A clinical predicament—diagnosis and differential diagnosis ofcutaneous facial sinus tracts of dental origin: a series ofcase reportsMonika Gupta, MDS,a Debdutta Das, MDS,a Ravi Kapur, MDS,b and Nikhil Sibal,b

Haryana, IndiaM. M. COLLEGE OF DENTAL SCIENCES AND RESEARCH

A cutaneous draining sinus tract of dental origin is often a diagnostic challenge, because of its uncommonoccurrence and absence of dental symptoms. Proper diagnosis, treatment, and the elimination of the source ofinfection are a must; otherwise, it can result in ineffective and inappropriate outcome of treatment. This articlepresents 4 cases of facial lesions misdiagnosed as being of nonodontogenic origin. The correct diagnosis in each casewas cutaneous sinus tract secondary to pulpal necrosis, suppurative apical periodontitis, and osteomyelitis. In allcases, facial sinus tracts of dental origin were excised and the source of infection eliminated. The purpose of thispaper is to provide diagnostic guidelines and examination protocols for differential diagnosis of cutaneous facial sinus

tracts of dental origin. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e132-e136)

A cutaneous sinus tract of dental origin is relativelyuncommon and may easily be misdiagnosed, owing toits uncommon occurrence and absence of dental symp-toms.1 Such a lesion continues to be a diagnostic di-lemma. A systematic review of several reported casesrevealed that patients have had multiple surgical exci-sions, radiotherapy, multiple biopsies, and multiple anti-biotic regimens, all of which had failed, with recurrence ofthe cutaneous sinus tract, because the primary dental eti-ology was never correctly diagnosed or addressed to.2

However, all chronic draining sinus tracts of the faceand/or neck should signal the need for thorough dentalevaluation. The purulent by-products of pulpal infec-tion will seek the path of least resistance when exitingfrom the root apex area and travelings through bone andsoft tissue. Once the cortical plate has been penetrated,the sinus tract’s exit point is determined by the locationof muscle attachments and fascial sheaths. Dental eti-ology can be confirmed by tracing the sinus tract to itsorigin with gutta-percha or similar radiopaque material,both by orthopantomogram and intraoral periapical ra-diographic examination and by pulp vitality testing.

Differential diagnosis of a cutaneous draining sinustract should include suppurative apical periodontitis,

aOral and Maxillofacial Surgery, M.M. College of Dental Sciencesand Research, Mullana, Ambala (Haryana), India.bConservative Dentistry and Endodontics, M.M. College of DentalSciences and Research, Mullana, Ambala (Haryana), India.Received for publication Feb. 20, 2011; returned for revision Mar. 6,2011; accepted for publication May 1, 2011.1079-2104/$ - see front matter© 2011 Mosby, Inc. All rights reserved.

doi:10.1016/j.tripleo.2011.05.037

e132

osteomyelitis, congenital fistula, salivary gland fistula,an infected cyst, and deep mycotic infection. Skin le-sions, such as pustules, furuncles, foreign-body lesions,squamous cell carcinoma, and granulomatous disordersmay be superficially similar in appearance to a drainingsinus tract of dental origin, but they are not true sinustracts.1

Definitive treatment of the draining sinus tract re-quires elimination of the source of infection, either byroot canal therapy in case of restorable tooth or byextraction in case of nonrestorable tooth, along withcomplete excision of sinus tract lining.

CASE REPORTSCase 1

A healthy 12-year-old girl had a pedunculated tumor-likegrowth under her chin, 1 cm in diameter for the past 2 years.Previous treatment of the patient was with systemic antibiot-ics and repeated excision 4 times, which were unsuccessful.Intraoral examination revealed that the patient had a slightdistoincisal angle fracture of tooth 31. Electric pulp test andheat test were nonresponsive in teeth 31, 32, and 41. Theother teeth responded within normal limits. Radiologic exam-ination with gutta-percha cone introduced through the sinusopening revealed a radiolucent area in relation to tooth 31extending mesially to the distal surface of the root of tooth 41and distally to the mesial surface of the root of tooth 32.Endodontic therapy in teet 31, 32, and 41 was started; thecanals were enlarged and made infection free with sodiumhypochlorite solution and hydrogen peroxide. Subsequently,an elliptic incision was placed around the extraoral discharg-ing sinus, and the whole sinus tract was excised, starting fromthe extraoral side to the origin, by combination of sharp andblunt dissection; currettage of the apical pathology was done.

After that, root canal fillings with gutta-percha cones, api-

ntomog

OOOOEVolume 112, Number 6 Gupta et al. e133

coectomies, and retrograde fillings with glass ionomer cementof involved teeth were performed (Fig. 1).

Case 2A 35-year-old woman sought treatment with a chief com-

plaint of purulent and hemorrhagic discharge from the sub-mandibular region for 6 months after extraction. The patientgave a history of excision of sinus lining done twice, but thepurulent discharge continued. The patient was suffering fromuncontrolled type II diabetes for the past 10 years. Radiologicexamination revealed an irregular radiolucent area with thepresence of a radiopaque mass inside the socket of tooth 46.First, her uncontrolled diabetes was controlled in consultationwith an endocrinologist. Then an extraoral spindle-shapedincision was placed around the extraoral discharging sinus.With the help of blunt and sharp dissection, the cord-likesinus tract was identified, starting from the extraoral side tothe origin, and the whole sinus tract was excised. After that,soft bone was removed with bone rongeur, reached up to thesocket of tooth 46, which was confirmed by passing smoothstellate through from extraoral to intraoral region, and seques-trectomy was performed from the socket of tooth 46. Histo-pathologic report confirmed osteomyelitis (Fig. 2).

Case 3A 14-year-old girl presented with an extraoral discharging

sinus with tumoral mass on the left cheek for 3 years. Thepatient had carious exposure of tooth 36 with slight mobility.Electric pulp test and heat test was nonresponsive in tooth 36.Radiologic examination with gutta-percha cone introducedthrough the sinus revealed irregular radiolucency in the fur-cation area of tooth 36. Endodontic therapy in tooth 36 was

Fig. 1. A, Preoperative extraoral view showing gutta-perchaslight fracture of distoincisal angle of left central incisor ofradiolucent area at the apex of the mandibular right central ihealed sinus tract area on the chin. E, Postoperative orthopa

started; the canals were enlarged and made infection free with

sodium hypochlorite and hydrogen peroxide, and root canalfilling was done with gutta-percha cones. Subsequently, aspindle-shaped incision was placed around the extraoral dis-charging sinus; the whole sinus tract was excised startingfrom the extraoral side to the origin by a combination of sharpand blunt dissection. Curettage of pathologic tissue from thefurcation area and periodontal therapy was instituted (Fig. 3).

Case 4A 45-year-old woman wanted to get rid of nonhealing pus

discharge from a growth on her left cheek of 10 months’duration. Drug history of repeated antibiotics administrationwas reported. Radiologic examination with gutta-percha coneintroduced through the sinus opening revealed a periapicalradiolucent area in relation to tooth 25. Complete excision ofthe sinus lining as in the other cases, along with extraction oftooth 25, was done (Fig. 4).

DISCUSSIONExtraoral manifestation of pulpoperiradicular patho-

sis, is easily misdiagnosed by physicians and dentists.A sinus tract prevents swelling or pain from pressurebuild-up, because it provides drainage from the primaryodontogenic site.3

Diagnostic guidelinesThe following guidelines are advocated.

1. Evaluation of a cutaneous sinus tract must beginwith a thorough history and awareness that anycutaneous lesion of the face and neck could be of

d into the sinus tract on the chin. B, Intraoral view showingandible. C, Orthopantomogram of gutta-percha traced to aleft central incisor, and left lateral incisor. D, Postoperativeram after 7 months.

insertethe m

ncisor,

dental origin. An acute or painful onset and the

bmand

OOOOEe134 Gupta et al. December 2011

cutaneous tract and lesion are seldom accompaniedby symptoms from the oral cavity.

2. Palpation of the tissues surrounding the sinus tract

Fig. 2. A, Extraoral view of the sinus tract in the right submanarea at apical area with presence of radiopaque mass inside thshowing gutta-percha traced to a radiolucent area at theorthopantomogram. E, Healed sinus tract area in the right su

Fig. 3. A, Intraoral periapical radiograph with files. B, Periapinserted into sinus tract. D, Sinus lining removed and curettaperiapical radiograph shows healing furcation area.

should reveal a cord-like tract attached to the under-

lying alveolar bone in the area of the suspect tooth.During palpation, an attempt should be made to“milk” the sinus tract; production of a purulent

r region. B, Orthopantomogram showing irregular radiolucentet of right first molar of the mandible. C, Orthopantomogramf the right first molar of the mandible. D, Postoperativeibular region.

diograph after obturation with gutta-percha. C, Gutta-percharanulation tissue done from furcation area. E, Postoperative

dibulae sockapex o

ical rage of g

discharge confirms the presence of a tract.

sinus t

OOOOEVolume 112, Number 6 Gupta et al. e135

3. If the sinus tract is patent, a lacrimal probe or agutta-percha cone can be used to trace its track fromthe cutaneous orifice to the point of origin, which isusually a nonvital tooth, but in edentulous patientscould be a retained tooth fragment, an impactedtooth, or an odontogenic cyst. A radiograph is thenexposed with the probe in situ, pointing to the originof the primary pathosis. Oral examination may re-veal �1 severely decayed teeth or a healthy lookingtooth with an intact crown or slight fracture ofcrown.

4. Pulp tests and periradicular diagnostic testing shouldbe performed on the suspected tooth and adjacentteeth. More than 1 tooth may be pulpally involvedand associated with the cutaneous odontogenic sinustract.

5. Microbiologic culturing and sensitivity test of thesinus tract exudate should be done for microbialflora identification. Culture should also be carriedout for suspected fungal or syphilitic infections.

6. Physiologic and anatomic factors that influence thespread and ultimate localization of dental infectionsneed to be considered. The ultimate path of the sinus(regardless of the source) depends on several fac-tors, most importantly the anatomy of tooth in-volved, muscular attachments to the jaw, fascialplanes of the neck, and involvement of permanent or

Fig. 4. A, Preoperative extraoral view showing gutta-perchshowing carious exposed left second premolar in the maxilla.the apex of left second premolar in the maxilla. D, Excised

deciduous teeth. Cutaneous sinus tracts rather than

intraoral sinus tracts are likely to occur if the apicesof teeth are superior to the maxillary muscle attach-ments or inferior to mandibular muscle attachments.

Examination protocols for differential diagnosisThe clinical differential diagnosis includes pustule,

actinomycosis, osteomyelitis, orocutaneous fistula,neoplasms, local skin infections (carbuncle and in-fected epidermoid cyst), and pyogenic granuloma.Other causes are salivary gland fistula, thyroglossalduct cyst, branchial sinus, dacryocystitis, and suppura-tive lymphadenitis.

Pustule is the most common of all purulent draininglesions and is readily recognized by its superficial lo-cation and short course.

Actinomycosis exhibits multiple draining lesions andcharacteristic fine yellow granules in the purulent dis-charge. The tooth is often not involved radiographi-cally. If a sinus tract does not close after appropriateremoval of the primary cause, the most common alter-native cause is actinomycosis.

Osteomyelitis of jaw is usually secondary to sometype of exogenic trauma, acquired infection after ex-traction of diseased teeth, impacted teeth, or retainedroots. It rarely gives rise to a cutaneous sinus and ismostly associated with history of some debilitating

ted into the sinus tract on the left cheek. B, Intraoral viewthopantomogram of gutta-percha traced to radiolucent area atract along with extracted tooth.

a inserC, Or

systemic disease or fracture.

OOOOEe136 Gupta et al. December 2011

Orocutaneous fistula is a common sequela of traumato the head and neck region and leads to continualleakage of saliva to lower face or neck.

Neoplasm usually presents with fixation to underly-ing osseous structures.4

Carbuncle involves a group of hair follicles andweeping ooze; a red swollen lump under the skin has awhite or yellow center.

Infected epidermoid cyst or sebaceous cyst isa su-perficial, solitary, freely moveable secondarily infectedmass.5

Pyogenic granuloma is small reddish vascular lumpon the skin; it bleeds easily owing to a high number ofblood vessels.5

A salivary gland fistula has a characteristic locationand associated patient history. Moreover, the defect isnot through and through as in orocutaneous fistula.Probing the duct and performing sialography aid indiagnosis.

Thyroglossal duct cyst and branchial sinus are de-velopmental lesions and therefore are observed early inlife. The former is found high up along the midline andextrudes when the tongue is protruded, whereas thelatter is found in the lateral neck region.4

Dacaryocystitis is redness, swelling, and pus oozenear the inner corner of eye.

Suppurative lymphadenitis usually occurs in teenag-ers or young adults and presents with a sore throat,fever, malaise, and prominent tender cervical lymph-adenopathy. The pharynx is red with gray-yellow exu-

dates. Neck stiffness is a symptom.5

In conclusion, the cutaneous dental sinus is an un-common but well documented condition. Its diagnosisis not always easy unless the treating clinician bears inmind the possibility of its dental origin. A thoroughdiagnosis requires cooperative referrals between physi-cians, dermatologist, surgeons, and dentists. Recogni-tion of the true nature of the lesion facilitates prompttreatment, minimizes patient discomfort and estheticproblems, and reduces the possibility of further com-plications.

REFERENCES1. Bradford RJ, Nijole AR, Joesph EVC. Diagnosis and treatment of

cutaneous facial sinus tracts of dental origin. J Am Dent Assoc1999;130:832-6.

2. Tidwell E, Jenkins JD, Ellis CD, Hutson B, Cederberg RA. Cu-taneous odontogenic sinus tract to the chin: a case report. IntEndod J 1997;30:352-5.

3. Robert JB, Joseph L. A dermatologic lesion resulting from amandibular molar with periradicular pathosis. Oral Surg J1981;52:210-2.

4. Mittal N, Gupta P. Management of extra oral sinus cases: aclinical dilemma. J Endod 2004;30:541-7.

5. Marx E. Stern D. Oral and maxillofacial pathology, a rationale fordiagnosis and treatment. Hanover Park, IL; Quintessence; 2003. p.21, 628.

Reprint requests:

Dr. Monika Gupta, MDS (Oral and Maxillofacial Surgery)Senior lecturerM. M. College of Dental Sciences and ResearchHouse 879, sector-8Panchkula, Haryana, IndiaPin code 134109

monikabox@yahoo.com