Chronic apical abscess with extraoral sinus tract, treatment of a 12 years old patient: a case report

Abstract

Aim To describe the treatment of a chronic apical abscess with extraoral sinus tract which appeared as cutaneous abscess. Introduction In rare instances, the sinus tract of dental origin arises on the skin of the patient’s face. Due to the asymptomatic nature of chronic apical abscess this clinical condition might be misdiagnosed as local cutaneous infection, abscess, furuncle and other skin pathologies that are more common among teenagers. The surgical treatment or medication only is usually ineffective in those cases as the cause of infection remains untouched and the skin nodule tends to reappear. It is evident that extraoral sinus tract opened due to chronic periapical abscess should heal spontaneously once the source of the infection is eliminated by effective endodontic treatment of causative tooth. Case Presentation A 12 years old female patient presented for treatment with a main complaint of a painless skin nodule in the left submandibular area. Severe caries of tooth 36 was discovered during the examination by general practitioner. The tooth was asymptomatic and pulp sensitivity test was negative. The initial treatment was started, then the patient was referred to an endodontist for evaluation and treatment of the tooth 36. The temporary filling and periapical radiolucency were detected evaluating the periapical x-ray (Fig. 1). During the first apointment, the root canals were shaped, disinfected, filled with calcium hydroxide paste, endodontic cavity was isolated with temporary filling. At the time of the next appointment the skin nodule was infiltrated and superficial accumulation of pus was observed (Fig. 2). A surgical incision of cutaneous abscess was performed for a better drainage. Two weeks later the resolution of extraoral sinus was evident (Fig. 3). The canals of mesial root were obturated with TotalFill BC sealer (FKG Dentaire Sàrl, Switzerland) and gutta-percha, calcium silicate based cement (Biodentine (Septodont, USA)) was used for obturation of an apical part of the distal root. Then the crown of the tooth was restored with permanent filling. During a follow-up after six months the tooth 36 was asymptomatic, the extraoral sinus tract was absent and healing process of periapical tissues was evident in periapical radiograph (Fig. 4 and Fig. 5). Discussion A cutaneous abscess in the facial area can be an expression of undiagnosed chronic apical abscess. Some authors claim extraoral sinus tract might arise more frequently in paediatric patients due to teeth being partially errupted and/or relatively deeper seated within the developing alveolar process and closer to the external cortex (1, 2). It can be speculated that extraoral sinus tract of dental origin could be difficult to differentiate from dermatological pathology especially in young patients as infections in the facial area are more prevalent among teenagers. Nevertheless, currently there is no clinical evidence to fully support this statement as case reports regarding chronic apical abscess with sinus tract present patients of diverse age (1 - 5). Conclusion & Clinical Relevance A chronic apical abscess may cause the development of an extraoral sinus tract that can be misdiagnosed as a cutaneous pathology. After establishing the diagnosis of chronic apical abscess with extraoral sinus tract endodontic treatment should be the treatment of choice if the tooth is restorable. Thus, a thorough dental examination in cases of nonhealing cutaneous pathology is recommended to avoid misdiagnosing and mistreatment paying attention to young patients.