A 55-year-old woman with a history of systemic lupus erythematosus and secondary Sjögren syndrome presented with a 2-year history of facial swelling and intermittent drainage from a skin lesion on her left jaw. The patient denied both trauma to the jaw and tooth pain. Daily medications included hydroxychloroquine 200 mg and atorvastatin 20 mg.
An intraoral examination revealed erythema on the gingival tissue, which was attributed to her removable dentures; no other visible abnormalities were noted. On physical examination, there was an area of skin dimpling on her left mandible that was covered with scabbing (Figure 1). The lesion was tender to palpation, and palpation resulted in drainage of serosanguinous fluid.
Cutaneous fistula on the patient’s face. A radiopaque marker was placed to trace the sinus tract.
A radiopaque marker was placed into the cutaneous fistula opening, and a panoramic radiograph was taken to trace the origin of the tract. Radiography showed periapical radiolucency and osteolysis around the lower left second premolar (Figure 2), suggesting the orocutaneous fistula was from an odontogenic source.
Panoramic radiograph showing periapical radiolucency and osteolysis (arrow) around the tooth that was the source of the patient’s infection.
Root canal therapy and dental extraction were discussed with the patient as treatment options. She chose dental extraction, which resulted in symptom resolution and fistula healing at the 4-week follow-up (Figure 3). No further intervention was required.
The patient’s fistula was healing 4 weeks after the tooth extraction.
CUTANEOUS FISTULA FROM AN ODONTOGENIC INFECTION
Draining lesions on the face are uncommon but have a broad differential diagnosis, including orofacial manifestation of Crohn disease, bisphosphonate-related osteonecrosis of the jaw, osteomyelitis, mucocutaneous actinomycosis, pyogenic granuloma, and surgical complication after resection for oral cavity cancer.1–4 However, a benign odontogenic source should always be considered for long-standing, nonhealing lesions, even when a patient does not have dental complaints, because infections tend to spread through fascial planes of least resistance.4 Once the infection breaks through the soft tissues, these lesions are painless because there is a pathway for the fluid to drain.4 This patient had a dental pulp infection that spread through the mandibular buccal plate and into the soft tissues of the face, resulting in a persistent draining fistula.
Odontogenic infections are usually polymicrobial in composition, especially those that spread to the deep fascial space,5 and are caused by a variety of bacteria. Routine cultures of odontogenic abscesses most commonly isolate Streptococcus, Staphylococcus, and Prevotella species.2,6 Adjunctive empiric antibiotic therapy can be considered for these chronic infections.7 In this patient, the dental extraction removed the source of the infection.
Immunosuppression can play a significant role in oral infection severity. Patients with diseases that cause immunosuppression, such as human immunodeficiency virus infection, or who take long-term immunosuppressive medications are at a higher risk of developing oral infections from periodontal disease.8 Although this patient was not immunocompromised, systemic lupus erythematosus, a chronic autoimmune disease, increases the risk of periodontal disease.9
DISCLOSURES
Dr. Khanna reports no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
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