Download management of extra oral sinus using shoe lace technique

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CASE REPORT
MANAGEMENT OF EXTRA ORAL SINUS
USING SHOE LACE TECHNIQUE
AUTHORS:
Dr. Chandra Vijay Singh
(MDS)
Senior Lecturer
Dr. Anurag Singhal
(MDS)
Prof.& Head
Dr. Anuraag Gurtu
(MDS)
Reader
Dr. Chandrawati Guha
(MDS)
Reader
Department of Conservative
Dentistry & Endodontics
Institute of Dental Sciences, Bareilly
INTRODUCTION
The term sinus tract "refers to a tract leading from
an enclosed area of inflammation to an epithelial
surface" (An 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)
When an acute periapical abscess forms, it will
drain along a path of least resistance. The odontogenic
abscess may spread to deeper tissues causing fascial
space infection or it may establish an 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 facialmuscle attachments. After formation of a sinus tract, the
inflammation at the apex of the root may persist for a
long period of time because of the drainage through the
sinus tract, a chronic abscess can remain asymptomatic
for extended periods of time. If there is a closure of the
sinus tract, then the chronic abscess may become
symptomatic. (2)
Sinus tracts on the oral mucosa adjacent to teeth
usually disappear spontaneously with elimination of the
causative factor. Although sinus tracts of pulpal origin
are common, they are seldom of periodontal origin.(3)
Cutaneous sinus tracts of dental origin have been
well documented in the medical literature (LewinEpstein et al. 1978; Kaban 1980; Spear et al. 1983; Cioffi
et al. 1986; Held et al. 1989; Hodges et al. 1989; Cohen
& Eliezri 1990) and the dental literature (Bernick &
Jensen 1969; Strader & Seda 1971; Sakimoto &
Stratigos 1973; Braun & Lehman 1981; Sharma &
Chauchan 1985; McWalter et al. 1988; Maple & Eichel
1993; Caliskan et al. 1995).(4,5,6,7,8)
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 recurrence of the
cutaneous sinus tract, as the primary etiology was dental
that was never correctly diagnosed or addressed.(10)
The present case report discusses an extraoral sinus
tract which was cutaneous in nature whose early and
prompt diagnosis led to its timely treatment by
endodontic therapy.
CASE REPORT:
A 30 year old male patient reported to the Department
Of Conservative Dentistry and Endodontics with chief
complaint of pus discharge around the submental
region associated with mild pain since last 2 weeks.
Detailed clinical examination revealed patient had
Journal of Dental Sciences & Oral Rehabilitation
grossly carious lower anterior teeth (31, 32, 41, 42). He
also presented with deep bite. Extra oral examination
revealed a cutaneous sinus tract near the chin.
Radiographic examination revealed that tooth 41 was
the cause.Vitality of the teeth were checked using
electric pulp tester and mandibular right central and
lateral incisors were found to be non vital.
Root canal treatment of the involved teeth and
management of the extraoral sinus tract was planned
using “Shoe Lace Technique”. Shoe Lace Technique
involved managing the sinus where a gauge piece
soaked in betadiene was inserted extraorally to disrupt
the epithelium of sinus tract to make a patency for pus
drainage.
Under local anesthesia flap reflection was performed
and the root was exposed. The granulation tissue was
removed using curettes (API). Shoe Lace Technique
was performed to disrupt the epithelium of sinus tract
The flap was repositioned and sutured using sling
suture technique. Patient reported back asymptomatic
after 3 months.
DISCUSSION
Cutaneous sinus tracts typically present as fixed,
nontender, erythematous, nodulocystic lesions on the
skin of the lower face. The patient is usually unable to
recall an acute or painful onset and the lesion is seldom
accompanied by symptoms in the oral cavity (4). Once
the infection from the offending tooth has perforated
the periosteum, the tooth may become asymptomatic.
Digital palpation of the involved area frequently
reveals a "cord" of tissue connecting the painless skin
lesion to the involved maxilla or mandible. During
palpation, an attempt should be made to 'milk' the sinus
tract; production of a purulent discharge confirms the
presence of a tract (Cohen & Eliezri 1990). (9) Often,
both the nodule and perilesional skin are slightly
retracted below the level of the surrounding skin
surface (7). The majority of dental sinus tracts develop
intraorally. When an extraoral dental sinus tract occurs,
it most often develops in close proximity to the
offending tooth (8).
Approximately 80% of reported cases of cutaneous
sinus tracts of odontogenic origin are associated with
mandibular teeth. Therefore, the most common areas of
involvement are the chin and submental regions (2).
Tracts in the mandibular and submandibular regions
are most often associated with mandibular molars (8).
Laskin has described the propagation of odontogenic
infection as being influenced by the relationship of the
root apices to the alveolar process and by the
arrangement of the muscles and fascia of the face and
neck. He also emphasized that these structures
represent only relative barriers and that systemic
reaction of the patient still governs the extent of spread
(9).
Evaluation of a cutaneous sinus tract must begin
41
with a thorough history and awareness that any cutaneous lesion of the
face and neck could be of dental origin (Lewin-Epstein et al. 1978; Cioffi
et al. 1986; Cohen & Eliezri 1990).(8)
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 (Sakimoto & Stratigos 1973; Mitchell
1994). (3, 9)
A radiograph is then exposed with the probe in situ, pointing to the
origin of the primary pathosis. Oral examination may reveal one or more
severely decayed teeth or a healthy looking tooth with an intact crown.
Pulpal and periradicular diagnostic testing should be performed on the
suspect tooth and adjacent teeth. More than one tooth may be pulpally
involved and associated with the cutaneous odontogenic sinus tract.
Cutaneous sinuses have a wide range of incidence. The youngest
individual reported to have a cutaneous odontogenic sinus tract was a boy
aged 10 months (Cohen & 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 & Eliezri
1990). Most patients are unaware of an associated dental problem (Cioffi
et al. 1986; Hodges et al. 1989; Caliskan et al. 1995), thus delaying the
correct diagnosis of the cutaneous lesion with its primary odontogenic
origin.(10) These patients are usually healthy. The sinus tract prevents
swelling or pain from pressure build-up because it provides drainage of
the odontogenic primary site (McWalter et al. 1988). Thus, the draining
sinus tract maintains a localized condition and prevents systemic
involvement.
Treatment involves making a patent pathway for the pus to drain. Many
methods have been propagated which range from periapically perforating
the root of tooth during root canal treatment thus draining the pus through
orthograde approach to creating an extraoral pathway for providing rapid
relief to the patient in case of large sinuses. Shoe Lace Technique is one
such method where the sinus is managed extraorally by inserting a gauge
piece soaked in betadiene to make a patency for pus drainage.
REFERENCES
1. N Cohenca, S Karni, I Rotstein. Extraoral Sinus Tract Misdiagnosed
as an Endodontic Lesion. J Endod 2003; 29 (12):841-843.
2. Am Association of Endodontists. Glossary of contemporary
terminology for endodontics, 5th edn. Chicago: Am Asso of
Endodo, 1994;22.
3. Heling I, Rotstein I. A persistant oronasal sinus tract of endodontic
origin. J Endod 1989; 15:132–4.
4. E .Tidwell, JD. Jenkins, CD. Ellis, B. Hutson, RA. Cederberg.
Cutaneous odontogenic sinus tract to the chin: a case report. Int
Endod J. 1997; 30,:352–355.
5. Braun RJ, Lehman JA. A dermatologic lesion resulting from a
mandibular molar with periapical pathosis. Oral Surg.1981; 52:
210–12.
6. Bernick SM, Jensen JR. Chronic draining extraoral fistula of 32
years duration. Oral Surg. 1969:27: 790–4.
7. Caliskan MK, Sen BH, Ozinel MA. Treatment of extraoral sinus
tracts from traumatized teeth with apical periodontitis. Endod
DentTraumatol. 1995; 11: 115–20.
8. CioffI GA, Terezhalmy GT, Parlette HL. Cutaneous draining sinus
tract: an odontogenic etiology. Journal of the Academy of
Dermatology. 1986;14:94–100.
9. Valderhaug J. A histologic study of experimentally produced intraoral odontogenic fistulae in monkeys. Int J Oral Surg 1973;2:54–61.
10. Johnson BR, Remeikis NA, Van Cura JE. Diagnosis and treatment
of cutaneous facial sinus tracts of dental origin. J Am Dent Assoc
1999;130:832–6.
11. 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.
FIG I: PREOPERATIVE PICTURE
FIG II: PRESENCE OF AN EXTRA ORAL SINUS ON RIGHT SIDE
FIG III: USING SHOE LACE TECHNIQUE TO MAINTAIN PATENCY
FIG IV; REFLECTION OF FLAP AND REMOVAL
OF GRANULATION TISSUE
FIG V : REPOSITIONING AND APPLYING INR
AORAL & EXTRAORAL SUTURES
Journal of Dental Sciences & Oral Rehabilitation
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