Rhinosinusitis and Endodontic Disease.ppt

About rhinosinusitis and endodontic disease

2. Rhinosinusitis and Endodontic Disease
Dr. Neda Naghavi

3. THE PARANASAL SINUSES
Dr. Neda Naghavi

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6. Thesinusesarelinedwithamembraneof
ciliatedandnonciliatedpseudostratified
columnarepitheliumthatiscontinuouswith
thenasalcavities.
The largest of the paranasal sinuses and most
prone to infection are the maxillary sinuses.
Dr. Neda Naghavi

7. Anatomy and Function
Dr. Neda Naghavi

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Anatomy
Of Maxillary Sinus

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10. Rhinosinusitis:
Etiology
Dr. Neda Naghavi

11. Thesinusostiaareconsideredtobetheprimaryfocalpointforsinus
disease,withobstructionbeingthemajorpathophysiologicfactorin
rhinosinusitis.
Sinusobstructioniscommonlycausedbyinflammatoryedemaofthe
liningmucosausuallyinresponsetoavirus,allergenorbacteria.
mucosausuallyinresponsetoavirus,allergenorbacteria.Ostial
blockagecanalsooccurfromananatomicobstructionsuchasaseptal
deviationorpolyp,oraforeignbodyobstructionsuchasdriedmucous.
Dr. Neda Naghavi

12. Rhinosinusitis:Symptoms
•nasal congestion
•facial pain and pressure
•purulent rhinorrhea
•cough
•headache
•fever and fatigue
•pain in the maxillary posterior teeth
Dr. Neda Naghavi

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14. Rhinosinusitis: Diagnosis
•Clinical examination
•Patient’s history
•Physical signs and symptoms
•Radiography
Dr. Neda Naghavi

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16. Rhinosinusitis. Coronal CT image shows fully obstructed right (R) maxillary,
ethmoid, and frontal sinuses, as well as mucosal thickening on the floor of the left
maxillary sinus.
Dr. Neda Naghavi

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18. Non-surgical Treatment
•Acute sinusitis
–Antibiotics –ten days to three weeks
–Nasal steroids –six to eight weeks
–Nasal saline irrigations –six to eight weeks
–Mucocilia may take up to four to six weeks to
resume normal function
–CT scan of sinuses if indicated
–Optional:
•Nasal spray decongestants –three days only
•Short course of oral steroids
–Surgery if indicated
Dr. Neda Naghavi

19. Distinguishing Differences Between
Symptoms Of Odontalgia And Sinus Pain
Dr. Neda Naghavi

20. Maxillary sinuses: Nerve Supply
Dr. Neda Naghavi

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22. Distinguishing Differences Between Symptoms
Of Odontalgia And Sinus Pain
•Proper diagnosis always starts with a complete medical and dental history
•Clinical examinations
•Radiography
Dr. Neda Naghavi

23. Distinguishing Differences Between Symptoms
Of
Odontalgia And Sinus Pain
•Do you have chronic allergies, a current cold, congestion, nasal
drainage, or a history of sinus infections or problems?
•Maxillary sinusitis:
–dull aching pain that is difficult to pinpoint or localize to a single tooth.
–feel pressure in cheeks and below eyes
–Erythema
–Positional changes can cause increased pain
–all teeth proximate to the sinus floor test positive to percussion
•pain of pulpal origin:
-more easily localized
-unchanged with variations in position
-only the specific offending tooth is percussion sensitive
-The key diagnostic test: thermal pulp sensibility response
Dr. Neda Naghavi

24. Maxillary Sinusitis Of Dental Origin
(MSDO)
Dr. Neda Naghavi

25. Types of odontogenic pathology
Dr. Neda Naghavi

26. Endodontic pathosisaffects the maxillary
sinus tissues in varying degrees:
periostitis
mucositis
sinusitis
Dr. Neda Naghavi

27. Periapical Osteoperiostitis
•Inflammatoryexudatefromapical
periodontitis,adjacenttothe
maxillarysinus,canpenetratethe
antralcortexandsubsequently
detachandlifttheperiosteum,
displacingitintothesinus,and
inducingperiostitis.
•Whenirritatedbyinflammatory
stimuli,thecambiumlayercontains
progenitorcellsthatdevelopinto
osteoblastsandbegintoproduce
newbone
Dr. Neda Naghavi

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29. Periapical Mucositis
•Ifperiradicularinflammationpenetrates,
orperforates,theantralcortexand
associatedperiosteum,alocalized
mucosaltissueresponsecandevelopin
thesinus.
•Thislocalizedinflammationand
swellingofthesinusmucosal
membranepresentsasaradiopaque
soft-tissueexpansioncalledaperiapical
mucositis.
Dr. Neda Naghavi

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32. Odontogenic Rhinosinusitis
•Sinusinflammatoryresponsetoadental
infectionmayremainlocalizedtothefloor
ofthemaxillarysinusintheformofan
osteoperiostitisand/or mucositis,
however,inprogressedcases,apartialor
fullobstructionofthemaxillarysinuscan
develop.
•Thereportedfrequencyofodontogenic
rhinosinusitisvariesconsiderably,
between4.6%and47%ofallsinus
infections.
•Oneofthechallengesindiagnosing
odontogenicrhinosinusitisisthatpatients
oftenhaveprimarysymptomsofmaxillary
sinusitis,yetarerarelyabletolocalize
paintoaspecifictoothorsenseany
dentalpainatall.
Dr. Neda Naghavi

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35. Diagnosing a possible dental etiology in a
patient with rhinosinusitis
•Any pulpal necrosis and periapical disease
Evaluate all previous endodontic treatment
periapical or panoramic radiographs
Radiographic evaluations
Sinus CT or CBCT imaging
Dr. Neda Naghavi

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Patient Symptoms Diagnosing MSEO can be challenging.
Experience a wide variation of dental and sinonasal symptoms
including no symptoms.
Typical endodontic symptoms are often not present with MSEO.
Thermal pain is usually absent because source teeth for MSEO are
most often necrotic or have failing endodontic therapy.
Percussion tenderness is typically absent in MSEO because periapical
infection is essentially draining into the sinus, eliminating pressure.
For this same reason, swelling or intraoral sinus tracts rarely form.
Diagnosing a possible dental etiology in a
patient with rhinosinusitis

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often experience common sinonasal symptoms, which include congestion,
rhinorrhea, retrorhinorrhea, facial pain, and foul odor.
sinonasalsymptomsandwithoutlocalizeddentalpainwilltypicallyfirst
seekcarefromtheirprimarycarephysicianorENTspecialistwhomay
misdiagnoseandtreatMSEOasaprimarysinusinfectionsinceadental
sourceisoftenoverlookedduringroutineENTexaminations.
Current ENT clinical guidelines for the medical management of
rhinosinusitis offer no guidance in this area, making no mention of dental
infections as a potential cause of sinusitis.
For physicians and ENT specialists, findings that should raise the suspicion
of MSEO are a history of repeated episodes of unilateral maxillary sinus
infections, particularly when associated with a patent sinus ostium or
previously unsuccessful sinus surgery.
Diagnosing a possible dental etiology in a
patient with rhinosinusitis

38. Treatment
Ifasinusinfectionisdeterminedtobecausedbyaperiapical
infection,endodontictherapy,orextraction,shouldprovide
fullresolutionofthedisease.However,clinicaland
radiologicalfollow-upisessentialasconcomitant
managementoftheassociatedrhinosinusitisbyanENTand
maybenecessaryinsomeadvancedcases.
Dr. Neda Naghavi

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42. SURGICAL TREATMENT
•Open sinus procedures
–Caldwell Luc
–Trephination
–Frontal sinus osteoplastic flap
•Balloon sinuplasty
•Functional endoscopic sinus surgery (FESS)
Dr. Neda Naghavi

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•This32-year-oldfemalehadbeensufferingwithrightmaxillarysinusinfectionsfor7years
andhadbeenonmultipleroundsofantibioticsandsteroids.Shehadalsoundergonetwo
sinussurgeries,includingamiddlemeatalantrostomyandlateraCaldwell-Lucsurgeryto
removewhattheradiologistdiagnosedasa“polyp”ontherightmaxillarysinusfloor,butthe
“polyp”soonreappeared,asdidhersinusinfectionandsymptoms.AnENTspecialistsent
hertoherdentisttoruleoutadentalinfectionandwastoldthat“thetoothhadarootcanal
treatmentdone10yearsagoandtheX-raylookedgood.”Shelatersawanendodontist,
whereacarefulexaminationandconebeamCTscanrevealedanuntreatedmesialcanal
andalargeperiapicalosteoperiostitislesionoverthebuccalroots,correspondingtothe
recurring“polyp”notedbytheradiologist.Followingendodonticretreatmentthepatient
quicklyexperiencedcompleteresolutionofherlongstandingsinusinfectionandsymptoms
withnofurthersinustreatmentsoruseofantibiotics.ItisrecommendedthatENTphysicians
referpatientsthatpresentwithrecurrentandnonresolvingunilateralsinusinfectionstoan
endodontistforathoroughendodonticexaminationtoruleoutanodontogenicsource.

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