JOURNAL OF ENDODONTICS Copyright © 2004 by The American Association of Endodontists
Printed in U.S.A. VOL. 30, NO. 7, JULY 2004
CASE REPORT/CLINICAL TECHNIQUES Management of Extra Oral Sinus Cases: A Clinical Dilemma Neelam Mittal, BDS, MDS, and Pooja Gupta, BDS
The most common cause of a cutaneous sinus tract is a chronic periradicular abscess. These abscesses arise from bacterial invasion, chemical irritation, or trauma. The most common initiating factor of the periradicular abscess is carious exposure and subsequent bacterial invasion of the tooth pulp (15). The inflammatory process begins in a necrotic pulp and spreads into the surrounding periodontal ligament and bone. The first pathological change is apical periodontitis. The inflammatory and immunological processes then induce bone resorption. The marrow spaces are involved, resulting in the formation of a localized abscess, the suppurative osteitis. The inflammation then spreads peripherally until the cortex of the bone is destroyed and a subperiosteal abscess forms (16). The periosteum is pierced. Then, depending on factors like gravity, virulence of microorganisms and, most importantly, anatomic arrangement of adjacent muscles and fasciae, either a cutaneous sinus or an intraoral sinus forms (17). The purpose of this case series is to offer some diagnostic guidelines, differential diagnoses, and treatment modalities for similar patients with the aid of a few clinical cases.
The cutaneous sinus tract of dental origin is an uncommon but well documented condition. Its diagnosis is not always easy unless the treating clinician considers the possibility of its dental origin. Such patients may undergo multiple surgical excisions, biopsies, and antibiotic regimens, but all of them fail with the recurrence of the sinus tract. This is because the primary etiology is incorrectly diagnosed. This case report describes the treatment of four patients presenting with variable complaints of pain and purulent or hemorrhagic discharge from lesions of the face. Clinical and radiographic examination revealed carious teeth with radiolucent areas indicating chronic periradicular abscess. The teeth were restorable, so nonsurgical endodontic therapy was performed in all of them. No systemic antibiotic therapy was provided. The patients responded well, and the cutaneous lesions healed uneventfully. Improper diagnosis can lead to needless loss of teeth that can be otherwise maintained through timely and proper management.
CASE REPORT 1 A 15-year-old boy came to the Department of Dentistry, Banaras Hindu University, Varanasi, India, with the chief complaint of a swelling in the chin region. The swelling had been present for a few months, with repeated episodes of bleeding from it. The medical history was noncontributory. Dental history revealed a history of trauma approximately 2 years before. Clinical examination revealed an erythematous symmetrical nodule approximately 1.5 cm in diameter on the left side of the chin (Fig. 1). The nodule was soft. Palpation elicited a bloody and purulent discharge from it. Intraorally, no vestibular swelling was present, although the labial alveolar mucosa was tender on palpation. Teeth #23, #24, and #25 were slightly tender on percussion, but the rest of the mandibular anterior teeth (#22, #26, #27) responded within normal limits. The teeth were firm (no detectable mobility) and did not reveal any periodontal defects on probing. A periapical radiograph showed a diffuse 3-cm by 3-cm radiolucency surrounding teeth #23, #24, #25, and #26 (Fig. 2). Electric pulp test and heat test (using temporary stoppings of gutta-percha) were
Cutaneous sinus tracts of dental origin have been well documented in the medical literature (1–7), dental literature (8 –14), and dermatological literature. However, these lesions continue to be a diagnostic dilemma. Such patients usually seek treatment from a physician or a surgeon instead of a dentist and often undergo multiple surgical excisions, radiotherapy, multiple biopsies, and multiple antibiotic regimens with eventual recurrence of the cutaneous sinus tract because the primary dental cause is frequently misdiagnosed. Misdiagnosis usually leads to a destructive treatment of the local skin lesions that is not curative but is often mutilating. Even skin biopsy may produce unnecessary scarring. On the other hand, the recognition of this entity leads to simple and effective treatment consisting of removal of the infected pulp canal tissue, resulting in minimal cutaneous scarring (15). 541
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Journal of Endodontics TABLE 1. Summary of the pulp tests performed
Case
Pulp tests performed
Teeth tested
1
Electric pulp test Heat test (temporary stoppings of gutta-percha)
Mandibular anteriors (#22–#27)
2
Electric pulp test Heat test
Mandibular right posterior teeth (#28–#31)
3
Electric pulp test Heat test No pulp tests were performed because nonsurgical endodontic therapy had already been started in tooth #30
Maxillary left posterior teeth (#12–#15)
4
FIG 1. Clinical examination revealed an erythematous symmetrical nodule approximately 1.5 cm in diameter on the left side of the chin.
Response #23, #24, #25: nonresponsive #22, #26, #27: responded within normal limits #30: nonresponsive #28, #29, #31: responded within normal limits #14: nonresponsive #12, #13, #15: normal response
FIG 3. Treatment consisted of a cutaneous drainage with nonsurgical endodontic treatment.
drainage with nonsurgical endodontic treatment (Fig. 3). The cutaneous lesion healed within a month of this treatment. CASE REPORT 2
FIG 2. A periapical radiograph showed a diffuse 3-cm by 3-cm radiolucency surrounding teeth #23, #24, #25, and #26.
performed on all mandibular anterior teeth. Teeth #23, #24, and #25 were nonresponsive to these stimuli, but teeth #22, #26, and #27 responded within normal limits (Table 1). Thus, a diagnosis of pulpal necrosis with chronic suppurative periradicular periodontitis was made for teeth #23, #24, and #25. Treatment consisted of a cutaneous
A 24-year-old man came to the Department of Dentistry, Banaras Hindu University, complaining of a cutaneous lesion on his right cheek that had persisted for a long time. The patient stated that the lesion had been a painful nodule with frequent discharge of purulent material a few months ago, but the symptoms had now decreased. Clinical examination revealed an 8-mm by 15-mm lesion on right side of his cheek, 1.5 cm superior to the inferior border of the mandible (Fig. 4). The opening was crusted, and there was minimal swelling of the right cheek. The intraoral examination revealed a grossly carious tooth #30 that was tender on percussion. The buccal alveolar mucosa adjacent to it was tender to palpation. The remaining mandibular right posterior teeth responded within normal limits to percussion and palpation. Pulp testing (electric pulp test and heat test using temporary stoppings of gutta-percha) elicited nonresponsiveness from the suspect tooth. No signs of mobility or periodontal pockets were present in relation to tooth #30. An intraoral periapical radiograph revealed a periradicular radiolucency around the mesial root of tooth #30 (Fig. 5). Thus, a diagnosis of pulpal necrosis with chronic suppurative periradicular periodontitis and cutaneous drainage was made in tooth #30. Nonsurgical endodontic therapy was instituted on tooth #30, with uneventful healing (Fig. 6).
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FIG 5. An intraoral periapical radiograph revealed a periradicular radiolucency around the mesial root of tooth #30. FIG 4. Clinical examination revealed an 8-mm by 15-mm lesion on right side of his cheek, 1.5 cm superior to the inferior border of the mandible.
CASE REPORT 3 A 25-year-old man sought treatment with the chief complaint of a purulent and hemorrhagic discharge from his left cheek. Clinical examination revealed the characteristic lesion containing a sinus tract opening occurring in a retracted depression on the left cheek (Fig. 7). Palpation elicited a purulent and hemorrhagic discharge from the sinus tract. The past dental history revealed that the patient had undergone multiple surgical excisions for the same lesion, but that the sinus tract always recurred. The pathologist reported that the lesion was a chronic abscess. The patient was referred to Department of Dentistry to rule out any dental cause behind the sinus tract. The intraoral examination revealed a grossly carious lesion on tooth #14. All the maxillary left posterior teeth responded within normal limits to percussion, but there was slight tenderness on palpation. No intraoral swelling or mobility of the involved tooth was evident. Periodontal probing depths were also normal in the entire mandibular left posterior region. Radiographic examination and pulp testing (electric pulp test and heat test with temporary stoppings of gutta-percha) showed tooth #14 to be nonresponsive. A diagnosis of chronic suppurative periradicular periodontitis with cutaneous drainage caused by necrotic pulp was made in tooth #14 (Fig. 8). Because the tooth was restorable, nonsurgical endodontic treatment was performed, with satisfactory healing (Fig. 9).
FIG 6. Nonsurgical endodontic therapy was instituted on tooth #30, with uneventful healing.
CASE REPORT 4 A 10-year-old girl came to the Department of Dentistry with her parents because of pain and continuous purulent discharge from a lesion on her right cheek. Her past dental history indicated that the patient had reported to the Department 10 months before when the lesion first developed. A pulpectomy was performed on tooth #30, and the patient was instructed to have the endodontic treatment, but she never followed up on this recommendation. Now the lesion had again developed over the period of the previous 2 months. Clinical examination revealed a 4-mm by 5.5-mm erythematous nodule in the right cheek, located 1.3 cm below the lower border
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FIG 7. Clinical examination revealed the characteristic lesion containing a sinus tract opening occurring in a retracted depression on the left cheek.
of the right ear and 1.2 cm above the inferior border of the mandible (Fig. 10). The nodule and its surrounding area were retracted below the surface and were tender on palpation. There was also a purulent discharge emanating from the lesion. The intraoral examination disclosed a carious lesion in tooth #30 with an open access preparation filled with food debris. The tooth was tender on percussion. No intraoral vestibular swelling was present, but a stalklike communication continuous from the apical area of tooth #30 to the cutaneous lesion was palpable. No mobility or gross periodontal defects were present in relation to the suspect tooth. An intraoral periapical radiograph (Fig. 11) revealed a periradicular rarefaction surrounding both the mesial and distal roots of tooth #30. The adjacent teeth, however, revealed no apparent pathosis. Nonsurgical endodontic therapy was completed in tooth #30 (Fig. 12). DISCUSSION Nonsurgical endodontic therapy was completed in all the cases. No antibiotic therapy was instituted during the entire treatment. The results were favorable, and the extraoral sinus tracts healed without any surgical treatment. Clinically, the patients were asymptomatic, and although in some cases dimpling or retraction was evident after healing, the patients refused elective plastic surgery. In two cases, the reduction in the size of radiolucency was evident in postobturation radiographs (Fig. 2, 11), whereas others
Journal of Endodontics
FIG 8. A diagnosis of chronic suppurative periradicular periodontitis with cutaneous drainage caused by necrotic pulp was made in tooth #14.
did not show any increase in the size over the periods in which the patients returned for recall evaluation (Fig. 5, 8). When the patients were re-examined after approximately 3 weeks, they were found to be completely asymptomatic, with no recurrence of the previous swelling. However, no radiographs were taken at that time, because the period was believed to be too short for any visible radiographic changes. The teeth were then restored with metal ceramic crowns. Diagnostic Guidelines The evaluation of a cutaneous sinus tract must begin with a thorough history and awareness that any cutaneous lesion of the face and neck could be of dental origin (1, 4, 7). The patients’ history may include a complaint of dental problems. However, patients may not remember any history of an acute or painful onset. There may also be complaints of episodic bleeding or drainage from the cutaneous site with persistence of the cutaneous lesion. Occasionally, there is a history of injury to the tooth. The correct diagnosis of the cutaneous sinus of dental origin should be suspected by the gross appearance of the lesion. The cases typically present as erythematous, symmetrical, smooth, nontender nodules 1 to 20 mm in diameter, with crusting and periodic drainage in some cases. The most characteristic feature of the nodule is its depression or retraction below the normal surface (15). This cutaneous retraction or dimpling is caused by the fixation of the tract with the underlying tissues and may be secondary to the healing process or a late finding in active disease. Lesions previously biopsied or treated are usually characterized by the absence
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FIG 9. Because the tooth was restorable, nonsurgical endodontic treatment was performed, with satisfactory healing.
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FIG 11. An intraoral periapical radiograph revealed a periradicular rarefaction surrounding both the mesial and distal roots of tooth #30.
FIG 12. Nonsurgical endodontic therapy was completed in tooth #30. FIG 10. Clinical examination revealed a 4-mm by 5.5-mm erythematous nodule in the right cheek, located 1.3 cm below the lower border of the right ear and 1.2 cm above the inferior border of the mandible.
of at least part of the nodule and frequently by an orifice of draining sinus at the base of the fixed depression (15). Palpation of the involved area often reveals a cordlike tract attached to the underlying alveolar bone (maxilla or mandible) in the area of the suspected tooth (14). If the sinus tract is patent, a lacrimal probe or gutta-percha cone can be introduced into the sinus opening and passed through the sinus until it meets the area of the tooth. An intraoral periapical radiograph should then be
exposed with the probe in situ pointing to the origin of the pathosis, which is usually a nonvital tooth, but in edentulous patients could be a retained tooth fragment, an impacted tooth, or an odontogenic cyst (14). Stoll and Solomon (15) emphasized the importance of intraoral radiographs compared with the extraoral radiographs. Intraoral radiographs produce much better detail and contrast of teeth and associated structures than extraoral radiographs. They also eliminate much of the obscurity and confusion in interpretation caused by superimposition of adjacent bony anatomic structures seen in extraoral radiographs.
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Pulp tests should then be performed on the suspect tooth and the adjacent teeth, because more than one tooth may be pulpally involved and associated with the cutaneous odontogenic sinus tract (14). An important diagnostic modality is the determination of nature of fluid draining (if any) from the cutaneous sinus. During palpation, an attempt should be made to milk the sinus tract. Any discharge obtained should be scrutinized to determine its nature (saliva, pus, or cystic fluid) (7, 18). Culture and sensitivity testing of the fluid should also be performed to rule out fungal and syphilitic infection (9). Laskin (17) has elaborated on the physiologic and anatomic factors that influence the spread and ultimate localization of dental infections. Stoll and Solomon (15) also emphasized that the ultimate path of the sinus (irrespective of the source) depends on several factors, most importantly the anatomy of tooth involved, muscular attachments to the jaw, fascial planes of the neck, and involvement of permanent or deciduous teeth. Cutaneous rather than intraoral lesions are likely to occur if the apices of teeth are superior to maxillary muscle attachments or inferior to mandibular muscle attachments (4).
Differential Diagnosis The clinical differential diagnosis includes pustule (18), actinomycoses (1, 3, 4), osteomyelitis (4, 10), orocutaneous fistula (18), neoplasms, local skin infections (carbuncle and infected epidermoid cyst), pyogenic granuloma, chronic tuberculosis, and gumma of tertiary syphilis. Other causes are salivary gland fistula, thyroglossal duct cyst, branchial sinus, dacryocystitis, and suppurative lymphadenitis (1, 4). Pustule is the most common of all purulent draining lesions and is readily recognized by its superficial location and short course (18). Actinomycosis exhibits multiple draining lesions and characteristic fine yellow granules in the purulent discharge. The tooth is often not involved radiographically (18). If a sinus tract does not close after appropriate removal of the primary cause, the most common alternative cause is actinomycosis (10). Osteomyelitis of jaw is usually secondary to some type of exogenic trauma, acquired infection after extraction of diseased teeth, impacted teeth, or retained roots. It rarely gives rise to a cutaneous sinus and is mostly associated with H/o some debilitating systemic disease or fracture (15). Orocutaneous fistula is a common sequela of trauma to the head and neck region and leads to continual leakage of saliva or to lower face or neck (18). Malignancy usually presents as fixation to underlying skin with involvement of underlying osseous structures (7, 15). A salivary gland fistula has a characteristic location and associated patient history. Moreover, the defect is not through and through as in orocutaneous fistula. Probing the duct and performing sialography aid diagnosis (18). Thyroglossal duct cyst and branchial sinus are developmental lesions and therefore are observed early in life. The former, however, is found high in midline and is stressed when the tongue protrudes, whereas the latter is found in the lateral neck region (18).
Journal of Endodontics
Some difference exists in the literature regarding the removal of sinus tract itself. Winstock (19) recommends excision of the cutaneous lesion and sinus in continuity at the time of treatment of the dental pathology with immediate plastic repair of the cutaneous site. Kwapis and Baker (20) believe that because a sinus tract heals by scar formation, its effects on skin depression are most noticeable during facial movements like mastication or speaking; thus, it should be removed concomitantly at the time of treatment. But most authors believe that once the primary odontogenic cause is removed, the sinus tract and cutaneous lesion heal without treatment. Healing occurs by secondary intention in most cases. Cosmetic surgical treatment may be required at a later date if the healing results in cutaneous retraction or dimpling (1, 3, 4, 7, 12, 14). A cutaneous sinus tract is a localized entity and is not an indication for antibiotics. The antibiotic therapy is actually unsuccessful and may be misleading in that the drainage may stop temporarily (5). Systemic antibiotic administration is not recommended in patients with a cutaneous odontogenic sinus tract who have a competent immune system, no signs and symptoms of systemic involvement, and no systemic condition requiring prophylactic antibiotic cover. In fact, the sinus tract prevents swelling and pain caused by pressure build-up by providing drainage of the primary odontogenic site (12, 14). The histology of these tracts is often characterized as fragments of granulation tissue that are focally lined by stratified squamous epithelium (4). Some controversy exists about whether these tracts are lined by epithelium. Thoma (21) believes that tracts are epithelial-lined if they are of chronic duration. Seltzer (22) says that sinus tracts can be lined with either granulomatous tissue or epithelium. A cutaneous sinus may develop as early as a few weeks (3, 14) or as late as 30 years (7, 14). Approximately 80% of reported cases are associated with mandibular teeth and 20% with maxillary teeth (6). The most common areas of involvement are the chin and submental regions (4, 6). Other sites of drainage are the cheek, canine space, nasolabial fold, nose, upper lip, and inner canthus of the eye (4, 6, 7, 12). Cases of sinus tracts erupting in remote areas like the neck, chest, and thigh have also been reported. The cutaneous dental sinus is an uncommon but well documented condition. Its diagnosis is not always easy unless the treating clinician bears in mind the possibility of its dental origin. A thorough diagnosis requires cooperative referrals between physicians (especially dermatologists), surgeons, and dentists. Recognition of the true nature of the lesion facilitates prompt treatment, minimizes patient discomfort and esthetic problems, and reduces the possibility of further complications greatly. Dr. Mittal is Incharge, Department of Operative Dentistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India, World Health Organization Fellow, United States and Canada, and Common Wealth Fellow, London, United Kingdom; and Dr. Gupta is a Junior Resident, Department of Operative Dentistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. Address requests for reprints to Dr. Mittal, Incharge, Department of Operative Dentistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India. E-mail address:
[email protected].
Treatment Guidelines
References
Nonsurgical endodontic therapy is the treatment of choice if the tooth is restorable (4, 6, 14). Extraction is indicated for nonrestorable teeth (14).
1. Lewin-Epstein J, Raicher S, Aziz B. Cutaneous sinus tracts of dental origin. Arch Dermatol 1978;114:1158 – 61. 2. Kaban LB. Draining skin lesions of dental origin: the path of spread of chronic odontogenic infection. Plast Reconstr Surg 1980;66:711–7.
Vol. 30, No. 7, July 2004 3. Spear KL, Sheridan PJ, Perry HO. Sinus tracts to the chin and jaw of dental origin. J Am Acad Dermatol 1983;8:486 –92. 4. Cioffi GA, Terezhalmy GT, Parlette HL. Cutaneous draining sinus tract: an odontogenic etiology. J Am Acad Dermatol 1986;14:94 –100. 5. Held JL, Yunakov MJ, Barber RJ, Grossman ME. Cutaneous sinus of dental origin: a diagnosis requiring clinical and radiological correlation. Cutis 1989;43:22– 4. 6. Hodges TP, Cohen DA, Deck D. Odontogenic sinus tracts. Am Family Practice 1989;40:113– 6. 7. Cohen PR, Eliezri YD. Cutaneous odontogenic sinus simulating a basal cell carcinoma: case report and literature review. Plast Reconstr Surg 1990; 86:123–7. 8. Bernick SM, Jensen JR. Chronic draining extra oral fistula of 32 years duration. J Oral Maxillofac Surg 1969;27:790 – 4. 9. Sakimoto E, Stratigos GT. Bilateral cutaneous sinus tracts of dental etiology: report of a case. J Oral Surg 1973;31:70 – 4. 10. Braun RJ, Lehman JAA. Dermatologic lesion resulting from a mandibular molar with periapical pathosis. J Oral Maxillofac Surg 1981;52:210 –2. 11. Sharma JK, Chauchan VKS. Extra oral sinus and its management. Int J Oral Surg 1985;14:346 –9. 12. McWalter GM, Alexander JB, delRio CE, Knott JW. Cutaneous sinus tracts of dental etiology. Oral Surg 1988;66:608 –14.
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13. Caliskan MK, Sen BH, Ozinel MA. Treatment of extra oral sinus tracts from traumatized teeth with apical periodontitis. Endod Dent Traumatol 1995; 11:115–20. 14. Tidwell E, Jenkins JD, Ellis CD, Hutson B, Cederberg RA. Cutaneous odontogenic sinus tract to the chin: a case report. Int Endod J 1997;30:352–5. 15. Stoll HL, Solomon HA. Cutaneous sinuses of dental origin. JAMA 1963;184:120 – 4. 16. Mahler D, Joachims HZ, Sharon A. Cutaneous dental sinus imitating skin cancer. Br J Plast Surg 1971;24:78 – 81. 17. Laskin DM. Anatomic considerations in diagnosis and treatment of odontogenic infections. J Am Dent Assoc 1964;69:308 –16. 18. Wood G. Pitts, fistulas, and draining lesions (H.M. Cherrick, chapter ed.): Differential diagnosis of oral lesions. 3rd ed. St. Louis, MO: CV Mosby Co, 1985:199 –201. 19. Winstock D. Four cases of external facial sinuses of dental origin. Proc R Soc Med 1959;52:749 –51. 20. Kwapis BW, Baker WD. Cutaneous fistula of dental origin. J Oral Surg 1956;14:319. 21. Thoma KH. Oral surgery. 4th ed. St. Louis, MO: CV Mosby Co, 1963: 733. 22. Seltzer S. Endodontology: biologic considerations in endodontic procedures. 2nd ed. Lea and Febiger, 1988:200.
