DIAGNOSIS AND TREATMENT OF CUTANEOUS FACIAL SINUS TRACT OF DENTAL ORIGIN

Al Kaabi M. and Al Kubaisi S.
Dental Department, Hamad Medical Corporation, Doha, Qatar

Abstract:

Intermittently draining cutaneous sinus tracts in the area of the face and neck may be caused by chronic dental infection. Diagnosis of the causes may be challenging but is the key to successful therapy. A case of cutaneous facial sinus tract related to a mandibular molar is presented. Nonsurgical endodontic treatment was performed. Healing was rapid and uneventful.

Introduction:

Although the most common cause of the intermittently suppurating cutaneous sinus tract in the face and neck area is chronic dental infection, chronic draining sinus tracts of the face and neck continue to be a diagnostic challenge(1).

A review of the literature reveals that these patients sometimes undergo multiple surgical excisions and biopsies before it is recognized that the origin of the sinus tract is the extension of pulpal disease into the periradicular area(2). Tidwell et al.1997 reported a case which takes over 15 years to recognize a dental origin(3).

Dentocutaneous fistula may occur at any age but Cioffi and colleagues in a review of 137 patients from the literature noted an average age of 31 years with the distribution between both sexes about equal(1).

The sites of dentocutaneous fistula are usually anatomically close to the causative tooth. The most common sites are the chin and mandible(4,5). Mandibular incisors and cuspids typically drain to the chin or submental region, and premolar and molar infections typically drain above the inferior border in the submandibular region of the anterior triangle of the neck(6). Occasionally the opening of the sinus tract may be found at a far distance from the dental infection. Endelman(7) described a patient in whom a sinus from a tooth infection opened on the chest wall and another on the upper one-third of the thigh. Green (8) reported a patient with a fistula over the lacrimal sac originating from the upper canine root. Blair(9) found that an alveolar abscess might discharge in the region of the inner canthus of the eye.

Because these lesions are often diagnosed incorrectly, they are also treated ineffectively.

This report involves a case of cutaneous facial sinus tract of dental origin, its diagnosis and treatment.

Case Report:

A 25- year old woman referred to the Oral & Maxillofacial Surgery Clinic with a lesion in the right lower side of the face (Figure 1). Head and neck examination disclosed no abnormalities except for an erythematous area, approximately 2 cm in diameter, above the inferior border of the mandible. A red cutaneous depression, approximately 1 cm in diameter, was visible in the center of this area. Moderate pressure produced discharge of pus and serous fluid.

Figure 1

Intraoral examination revealed that the mandibular first and second molars had occlusal amalgam restorations. There was no response to electric pulp testing (Figure 2) performed on the mandibular right first molar, and neither percussion of the tooth nor palpation of the area revealed any abnormality.

Figure 2

Periapical radiograph of the right second premolar, first and second molars teeth showed no abnormality except for large amalgam restorations (Figure 3a & 3b). To verify the origin of this sinus, a size 35 gutta-percha cone was inserted in the sinus tract, and a radiograph was taken (Figure 4).

Figure 3a

Figure 3b

Figure 4

The gutta-percha cone revealed the source of the drainage to be a lesion lateral to the distal root of the mandibular right first molar (Figure 5).

Figure 5

A clinical diagnosis of chronic alveolar abscess of the lower left first molar was made. Since the tooth is a restorable one, the patient was referred to receive root canal therapy.

A non-surgical endodontic treatment started, the root canal system was cleaned and shaped using crown down technique and irrigated with 0.25% sodium hypochlorite as a disinfectant. Calcium hydroxide was used as an intra canal medicament. Two weeks after the initial presentation, the root canals were obturated with gotta percha using lateral condensation technique (Figure 6). After 1 month periapical radiograph showed that healing of the lesion had commenced (Figure 7). A small pink scar, slightly depressed, was barely noticeable (Figure 8), and the patient continues to be without symptoms.

Figure 6

Figure 7

Figure 8

Discussion:

The spread of odontogenic infections is well described in the literature.

Recognition of a sinus tract origin is the first step in diagnosis. Intraoral periapical radiographs should be taken routinely when such lesions are present, preferably with a gotta-percha cone threaded into the sinus tract. Because of gotta-percha’s radiopacity, the source of the infection will be revealed. Any chronic suppurative lesion on the middle or lower portion of the face should be investigated for possible dental cause. If the primary infection site is the pulp of a tooth, the logical diagnosis would be a chronic alveolar abscess, which is defined as a long-standing low grade infection of the periradicular alveolar bone(10).

A periapical dental abscess may be initiated by caries, periodontal disease, trauma, or thermal or chemical injury. Most dental infections develop acute symptoms and the patient seeks early treatment. In chronic situations, however, the local inflammatory process slowly progresses and develops into an abscess occasionally with extensive necrosis of the surrounding tissue. The infection spreads in a relatively concentric manner and may drain through a cavity in the tooth or extend through alveolar bone and eventually erupt through the nearest alveolar cortical plate to form a subperiosteal abscess. Once through the cancellous alveolar bone, the pathway of decompression progresses along the path of least resistance, limited only by muscular insertions and facial planes(11). Muscular attachments determine whether an intraoral or extraoral fistula develops(12).

In the mandible, if the osseous opening occurs above the muscle attachment, a sinus tract may open intraorally into the vestibule. If, on the other hand, the osseous opening occurs below muscle attachment, a sinus tract may open extraorally along the mandibular border or the suppurative material may empty into an anatomic space, which may produce cellulitis. In the maxilla, the reverse is true. If the osseous opening occurs below the muscle attachment, a sinus tract may open intraorally into the vestibule. If the osseous opening occurs above the muscle attachment, a sinus tract may open extraorally into the cheek or the suppurative material may empty into an anatomic space, which may produce a cellulitis.

The opening of the fistula usually presents as a granulomatous lesion, or as a papilla surrounded by granulation tissue. The wall of the persistent sinus becomes fibrous with adhesions between the abscess and the skin. The skin can appear to be fixed to the bone and is drawn inward leading to a suspicion of neoplasm.

Histologically, these lesions consist of granulation tissue or connective tissue heavily infiltrated with inflammatory cells. Polymorphonuclear leukocytes are the predominant type of cell centrally within the lesion with numerous lymphocytes and plasma cells toward the periphery(13).

Microorganisms and their products have been implicated as the major factor in the development of periradicular lesions. Most of these microorganisms tract their way to the root canal system through carious crown, root, open dentinal tubules or lateral tracts and less commonly through blood-borne infection.

These microorganisms consist of cocci, rods and scores of filamentous specious both facultative and obligate anaerobes. Those bacteria have to survive in an inhospitable environment to cause infection and have to escape the action of defense cells and the complement system of the host(14).

If the tooth is restorable and there is no serious periodontal disease, endodontic treatment (Root Canal therapy) should be the therapy of choice, or extraction and curettage will be unavoidable.

Icioff et al(1) in a study of the literature, when a correct diagnosis was made, only 10% of the teeth received root canal therapy, whereas the rest were needlessly extracted.

Calcium hydroxide paste usage was advocated for rapid and successful treatment of necrotic pulp tissue(15). Safavi & Nicolos 1994(16), studied the action of calcium hydroxide on bacterial biological properties and found that it alters its lipopolysaccharide, inactivats enzymatic activity and upses their transport mechanism.

Moreover it creates high pH environment and absorbs CO2 that is required for bacterial growth(17). The sinus tract usually disappears in 5-14 days after the root canal system has been thoroughly cleansed. These tracts will heal by granulation after the elimination of the infection in the root canal(18). Occasionally, healing of the sinus tract leaves a puckered, hyperpigmented or pink scar. A surgical scar revision may be accomplished with excellent results.

Conclusion:

Chronic, draining dental infection is one of the most common causes of fistulae of the face and neck. An understanding of the pathogenesis of cutaneous fistulae arising from dental infections will lead to proper early diagnosis and treatment without unnecessary surgery.

References:

1. Cioffi GA, Terezhalmy GT, Parlette HL. Cutaneous draining sinus tract: an odontogenic etiology. Jam Acad Dematol 1986; 14: 94-100.

2. Lewin-Epstien J, Taicher S, Azaz B. Cutaneous sinus tracts of dental origin. Arch Dermatol 1978; 114: 1158-61.

3. Tidwell E, Jenkins JD, Ellis CD, Hutson B, Cederberg RA. Cutaneous odontogenic sinus tract to the chin: a case report. Int Endod J 1997 sep; 30 (50): 352-5.

4. Spear KL, Sheridan PJ, Perry HO. Sinus tracts to the chin and jaw of dental origin. J Am Acad Dermatol 1983; 8: 486-492.

5. Javid B, Barkhordar RA. Chronic extraoral fistulae of dental origin. Compend contin Edu Dent 1989; 10: 8-14

6. Busselberg LF, Horton CE, Carraway JH. Cysts and sinuses of the face resulting from dental abscesses. Surg Gynecol Obstet 1979; 149: 717-718.

7. Endelman J. Dental pathology. 2nd ed. St Louis, CV Mosby, P264.

8. Green J Jr. Inflammatory swellings simulating dacryocystitis. Trans Am Ophthalmol soc 1924; 22: 244-252.

9. Blair VP. Surgery of the mouth and jaws. 3rd ed. St Louis, CV Mosby, 1920, P376.

10. Marasco PV Jr, Taylor RG, Marks MW, and Argenta LC: dentocutaneous fistula. Ann Plast surg 1992; 29: 205-210.

11. McCarthy Pl. Cutaneous lesions resulting from sinuses of dental origin. J dermatol Surg Oncol 1981; 7:981-984.

12. Lewin-Epstein J, Shlomo T, Badri A. Cutaneous sinus tracts of dental origin. Arch Dermatol 1978; 114: 1158-1161.

13. Mahler D, Joachimis HZ, Sharon A. Cutaneous dental imitating skin cancer. Br J Plast Surg 1971; 24: 78-81.

14. Siqueira JF, Lopes HP.Bacteria on the apical root surface of untreated teeth with periradicular lesions: a scanning electron microscopy study. Int Endodo J 2001; 34:216-220.

15. Carliskan Mk, sen BH, Ozinel MA. Treatment of extraoral sinus tracts from traumatized teeth with apical periodontitis. Endod Dent Traumatol 1995 Jan; 11(3): 115-20.

16. Safavi KE, Niclos FC. Alteration of biological properties of bacterial lipopolysaccharide by calcium hydroxide treatment. J Endod 1994; 20: 127-9.

17. Kontakiotis EG, Wu MK, Wesselink PR. Effect of calcium hydroxide dressing on sealing of permanent root filling. Endo and Dent traumatol J 1997; 13: 281-4.

18. MaWalter GM, AlexanderJB, Rio CE, Knott JW. Cutaneous sinus tracts of dental etiology. Oral Surg Oral Med Oral Patho 1988; 66: 608-14.