Sinusitis As a Source of Dental Pain

Figure 1. Sagittal view of the maxillary sinus showing the proximity of the roots of the maxillary teeth
Figure 2. Periapical radiograph of maxillary teeth and sinus floor

There are 7 sinuses (air-filled cavities) in the head. They include the maxillary, ethmoid, mastoid, sphenoid, and frontal sinuses (the frontal sinuse is the only sinuse that is not bilateral).1 Sinusitis, an inflammation of the sinuses, is a common problem affecting almost all people at some point in their lives. It is a chronic problem for approximately 15% of the population (>31 million people) in the United States.2,3 A study done by the Agency for Healthcare Policy and Research revealed that in 1992 Americans spent 2 million dollars in prescription cold medications and more than 2 billion dollars for over-the-counter medications.4 Another study showed that acute and chronic sinusitis was the fifth most common diagnosis for which antibiotics were prescribed. That study noted that there was also a trend toward using more expensive, broad-spectrum antibiotics.5 Causes of the inflammation that lead to sinusitis can include allergic responses, chemical irritation, infections, mechanical obstruction, and an infected maxillary tooth.6,7,8 Approximately 10% of sinusitis is due to a dental source.2


The sinus that most commonly becomes infected is the maxillary sinus (atrium of Highmore), due to its prominent exposure to the environment and the anatomy that allows drainage of the cavity.1,6 The Schniderian membrane lines all of the sinuses. The psudeostratified, ciliated columnar epithelium has Goblet cells within the membrane that secrete mucus, and the cilia sweep the mucus toward the opening (ostium).1,9 In the maxillary sinus, the mucus must move upward to drain from the sinus and to the ethmoid infundibulum in the middle meatus of the nasal cavity.1,2 When a patient is standing, the maxillary sinus does not drain easily because the ostium from which the sinus drains is superior to the floor of the sinus. (Figure 1). This drainage pattern makes the maxillary sinus prone to infection.1 The average size of a maxillary sinus is approximately 15 cc, so it can fill relatively quickly.7

Sinusitis is important in clinical dental practice because one of the symptoms of maxillary sinusitis is pain that can mimic pain of dental origin (odontogenic maxillary sinusitis).10 When a patient is complaining of maxillary posterior tooth pain, it is incumbent on the dentist to differentiate between pain of odontogenic origin and pain from the maxillary sinus.11 The purpose of this paper is to assist the dentist in identifying or eliminating acute sinusitis as a source of dental pain.

THE DIAGNOSTIC PROCESS

Table 1. Steps to evaluate sinus pain versus tooth pain
  • History of previous episodes of sinusitis
  • Clinical exam; palpation of maxillary bone over the sinuses and evaluation of the teeth to identify a possible dental origin
  • Radiographs, including periapical and possibly panographic x-rays
  • Vitality testing of the tooth, including electric pulp testing, ice, heat, and percussion
  • Rule out sinusitis by treating the pain with a drug regime effective in treating sinusitis

When attempting to make a diagnosis of pain in the maxillary posterior region, the dentist must first rule out a problem of dental origin. The differentiation of odontogenic pain from sinus pain includes consideration of the history of the pain and whether the patient has a history of sinusitis10 (Table 1). The radiographic evaluation includes a periapical x-ray and possibly a panographic x-ray. A radiograph commonly used by physicians and oral maxillofacial surgeons to diagnose sinusitis is a Water’s view, an anterior-posterior radiograph. If available, a computerized tomography scan can be helpful. The last 2 imaging techniques focus primarily on the sinus and are not usually useful to rule out teeth as the source of the problem/pain. An increased fluid level in the sinus may indicate an infection.12 This will help determine the status of the tooth and the proximity of the roots of the maxillary posterior teeth to the sinus (Figure 2). The clinical evaluation consists of palpation over the sinus and an examination of the teeth, including assessment of tooth vitality.


There are several indications that the pain the patient is experiencing may be originating from the sinuses, not the teeth. These include the absence of pathology on the dental radiographs, close proximity of the floor of the maxillary sinus to the roots of the maxillary teeth (Figure 2), and a patient complaint of pain originating from several teeth.10 Certainly, if the patient complains of sinus pain—especially bilateral pain—as well as tooth pain, then the clinician should be suspicious that the sinus is the source of the pain. Typical signs and symptoms of sinusitis are tenderness over the sinuses, nasal congestion, nasal discharge with a foul odor, fever, headache, and dental pain (Table 2).2,13

Table 2. Common signs and symptoms of sinusitis
  • Tenderness over the sinuses
  • Nasal congestion
  • Headache
  • Foul odor
  • Nasal discharge
  • Fever
  • Dental pain

It is certainly possible that an infected tooth can cause a sinusitis. Usually the first maxillary molar is involved because of its location.6 If this is the case, the radiograph may reveal an obvious periapical radiolucency, a widened periodontal ligament space at the apex of a tooth, or a tooth with extensive restorations and/or caries. A tooth that is in the area of complaint may also be sensitive to percussion or test negative when vitality is evaluated. It should be noted that there are a variety of sources of pain in the maxillary posterior region. Depending on the presentation and the results of the clinical and radiographic evaluation, all should be considered. These are listed in Table 3. It is beyond the scope of this paper to discuss these other sources of pain.

TREATMENT

Table 3. Possible sources of pain in the maxillary area
  • TMJ disorders
  • Odontogenic (endodontic, periodontal, tooth fracture)
  • Sinusitis
  • Bruxism
  • Temporal arteritis
  • Pathology

If the dentist suspects acute sinusitis (duration of less than 4 weeks6) as the source of a patient’s dental pain, the dentist can either refer the patient to a physician to manage the sinusitis or can treat the sinusitis with the intention of ruling out that problem as the source of the dental pain. If there are clear indications of sinusitis, the option of referring the patient to a physician may be preferred.


It is also important to note that dentists cannot treat sinusitis when there are no dental symptoms. This is not part of the training of general dentists. Sinusitis causing tooth pain versus sinusitis without tooth pain may seem to be a minor distinction (ie, both situations would use the same medications), but the distinction is important. If the patient is not having any dental symptoms, then it is medically/legally inappropriate for the dentist to treat the sinusitis. The patient (or friend or colleague) with sinus problems and no dental complaint should be referred to a physician for appropriate therapy. 

It should also be noted that chronic sinusitis, which lasts greater than 12 weeks, is most appropriately managed by a physician.6 Because the cause of chronic sinusitis can be difficult to determine, the treatment of such infections is multifaceted and is partially dependent on the drugs used in the prior episode(s), the outcome of treatment, and other factors. This paper focuses only on the treatment of acute sinusitis.

If the dentist decides to treat the sinusitis to rule this infection out as the source of the dental pain, then knowledge of the different medications used to treat sinus infections is essential. The treatment of a sinus infection depends on the source of the infection and whether it is acute or chronic. Treatment of sinusitis focuses on 2 concerns: facilitating drainage and treating the infection.6
Table 4. Decongestants (sympathomimetics) used to treat sinusitis

Topical decongestants:

  • Phenylephrine HCL (Neo-Synephrine) 2 drops or 2 sprays into each nostril q 4 hours
  • Oxymetazoline HCL (Afrin) 2 sprays into each nostril bid

Systemic decongestants:

  • Pseudoephedrine (Sudafed) 30 mg q 6 hours
  • Chlorpheniramine(Chlor-Trimeton) 4mg q 4 to 6 hours

Table 5. Antihistamines used to treat sinusitis

Sedating:

  • Diphenhydramine (Benadryl) 25 mg q 6hours
  • Clemastine (Tavist) 1.34 mg bid

Nonsedating:

  • Fexofenadine (Allegra) 180 mg q d
  • Loratadine (Claritin) 10 mg q d

Table 6. Antibiotics used to treat acute sinusitis
  • Amoxicillin 500 mg tid
  • Augmentin 875 mg bid (amoxicillin 875 mg, clavulonic acid 125mg)

Antibiotic of choice for penicillin-allergic patients:

  • Trimethoprim 160 mg/Sulfamethoxazole 800 mg, (Bactrim DS or Septra DS) 1 tab bid

Antibiotic of choice for penicillin and sulfa allergic patients:

  • Azithromycin, (Zithromax, Z-Pak) 500 mg on day 1 and 250 mg on day 2 to 5

Table 7. Prescriptions for use in treating sinusitis to rule out a dental infection
Decongestants Rx: Sudafed, 60 mg
Disp. 21
Sig. take 1 tablet 3x a day
OR
Rx: Afrin Nasal Spray
Disp. 1 canister
Sig. 2 sprays in each nostril 3x a day
Antibiotics Rx: Amoxicillin, 500 mg
Disp. 28 tablets
Sig. 1 tablet 4x a day
OR
Rx: Augmentin, 875 mg
Disp. 14
Sig. 1 tablet 2x a day
  OR    
  Antibiotic if the patient is allergic to penicillin:
Rx: Bactrim DS
Disp. 14
Sig. 1 tablet 2x a day
   
Antihistamine Rx: Claritin 10 mg
Disp. 7
Sig. 1 tablet per day
   


Most sinus infections are due to viral infections and can be treated with either topical or systemic sympathomimetic decongestants (Table 4). These are used to reduce tissue edema and allow drainage.6 Caution is needed, since the use of topical decongestants for more than 3 days can lead to rebound congestion that can confuse the clinical presentation and prolong the symptoms.2,6 It is also possible to use antihistamines to prevent or reduce edema (Table 5), but these drugs may promote drying of the mucosa and are less effective than a decongestant. Antihistamines are of benefit if there is an allergic component.2

The other concern when treating sinusitis is management of the infection with antibiotics. The antibiotic of choice depends on whether the infection is acute (<4 weeks in duration) or chronic (>12 weeks in duration) or is a recurrent episode. Acute sinus infections are generally due to Streptococcus pneumoniae (30% to 50%), Haemophilus influenzae (20% to 40%), and Moraxella catarrhalis (5% to 10%).2,14,15 Chronic infections are due to the same bacteria as acute sinusitis but also include a number of anaerobic bacteria such as Bacteroides, Staphylococcus aureus, alpha hemolytic streptococci, Peptostreptococcus, Pseudomonas, and Streptococcus proteus.2,9 Fungi and viruses may also play a role in maxillary sinusitis. Odontogenic maxillary sinusitis is most often associated with Peptostreptococcus, Fusobacterium, and Bacteroides.

The antibiotic of choice for an acute sinus infection is amoxicillin or Augmentin (amoxicillin and clavulanic acid). Bactrim, a combination of sulfa drugs, is used for penicillin-allergic patients (Table 6). Antibiotics alone are not sufficient in chronic sinusitis, and surgery may be indicated.16

SUMMARY 
Sinusitis is a common medical problem that can occasionally manifest as dental pain. If the patient is experiencing dental pain in the maxillary posterior teeth, then it is appropriate for the dentist to rule out sinusitis as a source of the problem before proceeding with definitive dental treatment. Often there is an obvious odontogenic source of the pain, and this should be resolved first, but in other situations it is difficult to determine the cause of the symptoms. In some patients, the source of the pain is so equivocal that it may be necessary to treat the patient for sinusitis to eliminate this as the source of the dental pain (Table 7). In this process, the dentist has one of 2 options: either refer the patient to a physician or treat the sinusitis. The option chosen regarding patient management is made by the dentist and depends on the particular clinical situation and the dentist’s training and experience.


References

 

  1. Abubaker AO. Applied anatomy of the maxillary sinus. Oral Maxillofacial Surg Clin North Am. 1999;11(1):1-14.
  2. Rogerson K. Microbiology of the maxillary antrum: treatment of infections. In: Kelly JJ, ed. Oral and Maxillofacial Surgery Knowledge Update. Vol 1. Rosemont, Ill: American Association of Oral and Maxillofacial Surgeons; 1994:49-59.
  3. Piccirillo JF, Mager DE, Frisse ME, et al. Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. JAMA. 2001;286:1849-1856.
  4. Evidence Report/Technology Assessment Number 9: Diagnosis and Treatment of Acute Bacterial Rhinosinusitis. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research; 1999. AHCPR publication 99-E015.
  5. McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA. 1995;273:214-219.
  6. Julian R. Maxillary sinusitis, medical and surgical treatment rationale. Oral Maxillofacial Surg Clin North Am. 1999;11(1):69-81.
  7. Abubaker AO, Benson KJ, eds. Oral and Maxillofacial Surgery Secrets. 1st ed. Philadelphia, Pa: Hanley & Belfus, Inc; 2001:227.
  8. Bertrand B, Rombaux P, Eloy P, et al. Sinusitis of dental origin. Acta Otorhinolaryngol Belg. 1997:51:339-352.
  9. Wilk R. Physiology of the maxillary sinus. Oral Maxillofacial Surg Clin North Am. 1999;11(1):15-20.
  10. Okeson JP, Falace DA. Nonodontogenic toothache. Dent Clin North Am. 1997;41:367-383.
  11. Sandler HJ. Clinical update—the teeth and the maxillary sinus: the mutual impact of clinical procedures, disease conditions and their treatment implications. Part 2. Odontogenic sinus disease and elective clinical procedures involving the maxillary antrum: diagnosis and management. Aust Endod J. 1999;25:32-36.
  12. Laine F. Diagnostic imaging of the maxillary sinus.Oral Maxillofacial Surg Clin North Am. 1999;11(1):45-67.
  13. Rafetto L. Clinical examination of the maxillary sinus.Oral Maxillofacial Surg Clin North Am. 1999;11(1):35-44.
  14. Haug R. The changing microbiology of maxillofacial infections. Oral Maxillofacial Surg Clin North Am. 2003;15(1):2-15.
  15. Weymouth L. Microbiology of the maxillary sinus. Oral Maxillofacial Surg Clin North Am. 1999;11(1):21-34.
  16. Flynn T. Principles of antibiotic selection. Oral Maxillofacial Surg Clin North Am. 2003;15:17-38.

Dr. Jacobsen has a PhD in comparative pharmacology and toxicology. He is director of the Oral Medicine Clinic at the University of the Pacific Dental School. He is a diplomate of the American Board of Oral Medicine and past chairperson of the council on Dental Therapeutics of the ADA. He received the 1999 Gordon J. Christensen Lecturer Recognition Award and writes the Dental Drug Booklet, a succinct handout and reference on commonly prescribed dental medications.He can be reached at (415) 929-6609 or at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 

Dr. Casagrande is an associate professor in the Department of Oral and Maxillofacial Surgery at the University of the Pacific Dental School and is the director of the Oral and Maxillofacial Surgery Training Program at Highland Hospital in Oakland Calif. She is trained in both medicine and dentistry.




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shabaz (27.07.2013 (13:57:31))
dental Yes No THIS ARTICLE IS VERY USEFUL FOR ME


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