This summary is based on the article published in the British Dental Journal: Facial cutaneous sinuses of dental origin: a diagnostic challenge (December 2013)
Key Message
- A dental aetiology must always be considered for any cutaneous sinus tract in the head or neck.
- Elimination of the dental source of infection results in resolution of the sinus tract without the need for surgical excision and long-term unacceptable aesthetic results.
The article
- Depicts the clinical presentation of facial cutaneous sinus tracts.
- Explains how to correctly diagnose facial cutaneous sinuses.
- Describes the management of facial cutaneous sinuses.
Context
- It is common for practitioners to misdiagnose the cause of facial cutaneous sinus tracts, failing to recognise that many have an odontogenic cause.
- Chronic infection around the apex of a dental root can drain to the mouth or less commonly to the skin via a sinus tract.
- Dental symptoms are not always present and this confuses the clinical picture further. Failure to identify an odontogenic cause may result in unnecessary and ineffective treatment.
- Elimination of dental infection via tooth extraction or root canal treatment leads to resolution of the cutaneous sinus.
- The article presents a series of cutaneous draining sinuses of dental origin that resolved rapidly following dental treatment and highlights the importance of including odontogenic infection in the differential diagnosis of such a lesion in the head and neck.
Natural History of the Condition
- Infection around the root apex of a tooth arises following pulpal necrosis, which is usually the result of dental caries or traumatic injury. The inflammatory process that starts in the dental pulp spreads to the periodontal ligament and into the surrounding bone9 to initiate a periapical dental abscess.
- This progresses slowly, resorbing bone and spreading towards the cortical plate along the path of least resistance. Once the abscess perforates through the cortical bone it may spread into a fascial space, localise into an abscess, or may develop into a cellulitis.
- The development of a sinus tract from an abscess drains the suppuration, most commonly into the mouth, and less commonly onto the skin.
- If the infection tracks out of the jaw above the buccinator muscle attachment in the maxilla or below the mentalis, mylohyoid or buccinator attachments in the mandible, the sinus drains extra-orally.
- If the perforation of the cortical plate is below the muscle attachments in the maxilla and above the muscle attachments in the mandible, the sinus is more likely to drain intra-orally. The point of drainage depends in part on the length of the root and the position of the apex relative to the muscular attachments.
- As a result of drainage, chronic low grade infection is not always associated with a history of acute pain and patients seldom relate the cutaneous lesion with a dental cause.
Clinical Presentation
- The extra-oral draining sinus typically presents as an erythematous, smooth, non-tender nodule with crusting, which drains pus periodically.9 ‘Dimpling’ or retraction below the normal skin surface is characteristic.9 It is usually possible to palpate a cord-like tract that attaches tothe underlying alveolar bone in the area of the suspected tooth.
- Symptoms from the teeth may only present in 50% of patients and this may be why patients often initially seek help from a physician. In addition, the cutaneous draining sinus may be some distance from the primary odontogenic cause and these two factors combined may contribute to a delay in diagnosis. The involved tooth is always non vital but may not always be tender to percussion.
- Mandibular teeth are implicated over maxillary teeth in a ratio of 4:1 with 50% of mandibular sinuses emanating from lower incisors or canines. It is not surprising therefore that the commonest cutaneous sinus tract is seen in the chin or submental region. Premolars will commonly point to the submandibular region while lower molars can point on submandibular skin or to the cheek. Maxillary incisors may point to the floor of the nose, while canine teeth will commonly point to below the inner canthus of the eye. Maxillary premolars and molars may point to the cheek.
Diagnosis
- To reach a correct diagnosis, the attending clinician must look carefully for a potential odontogenic infection.
- A thorough history may pick up the incidence of any traumatic injuries to the teeth, recently or in the past.
- Sometimes patients are able to recall a history of toothache before the development of the sinus.
- Intraoral examination should identify any discoloured or heavily restored teeth.
- Pulp testing and intraoral radiographs will help to identify the culpable tooth.
- A radiopaque marker (gutta-percha point) may be inserted into the sinus before radiographic exposure to determine the source.
Differential Diagnosis
- Dental infection is the most prevalent aetiology for cutaneous sinus tracts in the face and neck region and should be considered first in a differential
- diagnosis.
- Other causes include: osteomyelitis, actinomycosis, foreign body, local skin infection, pyogenic granuloma, salivary gland and duct fistula,
- suppurative lymphadenitis and neoplasm among others.
Treatment
- The dental infection must be managed, either with endodontic treatment or extraction.
- Surgical excision of the cutaneous sinus is not necessary as spontaneous closure of the tract is expected within 5 to 14 days of dental treatment.
- Healing occurs by secondary intention and occasionally a residual scar may persist. In these cases surgery may be indicated to improve aesthetics.
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