An Unusual Association of Extraoral Sinus Tract

With Unerupted Permanent Tooth

Kakade. A, Juneja.A
Pediatric Dentistry. 2013;35;3:284-287
INTRODUCTION

• Pre-eruptive caries, with its various

presentations, has challenged clinicians and
researchers with respect to its origin and
progression.
• Though there have been many cases
reported about pre-eruptive caries and its
origin, none have been conclusive in
explaining the phenomenon.
• Cutaneous sinus tracts of dental origin have been
well documented in dental literature, yet these
lesions continue to be a diagnostic dilemma for
clinicians.
• Such patients usually seek treatment from a
physician or medical surgeon instead of a dental
surgeon and often undergo multiple surgical
excisions, radiotherapy, biopsies, and multiple
antibiotic regimens.
• Treatment typically fails eventually, however,
because the primary dental cause has been
overlooked.
• This can sometimes be destructive and mutilating
rather than curative.
• The most common cause of a cutaneous sinus
tract of dental origin is a chronic periradicular
abscess arising from bacterial invasion, chemical
irritation, trauma, caries, and, more rarely, pre
eruptive caries.
• These cutaneous sinus tracts are most commonly
located on the chin or cheek or in the
submandibular area but are rarely in the nasal
region.
• All chronic draining sinus tracts of the face or
neck, however, should be thoroughly assessed to
rule out any dental association.
• Intracoronal radiolucencies associated with
unerupted permanent teeth present the clinician with
a major challenge.
• The pathogenesis of pre-eruptive intracoronal
résorption is unclear, since the developing tooth is in
its crypt and is not likely to be infected with
cariogenic micro-organisms.
• Although this condition was first reported in 1941, it
is rarely observed and its prevalence is unknown.
• According to Brooks, it is most commonly found in
mandibular molars and premolars.
Four theories have been proposed to explain
intracoronal radiolucencies associated with
unerupted teeth:

(1) Apical inflammation of a primary precursor,

which affects the permanent successor;
(2) Dental caries;
(3)Developmental abnormality manifesting itself
as hypoplasia or as an inclusion of
uncalcified enamel matrix; and
(4) Internal or External résorption.
 PURPOSE OF CASE REPORT

The purpose of this article was to report an unusual case

showing association of an unerupted tooth bud of the
permanent mandibular left second molar with
intracoronal radiolucency and extraoral draining sinus in
the submandibular region.
CASE REPORT

• A 7-year-old girl, accompanied by her elder brother,

presented as an outpatient to the Department of Pédiatric
Dentistry.
• Chief complaint of recurrent pus discharge in the left
submandibular region occurring over the past six to seven
months.
• Two months earlier, the patient had visited a dental
surgeon, who considered the primary mandibular left
second molar as the carious causative agent and extracted
it. The condition, however, did not improve.
There was no history of any associated pain or trauma to
her teeth. An extraoral examination revealed the presence
of a draining sinus in the left submandibular region
An intraoral examination revealed healthy color,
contour, and texture of the alveolar mucosa distal
to the first molar
An orthopentamograph revealed….
All other conditions related to extraoral
sinus were ruled out

• Including tuberculosis, osteomyelitis, actinomycosis, a

local skin infection, or an underlying cancerous condition.
• A thorough medical history, medical examination,
complete blood and microbiological investigations, and a
pediatric referral were performed to rule out differential
diagnosis.
• FINAL DIAGNOSIS was that the sinus tract was the result
of the abscess of an unerupted permanent mandibular second
molar demonstrating the decreased radiodensity of the
crown suggestive of carious involvement.
• The decision was made to extract the tooth bud,
under general anesthesia.
• The patient and her brother were told about the
condition's cause and the recommended procedure.
• After obtaining the necessary written consent from
the brother, assessment for general anesthesia was
performed.
 TREATMENT PROCEDURE

.
MEDICATIONS

• The patient was started on preoperative antibiotics

amoxicillin and cloxacillin combination (10-15
mg/kg three times a day (total dose 750 mg per day)
along with metronidazole (7.5-10 mg/kg in three
divided doses per day) and an anti-inflammatory
drug, paracetamol (10-15 mg/kg/dose, three times a
day) and ibuprofen(10 mg/kg/dose) one day prior to
the surgery.
The incision was made distal to the permanent
first molar, and the tissue was retracted, revealing
the defect
• The bone was removed using a low-speed bur and normal
saline and all the necrosed bone surrounding the defect
was removed. This allowed for better visualization of the
crown of the permanent mandibular second molar
which was later surgically excised
along with the lesion's lining….
• The crown of the extracted tooth was found to be
carious, thus confirming dental caries as the cause
of the intracoronal radiolucency visible in the
orthopentamograph.
• After removing the tooth bud, the cavity was
thoroughly irrigated with metronidazole solution and
bleeding was controlled.
• The bony defect was filled with Absorbable Gelatine
Sponge, and the region was sutured.
The patient was discharged following four to six
hours postoperative monitoring. The patient
returned for regular follow-up one week
one month later….
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
of oral cavity, thus making it more difficult to reach
conclusive diagnosis.
• An odontogenic infection beginning within the tooth leads
to an inflammatory response.
• These inflammatory and immunological processes include
bone résorption, and the resultant fluid may either be
confined within the bone or, ultimately, break through
cortical bone and periosteum into soft tissue spaces.
• If the fluid that has reached the cutaneous surface
is allowed to spontaneously drain, healing is by
secondary intention.
• Fibrosis occurs, which results in undesired
dimpling, scarring, and or a chronic extraoral
draining sinus tract.
• Scarring not only has a pathological association
but also leads to facial disfigurement, indirectly
causing psychological trauma to the patient.
• Stoll and Soloman also emphasized that the
ultimate path of the sinus tract (irrespective of the
source) depends on several factors, most
importantly the anatomy of the tooth involved,
muscular attachments of the jaw, fascial planes of
the neck, and involvement of permanent or
primary teeth.
• Cutaneous rather than intraoral lesions are likely
to occur if teeth apices are superior to maxillary
muscle attachments or inferior to mandibular
muscle attachments.
Clinical differential diagnosis includes

• Pustule
• actinomycosis,
• Osteomyelitis
• orocutaneous fistula, Neoplasm
• local skin infections (carbuncle and infected
epidermoid cyst)
• Chronic tuberculosis
• gumma of tertiary syphilis.
• Other causes are salivary gland fistula, thyroglossal
duct cyst, branchial sinus, dacrocystitis, and
suppurative lymphadenitis
• Most dental abscess may be initiated by caries,
periodontal disease, trauma, or tooth injury.
• The infection may slowly move through the
cancellous bone following the path of least
resistance and perforate the cortical plate to
present either intra- or extraorally.
• Also, the associated cutaneous lesion may
develop over a long period of time and is often
distant from the primary infection site.
• Although most dental abscesses in children results
from caries or trauma, a percentage originate from
unusual conditions ranging from developmental
abnormalities to acquired conditions.
• These abscesses may be prevented by timely and
accurate diagnosis and appropriate preventive
measures.
• Knowledge of these conditions would aid the
general practitioner in the differential diagnosis
and treatment of these entities.
THANK YOU