Oral Cutaneous Fistulas Treatment & Management

  • Author: James Cade, DDS; Chief Editor: William D James, MD   more...
 
Updated: Aug 5, 2011
 

Medical Care

To properly treat any infection, drainage is necessary to decrease the number of microbes and reduce the amount of substrate on which they grow. Antibiotic coverage is necessary to eliminate or reduce the number of microbes causing the infection.

  • With most dental infections, penicillin is the drug of choice. Penicillin and amoxicillin with or without clavulanic acid are administered empirically to treat the infection before culture and sensitivity results are available. If the patient has an allergy to penicillin, erythromycin (next antibiotic of choice), azithromycin, clarithromycin, or clindamycin can be administered.
  • Amoxicillin is often used because of its rapid absorption in the gastrointestinal tract. Amoxicillin with clavulanic acid (Augmentin) is effective in broad-spectrum infections with both gram-positive and gram-negative organisms.
  • Doxycycline is effective in the treatment of periodontal disease. The combination of amoxicillin and metronidazole is also effective in treating severe periodontitis in individuals who are HIV positive.
  • Intravenous medications that are useful in the treatment of serious facial and orbital infections include nafcillin; cefazolin; ceftriaxone; vancomycin; levofloxacin; and beta-lactam/beta-lactamase inhibitors, including piperacillin/tazobactam, ticarcillin/clavulanate, and ampicillin/sulbactam.
  • The treatment of osteomyelitis and actinomycoses infections may require the intramuscular or intravenous administration of penicillin G, followed by oral antibiotics for 6 weeks to 6 months.
    • The removal of sequestered or necrotic bone also is indicated.
    • Hyperbaric oxygen may be necessary in patients with severe osteomyelitis and osteoradionecrosis. Hyperbaric oxygen is used to promote vascularization, osteogenesis, and collagen synthesis.[24]
  • Andrews et al reported on the use of a negative-pressure vacuum-assisted closure technique for orocutaneous fistulas.[25]
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Surgical Care

  • Dental infections: Incision and drainage is often necessary. This treatment includes extraction of the affected tooth, pulpotomy, or pulp removal and drainage. If the tooth is salvageable, endodontic therapy usually eliminates the infection. In more serious infections, an incision into the soft tissue with dissection may be necessary. Effective drainage in indurated cellulitis infections can be difficult.
  • Salivary gland fistulas[26, 27] : Treatment includes apposition of the severed duct ends, suturing of the proximal intact portion to the buccal mucosa, and creation of an artificial internal fistula, which drains into the oral cavity.
  • Mucoceles: Treatment includes removal of the fluid-filled sac and surrounding minor salivary glands. This treatment has an excellent prognosis for cure.
  • Intraoral and extraoral fistulas[28] : Intraoral fistulas and many extraoral fistulas do not need to be treated surgically. Many heal with antibiotic treatment.
  • Oral antral fistulas: Repair these fistulas as soon as possible to prevent the spread of infection and patient discomfort. Waiting until any infection is resolved before repair is best. Decongestants and intensive antibiotic therapy may be needed. Wider incision of the sinus or nasal antrostomy may be necessary to drain the infection more rapidly and promote healing. Removal and curettage of the fistula also aids healing and clearing of infection. If a cleft or fistula from the oral cavity to the sinus is too large for surgical closure, prosthetic devices such as dentures and obturators can be used to prevent nasal speech and aspiration of liquids and food.
  • Cutaneous fistulas: Scarring may occur. Plastic or oral and maxillofacial surgery can be performed to address scarring.
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Consultations

  • Always consult an ophthalmologist when patients have orbital involvement.
  • Plastic or oral and maxillofacial surgeons can address scarring.
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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.

Specialty Editor Board

Maureen B Poh-Fitzpatrick, MD  Professor Emerita of Dermatology and Special Lecturer, Columbia University College of Physicians and Surgeons; Professor of Medicine (Dermatology), University of Tennessee Health Science Center College of Medicine

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: Lundbeck, Inc. Honoraria Review panel membership; Clinuvel Pharmaceuticals, Ltd. Honoraria Consulting

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

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.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

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Cutaneous fistula due to a dental infection that causes Ludwig angina. Courtesy of Alexander Pazoki, DDS, LSU School of Dentistry, New Orleans, La.
Gunshot wound causing an oral cutaneous fistula. Courtesy of Alexander Pazoki, DDS, LSU School of Dentistry, New Orleans, La.
Squamous cell carcinoma causing an oral cutaneous fistula. Courtesy of Alexander Pazoki, DDS, LSU School of Dentistry, New Orleans, La.
Squamous cell carcinoma of the sinus that penetrates the maxillary ridge.
 
 
 
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