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The ectopic sinus tract: report of cases
JOURNAL OF ENDODONTICS [ VOL 6, NO 6, JUNE 1980
The ectopic sinus tract: report of cases Bryce W . B o n n e s s , DDS, a n d Jerry F. T a i n t o r , DDS, MS
T h e i m p o r t a n c e of the sinus tract is discussed. T h r e e cases p r e s e n t e d in this article s h o w that a m o r e definitive diagnosis m a y be m a d e with the use of a tract m a r k e r . T h e e c t o p i c sinus tract c a n be disclosed b y the m a r k e r . This simple aid m a y help eliminate t r e a t m e n t of an u n i n v o l v e d tooth.
By defnition, a sinus tract "refers to a nonepithelialized tract leading from a chronic apical abscess to an epithelial surface, m Endodontists see sinus tracts almost daily. They may first become aware of the tracts by the patient's comments on the dental history or probably during the initial oral examination. The sinus tract may be present extraorally as a true fistula z'3 or intraorally. This paper is concerned with the latter case--the intraoral sinus tract and its significance. The sinus tract may vary in appearance from a small, slightly raised sessile or pedunculated mass to a raised swelling descriptively called the "gum boil" or parulis. Patients will report recurrent episodes of swelling and draining of the area in a cyclic manner. The tract is caused by frank pus eroding a channel through bone, periosteum, and mucosa, by the action of such enzymes as necrosin and the action of such cells as osteoclasts, macrophages, 4 and lymphocytes? The channel, or sinus tract, is most generally lined with granulation tissue containing chronic inflammatory cells. 6s The route is tor-
614
tuous and meandering, exiting as a stoma through which pus is periodically discharged. This point of exit is thought to penetrate through the area of least resistance and is usually dependent on the inclination of the root as well as the thickness of bone overlying the infection. The presence of the sinus tract has been associated with a lower incidence of paing; it has been suggested that single-appointment endodontic therapy can be accomplished in its presence with minimal posttreatment discomfort. 1~ In most instances, the tract heals without any intervention other than removal of its cause."-' The sinus tract may be associated with or without an accompanying lesion in the radiolucent area. The absence of a lesion may indicate loss of integrity of the cortical plate of bone? a Studies have shown that with a radiolucent area at the apex, the root canal may contain vital tissue? 4 Hence, vitality tests may n o t b e definitive in determining with which tooth the sinus tract is associated? 5 Furthermore, the diagnosis may be aided by the position of the existing
sinus tract. In the majority of instances, the sinus tract is in close approximation to the apex of the involved root. The tract may, however, be found in the sulcular area. When this occurs, the size of the tract may indicate the cause of the problem. Some authorities believe that if the tract allows single gutta-percha or silver cone penetration, the problem, in most instances, is of endodontic origin. However, if the tract allows penetration of multiple points, the lesion is most likely of periodontal origin. 1~ Thus, the value of determining the size of these lesions can begin to be appreciated. Position of the apex also may be of some importance. The midroot sinus tract has been associated with the cracked tooth syndrome or a perforation? G The sinus tract may be an indicator of cause of the pathologic condition; success or lack of treatment success; and involvement of specific teeth. The ability of the tract to indicate involvement of teeth may be valid only if interpretation is correct. First impressions may lead to an erroneous
conclusion with respect to locating the affected tooth. This paper hopes to point out that the operator should insert a small silver or gutta-percha point into the tract, thus using the tract as a valuable diagnostic aid. The distant or ectopic sinus tract has previously been discussed by the various endodontic textbooks, s'l~ The cases presented here reemphasize the importance of a disclosing technique of the sinus tract to determine the involved tooth.
Fig 1--Case 1. Sinus tract in area of apex of left central incisor.
Fig 3-Case 1. Radiograph showing tract crossing midline.
CASE R E P O R T S Case 1 A 31-year-old white man came for endodontic treatment in February 1975. The chief symptom was a palpable tenderness at the apex of the maxillary left canine. The medical history was noncontributory. A clinical examination of the patient disclosed complete jacket crowns on all six maxillary anterior teeth. The left canine was sensitive to both percussion and palpation. A sinus tract was noticed to the left of the frenum in the region of the left central incisor (Fig 1). Vitality testing disclosed a nonvital maxillary left canine and slight thermal sensitivity of the maxillary left central incisor. Tests on other teeth were within normal limits. Radiographs disclosed a previous endodontic treatment of the maxillary left lateral incisor and maxillary right central incisor (Fig 2). The right central incisor was treated 12 years previously and had both an 9 apical radiolucent lesion and apical root resorption. A gutta-percha cone was inserted through the sinus tract to determine the tract's origin. The cone crossed the midline and disclosed the right
Fig 2-Case 1. Preoperative radiograph.
central incisor as the offending tooth (Fig 3). The maxillary canine was treated with gutta-percha and sealer conventionally, whereas the right central incisor was treated surgically by performing an apicoectomy and retroamalgam (Fig 4). Healing was uncomplicated and the sinus tract had resolved by the end of two weeks. Case 2 A 35-year-old white man came for endodontic treatment in J a n u a r y
Fig 4-Case 1. Postoperative radiograph showing apicoectom~ and retroamalgam perfirmed.
1976. The patient had been referred by a general practitioner. The referral note indicated that the dentist thought that two or three teeth were involved in the extensive area of the lesion (Fig 5). The medical history was noncontributory other than the fact that the patient was under care of a physician for various allergies. A clinical examination disclosed a draining sinus tract through the mucosa between the maxillary left lateral incisor and canine (Fig 6). 615
JOURNAL OF ENDODONTICS I VOL 6, NO 6, JUNE 1980
Fig 7-Case 2. Radiograph taken showing more posterior view of area of lesion.
Fzg 9--Case 2. A two-week follow-up showing resolved lesion. Fig 5--Case 2. Radiograph sent by referring dentist.
d-,
Fig 8-Case 2. Radiograph tracing sinus tract to first premolar.
Fig 6-Case 2. Sinus tract located between maxillary left lateral incisor and canine.
Vitality tests disclosed findings within normal limits on the left central and lateral incisors and canine. However, the maxillary left first premolar tested nonvital on thermal and electric testing. A radiograph that included more of the posterior area than the one sent by the referring dentist disclosed that the first premolar was, indeed, in the region of the extensive lesion 616
(Fig 7). A gutta-percha cone was inserted through the tract, and a radiograph showed that the point of the cone was at the apexes of the first premolar (Fig 8). Hence, the origin of the tract was the first premolar and not the anterior tooth or teeth as first suspected. The first premolar was opened, debrided, medicated, and temporized. When the patient returned in two weeks, the tract had resolved (Fig 9). The endodontic therapy was completed by filling the tooth with guttapercha and sealer (Fig 10). Case 3 A 20-year-old white woman came for endodontic treatment in October
Fig lO--Case 2. Postoperative radiograph.
1977. The patient's medical history was noncontributory. The patient reported two "bubbles" on the maxillary left gingival area. A clinical examination disclosed two draining sinus tracts (Fig 11). The larger and more distal tract was in the apical area of the second premolar. The smaller and more mesial tract was interproximal at the midroot area of the first and second premolars. Amalgam restorations (MODs) were noticed in the maxillary first and second premolars. Vitality testing disclosed nonvitality of both premolars.
Radiographic examination disdosed a radiolucent area at the apex o f the first premolar and a normal periapical appearance of the second premolar (Fig 12). When a gutta-percha cone was placed in both sinus tracts, the more distal tract was shown to originate from the first premolar, whereas the more mesial tract was shown to originate from the midroot lesion on the second premolar (Fig 13). Both teeth were opened, and the canals cleaned and shaped. T h e canal of the first premolar was totally necrotic whereas some vital remnants of apical pulpal tissue were noticed in the second premolar. T h e canals of both teeth were filled with gutta-percha a n d sealer (Fig 14). At a one-week follow-up examination, both tracts had resolved.
DISCUSSION It is easy for the busy clinician to develop professional myopia. T h e previous cases showed that, although a sinus tract is in close proximity to a root apex, the origin of the tract m a y be some distance from the exit of the tract. We believe that operators should more frequently use a guttapercha cone as a tract marker. This can be easily and quickly done if taken at the time of the diagnostic film. This technique m a y add a new dimension to the operator's diagnostic acumen. Although sinus tracts are seen daily, they m a y serve m a n y overlooked functions. T h e most important of their functions may lie in their ability to be used as a diagnostic tool. This tool, however, is valid only if properly interpreted.
Fig l l-Case 3. Sinus tract drainage sites.
Fig 13-Case 3. Radiograph showing markers in place.
Fig 12--Case 3. Preoperative radiograph.
Fzg 14-Case 3. Postoperative radiograph.
SUMMARY
5. Horton, J.E., and others. Macrophagelymphocyte synergy in the production of c~steoclast activating factor. J Immunol 113(4):1278-1287, 1974. 6. Grossman, L.I. Endodontic practice, ed 8. Philadelphia, Lea & Febiger, 1974, p 83. 7. Harrison, J.W., and Larson, W.J. The epithelialized oral sinus tract. Oral Surg 42(4):511-517, 1976. 8'. Bender, I.B., and Seltzer, S. The oral fistula: its diagnosis and treatment. Oral Surg 14:1367-1376, 1961. 9. Clem, W.H. Posttreatment endodontic pain. JADA 81:1166-1170, 1970. 10. Seltzer, S.; Bender, I.B.; and Ehrenr~:ich, J. Incidence and duration of pain following endodontic therapy. Relationship to treatment with sulfonamides and to other factors. Oral Surg 14:74-82, 1961. 11. Wolch, I. One-appointment endodontic treatment. Dent J 41(11):613-616, 1975. 12. Stromberg, R.; Hasselgren, G.; and Bergstedt, H. Endodontic treatment of resorprive periapical osteitis with fistula. Swed Dent J 65(9):467-474, 1972. 13. Seltzer, S. Endodontology. New York, McGraw-Hill Book Go., 1971, p 160. 14. Cohen, S., and Burns, R.G. Pathways of the pulp. St Louis, C. V. Mosby Co., 1976, p 275. 15. Seltzer, S., and Bender, I.B. The dental pulp, ed 2. Philadelphia, J. B. Lippincott Co., 1975, p 344, 287. 16. Ingle, J.I., and Beveridge, E.E. Endodontics, ed 2. Philadelphia, Lea & Febiger, 1976, p 480.
Three cases of teeth with ectopic sinus tracts are discussed. T h e sinus tract m a y aid in making a more thorough and confirmatory diagnosis. T h e position of a sinus tract stoma is not necessarily in close proximity to the tooth of its origin. Dr. Bonness is assistant professor of endodontics, University of Nebraska, College of Dentistry, Lincoln. Dr. Taintor is associate professor and chairman of endodontles, University of California School of Dentistry, Los Angeles, 90024. Requests for reprints should be directed to Dr. Taintor.
References 1. An annotated glossary of terms used in endodontics, ed 2. Atlanta. American Association of Endodontists, 1973, p 28. 2. Harris, W.E. Unusual endodontic complication: report of a ease. JADA 83:358-363, 1971. 3. Lubit, F.A.; Senzer, J.; and Rothenberg, F. Extraoral fistulas of endodontic origin: report of two cases. J Endod 2(12):393-396, 1976. 4. Ingle, J.I., and Beveridge, E.E. Endodontics, ed 2. Philadelphia, Lea & Febiger, 1976, p 403.
617
The ectopic sinus tract: report of cases Bryce W . B o n n e s s , DDS, a n d Jerry F. T a i n t o r , DDS, MS
T h e i m p o r t a n c e of the sinus tract is discussed. T h r e e cases p r e s e n t e d in this article s h o w that a m o r e definitive diagnosis m a y be m a d e with the use of a tract m a r k e r . T h e e c t o p i c sinus tract c a n be disclosed b y the m a r k e r . This simple aid m a y help eliminate t r e a t m e n t of an u n i n v o l v e d tooth.
By defnition, a sinus tract "refers to a nonepithelialized tract leading from a chronic apical abscess to an epithelial surface, m Endodontists see sinus tracts almost daily. They may first become aware of the tracts by the patient's comments on the dental history or probably during the initial oral examination. The sinus tract may be present extraorally as a true fistula z'3 or intraorally. This paper is concerned with the latter case--the intraoral sinus tract and its significance. The sinus tract may vary in appearance from a small, slightly raised sessile or pedunculated mass to a raised swelling descriptively called the "gum boil" or parulis. Patients will report recurrent episodes of swelling and draining of the area in a cyclic manner. The tract is caused by frank pus eroding a channel through bone, periosteum, and mucosa, by the action of such enzymes as necrosin and the action of such cells as osteoclasts, macrophages, 4 and lymphocytes? The channel, or sinus tract, is most generally lined with granulation tissue containing chronic inflammatory cells. 6s The route is tor-
614
tuous and meandering, exiting as a stoma through which pus is periodically discharged. This point of exit is thought to penetrate through the area of least resistance and is usually dependent on the inclination of the root as well as the thickness of bone overlying the infection. The presence of the sinus tract has been associated with a lower incidence of paing; it has been suggested that single-appointment endodontic therapy can be accomplished in its presence with minimal posttreatment discomfort. 1~ In most instances, the tract heals without any intervention other than removal of its cause."-' The sinus tract may be associated with or without an accompanying lesion in the radiolucent area. The absence of a lesion may indicate loss of integrity of the cortical plate of bone? a Studies have shown that with a radiolucent area at the apex, the root canal may contain vital tissue? 4 Hence, vitality tests may n o t b e definitive in determining with which tooth the sinus tract is associated? 5 Furthermore, the diagnosis may be aided by the position of the existing
sinus tract. In the majority of instances, the sinus tract is in close approximation to the apex of the involved root. The tract may, however, be found in the sulcular area. When this occurs, the size of the tract may indicate the cause of the problem. Some authorities believe that if the tract allows single gutta-percha or silver cone penetration, the problem, in most instances, is of endodontic origin. However, if the tract allows penetration of multiple points, the lesion is most likely of periodontal origin. 1~ Thus, the value of determining the size of these lesions can begin to be appreciated. Position of the apex also may be of some importance. The midroot sinus tract has been associated with the cracked tooth syndrome or a perforation? G The sinus tract may be an indicator of cause of the pathologic condition; success or lack of treatment success; and involvement of specific teeth. The ability of the tract to indicate involvement of teeth may be valid only if interpretation is correct. First impressions may lead to an erroneous
conclusion with respect to locating the affected tooth. This paper hopes to point out that the operator should insert a small silver or gutta-percha point into the tract, thus using the tract as a valuable diagnostic aid. The distant or ectopic sinus tract has previously been discussed by the various endodontic textbooks, s'l~ The cases presented here reemphasize the importance of a disclosing technique of the sinus tract to determine the involved tooth.
Fig 1--Case 1. Sinus tract in area of apex of left central incisor.
Fig 3-Case 1. Radiograph showing tract crossing midline.
CASE R E P O R T S Case 1 A 31-year-old white man came for endodontic treatment in February 1975. The chief symptom was a palpable tenderness at the apex of the maxillary left canine. The medical history was noncontributory. A clinical examination of the patient disclosed complete jacket crowns on all six maxillary anterior teeth. The left canine was sensitive to both percussion and palpation. A sinus tract was noticed to the left of the frenum in the region of the left central incisor (Fig 1). Vitality testing disclosed a nonvital maxillary left canine and slight thermal sensitivity of the maxillary left central incisor. Tests on other teeth were within normal limits. Radiographs disclosed a previous endodontic treatment of the maxillary left lateral incisor and maxillary right central incisor (Fig 2). The right central incisor was treated 12 years previously and had both an 9 apical radiolucent lesion and apical root resorption. A gutta-percha cone was inserted through the sinus tract to determine the tract's origin. The cone crossed the midline and disclosed the right
Fig 2-Case 1. Preoperative radiograph.
central incisor as the offending tooth (Fig 3). The maxillary canine was treated with gutta-percha and sealer conventionally, whereas the right central incisor was treated surgically by performing an apicoectomy and retroamalgam (Fig 4). Healing was uncomplicated and the sinus tract had resolved by the end of two weeks. Case 2 A 35-year-old white man came for endodontic treatment in J a n u a r y
Fig 4-Case 1. Postoperative radiograph showing apicoectom~ and retroamalgam perfirmed.
1976. The patient had been referred by a general practitioner. The referral note indicated that the dentist thought that two or three teeth were involved in the extensive area of the lesion (Fig 5). The medical history was noncontributory other than the fact that the patient was under care of a physician for various allergies. A clinical examination disclosed a draining sinus tract through the mucosa between the maxillary left lateral incisor and canine (Fig 6). 615
JOURNAL OF ENDODONTICS I VOL 6, NO 6, JUNE 1980
Fig 7-Case 2. Radiograph taken showing more posterior view of area of lesion.
Fzg 9--Case 2. A two-week follow-up showing resolved lesion. Fig 5--Case 2. Radiograph sent by referring dentist.
d-,
Fig 8-Case 2. Radiograph tracing sinus tract to first premolar.
Fig 6-Case 2. Sinus tract located between maxillary left lateral incisor and canine.
Vitality tests disclosed findings within normal limits on the left central and lateral incisors and canine. However, the maxillary left first premolar tested nonvital on thermal and electric testing. A radiograph that included more of the posterior area than the one sent by the referring dentist disclosed that the first premolar was, indeed, in the region of the extensive lesion 616
(Fig 7). A gutta-percha cone was inserted through the tract, and a radiograph showed that the point of the cone was at the apexes of the first premolar (Fig 8). Hence, the origin of the tract was the first premolar and not the anterior tooth or teeth as first suspected. The first premolar was opened, debrided, medicated, and temporized. When the patient returned in two weeks, the tract had resolved (Fig 9). The endodontic therapy was completed by filling the tooth with guttapercha and sealer (Fig 10). Case 3 A 20-year-old white woman came for endodontic treatment in October
Fig lO--Case 2. Postoperative radiograph.
1977. The patient's medical history was noncontributory. The patient reported two "bubbles" on the maxillary left gingival area. A clinical examination disclosed two draining sinus tracts (Fig 11). The larger and more distal tract was in the apical area of the second premolar. The smaller and more mesial tract was interproximal at the midroot area of the first and second premolars. Amalgam restorations (MODs) were noticed in the maxillary first and second premolars. Vitality testing disclosed nonvitality of both premolars.
Radiographic examination disdosed a radiolucent area at the apex o f the first premolar and a normal periapical appearance of the second premolar (Fig 12). When a gutta-percha cone was placed in both sinus tracts, the more distal tract was shown to originate from the first premolar, whereas the more mesial tract was shown to originate from the midroot lesion on the second premolar (Fig 13). Both teeth were opened, and the canals cleaned and shaped. T h e canal of the first premolar was totally necrotic whereas some vital remnants of apical pulpal tissue were noticed in the second premolar. T h e canals of both teeth were filled with gutta-percha a n d sealer (Fig 14). At a one-week follow-up examination, both tracts had resolved.
DISCUSSION It is easy for the busy clinician to develop professional myopia. T h e previous cases showed that, although a sinus tract is in close proximity to a root apex, the origin of the tract m a y be some distance from the exit of the tract. We believe that operators should more frequently use a guttapercha cone as a tract marker. This can be easily and quickly done if taken at the time of the diagnostic film. This technique m a y add a new dimension to the operator's diagnostic acumen. Although sinus tracts are seen daily, they m a y serve m a n y overlooked functions. T h e most important of their functions may lie in their ability to be used as a diagnostic tool. This tool, however, is valid only if properly interpreted.
Fig l l-Case 3. Sinus tract drainage sites.
Fig 13-Case 3. Radiograph showing markers in place.
Fig 12--Case 3. Preoperative radiograph.
Fzg 14-Case 3. Postoperative radiograph.
SUMMARY
5. Horton, J.E., and others. Macrophagelymphocyte synergy in the production of c~steoclast activating factor. J Immunol 113(4):1278-1287, 1974. 6. Grossman, L.I. Endodontic practice, ed 8. Philadelphia, Lea & Febiger, 1974, p 83. 7. Harrison, J.W., and Larson, W.J. The epithelialized oral sinus tract. Oral Surg 42(4):511-517, 1976. 8'. Bender, I.B., and Seltzer, S. The oral fistula: its diagnosis and treatment. Oral Surg 14:1367-1376, 1961. 9. Clem, W.H. Posttreatment endodontic pain. JADA 81:1166-1170, 1970. 10. Seltzer, S.; Bender, I.B.; and Ehrenr~:ich, J. Incidence and duration of pain following endodontic therapy. Relationship to treatment with sulfonamides and to other factors. Oral Surg 14:74-82, 1961. 11. Wolch, I. One-appointment endodontic treatment. Dent J 41(11):613-616, 1975. 12. Stromberg, R.; Hasselgren, G.; and Bergstedt, H. Endodontic treatment of resorprive periapical osteitis with fistula. Swed Dent J 65(9):467-474, 1972. 13. Seltzer, S. Endodontology. New York, McGraw-Hill Book Go., 1971, p 160. 14. Cohen, S., and Burns, R.G. Pathways of the pulp. St Louis, C. V. Mosby Co., 1976, p 275. 15. Seltzer, S., and Bender, I.B. The dental pulp, ed 2. Philadelphia, J. B. Lippincott Co., 1975, p 344, 287. 16. Ingle, J.I., and Beveridge, E.E. Endodontics, ed 2. Philadelphia, Lea & Febiger, 1976, p 480.
Three cases of teeth with ectopic sinus tracts are discussed. T h e sinus tract m a y aid in making a more thorough and confirmatory diagnosis. T h e position of a sinus tract stoma is not necessarily in close proximity to the tooth of its origin. Dr. Bonness is assistant professor of endodontics, University of Nebraska, College of Dentistry, Lincoln. Dr. Taintor is associate professor and chairman of endodontles, University of California School of Dentistry, Los Angeles, 90024. Requests for reprints should be directed to Dr. Taintor.
References 1. An annotated glossary of terms used in endodontics, ed 2. Atlanta. American Association of Endodontists, 1973, p 28. 2. Harris, W.E. Unusual endodontic complication: report of a ease. JADA 83:358-363, 1971. 3. Lubit, F.A.; Senzer, J.; and Rothenberg, F. Extraoral fistulas of endodontic origin: report of two cases. J Endod 2(12):393-396, 1976. 4. Ingle, J.I., and Beveridge, E.E. Endodontics, ed 2. Philadelphia, Lea & Febiger, 1976, p 403.
617