Rhinosinusitis in oral medicine and dentistry
- Rhinosinusitis is a very common condition which is normally readily recognizable.
- Given the intimate anatomic relationship between the antrum and the posterior maxillary teeth, maxillary sinusitis can present as odontalgia.
- Distinguishing between odontogenic orofacial pain and pain associated with maxillary sinusitis is important to prevent unnecessary dental intervention and to direct patients to medical colleagues. Conversely, odontogenic infection can spread to involve the antrum, termed odontogenic sinusitis, or maxillary sinusitis of dental origin.
- Odontogenic sinusitis accounts for about 10–40% of all cases of sinusitis, and usually requires combined dental and medical treatment.
- Maxillary sinusitis can also be a complication of exodontia, resulting from tuberosity fractures, displaced teeth or root fragments and the creation of oro-antral communications and fistulae.
- Dental implants and endodontic materials can also impinge on the maxillary sinus, and are rare causes of sinusitis.
- Often it is stated that rhinosinusitis may contribute to a halitosis complaint, and widely used diagnostic protocols for rhinosinusitis sometimes list halitosis as a minor criterion. However, gold standards in halitotosis research, such as organoleptic assessment or gas chromatography have not been used to validate a correlation between objective (genuine) halitosis and sinusitis. The pathophysiology of this mechanism is unclear, and the relative importance of this alongside other causes of extraoral halitosis is debated.
Maxillary sinusitis masquerading as odontalgia
- Maxillary sinusitis is not uncommonly perceived as pain originating in the maxillary molar and premolar teeth, which may trigger patients to seek dental care. This is an example of so called non-odontogenic toothache.14
- In maxillary sinusitis, the posterior maxillary teeth may be tender to percussion, 16 and hypersensitive to cold stimuli.
- There may also be mucosal tenderness, oedema and erythema in the area over the sinus intraorally.14
- If periapical radiographs are carried out, artifactual widening of the periodontal ligament space may occur where the apices are superimposed on the sinus.
- Differentiation between odontalgia from maxillary sinusitis and dental causes of odontalgia (e.g. pulpitis or a dentoalveolar abscess) is achieved mainly through a careful history and examination.
- Classically, sinusitis pain increases during head movements (particularly when the head is placed below the level of the heart), or during valsala manoeuvre. The pain is worse when the head is held upright compared to when lying supine.17
- Potentially useful diagnostic aids are provided by the fact that local anesthetic given intraorally will not relieve sinusitis pain (whereas topical nasal anesthetic will).14
- A dental panoramic radiograph may show obvious pathology such as mucosal thickening or a fluid level in the inferior part of the sinus,3 appearing as radiopaque areas relative to the contralateral side.
- Other features of acute maxillary sinusitis are nonspecific (e.g. pyrexia, elevated erythrocyte sedimentation rate and elevated C-reactive protein), 18 and not particularly helpful in ruling out odontogenic infection.
Odontogenic maxillary sinusitis
- By tradition, odontogenic infection is considered a rare cause of sinusitis.
- Thickening of the sinus mucosa is almost 10 times more commonly demonstrated in individuals with periapical lesions.22
- The cause of odontogenic maxillary sinusitis is usually periapical or periodontal infection of a maxillary posterior tooth, where the inflammatory exudate has eroded through the bone superiorly to drain into the maxillary sinus.
- The causative organisms in odontogenic sinusitis tend to differ from non-odontogenic sinusitis. In the latter, normal nasal cavity commensals are frequently implicated, whereas in the former, the infection may involve oral commensals and is most commonly a predominantly anaerobic, polymicrobial infection of anaerobic streptococci spp., gram-negative bacilli, and Enterobacteriaceae.29
- Odontogenic maxillary sinusitis may be resistant to conventional sinusitis therapy.29 Rather, management of both the sinusitis and the dental cause is required to resolve the condition.
Maxillary sinusitis secondary to oro-antral communications and fistulae
- Fractures of the maxillary tuberosity may create oro-antral communications, especially if the tuberosity is completely removed.
- The risk assessment on all maxillary posterior teeth for extraction should include consideration of the possibility of creating oro-antral fistulae.
Rhinosinusitis as a cause of halitosis
- Sources listing halitosis as a possible symptom of sinusitis must be interpreted with caution.
- A marked lack of standardization of research methodologies has led to some authors calling for greater efforts in standardizing protocols in halitosis research.48
- To the author’s knowledge there is no available evidence of the exact pathophysiologic mechanism by which sinusitis may cause either an objective or subjective halitosis complaint.