A healthy 26 -year -old man applied to the dental clinic due to spontaneous toothache in his lower left first molar.
Irreversible pulpitis was diagnosed, based on history, clini-cal examination and panoramic radiograph. The pain had begun three days before. It was strong, spontaneous, and increased at night. The patient was taking intraoral pain-killers. Intraoral examination revealed a large filling with a marginal leakage. A periapical radiolucency around both root apices and proximal overhangs were visible on the panoramic radiograph (Fig. 1).
Further analysis of the panoramic radiograph revealed a periapical radiolucency in the region of tooth 31 (Fig. 1).
No caries, fillings or post -traumatic crown damage were found in any of the lower incisors. No history of dental trauma was reported. Minor crowding of the lower incisors
was found, but the patient had no history of orthodontic treatment. Sensitivity testing of this tooth was negative, although the adjacent teeth were not tested.
However, a cutaneous lesion of the chin was noticed during extraoral examination (Fig. 2). The patient reported unsuccessful dermatologic therapy, lasting altogether about 7 years. This included intraoral administration of antibi-otic: Amoxicillin with clavulanic acid (Amokisklav, Sandoz/
Lek, Stryków, Poland) and antihistamine (Amertil, Biofarm, Poznań, Poland), as well topical application of antibiotics:
Detreomycin, Mupirocin (Mupirox, Blau Farma, Warsaw, Poland) steroids (Hydrocortisone, Zentiva, Warsaw, Poland), Betamethasoni dipropionas + Gentamycini sulfas (Bedi-cort G, Zentiva, Warsaw, Poland), Erythromycin (Zineryt, Galderma Polska, Warsaw, Poland) and Ammonii bitumi-nosulfonas (Hasco, Bydgoszcz, Poland).
It was thus supposed that the lesion could constitute an orifice of the sinus tract of odontogenic origin.
Root canal treatment was initiated with pulp chamber access and biomechanical preparation of the canals. Irri-gation proceeded with 1% hypochlorite (Chloraxid, PPH Cerkamed, Nisko, Poland), 40% citric acid (Chema Ele-ktromet, Rzeszów, Poland) and 2% chlorhexidine (Chlorhex-idinum Gluconium, Polfa łódź SA, łódź, Poland). Dex-amethasoni acetas with Fracemytini sulfas and Polymixini B sulfas (Dexadent, Chema Elektromet, Rzeszów, Poland) with iodophorme (Jodoform FPIV, Pharma Cosmetic, Cracov, Poland) was used as a temporary medicament. Two weeks later, during the following appointment, the patient reported a smell of iodophorme on his chin; the drainage had stopped.
The skin lesion diminished, was lacking an inflammatory areola, and the patient was reporting partial remission.
A month after treatment initiation, a control periapical radiograph was made to assess the progress of the ther-apy. It revealed that the periapical lesion was larger than previously apparent from the panoramic radiograph, and included the region of the apex of tooth 41 as well. Sensi-tivity testing of tooth 41 was negative, and thus root canal treatment was also initiated (Fig. 3). Two weeks later the orfice closed completely.
Fig. 1. Panoramic radiograph before dental treatment. Visible periapical
radiolucencies in the regions of teeth 36, 31 Fig. 2. Nodular sinus tract opening on the chin
88 KATARZYNA GROCHOLEWICZ, JOANNA JANISZEWSKA-OLSZOWSKA, łUKASZ KACPERSKI
Fig. 3. Periapical radiograph during treatment Fig. 5. Periapical radiograph one year after treatment
Fig. 4. Patient’s chin one year after dental treatment
discussion
This condition is not a common finding – 12 case reports describing odontogenic sinus tracts to the chin have been found [2, 3, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16]. In the reported patient, 2 teeth were involved in the periapical lesion caus-ing an odontogenous sinus tract with extraoral drainage, as similarly described by Unal and Kaya [10], as well as Çalişkan et al. [16]. No sinus tracts have been found to orig-inate from teeth without periapical lesions [17], and thus all teeth adjacent to the bony lesion should be subjected to careful clinical and radiologic examination.
The described patient was not referred to the dental clinic due to the skin lesion. The incidental finding of this condition led to proper diagnosis and successful treatment.
It should be remembered that a chronic periapical abscess may result from previous trauma, as incisors are the most frequently traumatized teeth. The authors suppose that the described patient might have had a traumatic luxation injury of the lower central incisors, which was unnoticed but caused pulp necrosis. The minor lower incisor crowding present could have contributed to occlusal trauma. The diagnosis was particularly difficult since no crown damage was vis-ible, except for normal abrasion of the incisal edges.
After successful endodontic therapy the healing process might be associated with cutaneous retraction or dimpling, requiring surgical intervention for aesthetic reasons [18].
Due to persisting exudation, the root canals of both lower incisors were permanently filled after 3 months following ozone therapy. The filling was carried out using the method of gutta-percha lateral condensation with AH plus paste (Dentsplay DeTrey Gmbh, Konstanz, Germany) sealer.
In long -term observation the skin lesion healed com-pletely (Fig. 4). A follow -up periapical radiograph revealed no radiolucency or any other pathology, despite root canal overfilling with a gutta -percha point by dental students (Fig. 5).
ODONTOGENOUS SINUS TRACT TO THE CHIN – CASE REPORT 89 However, in this case, despite initial misdiagnosis and
-term unnecessary treatment, the lesion healed with a mini-mal scar, unnoticeable for the patient’s social environment.
In the case of a single chronic suppurative or nodulo-cystic facial lesion, a clinical examination, including sen-sitivity testing, as well as radiological assessment of the maxillary and mandibular dentition should always be per-formed to exclude an odontogenic cause. Early diagnosis is important to prevent further complications, including osteomyelitis or even sepsis.
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R O C Z N I K I P O M O R S K I E J A K A D E M I I M E D Y C Z N E J W S Z C Z E C I N I E 2013, 59, 2, 90–93
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