|Year : 2008 | Volume
| Issue : 6 | Page : 76-78
Diagnosis and treatment of mandibular extraoral sinus of periodontal origin in a 9-year-old boy: A case report
A Ozdemir1, G Guven2, A Dilsiz1, M Sencimen3
1 Department of Periodontology, Gülhane Military Medical Academy, Ankara, Turkey
2 Department of Pediatric Dental, Gülhane Military Medical Academy, Ankara, Turkey
3 Department of Maxillofacial Surgery, Gülhane Military Medical Academy, Ankara, Turkey
Gulhane Askeri Tip Akademisi, Dishekimligi Bilimleri Merkezi Agiz, Dis, Cene Hastaliklari ve Cerrahisi A.D. 06018 Etlik/ Ankara
| Abstract|| |
Cutaneous sinus tract of dental origin is the commonest of the many types of sinus tracts that are formed on the face and neck. Cutaneous sinus tracts may originate from local chronic osteomyelitis (Garre's osteomyelitis). Although the etiological factor is usually periapical infection, they are seldom of periodontal origin. Conventional periapical and panoramic roentgenograms are generally insufficient for diagnosis and treatment planning of cutaneous sinus tracts of periodontal origin. In the present case, computed tomography was used for diagnosis, and osteomyelitis was managed by periodontal treatment.
Keywords: Bone grafts, computed tomography, Garre′s osteomyelitis, intrabony defects, periodontal treatment
|How to cite this article:|
Ozdemir A, Guven G, Dilsiz A, Sencimen M. Diagnosis and treatment of mandibular extraoral sinus of periodontal origin in a 9-year-old boy: A case report. J Indian Soc Pedod Prev Dent 2008;26:76-8
|How to cite this URL:|
Ozdemir A, Guven G, Dilsiz A, Sencimen M. Diagnosis and treatment of mandibular extraoral sinus of periodontal origin in a 9-year-old boy: A case report. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2013 May 20];26:76-8. Available from: http://www.jisppd.com/text.asp?2008/26/6/76/43537
| Introduction|| |
Garre's osteomyelitis is a type of chronic osteomyelitis that generally affects children and adolescents. The most common cause for Garre's osteomyelitis is odontogenic infection and dental extraction. However, rarely, periodontologic reasons may be cause this type of osteomyelitis.  The infections that originate from periodontal tissue are generally expected to drain into the sulcus of the gingiva or through a sinus tract. This type of infection can be eliminated by endodontic treatment. However, sometimes infection may progress under the skin and drain from an extraoral fistula. This report presents a case of Garre's osteomyelitis. 
| Case Report|| |
A 9-year-old boy came with the complaint of a discharging sinus on the lower left side of the face. 6 months earlier a swelling had appeared in the mandibular left quadrant.. Antibiotics (amoxicillin + clavulanic acid) had been used intermittently, but even after treatment with antibiotics and anti-inflammatory agents there had been no significant reduction in the size of the swelling and a cutaneous sinus tract formed [Figure 1].
Various differential diagnoses were considered (e.g., tuberculosis, impetigo, and dental sinus) and, accordingly, the patient had been examined by pulmonologists, dermatologists, and otolaryngologists). In May 2006, aerobic and anaerobic bacterial culture of pus had been performed. Bacteroides ovatus en detected in the anaerobic culture but aerobic culture was negative and PCR was negative for Mycobacterium tuberculosis . Metronidazole had been prescribed for 5 days but the lesion persisted.
The patient was referred to the Pediatric Dental Department, Gülhane Military Medical Academy. After the patient had been examined by pedodontist.
Medical history and intraoral examination revealed nothing abnormal. Radiographic examination (periapical and panoramic) was normal. The patient had no caries; no endodontic treatment; no crown, root, or mandibular fracture; and no periapical or periodontal pathology [Figure 2].
Probing around the teeth revealed no deep pocketing except in the case of the left mandibular first molar. Despite the absence of signs of acute inflammation in the periodontal tissues, examination with a periodontal probe showed a 9-mm periodontal pocket buccal to the left mandibular first permanent molar [Figure 3].
Computed tomography (CT) was done. CT images revealed that there was severe bone resorption and proliferation of subperiosteal bone in the region of interest [Figure 4a, b] and [Figure 5].
Vitality test was positive and no pathological mobility was observed. There was also no deposition of calculus and microbial dental plaque.
The clinical and CT findings were considered to be indicative of Garre's osteomyelitis.
Oral hygiene instructions were given and scaling and root planning, subgingival curettage, and chlorhexidine irrigation was performed. Twelve days later a full-thickness buccal flap was elevated and curettage was performed. Bone graft Bio-gen® (BIOTECK® , str. Buttigliera, 26, 10020 Riva Presso
Chieri (TO)) was applied into the intrabony defect and the flap was repositioned and sutured. Chlorhexidine rinse was prescribed for 10 days [Figure 6a] and [Figure 6b]. No antibiotic was prescribed. The pus discharge through the sinus tract had fully disappeared 1 week following the operation. [Figure 7a] and [Figure 7b].
| Discussion|| |
Cutaneous sinus tracts of dental origin are the commonest among the many types of sinus tracts that are formed on the face and neck. Because these lesions are often misdiagnosed, they are also ineffectively treated.  Such patients may undergo multiple surgical excisions and biopsies and receive many courses of antibiotics, but all such measures fail and the sinus tract recurs. 
Cutaneous sinus tract may originate from local chronic osteomyelitis (Garre's osteomyelitis).  Although the etiological factor is usually a periapical infection, ,, these lesions are seldom periodontal in origin. ,
Garre's osteomyelitis (or periostitis ossificans) of the mandible is a rather rare condition that occurs as a hard swelling at the mandibular angle, persists for a long period, and is usually painful on palpation. The etiological factor is a low-grade irritation and infection, often a periapical infection of the first permanent molar or a fracture of the jaw.  Cutaneous sinus tracts in the face and neck region may also be observed. 
A sinus tract adjacent to teeth is usually considered to be of endodontic origin and root canal therapy is the primary treatment to achieve healing.  Although infection of the periodontal tissues has been mentioned in the literature as a potential etiologic factor for these sinuses, ,, it is rare in pediatric patients. In this case, there was a periodontal intrabony defect buccal to the left mandibular first permanent molar.
A case of Garre's osteomyelitis was described by Oulis et al.  in a child in whom the condition arose following a local periodontal infection in an ectopically erupting first permanent molar that was in infraocclusion. However, in our patient no such cause could be found.
Conventional periapical and panoramic radiography is generally do not contribute for diagnosis and treatment planning of cutaneous sinus tracts of periodontal origin. , In this case, we used CT to evaluate the status of the periodontal lesion and the origin of the sinus tract. We decided to use a bone graft because the depth of intrabony defect was approximately 9 mm.
| References|| |
|1.||al-Kandari AM, al-Quoud OA, Ben-Naji A, Gnanasekhar JD. Cutaneous sinus tracts of dental origin to the chin and cheek: Case reports. Quintessence Int 1993;24:729-33. [PUBMED] |
|2.||Mittal N, Grupta P. Management of extra oral sinus cases: A clinical dilemma. J Endod 2004;30:541-7. |
|3.||Oulis C, Berdousis E, Vadiakas G, Goumenos G. Garre's osteomyelitis of an unusual origin in a 8-year-old child: A case report. Int J Paediatr Dent 2000;10:240-4. [PUBMED] [FULLTEXT]|
|4.||Kannan SK, Sandhya G, Selvarani R. Periostitis ossificans (Garre's osteomyelitis) radiographic study of two cases. Int J Paediatr Dent 2006;16:59-64. [PUBMED] [FULLTEXT]|
|5.||McWalter GM, Alexander JB, del Rio CE, Knott JW. Cutaneous sinus tracts of dental etiology. Oral Surg Oral Med Oral Pathol 1988;66:608-14. [PUBMED] |
|6.||Urbani CE, Tintinelli R. Patent odontogenic sinus tract draining to the midline of the submental region: Report of a case. J Dermatol 1996;23:284-6. [PUBMED] |
|7.||Yang ZP, Lai YL. Healing of a sinus tract of periodontal origin. J Endod 1992;18:178-80. [PUBMED] |
|8.||Van den Bossche LH, Demeulemeester JD, Bossuyt MH. Periodontal infection leading to periostitis ossificans (Garre's osteomyelitis) of the mandible: Report of a case. J Periodontol 1993;64:60-2. [PUBMED] |
|9.||Ebihara A, Yoshioka T, Suda H. Garre's osteomyelitis managed by root canal treatment of a mandibular second molar: ?ncorporation of computed tomography with 3D reconstruction in the diagnosis and monitoring of the disease. Int Endod J 2005;38:255-61. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4a, b], [Figure 5], [Figure 6a], [Figure 6b], [Figure 7a], [Figure 7b]