Extra Oral Sinus

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Brazilian Journal of Dental Traumatology (2011) 2(2): 75-79© 2011 Sociedade Brasileira de Traumatologia DentariaISSN 2175-6155http://www.sbtd.org.br/journal

DIAGNOSIS OF CUTANEOUS SINUS TRACT IN ASSOCIATIONWITH TRAUMATIC INJURIES TO THE TEETH

Carlos Augusto de Melo Barbosa1, Fabio Tancredo2,Cassius de Freitas Fonseca2 and Marco Andre de Berredo Pinho2

Received on February 2, 2011 / Accepted on March 1, 2011

ABSTRACT

The present study reports two cases of trauma episodes of the lower anterior teeth, causing pulpal necrosis with periradicular periodontitis,resulting in the occurrence of cutaneous sinus tracts (fistula) to the chin. In both cases, previous misdiagnosis and inappropriate medical treatmentwere 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 makingthe diagnosis. The recognition of the dental origin leads to simple and effective endodontic treatment. The cutaneous sinus tract is expected todisappear within 7 to 14 days.

Keywords: dental trauma, necrotic pulp, sinus tracts, cutaneous.

Correspondence to: Carlos Augusto de Melo Barbosa

Rua Prudente de Moraes n◦ 1253, apto. 301, 22420043 Rio de Janeiro, RJ, Brazil. E-mail: [email protected] of Endodontics, School of Dentistry, University of Rio de Janeiro (UFRJ/UERJ), RJ, Brazil.2Department of Endodontics, Catholic University of Rio de Janeiro (PUC-Rio), RJ, Brazil.

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76 EXTRAORAL SINUS TRACTS & TRAUMATIC TEETH INJURIES

INTRODUCTION

Dental trauma has been receiving epidemiological expression as anemerging public health problem, as the caries prevalence is redu-ced with the preventive advances and the increase in violence rates,as well as in the popularity of radical contact sports [12]. Lin et al.[11] consider that vehicle accidents, falls, and violence are the threemajor causes of facial trauma.

Although cutaneous sinus tracts of dental origin have been welldocumented in the medical and dental literature, these lesions con-tinue to be a challenging diagnosis [15, 22]. The discharge of pu-rulent exudates usually is associated with periapical radiolucent areaand goes through tissues and structures along the path of least resis-tance [17]. The site of drainage can be located intra or extraorally,depending on certain circumstances such as: the tooth which isdiseased, and the apex position relatively to muscular attachments,bacterial virulence and lower host resistance [8]. In a cohort study of108 odontogenic sinus tracts Slutzky-Goldberg et al. [19] found just 1case with cutaneous sinus tract. In the report of Gupta & Hasselgren[7], all odontogenic sinus tracts (29 cases) had intraoral openings.

Studies revealed that the extraoral sinus tracts is most commonlyfound on the cheek, chin and angle of the mandibule, and in this waymaking the diagnosis more difficult to the clinician. These authors havereported how important is the interaction between physicians and den-tists is to avoid submitting patients to multiple biopsies, antibiotic re-gimens and unnecessary surgery, before correct diagnosis and endo-dontic therapy are in course [4, 7, 15, 22].

The cutaneous sinus tracts is a sequel to pathosis and that theclinician should be able to recognize the primary cause. Therefore,taking the patients’ history becames crucial in order to avoid misdiag-nosing a wide variety of diseases like ingrow hair, osteomyelitis, localskin infection and neoplasms [2]. The histology of these tracts is oftencharacterized as fragments of granulation tissue that are focally linedby epithelium [1]. Most infections are polymicrobial, and cultureoften yields growth of anaerobes or facultative anaerobes such asstreptococcal species. Chronic specific infections like tuberculosisand actinomycosis can also be a cause of sinus tracts in the headand neck region [6]. It has been observed that systemic antibiotictherapy will result in a temporary reduction of the drainage and appa-rent healing. Root canal therapy or surgical extraction is the treatmentof choice. Antibiotics may be used as an adjunct to treatment in thesetting of diabetes, immunosuppression, or systemic signs of infectionsuch as fever [18].

Kalaskar & Damle [10] reported a case of trauma to mandibularleft primary canine in a 4 year old girl causing crown fracture, pulpalnecrosis and the occurrence of extraoral sinus. The most interestingfinding in the report is that the mandibular permanent left lateral inci-

sor tooth bud and permanent left canine tooth bud came out throughextraoral sinus tract.

Mawardi et al. [13] reported the association of intra oral sinus tractsin patients with a history of intravenous bisphosphonate therapy.

The clinical cases reported in this paper emphasize the need ofa prompt recognition of the etiological factor for a correct treatmentplanning on facial cutaneous sinus tract.

REPORTS

Case 1

A 10 year-old- boy, with a fistula in the chin region (Fig. 1a) was re-ferred to the dental clinic of Endodontics at the School of Dentistry,University of Rio de Janeiro. Patient’s medical history has no signifi-cant findings. Dental history reported a traumatic injury on the man-dibular right central and lateral incisors, resulting from the impact of asmall steel ball during a game of marbles, approximately 6 months ago.His mother said that no clinical treatment was performed at the timebecause the boy had no complaints, but the presence of the wound onthe chin concerned her (sic).

Clinical examination revealed a fracture on the crown (Fig. 1b)that involved the pulpal camera of the mandibular right central incisor.Pulp sensitivity tests were negative to central and lateral right man-dibular incisors, but the rest of the anterior teeth responded withinnormal limits.

Radiographic examination of right anterior mandibular region re-vealed an extensive periradicular radiolucency associated with apicaland lateral areas of the mandibular right incisives and canine (Fig.1c). Despite the extensive apical and lateral areas of radicular invol-vement, mimicking the so called “endo-perio” lesion, the teeth werefirm (no signs of mobility), and did not reveal any periodontal pocketson probing.

Root canal therapy of both necrotic pulp teeth was performedand the cutaneous lesion healed without surgical or systemic treatment.

Case 2

A healthy 36-year-old man, with a chief complaint of recurrent cutane-ous fistula on the chin (Fig. 2a, b) came to the Department of Endo-dontics at The Catholic University. Past medical history revealed thatabout 8 months before, the patient had undergone a traffic accident.Two months later the fistula appeared on the chin region. At the timehe was submitted to a surgical intervention, in order to search for theorigin of the wound. The patient stated that the lesion had been afrequent discharge of purulent material, but the symptoms decreasedwhen he used antibiotics. However, the pus recurred every time the“therapy” was interrupted.

Brazilian Journal of Dental Traumatology, Vol. 2(2), 2011

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CARLOS AUGUSTO DE MELO BARBOSA, FABIO TANCREDO, CASSIUS DE FREITAS FONSECA and MARCO ANDRE DE BERREDO PINHO 77

� Figure 1 – Cutaneous odontogenic sinus tract in the chin (a), Intraoral view of the traumatized teeth. Fracture of #41 and coronal integrityof #42 (b), periapical diffuse radiolucency associated with teeth #41, #42 and #43.

� Figure 2 – Cutaneous odontogenic sinus tract in the chin (a), Close up of fistula (b), periapical radiograph of the suspected tooth (c).

� Figure 3 – Transoperatory radiograph of the endodontic treatment (a). clinical aspect after eight days with calcium hidroxide therapy (b).

Clinical examination revealed that all mandibular anterior teethhave normal appearance concerning integrity of its crowns. Howeverthe mandibular right central incisive has slight alteration in its colourand negative response to pulp sensitivity tests. The rest of all ante-rior teeth responded within normal limits. Radiographic examination ofthe right anterior mandibular region revealed a periapical radiolucencyassociated with right central incisive (Fig. 2c).

The root canal therapy was initiated without any systemic medicineand after 1 week, drainage had ceased (Fig. 3a, b). A 1 year followup showed the healing of the cutaneous lesion and resolution of theperiapical radiolucency (Fig. 4).

DISCUSSION

Cutaneous sinus tract and fistulization of the facial skin have a widerange of etiologies, the most common being odontogenic in origin.Such patients usually seek help from surgeons or dermatologists ratherthan dentists and often undergo multiple inappropriate treatment. Indiagnosis of cutaneous dental fistula, although the examiner usuallylooks for dental caries or periodontal diseases, he should bear inmind the possibility of dental traumatic injuries [3, 5, 7, 15]. In se-veral cases of teeth traumatism the pulp can be affected, even if thecrown-root integrity is not damaged. Odontogenic sinus tracts appearas a papule or nodule with purulent discharge usually in the chin or


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78 EXTRAORAL SINUS TRACTS & TRAUMATIC TEETH INJURIES

jaw [20]. Distant location of the sinus tract regarding its site of ori-gin and the scant of symptomatology may explain why this condition isfrequently overlooked [18]. Systemic antibiotic administration is notrecommended in patients with a cutaneous odontogenic sinus tractwho have a competent immune system. In fact, the fistula preventsswelling and pain caused by pressure build-up by providing drainageof the primary odontogenic site [15, 22]. In both cases in this studythe two mandibular central incisors presented pulpal necrosis and onlyone of the involved teeth has significant fracture of the crown.

� Figure 4 – Final radiographic of endodontic treatment (a) and radiographic completeperiapical healing 1 year after root canal filling (b).

Since Sundqvist’s reports [21], it has been demonstrated thatpulpo-periapical diseases in traumatized teeth with intact crown andnecrotic pulps occur only if the root canal becomes infected. Thesefindings corroborate those from Miller [14], Kakehashi [9] and Mol-ler [16] who stated that the contamination of the pulp canal withmicroorganisms is necessary to cause apical periodontitis, instead ofthe previous concept where mere pulp tissue degradation could be asignificant agent on the etiology of such lesions. In this report the casenumber 1 has the two mandibular central incisors with pulpal necrosisand only one of the involved teeth has fracture of the crown. In the case2 all mandibular teeth have integrity of their crowns.

Therefore, in traumatized teeth, even in absence of caries or toothfracture, the clinician must investigate the pulpal health of the teethin the contiguous area of cutaneous fistula.

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