Association between odontogenic conditions and maxillary sinus abnormalities

Odontogenic infection is a health problem that deserves special care, often related to apical periodontitis (AP) in a tooth with primary or secondary endodontic infection (failure in root canal treatment), or periodontal bone loss (PBL) due to severe periodontitis. In the maxillary arch, when the posterior teeth (premolars and molars) are the source of the infectious process, microorganisms from the root apex or periodontal pocket can invade the interior of the maxillary sinus due to their proximity triggering an inflammatory process from Schneider’s membrane lining the maxillary sinuses.

Root canal infection naturally progresses to the periapical region. A natural attribute of this infectious process is the formation of bacterial biofilm, whose characteristic in the primary infection is the predominance of anaerobic Gram-negative bacteria, while in the secondary infection, it is Gram-positive. Certainly, other biophysical conditions of the tooth can contribute to the involvement of other species of microorganisms (1-3).

The thickening of the mucosa greater than 2 mm is considered pathological and is frequently associated with odontogenic sinusitis of the maxillary sinuses. This reactive hyperplasia of the Schneiderian membrane, along with ostium obstruction, interferes with the physiological drainage of the sinus, resulting in mucus retention, decreased mucociliary clearance, and increased bacterial growth (4-6). Complications after dental procedures, such as an oroantral fistula or a foreign body inside the sinus (e.g., an implant), may also be related to odontogenic sinusitis.

Odontogenic sinusitis may present with chronic pain or unilateral pressure, intermittent drainage of nasal mucus and bad breath, but it may also be asymptomatic (3,7). Symptoms can appear 3 to 31 months after the onset of the infection. Maxillary sinus opacification on radiographs is frequently associated with nasal and sinus symptoms (8) including periapical abscess (9).

According to the American Association of Endodontists, imaging exams of odontogenic sinusitis involves periapical osteoperiostitis, periapical mucositis, partial obstruction, and total obstruction. Maxillary sinusitis of endodontic origin (MSEO) constitutes a pathogenesis with symptoms and radiographic signs that may mimic sinogenic sinusitis, which may first induce the search for primary care physicians or specialists in otorhinolaryngology. However, the care with endodontic treatment seeking to solve the cause of the infectious process becomes fundamental. This clinical condition involving a root canal infection advancing into the maxillary sinus (10). Cone-beam computed tomography (CBCT) is the best tool to accurately assess the dental condition and proximity of dental roots to the maxillary sinus due to its enhanced spatial resolution when compared to regular medical images or panoramic radiographs (11-13).

In a recent edition of the Annals of Palliative Care Medicine, Liu et al. (14) described “Association between odontogenic conditions and maxillary sinus abnormalities: a retrospective cone-beam computed tomographic study”; this evaluation highlights interesting data emphasizing that maxillary sinus abnormalities are highly associated with the distance from to site of the infection and the maxillary sinus. The study examines the possible correlations between the abnormalities of the maxillary sinus, septum walls of the maxillary sinus anatomic correlation between the maxillary sinus and teeth and, absent teeth with the odontogenic infections (periapical lesions, PBL, and the combination of the 2 lesions). The multiple logistic regression of the study pointed out that, in accordance with recent studies, male gender [odds ratio (OR) =1.653; P<0.001], the proximity of maxillary sinus with teeth with periapical lesions (OR =5.771; P<0.001), PBL (OR =2.778; P<0.001), or both endodontic and periodontal lesions combined (OR =13.818; P<0.001) significantly increases the odds of abnormalities of the maxillary sinus (14). The study’s sample size stands out compared with the current scientific literature, which makes the results meaningful.

The abnormalities considered included the horizontal thickness of the membrane, polypoid-like thickening, opacification of the sinus, and periostitis. However, due to the applied methodology, assessing the patients’ signs and symptoms were impossible. The hyperplasia of the mucosa is the abnormality most frequently found in retrospective studies using CBCT images and can be considered as an incidental finding as the exams were made for different reasons (8,15). Futures studies are mandatory, for a better understanding of the drainage of the maxillary sinus it is necessary the assessment of the patency or obstruction of the ostiomeatal complex, as well as the presence of accessory ostium.

The connection between odontogenic sinusitis and periodontal disease is well-documented in the literature. The combined endodontic-periodontal disease is associated with the thickening of the mucosa and serves as a warning of a hidden source of sepsis (16-18).

When only infections of endodontic origin are considered the scenario points to a challenging situation. A previous study showed that approximately half of the teeth with completed root canal treatments present AP (19). The absence of treatment of the mesiobuccal 2 (MB2) canal of the mesiobuccal root of maxillary molars is the main reason for the presence of apical disease in such teeth (20). It seems that the endodontic educational approach should consider better management of MB2 canals. The improvement of this training is also dependent on a better understanding of CBCT images resulting in proper diagnosis and treatment plan, especially in maxillary molars (21). Better training combining endodontic and CBCT will result in better levels of therapeutic success preventing failure in root canal treatment.

Approximately one-third of cases of odontogenic infections are not detected by radiographic images (22,23), leading to neglect by primary care providers, oral radiologists, and otolaryngologists (24). Failure to recognize and treat odontogenic sinusitis can impact a patient’s quality of life and lead to complications, especially, but not limited to, those undergoing radiotherapy, those with cardiovascular conditions, those needing dental implants, or those requiring maxillary grafts. A multidisciplinary approach is critical for proper diagnosis and effective treatment. Dental interventions, such as root canal treatment or extraction, have resolved the majority of cases and can help avoid sinus surgery. Intervention by an otolaryngologist is necessary for refractory cases to improve success and healing rates (2,25).

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-338/coif). The authors have no conflicts of interest to declare.

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References

1. Yoshida H, Sakashita M, Adachi N, et al. Relationship between infected tooth extraction and improvement of odontogenic maxillary sinusitis. Laryngoscope Investig Otolaryngol 2022;7:335-41. [Crossref] [PubMed]
2. Saibene AM, Collurà F, Pipolo C, et al. Odontogenic rhinosinusitis and sinonasal complications of dental disease or treatment: prospective validation of a classification and treatment protocol. Eur Arch Otorhinolaryngol 2019;276:401-6. [Crossref] [PubMed]
3. Craig JR, Tataryn RW, Aghaloo TL, et al. Management of odontogenic sinusitis: multidisciplinary consensus statement. Int Forum Allergy Rhinol 2020;10:901-12. [Crossref] [PubMed]
4. Carmeli G, Artzi Z, Kozlovsky A, et al. Antral computerized tomography pre-operative evaluation: relationship between mucosal thickening and maxillary sinus function. Clin Oral Implants Res 2011;22:78-82. [Crossref] [PubMed]
5. Taschieri S, Torretta S, Corbella S, et al. Pathophysiology of sinusitis of odontogenic origin. J Investig Clin Dent 2017; [Crossref] [PubMed]
6. Whyte A, Boeddinghaus R. The maxillary sinus: physiology, development and imaging anatomy. Dentomaxillofac Radiol 2019;48:20190205. [Crossref] [PubMed]
7. Yassin-Kassab A, Bhargava P, Tibbetts RJ, et al. Comparison of bacterial maxillary sinus cultures between odontogenic sinusitis and chronic rhinosinusitis. Int Forum Allergy Rhinol 2021;11:40-7. [Crossref] [PubMed]
8. Longhini AB, Ferguson BJ. Clinical aspects of odontogenic maxillary sinusitis: a case series. Int Forum Allergy Rhinol 2011;1:409-15. [Crossref] [PubMed]
9. Siqueira JF Jr, Lenzi R, Hernández S, et al. Effects of Endodontic Infections on the Maxillary Sinus: A Case Series of Treatment Outcome. J Endod 2021;47:1166-76. [Crossref] [PubMed]
10. American Association of Endodontists. Maxillary Sinusitis of Endodontic Origin. AAE Position Statement. Available online: https://www.aae.org/specialty/wp-content/uploads/sites/2/2018/04/AAE_PositionStatement_MaxillarySinusitis.pdf
11. Estrela C, Bueno MR, Leles CR, et al. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod 2008;34:273-9. [Crossref] [PubMed]
12. Aksoy U, Orhan K. Association between odontogenic conditions and maxillary sinus mucosal thickening: a retrospective CBCT study. Clin Oral Investig 2019;23:123-31. [Crossref] [PubMed]
13. Patel NA, Ferguson BJ. Odontogenic sinusitis: an ancient but under-appreciated cause of maxillary sinusitis. Curr Opin Otolaryngol Head Neck Surg 2012;20:24-8. [Crossref] [PubMed]
14. Liu S, Chen X, Wang XX, et al. Association between odontogenic conditions and maxillary sinus abnormalities: a retrospective cone-beam computed-tomographic study. Ann Palliat Med 2023;12:365-75. [Crossref] [PubMed]
15. Nunes CA, Guedes OA, Alencar AH, et al. Evaluation of Periapical Lesions and Their Association with Maxillary Sinus Abnormalities on Cone-beam Computed Tomographic Images. J Endod 2016;42:42-6. [Crossref] [PubMed]
16. Bisla S, Gupta A, Singh H, et al. Evaluation of relationship between odontogenic infections and maxillary sinus changes: A Cone Beam Computed Tomography-based study. J Oral Biol Craniofac Res 2022;12:645-50. [Crossref] [PubMed]
17. Phothikhun S, Suphanantachat S, Chuenchompoonut V, et al. Cone-beam computed tomographic evidence of the association between periodontal bone loss and mucosal thickening of the maxillary sinus. J Periodontol 2012;83:557-64. [Crossref] [PubMed]
18. Lu Y, Liu Z, Zhang L, et al. Associations between maxillary sinus mucosal thickening and apical periodontitis using cone-beam computed tomography scanning: a retrospective study. J Endod 2012;38:1069-74. [Crossref] [PubMed]
19. do Carmo WD, Verner FS, Aguiar LM, et al. Missed canals in endodontically treated maxillary molars of a Brazilian subpopulation: prevalence and association with periapical lesion using cone-beam computed tomography. Clin Oral Investig 2021;25:2317-23. [Crossref] [PubMed]
20. Carrion SJ, Coelho MS, Soares AJ, et al. Apical periodontitis in mesiobuccal roots of maxillary molars: influence of anatomy and quality of root canal treatment, a CBCT study. Restor Dent Endod 2022;47:e37. [Crossref] [PubMed]
21. Coelho MS, Rios MA. Current status of cone-beam computed tomography teaching in Brazilian undergraduate endodontic programs - A web-based survey. J Dent Educ 2023;87:358-63. [Crossref] [PubMed]
22. Goyal VK, Ahmad A, Turfe Z, et al. Predicting Odontogenic Sinusitis in Unilateral Sinus Disease: A Prospective, Multivariate Analysis. Am J Rhinol Allergy 2021;35:164-71. [Crossref] [PubMed]
23. Pokorny A, Tataryn R. Clinical and radiologic findings in a case series of maxillary sinusitis of dental origin. Int Forum Allergy Rhinol 2013;3:973-9. [Crossref] [PubMed]
24. Ly D, Hellgren J. Is dental evaluation considered in unilateral maxillary sinusitis? A retrospective case series. Acta Odontol Scand 2018;76:600-4. [Crossref] [PubMed]
25. Van Den Munckhof T, Patel S, Koller G, et al. Schneiderian membrane thickness variation following endodontic procedures: a retrospective cone beam computed tomography study. BMC Oral Health 2020;20:133. [Crossref] [PubMed]