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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 66-69

Management of extraoral sinus via nonsurgical root canal treatment

Department of Conservative Dentistry and Endodontics, D. Y. Patil School of Dentistry, Navi Mumbai, Maharashtra, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Priyanka Unnikrishnan
401/A, Raj Galaxy, CST Road, Kalina, Santacruz East, Mumbai - 400 098, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohr.ijohr_4_19

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Cutaneous sinus tracts of dental origin have been well-documented in the medical literature. However, these lesions continue to be a diagnostic dilemma. A review of several reported cases reveals that patients have had multiple surgical excisions, radiotherapy, multiple biopsies, and multiple antibiotic regimens, all of which have failed, with a recurrence of the cutaneous sinus tract, as the primary etiology was dental that was never correctly diagnosed or addressed. This case report demonstrates the healing of an extraoral draining sinus by means of conventional nonsurgical root canal treatment.

Keywords: Acute periapical abscess, extraoral sinus tract, nonsurgical endodontic treatment

How to cite this article:
Padhye L, Jagan IN, Unnikrishnan P, Mandke L, Kulkarni R, Toprani N. Management of extraoral sinus via nonsurgical root canal treatment. Indian J Oral Health Res 2018;4:66-9

How to cite this URL:
Padhye L, Jagan IN, Unnikrishnan P, Mandke L, Kulkarni R, Toprani N. Management of extraoral sinus via nonsurgical root canal treatment. Indian J Oral Health Res [serial online] 2018 [cited 2022 Aug 19];4:66-9. Available from: https://www.ijohr.org/text.asp?2018/4/2/66/257151

  Introduction Top

The term sinus tract “refers to a tract leading from an enclosed area of inflammation to an epithelial surface” (a annotated glossary of terms in endodontics). It also states that the term dental fistula “should be discouraged, and the more proper term sinus tract should be used.” In 1961, Bender and Seltzer reported that they found sinus tracts to be lined with granulation tissue not epithelium.[1] Cutaneous sinus tracts of dental origin are often initially misdiagnosed and inappropriately treated because of their uncommon occurrence and the absence of symptoms in approximately half the individuals affected.[2] Due to the extraoral location of the sinus, patients tend to seek medical care first. Formation of an acute periapical abscess leads to it draining along a path of least resistance.[3] The odontogenic abscess may spread to deeper tissues causing fascial space infection or it may establish intraoral or extraoral drainage in the form of a sinus tract. Intraoral or extraoral sinus-tract opening depends on the location of the perforation in the cortical plate by the inflammatory process and its relationship to facial muscle attachments. If the apices of the teeth are above the maxillary muscle attachments and below the mandibular muscle attachments, the infection may spread to extra-oral regions. After formation of a sinus tract, the inflammation at the apex of the root may persist for a long period because of the drainage through the sinus tract, a chronic abscess can remain asymptomatic for extended periods. If there is a closure of the sinus tract, then the chronic abscess may become symptomatic.

  Case Report Top

A 32-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of a boil on the upper right side of the face for 4 months. He reported with neither relevant medical history nor a history of tobacco habits. The boil had occurred for 4 months on the upper right side of the face. He visited the local doctor and was prescribed medication for the same. On taking medication, the boil had reduced slightly. On extraoral examination, a carbuncle was seen on the upper right side of the face near the right commissure of the lip [Figure 1]. The approximate size was 0.5 cm in diameter and it was round. No draining from the carbuncle was present, and on palpation, the area was not tender. An attempt was made to insert a 0.4/25% gutta-percha cone through the sinus opening to trace the source of infection. However, the gutta-percha cone could not be inserted more than a few millimeters. Palpation of the left and right submandibular and submental lymph nodes was done, and no enlargement or tenderness was noted.
Figure 1: Pretreatment showing extraoral sinus

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On intraoral examination, the tooth 15 was intact and an opaque, discolored distal marginal ridge was observed suggestive of deep proximal caries [Figure 2]. Unilateral buccal cortical plate expansion was felt near 15, and the tooth had no tenderness to palpation. He was advised an intraoral periapical radiograph for tooth 15.
Figure 2: Intraoral pretreatment image

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Radiographic interpretation [Figure 3] showed an ill-defined radiolucency which was seen near the distal part of the crown, involving the enamel, dentin, and approximating the pulp. A single root was seen with a single canal present. Lamina dura was lost from the mesial aspect of the root, and periodontal widening was present. An ill-defined radiolucency was seen in the periapical region suggestive of a periapical abscess. The tooth responded negatively to the pulp vitality test. The provisional diagnosis was a nonvital maxillary second premolar with an apical lesion and an extraoral sinus.
Figure 3: Preoperative radiograph

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In the first appointment, the rubber dam was applied and endodontic treatment was initiated. The canal was opened and the working length was obtained through radiographic method [Figure 4] and confirmed using an apex locator. Biomechanical preparation was done using sodium hypochlorite and saline as the irrigating solutions. Calcium hydroxide dressing was then placed into the canal, and a temporary restoration was given. He was recalled after 7 days, and the carbuncle on the cheek had reduced in size. A second-calcium hydroxide dressing was placed, and he recalled after 7 days. On returning to the clinic, the lesion showed a considerable reduction in size, the canal was reopened, calcium hydroxide was removed, the canal was dried using absorbent paper points, and finally, the tooth was obturated using the corresponding gutta-percha and the lateral compaction [Figure 5] and [Figure 6].
Figure 4: Working length radiograph

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Figure 5: Master cone radiograph

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Figure 6: Final obturation radiograph

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He was recalled after a week. There were considerable signs of healing of the extraoral lesion, and in 2 weeks, there was a complete resolution of the extraoral lesion. In the follow-up appointment in the 3rd month [Figure 7] and 6th month [Figure 8], he was found to be asymptomatic, and even the evidence of the extraoral sinus had disappeared.
Figure 7: Extraoral image 3 months posttreatment

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Figure 8: Extraoral image 6 months posttreatment

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  Discussion Top

Chronic infection around the apex of a dental root can drain in the mouth or less commonly on the skin through a sinus tract. Dental symptoms are not always present and this confuses the clinical picture further.[4] When a draining lesion is observed on the facial skin, an endodontic origin should always be considered in the differential diagnosis. Differential diagnosis of a cutaneous draining sinus tract should include suppurative apical periodontitis, osteomyelitis, pyogenic granuloma, congenital fistula, salivary gland fistula, infected cyst, and deep mycotic infection.[5] The evaluation of a cutaneous sinus tract must begin with a thorough patient history and awareness that any cutaneous lesion of the face and neck could be of dental origin. Approximately 80% of the reported cases are associated with mandibular teeth and 20% with maxillary teeth.[6] Most commonly involved areas are the chin and submental region. The other uncommon locations are the cheek, canine space, nasolabial fold, nostrils, and inner canthus of the eye.[7] If the sinus tract is patent, a lacrimal probe or a gutta-percha cone can be used to trace its track from the cutaneous orifice to the point of origin, which is usually a nonvital tooth.[8] Cutaneous sinuses have a wide range of incidence. The youngest individual reported to have a cutaneous odontogenic sinus tract was a boy who aged 10 months (Cohen and Eliezri 1990) and the oldest was 110 years of age (Cioffi et al. 1986). The cutaneous lesion may develop as early as a few weeks (Spear et al. 1983) or as late as 30 years (Cohen and Eliezri 1990). The principle to managing such lesions is to remove the source of dental infection. Conventionally, the root canal treatment was performed as a multiple visit procedure, as it was thought that the elimination of bacteria, and therefore its success, was possible only with a prolonged period of intracanal antimicrobial medicaments. However, the healing potential for the teeth that are treated in one or two visits with the placement of an intracanal medicament appears to be similar.[9],[10] The key to successful treatment is ensuring adequate measures to eliminate intracanal nonsurgical management of long-standing extraoral sinus in the submental region have proved that chlorhexidine and sodium hypochlorite were the best among the irrigants, as they could reduce the bacterial counts rapidly. Complete healing of the extraoral sinus indicates the adequacy of the disinfection procedure.[11] Unless the dental focal infection is treated adequately, reoccurrence is likely. If correctly diagnosed and treated, the sinus tract is expected to disappear within 7–14 days as was evident in the case reported.[12]

  Conclusion Top

It may be concluded that the correct diagnosis is the key to treat sinus tracts. Successful management of odontogenic extraoral sinus tracts with pulpal pathology depends on the proper diagnosis and removal of etiological factors by proper bio- and chemo-mechanical preparation and three-dimensional obturation. The present case report demonstrates nonsurgical conservative endodontic management which resulted in the elimination of a cutaneous sinus tract of dental origin with minimal scar formation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Cohenca N, Karni S, Rotstein I. Extraoral sinus tract misdiagnosed as an endodontic lesion. J Endod 2003;29:841-3.  Back to cited text no. 1
Cantatore JL, Klein PA, Lieblich LM. Cutaneous dental sinus tract, a common misdiagnosis: A case report and review of the literature. Cutis 2002;70:264-7.  Back to cited text no. 2
American Association of Endodontists. Glossary of Contemporary Terminology for Endodontics. 5th ed. Chicago: American Association of Endodontists; 1994. p. 22.  Back to cited text no. 3
Sammut S, Malden N, Lopes V. Facial cutaneous sinuses of dental origin – A diagnostic challenge. Br Dent J 2013;215:555-8.  Back to cited text no. 4
Abuabara A, Schramm CA, Zielak JC, Baratto-Filho F. Dental infection simulating skin lesion. An Bras Dermatol 2012;87:619-21.  Back to cited text no. 5
Mittal N, Gupta P. Management of extra oral sinus cases: A clinical dilemma. J Endod 2004;30:541-7.  Back to cited text no. 6
Cioffi GA, Terezhalmy GT, Parlette HL. Cutaneous draining sinus tract: An odontogenic etiology. J Am Acad Dermatol 1986;14:94-100.  Back to cited text no. 7
McWalter GM, Alexander JB, del Rio CE, Knott JW. Cutaneous sinus tracts of dental etiology. Oral Surg Oral Med Oral Pathol 1988;66:608-14.  Back to cited text no. 8
Trope M, Delano EO, Orstavik D. Endodontic treatment of teeth with apical periodontitis: Single vs. multivisit treatment. J Endod 1999;25:345-50.  Back to cited text no. 9
Weiger R, Rosendahl R, Löst C. Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions. Int Endod J 2000;33:219-26.  Back to cited text no. 10
Spratt DA, Pratten J, Wilson M, Gulabivala K. An in vitro evaluation of the antimicrobial efficacy of irrigants on biofilms of root canal isolates. Int Endod J 2001;34:300-7.  Back to cited text no. 11
Dincol ME, Yilmaz B, Ersev H, Mert Gunduz V, Arslanoglu B, Yalcin TY, et al. Treatment of extraoral cutaneous sinus tracts with non-surgical endodontic intervention: Report of six cases. J Istanb Univ Fac Dent 2015;49:35-40.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

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