SRM Journal of Research in Dental Sciences

REVIEW ARTICLE
Year
: 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)
India

Abstract

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


How to cite this URL:
Saigal S, Sial S, Bhargava A. Rhinosinusitis, a common cause of dental pain. SRM J Res Dent Sci [serial online] 2012 [cited 2019 Nov 13 ];3:247-250
Available from: http://www.srmjrds.in/text.asp?2012/3/4/247/114969


Full Text

 Introduction



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]

 Staging



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}

 Etiopathogenesis



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]

 Discussion



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]

References

1Becker DG. Sinusitis. J Long Term Eff Med Implants 2003;13:175-94.
2Hauman CH, Chandler NP, Tong DC. Endodontic implications of the maxillary sinus: A review. Int Endod J 2002;35:127-41.
3Lanza DC, Kennedy DW. Adult rhinosinustis defined. Otolaryngol Head Neck Surg 1997;117:1-7.
4Shapiro GG, Rachelefsky GS. Introduction and definition of sinusitis. J Allergy Clin Immunol 1992;90:417-8.
5Osguthorpe JD. Adult rhinosinusitis: Diagnosis and management. Am Fam Physician 2001;63:69-76.
6Kretzschmar DP, Kretzschmar JL. Rhinosinusitis: Review from a dental perspective. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:128-35.
7Eloy P, Poirrier AL, De Dorlodot C, Van Zele T, Watelet JB, Bertrand B. Actual concepts in rhinosinusitis: A review of clinical presentations, inflammatory pathways, cytokine profiles, remodeling, and management. Curr Allergy Asthma Rep 2011;11:146-62.
8Winstead W. Rhinosinusitis. Prim Care 2003;30:137-54.
9Dykewicz ML, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol 2010;125:103-15.
10Robinson S, Douglas R, Wormald PJ. The relationship between atopy and chronic rhinosinusitis. Am J Rhinol 2006;20:625-8.
11Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolaryngol Head Neck Surg 1997;117:S35-40.
12Jones NS. CT of the paranasal sinuses: A review of the correlation with clinical, surgical and histopathological findings. Clin Otolaryngol Allied Sci 2002;27:11-7.
13Radman WP. The maxillary sinus-revisited by an endodontist. J Endo 1983;9:382-3.
14Julian RS. Maxillary sinusitis: Medical and surgical treatment rationale. Oral Maxillofac Surg Clin North Am 1999;11:69-81.
15Knops JL, McCaffrey TV, Kern EB. Physiology, clinical applications. Otolaryngol Clin North Am 1993;26:517-33.
16Benninger MS, Anon J, Mabry RL. The medical management of rhinosinusitis. Otolaryngol Head Neck Surg 1997;117:41-9.
17Das A, Bal A, Chakrabarti A, Panda N, Joshi K. Spectrum of fungal rhinosinusitis; histopathologist's perspective. Histopathology 2009;54:854-9.
18Brook I. Microbiology of acute and chronic maxillary sinusitis associated with an odontogenic origin. Laryngoscope 2005;115:823-5.
19Drettner B, Lindholm CE. The borderline between acute rhinitis and sinusitis. Acta Otolaryngol 1967;64:508-13.
20Carenfelt C, Lundberg C. Purulent and non-purulent maxillary sinus secretions with respect to pO2, pCO2 and pH. Acta Otolaryngol 1977;84:138-44.
21Aust R, Drettner B. Oxygen tension in the human maxillary sinus under normal and pathological conditions. Acta Otolaryngol 1974;78:264-9.
22Abrahams JJ, Glassberg RM. Dental disease: A frequently unrecognized cause of maxillary sinus abnormalities? AJR Am J Roentgenol 1996;166:1219-23.
23Ericson S. Conventional and computerized imaging of maxillary sinus pathology related to dental problems. Oral Maxillofac Surg Clin North Am 1992;4:153-81.
24Ross IS. Some effects of heavy metals on fungal cells. Trans Br Mycol Soc 1975;64:175-93.
25Hybbinette JC, Mercke U. A method for evaluating the effect of pharmacological substances on mucociliary activity in vivo. Acta Otolaryngol 1982;93:151-9.
26Krennmair G, Lenglinger F. Maxillary sinus aspergillosis: Diagnosis and differentiation of the pathogenesis based on computed tomography densitometry of sinus concretions. J Oral Maxillofac Surg 1995;53:657-63.
27Legent F, Billet J, Beauvillain C, Bonnet J, Miegeville M. The role of dental canal fillings in the development of Aspergillus sinusitis: A report of 85 cases. Arch Otorhinolaryngol 1989;246:318-20.
28Dodd RB, Dodds RN, Hocomb JB. An endodontically induced maxillary sinusitis. J Endod 1984;10:504-6.
29Arias-Irimia O, Barona-Dorado C, Santos-Marino JA, Martínez-Rodriguez N, Martínez-González JM. Meta-analysis of the etiology of odontogenic maxillary sinusitis. Med Oral Patol Oral Cir Bucal 2010;15:70-3.
30Mehra P, Jeong D. Maxillary sinusitis of odontogenic origin. Curr Allergy Asthma Rep 2009;9:238-43.
31Mario CL, César CG, Iván SG, Jaime SP. Maxillary sinusitis of dental origin. A case report and literature review. Int J Odontostomatol 2009;3:5-9.
32Oscar AI, Cristina BD, Juan AS, Natalia MR, José MM. Meta-analisis of the etiology of odontogenic maxillary sinusitis. Med Oral Patol Oral Cir Bucal 2010;1:70-3.