A 27-year-old female referred, complaining of an extraoral sinus tract opening. The patient's medical history was unremarkable, and she was categorized as ASA I. The patient recalled the development of an extraoral sinus tract on the right submandibular region from six years ago. The patient visited an ear, nose, and throat (ENT) specialist upon noticing it. The specialist had prescribed chlorhexidine (CHX) mouthwash for 2 weeks. Due to no recovery and continuous pus discharge from the sinus tract, the patient referred to an infectious disease specialist, who prescribed daily use of 100 mg doxycycline for 6 months. The patient underwent sonography, which revealed a hypoechoic mass with unclear margins and no calcification. Due to the continuation of pus discharge, the patient was admitted to a hospital, and a general surgeon surgically resected the lesion.
However, the patient did not have the pathology report of the lesion with her. Pus discharge and the symptoms were resolved after the surgical procedure. However, the symptoms recurred one year later. The patient presented again to the general surgeon, and this time, she was diagnosed with tuberculosis. Polymerase chain reaction and cell culture were performed, which were found to be negative for Mycobacterium tuberculosis. The patient was scheduled for another surgical procedure with a diagnosis of a branchial cyst. The surgical procedure was performed, and the pathology report indicated an infected wall of a sinus tract. Pus discharge continued for another year after surgery, and the patient was referred to a maxillofacial surgeon, who recommended another surgical procedure, which was rejected by the patient. The patient used herbal medications for one year but the pus discharge continued. The patient presented to our dental school. In the first visit, a fistula on the right side of the neck was noticed. The clinical and radiographic examinations were performed (Fig. 1 A-D). The right mandibular first and second molars gave a negative response to pulp vitality tests. Teeth #30 and #31 were not sensitive to percussion and had no mobility. Periapical radiographs revealed severe bone destruction in the periapical region of tooth #31 and periodontal ligament (PDL) widening around the apex of tooth #30.
Cone-beam computed tomography (CBCT) was then requested for the patient, which indicated extensive bone destruction in the body of the mandible (Fig. 1E). Teeth #30 and #31 underwent root canal treatment (RCT). In the first treatment session, local anesthesia was induced by the injection of 2% lidocaine and 1:80,000 epinephrine (Persocaine-E, Daru Pakhsh, Tehran, Iran), and an access cavity was prepared in tooth #31. The working length was then determined. The canals were cleaned using the Edge Taper Platinum rotary system (EdgeEndo, Albuquerque, NM, USA) to #F2 file along with irrigation with 5.25% sodium hypochlorite (NaOCl; Hypo-EndoX, Morvabon, Iran). A mixture of calcium hydroxide powder (Golchadent, Tehran, Iran) and 2% CHX (MORVA-Sept, Morvabon, Tehran, Iran) was applied to the canals as an intracanal medicament. The second session was scheduled one week later. In the second session, there was no pus discharge, and the sinus tract was closed (Fig. 2A). Thus, RCT was completed, and the canals were filled with gutta-percha and AH-26 sealer (Dentsply, Konstanz, Germany) using the cold lateral compaction technique. Tooth #30 also underwent RCT, and the patient was referred to a prosthodontist for the final restoration of the respective teeth. The first follow-up session was scheduled at 3 months after the final restoration of the teeth.
At the 3- and 6-month follow-ups, the patient was asymptomatic clinically and radiographically, and the periapical radiograph showed evidence of bone regeneration (Fig. 2B-E).