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Copy of Surgery ppt

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zainab shaikh

on 3 September 2013

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Transcript of Copy of Surgery ppt

Pericoronitis : inflammation of soft tissue covering crown of partially erupted or impacted tooth and is caused most probably by normal oral flora.
For patients presenting with localized pain and swelling involving the pericoronal tissues, and in the absence of regional and systemic symptoms, it is recommended that local measures only are used.
(In addition to local pain and swelling, if the patient is exhibiting regional or systemic signs and symptoms)
What is Pericoronitis
Pericoronitis is defined as inflammation in the soft tissues surrounding the crown of a partially erupted tooth.
Seen in teeth that erupt very slowly or become impacted.
Most commonly affects the lower third molar.
When plaque or the bacterial layer (that remains on teeth after brushing) gets into flap of gums around teeth, it irritates the gums and leads to pericoronitis.
What is the difference between pericoronitis and supracoronitis
Supracoronitis : inflammation seen in soft tissue covering teeth which are going under normal eruption,which is local inflammation and degradation of tissue which allows the eruption of teeth and inflammation is gone after eruption of teeth.
The partial breakthrough of gum leaves opening for bacteria and causes infection.

Microorganism as streptococci , anaerobic , and normal oral flora .It doesnt always occur in all individuals with impaction . If a patient experiences mild transient decrease in host defences pericoronitis occurs.
Minor trauma from opposing maxillary third molar tooth.
Symptoms of Acute Phase of Pericoronitis
Symptoms of Sub-Acute Phase Pericoronitis
Symptoms of Chronic Phase of Pericoronitis
Purulent discharge from pericoronal space.

Halitosis, leucocytosis and malaise are also common in some cases of pericoronitis.

In addition patient may also notice sloughing or ulceration around the operculum.
Severe throbbing pain.

Extra oral swelling .

Restricted mouth opening .
the infection
gets spread in
sublingual and para- pharyngeal spaces then
Dysphagia occurs. The person has difficulty in swallowing food.
In the sub-acute phase of the systematic symptoms of pericoronitis become less acute .
Jaw stiffness.

Pus discharge.


Lymphadenopathy (in some cases)
Systemic features completely vanish till the chronic stage of pericoronitis, except for the state of severe exacerbation. In chronic phase of pericoronitis, patient report :
Dull pain .

Unpleasant bad taste .
With intraoral periapical radiographs one can easily identify bony defect around the third molar.
Differential diagnosis



Conventional radiography
Computed Tomography
Magnetic Resonance Imaging ( MRI )
It can be further divided into intraoral and extra oral views .

They actually lack importance in case of acute periocoronitis , as they don't show soft tissue lesions .
However , in case of chronic pericoronitis it may show some bone resorption in the area related to the pericoronitis .
It's the '' gold standard '' in head and neck imaging . CT scan is the most widely used advanced imaging modality in the evaluation of fascial infections . CT shows the extent of soft tissue involvement , i.e :
Complete extent of inflammatory process.

Epicenter of inflammatory process .

Accurately demonstrating the status of airway and involvement of various groups of lymph nodes .

Shows extent of osseous involvement adjacently .
It's an excellent imaging modality for soft tissues . It's a computer based tomographic technique that's developed to image tissues using position emission from isotopes , or signals derived from the nuclear magnetic resonance . That's why it plays an important rule in determing the infection spread through the facial spaces in pericoronitis .
Diagnostic investigations
CBC ( Complete blood count )
Erythrocyte Sedimentation Rate ( ESR )
Including the red blood cell count , white blood cell count , differential white blood cells count , an estimation of platelet number and a description of blood smear .
Helps to determine the nutritional state .

Helps to detect the presence of infection .

Helps to detect / rule out bleeding disorders .

Helps to determine whether the patient immune response will be adequate to facilitate post operative recovery .
• Red blood count : normal unless patient is already having anaemia, liver disease , polycythaemia or extreme dehydration.
• White blood count : increased ( leukocytosis ) , and in differential WBC count , values show special increase in NEUTROPHILS count .
• Platelet count : Normal unless patient is already having iron deficiency anaemia , hypersplenism , cirrhosis of the liver or viral infection .
It's a non specific test and values above normal are indicative of chronic infection , infarction , trauma and inflammatory process . So it shows increased value in case of pericoronitis .
These include:
• Debridement of plaque and food debris

• Drainage of pus

• Irrigation with sterile saline, chlorhexidine or hydrogen peroxide

• Elimination of occlusal trauma.
1. Gently flush the area with warm water to remove debris & exudate.

2. Apply topical anesthesia or gel if it’s painful and remove the debris under flap with the help of periodontal scaler.

3. Swab the area with antiseptic solution like 'bitadine'.
4.Occlusion is evaluated and determined if any opposing tooth is occluding with the pericoronal flap.
5.Occlusal adjustment is done if required.
6.If Flap is swollen and fluctuant then use a # 15 blade to make an anteroposterior incision to establish drainage.
7.Antibiotics are prescribed:
Metronidazole 400mg three times a day for five days
Phenoxymethylpenicillin 500mg four times a day for five days.
The two can be used in combination for severe infections FOR Patient who are allergic to penicillin, erythromycin 500mg four times a day for five days is suitable.
8.After acute symptoms subside you should take an evidence based decision to retain the tooth or extract it. likelihood of eruption of tooth in good functional position may postpone the extraction of affected tooth.
9.If tooth is retained then pericoronal flap is removed with peridontal knife or #15 blade or electrosurgery- Remove the tissue from occlusal as well as from distal part of the tooth. If only occlusal part is removed then it will form a deep pocket distal to the tooth with further periodontal problems
18 years old female patient presented with limited mouth opening , severe pain , minimal extraoral swelling at the left buccal area .
Clinical examination revealed partially erupted lower left third molar with severe tenderness at the anterior border of the ramus .


Entrapment of food under operculum during chewing occurs which is difficult to clean due to lack of access at the corner of mouth.
MALE : 4.7 to 6.1 million cells per microliter
FEMALE : 4.4 to 5.4 million cells per microliter
WHITE BLOOD CELLS : 4500 to 10000 cells per microliter
NEUTROPHILS : 40% to 60%
PLATELET : 150,000 to 400,000 platelets per microliter
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