1.5
Maxillary Sinusitis of Endodontic Origin
Maria Lessani and Shalini Kanagasingam
Objectives
Periapical infections involving the maxillary sinus are frequently undetected by both dental and medical professionals, due to the varied clinical and radiographic presentation. At the end of this case, the reader should be able to accurately diagnose and gain an understanding of the management of maxillary sinusitis of endodontic origin (MSEO), including the indications for referral to the Ear, Nose and Throat (ENT) specialist.
Introduction
The patient was a female aged 58 with history of sinusitis on and off for many years. She had seen ENT specialists on a few occasions and had been prescribed various antibiotics, steroids, and sinus washes, which did not completely resolve her symptoms. The patient reported that over the years she had learnt to live with one side of her nose feeling more or less blocked and heavy. She had not been seen by ENT for the past three years.
Chief Complaint
The patient reported a heavy feeling from the right sinus region and no symptoms from the teeth. There was no discomfort on biting and no sensitivity to hot or cold drinks.
Medical History
Unremarkable.
Dental History
The patient was a regular attender at her dentist and hygienist. The UR7 had been previously root canal treated over 20 years ago.
Clinical Examination
Extraoral examination revealed slight tenderness to palpation around the upper border of the masseter muscle on the right side and was otherwise unremarkable. Intraoral examination revealed a moderately restored dentition. Oral hygiene was good and generalised periodontal bone loss of about 30% was noted.
The UR7 was restored with a gold onlay and the UR6 had a disto‐occlusal composite restoration. The margins were sound and there was generalised recession noted around these teeth. The teeth were not tender to percussion or palpation.
Can we pulp test teeth with existing crowns?
Cold tests using certain refrigerant sprays (at temperatures as low as −50 °C) can penetrate through the restorations and elicit a response from a vital tooth. Hence, in this case Endo‐Ice was utilised, which provoked a positive response from the UR6 and no response from the UR7.
What did the radiograph reveal about the upper left molar region?
The periapical radiograph (Figure 1.5.1a) revealed:
- 30% horizontal bone loss.
- UR7 had an occlusal restoration that extended into its pulp chamber. UR7 has been inadequately filled with single cone gutta‐percha cones in the mesio‐buccal and disto‐buccal canals with multiple voids noted. The palatal canal does not appear to have been obturated. External inflammatory apical resorption was seen on the disto‐buccal, mesio‐buccal and palatal roots. The presence of periapical lesions could not be ascertained.
- UR6 had a disto‐occlusal restoration with intact margins and intact and uniform periodontal ligament space.
- The presence of the low‐lying maxillary sinus floor was noted.
Diagnosis and Treatment Planning
What was the diagnosis?
The provisional diagnosis was previously root treated with asymptomatic apical periodontitis associated with the UR7. The presence of periapical lesions could not be ascertained from the periapical radiograph. A discussion was carried out with the patient and a small field‐of‐view (40 × 40 mm) cone beam computed tomography (CBCT) was carried out in order to accurately visualise the apices of the maxillary posterior teeth and their relationship to the maxillary sinus.
What did the CBCT scan reveal?
The CBCT scan was reported on by a radiologist, who identified dehiscence of the floor of the maxillary sinus and the presence of sclerosing osteitis associated with the root apices of the UR7. Periapical lesions were associated with the mesio‐buccal, disto‐buccal, and palatal root apices. External inflammatory root resorption was noted on all three root apices. The partially visualised maxillary sinus was fully opacified and the patient was advised that an ENT opinion may be sought after endodontic intervention. There was an untreated mesio‐buccal canal. (Figure 1.5.1b–d).
What were the potential treatment options for this patient?
- No treatment
- Root canal retreatment (non‐surgical)
- Surgical retreatment
- Extraction
The CBCT report was discussed with the patient and she was made aware of the need for the ENT referral on completion of dental treatment.
Stay updated, free dental videos. Join our Telegram channel
VIDEdental - Online dental courses
