PATTERN OF RECURRENCE OF PERICORONITIS ATTHE UNIVERSITY OF NAIROBI DENTAL HOSPITAL

DURATION OF STUDY; JULY-AUGUST, 2003

INVESTIGATOR; WAGEREKA IRARIV28/1759/200BDS LEVEL III

SUPERVISORS

INTERNAL SUPERVISOR; DR.GATHECE L.W. B.D.S., M.P.H. (NBI)DEPARTMENT OF PERIODONTOLOGY,COMMUNITY AND PREVENTIVEDENTISTRY , FACULTY OF DENTAL SCIENCES.UNIVERSITY OF NAIROBI.

EXTERNAL SUPERVISOR; DR. M.L. CHINDIA B.D.S., MSc, FFDRCSiDEPARTMENT OF ORAL AND MAXILLOFACIALSURGERY, ORAL MEDICINE AND ORALPATHOLOGY, FACULTY OF DENTAL SCIENCES,UNIVERSITY OF NAIROBI.

A COMMUNITY DENTISTRY PROROSAL SUBMITTED IN PARTIALFULFILLMENT OF THE DEGREE OF BACHELOR OF DENTAL SURGERY,UNIVERSITY OF NAIROBI.

COST OF STUDY; Kshs 4050

TABLE OF CONTENTS page

Cover page 1

Table of contents 2

Summary 3

List of abbreviated words 4

Introduction 5

Literature review 6

Problem statement and justification 7

Objectives! hypothesis! variables 8

Materials and methods 9

Sample size 9

Data collection and analysis 11

Perceived benefits 12

Budgetary requirements 13

Data collection form 14

References 15

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SUMMARY

Pericoronitis is an infection that mainly occurs in younger age groups, around either

erupting or impacted teeth. It may be quite severe in some patients and has been known to

have life threatening complications.

The main objective of this study is to determine the pattern of recurrence of the condition

among a group of patients seen at The University of Nairobi Dental Hospital.

This is a descriptive cross-sectional retrospective study that will be carried out using the

records of patients who have been treated at the Oral Diagnosis or Minor Oral Surgery

clinics

The results will be of use to dentists in diagnosis and management of recurrent

pericoronitis.

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LIST OF ABBREVIATED WORDS

O.D

M.O.S.

Oral Diagnosis

Minor Oral Surgery

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INTRODUCTION

Pericoronitis is defined as the inflammation of gingival and soft tissues surrounding the

crown of an incompletely erupted tooth. 12It occurs most frequently on the mandibular third

molar but in rare cases may be seen in relation to the last standing maxillary or mandibular

second molars. 1 It is one of the most commonly cited reasons for removal of wisdom

teeth,11 though its presence does not necessarily mean that the associated tooth requires

removal. It is usually classified into three forms; acute, subacute and chronic, on the basis

of patient's history. The acute form is characterized severe, throbbing intermittent pain

which is exacerbated by chewing and interferes with sleep while radiating to the adjacent

tissues. In the acute subacute form, there is a dull continuous ache with less radiation of

pain. The patient may complain of stiff jaw of intraoral swelling, but there is less systemic

upset than in the acute variety. With the chronic form, the patient usually complains of dull

pain or mild discomfort of short duration, which is interspersed with remissions lasting

many months. 12

Unless the cause is removed, pericoronitis may present as a recurrent condition requiring

multiple episodes of treatment. In addition, subsequent episodes of pericoronitis tend to be

more severe. Acute pericoronitis is also known to precipitate sickle cell crises in

susceptible patients.' Some authors state that its incidence appears to be increasing, though

no conclusive evidence is given." A study by Von Wovern determined that the disease had

a 10% incidence among young adults in a Finnish population." This appears to broadly

concur with the findings of Batanieh, et al which determined an incidence of between 5-

9.8% in a Jordanian population? More research material concerning the magnitude and

trends of the disease, however, is scarce.

The purpose of this study is to investigate the patterns of recurrence of pericoronitis

among a group of patients who have been diagnosed with the condition at the University of

Nairobi Dental Hospital. The results obtained will be of use to clinicians as an aid to better

diagnosis and will also be used to improve management of recurrent pericoronitis.

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LITERATURE REVIEW

The pericoronal flap is vulnerable to irritation and is often directly traumatized when caught

between two opposing teeth. Its crypt like form also favours proliferation of microbes;

particularly since it is difficult to achieve adequate hygiene of the area.12 Inflammation thus

ensues, which may be acute subacute or chronic. The chronic forms are usually asymptomatic

and as a result of repeated infection, tend to have ulceration along the inner margin of the flap'

Leone et al, noted that the risk of acute pericoronitis is highest for a fully erupted, vertically

positioned mandibular third molar in contact with the second molar, at or above the occlussal

plane, and partially encapsulated by soft or hard tissues. 10

Further enlargement of tissues during an acute episode also inhibits drainage from the sulcus,

inducing the spread of inflammation into deeper structures, with accompanying trismuss, fever,

leucocytosis and foul breath. Retropharyngeal, peritonsillar, masseter space and temporal

abscesses may then result. Ludwig's angina, cavernous sinus thrombosis and acute meningitis

are relatively rare but serious complications of pericoronitis. A number of studies have also

shown that pericoronitis may be precipitated by respiratory tract infections, or, may even

precede them in some cases+' If left untreated, pericoronitis may present as a recurrent

condition requiring multiple episodes of treatment.

The National Health Service's (United Kingdom) policy on wisdom teeth states that a first

episode of pericoronitis, unless severe, should not be considered an indication for surgery. Only

the second or subsequent episodes should be considered for surgical management.

An audit by the Bristol Dental Hospital showed that 8% of all third molar extractions were

performed on what patients reported was the first episode of pericoronitis. Closer questioning of

the patients revealed that the patients may have had previous occurrences of unclear severity.

As a result of this finding, the audit recommended that closer questioning of the past history of

pericoronitis and its severity should be carried out by dentists.

Recent research suggests that 25-30% of all mandibular third molars are extracted due to

recurrent pericoronitis. Pratt et al, also showed that in two different groups of patients, recurrent

pericoronitis was the most common indication for third molar surgery.' Ackerman, Cohen and

Altini reported that patients with paradental cysts had also been shown to have an associated

history of recurrent pericoronitis." The cysts were also reported to be especially common on

lower third molars and are associated with enamel projections on the buccal bifurcation. 12

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In View of all this, not sufficient published literature is available on patterns of

pericoronitis recurrence. A workshop by the National Institute of Health in 1979 noted that

the incidence and recurrence of pericoronitis had not been adequately studied and were

deserving of further investigation. 8 The research material reviewed here does not

adequately describe the patterns of recurrence, for example; common sites and risk factors

for recurrence as well as gender variations in the recurrence of the disease.

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PROBLEM STATEMENT AND JUSTIFICATION

Pericoronitis, if the patient presents in the early stages of the disease, is relatively easy to

manage using conventional therapy. However, patients presenting at later stages are often

in more pain and at higher risk of developing systemic complications.

Recurrent episodes also have an aggravation of the signs and symptoms and are more

difficult to manage. This results in the loss of resources for the patient; as time lost at work

and costs incurred during treatment. Pericoronitis is thus a condition that is associated with

significant morbidity among any population.

Despite this, however, there are as yet very few published studies on its recurrence.

Therefore, the aim of this study will be to fill part of this knowledge gap. The information

gained will be useful in advising surgeons or general dentists on better methods of

diagnosis and management of the recurrent condition.

The results of the study will also be useful in formulating policy or planning protocol for

dental hospitals or the corresponding departments in hospitals on management of recurrent

pericoronitis.

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OBJECTIVES

To determine the patterns of recurrence of pericoronitis

Specific objectives

l. To determine the prevalence of recurrent pericoronitis

2. To determine the most common sites of recurrence

3. To determine the age distribution of recurrence

4. To determine the gender distribution of recurrence of the disease

5. To determine the commonest presenting complaint and findings (on examination) in

patients with recurrent pericoronitis

HYPOTHESIS

1. Recurrence is most common in the mandibular third molars

2. Recurrent episodes of pericoronitis are associated with more senous signs and

symptoms than the first episode in more than 50% of cases

VARIABLES

Independent variables

• Age

• Sex

Dependent variables

• Presenting complaint on recurrence

• Number of episodes reported

• Age at first and last episodes

• Site of recurrence

• Findings on examination.

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MATERIALS AND METHODS

Study design

This will be a descriptive retrospective study based on the records of patients diagnosed

with pericoronitis at University of Nairobi Dental Hospital.

Study area

The University of Nairobi Dental Hospital serves as a teaching and referral centre

providing under-graduate and post-graduate training for dental surgery students. It is

located along Argwings Kodhek road opposite the Nairobi Hospital's Lee Funeral Home.

Patients with a variety of dental diseases are examined and treated here.

SAMPLE SIZE

According to a study by Von Wovern, 10% of a sample of 130 students followed over

four years developed pericoronitis. 11 Therefore, for the purposes of calculating the sample

size, a prevalence rate of 10% in a normal population will be used.

Formula N= Z2 ( I-P)P

C2

Where N= sample size

Z= z value

P= prevalence

C> (100- confidence interval)

100

N= 1.962(0.9)0.1

N= 138.29, rounded off to 138

Sampling method; random

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DATA COLLECTION AND ANALYSIS

Information from the patient records will be collected using a data collection form.

Data to be collected includes: age, sex, file number, number of episodes reported, age at

first and last episodes, site of recurrence and presenting complaints.

The data will then be analyzed using computer software and presented in the form of bar

graphs and pie charts.

Inclusion criteria

All cases recorded at the MOS clinic files from the period 1993-2003.

Exclusion criteria

Records with the required information is missing

Ethical considerations

1. Approval will be sought from the relevant authorities

2. All information collected will be treated confidentially and no patients' names will be

used.

3. The information gained from the study will be applied such as to benefit all patients

equally.

Problems anticipated

1. Inaccuracy of patients' records at the M.O.S. and O.D. clinics

2. Time constraints

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PERCIEVED BENEFITS

1. The study will contribute to the body of knowledge on the patterns of recurrence of

pericoronitis.

2. The results will be used as an aid to better diagnosis and management of recurrent

pericoronitis by dentists and oral surgeons.

3. The results will be submitted in partial fulfilment of the degree of Bachelor of

Dental Surgery of the University of Nairobi.

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BUDGETARY REQUIREMENTS

ITEM QUANTITY UNIT COST TOTAL COST

(shillings) (shillings)Stationery

0 typing paper One ream 600 600

0 biro pens 10 100ten0 writing paper

three reams 300 900

diskettes five 50 250Internet access Ten hours 1 shilling per minute 600typing Forty pages 20 800Journals and four 100 400abstractsbinding Two reports 200 400GRAND TOTAL 4050

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DATA COLLECTION FORM

Fll-E AGE OF SEX NO. OF AGE AT AGE AT PRESENTING SITES OFNO. PATIENT EPISODES FIRST LAST COMPLAINT RECURRENCE

REPORTED EPISODE EPISODE ATRECURRENTEPISODES

1.2.3.4.5.6.7.8.9.10111213141516171819202122232425262728293031323334353637

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II

REFERENCES

1. Pratt C.A, Hekmatt M, Barnard lD.W. and Zaki G. A.; Indicationsfor third molar

surgery. l R. ColI. Surg. Edinburgh, 43, April 1998, 105-108

2. Meurmann lH., Rajasuo A, Murtoman H, Savolcinen S; Respiratory tract infections

and concomitant pericoronitis of the wisdom teeth. BMJ April 1995 ;310: 834-836

3. Batanieh A B, Al Q. M.; The predisposingfactors of mandibular third molars in a

Jordanian population. Quintessence Int. March 2003;34(3) 227-231

4. Ackerman G., Cohen M. A., Altini M; The paradental cyst: a clinicopathological study

of 50 cases. Oral Surgery, Oral Medicine, Oral Pathology. Sep 1987,64(3): 308-312

5. Cawson R.A, Odell E.W; Cawson's Essentials of Oral Pathology and Oral Medicine.

seventh edition,© Churchill Livingstone, 2002

6. Ngassapa D, Hassanali J, Amwayi P. and Guthua S; Essentials of Orofacial Anatomy.

© Dar es Salaam University Press, 1996

7. Howe G. L; Minor Oral Surgery, third edition, © John Wright & Sons Ltd. 1986

8. National Inst. Health; NIH Consensus development conference for removal of third

molars. J Oral Surgery1980; 38: 235-236

9. Von Wovern N. V and Nielsen H.O; Thefate of impacted third molars after the age of

20. Int. J Oral Maxillofacial Surg. 1989; 18(5): 277-280

10. Minoru Y, Kiyofumi F, Masakini I, Takafumi H; Root resorption of mandibular second

molar teeth associated with the prescence of impacted third molars. Australian Dental

Journal 1999; 44(20): 112-116

11. Editkorial; Surgical removal of third molars. BMJ 10 September 1994;309: 620-621

12. Grant D.A; Periodontics in the tradition of Orban and Gottlieb, © the c.v. Mosby

Company 1979

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