|Year : 2012 | Volume
| Issue : 1 | Page : 17-21
Non-surgical management of an extraoral cutaneous sinus tract of odontogenic origin using Nd:YAG laser: An endodontic challenge
Koustubh M Kulkarni, Lotika Beri, Swapnil Bhosale
Department of Conservative, Endodontics and Aesthetics Dentistry, Dr. D.Y. Patil Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||15-Sep-2012|
Koustubh M Kulkarni
Dr.D.Y.Patil dental college and hospital,Pimpri, Pune, Mahararshtra
Source of Support: None, Conflict of Interest: None
The extraoral cutaneous sinus tract of dental origin is an uncommon, but well-documented condition. However, several non-odontogenic disorders may also cause an extraoral sinus tract. The diagnosis is not always easy unless the treating clinician considers the odontogenic origin. The present case report discusses diagnosis and treatment of an extraoral cutaneous sinus tract of odontogenic origin in relation to a mandibular left cannine (diagnosed as asymptomatic suppurative periradicular abscess with an extraoral cutaneous sinus tract opening in the mandibular mental region). Non-surgical endodontic therapy was performed using Nd:YAG laser. To present a case report describing the diagnosis and treatment of an extraoral cutaneous sinus tract of odontogenic origin in relation to a mandibular left cannine. The patient responded well, and the cutaneous lesions healed uneventfully.
Keywords: Odontogenic infection, extracutenous sinus, Nd:YAG laser
|How to cite this article:|
Kulkarni KM, Beri L, Bhosale S. Non-surgical management of an extraoral cutaneous sinus tract of odontogenic origin using Nd:YAG laser: An endodontic challenge. J Dent Lasers 2012;6:17-21
|How to cite this URL:|
Kulkarni KM, Beri L, Bhosale S. Non-surgical management of an extraoral cutaneous sinus tract of odontogenic origin using Nd:YAG laser: An endodontic challenge. J Dent Lasers [serial online] 2012 [cited 2017 Sep 20];6:17-21. Available from: http://www.jdentlasers.org/text.asp?2012/6/1/17/100981
| Introduction|| |
Cutaneous sinus tracts of dental origin have been well documented in the medical, ,,, dental ,,, and dermatological literature. However, these lesions continue to be a diagnostic dilemma.
Such patients usually seek treatment from a physician or a surgeon instead of a dentist and often undergo multiple surgical excisions, radiotherapy, multiple biopsies and multiple antibiotic regimens, Misdiagnosis usually leads to destructive treatment of the local skin lesions that is not curative, and is often mutilating. Even skin biopsy may produce unnecessary scarring. 
The most common cause of a cutaneous sinus tract is a chronic periradicular abscess.  Virulence of microorganisms or most importantly, anatomical arrangement of adjacent muscles and fasciae, determine whether a cutaneous sinus or an intraoral sinus will form.
On the other hand, the correct identification of this entity leads to simple and effective treatment consisting of removal of the infected pulp canal tissue, resulting in minimal cutaneous scarring,
The treatment of these lesions includes root canal treatment of the involved tooth. The success of the treatment depends on cleaning, shaping and complete sterilization of root canals. Lasers  have been shown to effectively sterilize the root canal succeeded reduces on average, 99.91 percent. The purpose of the present case report is to describe the non-surgical treatment of an extraoral cutaneous sinus tract of odontogenic origin.
| Case Report|| |
A 46-year-old female patient was referred to the Department of Endodontics, Dr D.Y Patil Dental College for a dental opinion. The patient's chief complaint was pain and intermittent pus discharge from an opening located on submental region. The dental history revealed that mild discomfort and food retention in the mandibular left canine had been apparent for the previous three months. Extraoral examination revealed a cutaneous opening of size 6 x 13 mm in submental region with purulent discharge [Figure 1].
The intraoral examination revealed that tooth 33 had attrition with pulpal exposure.
The tooth was tender on percussion and there was pain on palpation. Electric pulp testing and thermal test using hot gutta-percha showed that there was no response with 33
No signs of mobility or periodontal pockets were present in relation to tooth 33. An intraoral periapical radiograph revealed well-circumscribed periradicular radiolucency associated with tooth 33, the OPG also revealed radiolucency associated with 33 which was extending till the submental region.
A size 20 gutta-percha cone was used to trace the sinus tract from the cutaneous opening and a radiograph was made.
The radiograph confirmed that the lesion was odontogenic in origin, traced to 33 the diagnosis of
Pulpal necrosis with suppurative periradicular periodontitis with 33 was confirmed.
Conventional access cavity was prepared with 33 and patency was checked using a size 10 K-file. The working length was determined using electronic apex locator. The electronically determined working length was confirmed radiographically using a size 15 K-file. The root canal was cleaned and shaped by rotary nickel-titanium ProTaper instruments till F3 During preparation, the canal was copiously irrigated with 5.2% sodium hypochlorite and 17% EDTA solution [Figure 2].
It was decided to sterilize the canal with Nd:YAG laser, three cycles of laser treatment:1.5w,15 Hz, short pulsed mode for five seconds. Fiber tip was moved in continuous circling motion, from the apical to the coronal direction. Calcium hydroxide was placed as an intracanal medicament and the access cavity was temporized.
The patient was recalled two weeks later. On the recall visit, the tooth was asymptomatic and the sinus tract had reduced in size .the tooth was obturated using lateral condensation technique, F3 was used as master cone and AH plus as sealer. On two month recall the sinus tract had healed completely [Figure 3].
| Discussion|| |
The evaluation of a cutaneous sinus tract must begin with a thorough medical history and awareness that any cutaneous lesion of the face and neck could be of dental origin. , The patient's history may include complaints of dental problems. However, patients may not remember any history of an acute or painful onset. A cutaneous sinus may develop as early as a few weeks or as late as 30 years. Approximately 80% of reported cases are associated with mandibular teeth and 20% with maxillary teeth.
The most common areas of involvement are the mental and submental regions. Other sites of drainage are the cheek, canine space, nasolabial fold, nose, upper lip and inner canthus of the eye. There may also be complaints of episodic bleeding or drainage from the cutaneous site with persistence of the cutaneous lesion.
Laskin  has elaborated on the physiological and anatomical factors that influence the spread and ultimate localization of dental infections. Stoll and Solomon  also emphasized that the ultimate path of the sinus (irrespective of the source) depends on several factors, most importantly the anatomy of the tooth involved, muscular attachments to the jaw, facial planes of the neck and involvement of permanent or deciduous teeth. Cutaneous, rather than intraoral lesions are likely to occur if the apices of teeth are superior to maxillary muscle attachments or inferior to mandibular muscle attachments. Occasionally, there is a history of a dental trauma.
The clinical differential diagnosis includes pustule,  actinomycoses, ,, osteomyelitis,  orocutaneous fistula, neoplasms, local skin infections (carbuncle and infected epidermoid cyst), pyogenic granuloma, chronic tuberculosis and gumma of tertiary syphilis. Other causes are salivary gland fistula, thyroglossal duct cyst, branchial sinus, dactyocystitis, and suppurative lymphadenitis
Pustule is the most common of all purulent draining lesions and is readily recognised by its superficial location and short course. Actinomycosis exhibits multiple draining lesions and characteristic fine yellow granules in the purulent discharge. The tooth is often not involved radiographically. If a sinus tract does not close after appropriate removal of the primary cause, the most common alternative cause is actinomycosis. Osteomyelitis of the jaw is usually secondary to some type of exogenic trauma, acquired infection after extraction of diseased teeth, impacted teeth or retained roots. It rarely gives rise to a cutaneous sinus and is mostly associated with a history of some debilitating systemic disease or fracture. Orocutaneous fistula occurs frequently after trauma to the head and neck region and leads to continual leakage of saliva or to lower face or neck.  Malignancy usually presents as fixation to underlying skin with involvement of underlying osseous structures.
The correct diagnosis of the cutaneous sinus of dental origin is usually suspected due to the gross appearance of the lesion. These typically present as erythematous, symmetrical, smooth, non-tender nodules 1 to 20 mm in diameter, with crusting and periodic drainage in some cases.  The most characteristic feature of these nodules is its depression or retraction below the normal surface. This cutaneous retraction or dimpling is caused by the fixation of the tract with the underlying tissues and may be secondary to the healing process or a late finding in active disease. Lesions previously biopsied or treated are usually characterized by the absence of at least part of the nodule and frequently by an orifice of draining sinus at the base of the fixed depression. Palpation of the involved area often reveals a cord-like tract attached to the underlying alveolar bone (maxilla or mandible) in the area of the suspected tooth. If the sinus tract is patent, a lacrimal probe or gutta-percha cone can be introduced into the sinus opening and passed through the sinus until it meets the area of the tooth. An intraoral periapical radiograph should then be carried out with the probe in situ pointing to the origin of the pathosis (this is usually a non-vital tooth, but in edentulous patients could be a retained tooth fragment, an impacted tooth or an odontogenic cyst). Stoll and Solomon emphasized the importance of intraoral radiographs compared with extraoral radiographs; intraoral radiographs produce much better detail and contrast of teeth and associated structures than do extraoral radiographs.
In the present case, a size 20 gutta-percha cone was used to trace the sinus tract from the cutaneous opening. It was confirmed radiographically that the lesion was odontogenic in origin. The tract led to the root apex of tooth 33.
Pulp sensibility tests were then performed on the suspected tooth as well as the adjacent teeth. This is because more than one tooth may be pulpally involved and associated with the cutaneous odontogenic sinus tract.
Non-surgical endodontic therapy is the treatment of choice if the tooth is restorable. Extraction is indicated for non-restorable teeth. ,
Some difference exists in the literature regarding the removal of the sinus tract itself.
Winstock  recommended excision of the cutaneous lesion and sinus in continuity at the time of treatment of the dental pathology with immediate plastic repair of the cutaneous site. Kwapis  and Baker believed that because a sinus tract heals by scar formation, its effects on skin depression are most noticeable during facial movements like mastication or speaking, thus, it should be removed concomitantly at the time of treatment. However, most authors pointed out that once the primary odontogenic cause is removed, the sinus tract and cutaneous lesion heal without further treatment. Healing occurs by secondary intention in most cases. Cosmetic surgical treatment may be required at a later date if the healing results in cutaneous retraction or dimpling. ,,,
Conventional root canal treatment aims at the removal of infected pulp and dentine layers by using mechanical techniques and bactericidal irrigants. However, these cleansing techniques are only successful to certain extent because:
Microorganisms are also present in the lateral canals and dentinal tubules.
The dentinal tubuli are small in diameter and due to the surface tension properties of conventionally used chemical substances do not allow chemical treatment to reach bacteria hidden in the tubuli. Kouchi et al could demonstrate that bacteria are capable of invading the periluminal dentin up to a depth of 1100um. On other hand chemical disinfectant penetrate no more than 100um into the dentine as indicated by Berutii et al. The discraparency of the penetration depth of microorganisms and bactericidal rinsing solutions often holds responsible for therapy resistant cases and long term failures which can be observed in conventional endodontics.
During the past few past years, several laser systems have gained widespread acceptance in endodontic therapy because lasers have been shown to be very effective in cleaning and disinfecting the root canal lumen. The same holds true for lateral dentinal tubules, which are not fully accessible in conventional root canal treatment and considered a reservoir for micro-organisms, which is difficult to restore.
Traditionally the Nd:YAG laser represents the longest reasearched device in this field. Hardee et al and Myers and McDaniel were among the first to propose the utilization of this wavelength in endodontics. Experiments like those of Klinkle et al demonstrated that Nd:YAG laser radiation although weakened by penetrating dentin layers has bactericidal effects till the depths of 1000um and above.
Studies by Moritz et al drew similar conclusions. This layer has a wavelength of 1064 nm; is poorly absorbed by water so it penetrates tissue deeply. Another possible explanation given by Odor et al is the ability of enamel prisms and dentine tubules to act as optical fibers, thus propagating laser light to the dentinal periphery of the root.
When the laser energy is absorbed by the target, a reaction may occur depending on the total amount of energy applied, whilst the interaction type depends on the power density and the pulse duration
Bactericidal effect of Nd:YAg laser; it has been postulated are due to thermal (heat based)destructive effects of lasers on bacteria.  Typically pulsed modes of operation for endodontic disinfection, are used to reduce the risk of thermal injury to the periodontal ligaments cells.
Thus Nd:YAG laser treatment may effectively replace conventional techniques for sterilization of root canals. Especially its improved disinfection efficacy , better penetrability, more effective root canal cleaning, and elimination of the need to use toxic solvents represents the main advantages.
Microorganisms not only contain virulent factors but also produce toxic products in periapical tissues, and contain endotoxin in their cell wall. Management of the teeth with pulp necrosis and chronic periapical reaction should not only be concerned with bacterial death, but also the inactivation of endotoxin.
Study by Assed S et al shows that calcium hydroxide  detoxifies bacterial endotoxin. Calcium hydroxide is not categorized as a conventional antiseptic, but is clinically effective in eliminating microorganisms from root canal space. Calcium hydroxide is recommended as intra canal medicaments because of antimicrobial properties, tissue dissolving ability, inhibition of tooth resorption, and induction of tissue repair by hard tissue formation. Lethal actions of calcium hydroxide on bacterial cells are probably caused by the damage to the bacterial cytoplasmic membrane, protein denaturation and damage to DNA.
Calcium hydroxide for endodontic use comes as a paste form which can be easily introduced into the canal. It is a strong alkaline substance, which has a pH of approximately 12.5. In an aqueous solution, calcium hydroxide dissociates into calcium and hydroxyl ions. The antimicrobial action of calcium hydroxide is related to the release of hydroxyl ions in an aqueous environment.  Calcium hydroxide, with its long acting antimicrobial and tissue solvent properties plays important role in endodontics. In the present case conventional root canal therapy combined with laser disinfection and calcium hydroxide as an intracanal medicament lead to complete healing of the extraoral cutaneous sinua tract.
Indicating that Nd:yag laser with output power of 1.5w, 15HZ for five seconds irradiations, ,, in adjunct to calcium hydroxide placed for two weeks was sufficient for disinfecting the root canal. The relatively long duration of irradiation and appropriate guidance of light conducting fiber (moving the fiber in a circular fashion from apical to coronal area)allows even treatment of the entire canal wall and irradiation of all bacteria; ensuring the complete disinfection root canals.
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[Figure 1], [Figure 2], [Figure 3]