What Is Odontogenic Sinusitis?
Odontogenic sinusitis is a type of sinusitis caused by dental infections or procedures. The condition often presents unilaterally. The paranasal sinuses become inflamed due to dental pathology developing due to dentoalveolar procedure, maxillary dentition infection, or maxillary dentition trauma. Odontogenic sinusitis develops during the fifth decade of life and affects men and women equally.
The most commonly affected paranasal sinus is maxillary sinuses due to their proximity to the upper teeth. The most common tooth associated with odontogenic sinusitis is the first, followed by the second and third molars. Odontogenic sinusitis accounts for 25 to 40 percent of unilateral chronic maxillary sinusitis.
The bacteria causing odontogenic infections are polymicrobial with a predominance of anaerobic organisms. Pepto-streptococcus, Prevotella, and Fusobacterium are commonly infecting microorganisms.
What Are Paranasal Sinuses?
Paranasal sinuses are air-filled cavities that develop from the facial bones of the skull. The four paranasal sinuses are maxillary, sphenoid, ethmoid, and frontal. These paranasal sinuses are designated after the bones from which they originate. The paranasal sinus helps humidify inspired air and facilitates alveolar gas exchange.
How Does Odontogenic Sinusitis Develop From Dental Infections?
Maxillary sinus and upper teeth have a dynamic interaction. Due to favorable anatomy, upper teeth infections cross the Schneiderian membrane (mucosal membrane covering the maxillary sinus) and trigger mucosal inflammatory reactions and altered muco-ciliary function in the maxillary sinus. The impaired mucociliary function causes altered mucus transport, impaired mucus defenses, and blocked sinus otia, which leads to bacterial infection and inflammation.
Felisati in 2013, classified sino-nasal complications as:
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First group: Odontogenic sinusitis starting before implant treatment.
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Second group: Odontogenic sinusitis developing after implant treatment.
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Third group: Classical odontogenic sinusitis developing due to dental disease or treatment.
What Are the Causes of Odontogenic Sinusitis?
The Schneiderian membrane violation could result from the following:
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Infectious Causes: Most commonly caused by dental and periodontal pathology. For example, dental caries, endodontic infection due to deep carious process which gradually causes pulp and periapical complications and complex endo periodontal lesions with the development of periodontal pockets.
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Iatrogenic Causes: It is the most common cause of odontogenic sinusitis. Almost 55.7 percent of cases have iatrogenic etiology. Common iatrogenic causes are improper sinus lift procedure, dental implant placement with dimension and insertion axis not adapted to patient’s clinical feature, foreign bodies due to perforation during endodontic treatment, overfilling of endodontic material beyond root apex, tooth extractions with or without pushing root fragment into the sinus cavity, orthognathic and cleft surgery procedures, and Le-fort osteotomies.
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Sinus communication with odontogenic cysts.
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Maxillary bone trauma.
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Neoplasms.
Classical odontogenic sinusitis is distinguished as bacterial and fungal sinusitis.
What Are the Symptoms of Odontogenic Sinusitis?
Odontogenic sinusitis has a non-specific presentation. Commonly observed symptoms are facial pain and pressure, postnasal drip, nasal congestion, unilateral purulent anterior rhinorrhea, foul smell or taste, and fatigue. There can be a reduction or loss of smell for up to 12 weeks due to Schneiderian membrane perforation from dentoalveolar pathology. Odontogenic sinusitis is a chronic condition, and the symptoms last for six months or more. The first manifestation of odontogenic sinusitis is nasal obstruction, but dental pain is often absent.
Sometimes, acute odontogenic sinusitis develops, along with infectious spread to orbit, intracranium, or bony structures.
How Is Odontogenic Sinusitis Diagnosed?
Individuals with suspected odontogenic sinusitis must undergo mouth and nose examination. Suspicion for odontogenic sinusitis occurs in features like unilateral maxillary sinus opacification and maxillary dental pathology on computed tomography, unilateral middle meatal purulence on nasal endoscopy, foul smell, and odontogenic bacteria in sinus culture.
Nasal endoscopy is a helpful tool for odontogenic sinusitis diagnosis. The tool helps confirm odontogenic sinusitis by assessing middle meatal purulence, edema, or polyps. Radiographic imaging is an essential diagnostic tool for the management of odontogenic sinusitis. Periapical and panoramic radiography helps visualize tooth roots but limits the correct visualization of multi-rooted teeth.
CT scans help plan surgical intervention in confirmed cases of odontogenic sinusitis as they provide a detailed view of paranasal sinus anatomy and help detect sino-nasal inflammation. CBCT helps determine maxillary floor thickness and the presence of sinus disease before implant placement.
How Is Odontogenic Sinusitis Treated?
Odontogenic sinusitis requires a multidisciplinary approach involving an ENT (ear, nose, and throat) specialist and a Maxillofacial surgeon to determine risks, benefits, and the timing of dental and sinus surgical interventions. Treatment of odontogenic sinusitis is complex, and each individual is treated based on etiology, clinical symptoms, and radiological features.
Medical therapy is the first line of treatment. It consists of at least two cycles of oral antibiotic treatment and nasal irrigation. Commonly used antibiotics are penicillin, but cephalosporins and fluoroquinolones can be used. The main aim of medical therapy is to alleviate symptoms while waiting for surgical treatment. However, in 15 to 20 percent of cases, odontogenic sinusitis resolves after two to three cycles. However, in most cases, antibiotics are unsuccessful in curing odontogenic sinusitis.
When medical therapy fails, surgical treatment cures odontogenic sinusitis. Before surgical treatment, the underlying dental pathology is treated with a root canal, apicoectomy, or tooth extraction. The surgical approach helps remove underlying pathology, allows drainage and ventilation of the sinus, and prevents disease recurrence. Depending on oral etiology and maxillary sinus floor condition, functional endoscopic sinus surgery (FESS) and oroantral fistula closure are used as treatment. Functional endoscopy helps eliminate infection through excision and aids in the removal of teeth, cysts, and dental materials. It also aids in sinus drainage and ventilation. A small oroantral fistula closes without intervention, but a larger or persistent fistula is closed with a buccal flap.
Dental implant-related odontogenic sinusitis is treated with primary endoscopic sinus surgery without needing implant removal. When an individual develops peri implantitis or mobile implants, the removal of implants becomes necessary.
Successful treatment of odontogenic sinusitis involves a combination of medical treatment, dental surgery, and FESS. When dental and sinus pathology are addressed, symptoms are resolved in 90 to 100 percent of cases.
What Are the Complications of Odontogenic Sinusitis?
Patients suffering from chronic odontogenic sinusitis have low quality of life. If left untreated, odontogenic sinusitis causes severe complications, such as the infection extending to the cranial structure or orbital cavity.
Conclusion
Odontogenic sinusitis is common in older age groups. However, the condition remains undiagnosed due to its non-specific symptoms. A multidisciplinary approach is needed for the proper diagnosis and treatment of odontogenic sinusitis. The treatment for the condition is complex and includes medical, surgical, and treatment of underlying pathology.
