SRM Journal of Research in Dental Sciences

: 2012  |  Volume : 3  |  Issue : 4  |  Page : 247--250

Rhinosinusitis, a common cause of dental pain

Sonal Saigal1, Shruti Sial2, Ankur Bhargava1,  
1 Department of Oral Pathology, Siddhpur Dental College and Hospital, Siddhpur, Patan, India
2 Department of Endodontics, Government Dental College and Hospital, Raipur, Chhatisgarh, India

Correspondence Address:
Ankur Bhargava
291 - A Block, Chitrakut Nagar, Bhuwana Extension, Udaipur (Rajasthan)


Rhinosinusitis is a more accurate term for what is commonly termed sinusitis, because the mucous membranes of the nose and sinuses are contiguous and subject to the same disease processes. It is a significant and increasing health problem that affects about 15% of the population in Western countries. It has a substantial impact on patients health related quality of life and daily functioning and represents a huge financial burden to society and the health care system as a result of the direct and indirect costs therefore the high incidence of this pathology reveals the need to recognize it as an important disease we have to be able to deal with in order to prevent it or even treat it whenever necessary. In this article, we provide an overview of Rhinosinusitis, including its classification, etiopathogenesis, staging and focusing over its diagnostic modalities.

How to cite this article:
Saigal S, Sial S, Bhargava A. Rhinosinusitis, a common cause of dental pain.SRM J Res Dent Sci 2012;3:247-250

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Saigal S, Sial S, Bhargava A. Rhinosinusitis, a common cause of dental pain. SRM J Res Dent Sci [serial online] 2012 [cited 2020 Jun 4 ];3:247-250
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The sinuses are chambers within the bones of the face and skull that are normally lined with a thin mucus producing membrane (called mucosa). There are four paired paranasal sinuses - the maxillary, ethmoid, frontal, and sphenoid sinuses. [1] The maxillary sinus is the first paranasal sinuses to develop in human fetal life. Its anatomical and clinical significance was first described by Nathaniel Highmore (Highmore 1651) in 1651 with a report on the drainage of an infected sinus through the extraction socket of a canine tooth. Since that report, the maxillary sinus or antrum of Highmore has played an important part in the dental treatment of maxillary teeth. [2] Sinusitis literally means "inflammation of the sinus cavities." This inflammation happens when a patient's nose and sinuses are exposed to anything that might irritate the membranous linings. Rhinitis refers to inflammation of the nasal mucosal linings only. Sinusitis refers to inflammation of the mucosal linings of the sinuses and is usually associated with and often preceded by rhinitis; ear, nose, and throat specialists today often use the term rhinosinusitis. However, the words rhinitis, sinusitis, and rhinosinusitis are often used interchangeably. [3],[4] Rhinosinusitis is a more accurate term for what is commonly termed sinusitis, because the mucous membranes of the nose and sinuses are contiguous and is subject to the same disease processes. Sinusitis without rhinitis is rare. [5]

 Classification of Rhinosinusitis

Based on symptoms and duration, rhinosinusitis is divided into 4 types: Acute, subacute, recurrent acute, and chronic. [6]

Acute rhinosinusitis (ARS) is a common upper respiratory tract disorder that involves inflammation of the nasal and paranasal sinus mucosa. It can be mild, moderate, or severe. Unlike a common cold, which typically resolves in <5 days, the symptomatology of ARS worsens after 5 days or persists for >10 days. However, in all cases, it resolves in <4 weeks. The symptomatology includes nasal congestion, purulent discharge, fever, headache, facial pain/pressure, dental pain, postnasal drip, cough, and tenderness around the sinus area. [7] [Table 1] summarizes different predisposing factors that can play a role in the development of ARS.{Table 1}

Recurrent ARS is defined as more than four acute episodes annually, each with intervening symptom-free intervals. Four episodes annually is an arbitrary standard that takes into account that the typical adult has two to three acute upper respiratory tract infections (URTI) episodes annually, which clinically may be difficult to distinguish from ARS.

Chronic rhinosinusitis (CRS) is defined as symptoms persisting for >3 months. Chronic symptoms may develop after an acute episode that fails to respond to medical therapy or when symptoms may arise insidiously. Acute exacerbation of chronic sinusitis is an episode of acute inflammation with worsening of existing problems or development of new symptoms of finite duration. Acute symptoms typically resolve with medical therapy, but chronic problems persist. [8] CRS is characterized by chronic inflammation of the nasal and paranasal sinus mucosa, cytokine release and tissue remodeling that includes changes in the extracellular matrix (ECM), protein deposition, and tissue structure. [9] Based on nasal endoscopy, CRS can be subdivided into two categories: CRS with and without nasal polyps. In the past, these two entities were considered as the expressions of one single disease, nasal polyposis being considered the end point of the evolution of CRS without nasal polyps. [9] The symptomatology consists of nasal congestion, anterior and posterior rhinorrhea, reduction of the sense of smell, and recurrent URTIs. Facial pain, pressure, and/or fullness are very common in this group in contrast to CRS with polyps. [10]


Although computed tomography (CT) findings have been used to develop a number of staging systems for rhinosinusitis, these approaches have proved too complex for use in routine clinical practices. [11] The staging systems that have been proposed such as those by Friedman et al., 1990, Kennedy 1992, and May et al., 1993 are not very much acceptable. [11],[12] However several attempts have been made to compare inter observer and intra observer agreement for a number of these systems. Gliklich and Metson found that their Harvard method was superior. They divided gross changes throughout the sinuses into four stages (stage 0 being normal) based on the pattern of involvement [Table 2]. [11],[12]{Table 2}


The pathophysiology of sinus disease is related to three factors: Patency of the ostia, function of the cilia, and the quality of the nasal secretions. These factors contribute to the adequate drainage of the sinus; [2] however, there are a number of etiological factors (anatomic factors, organisms, odontogenic pathology) that contribute to the progression of the disease as enumerated in [Table 3]. [6],[13-30]{Table 3}

 Presenting Symptoms and Diagnostic Modalities

Facial pain and pressure are the most frequent presenting symptoms that prompt patients to seek medical attention. The signs and symptoms consistent with a diagnosis of rhinosinusitis are classified into major and minor categories.

The major factors are facial pain, pressure, facial congestion (i.e., a description of fullness), nasal obstruction, paranasal drainage, hyposmia (decrease in the sense of smell), and fever.The minor factors usually include headache, dental pain, halitosis, fatigue, cough, and ear pain. The minor factors achieve diagnostic significance when one or more of the major factors are present among the symptoms. [6]

The use of imaging techniques is a key tool in establishing the diagnosis. Orthopantomography is useful to assess the relationship of the maxillary teeth with the maxillary sinus, the presence of air or pseudocyst, identifying movements of tooth roots, or the presence of teeth or foreign bodies inside the sinus, such as a dental implant. However, the time activity curve (TAC) is the gold standard for an adequate image of the maxillary sinus due to the ability to view the bone and soft tissue and to obtain thin sections and multiple points of view, which creates a real vision diagnosis of this condition. [31] When surgery is planned and it is a matter of defining bony anatomy at that point of view, CT has an invaluable role. It also has an important role in the management of the complications of rhinosinusitis. It helps define whether there is a subperiosteal collection of pus when the orbit is involved or whether there is intracranial involvement. CT also help in the diagnosis of atypical infection and malignancy. CT can be helpful when the surgeon has to reconsider the diagnosis, as the frequency of false positive findings are remarkable for the diagnosis of rhinosinusitis. [12]

Rhinosinusitis is a clinical diagnosis supported by endoscopic findings. The introduction of the endoscope as a tool to help sinus surgery, along with the philosophy of aerating and restoring mucociliary clearance, has stimulated interest in both the anatomy and pathophysiology of the paranasal sinuses. CT provides additional information, but, while it can provide more details than plain radiography, its place in the management of paranasal sinus disease is still evolving. Radiology does not tell us what the underlying pathological process is except in a few circumstances, for example, aspergillosis. Any clinical study, therefore, needs a pathological staging system as well as a radiological system. [12]


Rhinosinusitis is a disease that often involves dentist, both in its diagnosis and prevention. [32] It is important to place maxillary sinus pathosis on the list of differential diagnoses when evaluating patients who present with facial pain and maxillary dental pain. Dentist who understand the relationship between the facial sinuses and the oral structures are better prepared to arrive at an accurate diagnosis when treating their patients. Patients with ARS, chronic rhinosinusitis, or pathological conditions of dental origin in the maxillary region should receive appropriate treatment in a timely manner. The dentist is an important caregiver and member of the medical team who can have a positive impact on the proper evaluation and treatment of these patients with maxillofacial pain. The astute dentist will ensure a rapid and positive outcome for this group of patients. [6]


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