Every one of us frequently sees this particular case walk into the clinic. The scenario is quite familiar, almost memorized: a patient comes in, struggling to open their mouth properly, experiencing excruciating pain in the back of their jaw, and their breath isn’t exactly fresh. Upon examination, you find that piece of gum tissue, the operculum, covering the mandibular third molar is swollen, red, and bleeding at the slightest touch.
What’s the very first thing that pops into your mind? Most likely, we gravitate towards “conservative treatment.” A bit of subgingival irrigation, some antibiotics to control the infection, perhaps a mouthwash, and then we tell the patient, “Wait a couple of days for the inflammation to subside, and then we’ll see what’s next.”
What typically happens in most of these situations? The patient feels a bit better for two or three days… only to return with the exact same problem, sometimes even worse.
So, why does this occur? Was the treatment incorrect? No, the treatment was simply incomplete. It was missing the most crucial diagnostic step – the step that makes all the difference between treating a symptom and actually addressing the root cause of the problem.
In this article, we’re going to unveil the “hidden culprit” that often stands as the true reason behind pericoronitis. More importantly, we’ll show you how to treat it correctly right from the first visit.
The Real Culprit: Look Up Before You Treat Down!
In a significantly large percentage of pericoronitis cases, the problem isn’t solely with the lower third molar. The real issue often originates from above – specifically, from the opposing maxillary third molar.
It’s quite common for that upper wisdom tooth to be “over-erupted,” particularly if there isn’t an opposing tooth below it. So, what happens when the patient closes their mouth or chews? The sharp cusps of that over-erupted maxillary molar come down and bite directly into the soft gingival tissue (the operculum) covering the lower tooth.
This action creates continuous, chronic trauma to that gum tissue. Every single time the patient closes their mouth, a new injury occurs. With bacteria and food debris inevitably present in this area, this persistent trauma quickly escalates into acute, intensely painful inflammation.
We refer to this type of inflammation as Traumatic Pericoronitis. And in these specific instances, no amount of antibiotics or mouthwash will resolve the issue, simply because the source of the mechanical irritation remains with every single bite (1).
The Correct Diagnostic Approach: How to Uncover the Culprit
To avoid making this common mistake, your examination must be comprehensive. This extra step will take you perhaps 30 seconds, but it will save both you and your patient days of pain and distress.
-
Listen Carefully to the Patient: Ask them, “Does the pain increase more when you close your teeth together?” If they answer “yes,” that’s your first crucial clue.
-
Observe Closely: After thoroughly cleaning the area, examine the surface of the inflamed operculum. Can you spot any bite marks or an “impression” of the opposing tooth’s cusps? You might find a small wound or even an ulcer.
-
The Slow Bite Test: This is the most critical step. Ask the patient to bite down very slowly while you are intently observing the area. You will visually confirm the opposing molar’s cusp descending and impinging directly into the inflamed gum tissue below. This test provides a 100% definitive diagnosis.
-
Assess the Upper Molar’s Level: Visually check the occlusal plane. Is the maxillary third molar erupting beyond the level of the adjacent tooth? If so, this further confirms that it is over-erupted.
The Correct Treatment Protocol
Once you’ve performed a thorough examination, your treatment plan will be clear-cut and will generally fall into one of two scenarios:
Scenario 1: The Upper Molar is the Culprit (Traumatic Pericoronitis)
If you’ve confirmed that the opposing maxillary molar is impinging on the gum tissue below, then the treatment here is straightforward and direct: you must eliminate the source of the trauma.
-
The First and Most Essential Step: Upper Third Molar Extraction.
This is the definitive and true cure. As soon as you extract this tooth, you remove the source of mechanical irritation, allowing the lower gum tissue to heal and recover. Extracting an upper third molar is usually much simpler than a lower one, with fewer associated complications. -
Secondary Step: Palliative Care for the Lower Tooth.
After extracting the upper tooth, you might perform a simple irrigation under the inflamed gum with saline solution to cleanse any food debris and bacteria. Advise the patient to rinse with warm salt water or chlorhexidine mouthwash for two to three days. -
Do We Need Antibiotics? Generally, you won’t. Once the source of trauma is removed, the inflammation typically subsides very rapidly. Antibiotics might only be necessary if there are clear signs of spreading infection, such as significant facial swelling, severe dysphagia, or fever (2).
Scenario 2: The Upper Molar is Innocent (Simple Pericoronitis)
If your examination reveals that the upper molar is in its normal position and not contacting the lower gum, then this is a classic case of pericoronitis caused by food impaction and bacterial accumulation beneath the gum.
Here, conservative treatment plays the primary role:
-
Deep Irrigation and Disinfection: Use a blunt-ended syringe and thoroughly irrigate under the operculum with saline or chlorhexidine to flush out all food debris and any purulent discharge.
-
Operculectomy (Removal of Excess Gum Tissue): If the operculum is notably large and frequently causes issues, you might consider removing it. This is a straightforward procedure that can be performed under local anesthesia using a surgical blade, electrosurgery unit, or a soft tissue laser if available. Removing the operculum fully exposes the rest of the tooth and makes it much easier for the patient to keep the area clean, thus preventing recurrence (3).
-
Oral Hygiene Instructions: It’s crucial to educate the patient on how to use a small toothbrush or a water flosser to meticulously clean this area, preventing future food impaction.
-
Antibiotics: As mentioned, these are reserved only for cases showing clear signs of spreading infection.
The Takeaway: Think 3D Before You Treat
The most important lesson from this article is that you must always think in three dimensions. The problem you observe in the mandibular arch might actually originate from the maxillary arch. Before you even write a prescription for antibiotics and mouthwash, take an extra 30 seconds: lift the patient’s cheek and visually examine the opposing tooth.
This simple, additional step will dramatically enhance the accuracy of your diagnosis, making your treatment effective and definitive. More importantly, it will solidify your reputation as a skilled clinician whose patients don’t return with the same complaint a couple of days later.
