Long-term Outcomes of Endodontic Treatment in Traumatic Pulp Necrosis with Extensive Inflammatory Apical Periodontitis: A Case Report

INTRODUCTION

An infection that starts in periodontal tissue or a tooth communicates to the skin’s or mucous membrane’s surface by a tiny channel or tunnel known as an odontogenic sinus tract (OST), sometimes called a dental sinus.¹ By allowing the pus or infected material to drain out of the body, the sinus tract lessens the pressure and discomfort brought on by the illness. The sinus tract often manifests on the skin as a tiny, raised, reddish, or pinkish lump that may or may not be accompanied by pain, swelling, or a discharge of pus or blood. These tracts typically develop from infected mandibular teeth (80% of the time) rather than maxillary teeth (20%).² They therefore tend to occur more frequently in the submandibular or submental areas of the face.³ Because of its rare occurrence and the absence of associated symptoms in approximately half of the individuals affected, it is commonly misdiagnosed, usually leading to inappropriate treatment (e.g., surgical excision, biopsy, radiotherapy, and/or antibiotics) and eventual recurrence of the cutaneous sinus tract.^3,4 Thus, a diagnosis made with suspicion of odontogenic origin, appropriate examination methods, and prompt treatment will reduce or eliminate complications such as asepsis, osteomyelitis, and patient discomfort.⁴

In cutaneous sinus tract cases, cone-beam computed tomography (CBCT) has been recommended as the imaging modality for assessing the size and degree of bone deterioration around the apices and finding the affected tooth.⁵ This case report presents nonsurgical endodontic management with the aid of CBCT as a diagnostic tool and a 4-year follow-up of a nonvital mandibular central incisor with an OST.

CASE PRESENTATION

A 19-year-old female reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of pus drainage from the chin. With a history of trauma due to a road accident (5 years ago) and no relevant medical or dental history, the patient complained of swelling with pus discharge for the past 2 weeks. On palpation, the swelling was soft in consistency, suggesting possible fluid content and purulent discharge under digital pressure was evident from a sinus opening of approximately 2 mm diameter (Fig. 1).

Intraorally, Ellis Davey’s type I fracture was noted on #21 and #31 (Fig. 2), without any tenderness to percussion or mobility.

A #45 size 2% gutta-percha was used for tracing the sinus tract and an intraoral periapical radiograph (IOPA) was taken (Fig. 3).

The IOPA revealed a periapical lesion in relation to #31, #32, and #41 region. Following the “As-Low-As-Reasonably-Achievable (ALARA)” principle, the patient was advised for a low field of volume (FOV) CBCT scan.

The CBCT image reveals a periapical bony defect (12 mm approx. diameter) in relation to #31, #32, and #41 (Fig. 4A). The axial image slices revealed an intact lingual cortical bone and two sinus tracts from the bony defects to the chin (Figs 4B and C).

On further investigation, a pulp vitality test with an electric pulp tester revealed a nonvital pulp in relation to #31, whereas #32 and #41 responded positively, indicating an intact pulp. With the above findings and the patient’s history in consideration, a provisional diagnosis of pulp necrosis of traumatic origin with extensive inflammatory apical periodontitis.

On the first visit, after obtaining written consent from the patient, root canal treatment was initiated in #31 under local anesthesia and rubber dam isolation. Upon opening the access, pus discharge was evident. An apex locator was used to determine the working length. The canal was then shaped and cleaned. Saline irrigation of the root canal resulted in the irrigant oozing out of the extraoral sinus opening, confirming that the lesion was a sinus tract with an odontogenic origin from the left mandibular central incisor. Apart from saline, chlorhexidine (Asep-RC, Anabond Stedman, India) was used as an alternative irrigant to avoid the risk of apical extrusion of sodium hypochlorite during the instrumentation procedure. Saline and chlorhexidine were used to irrigate the canal during each instrumentation change. Calcium hydroxide (RC Cal, Prime Dental, India) was placed as an intracanal medicament and the access cavity was temporized with Cavit (3M, USA). In the second visit, after 2 weeks, the canal was irrigated with saline, followed by chlorhexidine as the final irrigant. Since the canal was dry, obturation was done using the lateral condensation method (Fig. 5).

A follow-up clinical image and IOPA were taken after 1 year suggesting possible ongoing healing of the bony defect (Fig. 6). The follow-up clinical image, IOPA of #31, #32, and CBCT image revealed complete healing of the bony defect (Fig. 7).

The electric pulp testing of #32 and #41 indicated intact vital pulp. Nevertheless, the patient was informed of a possible endodontic intervention if symptomatic in relation to #32 and #41 in the near future.

DISCUSSION

Odontogenic sinus tracts are rare conditions caused by chronic tooth infections that result in the formation of an extraoral fistula. The virulent byproducts of infection can then enter the soft tissue by infiltrating the bone, choosing the path of least resistance.⁶ Plans for diagnosing and treating OSTs have been widely documented in the literature.⁷ However, in this case report, a patient with an OST underwent a 4-year long-term follow-up that revealed great healing, no recurrence, and closure of the fistula without the need for surgery.

It is essential to determine whether an OST is odontogenic or nonodontogenic to appropriately treat it. The size of the lesion and the existence of periapical lesions can be determined by clinical and radiographic exams, such as CBCT and periapical radiography. Additionally, as was the case in this instance, a radiograph taken after introducing a gutta-percha cone into the sinus tract demonstrated that the infection had an odontogenic cause.⁸

Antibiotic therapy may temporarily halt exudate drainage, but complete eradication of the infection source is required to prevent the recurrence of the lesion. Cone-beam computed tomography can aid in the diagnosis and treatment of OSTs by determining the best treatment approach, as well as assessing the extent of the lesion.⁹

Sodium hypochlorite (NaOCl) is a common chemical disinfectant irrigant used as a chemical debridement of root canals. Nevertheless, there have been many case reports in the literature suggesting catastrophic complications.^10,11 Chlorhexidine (CHX) and NaOCl both can decrease bacterial infections following irrigation, and their antibacterial efficacy was not significantly different, according to a recent systematic review and meta-analysis. Even though CHX and NaOCl had comparable efficacy, their molecular mechanism of action was distinct. As a result, they are suitable for use as the primary antibacterial root canal irrigants.¹² In this particular case, we used chlorhexidine as an irrigant followed by the placement of calcium hydroxide for 2 weeks and a temporary restoration. Chlorhexidine, with its antimicrobial properties, helped to disinfect the canal, followed by systemic antibiotics and calcium hydroxide to treat the persistent infection.

The CBCT image slices also revealed the presence of two sinus tracts, which were formed due to the persistent infection within the canal. The healing of these lesions without surgical intervention demonstrates that endodontic lesions can be effectively treated noninvasively. The 4-year follow-up CBCT showed excellent bone formation around the affected tooth, reinforcing the effectiveness of nonsurgical treatment. Early diagnosis and a thorough examination of the fistula are essential in treating OSTs effectively. Without early intervention, diagnosis becomes difficult, and treatment may require surgical intervention. Odontogenic sinus tracts can occur anywhere from the second molar region to the submandibular area in the lower anterior. However, as demonstrated in this case, noninvasive treatment can be successful in effectively treating OSTs. A possible drawback of this procedure was the unavailability of a histopathological report.

CONCLUSION

This case report shows how a young female patient’s nonvital central incisor with asymptomatic apical periodontitis and a draining extraoral sinus was treated successfully. The noninvasive approach to this case ruled out possible associated comorbidities that are associated with a surgical approach. Cone-beam computed tomography scans with a low FOV helped with the diagnosis and planning of treatment. The importance of regular follow-up and monitoring of the vital teeth adjacent to the affected area was emphasized to the patient. Despite its drawbacks, this approach is consistent with the available scientific literature for treating periapical lesions with an endodontic etiology. Regardless of the size of the periapical lesion, this case report emphasizes the value of nonsurgical endodontic therapy.

ORCID

Hrudi Sundar Sahoo https://orcid.org/0000-0002-3259-8364

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