Australian Dental Journal 2003;48:4. 255

Non-surgical management of an oro-antral fistula in apatient with HIV infectionRM Logan,*† EA Coates*

AbstractBackground: The risk of post-extractioncomplications is higher in patients who areimmunosuppressed compared to other patients withnormal immune function. In addition, invasivedental procedures are more likely to have seriouscomplications in these patients. This case reportdemonstrates an effective non-surgical procedure totreat an oro-antral fistula in an HIV-infected man.Methods: The oro-antral fistula was de-epithelialized under local anaesthesia and the patientwore a surgical splint continuously, removing it onlyfor cleaning, for an eight week period.Chlorhexidine gel was regularly applied to the fittingsurface of the splint and the oro-antralcommunication. The patient was reviewed on aregular basis.Results: This procedure resulted in resolution of thepatient’s symptoms within two weeks. Completehealing of the oro-antral fistula was evidentfollowing eight weeks of wearing the surgical splint.Conclusions: This procedure provided an effectivemethod of treating an oro-antral fistula in animmunocompromised patient without causing anydetrimental effects to the patient’s overall health.Adequate pre-surgical assessment of patients priorto extractions is important in all patients to helpprevent the occurrence of such complications.

Key words: Oro-antral fistula, HIV infection, AIDS,immunosuppression.

(Accepted for publication 24 April 2003.)

Following the creation of an oro-antralcommunication, the patient may experience varioussymptoms including air and fluids passing into the noseand mouth. The diameter of the communicationusually decreases over time but often the ‘tract’ fromthe antrum to the mouth fails to heal and becomes linedby epithelium. Once this occurs the communication isreferred to as a fistula. This fistula acts as a pathwayfor infection and can result in the development of acutesinusitis which further impedes healing.

The likelihood of the development of acommunication is increased if there is pre-existing sinusdisease, periapical infections, or if the floor of the sinusis in close proximity to the tooth roots (e.g., antrumfloor dipping down between the roots of teeth). Inaddition, attempts to remove apices of teeth that havefractured during extraction may result in the creationof a communication between the maxillary sinus andoral cavity.

In the setting of human immunodeficiency virus(HIV) infection there have been very few reports of oro-antral fistulae occurring following extraction of teeth.One case report described the spontaneousdevelopment of an oro-antral fistula in a patient withHIV infection in association with HIV-relatedperiodontal disease.5 However, sinus disease iscommonly encountered in patients with HIV infection.6

Chronic HIV-related sinusitis is often related toPseudomonas aeruginosa, Staphylococcus aureus oranaerobic bacteria.6 Because of the increased prevalenceof chronic sinusitis in these patients, the risk of thedevelopment of oro-antral communications is increasedand when a communication occurs, eitherspontaneously or through a surgical event, healing isimpeded by the presence of sinusitis.

The treatment of oro-antral fistulae usually involvessurgical intervention. Various techniques have beenreported in the literature including local flaps (e.g.,palatal rotational advancement and buccaladvancement flaps), distant flaps (e.g., tongue flaps) orgrafts (e.g., bone).1,7 However, as previously mentionedif the fistulae are small (i.e., less than 5mm) and sinusdisease is absent or eliminated, then spontaneoushealing may occur. It is also important that the

INTRODUCTION

The development of oro-antral fistulae orcommunications are not common events following theextraction of teeth.1,2 When they do occur they usuallyresult as a consequence of extraction of teeth posteriorto the maxillary canines.2,3 In particular the uppersecond molar followed by the upper first molar teethare the most likely teeth to result in an oro-antralcommunication following their extraction.4

*Medically Compromised Patient Unit, Adelaide Dental Hospital.†Oral Pathology, Dental School, The University of Adelaide.

Australian Dental Journal 2003;48:(4):255-258C A S E R E P O R T

epithelial lining of the fistula is removed in order tofacilitate healing.3

The purpose of this case report is to describe analternative non-surgical treatment for an oro-antralfistula in a patient with HIV infection.

CASE REPORTA 34-year-old man who was infected with HIV was

referred to the Medically Compromised Patient Unit ofthe Adelaide Dental Hospital for the management of anoro-antral fistula that developed following extractionof his upper left first molar three months previously. Interms of his HIV disease he was significantlyimmunosuppressed (CD4 T+ lymphocyte count 82cells/mL). Prior to having the tooth extracted, thepatient had not had any problems with dentaltreatment.

Specialist surgical opinion favoured hospitalizationof the patient and surgical closure of the fistula.However, the patient’s general medical practitioner wasconcerned about the risks involved in such proceduresbecause of the patient’s significant immunosuppressionand requested a second specialist opinion from theMedically Compromised Patient Unit of the AdelaideDental Hospital.

On initial examination, a small oro-antral fistula waspresent at the site of the upper left first molar (Fig 1).

The patient complained that his main problem was notpain or discomfort, but that drinking and eating wasdifficult as fluids escaped into his nasal cavity. Theorthopantomogram radiograph taken at the time of theinitial appointment demonstrated the close proximityof the roots of the upper posterior teeth to themaxillary antrum as well as the significant loss of theremaining alveolus in the area of the extraction of the26 (Fig 2). The patient had no other oral problemsapart from moderate xerostomia that was attributed tohis HIV infection.

It was felt that surgical intervention wascontraindicated as a first line treatment in this patientbecause of his significant immunosuppression. Inaddition it was thought that because the fistula was notlarge and that there was no obvious sinus infectionpresent, simple local measures would facilitate healing.

Models of the upper and lower teeth were made andthese were used to construct an acrylic surgical splint(Fig 3) that entirely covered the edentulous area and thefistula. The splint was adjusted so that it was ascomfortable as possible when worn for extendedperiods of time.

The epithelial lining of the oro-antral fistula wasremoved by carefully curetting the lesion under localanaesthesia. The fitting surface of the splint was coatedwith chlorhexidine gel (0.02 per cent) prior toinsertion. The patient was instructed to wear the splintcontinually for the next two weeks removing it only forcleaning after meals at which time he was to applymore chlorhexidine gel to the fitting surface in the areaof the fistula. He was also advised to avoid or minimizeany activity that increased intra-oral or intranasalpressure (e.g., smoking, drinking through straws,blowing his nose etc). A review appointment wasarranged two weeks later.

RESULTSOn review, the intra-oral defect had reduced in size

and there was a marked improvement in the patient’ssymptoms. At this stage in the patient’s management

256 Australian Dental Journal 2003;48:4.

Fig 1. An oro-antral fistula present at the site of the upper left firstmolar.

Fig 2. Orthopantomograph of the dentition at the time of the initialexamination illustrating the state of the remaining alveolus. A small

fragment of amalgam is noted adjacent to the site of extraction.

Fig 3. Acrylic surgical splint constructed to cover the oro-antralfistula.

Australian Dental Journal 2003;48:4. 257

the only complicating factor was mildpseudomembranous candidiasis. It is likely that the useof the splint in conjunction with xerostomia andimmunosuppression resulted in the development of thecandidiasis. It was effectively treated using Daktarinoral gel (miconazole 20mg/mL). Because of theimprovement in symptoms and the oral candidiasis, itwas decided to reduce the amount of time that thepatient wore the splint.

At eight weeks after the initiation of treatment, thedefect had healed and symptoms completely resolved(Fig 4). At 12 months following initial presentation, thepatient remained symptom free and the clinicalappearance of the area is demonstrated in Fig 5.

DISCUSSIONThere are very few publications regarding the risks of

patients with HIV infection undergoing invasive dentalprocedures.8 According to Dodson et al.,9 the risk ofpost-extraction complications in patients with HIV

infection increases with the level of immunosuppressionand the rate of post-extraction complications in thesetting of HIV has been reported to range between 0.9-22 per cent.10,11

The most frequent post-extraction complications inpatients with HIV infection include delayed healing,alveolitis and surgical wound infection.12 There are fewreports in the literature of oro-antral fistulae occurringin association with HIV infection. Felix et al.5 reportedon an oro-antral fistula that occurred as an unusualcomplication of necrotizing ulcerative stomatitis ratherthan following a dental extraction. Surgical closure oforo-antral fistulae involving local flap procedures mayhave some degree of failure.13 The management of apatient with a large chronic oro-antral fistula that hadfailed to be treated by several local flap procedures wasreported by Godfrey.13 In that case report ultimateresolution of the problem was achieved usingvascularized temporoparietal fascia.

In the present case report, the patient’s generalmedical practitioner was reticent to allow the patient toundergo surgical treatment because of the degree ofimmunosuppression. Surgical closure of the lesionwould have taken an extended length of time, requiredgeneral anaesthesia and hospitalization of the patient.It has been reported that small fistulae, 5mm or less indiameter are likely to heal spontaneously. However, ifthey fail to heal or if they are larger, then surgicalmanagement is indicated.1 In the present case it was feltthat the fistula was small and that given improvementin local measures (i.e., de-epithelialization as well as theuse of the splint) healing should be facilitated.Additionally our patient did not have any clinical signsor symptoms of sinus infection. However, we didprescribe a course of broad spectrum antibiotics as theuse of antibiotics is recommended in the literature evenin the absence of sinus disease as a prophylacticmeasure during treatment.3 Compared to surgicalmanagement, the procedure that we have described wasminimally invasive and appeared to have very few risksassociated with it.

Adequate pre-surgical assessment of all patients priorto extractions is important in order to help prevent theoccurrence of such complications. This includesevaluation of both general and local factors that mayinfluence healing such as systemic health (e.g.,immunosuppression) and factors such as pre-existingsinus disease or periapical infection. Where there is apossibility of antral perforation either by anatomicalvariation or from the presence of chronic infection, theuse of a splint placed immediately following extractionof teeth may well prevent the development of a fistula.In such situations wearing the splint would benecessary for a much shorter period of time (e.g., one totwo weeks).

CONCLUSIONThis case report describes a procedure that provided

a simple and effective method of treating an oro-antralfistula in an immunocompromised patient without

Fig 4. Clinical appearance of the site of the upper left first molar eightweeks after the treatment started.

Fig 5. Clinical appearance of the site of the oro-antral fistula 12months after the initial presentation of the patient to the clinic

showing complete closure of the communication.

causing any detrimental effects to the patient’s overallhealth.

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Surg 1988;17:110-115.

2. Punwutikorn J, Waikakul A, Pairuchvej V. Clinically significantoroantral communications – a study of incidence and site. Int JOral Maxillofac Surg 1994;23:19-21.

3. Moore JR, Gillbe GV. Principles of oral surgery. 4th edn.Manchester University Press, 1991.

4. Guven O. A clinical study on oroantral fistulae. JCraniomaxillofac Surg 1998;26:267-271.

5. Felix DH, Wray D, Smith GL, Jones GA. Oro-antral fistula: anunusual complication of HIV-associated periodontal disease. BrDent J 1991;171:61-62.

6. Tami TA. The management of sinusitis in patients infected withthe human immunodeficiency virus (HIV). Ear Nose Throat J1995;74:360-363.

7. el-Hakim IE, el-Fakharany AM. The use of the pedicled buccalfat pad (BFP) and palatal rotating flaps in closure of oroantralcommunications and palatal defects. J Laryngol Otol1999;113:834-838.

8. Patton LL, Shugars DA, Bonito AJ. A systematic review ofcomplication risks for HIV-positive patients undergoing invasivedental procedures. J Am Dent Assoc 2002;133:195-203.

9. Dodson TB, Perrett DH, Gongloff RK, Kaban LB. Humanimmunodeficiency virus serostatus and the risk of postextractioncomplications. Int J Oral Maxillofac Surg 1994;23:100-103.

10. Glick M, Abel SN, Muzyka BC, DeLorenzo M. Dentalcomplications after treating patients with AIDS. J Am Dent Assoc1994;125:296-301.

11. Dodson TB. HIV status and the risk of post-extractioncomplications. J Dent Res 1997;76:1644-1652.

12. Diz Dios P, Fernandez Feijoo J, Vazquez Garcia E. Toothextraction in HIV sero-positive patients. Int Dent J 1999;49:317-321.

13. Godfrey PM. Sinus obliteration for chronic oro-antral fistula: acase report. Br J Plast Surg 1993;46:341-342.

Address for correspondence/reprints:Dr Richard M LoganOral Pathology Unit

Dental SchoolFaculty of Health Science

The University of AdelaideNorth Terrace

Adelaide, South Australia 5005Email: richard.logan@adelaide.edu.au

258 Australian Dental Journal 2003;48:4.