JIAOMR

10.5005/jp-journals-10011-1180
CASE REPORT An Unusual Case of a Cheek Abscess in a Patient with Oral Submucous Fibrosis

An Unusual Case of a Cheek Abscess in a

Patient with Oral Submucous Fibrosis
1
Sushma Pandey Dhakal, 2Keerthilatha M Pai, 3Ajay G Nayak, 4Ravidranath Vineetha
1
Lecturer, Department of Oral Medicine and Radiology, KIST Medical College and Hospital, Kathmandu, Nepal
2
Professor and Head, Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal, Karnataka, India
3
Reader, Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal, Karnataka, India
4
Assistant Professor, Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal, Karnataka, India

Correspondence: Sushma Pandey Dhakal, Lecturer, Department of Oral Medicine and Radiology, KIST Medical College and
Hospital, Kathmandu, Nepal, e-mail: pandeysusma@gmail.com

ABSTRACT

Abscess formation in the soft tissues of the face is not an uncommonly encountered phenomenon in dental practice. However, the presence
of oral mucosal pathologies can alter the manifestation of abscess formation. We report the illustration of a 51-year-old man, a known case
of oral submucous fibrosis, who presented to us with a buccal abscess. After drainage of the abscess 2 days later, a piece of meat-bone
was retrieved and found to be the causative factor. The paper discusses briefly the effects of such foreign body impaction and the clinician’s
role in the management.
Keywords: Oral submucous fibrosis, Cheek abscess, Foreign body.

INTRODUCTION 2.2 cm interincisal distance owing to oral submucous fibrosis.

The presence of foreign bodies lodged in the maxillofacial tissue
is a relatively common situation.1 Foreign bodies can penetrate
soft tissues through open wounds and lacerations sustained
during trauma or via direct impact against them.2 However,
impaction of a foreign body within the buccal mucosa of oral
submucous fibrosis (OSMF) patient with a resultant cheek
abscess is a rare and unreported clinical situation. The purpose
of this report is to highlight the significance of a thorough history
taking, clinical examination and keeping a high index of clinical
suspicion for a probable foreign body impaction when dealing
with unusual abscesses in the orofacial region.
CASE REPORT
A 51-year-old man presented with left-sided cheek pain of
5 days duration. He reported spontaneous occurrence of pain,
followed by the appearance of a swelling in the left cheek. The
pain was throbbing in nature, severe, localized, continuous and
caused severe distress on chewing from the left side. The patient
had a vague recollection of having developed pain and swelling
in the left cheek after having his food 5 days back. His past
dental history revealed that he had been diagnosed with oral
submucous fibrosis about 15 months prior to presentation and
was treated with intramucosal injections of corticosteroids and
hylauronidase. He had discontinued his arecanut chewing habit.
Patient also gave history of endodontic treatment in the adjacent
upper second molar 4 years prior.
Extraoral examination revealed no significant swelling over
the left side of the face. The mouth opening was reduced with a
The entire oral mucosa was blanched. In the left buccal mucosa
corresponding to the molar region there was a swelling
approximately 0.5 cm in diameter. On palpation, the swelling
was soft, fluctuant, severely tender (the patient barely permitted
palpation) and approximately 1ml of yellowish purulent exudate
was expressed from the sinus opening on application of mild
pressure. Vertical fibrotic bands were felt bilaterally in the
posterior buccal mucosae and circumoral fibrotic bands were
palpable in the upper and lower labial mucosae. Hard tissue
examination revealed a clinically absent left maxillary first molar
and a fractured silver amalgam restoration in the left maxillary
second molar that had a sharp buccal margin. Blood
investigation reports did not reveal any abnormal finding other
than mild leukocytosis. Vitality testing and periapical
radiographs for the adjacent teeth ruled out any odontogenic
cause for the abscess. The patient was empirically prescribed
oral antibiotic, amoxicillin, 500 mg TID for 5 days.
The patient reported back 2 days later with a yellowish,
curved, hard mass, measuring about 5 × 2 mm. He stated that
after 2 days of antibiotic therapy, the pain had reduced and he
had been able to manipulate the soft tissues of the cheek,
resulting in the mass coming out from the intraoral sinus opening
(Fig. 1). In view of this development, a radiograph of the left
cheek was obtained using an IOPA film to rule out any more
such foreign bodies or its remnants but no remnants were evident
in the radiograph. An in vitro radiograph of the calcified
exfoliated mass revealed variable radiodensity that did not
exhibit any feature of dental tissues (Fig. 2). This mass, was
sent for decalcification; however, during processing the mass

Journal of Indian Academy of Oral Medicine and Radiology, July-September 2011;23(3):S399-400 S399
Sushma Pandey Dhakal et al
Fig. 1: Mass coming out from the intraoral sinus opening
Fig. 2: An in vitro radiograph of the calcified exfoliated mass
fragmented into an amorphous powder thereby precluding the
microscopic identification of the exact nature of the mass. The
intraoral swelling resolved completely within a week with no
recurrence in the past 1 year.
DISCUSSION
Foreign bodies may get lodged at various anatomical sites
including ear, nose, bronchus, etc. but symptomatic impaction
of such foreign matter within the oral soft tissues is rare with
only few cases reported in the literature.3 This report presents
an interesting and unusual case of cheek abscess that resulted
as a consequence of impaction of a calcified foreign object.
Impaction of foreign substances within the oral mucosa, when
S400
definitively proved, always poses a dilemma to the clinician,
whether to leave it within and wait-and-watch, if the substance
is deemed to be nonoffensive to the tissues or attempt its surgical
removal. Although, it is not uncommon for foreign bodies to
be impacted in the oral soft tissues, the inert nature of the
impacted foreign body in most of the cases leads to absence of
symptoms or the object may induce an intense inflammatory
reaction in the surrounding tissues, that may get secondarily
infected leading to abscess and sinus formation4,5
This patient had already manifested OSMF in the past,
thereby leading to loss of normal suppleness and elasticity, with
stiffening of the mucosa. This could have enhanced the
possibility of penetration of foreign body into the buccal mucosa
further leading to abscess formation. The presence of impacted
matter was not initially suspected after clinical examination
given the absence of a specific history of tooth loss or trauma/
blow. Radiological investigations were also not sought for the
soft tissue as there was no suspicion of any solid body impaction
initially. The extreme tenderness in the buccal region also
precluded sufficient palpation of the swelling thereby adding
to the lack of consideration of the diagnosis. It is indeed fortunate
on our part to have retrieved the foreign body 2 days later. This
can be attributed to the resolution of the abscess after the
antimicrobial therapy and thus permitting the source of infection,
the impacted mass in this case, to be exfoliated.
Thus, through this report, we attempt to alert other clinicians
to consider the importance of the history and significance of
radiographic investigation of the soft tissues as well. Because
unlike the usual odontogenic etiology of a soft tissue abscess,
an impacted foreign body can also be a cause and needs to be
considered in the differential diagnosis especially in patients
with mucosal pathology like OSMF.
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2. Auluck A, Behanan AG, Pai KM, Shetty C. Recurrent sinus of
the cheek due to a retained foreign body: Report of an unusual
case. Br Dent J 2005;198:337-39.
3. Sethi A, Sabherwal A, Basu SK, Sareen D. An unusual cause of
recurrent cheek abscess: A clinical case. Braz J Oral Sci
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4. Cataldo E, Santis H. Response of the oral tissues to exogenous
foreign materials. J Periodontol 1974;45:93-106.
5. Spengos MN. Roentgeno-oddities: A pea in the cheek. Oral Surg
Oral Med Oral Pathol 1977;43:320-22.
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