Computed tomography evidence of dental restoration as aetiological factor for maxillary sinusitis

Maxillary Sinus Pathology and its Relationship with Pathology and Dental Treatments. Systematic Review

Introduction and objective: The aim of this review is to evaluate to what extent sinus pathology originates from dental pathology or treatment, and to assess the occurrence frequency of sinus pathology in its different forms using cone beam computed tomography (CBCT). Method: The literature review was conducted using PubMed, Scopus and the Cochrane Library. Forty-two articles were included (25 case series, ten cross- sectional studies, three case-control studies, two cohort studies, one prospective study, and one retrospective study). Results: Forty-two articles involving a total of 13,191 patients and 17,374 CBCTs were included in this review. The most frequent pathological findings were, by a considerable degree, inflammatory diseases, which represented 75.16% of the total findings, followed by infection (12.13%), tumours (6.88%), and high pneumatisation (2.07%). Within dental pathology, there is a direct Pearson correlation with polyps (1) and opacification (0.999), and an almost direct correlation with retention cysts (0.981) and sinus-associated dental elements (0.972). Conclusions: Our results further support the argument that dental modifications and treatments are an important cause of sinus pathology. For this reason, dental aetiologies must be taken into account by both dentists, maxillofacial surgeons and ENT when considering the most appropriate treatment for patients with maxillary sinusitis.

Odontogenic sinusitis: A state‐of‐the‐art review

Odontogenic sinusitis (ODS) is more common than historically reported, and is underrepresented in the sinusitis literature. ODS is distinct from rhinosinusitis in that it is infectious sinusitis from an infectious dental source or a complication from dental procedures, and most commonly presents unilaterally. ODS clinical features, microbiology, and diagnostic and treatment paradigms are also distinct from rhinosinusitis. ODS evaluation and management should generally be conducted by both otolaryngologists and dental providers, and clinicians must be able to suspect and confirm the condition. ODS suspicion is driven by certain clinical features like unilateral maxillary sinus opacification on computed tomography, overt maxillary dental pathology on computed tomography, unilateral middle meatal purulence on nasal endoscopy, foul smell, and odontogenic bacteria in sinus cultures. Otolaryngologists should confirm the sinusitis through nasal endoscopy by assessing for middle meatal purulence, edema, or polyps. Dental providers should confirm dental pathology through appropriate examinations and imaging. Once ODS is confirmed, a multidisciplinary shared decision‐making process should ensue to discuss risks and benefits of the timing and different types of dental and sinus surgical interventions. Oral antibiotics are generally ineffective at resolving ODS, especially when there is treatable dental pathology. When both the dental pathology and sinusitis are addressed, resolution can be expected in 90%–100% of cases. For treatable dental pathology, while primary dental treatment may resolve the sinusitis, a significant percentage of patients still require endoscopic sinus surgery. For patients with significant sinusitis symptom burdens, primary endoscopic sinus surgery is an option to resolve symptoms faster, followed by appropriate dental management. More well‐designed studies are necessary across all areas of ODS.

Odontogenic sinusitis (ODS) is one of the most common cause of unilateral maxillary sinus disease, but has been underrepresented in previous sinusitis literature.

Clinicians must be able to suspect ODS based on certain clinical features like unilateral middle meatal purulence on nasal endoscopy, subjective foul smell, and sinus computed tomography demonstrating maxillary sinus opacification with or without overt adjacent dental pathology.

Diagnosing ODS requires confirmation of infectious sinusitis by otolaryngologists ideally with nasal endoscopy, and confirmation of adjacent maxillary dental pathology by dental specialists.

Management centers on multidisciplinary collaboration and shared‐decision making between otolaryngologists, dental specialists, and patients.

Odontogenic sinusitis - case series and review of literature

BACKGROUND

Odontogenic sinusitis is a common cause of rhinosinusitis that is often undiagnosed and overlooked. No single sign or symptom is specific for odontogenic sinusitis, and failure to focus on the specific radiological features can delay diagnosis.

OBJECTIVE

This paper presents four cases of chronic sinusitis that had an odontogenic origin. Each case was referred for a second opinion. Three patients had previously undergone unsuccessful surgical management.

METHODS

The literature, and the associated contributory clinical, radiological and microbiological features required for correct diagnosis and management, are reviewed.

RESULTS

Each case resulted in a positive patient outcome following the involvement of both otolaryngology and maxillofacial surgery departments.

CONCLUSION

A high index of suspicion is advocated for odontogenic sinusitis in cases not responding to standard management plans. Collaboration with a maxillofacial specialist is important for diagnosis and management. This should be considered where standard management fails, or clinical features and radiological signs of odontogenic sinusitis are present. This paper also highlights the need for otolaryngologists to incorporate, at the very least, a basic dental history and examination as part of their assessment in recalcitrant cases.

Diagnosing odontogenic sinusitis of endodontic origin: A multidisciplinary literature review

PURPOSE

Endodontic disease is one of the most common causes of bacterial odontogenic sinusitis (ODS). Diagnosing ODS of endodontic origin involves otolaryngologists confirming sinusitis, and dental specialists confirming endodontic sources. The purpose of this study was to conduct a multidisciplinary literature review to highlight clinical and microbiological features of ODS, and the most optimal diagnostic modalities to confirm endodontic disease.

METHODS

An extensive review of both medical and dental literature was performed by rhinologists, endodontists, and an infectious disease specialist. Frequencies of various clinical and microbiological features from ODS studies were collected, and averages were calculated. Different endodontic testing and imaging modalities were also evaluated on their abilities to confirm endodontic disease.

RESULTS

ODS patients most often present with unilateral sinonasal symptoms for over 3 months, purulence on nasal endoscopy, and overt dental pathology on computed tomography (CT). Subjective foul smell, and maxillary sinus cultures demonstrating anaerobes and α-streptococci (viridans group) may be more specific to ODS. For endodontic evaluations, cold pulp testing and cone-beam CT imaging are most optimal for confirming pulpal and periapical disease.

CONCLUSION

Diagnosing ODS requires collaboration between otolaryngologists and dental specialists. Clinicians should suspect ODS when patients present with unilateral sinonasal symptoms, especially foul smell. Patients will generally have purulent drainage on nasal endoscopy, and both sinus opacification and overt dental pathology on CT. However, some patients will have subtle or absent dental pathology on CT. For suspected endodontic disease, endodontists should be consulted for at least cold pulp testing, and ideally cone-beam CT.

Association between maxillary sinus pathology and odontogenic lesions in patients evaluated by cone beam computed tomography. A systematic review and meta-analysis

Background

A study is made of the association between maxillary sinus pathology and odontogenic lesions in patients evaluated with cone beam computed tomography.

Material and Methods

A literature search was made in five databases and OpenGrey. Methodological assessment was carried out using the Newcastle-Ottawa tool for observational studies. The random-effects model was used for the meta-analysis.

Results

Twenty-one studies were included in the qualitative review and 6 in the meta-analysis. Most presented moderate or low risk of bias. The periodontal disease showed to be associated with the thickening of the sinus membrane (TSM). Mucous retention cysts and opacities were reported in few studies. The presence of periapical lesions (PALs) was significantly associated to TSM (OR=2.43 (95%CI:1.71-3.46); I2=34.5%) and to odontogenic maxillary sinusitis (OMS) (OR=1.77 (95%CI: 1.20-2.61); I2=35.5%).

Conclusions

The presence of PALs increases the probability of TSM and OMS up to 2.4-fold and 1.7-fold respectively. The risk differences suggests that about 58 and 37 of out every 100 maxillary sinuses having antral teeth with PALs are associated with an increased risk TSM and OMS respectively. The meta-evidence obtained in this study was of moderate certainty, and although the magnitude of the observed associations may vary, their direction in favor sinus disorders appearance, would not change as a result.

Key words:Sinus pathology, Odontogenic Sinusitis, Sinus membrane thickening, CBCT, Periapical lesions, Periodontal disease

Morphological variations of the maxillary sinus floor adjacent to periapical chronic injuries

Background

Today, there are several diagnostic methods to determine the exact size and nature of periapical lesions. Furthermore, there are studies that described thickening of the mucous membrane of the maxillary sinus (MS) in patients with periapical lesions and demonstrated a causal relation.

Aims

This study aims to evaluate the morphological variations of the MS floor (MSF) adjacent to chronic periapical lesions in molars and premolars using cone-beam computed tomography (CBCT).

Methods

Twenty-five CBCTs with periapical lesions adjacent to maxillary molars and premolars were evaluated. A total of 50 maxillary sinuses were analyzed (12 males and 13 women) taking into account density changes within the sinus cavity. The thickening of the sinus mucosa and the periapical lesions was measured in a caudal-cephalic direction. The axial and sagittal axis was taken as reference on the sagittal and coronal sections.

Statistical Analysis

Chi-square, Fisher exact, and the Mann-Whitney tests were used in this study.

Results

A significant association between the size of the periapical lesions (>4 mm) and the presence of MSF affectation was found on sagittal and coronal views (P < 0.001). No significant differences between the presence or absence of periapical lesions and the thickening of the sinus mucosa were found (P = 0.241). The presence of opacification on the MS had no direct associations with the periapical lesions.

Conclusions

Maxillary sinus floor affectation was associated with chronic periapical lesions >4 mm. The opacification or thickening of the sinus mucosa was not related with the periapical lesions.

Maxillary Sinusitis Associated With Peri-implantitis at Sinus Floor Augmented Sites: Case Series

PURPOSE

The purpose of this case series was to investigate treatment outcomes of maxillary sinusitis associated with peri-implantitis at sinus floor augmented sites for a 3-year follow-up.

MATERIALS AND METHODS

Eighteen implants in 8 patients diagnosed with maxillary sinusitis associated with peri-implantitis were reviewed. Four patients were treated with implant removal and antibiotics, and 4 patients were treated with implant removal, the modified Caldwell-Luc operation (CLOP), and antibiotics. Seven patients, who had 7 survived implants, were followed up to 3 years after treatment. The characteristics between failed and survived implants were compared. Radiographic parameters of survived implants were analyzed using the Friedman test.

RESULTS

Eleven failed implants from 8 patients exhibited approximately 10-mm pocket depths and mobility at diagnosis. Seven survived implants from 7 patients exhibited no significant changes in crestal bone loss at the facial side for 3 years after the treatments. Sinus mucosal thickening was significantly reduced during the 3-year follow-up after the treatments.

CONCLUSION

The progression of peri-implantitis in sinus floor augmented sites may lead to maxillary sinusitis. To confirm the efficacy of the intraoral approaches, such as the modified CLOP, systematic clinical studies with a large sample size and a long-term follow-up should be conducted.

Imaging of odontogenic sinusitis

The aetiological relationship between dental disease and procedures and mucosal disease within the maxillary sinus has received extensive attention in the recent otolaryngological and dental literature. In contrast, the concept of an odontogenic cause for sinusitis is not well appreciated by radiologists. Review of the maxillary dentition, the alveolar process, and the relationship of the tooth roots to the floor of the maxillary sinus should be an integral part of interpretation of imaging of the paranasal sinuses. The pathogenesis, clinical presentation, and imaging features of rhinogenic and odontogenic sinusitis are discussed and compared. Clinical definitions of rhinosinusitis are explained and the huge impact on healthcare of this disease is briefly discussed. Periapical inflammatory lesions, post-extraction oroantral communication, and procedures used to augment the alveolar process prior to placement of dental implants are the commonest causes of odontogenic sinusitis. Current estimates are that an odontogenic cause for maxillary sinusitis is present in 25-40% of cases. The incidence of odontogenic sinusitis is rising, extension outside the maxillary sinus is common, and the diagnosis is often delayed, resulting in inappropriate and failed treatment. Differentiation of rhinological and odontogenic causes of sinusitis is usually difficult on clinical grounds and imaging plays a key role in the distinction.

Incidence of Maxillary Sinus Disease Before Sinus Floor Elevation Surgery as Identified by Cone-Beam Computed Tomography: A Literature Review

The purpose of this study is to review the literature to assess the incidence of maxillary sinus disease before sinus floor elevation surgery (SFE) as identified by cone-beam computerized tomography (CBCT). Only studies in which CBCT was performed in patients for dental implant placement in the past 10 years were considered. Eleven studies were identified. A total of 1792 patients were collected. All the studies reviewed reported on thickening of the sinus mucosa as a criterion for sinus disease with different threshold values. All studies reported mucosal thickening (MT) ranging between 25.5% and 93.1%. The mean incidence of MT was 54.99%. Two studies examined the correlation of MT with clinical symptoms. Three studies reported evaluation of the ostiomeatal complex (OMC). There is a high probability of detecting a certain degree of MT in patients referred for SFE. There is no consensus regarding the threshold values beyond which MT is considered pathological. Independently from the threshold values or the type of MT, the studies lack correlation with clinical data regarding patients' sinusitis-related history or symptoms. CBCT with a large field of view to evaluate the OMC is appropriate in patients scheduled for SFE. Future studies should include a systematic correlation with clinical symptoms and the possible presence of OMC obstruction. A clinical assessment that includes nasal endoscopy is indicated when MT and obstruction of the OMC are identified. Surgical correction of OMC obstruction seems to be appropriate to increase the success rate and to avoid possible complication after SFE.

Association between Odontogenic Conditions and Maxillary Sinus Disease: A Study Using Cone-beam Computed Tomography

INTRODUCTION

The maxillary sinus can be affected by dental infections because of its close relationship with upper teeth. This study aimed to assess the most common types of maxillary sinus alterations and to associate them with odontogenic conditions using cone-beam computed tomographic (CBCT) images.

METHODS

CBCT scans of 400 patients showing sinus disease in 1 or both maxillary sinuses were evaluated. Sinus alteration was considered as follows: generalized or localized mucosal thickening (MT), maxillary sinusitis (MS), and retention cysts (RCs). The odontogenic conditions evaluated were inadequate endodontic treatment, periapical lesions, and periodontal bone loss. Descriptive and multiple logistic regression analyses were performed.

RESULTS

Sinus diseases were observed in 85.9% of the maxillary sinuses. The most prevalent condition was generalized MT (65.2%) followed by localized MT (24.8%), MS (6.4%), and RCs (3.6%). Generalized MT was more related to males (odds ratio = 1.45, P < .05) and periodontal bone loss (P < .05). Localized MT was associated with periapical lesions (odds ratio = 3.09, P < .05) and showed a close anatomic relationship between teeth and the sinus floor (odds ratio = 2.77, P < .05). There were no statistically significant associations between either MS or RCs and the odontogenic conditions studied.

CONCLUSIONS

The most prevalent sinus diseases were the generalized and localized MT, and they were the only ones related to odontogenic conditions (periodontal bone loss and periapical lesions, respectively). We emphasize that CBCT imaging is an appropriate method for evaluating the maxillary sinus findings and their associated odontogenic conditions.

Sinusitis and oroantral fistula in patients with bisphosphonate-associated necrosis of the maxilla

Background

The management of bisphosphonate related necrosis of the jaw has become clinical routine. While approximately two thirds of the lesions are in the mandible, one third is located in the maxilla. In 40–50 % of maxillary necrosis the maxillary sinus is involved, leading to maxillary sinusitis and oro-antral communications.

Methods

This retrospective single center study includes all patients with diagnosis of BP-ONJ of the maxilla and concomitant maxillary sinusitis. The information collected includes age, gender, primary disease, bisphosphonate intake, involving type of bisphosphonate, route of administration and duration of BP treatment previous to surgical treatment and treatment outcome.

Results

A total of 12 patients fulfill the criteria of the diagnosis of maxillary sinusitis associated to maxillary necrosis, of which 6 Patients showed purulent sinusitis. All patients underwent surgical treatment with complete resection of the affected bone and a multilayer wound closure. A recurrence appeared in one patient with open bone and no sign of sinusitis and was treated conservatively.

Conclusions

Purulent maxillary Sinusitis is a common complication of bisphosphonate-related necrosis of the maxilla. The surgical technique described can be suggested for the treatment of these patients.

IRAK4 gene polymorphism and odontogenic maxillary sinusitis

Objectives

This study aimed to evaluate whether a specific interleukin-1 receptor-associated kinase-4 (IRAK4) gene polymorphism had any influence on the development of changes in maxillary sinus, particularly in the presence of etiological factors of dental origin.

Materials and methods

The study population included 153 Portuguese Caucasians that were selected from a database of 504 retrospectively analysed computed tomography (CT) scans. A genetic test was performed, and a model was created through logistic analysis and regression coefficients. The statistical methodologies included were the independent Chi test, Fisher’s exact test, binary logistic regression and the receiver operating characteristic (ROC) curve.

Results

The estimated prevalence of IRAK4 gene polymorphism found in a Portuguese Caucasian population was 26.8 % (CI 95 %) [20.1, 34.7 %]. A model to predict the inflammatory response in the maxillary sinus in the presence etiological factors of dental origin was constructed. This model had the following as variables: previously diagnosed sinusitis, sinus pressure symptoms, cortical bone loss observed on CT, positive genetic test result and radiographic examination that revealed the roots of the teeth communication with the maxillary sinus, which are interpreted as risk factors.

Conclusions

The constructed model should be considered an initial clinical tool. The area under the ROC curve found, AUC = 0.91, revealed that the model correctly predicts the outcome in 91.1 % of cases.

Clinical relevance

The clinical relevance of this study lies in trying to achieve a potential tool (a model) that may assist the clinician in the implementation of suitable dental treatment plans in complex cases, with probable involvement of the maxillary sinus.

The significance of cone beam computed tomography for the visualization of anatomical variations and lesions in the maxillary sinus for patients hoping to have dental implant-supported maxillary restorations in a private dental office in Japan

Objectives

The purpose of the present study was to elucidate the significance of cone bean computed tomography (CBCT) for patients hoping to undergo implant-supported restorations of the maxilla. Therefore, two studies were planned. One was to compare the prevalence of anatomic variations and lesions in the maxillary sinus on CBCT of patients hoping to undergo implant-supported restorations of the maxilla with that in patients with other chief complaints in a private dental office in Japan. The other study was to elucidate the limitations of panoramic radiographs in the detection of anatomic variations and lesions in the maxillary sinus.

Study design

Sixty-one pairs of panoramic radiographs and CBCT were retrospectively analyzed in two groups of patients, those who hoped to undergo implant-supported restorations in the maxilla (Implant group) and those who did not (Non-implant group). The presence of anatomic variations and lesions in the maxillary sinus were analyzed.

Results

The detection rate of mucosal thickening was significantly higher in the Implant group than in the Non-implant group. The detection rates for the features analyzed were significantly lower on panoramic radiographs. In particular, the detection rates of internal and anterior locations of some features were noticeably lower on panoramic radiographs. A significant relationship was found between the change in the detection rate on panoramic radiographs and the widths of mucosal thickening or the lengths of the major axis of SOLs in the maxillary sinus. If the width of mucosal thickening or the length of the major axis of SOLs was <3 mm or <4 mm, respectively, the detection rate on panoramic radiographs was significantly decreased.

Conclusion

CBCT is important for patients hoping to undergo implant-supported restorations of the maxilla because of the mucosal thickening in the maxillary sinus in such patients and their lower detection rates on panoramic radiographs.

Transient swelling of the Schneiderian membrane after transversal sinus augmentation: a pilot study

OBJECTIVE

The predictability and simplicity of the Summers' technique for sinus floor elevation encouraged many clinicians to consider this new approach. The impact of such intervention on the sinus mucosa has, however, not been explored extensively. This pilot study followed the response of the Schneiderian membrane, longitudinally, via cone-beam CT images.

MATERIAL AND METHODS

Ten consecutive patients (five women, mean age 58.7 years) referred for implant therapy in the posterior part of the maxilla, in combination with a trans-alveolar sinus floor elevation (13 sinuses involved), were enrolled. CBCT images were taken prior to and at 1 week and 1 month after surgery. The changes in thickness of the Schneiderian membrane were scored at nine standardized points per sinus using reformatted cross-sectional images.

RESULTS

One week after sinus floor elevation, the Schneiderian membrane showed a significant swelling of 9.2 mm in the middle (SD 0.3; P < 0.005), 7.2 mm medially (SD 2.5; P < 0.005) and 3.9 mm laterally (SD 0,3; P < 0.05), respectively, resulting in an overall mean of 6.7 mm (SD 2.6), which fully disappeared 3 weeks later. This swelling involved the entire floor of the sinus and not only the augmented area.

CONCLUSIONS

Within the limitations of this pilot study, one can conclude that the Schneiderian membrane responds with a significant "transient" swelling (5-10× its size) during the first weeks of healing.

Diagnostic value of 2D and 3D imaging in odontogenic maxillary sinusitis: a review of literature

This review aims to explore whether 3D imaging offers an added value in diagnosis of odontogenic sinusitis. Odontogenic maxillary sinusitis accounts for approximately 10-12% of maxillary sinusitis cases. Proper diagnosis of odontogenic sinusitis is based on a thorough dental and medical examination and crucial to ensure therapeutic efficacy. To establish the odontogenic cause of maxillary sinusitis, 2D and 3D imaging modalities may be considered, each presenting distinct advantages and drawbacks. The available research indicates that 2D imaging modalities may often mask the origin of odontogenic maxillary sinusitis. This limitation is particularly evident in the maxillary molar region, stressing the need for 3D cross-sectional imaging. The advent of low-dose cone beam computed tomography in dentistry may be particularly useful when odontogenic maxillary sinusitis is not responsive to therapy. Yet, it seems that more research is needed to validate its use in odontogenic maxillary sinusitis.

Antral computerized tomography pre-operative evaluation: relationship between mucosal thickening and maxillary sinus function

OBJECTIVES

to assess the correlation between maxillary sinus inferior mucosal thickening and sinus outflow obstruction.

MATERIAL AND METHODS

the study included 280 computerized tomography (CT) scans (560 maxillary sinuses). CT aimed to assess sinusitis; trauma to the face and intubated patients were excluded. Mucosal thickening was graded as < 5 mm (1), < 10 mm (2), < 15 mm (3), < 20 mm (4) and > 20 mm (5), and classified by appearance as normal, rounded, circumferential, irregular, or complete. Maxillary sinus outflow was classified as patent or obstructed.

RESULTS

mucosal thickening was found in 36.1% of the maxillary sinuses, graded as 31.2% (1), 34.2% (2), 12.9% (3), 5.4% (4) and 16.3% (5), and classified as rounded (11.8%), irregular (10.4%), circumferential (8.8%) and complete (5.2%). Sinus outflow was obstructed in 15% of the scans. Mucosal thickening of < 5 mm (11.1%), < 10 mm (36.2%) and > 10 mm (74.3%) was associated with sinus obstruction (P<0.0001). Rounded (6.1%), circumferential (55.2%), irregular (38.8%) and complete (100%) mucosal appearances were associated with sinus obstruction (P<0.001). When statistically combined, a substantial risk for sinus obstruction was observed with irregular mucosal appearance of > 5 mm (56.5% for grade 2 up to 82.6% for grades 3-5) and circumferential appearance (21.4% for grade 1 up to 100% for grades 3-5). A low risk for obstruction was found with the rounded appearance (mean 6.1%).

CONCLUSIONS

irregular (> 5 mm), circumferential and complete mucosal appearance are associated with an increased risk for sinus outflow obstruction and an ENT consultation is recommended. A rounded mucosal appearance of any grade is associated with a low risk for sinus obstruction. Routine CT scans, including the maxillary sinus ostium, are recommended.

Spiral computed tomography based maxillary sinus imaging in relation to tooth loss, implant placement and potential grafting procedure

Objectives

The purpose of the present study was to explore the maxillary sinus anatomy, its variations and volume in patients with a need for maxillary implant placement.

Material and Methods

Maxillary sinus data of 101 consecutive patients who underwent spiral computed tomography (CT) scans for preoperative implant planning in the maxilla at the Department of Periodontology, University Hospital, Catholic University of Leuven, Leuven, Belgium were retrospectively evaluated. The alveolar bone height was measured on serial cross-sectional images between alveolar crest and sinus floor, parallel to the tooth axis. In order to describe the size of the maxillary sinus anteroposterior (AP) and mediolateral (ML) diameters of the sinus were measured.

Results

The results indicated that the alveolar bone height was significantly higher in the premolar regions in comparison to the molar region (n = 46, P < 0.01). The age showed negative relation to bone dimension (r = - 0.32, P = 0.04).

Anterior and posterior border of the maxillary sinuses were mostly located in the first premolar (49%) and second molar (84%) regions, respectively. Maxillary sinus septa were indentified in 47% of the maxillary antra. Almost 2/3 (66%) of the patients showed major (> 4 mm) mucosal thickening mostly at the level of the sinus floor. The present sample did not allow revealing any significant difference (P > 0.05) in maxillary sinus dimensions for partially dentate and edentulous subjects.

Conclusions

Cross-sectional imaging can be used in order to obtain more accurate information on the morphology, variation, and the amount of maxillary bone adjacent to the maxillary sinus.