronitis may occur with formation of dense fibrous tissue which may impede the eruption of the involved tooth. Bacteriology: It is usually a mixed infection. The causative organisms are many with fusiform bacilli and Vincent's spirochetes more predominant. When pericoronitis occurs in conjunction with a sore throat, streptococcal' bacteria are present. Treatment: Acute pericoronitis: When a pericoronal abscess with fluctuation is formed intra-orally, antibiotics are started, incision and drainage is performed followed by warm saline mouth rinses at intervals with continuation of antibiotics, gives adequate relief and usually the condition subsides in few days and no further treatment is necessary. Chronic pericoronitis: Surgical excision of the dense fibrous tissue overlying the tooth and applying a surgical pack, performed under local anaesthesia, will bring about a normal eruption of the tooth. Pericoronal Infection in Early Adulthood Etiology & Predisposing factors: It is due to bacterial growth under the pericoronal flap (operculum). Traumatic irritation from the opposing tooth predispose for the occurance of the condition by decreasing the vitality of the tissue which facilitate bacterial invasion particularly because the condition underneath the operculum is an ideal incubator for bacterial growth; because it permits humidity, warmth, relative deficiency of oxygen, relative immobility and rigidity of the tissue involved, accumulation of food debris, darkness, protection from the washing influence of saliva and continous traumatization by the opposing maxillary third molar particularly during mastication. Streptococci and a large variety of anaerobic bacteria (the usual bacteria that inhabit the gingival sulcus) cause pericoronitis. It can be treated initially by mechanically debriding the large periodontal pocket that exists under the operculum by using hydrogen peroxide as an irrigating solution. Hydrogen peroxide not only mechanically removes bacteria with its foaming action, it also reduces the number of anaerobic bacteria by releasing oxygen into the usually anaerobic environment of the oral cavity. Other irrigates, such as chlorhexidine or iodophors, can reduce the bacterial population of the pocket. Clinical pictures: I. Acute: It is a combination of extra and intra oral symptoms: a. Intraoral signs & symptoms: Sever sharp thropping pain. Sever trismus. Discomfort on swallowing. b. Extraoral signs & symptoms: Facial swelling is common in severe cases.

4 Fever, (pyrexia), malaise, anorexia, dehydration and other constitutional symptoms.. The regional lymph nodes are tender and enlarged (submaxillary adenitis). II. Subacute: Localized dull pain The pericoronal flap is swallen tender and reddened. Pus can be seen oozing from beneath the flap. Cuspal indentation on the flap if there is an impinging upper 3rd molar. Bad odor and taste (Faetor oris) and cheek ridging (due to bite of accomodation). Slight discomfort on swallowing and opening the mouth. Tender enlargement of the regional lymph nodes, the submandibular in case of pericoronitis of lower third molar in the affected side. III. Chronic (subclinical): The pericoronal flap appears dense, fibrous and slightly adherent to the underlying occlusal surface it is usually asymptomatic except for: Mild discomfort. Bad taste due to pus discharge Treatment: The treatment is not solicited unless the patient experiences a subacute or acute exacerbation. If the causative factor is irritation from overerupted upper 3rd molar it should be extracted or grinding of the opposing cusps if extraction is not feasable. There are three lines of treatment which are: A. Conservative: 1. Antibiotics e.g. oral penicillin V 250 mg/6hrs. or erythromcin this should continue for 3-5 days after the acute stage has subsided. 2. Irrigation under the flap with warm normal saline, or iodin lotion (6ml of 5% phenol + 12 ml tencture of aconite + 18 ml tencture of iodine + 24 ml glycerine) or 20 cc normal saline units of penicillin. The irrigation should be done every day to remove depris using locc syringe and 20 gouge 31/ 2 inch long curved blunt needle. 3. Mouth wash with hot normal salaine every 2 hours. 4. Insicion and drainage: When pericoronal abscess develops I & D should be performed once fluctuation is detected clinically incise the pericoronal abscess at the most prominent area wim no. 11 B.P.blade and insert a piece of rubber dam as a drain. B. Removal of the tooth (odontectomy): After the subsidence of acute stage, proper clinical and radiological examination should be carried out to determine the future line of treatment, the lower 3rd molar should be surgically removed when the tooth is impacted, malposed or there is no space for its proper eruption. C. Operculectomy: It is the surgical removal or excision of the pericoronal flap. It is indicated when only 1/ 3 of the occlusal surface is covered by the flap with good chance of proper eruption of the tooth. It is best done by electroscalpel which has the following advantages: 1. No pressure is needed so the cut can be done accurately with minimal trauma. 2. Minimal bleeding during operation. 3. The risk of spread of infection is minimized. 4. Easy procedure in this inaccessible area with minimal postoperative pain and discomfort. Technique : 1. The loop is placed under the flap as far posteriorly as possible and if possible around the distal surface of the toodi. 2. The loop is moved up to cut die bulk of the tissue. 3. The loop is then placed on the crest of the tissue about 5 mm. distal to the crown and cut down toward the cervical margin. If the electrosurgery unit is not available, the dense fibrous operculum could be excised with surgical scalpel using no. 12 B.P. blade or a special operculectomy knife with the blade at right angle

5 to the handle or with gingivectomy knife (Kerkland's knife) for better control of the cut in this inaccessible location. After operculectomy a small piece of periodontal pack is placed distal to the tooth. Complications: For patients who have (in addition to local swelling and pain) mild facial swelling, mild trismus secondary to inflammation extending into the muscles of mastication, and a low-grade fever, the dentist should consider administering an antibiotic along with irrigation and extraction. The antibiotic of choice is penicillin. Pericoronitis can lead to serious fascial space infections. Because the infection begins in the posterior mouth, it can spread rapidly into the fascial spaces of the mandibular ramus and the lateral neck. If a patient develops trismus (with an inability to open the mouth more than 20 mm), a temperature of greater than 38.3 C, facial swelling, pain, and malaise, the patient should be referred to an oral and maxillofacial surgeon, who may admit the patient to the hospital. Pericoronal Infection in Old Age For some reasons an impacted tooth may be left unextracted in the jaw of an edentulous patient, assuming that the tooth may stay asymptomatic or because of failure to diagnose the presence of that tooth with X-ray. When the patient wears full dentures they cause irritation to the soft tissues overlying that tooth which is affected also with some alveolar resorption and pericoronal infection may occur. This infection may also occur due to an odontoma embeded in the central portion of the jaw which starts to be symptomatic by pressure and irritation of full dentures worn by the edentulous patients. The treatment is to control the acute infection by general and surgical measures till the acute condition subsides then the impaction or odontoma are removed surgically. Prevention of pericoronitis can be achieved by removing the impacted third molars before they penetrate the oral mucosa and are visible. Although excision of the surrounding soft tissue, or operculectomy, has been advocated as a method for preventing pericoronitis without removal of the impacted tooth, it is very painful and usually does not work. The soft tissue excess tends to recur, because it drapes over the impacted tooth and causes regrowth of the operculum. The overwhelming majority of cases of pericoronitis can be prevented only by extraction of the tooth. 6. Materials for self control: А. Assignments for self control (tables, charts, drawings, graphs): B. Self-control tests: 1. On character of clinical flow distinguish an pericoronitis: A. Purulent, destructive, hyperostosis; B. Slight, average and serious form; C. Acute, subacute, chronic, aggravated D. Acute, sbacute, chronic 2. The clinical symptomatology at an acute pericoronitis is characterized by clinic: A. Acute periodontitis; B. Acute periostitis; C. Signs of all odontogenic inflammatory diseases of jaws. D. Acute odontogenic osteomyelitis 3. Pericoronitis can lead to serious fascial space infections: A. Space submentalis. B. Space sublingual s. C. Space pterygomandibular s D. Space submasticatory. 4. Pericoronitis caused by: A. Trauma. B. Infections agent. C. Spreading infection from adjacent region.

6 C. Tasks for self-control: The patient 27 years has addressed to the stomatologist with the complaints to a pain in mandible at the left near unerupting teeth, deterioration of a general state, headache, fervescence. Objectively: face asymmetric at the expense of a tumescence of mild tissues nearby to angle mandible; 38 partially erupting, surrounding mucous in region of these tooth is hydropic, hyperemic from both parties. A. What additional methods of examines are necessary for carrying out at the patient; B. To make a clinical diagnosis; To prescribe treatment to the patient. 7. Bibliography. Basic: 1. Contemporary Oral and Maxillofacial Surgery//Larry J. Peterson, Edvard Ellis III, James R.Hupp, Myron Tucker/ 2003, MOSBY, 776 p. 2. V.I. Mytchenok, A.I.Pan kevych Propedeutics of surgical stomatology / Vinnycya New book, Additional Sources: 1. Berman SA: Basic principles of dentoalveolar surgery. In Peterson LJ, editor: Principles of oral and maxillofacial surgery Philadelphia, 1992, JB Lippincott. 2. Byrd DL: Exodontia: modern concepts, Dent Clin North Am 15:273, Methodical Instruction is composed by docent Pan kevych A.I.