Cutaneous odontogenic sinus: an inflammatory mimicker of squamous cell carcinoma and epidermal cysts.

An odontogenic cutaneous sinus tract (OCST) of dental origin is an uncommon and frequently misdiagnosed lesion that is caused by chronic periodontitis. Given that OCSTs often lack symptoms, are located on the lower face, and can have notable variations in clinical appearance, they can be mistaken for more common dermatologic diagnoses such as squamous cell carcinomas (SCCs) and cysts. We present 2 patients with OCSTs who were referred for cutaneous surgery for a rendered diagnosis of an SCC and epidermal cyst. A proper diagnosis was rendered after a high index of suspicion, and clinicopathologic correlation led to additional testing and eventual referral to oral surgery for an OCST.

A Case of External Dental Fistula Related to a Fixed Cantilever Bridge.

An external dental fistula is a skin manifestation caused by an underlying dental problem. We report a rare case of external dental fistula associated with a fixed cantilever denture. A 77-year-old Japanese woman presented with an enlarging reddish granulomatous lesion on her right cheek that was diagnosed as an external dental fistula. A fixed cantilever denture had initially been attached to her upper jaw with her seven bona fide teeth. However, six teeth were completely lost and the denture was attached to only one tooth, which showed apical periodontitis. Subsequently, the external dental fistula developed. We should keep in mind that a patient with a fixed cantilever denture can suffer from apical periodontitis and a subsequent external dental fistula due to a failure to maintain appropriate oral hygiene.

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.

A Pathological Fracture of the Mandible due to Osteomyelitis following a Full Dental Clearance.

Orofacial infections following dental extractions are a common referral to an oral and maxillofacial department as an emergency, especially when combined with swelling and limited mouth opening. The case presented demonstrates a rare complication of chronic suppurative osteomyelitis with bilateral pathological fractures of the mandible, which occurred following a staged dental clearance. CPD/Clinical Relevance: Dental extractions are one of the most common treatments carried out by oral surgeons and general dental practitioners. This case highlights a rare but encountered complication of routine oral surgery and demonstrates when it is necessary to make an immediate referral to the local oral and maxillofacial surgery unit.

A case of nasal septal abscess caused by medication related osteonecrosis in breast cancer patient.

Antiresorptive drugs have been widely used to treat patients with hypercalcemia caused by malignancy, bone metastasis, multiple myeloma, and osteoporosis. However, it is well known that antiresorptive drugs can cause osteonecrosis of the jaw (ONJ). Herein, we report a rare case of nasal septal abscess caused by medication related osteonecrosis of the jaw (MRONJ) in a breast cancer patient. A 69-year-old woman was referred to our clinic for evaluation of nasal obstruction. Physical examination revealed a cherry-like swelling of the nasal mucosa emanating from the septum that obstructed both nasal cavities and a fistulous tract showing pus discharge after extraction of the bilateral maxillary central incisors (MCI) and the right maxillary lateral incisor (MLI). Computed tomography and panoramic radiography revealed extensive osteonecrosis of the maxilla and swelling of the nasal mucosa. The clinical diagnosis was nasal septal abscess caused by osteonecrosis of the maxilla. Surgical procedure was undertaken for this case. An indwelling drain was placed in the oral cavity, and sequestrectomy was performed with incision and drainage of the anterior portion of left nasal septum. The patient was doing well at the 7-month follow-up. The patient had a medical history of breast cancer with bone, lung, liver metastases, and had received intravenous bisphosphonate, which is one of the antiresorptive medicines, over the past 4 years. We suspect that this history played an important role in MRONJ induced nasal septal abscess.

Sclerosis in bisphosphonate-related osteonecrosis of the jaws and its correlation with the clinical stages: study of 43 cases.

We analysed the degree of sclerosis in the different stages of bisphosphonate-related osteonecrosis of the jaws (BRONJ) and studied the relation between the grade of sclerosis, the clinical symptoms, and the depth of lucency. We compared 43 patients with mandibular BRONJ with a control group of 40 cases with no bony lesions. The presence of sclerotic bone, cortical irregularities, radiolucency, fragmentation or sequestration, periostitis, and narrowing of the mandibular canal were studied from computed tomographic (CT) scans using the program ImageJ 1.47v (National Institute of Health, Bethesda, USA) to measure the radiolucency, width of the cortices, and degree of sclerosis. Patients with BRONJ had more severe sclerosis than controls (p<0.01). There was also a significant difference among the different stages of BRONJ, with the highest values found in stage III (p=0.02). The degree of sclerosis differed according to sex, type of bisphosphonate, and the clinical characteristics such as pain, or suppuration, but not significantly so (p>0.05). We conclude that the degree of sclerosis increases with the clinical stage of BRONJ, and is correlated with the depth of lucency.

Immediate loading of implants placed in patients with untreated periodontal disease: a 5-year prospective cohort study.

PURPOSE: To report the 5-year outcome of immediately loaded dental implants in patients with untreated periodontal disease. MATERIALS AND METHODS: This prospective cohort study included 103 consecutive patients (51 females and 52 males) with an average age of 52 years (range: 22 to 80 years) who were rehabilitated with 380 implants supporting 145 prostheses in both jaws (40 single; 33 partial and 72 complete rehabilitations). The implants were inserted in patients with active and untreated periodontitis. The patients did not receive any previous periodontal treatment before implant surgery, except for an oral hygiene session immediately before the implant surgery. In maintenance (every 6 months) patients received periodontal treatment as needed. Outcome measures were: prostheses failures; implant failures; complications; and marginal bone level changes. RESULTS: Fifteen patients dropped out of the study (14.6%). Two patients lost two implants (FDI positions nos.12 and 42), rendering a cumulative survival rate of 97.9% and 99.4% at 5 years of followup using the patient and implant as unit of analysis, respectively. The average (standard deviation) marginal bone resorption was 0.71 mm (0.42 mm) at 5 years. Mechanical complications occurred in 14 patients, consisting of prostheses fractures (10 provisional prostheses and 4 definitive prostheses). Thirteen implants (3.9%) in 13 patients (14.8%) presented peri-implant pathology. CONCLUSIONS: Within the limitations of this study, it is possible to conclude that the rehabilitation of patients with untreated periodontitis using immediately loaded dental implants is feasible in the medium-term, when periodontal therapy is provided after rehabilitation and the patients are regularly maintained.

Outcomes of periradicular surgery of maxillary first molars using a vestibular approach: a prospective, clinical study with one year of follow-up.

PURPOSE: The aim of the present prospective, randomized, controlled, clinical study was to compare the outcomes of periradicular surgery of the maxillary first molar tooth using the vestibular approach between 2 preoperative radiologic evaluation methods: cone beam computed tomography (CBCT) and conventional radiography. PATIENTS AND METHODS: Periradicular surgery was applied to the maxillary first molar tooth in 40 patients. The patients were divided into 2 groups. The patients in group 1 underwent examination and preoperative planning with CBCT, and the patients in group 2 underwent examination and preoperative planning with conventional radiography. The outcomes of the treatment were evaluated radiographically and clinically, and the data were analyzed statistically. RESULTS: The mean operative time was significantly shorter in group 1 than in group 2. According to the radiographic and clinical healing criteria used in the present study, the healing of patients in group 1 was rated as a success in 35%, an improvement in 40%, and a failure in 25%. In the group 2 patients, healing was rated as a success in 42.1%, an improvement in 31.6%, and a failure in 26.3%. Sinus membrane elevation was performed in 92.3% of all patients. Sinus membrane perforation occurred in 20% of the patients in group 1 and 36.8% of the patients in group 2. CONCLUSIONS: Periradicular surgery of maxillary first molars using a vestibular approach is a viable treatment method with a low complication rate. Preoperative CBCT examination demonstrated positive contributions to the treatment outcomes.

Odontogenic cutaneous draining sinus.

The aim of the present article was to discuss an unusual case report of the odontogenic cutaneous sinus with emphasis on diagnosis and treatment. The causative factor in this case was diagnosed intraoperatively due to infected follicular space in absence of any sign and symptoms. Timely diagnosis of the case could have prevented significant morbidity due to mistreatment medically and surgically with eventual recurrence.

To retrieve or not to retrieve the coronectomy root--the clinical dilemma.

UNLABELLED: Coronectomy of mandibular third molars is a well established technique that is going through a resurgence as it seems to reduce the risk of inferior dental nerve (IDN) injury. The reservation with the technique arises because of fear that the retained root will become infected and symptomatic over time. General dental practitioners will be responsible for the long-term review and care of these patients and, consequently, it is important that they are aware of the technique and its sequelae. CLINICAL RELEVANCE: Coronectomy of mandibular third molars to avoid nerve injury is becoming increasingly popular. It is important that general dental practitioners (GDPs) are aware of the immediate and later sequelae of treatment and the implication of the retained root.

Endodontic and surgical treatment of root damage caused by orthodontic miniscrew placement.

INTRODUCTION: Miniscrews are being increasingly used for anchorage control in orthodontics. Despite the concern over root damage caused by miniscrews, there are few reports of precise clinical evaluations and appropriate management of that damage. In the case presented herein, the root damage caused by the placement of miniscrews was repaired by root canal treatment and surgical intervention. METHODS: A 44-year-old man received orthodontic treatment for intrusion of the left maxillary first molar with a miniscrew anchorage system. During that treatment, the miniscrews had fallen out and had to be reinserted more than 6 times in the same area. Two years later, the patient complained of a spontaneous pain in the maxillary left molar region. Although the patient received root canal treatment, intraoral sinus tracts could still be detected, and the patient's discomfort persisted. Periradicular surgery revealed that the persistent infection was related to root surface damage caused by orthodontic miniscrew placement. Healing was achieved by a combination of root canal treatment and surgical intervention. RESULTS: Scanning electron microscopy of the damaged distobuccal root apex revealed a mature biofilm consisting of a network of matrix that contained mostly rod-like and spherical bacteria. At a 12-month recall checkup, the patient was free of pain. A repeat periapical radiograph revealed reduction of the pretreatment radiolucent lesion. CONCLUSIONS: More careful planning of miniscrew placement is necessary to lessen the danger of root damage. Furthermore, a precise evaluation of both root and pulpal damage and careful consideration of the choice of optimal treatment modality are needed.

Inflammatory implant periapical lesion prior to osseointegration: a case series study.

PURPOSE: To report 20 cases with implant periapical pathology diagnosed during the osseointegration phase, evaluating retrospectively the efficacy of the treatment with implant periapical surgery. MATERIALS AND METHODS: A retrospective chart review was conducted of all patients in whom implant periapical surgery was performed between 1996 and 2010. The criteria for diagnosing implant periapical pathology and, accordingly, performing implant periapical surgery were: (1) acute pain during the osseointegration period (8 weeks after implant placement) located in the area of the affected implant or presence of mucous fistula in relation with the implant apex; (2) absence of implant mobility; (3) non-dull percussion of nonsubmerged implants; and (4) presence or absence of implant periapical radiolucency. RESULTS: Twenty-two implants were diagnosed with periapical pathology in 20 patients (13 women and 7 men) with a mean age of 54.3 years (range, 32 to 70 years) and were consecutively treated by a surgical approach. In 19 implants, the diagnosis was acute apical peri-implantitis (nonsuppurated in 7 cases and suppurated in 12), as based on the symptoms and radiographic sign, and in 3 cases it was subacute apical peri-implantitis, as based on the presence of a fistula. After a minimum follow-up of 1 year, 20 implants remained functional, with no clinical or radiologic alterations; the survival rate of the treated implants was 91%. CONCLUSION: The early diagnosis of inflammatory implant periapical lesions during the osseintegration phase, and their prompt surgical treatment, led to a survival rate of the treated implants of 91%.

La fístula dentoalveolar: ¿un síntoma o una enfermedad? / The dentoalveolar sinus tract, a symptom or an illness?

La fístula dentoalveolar se desarrolla como una ruta de drenaje desde una lesión inflamatoria periapical, siguiendo el camino de menor resistencia, a través de hueso, periostio y mucosa. Puede salir a través de cualquier punto de la mucosa bucal o aún por la piel. Algunos profesionales están convencidos de que la presencia de una fístula indica una lesión seria que requiere cirugía apical e incluso la exodoncia. Sin embargo, su tratamiento tiene buen pronóstico, siendo la indicación correcta una adecuada terapia endodóntica no quirúrgica.

Multiple cemental tears.

A cemental tear is a pathologic condition in which a complete or incomplete separation of the cementum occurs along the root surface and is usually accompanied by a deep periodontal pocket. Past articles report that the incidence of cemental tears has usually been limited to 1 tooth per individual. We encountered a clinical case with cemental tears involving 14 teeth in 1 individual. Multiple cemental tears in 1 individual have not been previously described in the dental literature. We present the clinical and pathologic features of this rare case and suggest that the probable cause of multiple cemental tears is structural weakness of the cementum.

Dental infection simulating skin lesion.

Orocutaneous fistulas or cutaneous sinus, a tract of dental origin, is an uncommon but well-documented condition that usually requires emergency treatment. Such condition may be misdiagnosed by physicians and dentists and may sometimes be confused with bone and skin tumor, osteomyelitis, congenital fistula, salivary gland fistula, pyogenic granuloma, infected cyst, deep mycotic infection, and other pathologies. A case of facial sinus tract that was initially misdiagnosed by a physician as a nonodontogenic lesion is presented. Nonsurgical endodontic therapy was the treatment of choice for this case. Facial cutaneous sinus tracts must be considered of dental origin. Early diagnosis and prompt treatment minimize patient discomfort and esthetic problems, reducing the possibility of further complications such as sepsis and osteomyelitis.

Dental infection simulating skin lesion / Infecção dentária simulando uma lesão de pele

Orocutaneous fistulas or cutaneous sinus, a tract of dental origin, is an uncommon but welldocumented condition that usually requires emergency treatment. Such condition may be misdiagnosed by physicians and dentists and may sometimes be confused with bone and skin tumor, osteomyelitis, congenital fistula, salivary gland fistula, pyogenic granuloma, infected cyst, deep mycotic infection, and other pathologies. A case of facial sinus tract that was initially misdiagnosed by a physician as a nonodontogenic lesion is presented. Nonsurgical endodontic therapy was the treatment of choice for this case. Facial cutaneous sinus tracts must be considered of dental origin. Early diagnosis and prompt treatment minimize patient discomfort and esthetic problems, reducing the possibility of further complications such as sepsis and osteomyelitis.

A fístula orocutânea de origem dentária é uma condição incomum, bem documentada e geralmente requer tratamento de urgência. Esta condição pode ser confundida por médicos e dentistas com lesões ósseas, de pele, nas glândulas salivares, osteomielite, granuloma piogênico, cisto infectado, infecção fúngica, entre outras. Um caso de fístula facial que foi inicialmente diagnosticado por um médico como uma lesão não-odontogênica é apresentado e discutido. O tratamento de escolha foi a endodontia do dente envolvido, sem necessidade de cirurgia. A possibilidade de infecção dentária deve ser considerada em casos de fístula cutânea na região orofacial. O diagnóstico precoce e tratamento imediato podem minimizar o desconforto do paciente e problemas estéticos, além de reduzir a possibilidade de outras complicações, como osteomielite e sepse.

Root perforation associated with the use of a miniscrew implant used for orthodontic anchorage: a case report.

AIM: To highlight one of the possible complications associated with the inter-radicular placement of orthodontic miniscrews. SUMMARY: This case report describes the endodontic treatment and surgical repair of an iatrogenic root perforation involving a maxillary first molar tooth following the placement of an orthodontic miniscrew placed for anchorage purposes in the treatment of an adult patient. The orthodontic treatment plan was completed. The long-term follow-up shows a successful treatment outcome. KEY LEARNING POINTS: Inter-radicular placement of orthodontic miniscrews is a valuable source of anchorage in the treatment of orthodontic patients. Root perforation is a possible complication from inter-radicular placement of orthodontic miniscrews. Root perforation can be successfully treated, but may involve apical surgery.

Human histologic evaluation of the use of the dental putty for bone formation in the maxillary sinus: case series.

A proof-of-principle study was conducted to assess the safety and efficacy of dental putty as an alternative sinus augmentation biomaterial. Six healthy patients requiring a total of 10 sinus augmentations received sinus augmentations. All patients volunteered and signed an informed consent based on the Helsinki declaration of 1975, as revised in 2000. The sinus augmentation was performed under local anesthesia with a mucoperiosteal flap elevated to expose the buccal wall of the maxillary sinus. The space was then filled with the dental putty in several increments, and the window was covered with an absorbable collagen membrane. Biopsies were harvested from all 10 treated sinuses using a 3-mm trephine bur at the time of implant placement at either 6 or at 9 months after sinus augmentation. All patients completed the study without complications, except for 1 patient who reported fistulas at 1 and 2 months after the surgery. Clinical reentry revealed that regenerated bone on the osteotomy site was soft and immature. The ground sections of the biopsied cores revealed minimum amounts of trabeculation surrounded by an abundant array of irregular-shaped residual alloplastic particles embedded in loose connective tissue. The present study's findings revealed inadequate bone formation, although the material appears to be bioinert as there is no elicitation of inflammatory response.

A clinical predicament--diagnosis and differential diagnosis of cutaneous facial sinus tracts of dental origin: a series of case reports.

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