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Table of Contents   
CASE REPORT  
Year : 2021  |  Volume : 24  |  Issue : 2  |  Page : 223-227
Management of cutaneous sinus tract of odontogenic origin: Eighteen months follow-up


Department of Dental Medicine, Hospital Sahloul, Sousse; Department of conservative odontology and Endodontics at Hospital Sahloul, Sousse, Tunisia, Research Laboratory Oral Healh and Rehabilitation, Faculty of Dental Medicine, LR12ES11 University of Monastir, Monastir, Tunisia

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Date of Submission28-Jan-2021
Date of Decision27-May-2021
Date of Acceptance30-May-2021
Date of Web Publication09-Oct-2021
 

   Abstract 


An odontogenic cutaneous sinus tract is a pathologic canal that initiates in the oral cavity but opens externally at the cutaneous surface of the face or neck. It is frequently misdiagnosed, leading to inappropriate treatment. A 44-year-old female patient referred to us with a chronically draining lesion on his chin. The lesion previously was misdiagnosed by medical doctors and had undergone cryotherapy and surgery with a focus on the skin lesion and had received antibiotic therapy for a prolonged period of time. After clinical and radiologic examination the dental origin of the lesion was evident and proper endodontic treatment was performed followed by surgical treatment after the recurrence of pus discharge 2 weeks after the conventionnel root canal treatment. Five months later, after the treatment, the lesion showed an obvious healing. After 18 months, the patient was comfortable and a significant healing of the sinus tract was noted, the periapical radiograph shows clear regression of the periapical lesion and an improvement in bone trabeculation. The key to successful treatment of cutaneous sinus tract of dental origin must be appropriate communication between the dentist and the physician in order to achieve correct diagnosis and therapy in such cases.

Keywords: Cutaneous sinus tract; misdiagnosis; root canal treatment; surgical treatment

How to cite this article:
Kallel I, Moussaoui E, Kharret I, Saad A, Douki N. Management of cutaneous sinus tract of odontogenic origin: Eighteen months follow-up. J Conserv Dent 2021;24:223-7

How to cite this URL:
Kallel I, Moussaoui E, Kharret I, Saad A, Douki N. Management of cutaneous sinus tract of odontogenic origin: Eighteen months follow-up. J Conserv Dent [serial online] 2021 [cited 2021 Nov 30];24:223-7. Available from: https://www.jcd.org.in/text.asp?2021/24/2/223/327845



   Introduction Top


Cutaneous sinus tracts of odontogenic origin still represent a diagnostic dilemma due to its clinical similarity to bacterial infections, furuncles, traumatic injuries, osteomyelitis, and congenital fistula.

The possibility of an odontogenic origin is most often overlooked because most patients do not experience any dental symptoms. Moreover, cutaneous lesions do not always arise in close proximity to the underlying infection.

Patients visit dermatologists or general physicians and they frequently go through several surgical excisions, antibiotic sessions, biopsies, and even radiotherapy with ultimate recurrence of the cutaneous sinus tract.

The most common reason behind a cutaneous sinus tract of dental origin is a long-standing periradicular lesion. This inflammatory disorder leads to bone resorption. Several factors such as the path of least resistance, gravity, virulence of microorganisms, host resistance, and anatomic arrangement of neighboring musculature and fasciae may also lead to cutaneous sinus tract formation.[1],[2] Nonsurgical endodontic treatment is the preferred treatment in such cases.[1],[3]

The aim of this article was to report a case with a cutaneous lesion, previously misdiagnosed as a nonhealing entity. The patient underwent treatment with cryotherapy by her dermatologist. Then, the lesion recurred after being surgically excised by a maxillofacial surgeon. It was then diagnosed in a dental office as an odontogenic sinus tract. The report highlights the management of odontogenic cutaneous sinus tracts using endodontic therapy followed by endodontic surgery. The 1-year follow-up revealed a successful outcome in the presented case.


   Case Report Top


A 44-year-old female patient consulted the department of dental medicine at Sahloul University hospital in Sousse, Tunisia. She was referred from the department of maxillofacial surgery for a cutaneous sinus tract in her chin appearing a year ago. Her chief complaint was pus discharge from an opening located on the lower chin area over 1 year. The patient underwent a cryotherapy treatment with her dermatologist. Surgical excision was performed at the maxillofacial surgery department with no remission. The patient's medical history was noncontributory. Yet, she had a history of trauma due to an accidental fall at the age of 6 years. Clinical examination revealed mild pain in the lower left central incisor. Extraoral examination revealed a cutaneous sinus tract with depression aspect, accompanied with a purulent discharge in the submental region [Figure 1]a.
Figure 1: (a) Cutaneous sinus tract with depression aspect. (b) Periapical radiograph: periapical radiolucency in relation with #31 and widening of periodontal ligament in relation with #41. (c) Axial slice of computed tomography scan: a local perforation on the buccal alveolar table

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Palpation showed the presence of a cord-like tissue.

Intraorally, the two mandibular central incisors (#31 and #41) had moderate calculus deposition and dyschromia. No deep pockets were present. The teeth were nontender on percussion. Pulp testing showed no response on both teeth. Necrosis of teeth 31 and 41 could be explained by the notion of untreated old trauma at a young age.

Standard gutta-percha cone size 30 was used to trace the sinus tract from the cutaneous opening. Radiographically, the lesion was confirmed to have a dental origin. The tract led to the root canal apex of tooth #31.

Intraoral periapical radiograph revealed a well-circumscribed periapical radiolucency in relation with #31 and widening of periodontal ligament in relation with #41 [Figure 1]b. Computed tomography (CT) scan was conducted and the axial slice confirmed the periapical lesion associated with tooth 31. It also revealed a local perforation on the buccal alveolar table in front of the corresponding tooth [Figure 1]c.

Diagnosis of pulpal necrosis with chronic periradicular periodontitis and extraoral cutaneous sinus tract related to 31 was made. Endodontic treatment to both teeth #31 and #41 was planned.

During the first visit, following the application of a rubber dam, access openings were prepared under the dental operating microscope with an endo access bur (DentsplyMaillefer, USA) in the two mandibular central incisors. Later, patency was confirmed only in tooth #31 using a no. 10 K-file. The working length was then determined and recorded using an apex locator iPex (NSK, Tochigi, Japon). The root canal was prepared using rotary files, Protaper universal system (DentsplyMaillefer, USA), as well as a root canal conditioner Glyde (DentsplyMaillefer, USA) following the crown-down technique. The root canal was abundantly irrigated with 5.2% sodium hypochlorite and 17% EDTA solution with a manual agitation during the entire procedure. Then, a final rinse was performed with 2% Chlorhexidine solution. The canal was dried and Ca(OH)2 (Multi-Cal, Pulpdent Corporation, USA) was applied. Finally, the access cavity was sealed with Cavit-G (3M ESPE, USA).

For tooth#41, it was not possible to ensure patency due to the presence of calcification in the cervical third part of the root canal. A fragilization in the cervical part of the access cavity was identified during the attempt to find the orifice canal and therefore sealing the coronal cavity with Biodentine was decided.

At the 2-week follow-up, the teeth were clinically asymptomatic and no discharge from the sinus tract was noted. The root canal of tooth #31 was cleaned again with normal saline and it was rinsed with 2% chlorhexidine. Root canal obturation was performed using a master gutta-percha cone and a bioceramic endodontic sealer (BioRoot™ RCS).

At the 4-week follow-up visit, the teeth were clinically asymptomatic but the cutaneous sinus tract was productive again.

An endodontic surgery along with fistulectomy was decided to assure the curettage of the periapical lesion and the excision of the cutaneous sinus tract.

Full-thickness flap was reflected it revealed two fenestrations on the vestibular bone; one was located 5 mm below the corono-radicular junction related to radicular resorption, and the other was situated in the periapical lesion [Figure 2]a.
Figure 2: (a) Two fenestrations on the vestibular bone. (b) A cord-like tissue connecting the cutaneous fistula to the alveolar periosteum. (c) Root end preparation, and filling with intermediate restorative material. (d) Cutaneous suture

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The fenestrations were covered, respectively, by a granulous lesion with an individualized wall filled with pus and a cord-like tissue connecting the cutaneous fistula to the alveolar periosteum [Figure 2]b. A granulation tissue with underlying bone resorption was noted between the two lesions.

Curettage of the granulation tissue, followed by apical root resection, root-end preparation, and filling with intermediate restorative material were conducted [Figure 2]c.

Disinsertion of the 7 mm wide and 4 cm long cord-like tissue at its cortical origin was performed. It was followed by its dissection on the mucous and cutaneous side.

Sutures were placed intraorally and on the chin at the muscular and cutaneous levels [Figure 2]d.

A postoperative radiograph was carried out after the endodontic surgery [Figure 3]a.
Figure 3: (a) Postoperative radiograph after the endodontic surgery. (b) Obvious signs of initial healing of the fistulae after 1 week of the surgery. (c) Five months later: Significant healing of the sinus tract. (d) The check-up radiograph 5 months later: regression of the periapical lesion, but we noticed a cervical root fracture of the tooth 41. (e) Eighteen months later; total healing of the cutaneous sinus tract. (f) The check-up radiograph 18 months later: Clear regression of the periapical lesion and an

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The patient was recalled after 1 week for final restorations and check-up. Obvious signs of initial healing of the fistulae were observed and the prior depression aspect decreased [Figure 3]b.

A follow-up recall at 3 months was fixed but the patient missed the appointment. She consulted us after 5 months having as chief complain the mobility of tooth 41.

The clinical examination showed a significant healing of the sinus tract [Figure 3]c. The check-up radiograph revealed a regression of the periapical lesion but we noticed a cervical root fracture of the tooth 41 [Figure 3]d.

The extraction of the 41 was conducted and a replacement by a fixed prosthesis of the 41 has been planned.

The patient was recalled after 18 months, the patient was comfortable and significant healing of the sinus tract was noted [Figure 3]e, the periapical radiograph showed clear regression of the periapical lesion and an improvement in bone trabeculation [Figure 3]f.


   Discussion Top


Misdiagnosis

Cutaneous sinus tracts of dental origin have been well-documented in both medical[4],[5] and dental literature.[6] These lesions still present a diagnostic challenge because they often have a clinical appearance similar to other facial lesions, such as carcinomas, furuncles, osteomyelitis, bacterial infections, congenital fistulas, and pyogenic granulomas.[7]

Yet, a dental infection should be suspected as the primary etiology in chronic draining cutaneous sinus tracts of the face and neck. This diagnosis might easily be overlooked by physicians.[8] Patients may therefore undergo many inappropriate surgeries and courses of antibiotics before a definitive diagnosis is made and an appropriate therapy is initiated. In this context, our patient consulted her dermatologist who prescribed different antibiotics and a cryotherapy. She also underwent surgical excision in the maxillofacial department before being referred to our department.

Such diagnostic and therapeutic misadventures highlight the importance of communication between medical subspecialists and general dental practitioners in the evaluation of patients with head-and-neck lesions.

Clinicians should carefully investigate the possibility of a potential chronic odontogenic infection. Radiographic examinations, conventional or advanced imaging, should be performed to identify any radiolucency at the apex of the suspected teeth. These examinations could show the presence of infection. These investigations are notably more important if multiple teeth are suspected. The use of advanced 3D imaging is important, and patients should be evaluated using orthopantomography and cone-beam CT (CBCT). In the present case, CBCT identified the affected tooth and revealed the presence of local perforation of the vestibular table, which was not shown by the conventional 2D radiography.

Tracing with an endodontic gutta-percha point along the mucosal sinus tract during the radiographic examination can identify the affected tooth. However, this is not evident with cutaneous sinus tracts due to the distance between the orifice of the fistula and the alveolar bone as well as the presence of multiple levels: Cutaneous, muscular, and mucosal.[8]

Localization

The osteoclastic process of dental infection progresses gradually through the alveolar bone and the infection may spread into the adjacent soft tissues, eventually breaking through the skin.[9]

If the apices of the teeth are above the maxillary muscle attachments and below the mandibular muscle attachments, the spread of infection may be extraoral.[10] This was confirmed in our case.

Eighty percent of the described cases of cutaneous sinus tracts involve mandibular teeth. The remaining 20% involve maxillary teeth. The most common locations of cutaneous odontogenic sinuses are, therefore, the jaw and chin. Cutaneous sinus tracts involving maxillary anterior teeth are likely to appear on the upper lip region, the philtrum, nasolabial fold, nose, or infraorbital region. However, cutaneous sinus tracts involving maxillary posterior teeth might appear on the cheek.[11]

Treatment

Systemic antibiotic therapy results in a temporary reduction of drainage and an apparent healing. However, the tract recurs immediately once the antibiotic therapy is completed unless the initial source is not eliminated.[4]

Conventional root canal therapy and sometimes extraction in case of nonrestorable teeth are effective in achieving the healing of cutaneous sinus tracts in a few weeks.[12]

In fact, if it is properly diagnosed and treated, the tract is expected to disappear within 7–14 days.

The presence of an extended periapical lesion even with perforation of the alveolar table is not sufficient to decide to treat surgically the lesion.

A well-extended periapical lesion regression with the only root canal treatment was reported on the literature.[13],[14]

Similarly in our case after the endodontic treatment, we did not decide to do the first line surgery.

The failure to achieve healing with the use of only conventional endodontic treatment can be explained by the long age of the sinus tract and the well-epithelialized cord-like tissue, preventing a perfect disinfection and maintaining bacteria in the periapical lesion.

In case of chronic odontogenic sinus tract, conventional root canal treatment may not be sufficient for complete healing. In such cases, the cord-like tract must be eliminated. It can be either cut from its attachment to the underlying alveolar bone or removed by complete excision.[15],[16]

In our case, conventional root canal therapy was insufficient to achieve total healing of the cutaneous sinus tract because of the well-epithelialized cord-like tissue.

Radicular resorption and the associated granulous lesion could be additional etiologies.

The decision of an endodontic surgery along with fistulectomy was taken to assure the curettage of the periapical lesion, radicular resorption, and excision of the cutaneous sinus tract together with disinsertion of a cord-like tissue connecting the cutaneous fistula to the alveolar periosteum, thus allowing total healing of the cutaneous sinus tract.

Extraoral cutaneous sinus tracts are usually lined with granulomatous tissues having a lumen containing a purulent exudate. The exudate is mainly composed of PMNL.[10]

Caliskan et al. performed a microbiological culturing of cutaneous sinus tracts and found a mixed assortment of both obligate and facultative anaerobic bacteria, identified as representatives of both endodontic abscesses and skin infections.[6]

Unlike intraoral tracts, extraoral ones can heal with granulation tissues, leaving a cutaneous scar.[17] The patients may have to undergo a scar revision for esthetic reasons.


   Conclusion Top


Although odontogenic cutaneous sinus tracts frequently develop adjacent to the source of the underlying infection, the likelihood of a distant lesion must always be considered.

This case involved a cutaneous sinus draining in the chin, related to a nonvital mandibular incisor following dental trauma. The sinus was initially misdiagnosed by the physician and the maxillofacial surgeon, leading to inappropriate treatment attempts. After referral to the dental department, the underlying cause was recognized. Appropriate treatment was followed by a resolution of the lesion. This case report emphasizes the need for physicians, dermatologists, and maxillofacial surgeons, managing similar cases, to be aware of the dental origin of cutaneous sinuses in the head-and-neck region and to consider referral of their patients to a dental practitioner for further evaluation.

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.
Patni PM, Jain P, Prashanth MB, Jain N, Patni JM. Non-surgical management of an extraoral cutaneous sinus tract of odontogenic origin: An endodontic challenge. Endo (Lond Engl) 2010;4:285-91.  Back to cited text no. 1
    
2.
Mittal N, Gupta P. Management of extra oral sinus cases: A clinical dilemma. J Endod 2004;30:541-7.  Back to cited text no. 2
    
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Patni PM, Jain P, Patni MJ. Cutaneous sinus tract of dental origin. Postgrad Med J 2016;92:625.  Back to cited text no. 3
    
4.
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. 4
    
5.
Spear KL, Sheridan PJ, Perry HO. Sinus tracts to the chin and jaw of dental origin. J Am Acad Dermatol 1983;8:486-92.  Back to cited text no. 5
    
6.
Calişkan MK, Sen BH, Ozinel MA. Treatment of extraoral sinus tracts from traumatized teeth with apical periodontitis. Endod Dent Traumatol 1995;11:115-20.  Back to cited text no. 6
    
7.
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. 7
    
8.
Al-Obaida MI, Al-Madi EM. Cutaneous draining sinus tract of odontogenic origin. A case of chronic misdiagnosis. Saudi Med J 2019;40:292-7.  Back to cited text no. 8
    
9.
Giménez-García R, Martinez-Vera F, Fuentes-Vera L. Cutaneous sinus tracts of odontogenic origin: Two case reports. J Am Board Fam Med 2015;28:838-40.  Back to cited text no. 9
    
10.
Witherow H, Washan P, Blenkinsopp P. Midline odontogenic infections: A continuing diagnostic problem. Br J Plast Surg 2003;56:173-5.  Back to cited text no. 10
    
11.
Chang LS. Common pitfall of plastic surgeon for diagnosing cutaneous odontogenic sinus. Arch Craniofac Surg 2018;19:291-5.  Back to cited text no. 11
    
12.
Al-Kandari AM, Al-Quoud OA, Ben-Nadji A. Quintescence. Int 1993;10:729-33.  Back to cited text no. 12
    
13.
Soares JA, de Carvalho FB, Pappen FG, Araújo GS, de Pontes Lima RK, Rodrigues VM, et al. Conservative treatment of patients with periapical lesions associated with extraoral sinus tracts. Aust Endod J 2007;33:131-5.  Back to cited text no. 13
    
14.
Fernandes M, de Ataide I. Nonsurgical management of periapical lesions. J Conserv Dent 2010;13:240-5.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Cohenca N, Karni S, Rotstein I. Extraoral sinus tract misdiagnosed as an endodontic lesion. J Endod 2003;29:841-3.  Back to cited text no. 15
    
16.
McWalter GM, Alexander JB, del Rio CE, Knott JW. Cutaneous sinus tract of dental etiology. Oral Surg Oral Med Oral Path 1988;66:608-14.  Back to cited text no. 16
    
17.
Chkoura A, Elwady W, Taleb B. Surgical management of a cutaneous sinus tract: A case report and review of the literature. J Contemp Dent Pract 2010;11:049-55.  Back to cited text no. 17
    

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Correspondence Address:
Dr. Ines Kallel
Street Khelifa Karoui Sahloul 3, Sousse 4054
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcd.jcd_56_21

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