- Email: [email protected]
Nasal-apical communication associated with a pulpless tooth
0099-2399/88/1402 -00981502 00/0 JOURNAL Ot ICNDODONtlC5 Cooyngttt r 1988 by ~ Anlencan A~O(:~11O3 of EncIoOO~t,sls
Pt~nto(l ,n U S A
Vot
14 NO 2 ~:[B~UAn, 19~
CASE REPORTS Nasal-Apical Communication Associated with a Pulpless Tooth Joshua H. Brickman, DMD, John Kuchmas, DMD, and Joseph E. Skiribner, DOS
A patient presented with swelling and discomfort from a maxillary right central incisor which was accompanied by a soft tissue growth in the right nostril. Endodontic retreatment of the involved tooth resulted in the resolution and healing of the nasal lesion as well as the dental symptoms. The imporlance of considering the relationship between maxillary anterior teeth and the nasal cavity as a pathway of infection is emphasized and reviewed.
swelling or sensitivity to palpation was observed. The diagnosis v,as subacute alveolar abscess. Emergency treatment consisted of remo~nng the gutta-percha, placing a mcdzc.:led dressing (Metacres~l-acetatc), and placing temporar~ t'tll.w~g,, with Cavnt G (Premncr Dental Products C o . Nom,,tov, n. }'~,1 in the access openings of teeth R and ~). I he patient v,.a,, pl..,ed on pemcdhn VK (500 mg, two tablet,, at once. one t.~ ~lez every 6 h for 6 days) and told to return for complctt(~n of treatment in I week.
Periapical chronic inflammation from a tooth can cause the development of a dental sinus tract. It is usually found in the oral mucosa, but it can sometimes open onto the outer surface of the skin (I-10) by penetrating through the fasctal planes. The response and pathway of an infection is influenced by the virulence of the organism, resistance of the patient, tissue density, position of muscle attachments, gravity, and the site of the involved tooth. Maxillary central incisors tend to have their apicies closer to the labial porhon of the alveolar process and therefore the pathway of infection is generally through the bone m this region. Laskin (I I) states that the exudate from a maxillary incisor tends to be limnted to the loose alveolar tissue of the oral vestibule because the subacutaneous tissue at the base of the nose and the orbicular'is ons muscle act as resistant barriers. This article reports about a patient ~ho had an mtranasal mass that was found to be the result of a dental refection. Conventional root canal treatment of the invol,.ed tooth resulted m the reduction and disappearance of the intranasal lesion. CASE R E P O R T A 40-yr-old black female paticnt presented to the emergency clinic with pain and swelling in the maxillary anterior region. A review of the chart revealed that she had previously been treated in the emergency clinic 3 months earlier for discomfort in the same regaon. She initially complained of intermittent pare (of l-wk duration) which began when tooth 8 fractured. A horizontal fracture of the crown was noted. A radiograph at that time showed periapical pathosis around teeth 8 and 9 and that conventional endodontic treatment had previously been performed on these two teeth (about 6 yr previously). Both teeth were sensitive to percussion but no
FIG 1. PreoperatNe radiograph. Both teeth 8 and 9 show areas ol rardachon at apices. Tooth 8 shows slight overextensfon of filbng matenal.
98
Vol. 14, No. 2, February 1988
FIG 2. Extraoral photograph of initial nasal lesion (arrowheads)on the inner wall of the right nostril.
Nasal-Apical Communication
99
intermittent pain from the tooth along with headaches, a slight fever, and dizziness for the previous 2 wk. A review of her health history proved noncontributory and the diagnosis of a subacute alveolar abscess was made. While performing the oral examination the patient was continuously touching her right nostril and implied some sort of discomfort. Close examination revealed a large red nodular lesion on the inner (facial) wall of the right nostril. The patient complained that the "boil has been in my nose for about a year and is irritating." Palpation of the lesion induced a slight dull pain. Tooth 8 was reinstrumented to remove the remaining guttapercha and to ensure that the canal was cleared of any blockages. Since no exudate was observed, a medicated dressing of camphorated parachlorophenol was placed on a cotton pellet and placed in the pulp chamber along with a temporary filling of the access with Cavit G. The patient was placed on penicillin VK (500 mg, two tablets at once, one tablet every 6 h for 6 days). Prior to dismissal a photograph (Fig. 2) was taken of the intranasal lesion. The root canal was completed on tooth 8 without complication using gutta-percha (Indian Head, Union Broach Corp., Long Island, NY) for the master and lateral cones in lateral condensation with U / P root canal sealer (Sulton Chemists Inc., Englewood, NJ) (Fig. 3). An occlusal radiograph of the lesion was made to give another view of the periapical pathosis (Fig. 4).
FIG 3. Postoperative radiograph of tooth 8. The canal was thoroughly reinstrumented and obturated with gutta-percha and U/P root canal Sealer using the lateral condensation technique.
The patient did not return until 3 months later and was then referred to the Postgraduate Endodontic Clinic. She had SWelling in the labial vestibule, over teeth 7, 8, and 9, which was tender to palpation. Tooth 8 was sensitive to percussion. A radiograph was made (Fig. 1) showing incomplete removal of gutta-percha on her previous visit. The patient reported
FIG 4. Occlusal radiograDh to show the extent of the radiolucent area
(arrowheads) extending from the apex of tooth 8 to the floor of the nasal cavity.
100
Brickman et al.
J o u m a l of Endoclontiet
5. The subcutaneous tissue at the base of the nose and the location o f the obiculoris otis muscle were situated it~ such a position to allow the exudate to exit into the nasal cavity. 6. The nasal lesion healed after completion of endodontie treatment. S U M M A R Y AND C O N C L U S I O N
FIG 5. Photograph of 1-month recall. Partial resolution of the nasal lesion (arrowheads).
The patient returned for treatment of tooth 9 one month later. The patient had no symptoms from either her teeth or the nasal lesion. Upon examination of her nostril, there was a noticeable reduction in size of the mass (Fig. 5). The root canal treatment was completed on tooth 9, and the patient was given a recall appointment. At the 2-month recall, the lesion had totally resolved and the patient reported she was asymptomatic. DISCUSSION The nasal lesion was believed to be associated with the dental infection for the following reasons: 1. There was a close proximity of the labial swelling to the nasal lesion. 2. The induced pain from palpation of both lesions was similar. 3. Radiographically the proximity of the periapical radiolucency around tooth 8 corresponded to the location of the nasal lesion. 4. The pationt claimed the onset of pain from both lesions began about the same time.
A case involving the communication of a periapical infee. tion from a maxillary central incisor to the nasal cavity is reported. Upon successful completion of endodontic therapy to the involved tooth the nasal lesion resolved. Understanding the pathways of infection and careful clinical inspection of all related structures, intraorally and extraorally, are important factors to be considered by the successful practitioner. Dr. Bnckman is a postgraduate student. Department of Endodontics, New Jersey Dental School University of Med~ne and Dentistry of New Jersey. Newark, NJ. Dr. Kuchmas is clinical assistant professor, Department of Endo. dont=cs, New Jersey Dental School, t.,Iniversity of Medicine and Dentistry of New Jersey. Dr. Skiribner is professor/acting chairman. Department of Endodonbcs, New Jersey Dental School, University of Medicine and Dentistry of New Jersey
References
1 Anderson NP. Per.~stent sinus tracts of dental origin Arch Dermat01 Syphilo11937;35:1062-73. 2. Hamilton A Facial sinuses of dental origin Br J Surg 1959:46:433-41. 3 Smith EL, Petty AH. Chronic dental sinus of unusual location. Br d Dermatol 1962;74:450--3. 4. Tagami H. Yuoshitake K Chronic dental fistula on the nose. Acta Dermato11977;57:365-71. 5 Karp MP, Bernat JE, Cooney DR, Jewett TC Dental disease masquecadmg as suppurative lesions of the neck. J Pediatr Surg 1982;5:532-6. 6 Gorsky M. Kaffe I. Tamse A. A draining sinus tract of the chin: report Of a case. Oral Surg 1978;4:583-7. 7 Lubit FA, Senzer J. Rothenber F. Extraora} fistulas of endodontic origin: report of two cases. J Endodon 1976;12:393-6. 8. Scott MJ Jr. Scott MJ Sr. Cutaneous odontogenic sinus. J Am Acad Dermato11980:2:521-4 9. Cart W, Helm F. Wood R. Cutaneous lesion of dental origin. Quintessence Int 1975:12:75-8. 10. Bussetburg LF. Horton CE, Carraway JH. Cysts and sinuses of the face resulting from dental abscesses. Surg Gynecol Obstet 1979:149:717-8 11. Laskin DM. Anatomic considerations in diagnosis and treatment o4 edontogenic infections. J Am Dent Assoc 1964:69:308-16.
Pt~nto(l ,n U S A
Vot
14 NO 2 ~:[B~UAn, 19~
CASE REPORTS Nasal-Apical Communication Associated with a Pulpless Tooth Joshua H. Brickman, DMD, John Kuchmas, DMD, and Joseph E. Skiribner, DOS
A patient presented with swelling and discomfort from a maxillary right central incisor which was accompanied by a soft tissue growth in the right nostril. Endodontic retreatment of the involved tooth resulted in the resolution and healing of the nasal lesion as well as the dental symptoms. The imporlance of considering the relationship between maxillary anterior teeth and the nasal cavity as a pathway of infection is emphasized and reviewed.
swelling or sensitivity to palpation was observed. The diagnosis v,as subacute alveolar abscess. Emergency treatment consisted of remo~nng the gutta-percha, placing a mcdzc.:led dressing (Metacres~l-acetatc), and placing temporar~ t'tll.w~g,, with Cavnt G (Premncr Dental Products C o . Nom,,tov, n. }'~,1 in the access openings of teeth R and ~). I he patient v,.a,, pl..,ed on pemcdhn VK (500 mg, two tablet,, at once. one t.~ ~lez every 6 h for 6 days) and told to return for complctt(~n of treatment in I week.
Periapical chronic inflammation from a tooth can cause the development of a dental sinus tract. It is usually found in the oral mucosa, but it can sometimes open onto the outer surface of the skin (I-10) by penetrating through the fasctal planes. The response and pathway of an infection is influenced by the virulence of the organism, resistance of the patient, tissue density, position of muscle attachments, gravity, and the site of the involved tooth. Maxillary central incisors tend to have their apicies closer to the labial porhon of the alveolar process and therefore the pathway of infection is generally through the bone m this region. Laskin (I I) states that the exudate from a maxillary incisor tends to be limnted to the loose alveolar tissue of the oral vestibule because the subacutaneous tissue at the base of the nose and the orbicular'is ons muscle act as resistant barriers. This article reports about a patient ~ho had an mtranasal mass that was found to be the result of a dental refection. Conventional root canal treatment of the invol,.ed tooth resulted m the reduction and disappearance of the intranasal lesion. CASE R E P O R T A 40-yr-old black female paticnt presented to the emergency clinic with pain and swelling in the maxillary anterior region. A review of the chart revealed that she had previously been treated in the emergency clinic 3 months earlier for discomfort in the same regaon. She initially complained of intermittent pare (of l-wk duration) which began when tooth 8 fractured. A horizontal fracture of the crown was noted. A radiograph at that time showed periapical pathosis around teeth 8 and 9 and that conventional endodontic treatment had previously been performed on these two teeth (about 6 yr previously). Both teeth were sensitive to percussion but no
FIG 1. PreoperatNe radiograph. Both teeth 8 and 9 show areas ol rardachon at apices. Tooth 8 shows slight overextensfon of filbng matenal.
98
Vol. 14, No. 2, February 1988
FIG 2. Extraoral photograph of initial nasal lesion (arrowheads)on the inner wall of the right nostril.
Nasal-Apical Communication
99
intermittent pain from the tooth along with headaches, a slight fever, and dizziness for the previous 2 wk. A review of her health history proved noncontributory and the diagnosis of a subacute alveolar abscess was made. While performing the oral examination the patient was continuously touching her right nostril and implied some sort of discomfort. Close examination revealed a large red nodular lesion on the inner (facial) wall of the right nostril. The patient complained that the "boil has been in my nose for about a year and is irritating." Palpation of the lesion induced a slight dull pain. Tooth 8 was reinstrumented to remove the remaining guttapercha and to ensure that the canal was cleared of any blockages. Since no exudate was observed, a medicated dressing of camphorated parachlorophenol was placed on a cotton pellet and placed in the pulp chamber along with a temporary filling of the access with Cavit G. The patient was placed on penicillin VK (500 mg, two tablets at once, one tablet every 6 h for 6 days). Prior to dismissal a photograph (Fig. 2) was taken of the intranasal lesion. The root canal was completed on tooth 8 without complication using gutta-percha (Indian Head, Union Broach Corp., Long Island, NY) for the master and lateral cones in lateral condensation with U / P root canal sealer (Sulton Chemists Inc., Englewood, NJ) (Fig. 3). An occlusal radiograph of the lesion was made to give another view of the periapical pathosis (Fig. 4).
FIG 3. Postoperative radiograph of tooth 8. The canal was thoroughly reinstrumented and obturated with gutta-percha and U/P root canal Sealer using the lateral condensation technique.
The patient did not return until 3 months later and was then referred to the Postgraduate Endodontic Clinic. She had SWelling in the labial vestibule, over teeth 7, 8, and 9, which was tender to palpation. Tooth 8 was sensitive to percussion. A radiograph was made (Fig. 1) showing incomplete removal of gutta-percha on her previous visit. The patient reported
FIG 4. Occlusal radiograDh to show the extent of the radiolucent area
(arrowheads) extending from the apex of tooth 8 to the floor of the nasal cavity.
100
Brickman et al.
J o u m a l of Endoclontiet
5. The subcutaneous tissue at the base of the nose and the location o f the obiculoris otis muscle were situated it~ such a position to allow the exudate to exit into the nasal cavity. 6. The nasal lesion healed after completion of endodontie treatment. S U M M A R Y AND C O N C L U S I O N
FIG 5. Photograph of 1-month recall. Partial resolution of the nasal lesion (arrowheads).
The patient returned for treatment of tooth 9 one month later. The patient had no symptoms from either her teeth or the nasal lesion. Upon examination of her nostril, there was a noticeable reduction in size of the mass (Fig. 5). The root canal treatment was completed on tooth 9, and the patient was given a recall appointment. At the 2-month recall, the lesion had totally resolved and the patient reported she was asymptomatic. DISCUSSION The nasal lesion was believed to be associated with the dental infection for the following reasons: 1. There was a close proximity of the labial swelling to the nasal lesion. 2. The induced pain from palpation of both lesions was similar. 3. Radiographically the proximity of the periapical radiolucency around tooth 8 corresponded to the location of the nasal lesion. 4. The pationt claimed the onset of pain from both lesions began about the same time.
A case involving the communication of a periapical infee. tion from a maxillary central incisor to the nasal cavity is reported. Upon successful completion of endodontic therapy to the involved tooth the nasal lesion resolved. Understanding the pathways of infection and careful clinical inspection of all related structures, intraorally and extraorally, are important factors to be considered by the successful practitioner. Dr. Bnckman is a postgraduate student. Department of Endodontics, New Jersey Dental School University of Med~ne and Dentistry of New Jersey. Newark, NJ. Dr. Kuchmas is clinical assistant professor, Department of Endo. dont=cs, New Jersey Dental School, t.,Iniversity of Medicine and Dentistry of New Jersey. Dr. Skiribner is professor/acting chairman. Department of Endodonbcs, New Jersey Dental School, University of Medicine and Dentistry of New Jersey
References
1 Anderson NP. Per.~stent sinus tracts of dental origin Arch Dermat01 Syphilo11937;35:1062-73. 2. Hamilton A Facial sinuses of dental origin Br J Surg 1959:46:433-41. 3 Smith EL, Petty AH. Chronic dental sinus of unusual location. Br d Dermatol 1962;74:450--3. 4. Tagami H. Yuoshitake K Chronic dental fistula on the nose. Acta Dermato11977;57:365-71. 5 Karp MP, Bernat JE, Cooney DR, Jewett TC Dental disease masquecadmg as suppurative lesions of the neck. J Pediatr Surg 1982;5:532-6. 6 Gorsky M. Kaffe I. Tamse A. A draining sinus tract of the chin: report Of a case. Oral Surg 1978;4:583-7. 7 Lubit FA, Senzer J. Rothenber F. Extraora} fistulas of endodontic origin: report of two cases. J Endodon 1976;12:393-6. 8. Scott MJ Jr. Scott MJ Sr. Cutaneous odontogenic sinus. J Am Acad Dermato11980:2:521-4 9. Cart W, Helm F. Wood R. Cutaneous lesion of dental origin. Quintessence Int 1975:12:75-8. 10. Bussetburg LF. Horton CE, Carraway JH. Cysts and sinuses of the face resulting from dental abscesses. Surg Gynecol Obstet 1979:149:717-8 11. Laskin DM. Anatomic considerations in diagnosis and treatment o4 edontogenic infections. J Am Dent Assoc 1964:69:308-16.