What is the treatment for pericoronitis?

Treatment for Pericoronitis

Pericoronitis should be treated primarily with local measures (irrigation, debridement, and oral hygiene) rather than antibiotics, with antimicrobial therapy reserved only for severe cases with systemic involvement or when surgery must be delayed. 1, 2

Initial Management: Local Therapy First

The cornerstone of pericoronitis treatment is local intervention, not antibiotics 2:

• Irrigate the operculum with warm saline or chlorhexidine to remove debris and reduce bacterial load 1, 2
• Debride the area under the operculum to eliminate food particles and purulent material 2
• Instruct patients on meticulous oral hygiene with gentle brushing of the affected area 2
• Prescribe chlorhexidine mouth rinses to maintain local antisepsis 2

This local approach is effective for the vast majority of pericoronitis cases and should be attempted before considering antibiotics 2.

When to Use Antibiotics

Antibiotics are indicated only in specific circumstances 1, 2:

• Acute suppurative pericoronitis with systemic signs: fever, malaise, trismus, lymphadenopathy, or facial swelling 1, 2
• When surgical extraction must be postponed during the acute suppurative phase 1
• Preoperative prophylaxis in high-risk patients undergoing extraction 1

First-line antibiotic choice is amoxicillin-clavulanate (amoxicillin with clavulanic acid) because pericoronitis is caused predominantly by beta-lactamase-producing anaerobic organisms 1. Metronidazole is also commonly used, particularly given the prevalence of spirochetes and fusobacteria in pericoronitis 1, 3, 2.

A typical course is 3-5 days of antibiotic therapy, similar to other oral infections 1, 2.

Definitive Treatment: Surgical Extraction

Extraction of the involved third molar is the definitive treatment and is indicated as the most common reason for third molar removal 1:

• Timing of extraction: Perform after the acute infection resolves with local measures and/or antibiotics 1, 2
• Extraction during acute phase: Should be avoided due to increased risk of complications, though antibiotics can facilitate earlier surgery 1
• Quality of life improvement: Extraction prevents recurrent episodes and is the only way to eliminate the problem permanently 1, 4

Critical Pitfalls to Avoid

Antibiotic overuse is rampant in pericoronitis management and must be corrected 2:

• Surveys show approximately 75% of dentists prescribe antibiotics for pericoronitis, and over half of patients receive antibiotics—this is excessive and inappropriate 2
• Most cases respond to local therapy alone without antibiotics 2
• Unnecessary antibiotic use contributes to antimicrobial resistance, increased healthcare costs, and adverse drug effects 2

Retention of the tooth carries risks: While extraction has potential complications (nerve damage), retention can lead to serious, even life-threatening infections including Ludwig's angina or deep space infections 4.

Clinical Algorithm

1. Assess severity: Check for systemic signs (fever, trismus, swelling, lymphadenopathy) 1, 2
2. If mild (localized pain, no systemic signs): Local measures only—irrigation, debridement, oral hygiene instruction 2
3. If severe (systemic involvement): Add amoxicillin-clavulanate for 3-5 days 1, 2
4. Plan definitive treatment: Schedule third molar extraction after acute phase resolves 1
5. Monitor closely: If no improvement within 24-48 hours, reassess for complications or need for immediate extraction 2