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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Clinical Characteristics of Odontogenic Cutaneous Fistulas</title><author><name sortKey="Lee, Eun Young" sort="Lee, Eun Young" uniqKey="Lee E" first="Eun-Young" last="Lee">Eun-Young Lee</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kang, Ji Yeon" sort="Kang, Ji Yeon" uniqKey="Kang J" first="Ji-Yeon" last="Kang">Ji-Yeon Kang</name><affiliation><nlm:aff id="A2">Department of Oral and Maxillofacial Surgery, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kim, Kyung Won" sort="Kim, Kyung Won" uniqKey="Kim K" first="Kyung-Won" last="Kim">Kyung-Won Kim</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author><author><name sortKey="Choi, Ki Hwa" sort="Choi, Ki Hwa" uniqKey="Choi K" first="Ki Hwa" last="Choi">Ki Hwa Choi</name><affiliation><nlm:aff id="A3">Department of Dermatology, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author><author><name sortKey="Yoon, Tae Young" sort="Yoon, Tae Young" uniqKey="Yoon T" first="Tae Young" last="Yoon">Tae Young Yoon</name><affiliation><nlm:aff id="A3">Department of Dermatology, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author><author><name sortKey="Lee, Ji Yeoun" sort="Lee, Ji Yeoun" uniqKey="Lee J" first="Ji Yeoun" last="Lee">Ji Yeoun Lee</name><affiliation><nlm:aff id="A3">Department of Dermatology, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27489421</idno><idno type="pmc">4969468</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4969468</idno><idno type="RBID">PMC:4969468</idno><idno type="doi">10.5021/ad.2016.28.4.417</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000607</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000607</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Clinical Characteristics of Odontogenic Cutaneous Fistulas</title><author><name sortKey="Lee, Eun Young" sort="Lee, Eun Young" uniqKey="Lee E" first="Eun-Young" last="Lee">Eun-Young Lee</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kang, Ji Yeon" sort="Kang, Ji Yeon" uniqKey="Kang J" first="Ji-Yeon" last="Kang">Ji-Yeon Kang</name><affiliation><nlm:aff id="A2">Department of Oral and Maxillofacial Surgery, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong, Korea.</nlm:aff></affiliation></author><author><name sortKey="Kim, Kyung Won" sort="Kim, Kyung Won" uniqKey="Kim K" first="Kyung-Won" last="Kim">Kyung-Won Kim</name><affiliation><nlm:aff id="A1">Department of Oral and Maxillofacial Surgery, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author><author><name sortKey="Choi, Ki Hwa" sort="Choi, Ki Hwa" uniqKey="Choi K" first="Ki Hwa" last="Choi">Ki Hwa Choi</name><affiliation><nlm:aff id="A3">Department of Dermatology, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author><author><name sortKey="Yoon, Tae Young" sort="Yoon, Tae Young" uniqKey="Yoon T" first="Tae Young" last="Yoon">Tae Young Yoon</name><affiliation><nlm:aff id="A3">Department of Dermatology, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author><author><name sortKey="Lee, Ji Yeoun" sort="Lee, Ji Yeoun" uniqKey="Lee J" first="Ji Yeoun" last="Lee">Ji Yeoun Lee</name><affiliation><nlm:aff id="A3">Department of Dermatology, Chungbuk National University College of Medicine, Cheongju, Korea.</nlm:aff></affiliation></author></analytic><series><title level="j">Annals of Dermatology</title><idno type="ISSN">1013-9087</idno><idno type="eISSN">2005-3894</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>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.</p></sec><sec><title>Objective</title><p>The purpose of this study was to investigate the clinical characteristics of patients with odontogenic cutaneous fistulas.</p></sec><sec><title>Methods</title><p>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.</p></sec><sec><title>Results</title><p>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.</p></sec><sec><title>Conclusion</title><p>Extraoral and dental examinations are required to make a diagnosis of odontogenic cutaneous fistula. Thus, cooperation between dermatologists and dentists is essential.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Mittal, N" uniqKey="Mittal N">N Mittal</name></author><author><name sortKey="Gupta, P" uniqKey="Gupta P">P Gupta</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pasternak Junior, B" uniqKey="Pasternak Junior B">B Pasternak-Júnior</name></author><author><name sortKey="Teixeira, Cs" uniqKey="Teixeira C">CS Teixeira</name></author><author><name sortKey="Silva Sousa, Yt" uniqKey="Silva Sousa Y">YT Silva-Sousa</name></author><author><name sortKey="Sousa Neto, Md" uniqKey="Sousa Neto M">MD Sousa-Neto</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kim, Sh" uniqKey="Kim S">SH Kim</name></author><author><name sortKey="Park, Sj" uniqKey="Park S">SJ Park</name></author><author><name sortKey="Oh, Jj" uniqKey="Oh J">JJ Oh</name></author><author><name sortKey="Lee, Es" uniqKey="Lee E">ES Lee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Barbosa, Cam" uniqKey="Barbosa C">CAM Barbosa</name></author><author><name sortKey="Tancredo, F" uniqKey="Tancredo F">F Tancredo</name></author><author><name sortKey="Fonseca, Cf" uniqKey="Fonseca C">CF Fonseca</name></author><author><name sortKey="Pinho, Mab" uniqKey="Pinho M">MAB Pinho</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sadeghi, S" uniqKey="Sadeghi S">S Sadeghi</name></author><author><name sortKey="Dibaei, M" uniqKey="Dibaei M">M Dibaei</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chowdri, Na" uniqKey="Chowdri N">NA Chowdri</name></author><author><name sortKey="Sheikh, S" uniqKey="Sheikh S">S Sheikh</name></author><author><name sortKey="Gagloo, Ma" uniqKey="Gagloo M">MA Gagloo</name></author><author><name sortKey="Parray, Fq" uniqKey="Parray F">FQ Parray</name></author><author><name sortKey="Sheikh, Ma" uniqKey="Sheikh M">MA Sheikh</name></author><author><name sortKey="Khan, Fa" uniqKey="Khan F">FA Khan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Slutzky Goldberg, I" uniqKey="Slutzky Goldberg I">I Slutzky-Goldberg</name></author><author><name sortKey="Tsesis, I" uniqKey="Tsesis I">I Tsesis</name></author><author><name sortKey="Slutzky, H" uniqKey="Slutzky H">H Slutzky</name></author><author><name sortKey="Heling, I" uniqKey="Heling I">I Heling</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ghodsi, Sz" uniqKey="Ghodsi S">SZ Ghodsi</name></author><author><name sortKey="Ghiasi, M" uniqKey="Ghiasi M">M Ghiasi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Spear, Kl" uniqKey="Spear K">KL Spear</name></author><author><name sortKey="Sheridan, Pj" uniqKey="Sheridan P">PJ Sheridan</name></author><author><name sortKey="Perry, Ho" uniqKey="Perry H">HO Perry</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Samir, N" uniqKey="Samir N">N Samir</name></author><author><name sortKey="Al Mahrezi, A" uniqKey="Al Mahrezi A">A Al-Mahrezi</name></author><author><name sortKey="Al Sudairy, S" uniqKey="Al Sudairy S">S Al-Sudairy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cohen, Pr" uniqKey="Cohen P">PR Cohen</name></author><author><name sortKey="Eliezri, Yd" uniqKey="Eliezri Y">YD Eliezri</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cioffi, Ga" uniqKey="Cioffi G">GA Cioffi</name></author><author><name sortKey="Terezhalmy, Gt" uniqKey="Terezhalmy G">GT Terezhalmy</name></author><author><name sortKey="Parlette, Hl" uniqKey="Parlette H">HL Parlette</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Braun, Rj" uniqKey="Braun R">RJ Braun</name></author><author><name sortKey="Lehman, J" uniqKey="Lehman J">J Lehman</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Ann Dermatol</journal-id><journal-id journal-id-type="iso-abbrev">Ann Dermatol</journal-id><journal-id journal-id-type="publisher-id">AD</journal-id><journal-title-group><journal-title>Annals of Dermatology</journal-title></journal-title-group><issn pub-type="ppub">1013-9087</issn><issn pub-type="epub">2005-3894</issn><publisher><publisher-name>Korean Dermatological Association; The Korean Society for Investigative Dermatology</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27489421</article-id><article-id pub-id-type="pmc">4969468</article-id><article-id pub-id-type="doi">10.5021/ad.2016.28.4.417</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Clinical Characteristics of Odontogenic Cutaneous Fistulas</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Lee</surname><given-names>Eun-Young</given-names></name><xref ref-type="aff" rid="A1"></xref><xref ref-type="author-notes" rid="FN1">*</xref></contrib><contrib contrib-type="author"><name><surname>Kang</surname><given-names>Ji-Yeon</given-names></name><xref ref-type="aff" rid="A2">1</xref><xref ref-type="author-notes" rid="FN1">*</xref></contrib><contrib contrib-type="author"><name><surname>Kim</surname><given-names>Kyung-Won</given-names></name><xref ref-type="aff" rid="A1"></xref></contrib><contrib contrib-type="author"><name><surname>Choi</surname><given-names>Ki Hwa</given-names></name><xref ref-type="aff" rid="A3">2</xref></contrib><contrib contrib-type="author"><name><surname>Yoon</surname><given-names>Tae Young</given-names></name><xref ref-type="aff" rid="A3">2</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Lee</surname><given-names>Ji Yeoun</given-names></name><xref ref-type="aff" rid="A3">2</xref></contrib></contrib-group><aff id="A1">Department of Oral and Maxillofacial Surgery, Chungbuk National University College of Medicine, Cheongju, Korea.</aff><aff id="A2"><label>1</label>Department of Oral and Maxillofacial Surgery, Dongtan Sacred Heart Hospital, Hallym University, Hwaseong, Korea.</aff><aff id="A3"><label>2</label>Department of Dermatology, Chungbuk National University College of Medicine, Cheongju, Korea.</aff><author-notes><corresp>Corresponding author: Ji Yeoun Lee, Department of Dermatology, Chungbuk National University College of Medicine, 1 Chungdae-ro, Seowon-gu, Cheongju 28644, Korea. Tel: 82-43-269-6385, Fax: 82-43-266-1698, <email>jyl@chungbuk.ac.kr</email></corresp><fn id="FN1" fn-type="equal"><p><sup>*</sup>These authors contributed equally to this study.</p></fn></author-notes><pub-date pub-type="ppub"><month>8</month><year>2016</year></pub-date><pub-date pub-type="epub"><day>26</day><month>7</month><year>2016</year></pub-date><volume>28</volume><issue>4</issue><fpage>417</fpage><lpage>421</lpage><history><date date-type="received"><day>29</day><month>12</month><year>2014</year></date><date date-type="rev-recd"><day>05</day><month>8</month><year>2015</year></date><date date-type="accepted"><day>26</day><month>8</month><year>2015</year></date></history><permissions><copyright-statement>Copyright © 2016 The Korean Dermatological Association and The Korean Society for Investigative Dermatology</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/4.0"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/4.0">http://creativecommons.org/licenses/by-nc/4.0</ext-link>) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><sec><title>Background</title><p>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.</p></sec><sec><title>Objective</title><p>The purpose of this study was to investigate the clinical characteristics of patients with odontogenic cutaneous fistulas.</p></sec><sec><title>Methods</title><p>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.</p></sec><sec><title>Results</title><p>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.</p></sec><sec><title>Conclusion</title><p>Extraoral and dental examinations are required to make a diagnosis of odontogenic cutaneous fistula. Thus, cooperation between dermatologists and dentists is essential.</p></sec></abstract><kwd-group><kwd>Cutaneous</kwd><kwd>Fistula</kwd><kwd>Odontogenic</kwd><kwd>Tooth</kwd></kwd-group></article-meta></front><body><sec sec-type="intro"><title>INTRODUCTION</title><p>Odontogenic cutaneous fistula is caused by chronic dental infection. The fistula provides a path for pus drainage and infection of the facial area. In cases of dental infection, fistula openings are typically located in the intraoral gingival area, whereas extraoral openings usually arise as sequelae to bacterial invasion of dental pulp through a breach in the enamel and dentin caused by a carious lesion, trauma, or other causes<xref rid="B1" ref-type="bibr">1</xref>. If treatment is not initiated during the early inflammatory stage, the pulp becomes necrotic and infection spreads beyond the confines of the affected tooth into the periradicular area, where it causes apical lesions. Discharge of purulent exudate is usually associated with periapical radiolucent lesion, and this exudate flows through tissues and structures along paths of least resistance<xref rid="B2" ref-type="bibr">2</xref>. Although cutaneous fistulas of dental origin are rather common lesions, misdiagnosis and inappropriate treatment often occur. The reasons for misdiagnosis include varied morphologies and locations or asymptomatic chronic dental infections.</p><p>In the present study, we analyzed the clinical characteristics of odontogenic cutaneous fistulas. Our goal was to identify etiological factors important in ensuring correct treatment of facial cutaneous sinus fistulas.</p></sec><sec sec-type="materials|methods"><title>MATERIALS AND METHODS</title><p>This retrospective study was carried out at the Departments of Oral and Maxillofacial Surgery, and Dermatology of Chungbuk National University Hospital (Cheongju, Korea) by analyzing patients who visited from April 1994 to September 2014. All patients had a clinical and radiological diagnosis of odontogenic cutaneous fistula. X-ray (panoramic view) and intraoral examinations were used for dental evaluations.</p><p>Thirty-three patients were enrolled in the study. Clinical data included gender, age, morphology, location, originating tooth, time to evolution, recurrence, and treatment method. All patients were followed up for at least 1 year after surgical fistulectomy and tooth treatment.</p></sec><sec sec-type="results"><title>RESULTS</title><p>Thirty three patients were treated over a 21-year period. Thirty four fistulas were diagnosed as odontogenic cutaneous fistulas (one patient had two fistulas on both buccal cheeks) after clinical and radiologic evaluations. The patients consisted of 22 males and 11 females with an average age of 49.2 years (range 10~83 years) (<xref ref-type="table" rid="T1">Table 1</xref>). The most affected age group (13 patients, 39.4%) was ≥60 years of age.</p><p>Time to evolution was 1.5~144 weeks (mean; 26.4), and was greatest in those aged ≥60 years (<xref ref-type="table" rid="T1">Table 1</xref>).</p><p>The predominant morphology was dimpling, which occurred in 14 fistulas (41.2%). Other morphologies were nodule, abscess, and cyst (<xref ref-type="table" rid="T2">Table 2</xref>, <xref ref-type="fig" rid="F1">Fig. 1</xref>). The most frequent location was the mandibular body (11 fistulas, 32.4%). Other locations in decreasing order of occurrence were; the chin (mentum), buccal cheek, nasolabial fold (paranasal) region, submandibular region, infraorbital region, and mandibular angle (<xref ref-type="table" rid="T3">Table 3</xref>, <xref ref-type="fig" rid="F2">Fig. 2</xref>). One patient had two fistulas on both buccal cheeks, thus the total number of fistulas was 34. Cutaneous lesions were adjacent to causative teeth in 32 patients (97.0%). Only one patient had a lesion at a distant site. This case involved a 13-year-old girl, in whom the right upper canine was affected, but the fistula was located in the right infraorbital region (<xref ref-type="fig" rid="F1">Fig. 1D</xref>).</p><p>To examine the affected teeth in each patient, a panoramic view X-ray was taken (<xref ref-type="fig" rid="F3">Fig. 3</xref>). Of the 34 fistulas, 24 (70.6%) originated from a mandibular edentulous site or tooth, and the other 10 (29.4%) originated from a maxillary edentulous site or tooth (nine cases-10 fistulas). The teeth most frequently affected were molars (15 fistulas, 44.1%), followed by incisors (n=7, 20.6%), canines (cuspid; n=6, 17.6%), and premolars (n=2, 5.9%). Four fistulas (11.8%) affected edentulous sites. Relationships between locations and affected teeth are summarized in <xref ref-type="table" rid="T3">Table 3</xref>.</p><p>A clinical diagnosis of an odontogenic origin was made in six patients (18.2%). In two of these patients, fistulas were related to actinomycosis. One of the two patients developed an infection after bone grafting and miniplate fixation. In the other patient, the fistula was presumed to have been caused by osteoradionecrosis after radiation therapy for mandibular cancer.</p><p>The other 27 patients (81.8%) had been misdiagnosed in previous clinics, resulting in one or more recurrences. Initial misdiagnoses included epidermal cyst (8 cases, 24.2%), furuncle (7 cases, 21.2%), subcutaneous mycosis (5 cases, 15.2%), squamous cell carcinoma (3 cases, 9.1%), basal cell carcinoma (2 cases, 6.1%), and foreign body granuloma (2 cases, 6.1%).</p><p>Cutaneous lesions and affected teeth were treated by fistulectomy and extraction or endodontic therapy with antibiotic therapy. All 33 patients were followed up for 1 year. No recurrence was encountered (<xref ref-type="fig" rid="F4">Fig. 4</xref>).</p></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>Odontogenic cutaneous fistula is characterized by the presence of a draining sinus fistula originating from a localized area with pus and surrounded by granulation tissue in alveolar bone of the affected tooth. Its main causes are pulpal degeneration due to a carious tooth, tooth fracture, remaining tooth (root rest), and periodontal infection<xref rid="B3" ref-type="bibr">3</xref>. The majority of odontogenic sinus fistulas have an intraoral opening<xref rid="B4" ref-type="bibr">4</xref>, but in cases of chronic dental infection, the local inflammatory destructive process progresses slowly as an alveolar bone abscess. Once the inflammation passes through cortical bone and periosteum, it may spread into the surrounding soft tissue, limited by muscle attachments and facial regions (<xref ref-type="fig" rid="F4">Fig. 4</xref>)<xref rid="B3" ref-type="bibr">3</xref>.</p><p>The traditional consensus is that fistulas do not exhibit gender preference, with no significant relationship between prevalence and age<xref rid="B4" ref-type="bibr">4</xref><xref rid="B5" ref-type="bibr">5</xref><xref rid="B6" ref-type="bibr">6</xref><xref rid="B7" ref-type="bibr">7</xref>. However, in the present study, the 22 males seemed to be more affected than the 11 females. In addition, patients aged ≥60 years seemed to be most affected (<xref ref-type="table" rid="T1">Table 1</xref>). Older patients may present with no dental symptom because of the low-grade and insidious nature of the odontogenic infection. In terms of duration, time to evolution was shorter in younger patients (≤19 years of age) than in older patients (≥60). In these groups, mean time was 6.1 weeks (range 1.5~12 weeks) and 37.0 weeks (range 2~144 weeks), respectively. Symptom duration was greatest (144 weeks) in an elderly patient with a diagnosis of chronic osteomyelitis of the mandible.</p><p>Protracted evolution could also be due to a lack of diagnostic suspicion caused by the absence of significant dental symptoms in patients with a variety of clinical characteristics in skin<xref rid="B8" ref-type="bibr">8</xref>. This leads to misdiagnosis and unnecessary treatment.</p><p>The skin manifestations of odontogenic cutaneous fistulas are nonspecific and have rarely been mentioned in the literature. The orifice of a cutaneous sinus fistula can present as a dimpling, nodule, abscess, cyst, ulcer, draining lesion, or nodulocystic lesion with suppuration<xref rid="B9" ref-type="bibr">9</xref>. Samir et al.<xref rid="B10" ref-type="bibr">10</xref> described a classic lesion as an erythematous nodule of diameter up to 20 mm with or without drainage presenting skin retraction secondary to healing. In our experience, dimpling was the most frequently encountered manifestation (14 fistulas, 41.2%), though nodules, abscesses, and cysts were also observed.</p><p>The variable location of odontogenic cutaneous fistula is the main cause of diagnostic confusion, although locations are related to affected teeth. In the present study, 24 fistulas (70.6%) of mandibular origin were located in the lower third of the face and 10 fistulas (29.4%) of maxillary origin were located in the middle third. The most common location was the mandibular body. Other sites were the chin (mentum), buccal cheek, nasolabial fold (paranasal) region, submandibular region, infraorbital region, and mandibular angle. Twenty odontogenic cutaneous fistulas (58.9%) were located on the mandibular body or chin and originated from a mandibular tooth (<xref ref-type="table" rid="T3">Table 3</xref>), similar to previous reports<xref rid="B6" ref-type="bibr">6</xref><xref rid="B9" ref-type="bibr">9</xref>. Further study is required to determine whether mandibular teeth tend to drain extra-orally more often than maxillary teeth. Notably, misdiagnoses have also been reported in edentulous patients with fistulas resulting from infected implants, bones, or bone grafts<xref rid="B6" ref-type="bibr">6</xref>.</p><p>Although the most common cause of an intermittently suppurating cutaneous sinus fistula of the face and neck area is chronic dental infection, these lesions present a diagnostic challenge<xref rid="B1" ref-type="bibr">1</xref>. Importantly, previous misdiagnosis and inappropriate medical treatment result in ineffective treatment and repeated recurrence. In the present study, 27 of 33 patients were transferred from general clinicians and had experience of one or more recurrence.</p><p>The differential diagnosis reported in previous studies includes subcutaneous mycosis and neoplastic processes, such as, squamous cell carcinoma, basal cell carcinoma, and pyogenic and foreign body granolumas<xref rid="B9" ref-type="bibr">9</xref><xref rid="B11" ref-type="bibr">11</xref>. Diagnostic errors lead to multiple trials of antibiotics and unnecessary repeat surgical procedures<xref rid="B3" ref-type="bibr">3</xref>. When a lesion develops, being unaware of its dental origin, patients seek treatment from dermatologists or surgeons. Lack of dental examination possibly leads to inappropriate treatments<xref rid="B6" ref-type="bibr">6</xref>. Intraoral and dental examination and panoramic view X-ray imaging are critical for diagnosis (<xref ref-type="fig" rid="F3">Fig. 3</xref>)<xref rid="B4" ref-type="bibr">4</xref>. The guideline for achieving an accurate diagnosis is that focus should be placed on the accurate evaluation of involved teeth.</p><p>Permanent cure is obtained after proper dental treatment, such as, extraction or endodontic therapy, and appropriate treatment of the offending tooth can lead to lesion resolution<xref rid="B12" ref-type="bibr">12</xref>. Dimpling and hyperpigmentation of the skin usually diminishes slowly and sometimes, it remains in the face as a small dimple. Thus, surgical revision or fistulectomy may be needed in some cases for esthetic reasons<xref rid="B3" ref-type="bibr">3</xref><xref rid="B12" ref-type="bibr">12</xref><xref rid="B13" ref-type="bibr">13</xref>.</p><p>The variable characteristics of odontogenic cutaneous fistulas lead to diagnostic confusion. Odontogenic cutaneous fistulas should always be considered in the differential diagnosis of tumors and chronic facial lesions that recur despite treatment. Attending clinicians should carefully take patient history and examine the possibility of a potential odontogenic infection. The keys to making a correct diagnosis are chronicity (weeks, months, or even years) and the recognition that the facial lesion is related to a tooth by a sinus fistula. 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(A) Dimpling, (B) nodule, (C) abscess, (D) cyst.</title></caption><graphic xlink:href="ad-28-417-g001"></graphic></fig><fig id="F2" orientation="portrait" position="float"><label>Fig. 2</label><caption><title>Diagram showing the locations of odontogenic cutaneous fistulas. (A) Frontal view, (B) lateral view. ① Mandibular body (cheek), ② chin (mentum), ③ submandibular region, ④ mandibular angle, ⑤ buccal cheek, ⑥ nasolabial fold (paranasal), ⑦ infraorbital region.</title></caption><graphic xlink:href="ad-28-417-g002"></graphic></fig><fig id="F3" orientation="portrait" position="float"><label>Fig. 3</label><caption><title>Panoramic view. Radiolucent lesion of the periapical area of a mandibular molar (white arrow).</title></caption><graphic xlink:href="ad-28-417-g003"></graphic></fig><fig id="F4" orientation="portrait" position="float"><label>Fig. 4</label><caption><title>Odontogenic cutaneous fistula of the mandibular body region. (A) Extraoral photo; showing dimpling on the left mandibular body region. (B) The odontogenic cutaneous fistula was observed by orientating the root apex (#36; left mandibular first molar) to overlying cortical plates and muscular attachments. The fistula tract is indicated by a white arrow. (C) Resected fistula tract. (D) Postoperative photo showing diminished dimpling.</title></caption><graphic xlink:href="ad-28-417-g004"></graphic></fig><table-wrap id="T1" orientation="portrait" position="float"><label>Table 1</label><caption><title>Number of patients in the different age groups, genders, and time to evolution</title></caption><alternatives><graphic xlink:href="ad-28-417-i001"></graphic><table frame="hsides" rules="rows"><col width="16.75%" span="1"></col><col width="19.63%" span="1"></col><col width="19.63%" span="1"></col><col width="24.35%" span="1"></col><col width="19.63%" span="1"></col><thead><tr><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Age (yr)</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Male</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Female</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Time to evolution (wk)</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Total</th></tr></thead><tbody><tr><td valign="top" align="left" rowspan="1" colspan="1">≤19</td><td valign="top" align="center" rowspan="1" colspan="1">3 (9.1)</td><td valign="top" align="center" rowspan="1" colspan="1">2 (6.1)</td><td valign="top" align="center" rowspan="1" colspan="1">6.1 (1.5~12)</td><td valign="top" align="center" rowspan="1" colspan="1">5 (15.2)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">20~29</td><td valign="top" align="center" rowspan="1" colspan="1">4 (12.1)</td><td valign="top" align="center" rowspan="1" colspan="1">1 (3.0)</td><td valign="top" align="center" rowspan="1" colspan="1">22.8 (2~44)</td><td valign="top" align="center" rowspan="1" colspan="1">5 (15.2)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">30~39</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">2 (6.1)</td><td valign="top" align="center" rowspan="1" colspan="1">25.5 (3~48)</td><td valign="top" align="center" rowspan="1" colspan="1">2 (6.1)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">40~49</td><td valign="top" align="center" rowspan="1" colspan="1">4 (12.1)</td><td valign="top" align="center" rowspan="1" colspan="1">1 (3.0)</td><td valign="top" align="center" rowspan="1" colspan="1">20.8 (8~44)</td><td valign="top" align="center" rowspan="1" colspan="1">5 (15.2)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">50~59</td><td valign="top" align="center" rowspan="1" colspan="1">2 (6.1)</td><td valign="top" align="center" rowspan="1" colspan="1">1 (3.0)</td><td valign="top" align="center" rowspan="1" colspan="1">18.4 (16~48)</td><td valign="top" align="center" rowspan="1" colspan="1">3 (9.1)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">≥60</td><td valign="top" align="center" rowspan="1" colspan="1">9 (27.3)</td><td valign="top" align="center" rowspan="1" colspan="1">4 (12.1)</td><td valign="top" align="center" rowspan="1" colspan="1">37.0 (2~144)</td><td valign="top" align="center" rowspan="1" colspan="1">13 (39.4)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Total</td><td valign="top" align="center" rowspan="1" colspan="1">22 (66.7)</td><td valign="top" align="center" rowspan="1" colspan="1">11 (33.3)</td><td valign="top" align="center" rowspan="1" colspan="1">26.4 (1.5~144)</td><td valign="top" align="center" rowspan="1" colspan="1">33 (100)</td></tr></tbody></table></alternatives><table-wrap-foot><fn><p>Values are presented as number (%) or mean (range).</p></fn></table-wrap-foot></table-wrap><table-wrap id="T2" orientation="portrait" position="float"><label>Table 2</label><caption><title>Morphologies of the odontogenic cutaneous fistulas</title></caption><alternatives><graphic xlink:href="ad-28-417-i002"></graphic><table frame="hsides" rules="rows"><col width="54.05%" span="1"></col><col width="45.95%" span="1"></col><thead><tr><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Morphology</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Fistula no.</th></tr></thead><tbody><tr><td valign="top" align="left" rowspan="1" colspan="1">Dimpling</td><td valign="top" align="center" rowspan="1" colspan="1">14 (41.2)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Nodule</td><td valign="top" align="center" rowspan="1" colspan="1">11 (32.4)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Abscess</td><td valign="top" align="center" rowspan="1" colspan="1">7 (20.6)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Cyst</td><td valign="top" align="center" rowspan="1" colspan="1">2 (5.9)</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Total</td><td valign="top" align="center" rowspan="1" colspan="1">34 (100)<sup>*</sup></td></tr></tbody></table></alternatives><table-wrap-foot><fn><p>Values are presented as number (%). *Numbers of fistulas included two fistulas of one patient.</p></fn></table-wrap-foot></table-wrap><table-wrap id="T3" orientation="portrait" position="float"><label>Table 3</label><caption><title>Locations and affected teeth of the odontogenic cutaneous fistulas</title></caption><alternatives><graphic xlink:href="ad-28-417-i003"></graphic><table frame="hsides" rules="rows"><col width="22.13%" span="1"></col><col width="9.86%" span="1"></col><col width="9.86%" span="1"></col><col width="9.86%" span="1"></col><col width="13.28%" span="1"></col><col width="19.11%" span="1"></col><col width="15.9%" span="1"></col><thead><tr><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Location</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Right</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Left</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Midline</th><th valign="top" align="center" rowspan="1" colspan="1" style="background-color:rgb(192,192,192)">Total</th><th valign="top" align="center" rowspan="1" colspan="2" style="background-color:rgb(192,192,192)">Affected teeth</th></tr></thead><tbody><tr><td valign="top" align="left" rowspan="4" colspan="1">Mandibular body</td><td valign="top" align="right" rowspan="1" colspan="1">5</td><td valign="top" align="right" rowspan="1" colspan="1">6</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">11 (32.4)</td><td valign="top" align="left" rowspan="1" colspan="1">Mn</td><td valign="top" align="left" rowspan="1" colspan="1">Mn: 24 (70.6)</td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">1st, 2nd premolars</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">2</td><td valign="top" align="right" rowspan="1" colspan="1">6</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">1st, 2nd molars</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">2</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">Edentulous</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="4" colspan="1">Chin (mentum)</td><td valign="top" align="right" rowspan="1" colspan="1">3</td><td valign="top" align="right" rowspan="1" colspan="1">5</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="center" rowspan="1" colspan="1">9 (26.5)</td><td valign="top" align="left" rowspan="1" colspan="1">Mn</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">4</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">Incisors</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">3</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">Canine</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">Edentulous</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="3" colspan="1">Submandibular region</td><td valign="top" align="right" rowspan="1" colspan="1">3</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">3 (8.8)</td><td valign="top" align="left" rowspan="1" colspan="1">Mn</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">2</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">1st, 2nd molars</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">Edentulous</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Mandibular angle</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">1 (2.9)</td><td valign="top" align="left" rowspan="1" colspan="1">Mn: 3rd molar</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="3" colspan="1">Buccal cheek</td><td valign="top" align="right" rowspan="1" colspan="1">4</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">5 (14.7)</td><td valign="top" align="left" rowspan="1" colspan="1">Mx</td><td valign="top" align="left" rowspan="1" colspan="1">Mx: 10 (29.4)</td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">1st, 2nd premolars</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">4</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">1st, 2nd molars</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="3" colspan="1">Nasolabial fold</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">3</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">4 (11.8)</td><td valign="top" align="left" rowspan="1" colspan="1">Mx</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">2</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">Incisors</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1">Canine</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Infraorbital region</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="right" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">1 (2.9)</td><td valign="top" align="left" rowspan="1" colspan="1">Mx: canine</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Total</td><td valign="top" align="right" rowspan="1" colspan="1">18</td><td valign="top" align="right" rowspan="1" colspan="1">15</td><td valign="top" align="right" rowspan="1" colspan="1">1</td><td valign="top" align="center" rowspan="1" colspan="1">34 (100)</td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr></tbody></table></alternatives><table-wrap-foot><fn><p>Values are presented as number only or number (%). 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