Maxillary Sinusitis 11/12/18
November 12, 2018
There exists a strong relationship between dental infections and sinus disease; this was first described in 1943 as maxillary sinusitis of dental origin (MSDO). In fact, it has been reported in the literature that dental infections may account for more than 40% of maxillary sinusitis cases.
MSDO is a broad term which may be caused by many dental etiologies, including periodontal disease, endodontic disease, root fractures, implants, and iatrogenic causes such as dental extractions and over- extruded dental materials. If the etiology is not treated, your patient may suffer from chronic sinusitis infections, ineffective antibiotic regimens, and may see multiple MDs for extensive sinus surgeries.
For the purpose of today’s blog, I will refer to such sinusitis as Maxillary Sinusitis of Endodontic Origin (MSEO). In order to determine if a patient’s perceived “sinus infection” is from endodontic origin, a complete exam must be performed. This includes:
a. Typical endodontic symptoms (ie, hot/cold sensitivity, spontaneous pain) are not often present with MSEO. Usually these teeth are necrotic or present with post- treatment endodontic pathosis (failing root canal).
b. These patients often present with common sinonasal symptoms: UNILATERAL congestion, rhinorrhea, facial pain and/or foul odor.
c.Therefore it is important to pay attention to your patient’s symptoms, distinguish between UNILATERAL or BILATERAL pain, and perform proper vitality testing(s) when indicated.
2. Radiographic Examination
a. Using conventional PA films may be difficult to interpret due to anatomical structures (zygoma, palatal process, maxillary sinus, and buccal cortical plate) which may be superimposed over the roots and apices of the suspect offending maxillary tooth.
b. CBCT imaging has been shown to significantly improve the ability to detect sources of MSE
i. In a study published within the Journal of Endodontics, Low et al. showed that CBCT yielded 34% increase in the detections of apical radiolucent patterns when compared to PA films
ii. CBCT may be able to detect Periapical Mucositis- which is the formation of a “cloudy” expansion into the sinus. This is mucosal edema and coincides with the visible root apices near the sinus.
3. Treatment of MSEO
a. Removal of the irritants which are the cause
i. Root canal therapy, Non- surgical retreatment, surgical retreatment, or extraction
Attached are CBCT images of a patient that I saw this week who presented with a perceived “sinus infection.” She had seen her primary care provider multiple times with a unilateral “pressure headache”, was prescribed antibiotics, and reported that “it never went away.” I diagnosed tooth #3 with a necrotic pulp with symptomatic apical periodontitis, performed RCT, and follow up with the patient provided that her “headaches” went away.
The take home message: Diagnosis is key and many times a perceived “sinus infection” may be dental after all!
Below, from left to right: Sagittal, Coronal, and Axial images from CBCT. Note the proximity of the apices of tooth #3 to the sinus cavity. In addition, note the “cloudy” appearance within the sinus (PAM). This may explain the patient’s unilateral “pressure headaches” and symptomology.
If you wish to discuss more, please call or email me anytime!
Until next week-
Proper Patient Follow-up Upon Root Canal Completion 11/05/18
November 5, 2018
Dear Friends and Colleagues:
Words cannot describe how appreciative I am of your support during our transition into Cornerstone Endodontics! My family and I are absolutely thrilled to be a part of the Lincoln dental community.
If you have not visited our newly remodeled website, I strongly encourage you to do so. Karla and our office manager Jenn, worked many hours to design the site and it is now available for you and your patients to use. You can access it here: https://www.cornerstoneendo.com/welcome.html
In addition to assisting your patients, I would like to spend time with you each week via my personal “blog”- which can be accessed through our website and Facebook page. The blog will include topics of interest and some of my personal thoughts, which will be shared each Monday. Also included will be a “case of the week” that’s performed by either Karla, Jeri, or myself.
Should you have any topics of interest, you are welcome to call or send an email my way at firstname.lastname@example.org
Without further adieu, a question I generally get asked by patients once treatment is completed is
“When do I see my dentist next and does this tooth crown need a crown?”
When I answer this question, I typically like to back my response with literature and evidence based dentistry. Your patient will be told to have the permanent seal placed over the gutta percha within 30 days after RCT completion. Why 30 days? Khyat et al., published in the Journal of Endodontics, showed the bacteria which live in saliva can fully penetrate the obturated root canal system in under this time frame. While we like to pack a temporary restoration into the access cavity, we feel that it is in your patients’ best interest to have the access permanently restored within 30 days after completion of treatment, albeit the tooth may still be tender.
Posterior molars which have received endodontic therapy are typically advised to have cusp coverage with a crown restoration. Recent studies show that there is a correlation among the survival rate of endodontically treated teeth when restored with a crown. Anterior teeth with a conservative access cavity can be restored with a bonded restoration.
As you know- I’m always here to help you and your patients! Please reach out to me anytime at the office or via email: email@example.com
Until next time-