A 25-year-old man presents to the emergency department (ED) with left-sided jaw pain, swelling, and erythema of 3 days' duration. The patient states that he had an “infected molar” at the same site approximately 3 weeks ago and was treated with a course of antibiotics that was prescribed by his dentist. He subsequently felt better over the next 2 weeks, until a large “pimple” formed over his left jaw. He reports that the area since then has become increasingly painful, red, and swollen. He denies having any fever, chills, nausea, or vomiting. He also denies having a stiff neck or any difficulty swallowing or speaking.
What is the diagnosis?
HINT
He visited the dentist in the past month.
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Authors:
Robert J Paquette, MD, Assistant Professor, Department of Emergency Medicine, University of Southern California Keck School of Medicine
Nicolas Forget, MD, Senior Resident, Department of Emergency Medicine, University of Southern California Keck School of Medicine
eMedicine Editors:
Erik D. Schraga, MD, Department of Emergency Medicine, Kaiser Permanente, Santa Clara Medical Center, Calif
Rick G. Kulkarni, MD, Assistant Professor, Yale School of Medicine, Section of Emergency Medicine, Department of Surgery, Attending Physician, Medical Director, Department of Emergency Services, Yale-New Haven Hospital, Conn
ANSWER
Dentocutaneous fistula secondary to periodontal disease: Dentocutaneous fistulas, an uncommon complication of periodontal disease, may arise from chronic dental infections but are most commonly caused by periapical abscesses. The panoramic radiograph (Panorex, see Image 2) reveals a large periapical lucency on tooth #19, which is indicative of infection. The infection spread from the tooth apex through the alveolar bone and into the surrounding tissues. The result is what may appear from the facial skin to be a cutaneous abscess.
With dentocutaneous fistulas, preceding dental pain and cutaneous findings are often significantly separated in time, often by weeks; therefore, the odontogenic origin may not be easily recognized. It is also not uncommon for patients to omit their dental visit histories. These factors result in a diagnostic challenge for the treating physician, with a resultant risk of inadequate treatment by repeated cutaneous incision and drainage, along with antibiotic courses, before the odontogenic origin is identified. The differential diagnosis of purulent facial lesions includes foreign bodies, osteomyelitis, branchial clefts or thyroglossal fistulas, granulomatous disease, fistulas of the salivary glands or ducts, pyogenic granuloma, basal or squamous cell carcinoma, and common furuncles. The diagnosis is made by examining the oropharynx for any diseased teeth, looking for evidence of an apical abscess (eg, focal gingival swelling, discharge), and palpating the floor of the mouth for sinus tract cords.
The majority of patients with a dentocutaneous fistula will appear relatively well and do not require extensive testing in the acute care setting. Laboratory studies are not generally necessary, although Panorex radiographs of the mandible may be helpful in identifying the odontogenic source of infection. Therapy should be focused on achieving adequate pain control and initiating appropriate antibiotic coverage with oral penicillin or clindamycin, and the patient should be referred to an oral surgeon. The oral surgeon will drain the odontogenic abscess, and if the tooth is salvageable, root canal therapy may be sufficient to stop the infection. In more advanced disease, dental extraction is required. If an extensive cutaneous abscess has developed, incision and drainage in the ED may be necessary as a temporizing measure, until the patient can be seen by an oral surgeon for definitive treatment.
In severe cases with evidence of abscess involvement beyond a well-defined area, hemodynamic instability, concern for airway compromise, or other complications, patients may require a computed tomography (CT) scan of the face and neck to investigate for deep-space neck infections and possible involvement of the submandibular region or airway. These patients may also require expanded parenteral antibiotic coverage (with beta-lactam penicillins and vancomycin, given the increasing problems with antibiotic resistance) and admission to the hospital to the appropriate level of care.
The patient in this case had an oral surgery consult while he was in the ED. An incision and drainage were performed, and a Penrose drain was placed to allow for continued drainage. Antibiotic coverage with oral clindamycin was initiated. The drain was removed on post-procedure day 2, and the patient underwent a root canal of the affected tooth. At follow-up, he was reported to be healing well.
References:
Cade, J. Oral Cutaneous Fistulas. eMedicine from WebMD. Updated July 19, 2007. Available at: http://www.emedicine.com/derm/topic660.htm. Date accessed: February 2007.
Ferrera PC, Busino LJ, Snyder HS. Uncommon complications of odontogenic infections. Am J Emerg Med. 1996 May;14(3):317-22. [MEDLINE: 8639212]
Flynn TR, Shanti RM, Levi MH, Adamo AK, Kraut RA, Trieger N. Severe odontogenic infections, part 1: prospective report. J Oral Maxillofac Surg. 2006 Jul;64(7):1093-103. [MEDLINE: 16781343]
Marx JA, Hockberger RS, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002: 892-908.
