tracing and treating of intraoral sinus tract in single visit endodontics

1. {
Management Of
Intraoral Sinus Tract By
Single Visit Endodontics
Presented by : Dr. Aditya Shinde.
Guided by : Dr. Lalitagauri Mandke.

2. Case Report :-
Patient name :- XYZ
Age :- 49 yrs
Address :- Rabale
Chief Complaint:- Decay and Pain in upper back right region
followed by the pus drainage since two weeks.
Past dental history :- h/o of extraction in relation to #15 , 3
years ago.
No relevant medical history.

3. Clinical Examination :-
On extraoral Examination:- Lymph node were
not palpable , no external swelling or sinus
seen.
On intraoral examination:-
deep proximal caries related to #14.
draining sinus seen on labial mucosa in
relation with #14.
On evaluation on IOPA:-
periapical radiolucency seen around #14

4. RVG showing #25 GP tracing the sinusIntraoral picture
Sinus tract tracing !
• To trace the sinus tract a size#25 gutta percha cone was threaded into
the opening.
• Gutta percha cone was inserted untill the resistance was felt.
• After that periapical radiograph was taken to determine the path and
termination of the sinus tract.
• The cone extended till the palatal root of #14, thus confirming that
sinus was related to #14.

5. Provisional Diagnosis
CHRONIC PERIAPICAL ABSESS IN RELATION TO #14

6. Treatment plan :-
• Single sitting root canal treatment

7. Treatment :-
• Root canal treatment of #14 was proposed to the patient and treatment was
initiated.
• Caries excavation was done using spoon excavator & round carbide bur.
• Access cavity was made using endo-access bur (DENTSPLY mailefer).
• Buccal and palatal canal orifices were located and canals were traced.
• Working length was determined using Root ZX mini apex locator (J MORITA,
Japan) and confirmed on RVG.
• Cleaning and shaping was done using K files (MANI) and hand protaper
(DENTSPLY) with crown down technique.(enlarged till F1).
• During cleaning and shaping recapitulation and copious irrigation was done with
saline.

8. MASTER CONE RADIOGRAPH WAS TAKEN USING F1 GUTTA PERCHA
CONE.
APICAL TUGBACK WAS ALSO CONFIRMED.
Working length
radiograph
Master cone
radiograph

9.  Final irrigation protocol:- saline +
sodium hypocholrite
 Canals dried with paper points.
 Zinc oxide eugenol cement used as
sealer.
 Obturation done using lateral
condensation method.
 Temporary restoration given to seal
access cavity. Obturation RVG

10.  Prescribed antibiotics and analgesics
 Patient was advised to gargle twice a day with warm water with salt.
 Patient was recalled for check up after one week.
 It was observed that the sinus had resolved and patient was
asymptomatic, post obturation restoration was done with composite
resin cement.
Post obturationAfter one week
RVG
Introral healing
seen in one week

11. Radiograph after one month follow up

12. Discussion :-
• On occasion a chronic endodontic infection will drain through a intraoral
communication to the gingival surface and is known as a sinus tract. This
pathway, which is sometimes lined with epithelium extends directly from the
source of the infection to a surface opening, or stoma, on the attached gingival
surface.
• In general, a periapical infection that has an associated sinus tract is not painful,
although often there is history of varying magnitude before the sinus tract
developed. Besides providing a conduit for the release of infection exudate and
the subsequent relief of pain, the sinus tract can also provide a useful aid in
determining the source of given infection.
• The stoma of the sinus tract may be located directly adjacent to or at a distant
site from the infection. Tracing the sinus tract will provide the objectivity in
diagnosing the location of the problematic tooth.

13. • Carious exposure with bacterial invasion of the tooth pulp leading to a periapical
abscess is the most common cause of dentocutaneous sinus tracts. The
inflammation destroys the cancellous alveolar bone and proceeds along the
periosteum until perforation occurs. An intraoral or extraoral sinus can develop,
depending on the path of the inflammation, which is dictated by surrounding
muscular attachments and fascial planes. For example, if the bone perforation on
the mandible occurs above the muscular attachment, then an intraoral sinus will
result. If the perforation occurs below the level of muscular attachment, then a
cutaneous sinus will result.
• To trace the sinus tract a size #25 gutta percha cone is threaded into the opening of
the sinus tract. The cone should be inserted until the resistance is felt, after which
a periapical radiograph is taken. This will direct the clinician to which tooth is
involved and more specifically, which root of that tooth is the source of the
pathosis.
• The stomata of intraoral sinus tracts may open in the alveolar mucosa, in the
attached gingiva, or through the furcation or gingival crevice. They may exit
through either the facial or lingual tissues depending on the proximity of the root
apices to the cortical bone.

14. • Indications for SVE:-
1. Vital teeth.
2. Fractured anterior where esthetics is the concern.
3. Patients who required sedation every time.
4. Non-vital teeth with sinus tract.
5. Teeth with limited access.
6. Nonsurgical retreatment cases.
7. Medically compromised patients who require antibiotics prophylaxis.
8. Physically compromised patients who can not come to dental clinics frequently.
• Single sitting endodontics implies to cleaning, shaping and disinfection of root
canal system followed by obturation of the root canal at the same appointment.
• Criteria for case selection as given by Oliet include:-
1. Positive patient acceptance.
2. Absence of acute symptoms.
3. Absence of continuous hemorrhage or exudation.
4. Absence of anatomical interference like presence of fine, curved or calcified
canals.
5. Availability of sufficient time to complete the case.
6. Absence of procedural difficulties like canal blockage, ledge formation or
perforation.

15. • Single-visit endodontic treatment and multiple-endodontic treatment have
their advantages and disadvantages. In general, many dentists considered the
single-visit approach to be an alternative to a multiple-visit but have no
trouble replacing it. The success of endodontic treatment should be based on
careful case selection. There should be no shortcuts in any of the steps
throughout the treatment procedures. Clinicians should evaluate their own
clinical skills and the needs of the patient. Notwithstanding the single-visit
treatment approach, the clinicians should directly follow endodontic
principles.
• It has been suggested that the teeth with chronic apical periodontitis and a
draining sinus tract can be endodontically treated by a single visit procedure.
This sinus tract may act as a safety valve for the residual inflammatory
exudate. But a Cochrane systemic review showed that there was no study
which had investigated fistulas or sinus tract formations with respect to a
single-visit versus multiple-visit endodontic treatment.

16. Conclusion :-
Single visit endodontics has been shown to be an effective treatment
modality, which, when compared to multiple visit therapy, is more
beneficial to patients and dentists in many ways provided there is a careful
case selection and adherence to standard endodontic principles .
The prevention and elimination of apical infection are the goal of a
successful endodontics therapy, once the way to accomplish these goals is
determined, the decision to provide treatment in multiple visit or single
visit will follow itself.
The following case shows successful management of periapical infection
with sinus by single visit endodontic therapy.

17. References :-
• Pathways of Pulp – Stephen Cohen, Kenneth M. Hargreaves , 10th edition.
• Problem Solving In Endodontics – James Gutmann - 5th edition.
• Endodontics – John Ingle – 6th edition.
• Textbook of Endodontics - Nisha Garg, Amit Garg - 2nd edition.
• Clinical efficacy of treatment procedures in endodontic infection control and one year
follow-up of periapical healing. Waltimo T, Trope M, Haapasalo M, Ørstavik D. J Endod.
2005;12: 863-66 .
• Single or multiple visit endodontics: which technique results in fewer postoperative
problems. Int Endod J. 2008;2: 91-99 .
• Single versus multiple visits for endodontic treatment of permanent teeth. Figni F, Lodi
G, Gorm F, Gagliani M. Evidence based dentistry. 2008;1:24

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