Oral Cutaneous Fistulas Treatment & Management

Updated: Mar 06, 2017
  • Author: James E Cade, DDS; Chief Editor: William D James, MD  more...
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Treatment

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. [39]

Andrews et al reported on the use of a negative-pressure vacuum-assisted closure technique for orocutaneous fistulas. [40]

The possibility of a neoplastic cause may require biopsy and further treatment. If the biopsy specimen is positive for malignancy, a complete medical workup including MRI, positron emission tomography, and/or CT scanning is needed.

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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 [41, 42] : 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 [43] : 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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Prevention

The early detection of dental problems and preventative dentistry are the best deterrents of oral cutaneous fistula formation. Because poor oral hygiene and trauma cause most dental infections, good hygiene and the prevention of trauma may prevent oral cutaneous fistula formation.

With oral antral fistulas, 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 the aspiration of liquids and food.

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Long-Term Monitoring

With any cutaneous fistula or sinus tract, careful follow-up is mandatory. The potential for infection with swelling and pain is always present. Fistulas provide natural pockets in which infection can start.

The patient may require supportive care. Fistulas are unsightly and cause patient distress. Severe persistent infections, especially actinomycosis and osteomyelitis, can be distressing and frustrating for the patient.

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