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Table of Contents   
CASE REPORT  
Year : 2021  |  Volume : 24  |  Issue : 2  |  Page : 219-222
Nonsurgical management of cutaneous sinus tract of odontogenic origin: A report of two cases


Department of Conservative Dentistry and Endodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India

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Date of Submission06-Mar-2021
Date of Decision03-Jun-2021
Date of Acceptance13-Jun-2021
Date of Web Publication09-Oct-2021
 

   Abstract 

Discharging facial lesions of dental etiology are almost always difficult to diagnose. Due to the lack of dental signs in most patients, these lesions are often misunderstood and overlooked. Such patients often seek cosmetic therapy and end up undergoing unnecessary treatments, if an odontogenic source is not established. To make an accurate diagnosis, a comprehensive medical and dental history, as well as knowledge of the various presentations of facial lesions, is of pivotal importance. The cases identified here were misdiagnosed at first, and they were treated with antibiotics and surgical procedures as a result. Root canal operations were performed after referral to a dental unit, and the sinus tract eventually healed. This emphasizes the significance of taking odontogenic sources into account when treating head and neck lesions.

Keywords: Cone-beam computed tomography; cutaneous sinus; dental origin; extraoral sinus; medico-legal claims; missed canal; nonsurgical management; PR; skin lesions

How to cite this article:
Keerthana G, Duhan J, Sangwan P, Yadav R. Nonsurgical management of cutaneous sinus tract of odontogenic origin: A report of two cases. J Conserv Dent 2021;24:219-22

How to cite this URL:
Keerthana G, Duhan J, Sangwan P, Yadav R. Nonsurgical management of cutaneous sinus tract of odontogenic origin: A report of two cases. J Conserv Dent [serial online] 2021 [cited 2021 Nov 30];24:219-22. Available from: https://www.jcd.org.in/text.asp?2021/24/2/219/327846



   Introduction Top


The diagnosis of facial discharging lesions of dental origin presents a perplexing dilemma to the clinicians. The prime cause could be the chronic inflammation of periapical tissue associated with necrotic pulp, which is less common compared to intraoral sinus. These lesions are often overlooked since patients are usually free of dental symptoms. Such patients usually seek cosmetic therapy ending up in superfluous treatment such as multiple antibiotic regimes, surgical excisions, biopsies, or sometimes radiotherapy because of misdiagnosis of its primary dental origin.[1]

A sinus tract may occur due to localized infections such as traumatic or carious tooth, periodontitis, actinomycosis, or osteomyelitic lesion. Most often, microbial invasion into the pulp causes periapical inflammation of the affected tooth. This inflammatory process may spread to the skin by eroding the alveolar bone and spreading along the least resistant pathway. The site of extraoral drainage is dictated by various factors, namely the virulence of the microorganism and the anatomical arrangement of the facial muscles.[2],[3],[4]

Even though the diagnosis and management of cutaneous sinuses are well documented in case reports, patients are still exposed to inappropriate treatment. The cases reported here were initially referred to the Department of Dermatology of our institution and only after a delay, referral to the dental unit was effectively made.


   Case Report Top


Case report-1

A 34-year-old female was referred to our endodontic clinic by her dermatologist for discharging sinus below her chin. The patient complained of recurrent submental swelling, which was initially believed to be an infection caused by a sebaceous cyst. Based on the diagnosis, incision and drainage were performed followed by antibiotic course, but there was no resolution of symptoms. The patient was apparently healthy. Dental history revealed a history of trauma 12 years ago and root canal treatment is done twice approximately 2 years before. Clinical examination revealed a nonfluctuant, nontender submental enlargement of 40 mm in diameter with sinus tract. Palpation elicited a purulent discharge. Sinus was traced with gutta-percha and radiograph was taken. The intraoral periapical radiograph revealed sinus traced to apical regions of teeth 31 and 41. It also revealed diffuse periapical radiolucency with respect to previously root canal treated mandibular 31 and 41. The tooth was diagnosed as previously root canal treated with chronic periapical abscess and extraoral communication. The patient was explained about the treatment procedure and written consent was taken. Before cone-beam computed tomography (CBCT) referral, the teeth isolated with rubber dam were reaccessed and the previous filling was removed to decrease artifacts. CBCT revealed a missed canal and periapical radiolucency of 7.4 mm × 6.5 mm with respect to teeth 31 and 41 and fenestration of buccal cortical plate below the apex of 41.

Treatment and follow-up

Under isolation, root canal treatment was reinitiated. Two canals were located in 41 and single canal in 31. The working length was determined using an electronic apex locator (Root ZX mini, J. Morita Co., Kyoto, Japan), and biomechanical preparation of the canals was performed using hand files while flushing with 5.25% sodium hypochlorite and 17% ethylenediaminetetraacetic acid (Prevest Denpro Limited, Jammu, India), followed by final rinse of sodium hypochlorite. Interappointment calcium hydroxide medicament was placed. After a week, obturation was done by employing cold lateral compaction. Permanent composite restorations were used to restore the teeth (Valux Plus, 3M ESPE, St. Paul, MN, USA). The extraoral lesion and sinus resolved in 2 weeks. Complete healing of periapical tissues was evident at the 12-month follow-up period [Figure 1].
Figure 1: (a) Clinical photograph showing midline submental swelling, (b) Preoperative radiograph with sinus tracing in relation to 31, 41, (c) Coronal cone beam computed tomography view, (d and e) Axial and Sagittal cone beam computed tomography sections showing presence of two canals in 41, (f) Completion of root canal retreatment, (g) Clinical photograph showing complete resolution of cutaneous lesion (h) Follow-up at 12 months radiograph showing complete healing

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Case report 2

A 29-year-old woman consulted our clinic seeking a dental diagnosis for a chronic discharging facial lesions on the left side. The lesion was diagnosed with a furuncle initially. The patient disclosed that she had undergone antibiotic therapy for 5 days followed by incision and drainage. She also reported that the lesion had been painful initially with discharge on and off over previous weeks and the lesion did not heal despite seeking medical care. Extraoral examination revealed a 2 cm × 4.5 cm erythematous and crusted lesion immediately below the inferior margin of the mandible over the left facial region. Intraoral examination revealed a deeply carious left second premolar. Electric pulp testing and percussion testing showed a negative result. The sinus was traced with gutta-percha and radiograph was taken. Intraoral periapical radiography revealed a diffuse radiolucency involving the root of 35 and sinus tracing directed toward the periapex of 35. Informed consent was obtained from the patient after explaining the treatment procedure. After anesthetizing and isolating the tooth, access preparation was done. Cleaning and shaping of the canals were performed with the interappointment calcium hydroxide medicament. After 1 week, the tooth was re-entered and was obturated after ensuring the cessation of drainage. There was the absence of clinical signs and symptoms and sinus closure at 1-week follow-up. The periapical lesion had completely healed at 1-year follow-up [Figure 2].
Figure 2: (a) Preoperative clinical photograph showing ulcerative lesion with draining sinus in lower left border of mandible, (b) preoperative radiograph revealing periapical rarefaction of 35 with sinus tracing, (c) Completion of root canal treatment, (d) clinical photograph showing resolution of skin lesion, (e) Follow-up radiograph at 3 months, (f) Follow-up at 12 months showing complete bone healing

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   Discussion Top


Pulpal necrosis and chronic periapical periodontitis are two dental conditions that can contribute to the formation of dermal lesions in the orofacial region.[5],[6] Mandibular teeth infections account for nearly 80% of known cases, while maxillary tooth infections account for 20%.[7]

It is essential to have a complete medical and dental history, as well as knowledge of the diverse presentations of facial dermal lesions. These lesions are often, not seen adjacent to the offending tooth and unfortunately, only a few patients recall the tooth-related symptoms making the diagnosis arduous.

Clinicians should pay attention to the oral conditions of the patient such as caries, previous dental treatment, and periodontal health. Bimanual palpation of the submental and submandibular region has to be performed for soft tissue examination. Sinus tracts of dental origin can be diagnosed by using a pulp sensibility test and tracing the sinus with radiopaque material such as gutta-percha or using lacrimal probe followed by intraoral radiography.[3],[8],[9] There are many drawbacks to this diagnostic technique, including potential damage to the tissue, patient discomfort, and strain of the operator. This led to the advancement in noninvasive diagnostic tools such as CBCT with or without contrast agents. With the advent of CBCT, three-dimensional visualization of dentition as well as maxillofacial skeletal structures is possible.

The classic extraoral draining sinus with retraction or dimpling is not the usual presentation; it may be variable and at unusual sites. Facial swelling with multiple discharging sinuses has also been reported in the literature.[10] Hence, clinicians should have good knowledge about the differential diagnosis of orofacial and cervical cutaneous lesions. Such differential diagnosis includes actinomycoses,[5],[6] osteomyelitis,[6],[11] orocutaneous fistula,[12] neoplasms, carbuncle and infected epidermoid cyst, pyogenic granuloma, chronic tuberculosis, and tertiary syphilis.[5] Other reasons include salivary gland fistula, thyroglossal duct cyst, branchial sinus, and suppurative lymphadenitis.[5],[6]

The main treatment protocol aims at eliminating the focus of infection by complete debridement of the offending tooth. It is not uncommon to observe that antibiotics are being prescribed by dentists to all patients reporting with dental pain.[13] This raises the concern of antibiotic misuse in these instances. According to the European Society of Endodontology guidelines,[14] antibiotic therapy is not generally indicated unless there is a likelihood of systemic illness and the possibility of rapid dissemination.

In the case described here, the lesions were misdiagnosed as infected sebaceous cyst and furuncle. The lesion was accurately diagnosed with cutaneous sinus of endodontic origin based on a detailed clinical history and radiographic evidence. The dental etiology was confirmed when the extraoral sinus tract healed after root canal treatment. Patients with extra-oral sinuses are said to have numerous cosmetic surgeries and prolonged antimicrobial therapy before acquiring the accurate diagnosis in 50% of cases. Therefore, medical professionals must be familiar with the dental etiology of cutaneous sinuses. It is critical to develop interprofessional collaboration among dermatologists, maxillofacial surgeons, and dentists to avoid misdiagnosis and medicolegal allegations.


   Conclusion Top


The necessity of considering dental etiology in the clinical presentation of cutaneous discharging lesions in the region of the head and neck is highlighted in this case report. Early detection and prompt management of the condition may help patients prevent discomfort and negative cosmetic results. It is also important the clinicians should create awareness among the patients regarding the periodic oral check-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mittal N, Gupta P. Management of extra oral sinus cases: A clinical dilemma. J Endod 2004;30:541-7.  Back to cited text no. 1
    
2.
Kaban LB. Draining skin lesions of dental origin: The path of spread of chronic odontogenic infection. J Plast Reconstr Surg 1980;66:711-7.  Back to cited text no. 2
    
3.
Al-Kandari AM, al-Quoud OA, Ben-Naji A, Gnanasekhar JD. Cutaneous sinus tracts of dental origin to the chin and cheek: Case reports. Quintessence Int 1993;24:729-33.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Lewin-Epstein J, Taicher S, Azaz B. Cutaneous sinus tracts of dental origin. Arch Dermatol 1978;114:1158-61.  Back to cited text no. 5
    
6.
Cioffi GA, Terezhalmy GT, Parlette HL. Cutaneous draining sinus tract: An odontogenic etiology. J Am Acad Dermatol 1986;14:94-100.  Back to cited text no. 6
    
7.
Hodges TP, Cohen DA, Deck D. Odontogenic sinus tracts. Am Fam Physician 1989;40:113-6.  Back to cited text no. 7
    
8.
Cantatore JL, Klein PA, Lieblich LM. Cutaneous dental sinus tract, a common misdiagnosis: A case report and review of the literature. Cutis 2002;70:264-7.  Back to cited text no. 8
    
9.
Johnson BR, Remeikis NA, Van Cura JE. Diagnosis and treatment of cutaneous facial sinus tracts of dental origin. J Am Dent Assoc 1999;130:832-6.  Back to cited text no. 9
    
10.
Hennessy J, Kusanale A, Pratt C. A facial swelling with multiple discharging sinuses: A diagnostic conundrum. Oral Maxillofac Surg 2012;16:403-4.  Back to cited text no. 10
    
11.
Braun RJ, Lehman JA. Dermatologic lesion resulting from a mandibular molar with periapical pathosis. J Oral Maxillofac Surg 1981;52:210-2.  Back to cited text no. 11
    
12.
Woods NK, Goaz PW. Differential diagnosis of oral and maxillofacial lesions: Pits, fistulae, and draining lesions. St. Louis, MO CV: Mosby Co; 1985. p. 199-201.  Back to cited text no. 12
    
13.
Segura-Egea JJ, Velasco-Ortega E, Torres-Lagares D, Velasco-Ponferrada MC, Monsalve-Guil L, Llamas-Carreras JM. Pattern of antibiotic prescription in the management of endodontic infections amongst Spanish oral surgeons. Int Endod J 2010;43:342-50.  Back to cited text no. 13
    
14.
Segura-Egea JJ, Gould K, Şen BH, Jonasson P, Cotti E, Mazzoni A, et al. European Society of Endodontology position statement: The use of antibiotics in endodontics. Int Endod J 2018;51:20-5.  Back to cited text no. 14
    

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Correspondence Address:
Dr. Jigyasa Duhan
Department of Conservative Dentistry and Endodontics, Post Graduate Institute of Dental Science, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcd.jcd_125_21

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