eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Oral Cutaneous Fistulas: Differential Diagnoses & Workup

Author: James Cade, DDS, Clinical Dentist, Honeycutt Family Dentistry
Contributor Information and Disclosures

Updated: May 19, 2009

Differential Diagnoses

Cellulitis
Pulp Polyp
Cutaneous Tuberculosis
Squamous Cell Carcinoma
Mucocele and Ranula
Necrotizing Sialometaplasia
Oral Cutaneous Fistulas

Other Problems to Be Considered

The differential diagnoses include any dental and periodontal infection, odontogenic cysts and tumors, salivary gland lesions and neoplasms, and other benign and malignant neoplasms. The most common neoplastic cause of oral cutaneous fistulas is squamous cell carcinoma. Unless secondarily infected, oral cutaneous fistulas rarely, if ever, develop from benign neoplasms and cysts.

Workup

Laboratory Studies

  • Culture and sensitivity testing and, in selected cases, DNA probe testing may be used to identify the causative organism and determine treatment.
  • Serious dental infections may increase the erythrocyte sedimentation rate and neutrophil count. With chronic infections, lymphocyte and monocyte counts may subsequently increase.

Imaging Studies

  • In chronic periapical infections, a well-circumscribed radiolucency may be observed radiographically; however, in early infections, radiographic evidence may not be observed.
  • On radiographs, osteomyelitis appears as an area of radiolucency, radiopacity, or mixed radiolucency with poorly defined borders. The mandible is most commonly involved. These findings are also present in osteoradionecrosis
  • Unless the infection is rampant and severe, imaging studies such as a CT scanning or MRI usually are not necessary. If infection persists despite therapy, CT scanning and MRI may be necessary to determine its extent and to rule out a neoplastic cause. Computer-aided rapid prototyping in a 3-dimensional format with CT scans was reported to analyze each tooth root to aid in nonsurgical root canal therapy.19
  • Panoramic radiographs, lateral jaw plain radiographs, Waters radiographs, or periapical radiographs may be necessary for diagnosis and treatment, depending on the location and extent of the infection.
  • With oral antral and oral nasal fistulas, cloudy sinuses may be observed on panoramic or Waters radiographs. Radiographs occasionally show a break in the antral or nasal floor. If the opening to the palate is large enough, nasal speech occurs.

Procedures

  • The possibility of a neoplastic cause may require biopsy.

Histologic Findings

With acute infection, histologic sections show a preponderance of neutrophils and necrotic debris. Chronic infections are histologically characterized by numerous plasma cells, lymphocytes, and macrophages; often, a proliferation of blood vessels and connective tissue or granulation tissue is present.

In chronic osteomyelitis, sections of acellular bone are present, sometimes with little inflammatory infiltrate. When histologic sections are processed, decalcification of the specimen for sectioning can remove lacunar cells present in bone. This effect must be considered when histologic sections of bone are viewed.

Actinomycosis has characteristic pseudohyphae appearing as clublike projections that stretch out from a central basophilic-staining core. The absence of this finding does not rule out an actinomycotic infection.

Microscopic sections of mucoceles show minor salivary glands with chronic inflammation and a granulation wall that surrounds a pool of mucin.

More on Oral Cutaneous Fistulas

Overview: Oral Cutaneous Fistulas
Differential Diagnoses & Workup: Oral Cutaneous Fistulas
Treatment & Medication: Oral Cutaneous Fistulas
Follow-up: Oral Cutaneous Fistulas
Multimedia: Oral Cutaneous Fistulas
References
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References

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Further Reading

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Keywords

orofacial fistulas, sinus tract, intraoral fistulas, dentoalveolar abscesses, periapical infections, periapical granulomas, parulis, maxillary dental infections, trismus, mandibular space infections, osteomyelitis, lymphadenopathy, sialolith, dental implants, dens invaginatus, taurodontism, endodontics, maxillary sinusitis, Garre's osteomyelitis, dermoid cyst, Garre osteomyelitis

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Contributor Information and Disclosures

Author

James Cade, DDS, Clinical Dentist, Honeycutt Family Dentistry
James Cade, DDS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

Medical Editor

Maureen B Poh-Fitzpatrick, MD, Professor Emerita of Dermatology and Special Lecturer, Columbia University; Professor of Medicine (Dermatology), University of Tennessee
Maureen B Poh-Fitzpatrick, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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