Management of Extra Oral Sinus Cases: A Clinical Dilemma

High-Resolution Ultrasound of Odontogenic Cutaneous Sinus Tract: An International Multicentric Experience and a Review of the Literature

OBJECTIVES

To investigate the role of high-resolution ultrasound (HR-US) in the initial and differential diagnosis of the Odontogenic Cutaneous Sinus Tract (OCST) in a multicentric setting.

METHODS

Skin HR-US examinations of OCSTs performed between January 2019 and June 2023 at different Institutions were retrospectively reviewed. Epidemiological and clinical data (age, gender, location of the skin lesion, causative tooth, and the clinical suspicion) as well as HR-US imaging findings (morphology and length of the sinus tract, Doppler signal, and cortical bone interruption of maxilla or mandible) were collected. US examinations were performed by expert radiologists using a high-performance US scanner, employing a high-frequency linear probe (15 MHz or higher frequencies). In only one patient the HR-US exam was integrated with strain elastography (SE).

RESULTS

Sixteen patients were enrolled with a median age of 37.6 years (range 16-70 years). The most frequent clinical suspicion was epidermal cyst, while OCST was suspected in only two cases. In all cases, HR-US depicted the sinus tract as a nodular, triangular or "champignon-shaped" lesion in the subcutaneous layer, which continued with a slightly tortuous band structure, up to the focally interrupted cortical bone plate. Furthermore, color Doppler evaluation showed color signals around and/or within the lesion, expression of inflammation. On SE, the sinus tract showed a hard pattern, due to fibrous and granulomatous tissue.

CONCLUSIONS

HR-US, thanks to its high spatial resolution, allows the evaluation of OCST, and play a crucial diagnostic role, mainly when the clinical suspicious is different.

Case report of an extra-oral cutaneous sinus tract of endodontic origin in a patient with autism spectrum disorder

BACKGROUND AND OVERVIEW

Extraoral cutaneous sinus tracts (EOCST) are often misdiagnosed due to their unexpected appearance without history of odontogenic pain, discomfort, or cellulitis. Diagnosis can be further confounded in those with sensory processing difficulties since patients can have a hypersensitivity to sensory input, but simultaneously demonstrate hyposensitivity and indifference toward pain. EOCST misdiagnosis and resultant mismanagement can lead to multiple surgical excisions, biopsies, and elongated antibiotic regimens, with eventual lesion recurrence.

CASE DESCRIPTION

A 19-year-old white male with autism spectrum disorder in the period of transitional dental care presented with a history of a chronic EOCST. The patient required sedation for evaluation, biopsy, and was initially managed by infectious disease under the impression of an actinomycosis infection. The patient completed a twelve-month course of antibiotic therapy with subsequent lesion re-occurrence. Eventually, the diagnosis of an EOCST of dental origin was confirmed. It was determined that pulpal necrosis was due to localized dental trauma of the lower left central incisor, as a result of a self-injurious behavior. Root canal treatment eventually led to the resolution of the lesion. It took three years from initial clinical presentation for the resolution of the lesion.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Collaboration between the medical and dental healthcare team in diagnosis and treatment planning for a patient with special needs is essential to ensure prompt and appropriate care for this patient group.

A clinical dimple on facial skin related to dental origin: A case report

INTRODUCTION AND IMPORTANCE

Facial skin may experience many clinical manifestations which are numerous and need accurate diagnosis to reach the best treatment immediately and effectively. Dimpling of the skin may be diagnosed improperly due to lack of information related to diseases of dental origin. The objective of this study is to provide clarity on dental diagnosis and treatment options for extraoral dimpling caused by odontogenic infections.

CASE PRESENTATION

A 19-year-old girl presented with a dimple on her facial skin developed during the last month before her consultation. The dimple was located where a vertical line from the distal canthus crosses a horizontal line from the nasal alar. No systemic disease was discovered, and the dental history revealed recurrent failure of root canal treatment in the upper first molar.

CLINICAL DISCUSSION

Cutaneous sinuses originating from dental issues are characterized by a connection between the skin surface and a periapical dental abscess, which is caused by a long-dated tooth infection. Due to the patient's previous dental abscess in close proximity to the skin defect, a clinical diagnosis of an odontogenic cutaneous sinus was established.

CONCLUSION

It is crucial to recognize that skin lesions in the face and neck area can be a result of odontogenic infections. Careful clinical and radiographic examinations should be conducted to accurately diagnose and differentiate these conditions. By identifying the tooth associated with the lesion, unnecessary medications and incorrect interventions can be avoided, ensuring the implementation of appropriate treatment.

Multiple oral sinus tract and trismus leading to a surprising diagnosis of osteopetrosis: Case report

AIMS

We report a rare case of late diagnosis of malignant osteopetrosis in a 36-year-old male patient due to multiple intraoral sinus tracts and trismus.

CASE REPORT

The patient reported a history of facial scars that could not be attributed to the older external fistulas that were present and various complicated dental extractions since infancy. In addition, the patient had not been previously diagnosed with any other significant diseases other than blindness since infancy. Computed tomography revealed a marble-like sclerotic pattern of all cranial bones, a thickened parietal bone, and a narrowing of the encephalic space and the optic canal. Further laboratory and imaging studies revealed complete sclerosed bone of the chest and pelvis, anemia, reticulocitosis, extramedular hematopoiesis, altered dehydrogenasis lactate, and acid phosphatasis. An interdisciplinary treatment was initiated with medical and dental care monitoring. The patient is still receiving attention after 4 years of follow-up.

CONCLUSIONS

The outcome of this case represents the daily challenges faced by interdisciplinary care providers and reveals pearls and pitfalls that can serve as a reference for professional practice in such cases.

Four atypical cases of misdiagnosed facial cutaneous sinuses of dental origin

BACKGROUND

Odontogenic cutaneous sinus tracts are frequently misdiagnosed as cutaneous non-dental related pathologies, due to their lack of a typical morphology, their extraoral location, and the frequent absence of concomitant dental symptoms. An erroneous diagnosis may lead to long-lasting, invasive, and not resolutive surgical and medical treatments.

METHODS

Four patients referred to our department lamenting the presence of a recurrent facial cutaneous sinus tract. They all had already had different wrong diagnoses and were treated with not resolutive therapies or surgeries. After a clinical and radiographical oral examination, the cutaneous fistulas were found to have a dental etiology, and the extraction of the compromised tooth was performed.

RESULTS

One week after the tooth extraction, all the patients presented good healing of the intraoral mucosa. At the long-term follow-up in all four cases, the definitive closure of the extraoral sinus tract and a reduction of the scar was found.

CONCLUSIONS

If a facial sinus tract is present, the odontogenic etiology should always be considered, since it can easily bring to the correct diagnosis, leading to a rapid resolution of the fistula. Once the dental origin has been confirmed, the suggested treatment for a conclusive resolution of the cutaneous sinus tract is the endodontic treatment or the extraction of the affected tooth.

Nonsurgical management of cutaneous sinus tract of odontogenic origin: A report of two cases

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.

Odontogenic Cutaneous Fistula: A Case in Aged Patient With Delayed Diagnosis

ABSTRACT

Odontogenic cutaneous fistula is a pathologic communication between the cutaneous surface of the face and the oral cavity and it is a rare entity frequently misdiagnosed.Therefore, the lesion may persist for a long period before the correct diagnosis is made and odontogenic source is treated appropriately. Delay in diagnosis adds to the chronicity of the lesion and if not diagnosed in times fistula can even leave deforming scars.Considering the scarceness and diagnostic predicament of odontogenic cutaneous fistulas, the authors report a significant case of 80 years old female.

Surgical management of an odontogenic cutaneous fistula

A patient presented to our unit with a long history of a discharging skin infection on his left cheek, which came and went. He had been seen by numerous healthcare practitioners including his general practitioner, general dental practitioner and dermatologist, with no resolution. He was eventually diagnosed with an odontogenic cutaneous fistula (OCF), for which he underwent surgical management. The purpose of the study is to describe the diagnosis and surgical management of an OCF, from initial assessment through to postoperative review and discharge. Following surgical management of the OCF and treatment of the source of infection by dental extraction, the patient is no longer experiencing purulent discharge through his left cheek. The extraoral skin site of drainage at his left cheek has resolved completely, with minimal residual scarring. OCF can be managed by a number of different treatment modalities. The treatment of an OCF by surgical excision is presented.

Management of cutaneous sinus tract of odontogenic origin: Eighteen months follow-up

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.

An accurate diagnosis of odontogenic cutaneous sinus tract by different computed tomography unit setting

Due to their rarity and the lack of associated dental symptoms, odontogenic cutaneous sinus tracts (OCSTs) are often misdiagnosed and confused with cutaneous lesions or non-odontogenic infections. It has been estimated that 50% of individuals affected by OCSTs are subjected to inappropriate treatments before the correct diagnosis is established. We describe the diagnosis and treatment of two cases of OCSTs. By using a computed tomography (CT) with soft tissue window setting, the extent of cortical bone destruction and the path of the sinus tract in the soft tissue was easily identified. Thus, we recommend the use of imaging techniques such as CT, which can confirm the odontogenic origin and the exact location of the OCST.

Antibiotic Prescribing Practices in Endodontic Infections: A Survey of Dentists in Serbia

The study goal was to provide an overview of antibiotic prescribing practices of Serbian dentists when treating endodontic infections and to disseminate the current ESE (European Society of Endodontology) recommendations to the study participants. A link to an online questionnaire was sent to 628 Serbian dentists whose email addresses were publicly available on the Internet, 158 of whom responded to the survey, resulting in a 25.16% response rate. The significance of possible associations was assessed via the Chi-squared test and Cramer’s V measure of association, with p < 0.05 considered as statistically significant. According to the study findings, 55.7% of respondents prescribed a 5-day antibiotic course. Moreover, Amoxicillin 500 mg was the first-choice antibiotic for 55.1% of the respondents, followed by Clindamycin 600 mg (18.4%). For patients allergic to penicillin, 61.4% of respondents prescribed Clindamycin. Statistically significant differences emerged only in relation to acute apical abscess with systemic involvement, whereby dentists aged 46–55 were least likely to prescribe antibiotics in these clinical situations (p = 0.04). Analyses further revealed that recommendations for safe antibiotic prescribing practices were not always followed, as in certain cases, patients were given antibiotics even when this was not indicated. These findings highlight the need for additional education on responsible antibiotic use to prevent bacterial resistance.

Non-surgical management of an extraoral cutaneous sinus tract of odontogenic origin

Chronic apical periodontitis associated with dental pulp necrosis is the main cause of odontogenic extraoral cutaneous sinus openings. These tracts are often initially misdiagnosed unless the treating clinician considers a dental aetiology. This case report of a 19-year-old woman describes the diagnosis and treatment of an extraoral cutaneous sinus tract of odontogenic origin. Non-surgical conservative endodontic therapy was opted as the involved teeth were restorable. One month after the completion of obturation, there was closure of the sinus tract. One year follow-up showed complete resolution of the sinus tract with minimal scar formation.

CBCT assessment of bone thickness in maxillary and mandibular teeth: an anatomic study

OBJECTIVE

The site of the sinus tract depends on the rate of resistance against abscess exudate drainage, bone morphology, and distance from the root apex to the outer cortical bone. To assess apical bone thickness in buccal and palatal/lingual aspects of maxillary and mandibular teeth, using a high-resolution cone-beam computed tomography (CBCT) system.

METHODOLOGY

In total, 422 CBCT examinations were included in the study, resulting in a sample of 1400 teeth. The scans were acquired by PreXion 3D, with a high-resolution protocol. The bone thickness was taken as the distance between the center of the apical foramen and the buccal and lingual/palatal cortical bone. The quantitative variables were expressed as mean values±standard deviation. The independent samples were analyzed using the t-test or the Mann-Whitney test (p<0.05).

RESULTS

The lowest mean value of bone thickness was observed in the buccal cortical bone of the upper canines (1.49 mm±0.86) and in the upper central incisors (1.59 mm±0.67). In premolar teeth, the lowest values were found in the buccal cortical bone of upper first premolars (1.13 mm±0.68). In the posterior teeth, the lowest values were found in the buccal cortical bone of upper first molars (1.98 mm±1.33). In the lower second molar region, the buccal cortical bone (8.36 mm±1.84) was thicker than the lingual cortical bone (2.95 mm±1.16) (p<0.05).

CONCLUSIONS

The lowest mean values of bone thickness are in the buccal cortical bone of the maxillary teeth. In the mandible, bone thickness is thinner in the buccal bone around the anterior and premolar teeth, and in the lingual aspect of mandibular molars. All these anatomic characteristics could make the occurrence of the sinus tract more susceptible in these specific regions of the maxillary and mandibular alveolar bone.

Cardiologists' and cardiovascular surgeons' attitudes toward managing endodontic infections and oral health in patients with cardiovascular diseases

Objective: A relationship between dentists and medical doctors should be encouraged to reduce cardiovascular risk in cardiac patients with dental infection. The aim of this study was to evaluate the attitudes of cardiologists and cardiovascular surgeons (cardiac specialists) toward managing endodontic infections and oral health in patients with cardiovascular diseases (CVDs).Methods: A survey of 16 questions assessing knowledge of endodontic infection, dental examination, timing of endodontic treatment, and antibiotic prophylaxis was sent to cardiac specialists in Turkey. The participants' responses were compared by means of the chi-square test (p ≤ 0.05).Results: Responses were received from 444 (44.71%) participants. Of all participants, 91.4% agreed that endodontic infections are important diseases that should be treated. Cardiac patients were referred to a dentist by 66.6% of the cardiologists and 80.3% of the cardiovascular surgeons (p = 0.002). Almost all participants (97.3%) believed that the heart health of cardiac patients with endodontic infections could be negatively affected by this infection.Conclusion: Although there is not yet any conclusive evidence on whether the presence of an endodontic infection may have an impact on CVDs, this study showed that most cardiac specialists attached importance to endodontic infections.

Primary molar with chronic periapical abscess showing atypical presentation of simultaneous extraoral and intraoral sinus tract with multiple stomata

Chronic periapical abscess drains through a sinus tract either intraorally or extraorally. However, intraoral drainage is more common than extraoral in both dentitions. Nevertheless, the simultaneous presentation of extraoral and intraoral sinus tract is very rarely reported in primary dentition. This case report discussed the management of a girl aged 7 years with a chronic periapical abscess of tooth no. 85 with both non-healing extraoral and intraoral sinus tract having multiple stomata. Non-vital pulpectomy using calcium hydroxide paste intracanal dressing was performed initially until 2 weeks without remarkable healing; then antibiotic dressing consisting of a mixture of ciprofloxacin, metronidazole and clindamycin was placed as an intracanal medicament for 1 week, which shows uneventful healing of both intraoral and extraoral sinus tract. This case report clearly indicates about how history, correct diagnosis and appropriate treatment of endodontic infection associated with sinus tract can be conservatively healed with endodontic treatment alone.

Cone-beam Computed Tomography as a Noninvasive Assistance Tool for Oral Cutaneous Sinus Tract Diagnosis: A Case Series

An oral cutaneous sinus tract is a relatively uncommon condition that is generally associated with long-standing periapical inflammation. The traditional process of oral cutaneous sinus tract diagnosis is an invasive method based on the insertion of a lacrimal probe or wire. The present article describes the use of cone-beam computed tomographic imaging as a noninvasive assistant tool for the verification of the odontogenic origin.

A linguoverted impacted tooth with orocutaneous fistula - a rare case report

The orocutaneous fistulous tract of odontogenic origin is often a diagnostic challenge, due to its rare manifestation and absence of dental signs and symptoms. The odontogenic cutaneous fistula is often misdiagnosed as a superficial skin lesion of non-odontogenic origin delaying the treatment. The diagnosis and treatment must be precise and swift to improve the clinical outcome and minimize the complications.

This article presents a rare case of odontogenic keratocyst involving a linguoverted impacted third molar presenting as orocutaneous fistula. The patient was initially treated with empirical antibiotic therapy with no resolution of the cutaneous fistula and thickening of the skin around the sinus opening resulting in cosmetic deformity. Once the fistula was attributed to the underlying odontogenic cyst, treatment was done by cyst enucleation along with the extraction of tooth and fistula excision. The purpose of the paper is to emphasize the importance of early and accurate diagnosis and prompt management of the orocutaneous fistula due to the odontogenic origin.

An uncommon cause for a non-healing cutaneous fistula in the parotid gland area - A case report

Introduction

Orocutaneous fistulae of dental origin are uncommon but well documented in the literature. This condition is often misdiagnosed because of the multiplicity of manifestations and the atypically presentation of the condition. Dental symptoms are rare. This makes diagnosis and treatment a challenging process.

Presentation of a case

A 67-year-old patient presented in the emergency room with an abscess in the parotid area. After incision and drainage the patient developed a non-healing fistula in the region of the parotid. Multiple treatment attempts and several investigations did not solve the problem. Finally, a panoramic x-ray showed a hidden, infected and displaced tooth in the right mandibular angle. After surgical extraction of the tooth and fistula excision, healing was uneventful and there was no recurrence.

Discussion

Given the diagnostic challenge, the real origin of the condition is frequently only discovered after several unnecessary interventions that may have harmed the patient. The key to early diagnosis is dental examination and dental radiographs. The goal of treatment is the elimination of the infection by surgical extraction of the tooth or non-surgical endodontic therapy.

Conclusion

Early diagnosis and rapid treatment minimize patient discomfort and reduce the probability of further complications. The differential diagnosis of sinus tract of dental origin should be considered in any case of unclarified non-healing skin lesion in the head and neck area, especially if initial treatments have failed. An early interdisciplinary approach is essential.

Cutaneous dental sinus of submental region: an eight years follow-up

A 22-year-old female patient had a history of a 7-month recurrent pus discharge from her chin. She had been previously treated by physicians, dermatologist, and surgeons. The sinus kept re-occurring and she was referred to dental hospital for opinion.

The patient had cutaneous opening of size 5 mm × 6 mm with purulent discharge in submental region. Patient had undergone three surgical excisions and multiple antibiotic regimens. Patient had a history of trauma due to fall six years back. A 30 number standard gutta-percha was used to trace the sinus tract and dental origin was confirmed radiographically. The tract led to in-between the root canal apices of both mandibular incisors. Treatment included non-surgical endodontic treatment with both mandibular central incisors and antibiotic coverage following bacterial culture of discharge. The pus culture showed Streptococcus anginosus which was found to be sensitive to penicillin. Patient was kept on 1-week course of oral amoxicillin-clavulanate along with root canal therapy.

The cutaneous sinus healed following root canal treatment and antibiotic coverage. On an 8-year follow-up skin of sub-mental region appeared normal and peri-apical healing with both mandibular central incisors was evident radiographically. Cutaneous lesions on face may be of dental origin. A cross referral between dentists, physicians, surgeons, and dermatologists should be considered in such cases.

Esthetic Improvement of a Nasolabial Cutaneous Sinus Tract

A cutaneous sinus tract of dental origin is relatively uncommon and may easily be misdiagnosed, owing to its uncommon occurrence and absence of dental symptoms. Such a lesion continues to be a diagnostic dilemma. The case described here presented a nasolabial cutaneous sinus tract of dental origin that was treated by a surgical approach with an excellent esthetic improvement.

A Festive Case Series of Emergencies, Admissions and Friendship at a Busy Oral and Maxillofacial Unit

The festive season presents oral and maxillofacial surgery (OMFS) dental core trainees (DCTs) with the challenges of managing an eclectic mix of emergencies. We present three such patients in this case series. First, Patient A, a 39-year-old homeless male who presented with a maxillary extra-oral draining sinus. Secondly, Patient B, a 38-year-old intra-venous (IV) drug user who suffered pan-facial fractures following an alcohol-fuelled assault. Finally, Patient C, a 38-year-old male who sustained a left zygomatic complex fracture a week previously, in attendance for corrective surgery. Despite the hardship, there was still festive cheer to be had by these individuals. Clinical relevance: Primary and secondary care practitioners should be aware of the advanced clinical presentation of dental and maxillofacial emergencies that occur over holiday periods.

Antibiotic prescription for endodontic infections: a survey of Brazilian Endodontists

AIM

To investigate antibiotic prescribing habits reported by Brazilian endodontists in specific clinical situations.

METHODOLOGY

Brazilian endodontists (n = 13 853) were invited to answer an online questionnaire. The questionnaire consisted of two parts: the first part contained personal data such as age, gender, years of experience and location of endodontic practice; the second part included questions regarding their behaviour when prescribing antibiotics in dental practice. The subjects provided their registration number in the Regional Council of Dentistry (RCD) to prevent duplication of data. Data were collected and analysed by SPSS 17.0 (SPSS, Inc., Chicago, IL, USA). Chi-square and Fisher's exact tests were used to test the significance of possible associations (P < 0.05).

RESULTS

From the 13 853 questionnaires, a total of 615 were answered (4.44%). The first-choice antibiotic was amoxicillin (81.5%), followed by amoxicillin + clavulanic acid (30.7%). For acute apical abscesses with intra- and extraoral diffuse swelling, fever and trismus, 90.1% reported they would prescribe antibiotics, whilst 88.1% reported they would prescribe antibiotics even without extraoral swelling, fever and trismus, and 20.5% would prescribe antibiotics in cases of chronic apical periodontitis, and sinus tract. The first-choice antibiotics varied by age of dentist (P < 0.001) and time elapsed since their endodontic graduation (P = 0.001).

CONCLUSIONS

Many endodontists reported prescribing antibiotics in situations where they would not be indicated. Likewise, the general administration of antibiotics was longer in duration than necessary, reinforcing the need of continuous education regarding the use of antibiotics.

Non-Surgical Endodontic Therapy as Treatment of Choice for a Misdiagnosed Recurring Extraoral Sinus Tract

The purpose of this article is to present the treatment of an odontogenic cutaneous sinus tract with exuberant extraoral granulation tissue and its successful endodontic treatment and follow up with Cone-Beam Computed Tomography (CBCT). In this case, a 31-year-old woman was referred for management of a reddish nodule on her chin. Previous surgical and antibiotic intervention by the dermatologist had not resolved the problem. Profound clinical and radiological examination (including CBCT) revealed apical periodontitis of tooth 32 to be the cause of the recurring cutaneous sinus tract. Conservative non-surgical root canal treatment was performed. With the aid of a topical corticosteroid and supplemental antibiotic therapy, healing of the apical periodontitis and resolution of the granulation tissue was evident after 1 year both clinically and radiographically. This case report emphasises the need for more awareness by dermatologists and other medical practitioners for the differential diagnosis of extraoral sinus tracts. Correct diagnosis of the dental cause can prevent unnecessary and multiple antibiotic and surgical interventions. Antibiotic therapy should never be administered without addressing the underlying dental cause. Conservative non-surgical endodontic treatment is the treatment of choice for an extraoral sinus tract of endodontic origin.

Odontogenic cutaneous sinus tract presenting as a growing cheek mass in the emergency department

An odontogenic cutaneous sinus tract (OCST) is a rare extraoral sinus tract related to a chronic draining dental infection, typically apical periodontitis. OCST usually presents as an erythematous and non-tender nodule and often requires endodontic treatment for resolution of the sinus tract. If there is disruption of the mandibular cortex, it may be difficult to differentiate an OCST from a non-odontogenic malignant mass in patients without dental symptoms. This report describes a rare case of OCST presenting as a left cheek mass in a 21-year-old man which was initially diagnosed in the emergency department.

Extraoral cutaneous sinus tracts of dental origin in the paediatric patient. A report of three cases and a review of the literature

BACKGROUND

An extraoral sinus of odontogenic origin within the face and neck region is normally the consequence of long-standing chronic infection due to caries, trauma or periodontal infection. There is little reported literature on the prevalence of extraoral cutaneous sinus lesions in the paediatric dental patient as presentation is often delayed resulting in misdiagnosis and consequential mismanagement.

CASE REPORT

The cases discussed concentrate on the aetiology, history, presentation and diagnosis of extraoral sinus lesions that presented in children referred to the Child Dental Health Department at the University Dental Hospital of Manchester over a six-month period.

CONCLUSIONS

The importance of correct diagnosis and treatment management of an extra oral cutaneous sinus in the paediatric patient only occurred when the child attended a specialist led paediatric dental clinic for consultation.

Clinical Characteristics of Odontogenic Cutaneous Fistulas

Background

Odontogenic cutaneous fistula appears as dimpling or a nodule with purulent discharge, usually in the chin or jaw. Affected patients usually seek help from dermatologists or surgeons rather than from dentists. However, clinical symptoms of facial skin fistula without dental problems can lead to misdiagnosis.

Objective

The purpose of this study was to investigate the clinical characteristics of patients with odontogenic cutaneous fistulas.

Methods

This retrospective observational study was performed at Chungbuk National University Hospital by analyzing patients who visited from April 1994 to September 2014. Following clinical and radiographic examinations, the paths and origins of sinus fistulas were determined. Investigated factors were gender, age, morphology, location, originating tooth, time to evolution, recurrence, and treatment method.

Results

Thirty-three patients (22 males, 11 females; average age 49.2 years) were examined during the investigation period. Thirty-four fistulas were diagnosed as odontogenic cutaneous fistulas. The most common morphology was dimpling (n=14, 41.2%). The various locations observed were related to the originating tooth. The most common site was the mandibular body related to mandibular molars. The referral clinical diagnosis was of odontogenic origin in 6 cases (18.2%). The majority of patients had experienced recurrence after treatment in previous clinics that had failed to diagnose odontogenic cutaneous fistula. Surgical fistulectomy and/or tooth treatment were performed in all cases. All patients were followed-up for 1 year. None showed signs of recurrence.

Conclusion

Extraoral and dental examinations are required to make a diagnosis of odontogenic cutaneous fistula. Thus, cooperation between dermatologists and dentists is essential.

Pilonidal sinus of the chin: mistreated as a dental fistula

Pilonidal sinus is a chronic inflammatory condition associated with penetration of hair particles into the skin. It is rare in the chin area and, to our knowledge, there is only one such reported case. A 56-year-old man was previously admitted to a private clinic, with a hard mass on his anterior buccal sulcus. Three of the patient's teeth were extracted as the swelling was thought to be associated with a dental infection. Because the fistula did not resolve, the patient was referred to our department. Following radiological and clinical examinations, the hard mass was reached intraorally and hair shafts were seen inside it. The area was closed primarily after cleaning the inflammatory tissues and the hairs. The recovery period was uneventful. In this case report, we present a pilonidal sinus encountered in the chin area, the wrong treatment initially given to the patient and the subsequent treatment carried out by us.

Nasal Sinus Tract of Odontogenic Origin: Report of a Case

Extraoral sinus tract often poses a diagnostic challenge to the clinician owing to its rare occurrence and absence of symptoms. The accurate diagnosis and comprehensive management are inevitable as the aetiology of such lesions is often masked and requires holistic approach. The present case report encompasses the management of an extraoral discharging sinus tract at the base of the right nostril in a chronic smoker. The lesion which was earlier diagnosed to be of nonodontogenic origin persisted even after erratic treatment modalities. Our investigations showed the aetiology of sinus tract to be odontogenic. Initially, a five-step program as recommended by the Agency for Health Care Research and Quality was used for smoking cessation followed by root canal therapy (RCT) and surgical management of the sinus tract. The patient has been under stringent follow-up and no reoccurrence has been noted.

Odontogenic cutaneous sinus tract associated with a mandibular second molar having a rare distolingual root: a case report

Introduction

Odontogenic cutaneous sinus tracts are often misdiagnosed as lesions of non-odontogenic origin, leading to the treatment of patients with unnecessary and ineffective therapies. Sinus tracts of endodontic origin usually respond well to endodontic therapy. However, root canal treatment of mandibular molars with aberrant canal anatomy can be diagnostically and technically challenging. Herein we present a patient with a cutaneous odontogenic sinus tract in the right submandibular area.

Case report

A 23-year-old Chinese female patient presented with a cutaneous odontogenic sinus tract that was initially misdiagnosed as a sebaceous cyst. The patient had undergone surgical excision and traditional Chinese medical therapy before endodontic consultation. With the aid of cone beam computed tomography (CBCT), it was confirmed that the causative factor of the cutaneous odontogenic sinus tract was chronic periapical periodontitis of the right mandibular second molar, which had a rare and curved distolingual root. The resolution of the sinus tract and apical healing was accomplished following nonsurgical root canal treatment.

Conclusion

A dental aetiology must be included in the differential diagnosis of cutaneous sinus tracts in the neck and face. Elimination of odontogenic cutaneous sinus tract infection by endodontic therapy results in resolution of the sinus tract without surgical excision or systemic antibiotic therapy. This case report also indicates that CBCT imaging is useful for identifying the tooth involved, ascertaining the extent of surrounding bone destruction and accurately managing the aberrant canal morphology.

Cutaneous sinus tract in association with traumatic injury to the teeth

The present case report is of trauma episode of the lower anterior teeth, causing pulpal necrosis with periradicular periodontitis, resulting in the occurrence of cutaneous sinus tracts (fistula). Previous misdiagnosis and inappropriate medical treatment were ineffective. Only when properly referred to dentists, the differential diagnosis was made. The guideline to diagnose cutaneous sinus tracts (fistula) is based mainly on accurate pulp sensitivity tests of the involved traumatized teeth. Intraoral and dental examinations are critical in making the diagnosis. The case presented here shows that cutaneous odontogenic sinus tracts associated in traumatized teeth, even in absence of caries or tooth fracture.

How to cite this article: Mishra R, Khan TS. Cutaneous Sinus Tract in Association with Traumatic Injury to the Teeth . Int J Clin Pediatr Dent 2013;6(3):205-207.

Submental cutaneous sinus tract of mandibular second molar origin

AIM

To report a case in which a submental cutaneous sinus tract resulted from apical periodontitis associated with a mandibular second molar.

SUMMARY

A 53-year-old man presented with a chronic cutaneous sinus tract in the submental region, which had previously been misdiagnosed as a thyroglossal fistula. The origin of the sinus tract was shown by sinus tract angiography to be the left mandibular second molar (tooth 37), which had apical periodontitis. The sinus tract healed after extraction of the tooth and partial excision of the lesion from an extraoral approach. Histological examination confirmed that the tract was lined with granulation tissue and not with epithelial tissue. A submental sinus tract drainage pathway was observed. Prompt dental evaluation, especially of all mandibular teeth, should be considered when assessing cases of submental cutaneous sinus tracts.

KEY LEARNING POINTS

An odontogenic origin should be part of the differential diagnosis for orofacial skin lesions. Cutaneous sinus tracts of mandibular molar origin are complex and thus a comprehensive examination should be stressed. It is necessary to examine all mandibular teeth in cases of odontogenic submental cutaneous sinus tracts. Sinus tract angiography can be used to identify the sinus tract pathway and to confirm the associated teeth. The treatment of an odontogenic cutaneous sinus tract requires the elimination of the source of infection.

Odontogenic cutaneous draining sinus

The aim of the present article was to discuss an unusual case report of the odontogenic cutaneous sinus with emphasis on diagnosis and treatment. The causative factor in this case was diagnosed intraoperatively due to infected follicular space in absence of any sign and symptoms. Timely diagnosis of the case could have prevented significant morbidity due to mistreatment medically and surgically with eventual recurrence.

Periapical infection masquerading as a nasal pustule

Periapical infections may give rise to intraoral and extraoral complications. Extraoral manifestation of periapical infection without an accompanying dental symptom may lead to presentation first to Medical doctor. This is a case of pulpal necrosis of right maxillary central incisor (tooth #11) with a discharging sinus, in the floor of the right nostril. Failure to associate the discolored tooth #11 and a discharging sinus in the floor of the right nostril, lead to the initial presentation of the patient to the Otorhinolaryngologist. The recurrent discharge from the sinus continued despite prolonged antibiotics administration. This case report showed that extraoral sinus tract of dental origin in the nostril poses a diagnostic challenge. It is expected to raise awareness of clinicians about the unusual presentations of periapical infection. There is a need for examination of the maxillary incisors in patients presenting with nasal pustule.

Odontogenic cutaneous fistulas: clinical and epidemiologic characteristics of 75 cases

BACKGROUND

Odontogenic cutaneous fistulas arise as a sequel of bacterial invasion of the dental pulp, become necrotic, and infection spreads into the periradicular area resulting in dissection and breakthrough to form sinus tracts that drain towards the skin. The objective of this study was to investigate the clinical and epidemiologic characteristics of patients diagnosed with odontogenic cutaneous fistulas.

METHODS

A retrospective study was done between January 2001 and December 2011. Cases were included with a clinical and radiological diagnosis of odontogenic cutaneous fistulas. The variables investigated were frequency, gender, age, localization, morphology, time of evolution, and referral clinical diagnosis. Data were analyzed using descriptive statistical methods.

RESULTS

During an 11-year period, 75 cases were found. Female gender predominated with 53% of the cases, and the mean age was 45 ± 26 years. The most frequent location was the mandible angle, in 36% of the cases, and the most common morphology was a nodule, in 52%. The mean time of evolution was 8 ± 11 months. The referral clinical diagnosis was odontogenic cutaneous fistulas in 51% of the cases.

CONCLUSIONS

Our results are similar to those previously published-the diagnosis was suspected in only half of the cases. We consider it important that odontogenic cutaneous fistulas be included among the differential diagnosis of cutaneous facial lesions to avoid delaying appropriate treatment.

Non-Surgical Management of Mandibular Molar with Multiple Intra-oral Sinus Tracts: A Case Report

Multiple intra-oral sinus tracts of dental origin are an uncommon condition. Patients with this condition may undergo surgical extraction, biopsies and antibiotic regimens, but all of them fail with the recurrence of the sinus tract. A proper diagnosis and management are important, to avoid any complications. This case report has described the conventional root canal treatment of a patient who had three distant intra-oral sinuses which had occurred due to an intact tooth with pulp necrosis, who had a history of accidentally biting on a hard food object and having a periapical radiolucency which indicated a chronic periradicular abscess. At follow up examination, the tooth was found to be asymptomatic and radiographically, it showed repair of the lesion.

Dental infection simulating skin lesion

Orocutaneous fistulas or cutaneous sinus, a tract of dental origin, is an uncommon but well-documented condition that usually requires emergency treatment. Such condition may be misdiagnosed by physicians and dentists and may sometimes be confused with bone and skin tumor, osteomyelitis, congenital fistula, salivary gland fistula, pyogenic granuloma, infected cyst, deep mycotic infection, and other pathologies. A case of facial sinus tract that was initially misdiagnosed by a physician as a nonodontogenic lesion is presented. Nonsurgical endodontic therapy was the treatment of choice for this case. Facial cutaneous sinus tracts must be considered of dental origin. Early diagnosis and prompt treatment minimize patient discomfort and esthetic problems, reducing the possibility of further complications such as sepsis and osteomyelitis.

Cutaneous sinus tract of dental origin in children-a report of 28 new cases

Little is known about the characteristics of cutaneous sinus tract (CST) of dental origin in children. 28 cases of CST of dental origin in children were evaluated. Age, sex, site of skin lesion, duration until diagnosis, teeth involved, etiology, treatment, and outcome were recorded. The last dental care visit was also recorded. The mean age was 10.25 years (range 4-16). The male to female ratio was 1:1.74. The mandibular-submandibular area was the most common site of skin lesions. The mandibular first molar was the most involved tooth, followed by the mandibular incisor. Caries was the most common etiology. The mean duration of lesions until correct diagnosis was 6.5 months (range 0.3-12 mos). The treatment was root canal therapy or extraction. After appropriate dental treatment, CSTs resolve rapidly. Surgical revision of the scars were indicated in eight (29%) patients, to provide better cosmetic results. In these patients, the duration of lesions were longer. Preventive dental care, as indicated by last dental care visit, was poor. CST in children is different from that in adults in terms of sites of skin lesions, duration of lesions, and involved tooth and similar to that in adults in terms of etiology and treatment modality. Early treatment of the dental infection may cause healing of the cutaneous lesion spontaneously, without a scar.

Cutaneous sinus tracts (or emerging sinus tracts) of odontogenic origin: a report of 3 cases

Three cases are presented in which patients presented with either cutaneous swelling or cutaneous sinus tracts of odontogenic origin. A cutaneous sinus tract of odontogenic origin is a pathway through the alveolar bone that typically begins at the apex of an infected tooth or of an infected portion of the dental alveolus and empties infected material (pus) through the skin. Where as the more common finding of an oral fistula is a pathway from the apical periodontal area of a tooth to the surface of the oral mucous membrane, permitting the discharge of suppurative material. Diagnosis, etiology and treatment are discussed with reference to patient history, clinical examinations, imaging, and treatment perspectives.