Migratory and misleading abscess of oro-facial region.

Acute pericoronitis usually presents with severe localized pain, swelling and sometimes trismus. However, chronic pericoronitis and periodontal abscess produce a dull pain, moderate swelling and are occasionally seen migrating into distant sites producing fistulae intra-orally and/or extra-orally. This may quite often cause diagnostic dilemmas necessitating thorough medical and dental history, careful clinical examination and sometimes special investigations to confirm the etiology and or origin of infection. Here, we present three such cases and their management.

INTRODUCTION

Dental infections involving the teeth or associated tissues are caused by oral pathogens that are predominantly anaerobic and usually of more than one species. Origins of infections are most commonly progressive dental caries or extensive periodontal diseases. Other causes could be related to pathogens introduced deeper in the oral tissues by trauma caused by dental procedures such as the contamination of dental surgical sites (e.g., tooth extraction) and needle tracks during local anesthesia administration.

Cutaneous sinus tract of the face due to odontogenic infections are uncommon. Most of the reported cases have been caused by chronic periapical abscess of the mandibular teeth.[12] The remoteness of the cutaneous sinus tract from its sites of origin within the oral cavity often leads to misdiagnosis and needless cutaneous surgery. Patients are assuming the cutaneous sinus to be unrelated to the dental infection, often seek treatment from a dermatologist or from their physician. After a misdiagnosis of the lesion, topical and surgical therapies are frequently attempted on the cutaneous aspect of the lesion, and no dental treatment is provided. Sometimes, there is an initial cessation of pus from the sinus, along with apparent healing, but there is always a recurrence as the primary etiology is unnoticed. Treatment must be focused on the elimination of the source of infection; once the infection is eliminated there is a prompt resolution of the sinus tract. If the source of the infection is a retained root or nonrestorable tooth or if the involved tooth is periodontally hopeless, extraction of the tooth is the only possible treatment. A report indicated that 75%of cutaneous sinus tracts are treated by tooth extraction.[2] Many pathologic conditions in and around the oral cavity, including the common periapical dental abscess, the less common recurrent squamous cell carcinoma, a rare developmental anomaly, can manifest on the face and neck as cutaneous sinus tracts.[123] Here we report three cases of cutaneous sinus tract of dental origin that underwent complete resolution following treatment in three cases.

CASE REPORTS

Case 1

A male patient aged 26 years presented to the department of Periodontology with a nodular swelling of the cheek of 8 months duration. Furthermore, complained of occasional purulent discharge since 8 months. Patient had no significant medical history. History further revealed the occurrence of swelling in cheek, well localized, reduced after burst. Patient had experienced pain in upper posterior tooth before swelling. Thorough history also revealed that he had visited a dermatologist for the same and was advised with medication, after which the lesion did not heal. Patient then visited dentist who referred him to the institution for the management of the same. When the patient was examined, he had tender nodular swelling on cheek Routine blood investigations were performed prior to the initiation of the treatment. Diabetic and infective status (HIV and HbsAg tests) were checked to rule the immunocompromised status. Treatment included tracing the sinus tract intra-orally and excision along with the extraction of the involved molar tooth. Healing was uneventful [Figure 1a–h].

Figure 1

(a) Preoperative photograph of the extra-oral chronic fistula (b) Preoperative photograph of the intraoral proximal caries (c) Intra-operative photograph of fistula tract (d) Fistula tract excision (e) Intra-oral closure (f) Postoperative healing socket (g) Postoperative extra-oral closure (h) Postoperative healed sinus after 3 weeks

Case 2

A male patient aged 22 years presented with a draining sinus on the cheek. Clinically, a draining lesion on the left cheek 2 cm above the inferior border of the mandible was noticed. Patient also complained of pain in right cheek, followed by light red discharge since 1-month. Dental examination revealed carious lesion on the maxillary molar teeth and radiograph showed abscess extending beyond the pulp and involving the periapical area. Gutta-percha cone was inserted into the sinus tract and gently pushed inside until there was no resistance. Antero-posteror view radiograph showed the tip of the gutta-percha cone to be close to the lesion. No specific complaints related to teeth or soft tissue intraorally. Porcelain crown on incompletely obturated root canals was evident on the radiograph. Management included antibiotic therapy with abscess drainage, scaling and root planning. The extra-oral active discharge gradually stopped. Patient is referred for root canal treatment no. 16 followed by prosthetic rehabilitation [Figure 2a–e].

Figure 2

(a) Preoperative extra oral draining fistula (b) Preoperative intra oral lesion (c) Preoperative intra oral periapical radiograph (d) Preoperative antero-posterior view radiograph revealing the course of the sinus tract (e) Postoperative intra-oral photograph after 2 weeks

Case 3

A 30-year-old male patient complained of recurrent swelling and discharge from right cheek. On two occasions, patient had experienced bad breath and reduced mouth opening. Once, a stab incision and drainage was attempted extra orally by a dermatologist. Clinical features included linear depressions evident in right cheek, discharge positive on palpation. Intra oral examination revealed nothing significant except an impacted third molar with mild pericoronitis. Computed tomography revealed the entire course of the sinus tract from its site of origin to its exit on extra-oral region. Management included antibiotic therapy; extra oral fistula was traced till mandibular third molar. Surgical extraction of third molar was done, and fistula excised. Extra-oral surgical wound was treated with Limberg's flap. Healing was uneventful. Patient is under follow-up [Figure 3a–g].

Figure 3

(a) Preoperative extra-oral photograph showing the scar of the previous stab incision attempted by the surgeon (b) Intra-oral photograph showing the infection around the right mandibular third molar region (a and d) Computer tomograph revealing the course of the sinus tract (e-g) Intra-operative showing excision of fistula and Limberg's flap, postoperative photographs

DISCUSSION

Infections originating in a tooth or its supporting structures or in the jaws or soft tissues can spread to distant sites of head and neck and chest region. The path of an infection could be understood from the thorough knowledge of the anatomy of the head and neck. In the facial region, the loose, fat-containing tissue of the lips and cheeks is continuous. However, it is partially partitioned by the muscles of facial expression, which arise from the bones of the face and which, as variably wide plates, traverse the subcutaneous tissue, to end in the skin. In infections that are not caused by extremely virulent bacteria, the muscles with their thin perimysia play a role in directing the spread of the infection. In this respect, dental abscesses that erode and perforate the outer compact lamella of the upper or lower jaw sometimes do not progress toward the oral vestibule, but find their way through the subcutaneous tissue to the skin.[4]

The muscles and fasciae constitute a relative barrier to the spread of infection; the sinus tract may or may not become cutaneous depending on its location relative to the mandibular and maxillary attachments of the facial muscles. If the apex of the involved tooth is superior to the muscle attachment on the maxilla or inferior to the muscle attachment on the mandible, the infection may spread extra-orally to form a cutaneous sinus.[4]

Oral cutaneous fistula leads to esthetic problems due to the continued leakage of saliva from the oral cavity to the face. Causes for oro-cutaneous fistulae include due to malignancy, inflammation, trauma being the most common causes.[5] Other causes may be due to failed implants leading to possible extra-oral sinus tract discharge, failed endodontic therapy.[67] Interestingly even calculus formation was reported as a cause of a persistent sinus tract after root canal therapy in two cases. In one case reported (Ricucci et al.), sinus tract developed that did not heal after conventional root canal therapy and apical surgery.[8] Extraction of that tooth revealed calculus like material on the root surface. Other case had showed radiographic signs of healing after apicectomy. Histology of the apical biopsy specimen demonstrated a calculus like material on the surface of the root apex. The presence of calculus on the root surfaces of these teeth may have contributed to endodontic treatment failure.[8]

Neoplastic fistulae result from the penetration of a neoplasm from the oral cavity to the overlying skin (most common cause, squamous cell carcinoma.). Actinomycosis, although rare is one of the most common infections that result in a fistula from the oral cavity to the skin. Fistulae may arise from the developmental cysts of the neck region, such as thyroglossal duct, dermoid, sebaceous, preauricular and branchial arch cysts. Nasopalatine duct cysts occasionally secrete fluid to the anterior palate and the site of the duct. Lymph nodes infected with mycobacterium tuberculosis cause scrofula, a condition in which infection spreads from the node to the skin through a sinus tract. This infection most commonly occurs in the neck. Cat-scratch disease is another consideration in the differential diagnosis of sinus tracts from lymph nodes.[9]

In all the three cases reported here, tooth and associated tissues were identified as the etiology for the spread of the infections to oral and extra-oral tissues.

CONCLUSION

The presence of a cutaneous sinus on the face must alert the physician, surgeon or the dermatologist to make a dental examination. This case series illustrates that pericoronitis and other infections of the oral cavity can present with a well-localized abscess away from the causative site. An understanding of the anatomy of the region is very important to establish a correct diagnosis and deliver prompt treatment.