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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Managing the Cutaneous Sinus Tract of Dental Origine</title><author><name sortKey="Janev, Edvard" sort="Janev, Edvard" uniqKey="Janev E" first="Edvard" last="Janev">Edvard Janev</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Redzep, Enis" sort="Redzep, Enis" uniqKey="Redzep E" first="Enis" last="Redzep">Enis Redzep</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27703580</idno><idno type="pmc">5042640</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5042640</idno><idno type="RBID">PMC:5042640</idno><idno type="doi">10.3889/oamjms.2016.100</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">001F57</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001F57</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Managing the Cutaneous Sinus Tract of Dental Origine</title><author><name sortKey="Janev, Edvard" sort="Janev, Edvard" uniqKey="Janev E" first="Edvard" last="Janev">Edvard Janev</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Redzep, Enis" sort="Redzep, Enis" uniqKey="Redzep E" first="Enis" last="Redzep">Enis Redzep</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></analytic><series><title level="j">Open Access Macedonian Journal of Medical Sciences</title><idno type="eISSN">1857-9655</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 id="st1"><title>BACKGROUND:</title><p>Draining cutaneous sinus tract in chin area may be caused by chronic periapical dental infections. Misdiagnosis of these lesions usually leads to destructive invasive treatment of the sinus tract that is not correct and curative.</p></sec><sec id="st2"><title>CASE REPORT:</title><p>A 31-year-old male patient referred to us with a chronically draining lesion on his chin. The lesion previously was misdiagnosed by medical doctors and had undergone two times 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 and surgical treatment was performed. Three months later, after the treatment, the lesion showed total healing and reoccurrence occurred.</p></sec><sec id="st3"><title>CONCLUSION:</title><p>The key to successful treatment of cutaneous sinus tract of dental origin must be in appropriate communication between the dentist and the physician in order to achieve correct diagnosis and therapy in such cases.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Marasco, Pv" uniqKey="Marasco P">PV Marasco</name></author><author><name sortKey="Taylor, Rg" uniqKey="Taylor R">RG Taylor</name></author><author><name sortKey="Marks, Mw" uniqKey="Marks M">MW Marks</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Karp, Mp" uniqKey="Karp M">MP Karp</name></author><author><name sortKey="Bernat, Je" uniqKey="Bernat J">JE Bernat</name></author><author><name sortKey="Cooney, Dr" uniqKey="Cooney D">DR 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Open Access Maced J Med Sci</journal-id><journal-id journal-id-type="iso-abbrev">Open Access Maced J Med Sci</journal-id><journal-title-group><journal-title>Open Access Macedonian Journal of Medical Sciences</journal-title></journal-title-group><issn pub-type="epub">1857-9655</issn><publisher><publisher-name>Institute of Immunobiology and Human Genetics</publisher-name><publisher-loc>Republic of Macedonia</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27703580</article-id><article-id pub-id-type="pmc">5042640</article-id><article-id pub-id-type="publisher-id">OAMJMS-4-489</article-id><article-id pub-id-type="doi">10.3889/oamjms.2016.100</article-id><article-categories><subj-group subj-group-type="heading"><subject>Stomatology – Case Report</subject></subj-group></article-categories><title-group><article-title>Managing the Cutaneous Sinus Tract of Dental Origine</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Janev</surname><given-names>Edvard</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1">*</xref></contrib><contrib contrib-type="author"><name><surname>Redzep</surname><given-names>Enis</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib></contrib-group><aff id="aff1"><italic>Faculty of Dentistry, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia</italic></aff><author-notes><corresp id="cor1"><label>*</label><bold>Correspondence:</bold> Edvard Janev. Faculty of Dentistry, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia. E-mail: <email xlink:href="edijanev@hotmail.com">edijanev@hotmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><day>15</day><month>9</month><year>2016</year></pub-date><pub-date pub-type="epub"><day>06</day><month>9</month><year>2016</year></pub-date><volume>4</volume><issue>3</issue><fpage>489</fpage><lpage>492</lpage><history><date date-type="received"><day>28</day><month>6</month><year>2016</year></date><date date-type="rev-recd"><day>08</day><month>7</month><year>2016</year></date><date date-type="accepted"><day>24</day><month>8</month><year>2016</year></date></history><permissions><copyright-statement>Copyright: © 2016 Edvard Janev, Enis Redzep.</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/2.5/"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><abstract><sec id="st1"><title>BACKGROUND:</title><p>Draining cutaneous sinus tract in chin area may be caused by chronic periapical dental infections. Misdiagnosis of these lesions usually leads to destructive invasive treatment of the sinus tract that is not correct and curative.</p></sec><sec id="st2"><title>CASE REPORT:</title><p>A 31-year-old male patient referred to us with a chronically draining lesion on his chin. The lesion previously was misdiagnosed by medical doctors and had undergone two times 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 and surgical treatment was performed. Three months later, after the treatment, the lesion showed total healing and reoccurrence occurred.</p></sec><sec id="st3"><title>CONCLUSION:</title><p>The key to successful treatment of cutaneous sinus tract of dental origin must be in appropriate communication between the dentist and the physician in order to achieve correct diagnosis and therapy in such cases.</p></sec></abstract><kwd-group><kwd>Fistula</kwd><kwd>cutaneous sinus tract</kwd><kwd>periapical dental infections</kwd><kwd>root canal</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>Introduction</title><p>The successful treatment of cutaneous sinus tract of dental origin depends on the diagnosis of the source which may be very challenging. These lesions present a diagnostic problem and misdiagnosis leads to incorrect and unsuccessful treatment. Very often the possibility of an odontogenic origin is overlooked because most of the patients do not experience any dental symptoms.</p><p>Treatment with systemic antibiotics results in temporary cessation of the drainage which returns immediately after antibiotic treatment is over. The diagnosis may be challenging for several reasons:</p><p><list list-type="order"><list-item><p>The cutaneous lesions do not always arise in close proximity to the underlying infection and only half of all patients ever recall having had a toothache.</p></list-item><list-item><p>The sinus tract appears most commonly on the chin or jaw line but they also can appear elsewhere on the face and neck [<xref rid="ref1" ref-type="bibr">1</xref>, <xref rid="ref2" ref-type="bibr">2</xref>].</p></list-item><list-item><p>Lesions have been reported to occur as far away from oral cavity as the chest, tight or sacrum [<xref rid="ref2" ref-type="bibr">2</xref>-<xref rid="ref5" ref-type="bibr">5</xref>].</p></list-item><list-item><p>Because cutaneous lesions can mimic other disorders, several inappropriate surgeries and courses of antibiotics are commonly used before definite therapy is instituted [<xref rid="ref2" ref-type="bibr">2</xref>, <xref rid="ref6" ref-type="bibr">6</xref>, <xref rid="ref7" ref-type="bibr">7</xref>].</p></list-item></list></p><p>Patients with extraoral drainage from periapical pathosis may be unaware of any dental problem and tend to seek treatment from physicians, who may not give high priority to chronic dental infections.</p><p>The differential diagnosis should include:</p><p><list list-type="bullet"><list-item><p>Infected pylar or epidermal cyst</p></list-item><list-item><p>Carbuncle</p></list-item><list-item><p>Pyogenic granuloma</p></list-item><list-item><p>Suppurative lymphadenitis</p></list-item><list-item><p>Foreign body reaction</p></list-item><list-item><p>Thyroglossal tract fistula</p></list-item><list-item><p>Branchial cleft fistula</p></list-item><list-item><p>Actinomycosis</p></list-item><list-item><p>Basal cell and squamous cell carcinoma [<xref rid="ref8" ref-type="bibr">8</xref>-<xref rid="ref11" ref-type="bibr">11</xref>]</p></list-item></list></p><p>Dental etiology of these lesions can be confirmed by:</p><p><list list-type="bullet"><list-item><p>Tracing the sinus tract to its origin with gutta percha or other radioopaque material</p></list-item><list-item><p>Pulp vitality testing</p></list-item><list-item><p>Periapical films</p></list-item><list-item><p>Panoramic films</p></list-item></list></p></sec><sec id="sec1-2"><title>Case Report</title><p>A 31-year-old male patient referred to our clinic with a chronically draining lesion on his chin. His history revealed that he had this lesion for more than 5 months and had undergone two times surgery and received antibiotics for prolonged period of time.</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Skin lesion located on chin area</p></caption><graphic xlink:href="OAMJMS-4-489-g001"></graphic></fig><p>Dental history revealed no pain or any dental symptoms but he recalls to a direct blunt trauma to the anterior mandibular region. The periapical radiograph showed a large radiolucent area around lower right first incisor. There was no electric or thermal pulp testing performed on the same tooth. Neither percussion nor palpation revealed any abnormality.</p><fig id="F2" position="float"><label>Figure 2</label><caption><p>Rtg diagnosis of chronical periodontitis periapical and root canal treatment</p></caption><graphic xlink:href="OAMJMS-4-489-g002"></graphic></fig><p>The tooth was treated with calcium hydroxide and glycerine and antibiotics for 14 days. After the initial filling of the root canal, an apicoectomy and sinus excision was performed. Three months postoperative control revealed no sinus fistula or exudates from chin or from the mucosa.</p><fig id="F3" position="float"><label>Figure 3</label><caption><p>Surgical removal of periapical lesion with apical resection</p></caption><graphic xlink:href="OAMJMS-4-489-g003"></graphic></fig></sec><sec sec-type="discussion" id="sec1-3"><title>Discussion</title><p>If correctly diagnosed and treated the tract is expected to disappear within 7 to 14 days. Systemic antibiotic therapy will result in a temporary reduction of the drainage and apparent healing [<xref rid="ref12" ref-type="bibr">12</xref>]. This tract however will recur immediately the AB therapy is completed unless the initial source is not eliminated [<xref rid="ref12" ref-type="bibr">12</xref>].</p><fig id="F4" position="float"><label>Figure 4</label><caption><p>Curettage of the fistula</p></caption><graphic xlink:href="OAMJMS-4-489-g004"></graphic></fig><p>Extraoral cutaneous sinus tracts are usually lined with granulomatous tissue with a lumen containing a purulent exudate. The exudate is composed mainly of PMNL [<xref rid="ref13" ref-type="bibr">13</xref>, <xref rid="ref14" ref-type="bibr">14</xref>]. Unlike intraoral tracts, extraoral tracts heal with granulation tissue leaving a cutaneous scar [<xref rid="ref15" ref-type="bibr">15</xref>]. The patients may have to undergo a revision of the scar.</p><fig id="F5" position="float"><label>Figure 5</label><caption><p>Total recovery in mental extraoral area a few weeks later</p></caption><graphic xlink:href="OAMJMS-4-489-g005"></graphic></fig><p>Eighty of reported cases of odontogenic origin are associated with mandibular teeth [<xref rid="ref16" ref-type="bibr">16</xref>]. The sinus tract usually disappears in 5 to 14 days after the root canal system has been thoroughly cleansed [<xref rid="ref17" ref-type="bibr">17</xref>]. An intraoral and extraoral sinus can develop depending on the path of the inflammation dictated by surrounding muscular attachments and facial planes [<xref rid="ref18" ref-type="bibr">18</xref>].</p><p>The majority of sinuses arisen are intraoral [<xref rid="ref19" ref-type="bibr">19</xref>, <xref rid="ref20" ref-type="bibr">20</xref>]. A retained root fragment can be the cause in edentulous patients [<xref rid="ref21" ref-type="bibr">21</xref>, <xref rid="ref22" ref-type="bibr">22</xref>]. Most infections are polymicrobial and culture often yields growth of anaerobes or facultative anaerobes such as streptococcal spices [<xref rid="ref2" ref-type="bibr">2</xref>, <xref rid="ref19" ref-type="bibr">19</xref>, <xref rid="ref23" ref-type="bibr">23</xref>, <xref rid="ref24" ref-type="bibr">24</xref>]. Due to two time’s surgical interventions and a prolonged antibiotic usage, we did not see relevant to have an antibiogram as it would not reflect the exact picture of the flora.</p><p>Johnson et al. believe that the application to heat to the face may contribute to the cutaneous exit of these sinus tracts since it is well known that the heat causes vasodilatation and increase blood flow to the local area [<xref rid="ref12" ref-type="bibr">12</xref>]. Caliskan and colleagues presented three cases of cutaneous sinus tracts that were treated with CaOH and glycerine mixture intensionally placed beyond the apex. They performed microbiological culturing and found a mixed assortment of both obligate and facultative anaerobic bacteria identified as representatives of both endodontic abscesses and skin infections [<xref rid="ref25" ref-type="bibr">25</xref>].</p><p>Conventional root canal therapy and sometimes extraction of the tooth are effective in achieving healing of cutaneous sinus tracts in a few weeks. In general, it is not necessary to treat the skin lesion, except for esthetic reason [<xref rid="ref26" ref-type="bibr">26</xref>]. Al-Kandari reported completely healing of the sinus tract after proper root-canal treatment without surgical treatment in three months leaving a small scar [<xref rid="ref27" ref-type="bibr">27</xref>].</p><p>In this case, the skin lesion was treated surgically because the patient had undergone two times surgical intervention with the focus on the skin lesion and had a bigger defect on his chin. Also, the time of healing is shortened with additional surgical removal and apical resection.</p><p>In conclusion, the key to successful treatment of cutaneous sinus tract of dental origin must be in appropriate communication between the dentist and the physician in order to achieve correct diagnosis and therapy in such cases. 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