Odontogenic cutaneous sinus tract presenting as a growing cheek mass in the emergency department.

An odontogenic cutaneous sinus tract (OCST) is a rare extraoral sinus tract related to a chronic draining dental infection, typically apical periodontitis. OCST usually presents as an erythematous and non-tender nodule and often requires endodontic treatment for resolution of the sinus tract. If there is disruption of the mandibular cortex, it may be difficult to differentiate an OCST from a non-odontogenic malignant mass in patients without dental symptoms. This report describes a rare case of OCST presenting as a left cheek mass in a 21-year-old man which was initially diagnosed in the emergency department.

Cutaneous Sinus Tract from Mandibular Second Molar with C-shaped Canal System and Improper Former Root Canal Treatment: A Case Report.

Here, we report the diagnosis and treatment of an extraoral cutaneous sinus tract originating in a mandibular second molar with a C-shaped root canal system. The patient was referred to our department by a dermatologist after a series of unsuccessful treatments, including antibiotics. Diffuse radiolucency on a preoperative radiograph revealed that earlier root canal treatment had been only partially successful. Consequently, we performed retreatment of the root canal comprising removal of the former restoration and gutta-percha, cleaning and shaping, and passive irrigation with sodium hypochlorite. The patient responded well, and the cutaneous lesion completely resolved uneventfully within 1 month postoperatively. Preoperative recognition and thorough knowledge of the root canal anatomy and conventional methods of obturation are necessary in performing successful endodontic treatment.

Submental cutaneous sinus tract of mandibular second molar origin.

AIM: To report a case in which a submental cutaneous sinus tract resulted from apical periodontitis associated with a mandibular second molar. SUMMARY: A 53-year-old man presented with a chronic cutaneous sinus tract in the submental region, which had previously been misdiagnosed as a thyroglossal fistula. The origin of the sinus tract was shown by sinus tract angiography to be the left mandibular second molar (tooth 37), which had apical periodontitis. The sinus tract healed after extraction of the tooth and partial excision of the lesion from an extraoral approach. Histological examination confirmed that the tract was lined with granulation tissue and not with epithelial tissue. A submental sinus tract drainage pathway was observed. Prompt dental evaluation, especially of all mandibular teeth, should be considered when assessing cases of submental cutaneous sinus tracts. KEY LEARNING POINTS: An odontogenic origin should be part of the differential diagnosis for orofacial skin lesions. Cutaneous sinus tracts of mandibular molar origin are complex and thus a comprehensive examination should be stressed. It is necessary to examine all mandibular teeth in cases of odontogenic submental cutaneous sinus tracts. Sinus tract angiography can be used to identify the sinus tract pathway and to confirm the associated teeth. The treatment of an odontogenic cutaneous sinus tract requires the elimination of the source of infection.

A prospective study of the factors affecting outcomes of nonsurgical root canal treatment: part 1: periapical health.

AIM: To investigate the probability of and factors influencing periapical status of teeth following primary (1°RCTx) or secondary (2°RCTx) root canal treatment. METHODOLOGY: This prospective study involved annual clinical and radiographic follow-up of 1°RCTx (1170 roots, 702 teeth and 534 patients) or 2°RCTx (1314 roots, 750 teeth and 559 patients) carried out by Endodontic postgraduate students for 2-4 (50%) years. Pre-, intra- and postoperative data were collected prospectively on customized forms. The proportion of roots with complete periapical healing was estimated, and prognostic factors were investigated using multiple logistic regression models. Clustering effects within patients were adjusted in all models using robust standard error. RESULTS: proportion of roots with complete periapical healing after 1°RCTx (83%; 95% CI: 81%, 85%) or 2°RCTx (80%; 95% CI: 78%, 82%) were similar. Eleven prognostic factors were identified. The conditions that were found to improve periapical healing significantly were: the preoperative absence of a periapical lesion (P = 0.003); in presence of a periapical lesion, the smaller its size (P ≤ 0.001), the better the treatment prognosis; the absence of a preoperative sinus tract (P = 0.001); achievement of patency at the canal terminus (P = 0.001); extension of canal cleaning as close as possible to its apical terminus (P = 0.001); the use of ethylene-diamine-tetra-acetic acid (EDTA) solution as a penultimate wash followed by final rinse with NaOCl solution in 2°RCTx cases (P = 0.002); abstaining from using 2% chlorexidine as an adjunct irrigant to NaOCl solution (P = 0.01); absence of tooth/root perforation (P = 0.06); absence of interappointment flare-up (pain or swelling) (P =0.002); absence of root-filling extrusion (P ≤ 0.001); and presence of a satisfactory coronal restoration (P ≤ 0.001). CONCLUSIONS: Success based on periapical health associated with roots following 1°RCTx (83%) or 2°RCTx (80%) was similar, with 10 factors having a common effect on both, whilst the 11th factor 'EDTA as an additional irrigant' had different effects on the two treatments.

Endodontic-periodontal management of two rooted maxillary lateral incisor associated with complex radicular lingual groove by using spiral computed tomography as a diagnostic aid: a case report.

AIM: To present the successful endodontic and periodontal management of a two rooted maxillary lateral incisor tooth with a complex radicular lingual groove and severe periodontal destruction using spiral computed tomography as a diagnostic aid. SUMMARY: A 30-year-old male patient presented with a chief complaint of mobility and discharge of pus in an upper front tooth. Clinical examination revealed a sinus tract on the labial gingival surface and a 10-mm-deep periodontal pocket associated with maxillary left lateral incisor tooth. On the lingual side, a groove emerging from cingulum, continuing mesioapically down the lingual aspect of tooth was found. Intraoral periapical radiographs demonstrated a lateral periodontal defect around the mesial aspect and a diffuse radiolucency at the apex of maxillary left lateral incisor tooth. The sinus tract was traced with gutta-percha to the maxillary left lateral incisor that showed an accessory root surrounded by a large radiolucent area. A spiral computed tomographic scan for better understanding of the complicated root canal morphology of the tooth was performed. Based on the clinical, radiographic and spiral computed tomographic findings, a diagnosis of an endo-perio lesion in tooth 22 was made. Management consisted of conventional root canal treatment, radiculoplasty, root resection of accessory root and surgical curettage of the periodontal defect. Follow-up with radiographic examination at 3 months and 1 year was performed. At 1-year recall, the patient was asymptomatic, there was no evidence of the sinus tract and a 3-mm nonbleeding pocket was present in relation to tooth 22. Progression of hard tissue healing was observed in the periapical radiograph taken 1 year postoperatively. KEY LEARNING POINTS: The key to achieving favourable results in this particular type of developmental anomaly is accurate diagnosis and treatment planning. The health of the periapical osseous tissues appears to be the provital factor for tooth retention. A favourable outcome can only be achieved with a comprehensive treatment approach that effectively manages all local factors that are contributing to the disease process.

[An index for untreated severe caries]. / Een index voor onbehandelde ernstige cariës.

Hardly any data are available on the clinical consequences of untreated severe caries, because there is no method to quantify the prevalence of oral conditions resulting from untreated caries. In the Philippines, an index was developed which records for (the location of) each tooth whether caries has reached the dental pulp, whether ulceration is present in the surrounding soft tissues due to sharp edges of fragments of a tooth lost due to caries, or whether a fistula or abscess is present. By adding the index to the existing Decayed Missing Filled Tooth index, insight is provided on the extent and the consequences of untreated caries and research may be carried out on its possible impact on the general health and wellbeing of national populations.

A clinicopathologic correlation in the diagnosis of periradicular lesions of extracted teeth.

PURPOSE: We aimed to determine the contributory percentage of histopathologic diagnoses of routine biopsies and to ascertain the possible indicators for histopathologic examination to confirm the clinical diagnosis of periradicular lesions of extracted teeth. PATIENTS AND METHODS: This was a prospective study carried out over a period of 8 months on patients who had single tooth extraction and routine histopathologic examination of recoverable periradicular tissues from extracted teeth. RESULTS: A total of 136 patients participated in this study. There was a male/female incidence ratio of 3:2 and most of the patients with histopathologically diagnosed lesions were within the first, second, and third decades of life (n = 49, 36.0%). Seventy-five (55.2%) cases had histopathologically diagnosed periradicular lesions, which were mostly periapical abscess (n = 30, 22.8%) and inflammatory (periapical) granuloma (n = 23, 16.9%). Some clinical and radiologic features were associated significantly with histopathologic diagnosis of some periradicular lesions (P < .05). There also was a significant correlation of clinical diagnosis with histopathologic diagnosis of inflammatory (periapical) granuloma, periapical abscess, chronic osteomyelitis, and Burkitt's lymphoma (P < .05). CONCLUSIONS: This study shows a higher contributory percentage of histopathologic diagnoses after routine biopsies, compared to previous reports from selected biopsies of periradicular lesions. We identified clinical indicators for predicting possible histopathologic diagnosis of some periradicular lesions, in particular, those that predict possible histologic diagnosis of neoplastic periradicular lesions.

Clinicopathological profile and surgical results of nonhealing sinuses and fistulous tracts of the head and neck region.

PURPOSE: The sinus and fistulous tracts in the head and neck region often pose a challenge to the surgeon, and are usually misdiagnosed, resulting in treatment failure. MATERIALS AND METHODS: This study included 117 patients who presented to the Department of Dental and Maxillofacial Surgery, Department of General Surgery, and Department of Dermatology of the Sheri-Kashmir Institute of Medical Sciences Medical College (Srinagar, India) over a period of 7 years. All 117 patients were analyzed using clinical methods, radiologic studies, and laboratory investigations. RESULTS: The mean age of patients was 30 years, with a male-to-female ratio of 3:2. A dental origin was noticed in 55% of these tracts, followed by tracts originating from infected implants or bone grafts (20%) and chronic osteomyelitis (11%). Eighty percent of these tracts had a mandibular origin (and from the anterior part) (53%). Maxillary tracts arose mostly from the posterior part of the bone (70%). The commonest presenting symptom was discharge from a nonhealing wound. Anterior mandibular tracts were straight and short (84%), whereas posterior mandibular tracts were mostly long and curved (75%). Misdiagnosed and mismanaged sinuses and fistulas were mostly of odontogenic origin (70%). Radiologic studies were the most useful diagnostic tools in tracts related to dental pathology, infected implants/bone grafts, and chronic osteomyelitis. Proper treatment of basic pathology was followed by complete healing in 96% of patients. CONCLUSION: All patients with sinus or fistulous tracts in the head and neck region should be properly assessed and evaluated for proper diagnosis and treatment, to prevent the recurrence and chronicity of these lesions.

Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision.

Pulp canal obliteration (PCO) is a sequela of tooth trauma. The dental clinician faced with this condition has to make a difficult decision. The aim of this study was to evaluate the clinical signs and symptoms associated with teeth with PCO and to assess the status of the periapical tissues using the periapical index (PAI) as an aid in making a treatment decision. The study included teeth diagnosed with PCO in patients with a history of traumatic injury to the involved teeth. Histories of associated signs and symptoms including pain, swelling and drainage from a sinus tract were elicited. Tooth color, sensibility to electric pulp testing, mobility and percussion tenderness were recorded. The periapical status was assessed using the PAI. Two hundred and seventy-six teeth were diagnosed with PCO. One hundred and fifty-seven (56.9%) and 119 (43.1%) demonstrated partial or total PCO, respectively. Yellow discoloration presented most frequently, occurring in 186 (67.4%) teeth. Sixty-two (33.3%) of these had developed periapical lesions and reacted negatively to sensibility testing. Fifty-seven (30.7%) of these teeth presented radiographically with a normal periapical appearance and reacted normally to sensibility testing, whereas 67 (36.0%) presented with small changes in the periapical bone pattern and reacted in the high normal range to sensibility testing. Teeth with PAI scores < or =2 presented with occasional spontaneous pain. Teeth with PAI scores > or =3 presented with clinical symptoms and signs ranging from pain on percussion to spontaneous pain, and slight swelling to sinus tract drainage. Based on the findings of this study, endodontic treatment should be initiated in teeth with tenderness to percussion, PAI scores > or =3 and a negative response to sensibility testing.

A nasopalatine duct cyst in a 7-year-old child.

The nasopalatine duct cyst (NPDC) is a developmental cyst of the anterior palate's midline, usually presenting as an asymptomatic swelling located just behind the maxillary central incisors. It is the most common non-odontogenic cyst of the jaws but is seen rarely in children. The purpose of this paper was to report an unusual case of nasopalatine duct cyst in a 7-year-old boy who presented with a slow-growing, slight swelling of the anterior palate together with malpositioned permanent maxillary central incisors. Although rare in children, NPCD should be included in the differential diagnosis of anterior palate swelling, particularly if associated with malpositioned maxillary central incisors.

A case of cutaneous odontogenic sinus.

Despite the fact that cutaneous sinus tracts of odontogenic origin are well documented, the condition is still commonly misdiagnosed, because chronic periapical periodontitis may be asymptomatic and is rarely open to the skin. A 75-year-old Japanese woman presented to our clinic with the chief complaint of a left cheek skin lesion with mild pain. Physical examination revealed a subcutaneous nodule covered with erythematous skin on her left buccal region. Cultures from the subcutaneous nodule grew Bacteroides species and Peptostreptococcus micros but did not yield acid-fast bacilli, fungi, or Actinomyces. Stains of smeared pus showed a considerable number of Gram-negative rods. The histopathological examination revealed a focal abscess formation in the lower dermis and subcutaneous tissue. Dental evaluation, including an orthopantogram, showed a radiolucent alveolar area at the left lower first molar apex, suggesting a periapical abscess. Antibiotic therapy for three weeks associated with surgical root canal therapy eliminated the subcutaneous nodule. A high degree of suspicion is required to correctly diagnose a lower facial lesion as being of odontogenic origin, and prompt dental evaluation should be considered.

[Fractures of the canines require attention]. / Een hoektandfractuur verdient de juiste aandacht.

Hardly any attention was paid to a barely visible fracture of a canine tooth (104) in an 18-month-old dog. When the dog was 6-years old, a fistulous opening was seen on the bridge of the nose. A year later, radiography revealed a periapical process. The investigations performed and treatment given are described, as is the correct way to handle fractures of the canines.

Odontogenic cutaneous fistulas: clinical and epidemiologic characteristics of 75 cases.

BACKGROUND: Odontogenic cutaneous fistulas arise as a sequel of bacterial invasion of the dental pulp, become necrotic, and infection spreads into the periradicular area resulting in dissection and breakthrough to form sinus tracts that drain towards the skin. The objective of this study was to investigate the clinical and epidemiologic characteristics of patients diagnosed with odontogenic cutaneous fistulas. METHODS: A retrospective study was done between January 2001 and December 2011. Cases were included with a clinical and radiological diagnosis of odontogenic cutaneous fistulas. The variables investigated were frequency, gender, age, localization, morphology, time of evolution, and referral clinical diagnosis. Data were analyzed using descriptive statistical methods. RESULTS: During an 11-year period, 75 cases were found. Female gender predominated with 53% of the cases, and the mean age was 45 ± 26 years. The most frequent location was the mandible angle, in 36% of the cases, and the most common morphology was a nodule, in 52%. The mean time of evolution was 8 ± 11 months. The referral clinical diagnosis was odontogenic cutaneous fistulas in 51% of the cases. CONCLUSIONS: Our results are similar to those previously published-the diagnosis was suspected in only half of the cases. We consider it important that odontogenic cutaneous fistulas be included among the differential diagnosis of cutaneous facial lesions to avoid delaying appropriate treatment.

[Cutaneous sinus tract due to an asymptomatic dental infection]. / Fisteldannelse i huden som følge af enubehandlet asymptomatisk tandinfektion.

Pyogenic cutaneous lesions of the cervicofacial region may have a variety of causes but one possibility that should be considered is a cutaneous sinus tract (CST) of dental origin. Correct diagnosis is based on a high index of suspicion and radiologic evidence of a dental pathology. Patients with odontogenic CST should be referred to a dentist and the treatment consists of either endodontic therapy or extraction of the involved tooth. We present a case report with misdiagnosis of CST of dental origin.

Histopathologic observations on late oral implant failures.

BACKGROUND: Despite good success rates of osseointegrated oral implants, failures do occur. To minimize losses, failure mechanisms should be elucidated. PURPOSE: This study sought to describe the morphology of tissues surrounding late failed Brånemark implants in relation to their clinical and radiographic findings to acquire a better understanding of the etiologic factors. MATERIAL AND METHODS: Ten failed implants and their surrounding tissues were consecutively retrieved from nine patients after prosthesis placement (late losses). On radiographs, a radiolucent line was visible around nine clinically mobile implants. Tightening of the abutment screw evoked pain at seven mobile implants. Clinically, no other visual inflammatory sign or symptom was manifest. A fistula originated from one stable implant, surrounded on radiographs by a diffuse bone rarefaction. Retrieved implants were electrochemically dissolved. Intact tissue-implant thin (1 micron) and ultrathin (70-80 nm) sections were analyzed with light and transmission electron microscopy. RESULTS: Peri-implant marginal tissues displayed moderate inflammatory infiltrates located adjacent to and beneath the junctional epithelium. One patient affected by oral lichen planus displayed an intense lymphocyte/plasma cell-dominated immune reaction. Deep peri-implant tissues surrounding mobile implants consisted of a dense, fibrous tissue capsule with minimal inflammation. Epithelial downgrowth was observed around four implants. Small areas of nonmineralized bone in contact with the implant were noticed in the apical portion of two implants. One implant was almost entirely colonized by bacterial plaque with the exception of its apical portion, where bone-implant contact was observed. The stable implant was characterized by bone-implant contact. CONCLUSION: Altogether clinical, radiographic, and histologic findings indicated that two major etiologic factors might have been implicated in the failure process of the investigated implants: excessive occlusal load in relation to the bone-supporting capacity and, in two cases, infection.

A bizarre facial sinus.

A 63-year-old Caucasian man presented to his general dental practitioner with a spontaneously exfoliated lower central incisor and hair growing from the socket. Examination revealed a hair-filled sinus from the skin of the median aspect of his chin to the socket of the exfoliated tooth. This was confirmed histopathologically following excision biopsy.