Facial cutaneous sinuses of dental origin – a diagnostic challenge

Abstract

It is common for practitioners to misdiagnose the cause of facial cutaneous sinus tracts, failing to recognise that many have an odontogenic cause. Chronic infection around the apex of a dental root can drain to the mouth or less commonly to the skin via a sinus tract. Dental symptoms are not always present and this confuses the clinical picture further. Failure to identify an odontogenic cause may result in unnecessary and ineffective treatment. Elimination of dental infection via tooth extraction or root canal treatment leads to resolution of the cutaneous sinus. We present a series of cutaneous draining sinuses of dental origin that resolved rapidly following dental treatment and hope to highlight the importance of including odontogenic infection in the differential diagnosis of such a lesion in the head and neck.

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“…A study published by Miri et al [13] which was realized in Iran in 1,527 patients with a personal history of endodontic treatment, it was found a frequency of a sinus tract of 9.9% in contrast with another study reported by Sadeghi et al [14] in 2011 in a very similar population with the same procedence and under canalicular therapy, in 728 patients it was set a prevalence of 14.7% [13,14] submitting the patient to unnecessary antibiotic treatments, biopsies, resections, and even radiotherapy, with a not so favorable outcome and a recurrence of the fistula [1][2][3]. Patients with or cutaneous fistulas it has been thought that odontocutaneous fistulas are more frequent in children and adolescents, due to the fact that the alveolar processes are not fully developed, although, it has been seen in patients older than 20 years of age [9]. The average of the patient age varies: Sadeghi et al [14] reported an age range of 10-69 years; in the Guevara et al [15] study the mean was 45 years with a higher presentation of sinus tracts in patients older than 51 years.…”

“…Vicentii, orphyromonas gingivalis Veillonella parvula, Enterococcus faecalis, Campylobacter gracellis and Neisseria mucosa invade the tooth through the enamel and dentin, infecting the pulp causing necrosis, periodontitis and formation of the periapical abscess, rich in anaerobic bacteria. Usually this process is acute and renders the patient to seek medical attention [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. With the passing of time between six months and 30 years, added to the partial and temporal recovery, symptoms may be masked meanwhile the infectious process continues and intensifies, becoming chronic.…”

“…With the passing of time between six months and 30 years, added to the partial and temporal recovery, symptoms may be masked meanwhile the infectious process continues and intensifies, becoming chronic. At this point, the purulent material finds a way out through an abnormal canal that connects the alveolar abscess with an orifice in the interior of the mouth (intraoral sinus tract), or into the skin (extraoral sinus tract) [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. Based on a recent report, extraoral fistulas are more common in women and adults and intraoral fistulas are usually found in children [16].…”

“…If on the contrary, there is perforation of the cortical on top of the muscular union in the maxillary and underneath the mandible, the tract is an extraoral odontocutanous fistula. The purulent material tries to find a way out through a place that presents less resistance, in order to relieve the pain and the edema, the purulent material does this by passing through the periodontal ligament, bone and soft tissue right into the epidermis, creating an abscess o cellulites of the skin, which leads to a hole in the skin [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. Besides cavities being the most common cause of periapical infection, there can be other causes such as trauma, root retentions, odontogenic cysts or chronic mandibular infections that lead to odontocutaneous fistulas [24].…”

“…Fortunately, life threatening complications such as osteomyelitis and sepsis are not very common [5,6]. Whenever a patient has a facial o cervical fistula, it is mandatory a complete oral exploration looking for an odontogenic abscess besides a fibrous tissue (fistula) on the mandibular angles, cheeks or chin that connects jugal with gingival mucosa, causing the skin retraction [7][8][9]. It is necessary to be corroborated the periapical infection with a panoramic x ray, or it may be done by drawing the sinuous tract con radiopaque material such as gutta percha, and then takes the x-ray [10][11][12].…”