Young Woman With a Dimpled Lesion on Her Cheek

HISTORY

A healthy 23-year-old woman presents with a 1-year history of an unsightly, non-tender, dimpled lesion on the right cheek that intermittently drains purulent discharge.

The patient reports no relevant past medical history. She has seen numerous physicians over the past year and received several courses of antibiotics without improvement. She is emotionally distraught over the change in her facial appearance.

What’s Your Diagnosis?

 (Answer on next page.)

    ANSWER: Cutaneous Sinus of Dental Origin    

A cutaneous sinus of dental origin is a well-recognized sequela to chronic dental infection but is frequently misdiagnosed. Health care providers fail to obtain a dental history, and patients do not associate the cutaneous findings with often subtle oral symptoms.

The precipitating event is the development of a periapical abscess from a dental caries. If the infection leads to obvious clinical symptoms (pain, swelling, etc) from cellulitis or osteomyelitis, it is promptly recognized and treated. A less virulent infection, however, may be contained by the immune system but slowly erodes to an epithelial surface forming a sinus tract. This tract may extend to the oral mucosal surface (intraoral dental sinus tract) or the facial skin (cutaneous sinus of dental origin). Patients are often asymptomatic because no inflammatory focus develops.

CLINICAL FEATURES

A cutaneous sinus of dental origin initially presents as a small, erythematous papule with focal ulceration. Fixation of the tract to the surrounding soft tissue results in dimpling of the surrounding skin. The patient may report variable degrees of drainage from the site. Depending on the anatomic location of the periapical abscess, the sinus can present on the cheek, mandible, chin, upper lip, nose, nasolabial fold, or medial canthus. The tract follows the course of least resistance and is influenced by fascial sheaths and muscle attachment.

DIAGNOSIS AND TREATMENT

Lesions are initially mistaken for cysts, localized skin infections, pyogenic granulomas, or even skin cancers. Often, affected patients will undergo unnecessary, non-diagnostic skin biopsies. A high index of suspicion is required for diagnosis, and a full dental history should be obtained. If a known infected tooth exists in the correct anatomic distribution, the diagnosis is confirmed. Otherwise, patients should be referred to a dental surgeon for comprehensive evaluation, including consideration of panoramic or periapical radiographs. Dental etiology can be confirmed by tracing the sinus tract to its origin with use of gutta-percha or similar radiopaque material.1 Treatment of choice includes root canal therapy or dental extraction, which allows for spontaneous resolution of the tract and improvement of the skin changes.2

OUTCOME OF THIS CASE

This patient had a known periapical abscess, but did not disclose that information to us until we inquired about her dental history. After a tooth extraction, she returned for a 2-month follow-up visit, with significant spontaneous aesthetic improvement (Figure).

References

1. Gupta M, Das D, Kapur R, Sibal N. A clinical predicament—diagnosis and differential diagnosis of cutaneous facial sinus tracts of dental origin: a series of case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(6):e132-e136.
2. Mardones F, Oroz J, Munoz C, Alfaro C, Soto R. Cutaneous facial sinus tract of dental origin. Pediatric Dermatology. 2010;27:410-411.