How I do it : an Asian way

Current
pathophysiology
and
odontogenic maxillary sinusitis

management

of

Kiminori Sato, Shun-ichi Chitose, and Hirohito Umeno

Department of Otolaryngology-Head and Neck Surgery, Kurume University School of Medicine, Kurume, Japan
Corresponding authors: Kiminori Sato E-mail:kimisato@oct-net.ne.jp

Summary

Background and Objectives: A dental caries of the maxilla accompanied with unilateral opacification of the
maxillary antrum was once a common type of odontogenic maxillary sinusitis (OMS), however, current
pathophysiology and management of OMS have changed. The current pathophysiology and management of the
OMS are reviewed.
Data sources: Summary of our latest results.
Study selections: Review.
Results and conclusion: Regarding the etiology, it has become rare that untreated dental caries cause OMS.
Instead, many causative teeth of OMS have already received dental treatment, especially root canal treatment,
that is, endodontics. The root canals of most of these teeth are incompletely filled with a filling material. The
pathological findings for the causative teeth show pulpal necrosis and apical lesions after the root canal
treatment. Apical lesions in incorrectly treated teeth cause ostitis and OMS. Consequently, the cause of OMS
should be examined, even if a dental procedure has been performed. Additionally, complications such as
maxillary sinusitis associated with dental implantation have also increased.
Regarding the diagnosis, a conebeam CT is far more successful in identifying OMS. Evaluation of all
patients with persistent chronic rhinosinusitis should include inspection of the maxillary teeth using conebeam
CT scan for evidence of periapical or marginal lucencies.
Regarding treatment, endoscopic sinus surgery is highly indicated for surgery-requiring intractable OMS. If
the ventilation and drainage of the maxillary sinus is successfully restored after surgery, apical lesions and
odontogenic infection will lead to silent chronic lesions using only antibiotic therapy and most causative teeth
can be preserved.
Keywords: odontogenic maxillary sinusitis, pathophysiology, management, endodontics, dental implantation,
endoscopic sinus surgery

Introduction

Odontogenic maxillary sinusitis (OMS) was one of

the earliest recognized causes of rhinosinusitis. For well
over 100 years, it has been well known that maxillary
dental infection can cause sinusitis. Conventionally, a
dental caries of the maxilla accompanied with unilateral
opacification of the maxillary antrum was once a
common type of OMS. However, current
pathophysiology and management of OMS have
changed.1
Regarding the etiology of OMS, it has become rare
for untreated dental caries to cause OMS. Instead, most

teeth which cause OMS have already received dental

treatment, especially root canal treatment, that is
endodontics.1,2,3 Consequently, the cause of OMS
should always be questioned, even if a dental
procedure has been performed. Evaluation of all
patients with persistent chronic rhinosinusitis should
include inspection of the maxillary teeth with a
conebeam CT scan for evidence of periapical or
marginal lucencies. Recently, dental implantation is
routinely performed in many dental institutions.
Consequently, complications such as maxillary sinusitis

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Current odontogenic maxillary sinusitis

A.

B.

Figure 1. Conebeam CT (3D Accuitomo, MORITA Mfg,

Corp., Japan)

associated with dental implant surgery are also

increased.4,5
Regarding the diagnosis of OMS, conebeam CT
(Figure 1) is extremely useful in the diagnosis of OMS.6
Plain dental films and dental evaluations frequently fail to
detect maxillary dental infection that could cause OMS.
The relationship between causative teeth and the
maxillary sinus can be observed and OMS can be
accurately diagnosed. In addition to the accurate
diagnosis of apical lesions, the maxilla, the maxillary
sinus, the periodontal ligament space, the lamina dura,
the pulp cavity, the root canal, and the canal-treated
root of causative teeth can be observed as well as the
presence or absence of apical periodontitis, alveolar
ostitis, and marginal periodontitis.
Metal artifacts are minimized, making conebeam CT
useful in the diagnosis of periodontal tissue and
causative teeth, including root-canal-treated and crownrestored teeth.
Regarding the treatment of OMS, endoscopic sinus
surgery is highly indicated for intractable OMS requiring
surgery.1,2 On the other hand, there is no consensus for
the management of causative teeth of OMS.1,2,7
Additionally, there is no consensus for the management
of implant body and filling materials used in maxillary
sinus augmentation surgery when a dental implant
causes intractable maxillary sinusitis 4,5.

Figure 2. Histoanatomy around the tooth1

A: Vessels are abundant in the periodontal membrane,
and directly connected with alveolar bone marrow.
B: Odontogenic inflammation in relation to the floor of
maxillary sinus (dotted line circle), maxillary sinus is at
risk of becoming inflamed.

The purpose of the present paper is to summarize

our latest results concerning the current
pathophysiology and management of OMS.
Current OMS pathophysiology
Vessels are abundant in the periodontal membrane,
and directly connected with alveolar bone marrow
(Figure 2A). Consequently, periapical and marginal
inflammations of the tooth are easily spread to the
alveolar bone via the periodontal membrane.1

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ASIAN RHINOLOGY JOURNAL 2015;2:48-60

Figure 3. Pathophysiology of OMS

Additionally, maxilla is a spongy bone consisting of

branching bony spicules (trabeculae) and bone
marrow.1 Consequently, inflammations are easily
spread.
When odontogenic inflammation is constantly
present at the floor of the maxillary sinus (Figure 2B), the
maxillary sinus is exposed to the potential danger of
inflammation. Triggers such as the common cold or a
dental treatment procedure will lead to OMS.1
Inflammation chains between dental lesions,
odontogenic infection and retardation factors influence
OMS. And a vicious circle of inflammation in the closed
sinus results in intractable maxillary sinusitis (Figure 3).1
It is very important to consider the OMS not as maxillary
sinusitis but as an odontogenic rhinosinusitis.1
Regarding the retardation factors on the cure of
sinusitis, i.e. mucociliary function, bacteria and virus
infection and occlusion of ostiomeatal complex,
combination of these factors cause inflammatory vicious
circle in the closed sinus and result in intractable OMS.1
Our report on histopathological study of OMS had
found that there were no decrease in the number of
ciliated cells, no hypertrophy of goblet cells, and the
secretions were not viscous (Figure 4).1 Consequently,
damage of the ciliated epithelium is not severe and
there is a possibility that the mucociliary function can
recover when the ventilation and drainage of the sinus is
successfully restored.1 As a result, the treatment

strategy should focus on how to manage two factors:

infection and occlusion of the ostiomeatal complex.1,2,7
Current OMS etiology
Current etiologies of the OMS1 are apical
periodontitis (either caused by dental caries or following
dental restoration, trauma and endoodontic
procedures), marginal periodontitis, dental treatment
(including dental implantation), maxillary cysts, foreign
bodies in maxillary sinus, oroantral perforation and
fistula, the distance between the root apex and the floor
of maxillary sinus and retardation factors influencing the
cure of maxillary sinusitis.
OMS following dental procedures are increasing.
The most common cause is apical lesions (periodontitis)
following root canal treatment (endodontics). Recently,
complications associated with implant surgery have also
increased. Table 1 shows the current OMS following
dental procedures.
OMS caused by dental caries (Figure 5A and 5B)1
Dental caries causes pulpitis and pulp necrosis in
the root canal. The pulp inflammation causes apical
lesions (apical periodontitis), which results in
odontogenic infection such as alveolar ostitis. When
odontogenic inflammation is constantly presented at the
maxillary sinus floor, the sinus is prone to possible
inflammation.1 Our data has shown that it was rare that
an untreated dental caries caused OMS. Most causative
teeth of OMS had already received dental treatment.1,2
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Current odontogenic maxillary sinusitis

Figure 4. Histopathology of mucosa in OMS shows that the damage of maxillary sinus ciliated epithelium is not
severe.1

OMS caused by dental endoodontics (Figure 6A and

6B)1,2
When the root canals of teeth are incompletely filled
with a filling material during endoodontics, insufficient
root canal treatment causes pulpitis and pulp necrosis in
root canal at the root apex. The pathological studies of
the causative teeth show pulpal necrosis and apical
lesions after the root canal treatment. The pulp
inflammation causes apical lesions (apical periodontitis),
consequently, odontogenic infection such as alveolar
ostitis occurs. When the odontogenic inflammation is
constantly present at the floor of the maxillary sinus, the
maxillary sinus is at risk of becoming inflamed.

OMS caused by dental restoration (Figure 7A and 7B)8

When dentists perform caries cutting, cavity
preparation, and inlay restoration, the pulp chamber and
dental pulp are never exposed. Why do pulpitis and
apical lesion occur following dental restoration? There
are dentinal tubules in the dentin. Even though the pulp
chamber and dental pulp are not exposed during dental
restoration, an apical lesion following pulpitis can occur
via dentinal tubules. Bacteria invade the dentinal tubules
by way of leakage between the cavity preparation and
inlay restoration.
The pulp inflammation causes an apical lesion
(apical periodontitis), odontogenic infection and
maxillary sinusitis.

Table 1. Current OMS following dental procedures

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ASIAN RHINOLOGY JOURNAL 2015;2:48-60

A.

B.

Figure 5. A. Pathophysiology of OMS caused by dental caries

B. OMS caused by dental caries1
Patient had canine caries. Conebeam CT showed apical lesion which caused maxillary sinusitis on the right side.

OMS caused by tooth fracture (Figure 8A and 8B)1,9

Trauma, biting pressure, and dental procedures are
the causes of tooth fracture. When the pulp is exposed
following tooth fracture, the pulp is infected. Even
though the pulp is not exposed, the pulp is injured at the
apical foramen. As a result, acute and chronic
periodontitis occur and become the cause of OMS.
OMS caused by foreign bodies in the maxilla and
maxillary sinus following dental procedures (Figure 9)1
Filling material used for the root canal treatment
(endoodontics) can become a foreign body in the
maxilla or maxillary sinus and causes maxillary sinusitis.
OMS caused by tooth extraction (Figure 10)1
One cause is that the surgical procedures for tooth
extraction cause odontogenic infections such as OMS.
Additionally, odontogenic infections, such as OMS, can

also be caused by oroantral perforation following tooth

extraction.
OMS caused by dental implantation (Figure 11, 12)1,3,4,5
Recently, dental implantation has begun to be
routinely performed in many dental institutions.
Consequently, complications such as maxillary sinusitis
associated with dental implant surgery have also
increased.
Implant surgery includes tooth extraction, maxillary
sinus augmentation, and implant placement.
Occasionally, an implant body migrates into the
maxillary sinus. There are two pathogenic mechanisms
underlying the development of maxillary sinusitis
following dental implantation. One is that the surgical
procedures for the placement of dental implants cause
odontogenic infections and maxillary sinusitis, while at
the same time, OMS can also be caused by chronic
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Current odontogenic maxillary sinusitis

A.

B.

Figure 6A. Pathophysiology of OMS following endodontics

Figure 6B. OMS following endodontics
The right second molar has undergone endodontics and coronal restoration. The conebeam CT shows apical lesion
following insufficient root canal treatment, which result in maxillary sinusitis on the same side.

inflammation of adjacent teeth, such as apical

periodontitis. (Figure 12)
Current OMS treatment
1) Management of intractable OMS and causative
teeth1,2,3,7,8
There is no consensus for the management of
causative teeth. When the causative tooth is extracted,
the inflammation chain between dental lesions and OMS

improves. However, other inflammation chains, such as

odontogenic infections and retardation factors still exist
(Figure 3). The worst situation for the patient is that
sinusitis is not cured even though the tooth has been
extracted.
As previously mentioned about the histopathological
findings of OMS, ciliated epithelium damage is not
severe, thus, the possibility that the mucociliary function
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ASIAN RHINOLOGY JOURNAL 2015;2:48-60

A.

B.

Figure 7A. Pathophysiology of OMS following dental restoration

Figure 7B. OMS following dental restoration8
The right first molar has undergone inlay restoration. The conebeam CT shows apical lesion following inlay
restoration and maxillary sinusitis on the same side.

can recover when the ventilation and drainage of the

sinus is successfully restored.
Regarding the retardation factors on the cure of OMS
(Figure 4), the treatment strategy is how to manage the
two factors: infections and occlusion of the ostiomeatal
complex.
It has been said that successful treatment of the
OMS firstly requires management of the odontogenic
source. However, the management of a previously
treated tooth, such as a root-canal-treated tooth, is
challenging. If the ventilation and drainage of the
maxillary sinus is successfully restored after endoscopic
sinus surgery, apical lesions and odontogenic infection
will lead to silent chronic lesions using only antibiotic

therapy and most causative teeth can be preserved.

That is the reason why endoscopic sinus surgery
preceding causative tooth extraction is highly indicated
for surgery-requiring intractable OMS.
2) Management of maxillary sinusitis caused by dental
implantation4,5
One of the controversies is that there is no
consensus for the management of implant body and
filling materials used in maxillary sinus augmentation
surgery when a dental implant causes intractable
maxillary sinusitis. Fortunately, implant body and filling
materials themselves do not have inflammation, so if the
ventilation and drainage of the maxillary sinus is
successfully restored after endoscopic sinus surgery,
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Current odontogenic maxillary sinusitis

Figure 8A. Pathophysiology of OMS caused by tooth fracture

Figure 8B. This patient complained of nasal symptoms after the second premolar had been extracted. The CT scan
shows maxillary sinusitis on the right side. The conebeam CT shows the tooth root fracture of the first molar. The
apical lesion caused by this fracture resulted in maxillary sinusitis. Probably, the tooth root was fractured when the
adjacent second premolar was extracted.

maxillary sinusitis can be cured (Figure 13). The

odontogenic infection will lead to silent chronic lesions
using only antibiotic therapy and most implant bodies
can be preserved. When integration of the implant body
is good, endoscopic sinus surgery preceding implant

body extraction is highly indicated for surgery-requiring

intractable maxillary sinusitis.
Endoscopic sinus surgery is also highly indicated
and is the procedure of first choice for the extraction of
migrated dental implant as foreign body in the maxillary
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Figure 9. This patient complained of nasal symptoms

after a dental procedure. Filling material used for the root
canal treatment (endoodontics) has become a foreign
body in the maxillary sinus and causes OMS.

Figure 10. This patient complained of nasal symptoms

following tooth extraction. Oroantral perforation
following third molar extraction causes OMS.

Figure 11. Pathophysiology of maxillary sinusitis caused by dental implantation

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Current odontogenic maxillary sinusitis

B.

A.

C.

D.

Figure 12. OMS caused by dental implantation

Patient complained of nasal symptoms after the implant body placement had been performed (A, arrow). The
conebeam CT scan shows the intractable right maxillary sinusitis (B). Implant procedures trigger the
exacerbation of chronic odontogenic inflammation of adjacent teeth, such as an apical lesion, that is
periodontitis. Endoscopic sinus surgery was performed without extracting the implant body. The implant body
did not penetrate the antral mucosa (C). Ventilation and drainage of the maxillary sinus is successfully restored
after endoscopic surgery, most implant bodies can be preserved using only antibiotic treatment. At the end
superstructures were able to be attached to the implant bodies (D, arrow).

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Figure 13. Pathophysiology of maxillary sinusitis caused by dental implantation

Figure 14. Flexible bending suction tube for the extraction of dental implant in the maxillary sinus.

sinus. When an implant body is extracted under

endoscope, a flexible bending suction tube is very
useful (Figure 14). Endoscopic procedures for the
extraction of a migrated implant body should be
arranged according to the pathophysiology. a) In the
case of a migrated implant body alone, endoscopic
maxillotomy followed by extraction of the implant body
should be performed. b) In the case of a migrated

implant body accompanied with septal deviation,

endoscopic maxillotomy and intranasal corrective
surgery (septoplasty) followed by extraction of the
implant body should be performed.
c) In the case of a migrated implant body
accompanied with sinusitis, endoscopic sinus surgery
followed by extraction of the implant body should be
performed (Figure 15).

58

Current odontogenic maxillary sinusitis

A.

B.

Figure 15. Maxillary sinusitis caused by the implant migration into the maxillary sinus.
A: The conebeam CT scan shows the implant body has migrated into the maxillary sinus accompanied with septal
deviation and sinusitis. The apical lesion, periodontitis, can be seen on the same side. The dental implant surgery
might trigger the exacerbation of chronic odontogenic inflammation of the adjacent tooth.
B: First of all, endoscopic septoplasty was performed to get working space and to enlarge the ostiomeatal complex.
After the endoscopic septoplasty was performed, endoscopic sinus surgery was then carried out. The left maxillary
sinus was viewed with a 70-degree angled endoscope via an enlarged left natural ostium, antral mucosa was
edematous and the migrated implant body could not be detected. The edematous antral mucosa was curetted using
the microdebrider. The migrated implant body was extracted using the suction tube.

Discussionandconclusion

The current pathophysiology and management of

OMS are summarized. OMS is an ancient but
underappreciated cause of maxillary sinusitis.
1) Current pathophysiology and etiology of OMS 1-5,8,9.
Regarding the etiology, it has become rare that
untreated dental caries cause OMS. Instead, most teeth
causing OMS are teeth that have received a root canal
treatment, that is, endodontics. Apical lesions in
incorrectly treated teeth cause ostitis and OMS.
Consequently, the cause of OMS should be examined,
even if a dental procedure has been performed.
Additionally, complications such as maxillary
sinusitis associated with dental implantation have also
increased. There is the possibility of two pathogenetic
mechanisms underlying the development of maxillary
sinusitis caused by dental implant placement and/or

maxillary sinus augmentation surgery. One mechanism

is that the surgical procedure for the placement of
dental implants itself causes odontogenic infections
such as OMS, while odontogenic infections, such as
OMS, can also be caused by chronic infection of
adjacent teeth, such as in the case of apical
periodontitis.
2) Current diagnosis of OMS 1,6.
Conebeam CT is far more successful in identifying
dental-caused sinusitis. Evaluation of all patients with
persistent chronic rhinosinusitis should include
inspection of the maxillary teeth using a conebeam CT
scan for evidence of periapical or marginal lucencies.
3) Current treatment of OMS
Endoscopic sinus surgery is highly indicated for
surgery-requiring OMS. If the ventilation and drainage of
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ASIAN RHINOLOGY JOURNAL 2015;2:48-60

the maxillary sinus is successfully restored after surgery,

most of the causative teeth (root-canal-treated teeth with
apical lesions) can be preserved with only antibiotic
treatment.
There is no consensus for the management of fixture
(implant body) and filling materials used in maxillary
sinus augmentation surgery when a dental implantation
causes intractable maxillary sinusitis. However,
endoscopic sinus surgery is highly indicated for
surgery-requiring maxillary sinusitis. If the ventilation and
drainage of the maxillary sinus is successfully restored
after surgery, most of the well-integrated fixture (implant
body) can be preserved.
Endoscopic sinus surgery is also indicated and is
the procedure of first choice for the extraction of a
migrated dental implant as a foreign body in the
maxillary sinus in patients with intractable maxillary
sinusitis.

Reference

1. Sato K. Current Odontogenic Maxillary Sinusitis. Fukuoka: Kyushu

University Press; 2011.
2. Sato K: Pathology of recent odontogenic maxillary sinusitis and the
usefulness of endoscopic sinus surgery. Nippon Jibiinkouka Gakkai
Kaiho (Tokyo) 2001; 104: 715-20.
3. Sato K: Complication of dental implant procedure. Nippon
Jibiinkouka Gakkai Kaiho (Tokyo) 2012; 115: 994-5.
4. Sato K: Odontogenic maxillary sinusitis caused by dental implant.
Management of implant and the role of endoscopic sinus surgery.
Oto-Rhino-Laryngology (Tokyo) 2011; 54: 398-405.
5. Sato K: Endoscopic extraction of a foreign body (dental implant)
from the maxillary sinus. Oto-Rhino-Laryngology (Tokyo) 2013; 56:
54-8.
6. Sato K: Odontogenic maxillary sinusitis diagnosed using conebeam
X-ray CT. Oto-Rhino-Laryngology (Tokyo) 2007; 50: 214-21.
7. Sato K: Management of teeth causing odontogenic maxillary
sinusitis on endoscopic sinus surgery. Prac Otol (Kyoto) 2006; 99:
1029-34.
8. Sato K: Odontogenic Maxillary Sinusitis caused by dental
restoration. Nippon Jibiinkouka Gakkai Kaiho (Tokyo) 2014; 117:
809-14.
9. Sato K: Odontogenic maxillary sinusitis caused by a fractured
tooth. Nippon Jibiinkouka Gakkai Kaiho (Tokyo) 2008; 111: 739-45.

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