Maxillary

Sinusitis of
Endodontic
Origin
Fall 2018

ENDODONTICS:
Colleagues for Excellence
Published for the Dental Professional Community by the

aae.org/colleagues
 ENDODONTICS: Colleagues for Excellence

Endodontic infections that develop in maxillary posterior teeth can easily spread into the maxillary sinuses due to
their proximity to the antral floor. Typically, only a few millimeters of bone or less separates their root apices from
the antrum, and occasionally, no bony partition exists at all, with the roots apices in direct contact with sinus mucosal
tissue. (1,2)
The relationship between dental infections and sinus disease is well documented in the dental and medical literature
and was first referred to in 1943 as maxillary sinusitis of dental origin (MSDO). (3) Numerous investigators since have
discovered that this condition, also termed odontogenic sinusitis, is a prevalent and common disease process (4-19),
with sinus mucosal inflammation seen in 60-80% of patients with infections originating in the maxillary posterior
teeth. (4,5,6) The literature also indicates that dental infections may account for more than 40% of maxillary sinusitis
cases. (7-10)
Despite its high prevalence, odontogenic sinusitis frequently goes unrecognized by dentists, radiologists, and
otolaryngologists - Ear, Nose and Throat (ENT) specialists, with its sequelae often misdiagnosed as sinogenic sinusitis.
(10,15,16) Studies have shown that routine general dental examinations using periapical radiographs failed to
diagnose odontogenic sinusitis in as high as 86% of the cases. (12,15)
MSDO or odontogenic sinusitis is a broad term used to describe any degree of sinus infection and symptoms, caused
by multiple dental etiologies, including periodontal disease, endodontic disease, root fractures, dental implants, dental
extractions, oral-antral fistulae, and iatrogenic causes such as extruded dental materials, displaced teeth and foreign
bodies. (4,11,17-22) While these can all be odontogenic sources for sinusitis, it is important to distinguish these
etiologies from maxillary sinusitis of endodontic origin (MSEO), as they each have a different pathogenesis and require
markedly different clinical treatments. MSEO refers specifically to sinusitis caused by endodontic infection, excluding
sinusitis secondary to other dental etiologies.
Recognition of MSEO is important as failure to identify and properly manage the endodontic pathosis will result in
the persistence of sinus disease and the failure of medical sinus therapies. If left undiagnosed, patients often suffer
with chronic sinus infections, ineffectual antibiotic regimens, and may even undergo multiple sinus surgeries, never
realizing that an endodontic infection is the source. MSEO also has the potential to advance to more serious or even
life-threatening cranio-facial infections. In these severe and rare cases, endodontic infection can spread via the
maxillary sinus causing orbital cellulitis, blindness, meningitis, subdural empyema, brain abscess and life-threatening
cavernous sinus thrombosis. (6,23-26)

Diagnosis
1. Patient Symptoms
Diagnosing MSEO can be challenging because patients with this condition 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.
Patients with MSEO will often experience common sinonasal symptoms, which include congestion, rhinorrhea,
retrorhinorrhea, facial pain, and foul odor. (27,28) Patients with sinonasal symptoms and without localized dental
pain will typically first seek care from their primary care physician or ENT specialist who may misdiagnose and
treat MSEO as a primary sinus infection since a dental source is often overlooked during routine ENT examinations.
(10,15,28) 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. (29) 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. (16) (See
Case Feature)
Dentists should always keep sinonasal disease in mind when examining any dental infection in the posterior maxilla
and rely on their local endodontists who work closely with ENT specialists to diagnose MSEO and distinguish it from
sinogenic sinusitis. Dentists should not attempt to make a final diagnosis of non-odontogenic sinus disease, nor offer
treatment that is outside the scope of dental practice.

2. Radiographic Examination
While periapical radiographs are the most widely used imaging modality in endodontics, the posterior maxilla
presents significant and unique interpretation challenges when using conventional 2D imaging. (30) Anatomic
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 Maxillary Sinusitis of Endodontic Origin

structures such as the zygoma, palatal process, maxillary sinus, and buccal cortical plate are often superimposed
onto the dental roots, obscuring or concealing periapical infection. Conventional periapical radiographs also do not
consistently reveal mucosal thickening or fluid in sinuses, which are of important diagnostic value in MSEO.
Limited field CBCT imaging has been shown to significantly improve the ability to detect odontogenic sources for
sinusitis. (31) In a study by Low et al. (32), CBCT revealed 34% more lesions than periapical radiography, as well as
significantly more expansion of lesions into the maxillary sinus, mucosal thickening, and untreated canals. Mucosal
changes associated with dental infections were found with a prevalence of 77%, compared to only 19% using
conventional radiographs.
Throughout the dentition, the dental roots are typically surrounded by alveolar bone, and endodontic disease
manifests radiographically as distinct periradicular radiolucent lesions or thickening of the periodontal ligament.
The radiographic appearance of endodontic disease on sinus tissues, however, is quite different. (33-36) Two unique
radiographic findings associated with periradicular inflammation of the sinus mucoperiosteum are periapical
osteoperiostitis and periapical mucositis. (34)

Periapical Osteoperiostitis (PAO)

The presence of apical periodontitis adjacent to the maxillary sinus cortical floor will often expand the sinus
periosteum, displace it upward into the sinus, and subsequently induce a periosteal reaction that continues to deposit
a thin layer of new bone on the inner periphery of the periosteum as it expands. This reactive osteogenesis, termed
periapical osteoperiostitis (PAO), forms a thin, hard-tissue dome on the sinus floor and presents on radiographs and
CT images as a radiopaque “halo” appearance. (34) (Fig 1) PAO lesions may or may not be symptomatic and may be
accompanied by varying degrees of adjacent mucosal edema and sinus fluid levels.

Periapical Mucositis (PAM)

Symptomatic or asymptomatic apical periodontitis adjacent to the antral mucosa will typically produce a localized
mucosal tissue edema termed periapical mucositis, which appears radiographically as a mucosal thickening or dome-
shaped soft tissue expansion in the floor of the sinus. (34) (Fig 2) Often there is no evident osseous destruction or PAO
halo making PAM more difficult to recognize radiographically as having an endodontic source. Mucosal edema on the
sinus floor and particularly dome-shaped mucosal swellings directly over dental root apices should raise the suspicion
of a dental etiology. Clinicians should be mindful, however, that PAM may have a similar appearance to mucous
retention cysts, antral polyps, mucosal thickening caused by periodontal disease, and sinogenic mucosal thickening.
As with all endodontic diagnoses, a determination of etiology cannot be made based on radiographic examination
alone. Careful endodontic clinical examination of pulpal status is imperative to distinguish PAM from other mucosal
abnormalities.

Maxillary Sinusitis of Endodontic Origin Sinus Obstruction

Sinus obstructions cannot be determined with periapical radiographs but are easily seen on sinus CT imaging. Even
with CT, however, the obstruction may be difficult to recognize as having an endodontic etiology. (Fig 3) Careful
radiographic examination for evidence of PAO is helpful in making this determination but, as seen with PAM lesions,
periapical radiolucencies or osseous changes do not always exist. A history of unilateral sinus obstruction, particularly
if recurrent and/or associated with a patent ostium is a strong indicator for possible MSEO. Clinical endodontic
examination, however, is essential to confirm or rule out a potential endodontic source. (16)

3. Clinical Examination
A thorough clinical endodontic examination is essential for diagnosing or ruling out MSEO. When diagnosing a
possible endodontic etiology in patients with sinusitis, the clinician must look carefully for any teeth with pulpal
necrosis and evaluate all prior endodontic treatments for possible failure in the suspected quadrant. Because MSEO
is a bacterial disease, typically, only teeth with an infected necrotic pulp or failing endodontic treatment will cause
significant sinonasal disease or sinonasal symptoms. (36) When examining maxillary posterior teeth with existing
root canal treatment, one must carefully examine for any untreated or sub-optimally filled canals, inadequate core
restorations, or leaking coronal restorations that may provide evidence of endodontic failure and a bacterial source for
MSEO. (37)

Treatment of Maxillary Sinusitis of Endodontic Origin

The objectives for treatment of MSEO are removal of the pathogenic microorganisms, their by-products, and pulpal
debris from the infected root canal system that are causing the sinus infection and preventing reinfection. Appropriate
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 ENDODONTICS: Colleagues for Excellence

A B C

Fig. 1. Periapical osteoperiostitis. A. Periapical radiograph of a right maxillary first molar with periapical osteoperiostitis or “halo” lesions over
the MB and P root apices. Clinical examination confirmed pulpal necrosis. B. Coronal and C. sagittal CBCT images of the same necrotic molar
displaying periapical osteoperiostitis (arrows) with associated mucosal edema of the right maxillary sinus.

A B

C D

Fig. 2. Periapical mucositis. A. Periapical radiograph of a failing root canal therapy of tooth #4. B. CBCT reveals an untreated lingual canal tooth #4
with a periapical abscess perforating the sinus floor causing mucosal edema (arrows) in the right maxillary sinus. C. Periapical radiograph following
endodontic treatment of tooth #4. D. 6-month post-operative CBCT showing osseous healing and resolution of the periapical mucositis.

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 Maxillary Sinusitis of Endodontic Origin

A B C

D E F

Fig. 3. MSEO sinus obstruction. A. Coronal CT image of a fully obstructed left maxillary sinus (arrow). The patient had experienced recurrent
left maxillary sinus infections and nasal congestion for several years with no resolution despite multiple antibiotic regimens and adjunctive sinus
treatments. B. 4-month postoperative coronal CT image showing full resolution of the maxillary rhinosinusitis following endodontic therapy of
the necrotic first and second maxillary molars. No other sinus treatment was performed, nor antibiotics administered. C. Pre-op and D. 4-month
postoperative sagittal CT images. E. Pre-op Coronal CBCT. F. One-year recall coronal CBCT showing osseous healing and full resolution of sinus
infection.

treatment options include non-surgical root canal therapy, periradicular surgery when indicated, intentional
replantation, or extraction of the infected tooth. Patients should be informed of all treatment options and the
prognosis of each option, to include risks of no treatment.
Clinicians performing endodontic treatment in the posterior maxillary dentition should have extensive knowledge
of maxillary root canal anatomy, the necessary armamentarium, and requisite clinical skill considering the anatomic
complexities and challenges in this region. Maxillary molars typically have the most complex anatomy in the
dentition, and inadequate root canal treatment, particularly missed mesio-buccal canal systems, is a common cause
of endodontic failure in maxillary molars. (38-42) The close anatomic proximity of maxillary molar root apices to the
floor of the maxillary sinus can lead to persistent MSEO if canals are left untreated or root canal failure occurs in these
teeth. Endodontists are specialists in managing complex root canal systems and should be heavily relied upon for root
canal treatment of maxillary molars.
Use of systemic antibiotics to manage MSEO should follow the guidelines set forth in the AAE Guidance on the Use of
Systemic Antibiotics in Endodontics. (43) Apart from spreading infections, antibiotic therapy is unwarranted in the
treatment of MSEO and ineffective as a definitive solution. While antibiotic therapy may offer temporary relief of
symptoms by improving sinus clearing, their sole use is inappropriate without definitive debridement and disinfection
of the root canal system.
Similarly, surgical intervention of the maxillary sinus that is focused strictly on removing diseased sinus tissue
and establishing drainage is inadequate if the endodontic component is neglected. Although these procedures are
performed with the goal of re-establishing sinus aeration and drainage, and may provide relief of some symptoms,
it is well documented that neglecting the dental etiology and focusing only on medical and surgical therapies of the
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 ENDODONTICS: Colleagues for Excellence

ostiomeatal complex (OMC) will not resolve MSEO. (10,44-46)

The dental literature provides numerous case reports showing full resolution of MSEO following endodontic treatment.
(4,13,14,15,47-53) It should be noted, however, that endodontic treatment alone may not resolve all cases of MSEO,
therefore clinical and radiological follow-up is essential as concomitant management of the associated rhinosinusitis by an
ENT specialist may be necessary in some cases. (10,28,50,51,54-57) A collaborative effort and open referral relationship
between general dentists, endodontists, and ENT surgeons is essential to achieve the best outcomes for patients with MSEO.

Conclusion
MSEO is fundamentally an endodontic infection manifesting in the maxillary sinus and is a common, yet underappreciated
disease process. Symptoms and radiographic signs of MSEO often mimic sinogenic sinusitis leading patients to first seek
care from their primary care physician or ENT specialist, whose treatment will not resolve MSEO if the endodontic source
is overlooked. MSEO is also frequently overlooked in general dental practice due to a lack of dental symptoms and an
obscured or atypical radiographic presentation. The expanded availability of in-office cone-beam computed tomography has
increased clinicians’ recognition and ability to diagnose MSEO. Clinical endodontic examination, however, remains essential
for correct diagnosis. Endodontists are uniquely trained and equipped to diagnose and properly manage endodontic disease
that manifests in the maxillary sinus. Solid referral relationships and improved communication between general dentists,
endodontic specialists and ENT surgeons are critical to providing appropriate patient care when managing MSEO.

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45. Kulacz R., Fishman G, Levine H. An unsuccessful sinus surgery caused by dental involvement within the floor of the maxillary sinus. Op Techniques
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53. Nurbakhsh B, Friedman S, Kulkarni GV, et al. Resolution of maxillary sinus mucositis after endodontic treatment of maxillary teeth with apical
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 Endodontic Case Study
This feature in Colleagues for Excellence highlights endodontic treatment that demonstrates the benefits of
treatment planning and partnership with an endodontist to improve patient outcomes.

This 32-year-old female had been suffering with right maxillary sinus infections for 7 years and had been on multiple rounds of antibiotics
and steroids. She had also undergone two sinus surgeries, including a middle meatal antrostomy and later a Caldwell-Luc surgery to remove
what the radiologist diagnosed as a “polyp” on the right maxillary sinus floor, but the “polyp” soon reappeared, as did her sinus infection and
symptoms. An ENT specialist sent her to her dentist to rule out a dental infection and was told that “the tooth had a root canal treatment done 10
years ago and the X-ray looked good.” She later saw an endodontist, where a careful examination and cone beam CT scan revealed an untreated
mesial canal and a large periapical osteoperiostitis lesion over the buccal roots, corresponding to the recurring “polyp” noted by the radiologist.
Following endodontic retreatment the patient quickly experienced complete resolution of her longstanding sinus infection and symptoms with
no further sinus treatments or use of antibiotics. It is recommended that ENT physicians refer patients that present with recurrent and non-
resolving unilateral sinus infections to an endodontist for a thorough
endodontic examination to rule out an odontogenic source. It is also A. B.
recommended that general dentists refer complex maxillary molars
to an endodontist for careful diagnosis and treatment to ensure the
best possible outcome as these teeth have a high potential to be a
source for maxillary sinusitis of endodontic origin.

A. Coronal sinus CT showing right maxillary sinusitis and a periapical osteoperiostitis Pre-operative periapical
lesion on the floor the right maxillary sinus. B. Coronal CT reveals the the middle- radiograph.
meatal antrostomy and the Caldwell-Luc osteotomy to remove the “polyp.”

Pre-op sagittal and coronal CBCT images Post-operative Six-month recall CBCT image showing
showing the periapical osteoperiostitis radiograph following progression of osseous healing, re-
lesion and mucositis over the buccal root retreatment of tooth #3. establishment of sinus floor, and resolution
apices of tooth #3. of the mucositis. Further recall is planned
to confirm completion of osseous healing.

The AAE wishes to thank Dr. Roderick W. Tataryn for authoring this issue of the newsletter, as well the following article
reviewers: Drs. Mark Desrosiers, Alan Gluskin, Patrick Taylor, Avina Paranjpe, and Ryan Brandtz.
Exclusive Online Bonus Materials: Maxillary Sinusitis of Endodontic Origin
This issue of the Colleagues newsletter is available online at aae.org/colleagues with the following bonus material:
• AAE Position Statement: Maxillary Sinusitis of Endodontic Origin. 2018

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