Migratory and Misleading Abscess

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470 Journal ofIndian Society of Periodontology- Vol 19, Issue 4, Jul-Aug 2015

Address for

correspondence:

Dr. Dhruvakumar Deepa,

B-10, Ambedkar Bhawan,

Subhartipuram, Meerut,

Uttar Pradesh, India.

E-mail: deepa_arun@

rediffmail.com

Submission:28-05-2014

Accepted:02-02-2015

Department of Oral

and Maxillofacial

Surgery, 1Department

of Periodontology,

Subharti Dental College

and Hospital, Meerut,

Uttar Pradesh, India

Migratory and misleading abscess oforofacial region

Kubsad Veerabhadrappa ArunKumar, Dhruvakumar Deepa1

Abstract:

Acute pericoronitis usually presents with severe localized pain, swelling and sometimes trismus. However,

chronic pericoronitis and periodontal abscess produce a dull pain, moderate swelling and are occasionally seen

migrating into distant sites producing stulae intraorally and/or extraorally. This may quite often cause diagnosticdilemmas necessitating thorough medical and dental history, careful clinical examination and sometimes special

investigations to conrm the etiology and or origin of infection. Here, we present three such cases and theirmanagement.

Key words:

Migratory abscess, oro-facial abscess, pericoronitis, spread of infection

INTRODUCTION

Dental infections involving the teeth orassociated tissues are caused by oralpathogens that are predominantly anaerobicand usually of more than one species. Origins ofinfections are most commonly progressive dentalcaries or extensive periodontal diseases. Othercauses could be related to pathogens introduceddeeper in the oral tissues by trauma caused bydental procedures such as the contaminationof dental surgical sites (e.g., tooth extraction)and needle tracks during local anesthesia

administration.

Cutaneous sinus tract of the face due toodontogenic infections are uncommon. Most ofthe reported cases have been caused by chronicperiapical abscess of the mandibular teeth. [1,2]The remoteness of the cutaneous sinus tract fromits sites of origin within the oral cavity oftenleads to misdiagnosis and needless cutaneoussurgery. Patients are assuming the cutaneoussinus to be unrelated to the dental infection,often seek treatment from a dermatologist orfrom their physician. After a misdiagnosis ofthe lesion, topical and surgical therapies arefrequently attempted on the cutaneous aspect ofthe lesion, and no dental treatment is provided.Sometimes, there is an initial cessation of pusfrom the sinus, along with apparent healing,

but there is always a recurrence as the primaryetiology is unnoticed. Treatment must befocused on the elimination of the source ofinfection; once the infection is eliminated thereis a prompt resolution of the sinus tract. If thesource of the infection is a retained root ornonrestorable tooth or if the involved tooth isperiodontally hopeless, extraction of the tooth is

the only possible treatment. A report indicatedthat 75%of cutaneous sinus tracts are treated bytooth extraction.[2]Many pathologic conditionsin and around the oral cavity, including thecommon periapical dental abscess, the lesscommon recurrent squamous cell carcinoma, arare developmental anomaly, can manifest on theface and neck as cutaneous sinus tracts. [1-3]Herewe report three cases of cutaneous sinus tract ofdental origin that underwent complete resolutionfollowing treatment in three cases.

CASE REPORTS

Case 1

A male patient aged 26 years presented to thedepartment of Periodontology with a nodularswelling of the cheek of 8 months duration.Furthermore, complained of occasional purulentdischarge since 8 months. Patient had nosignificant medical history. History furtherrevealed the occurrence of swelling in cheek,well localized, reduced after burst. Patient hadexperienced pain in upper posterior tooth beforeswelling. Thorough history also revealed that hehad visited a dermatologist for the same and wasadvised with medication, after which the lesiondid not heal. Patient then visited dentist whoreferred him to the institution for the managementof the same. When the patient was examined, hehad tender nodular swelling on cheek Routine

blood investigations were performed prior tothe initiation of the treatment. Diabetic andinfective status (HIV and HbsAg tests) werechecked to rule the immunocompromisedstatus. Treatment included tracing the sinustract intra-orally and excision along with theextraction of the involved molar tooth. Healingwas uneventful [Figure 1a-h].

Case Report

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DOI:

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ArunKumar and Deepa: Migratory abscess

Journal ofIndian Society of Periodontology- Vol 19, Issue 4, Jul-Aug 2015 471

Figure 2:(a) Preoperative extra oral draining stula (b) Preoperative intra oral lesion (c) Preoperative intra oral periapical radiograph (d) Preoperative antero-posterior view

radiograph revealing the course of the sinus tract (e) Postoperative intra-oral photograph after 2 weeks

d

cba

e

Figure 3:(a) Preoperative extra-oral photograph showing the scar of the previous stab incision attempted by the surgeon (b) Intra-oral photograph showing the infection

around the right mandibular third molar region (a and d) Computer tomograph revealing the course of the sinus tract (e-g) Intra-operative showing excision of stula and

Limbergs ap, postoperative photographs

dc

g

b

f

a

e

Figure 1:(a) Preoperative photograph of the extra-oral chronic stula (b) Preoperative photograph of the intraoral proximal caries (c) Intra-operative photograph of stula

tract (d) Fistula tract excision (e) Intra-oral closure (f) Postoperative healing socket (g) Postoperative extra-oral closure (h) Postoperative healed sinus after 3 weeks

d

h

c

g

b

f

a

e



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472 Journal ofIndian Society of Periodontology- Vol 19, Issue 4, Jul-Aug 2015

Case 2

A male patient aged 22 years presented with a draining sinuson the cheek. Clinically, a draining lesion on the left cheek2 cm above the inferior border of the mandible was noticed.Patient also complained of pain in right cheek, followed

by light red discharge since 1-month. Dental examinationrevealed carious lesion on the maxillary molar teeth andradiograph showed abscess extending beyond the pulp and

involving the periapical area. Gutta-percha cone was insertedinto the sinus tract and gently pushed inside until there wasno resistance. Antero-posteror view radiograph showedthe tip of the gutta-percha cone to be close to the lesion. Nospecic complaints related to teeth or soft tissue intraorally.Porcelain crown on incompletely obturated root canals wasevident on the radiograph. Management included antibiotictherapy with abscess drainage, scaling and root planning.The extra-oral active discharge gradually stopped. Patient isreferred for root canal treatment no. 16 followed by prostheticrehabilitation [Figure 2a-e].

Case 3

A 30-year-old male patient complained of recurrent swelling

and discharge from right cheek. On two occasions, patient hadexperienced bad breath and reduced mouth opening. Once,a stab incision and drainage was attempted extra orally by adermatologist. Clinical features included linear depressionsevident in right cheek, discharge positive on palpation.Intra oral examination revealed nothing signicant exceptan impacted third molar with mild pericoronitis. Computedtomography revealed the entire course of the sinus tract fromits site of origin to its exit on extra-oral region. Managementincluded antibiotic therapy; extra oral stula was traced tillmandibular third molar. Surgical extraction of third molarwas done, and stula excised. Extraoral surgical wound wastreated with Limbergs ap. Healing was uneventful. Patientis under follow-up [Figure 3a-g].

DISCUSSION

Infections originating in a tooth or its supporting structuresor in the jaws or soft tissues can spread to distant sites of headand neck and chest region. The path of an infection could beunderstood from the thorough knowledge of the anatomy ofthe head and neck. In the facial region, the loose, fat-containingtissue of the lips and cheeks is continuous. However, it ispartially partitioned by the muscles of facial expression, whicharise from the bones of the face and which, as variably wideplates, traverse the subcutaneous tissue, to end in the skin. Ininfections that are not caused by extremely virulent bacteria,the muscles with their thin perimysia play a role in directing

the spread of the infection. In this respect, dental abscesses thaterode and perforate the outer compact lamella of the upper orlower jaw sometimes do not progress toward the oral vestibule,

but nd their way through the subcutaneous tissue to the skin.[4]

The muscles and fasciae constitute a relative barrier to thespread of infection; the sinus tract may or may not becomecutaneous depending on its location relative to the mandibularand maxillary attachments of the facial muscles. If the apex ofthe involved tooth is superior to the muscle attachment on themaxilla or inferior to the muscle attachment on the mandible, theinfection may spread extra-orally to form a cutaneous sinus.[4]

Oral cutaneous stula leads to esthetic problems due to thecontinued leakage of saliva from the oral cavity to the face.Causes for orocutaneous stulae include due to malignancy,inammation, trauma being the most common causes.[5]Othercauses may be due to failed implants leading to possibleextra-oral sinus tract discharge, failed endodontic therapy.[6,7]Interestingly even calculus formation was reported as a causeof a persistent sinus tract after root canal therapy in two cases.

In one case reported (Ricucci et al.), sinus tract developedthat did not heal after conventional root canal therapy andapical surgery.[8]Extraction of that tooth revealed calculuslike material on the root surface. Other case had showedradiographic signs of healing after apicectomy. Histology of theapical biopsy specimen demonstrated a calculus like materialon the surface of the root apex. The presence of calculus on theroot surfaces of these teeth may have contributed to endodontictreatment failure.[8]

Neoplastic stulae result from the penetration of a neoplasmfrom the oral cavity to the overlying skin (most common cause,squamous cell carcinoma.). Actinomycosis, although rareis one of the most common infections that result in a stula

from the oral cavity to the skin. Fistulae may arise from thedevelopmental cysts of the neck region, such as thyroglossalduct, dermoid, sebaceous, preauricular and branchial archcysts. Nasopalatine duct cysts occasionally secrete uid to theanterior palate and the site of the duct. Lymph nodes infectedwith mycobacterium tuberculosis cause scrofula, a conditionin which infection spreads from the node to the skin througha sinus tract. This infection most commonly occurs in the neck.Cat-scratch disease is another consideration in the differentialdiagnosis of sinus tracts from lymph nodes.[9]

In all the three cases reported here, tooth and associated tissueswere identied as the etiology for the spread of the infectionsto oral and extra-oral tissues.

CONCLUSION

The presence of a cutaneous sinus on the face must alert thephysician, surgeon or the dermatologist to make a dentalexamination. This case series illustrates that pericoronitisand other infections of the oral cavity can present with awell-localized abscess away from the causative site. Anunderstanding of the anatomy of the region is very importantto establish a correct diagnosis and deliver prompt treatment.

REFERENCES

1. Spear KL, Sheridan PJ, Perry HO. Sinus tracts to the chin and jaw

of dental origin. J Am Acad Dermatol 1983;8:486-92.2. Ciof GA, Terezhalmy GT, Parlette HL. Cutaneous draining sinustract: An odontogenic etiology. J Am Acad Dermatol 1986;14:94-100.

3. Cherrick HM. Pits, stula and draining stula and draininglesions. In: Wood NK, Goez PW, editors. Differential Diagnosisof Oral Lesions. 3rded. St. Louis: Mosby; 1985. p. 184.

4. Flynn TR. Anatomy of oral and maxillofacial infections. In:Topazian RG, Goldberg MH, Hupp JR, editors. Oral andMaxillofacial Infections. 4th ed. Philadelphia: W. B. SaundersCompany; 2002. p. 188-213.

5. al-Kandari AM, al-Quoud OA, Ben-Naji A, Gnanasekhar JD.Cutaneous sinus tracts of dental origin to the chin and cheek:Case reports. Quintessence Int 1993;24:729-33.



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Journal ofIndian Society of Periodontology- Vol 19, Issue 4, Jul-Aug 2015 473

6. Tzm TF, Senimen M, Ortakoglu K, Ozdemir A, AydinOC, Keles M. Diagnosis and treatment of a large periapicalimplant lesion associated with adjacent natural tooth: A casereport. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2006;101:e132-8.

7. Tanalp J, Dikbas I, Delilbasi C, Bayirli G, Calikkocaoglu S.Persistent sinus tract formation 1 year following cast post-and-corereplacements: A case report. Quintessence Int 2006;37:545-50.

8. Ricucci D, Martorano M, Bate AL, Pascon EA. Calculus-like

deposit on the apical external root surface of teeth withpost-treatment apical periodontitis: Report of two cases. Int Endod

J 2005;38:262-71.

9. Medscape Drugs and Diseases. Oral Cutaneous Fistulas .Available from: http://www.emedicine.medscape.com/article/1077808-clinical. [Last updated on 2013 Jul 12].

How to cite this article:ArunKumar KV, Deepa D. Migratory and

misleading abscess of oro-facial region. J Indian Soc Periodontol

2015;19:470-3.

Source of Support:Nil, Conict of Interest:None declared.


Migratory and Misleading Abscess

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