M Ferguson
Context
- 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.
Key Points
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.
References
List of references included in the review (PDF)
Very good and well-timed article.As of 12 noon today I have had 3 patients in less than 24 hours present with sinusitis presenting as posterior maxillary toothaches.That last point can’t be stressed enough:they present with multiple teeth that are symptomatic,confirmed with percussion tests.
Another diagnostic trick(but is not 100% accurate..can have false negatives),is the “Sinus Test”,whereby you get the pt to sit sideways in the chair,and have them bend over for about 15 seconds to bring the blood pressure up in the sinus.It can trigger an increase in pressure/pain to the area.And this trigger may pesent itself delayed a few seconds after they have sat up.
With these findings,it is rare for 2-3,or even 4 teeth in a row that would be abscessing,but must be part of the list of possibilities,and must be ruled out.In my experience,the only other issue that is often seen as the cause is excessive grinding/clenching,associated with increased stress,or TMJ problems,and excessive acidic exposure to teeth with recession.3 particular periods in the year I see the latter:
1.Late summer,when tomatoes are in abundance.
2.Mid-fall,especially in my area,as there are many apple orchards.It only takes a few extra a day to cause the teeth to be symptomatic.
3.Christmas time,when patients are eating Mandarins(Tangerines)like candy.
It cannot be stressed enough that all these possibe etiologies must be explored,then narrow down the diagnosis to odontogenic in origin.A low-grade infection may not be felt in the sinus by the patient…they feel the origin of the nerve,the tooth,even if it is triggered somewhere else along the nerve(floor of the sinus).
Come fall and winter every year,patients present with secondary infections to sinus(and lung)after a particularly difficult and taxing bout of the flu or a cold(as mentoned about the last 24 hours in this office).Severe allergies any time of the year is also a contributing factor.
I agree with the author that communication and referral to the medical GP should be persued.As much as the sinus is a “grey area” between Dentistry and Medicine,and that we can prescribe antibiotics because the sinus is affecting “our teeth”,I feel that the GP should be consulted and be the initiator of treatment,so that they can monitor progress,know the history,and decide to refer to an ENT in cases of chronic or repeated acute problems.
May I know what role do allergies play in sinusitis?
great information and good article. Thank you for sharing with us. Thank you so much.