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Two unusual cases of dental (periapical) infection

  • Author(s): Ghodsi, Seyedeh Zahra
  • Ghiasi, Maryam
  • et al.
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Two unusual cases of dental (periapical) infection
Seyedeh Zahra Ghodsi MD, Maryam Ghiasi MD
Dermatology Online Journal 12 (4): 15

Tehran University of Medical Sciences, Department of Dermatology, Razi Hospital, Tehran, IRAN. zghodsi@ut.ac.ir

Abstract

Cutaneous sinus tracts of dental origin are often a diagnostic challenge. A delay in correct diagnosis can result in inappropriate treatments. We describe two unusual cases of periapical infection. The first patient presented with a fistulized tumoral mass under the chin present for 1 year. The patient had only one tooth, and that was anatomically unrelated to the tumor. Radiological examination showed a dormant tooth that was infected periapically. The second case was a man who complained of asymmetry and change in his left nasolabial fold of 4-5 week's duration. On examination, the nasolabial folds were asymmetric without any sign of facial palsy. On intraoral examination, there was a severely decayed tooth on the same side. Radiological survey confirmed periapical infection. A few weeks after proper treatment, the nasolabial folds became symmetric.


Introduction:

Chronic periapical infection of a tooth may produce a sinus tract that eventually appears beneath the skin surface. These sinus tracts can be a diagnostic challenge because of their uncommon occurrence and the absence of symptoms. A correct diagnosis is based on a high index of suspicion. Early treatment of these lesions can prevent unnecessary surgical treatment. We describe two cases with unusual presentation of periapical infection.


Clinical synopses


Case 1


Figure 1Figure 2
Figure 1. Fistulized tumoral mass under chin
Figure 2. A dormant tooth that was detected in radiological examination

A 32-year-old man presented with fistulized tumoral mass under his chin of 1-year duration. The patient had one tooth only and that was anatomically unrelated to the tumor. Radiological examination showed the presence of a dormant tooth that was infected periapically.


Case 2


Figure 3
Figure 3. Asymmetry of nasolabial folds

A 37-year-old man complained of asymmetry and change in his left nasolabial fold of 4-5 week's duration. On examination, the nasolabial folds were asymmetric. There was no sign of facial palsy. On intraoral examination, there was a severely decayed tooth on the same side; radiological survey revealed a periapical infection. After a few weeks proper treatment, the nasolabial folds became symmetric.


Discussion

Chronic periapical infection around a tooth can produces a burrowing, practically asymptomatic, sinus tract that eventually appears beneath the surface of the gum, palate, or periorificial skin forming a fistulous opening with an inflamed red nodule at the orifice. It may appear anywhere from the inner ocular canthus to the neck, but is most often seen on the chin or along the jaw line.

Because patients with cutaneous facial sinus tracts of dental origin often do not have obvious dental symptoms, possible dental etiology may be overlooked [1, 2, 3] especially if there is no suspicious tooth on first inspection (as with our first case).

Evaluation of a cutaneous sinus tract must begin with a thorough history and the awareness that a cutaneous lesion of the face and neck could be of dental origin. Patients, unaware that the cutaneous sinus could be related to dental infection, often seek treatment from a dermatologist or family physician [1]. In our second case the change in left nasolabial fold possibly was related to the soft tissue edema resulting from the periapical infection. This presentation is so vague for dental infection and, to the best of our best knowledge, the first reported one in the literature.

In the medical literature, approximately half the patients with cutaneous sinus tract of dental origin have undergone multiple unsuccessful attempts at incision and drainage, numerous trials of antibiotics [1, 2, 3, 4], radiation therapy [2], electrodesiccation [2], intralesional injection of steroid[5], oral steroid [5], and laser therapy [5].

Physicians should remain aware about the unusual presentations of periapical infection.

References

1. Cantatore JL, Klein PA, Lieblich LM. Cutaneous dental sinus tract, a common misdiagnosis: a case report and review of the literature. Cutis 2002 Nov; 70(5):264-7. PubMed

2. Gulec AT, Seckin D, Bulut S, Sarfakoglu E. Cutaneous sinus tract of dental origin. Int J Dermatol. 2001 Oct; 40(10): 650-2. PubMed

3. Jonson BR, Remeikis NA, Van Cura JE. Diagnosis and treatment of cutaneous facial sinus tracts of dental origin. J.Am Dent Assoc 1999 Jun; 130(6): 832-6. PubMed

4. Mittal N, Gupta P. Management of extra oral sinus cases: a clinical dilemma. J Endod 2004 Jul; 30(7): 541-7. PubMed

5. Tavee W, Blair M, Graham B. An unusual presentation of a cutaneous odontogenic sinus.Arch Dermatol 2003 Dec; 139(12): 1659-60. PubMed

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