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This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
The main goal of endodontic treatment is to prevent or cure apical periodontitis. Due to anatomical relationships, periapical lesions of upper premolars and molars can induce odontogenic infection inside maxillary sinus.
A variety of terms have been established for dental-induced maxillary sinusitis. Characterized as antral-nasal syndrome by Selden,
Periapical lesions that originated from endodontic pathologies and penetrated maxillary sinus are mainly associated with maxillary molars. Molars are 11 times more likely than premolars to cause MSEO when both teeth are present.
This paper reports a case series of MSEO associated with upper first maxillary molars that were successfully treated with single-visit nonsurgical antiseptic RCT without any surgical intervention.
Case report 1
A 43-year-old male was referred to endodontic practice by general dental practitioner for endodontic retreatment of 26 tooth. Tooth underwent RCT 5 years ago. The patient reported nonspecific recurrent pain in the left facial area for 3 months; there was no history of laryngological treatment nor other general health diseases. Extraoral examination revealed tenderness to percussion in the left maxillary sinus area. In an intraoral examination, tooth 26 gave a slightly positive reaction to percussion test. There was fistula present in the projection of root apex. Intraoral periapical preoperative radiograph revealed periapical lesion. All canals were underfilled with poor condensation of obturating material. Because the presence of maxillary sinusitis was suspected, standard radiological diagnostics was supplemented with preoperative CBCT [shown in (a-c) Preoperative sagittal and coronal cross-sections of 26 tooth show chronic apical periodontitis coexisting with maxillary sinusitis of endodontic origin with periapical osteoperiostitis and periapical mucositis symptoms; (d-f) 1-year control cone-beam computed tomography systems shows complete reconstruction of bone and resolution of sinusitis symptoms.
After performing infiltration anesthesia with 1 amp of 4% articaine with 1 adrenaline both buccally and palatally (Septanest 1:200, Septodont, France) and isolation of operating field with a rubber dam (Hygienic Dental Dam Kit, Coltene/Whaledent, Switzerland), access to canals was prepared in DOM (Leica M320, Leica Microsystems, Germany). Glide-path was obtained in all four root canals using ISO 10 C-pilots (VDW, Germany) with working length assessment with Raypex 6 electronic apex locator (VDW, Germany). Chemomechanical preparation was performed with Endostar E3 rotary instruments (PolDent, Poland) with crown-down technique up to ISO size 30.04, followed by MTwo rotary file ISO 35.04 (VDW, Germany) as a MAF. During all mechanical preparation, all canals were copiously irrigated with 40 ml 5.25% sodium hypochlorite (NaOCl) (Chloraxid, Cerkamed, Poland), and after MAF preparation final irrigation protocol was performed in all canals: 5.25% NaOCl with ultrasonic activation with passive ultrasonic irrigation (PUI) method in amount of 5 ml/canal, 40% citric acid with PUI for smear layer removal in amount of 5 ml/canal, and final flush with 2% chlorhexidine 5 ml/canal for the additional antimicrobial effect with manual dynamic irrigation (MDI). All canals were dried with sterile paper points (MetaBiomed, Korea) and obturated with vertical compaction of warm gutta-percha (continuous wave of condensation technique) using 35.04 master apical cones (MACs) (MetaBiomed, Korea) coated in a small amount of AH Plus sealer (Dentsply Sirona, USA), followed by back-fill of 200°C heated gutta-percha with Super Endo B and L system (B and L Biotech, USA). Postoperative intraoral radiograph was taken to assess the direct postoperative effect of the treatment. The patient was instructed to come to 6-month, 1-year, and 2-year control visits. Because there have been no flare-ups and no postoperative complications during 12-month posttreatment period, the patient did not show up for the first 6-month control and no control radiovisiography (RVG) follow-up was made at that time. The patient came back after 12-month period, and control Cone-beam computed tomography (CBCT) was done
Case report 2
A 61-year-old female came to dental office due to pain and swelling in the right maxillary area. The patient reported strong spontaneous pain in the right facial area that lasted for 12 h, nasal obstruction, and pain while bending over. The patient had no history of laryngological treatment nor other general health diseases. Extraoral examination revealed tenderness of the right buccal area, pain to palpation, and percussion. Intraoral examination showed redness and swelling of oral mucosa in the projection of 16 apical area, tooth 16 was highly responsive for percussion and restored with prosthetic crown. Intraoral periapical preoperative radiograph revealed no pathologies. Tooth 16 underwent RCT in the past. Because the presence of MSEO was suspected, radiological diagnostics was supplemented with preoperative CBCT (a and b) Preoperative sagittal and coronal cross-sections of 16 tooth show chronic apical periodontitis coexisting with maxillary sinusitis of endodontic origin with periapical osteoperiostitis and periapical mucositis signs; (c and d) 8-month control cone-beam computed tomography systems shows complete resolution of sinusitis symptoms and healing of periapical bone.
Patient signed informed consent
Infiltration anesthesia with 2 amp. of 4% articaine with 1:100,000 adrenaline, both buccally and palatally (Septanest 1:100, Septodont, France) was performed followed by isolation of operating field with a rubber dam (Hygenic Dental Dam Kit, Coltene/Whaledent, Switzerland). Access to canals was prepared in DOM (Leica M320, Leica Microsystems, Germany). Glide-path has been obtained in all four root canals using ISO 10 C-pilots (VDW, Germany), followed by chemomechanical preparation with Endostar E3 (PolDent, Poland) to ISO size 30.04 and MTwo ISO 35.04 (VDW, Germany) as MAF. Working length was assessed with Raypex 6 electronic apex locator (VDW, Germany). During all mechanical preparation, all canals were copiously irrigated with 50 ml 5.25% sodium hypochlorite (NaOCl) (Chloraxid, Cerkamed, Poland), and after MAF preparation, final irrigation protocol was performed in all canals: 5.25% NaOCl with ultrasonic activation with PUI method in the amount of 5 ml/canal, 40% citric acid with PUI for smear layer removal in amount of 5 ml/canal, and final flush with 2% chlorhexidine 5 ml/canal for additional antimicrobial effect with MDI. All canals were dried with sterile paper points (MetaBiomed, Korea) and obturated with vertical compaction of warm gutta-percha (continuous wave of condensation technique) using 35.04 MACs (MetaBiomed, Korea) coated in a small amount of AH Plus sealer (Dentsply Sirona, USA), followed by back-fill of 200°C heated gutta-percha with Super Endo B and L system (B and L Biotech, USA). Postoperative intraoral radiograph was taken to assess the direct postoperative effect of the treatment. The patient was instructed to come to 6-month, 1-year, and 2-year control visits. At 6-month control, intraoral periapical radiographs were taken, and control CBCT was made in an 8-month control period
If the development of sinusitis has endodontic origin, it is most likely to heal after nonsurgical endodontic therapy.
CBCT is a method of choice in MSEO diagnostics, as CT of standard collimation (3 mm thick) fails to demonstrate dental origin of sinusitis.
There are scientific publications that show a high ratio of maxillary sinusitis resolution after performing multivisit nonsurgical RCT with the application of antimicrobial agents to endodontic space in-between visits.
Sinus involvement in endodontic pathologies requires individual, multidisciplinary approach, specialistic RCT with precise working length assessment, effective antimicrobial irrigation protocol, and advanced radiographic diagnostic tools. It should be emphasized that chemomechanical preparation and obturation should stop exactly at physiological foramen and any extrusion of irrigants, debris, and obturation materials should be avoided while still managing to obtain apical patency. Over instrumentation and inadvertent extrusion of antiseptics into maxillary sinus can cause serious complications that will decrease the success ratio.
MSDO treatment protocol should start with nonsurgical antiseptic RCT and should be supplemented with surgical or laryngological management only if signs of healing in follow-ups are not observed. Single-visit nonsurgical endodontic treatment can be effective in MSEO management. CBCT is a method of choice in MSEO diagnostics. Endodontists are well trained and well equipped to treat MSDO and the cooperation between ENT specialists, maxillofacial surgeons, and endodontists are crucial for both: Good diagnostics and treatment.
Highlights
Even big apical lesions with advanced maxillary sinusitis can heal completely after single-visit nonsurgical endodontic treatment MSEO treatment protocol should start with RCT and this noninvasive single-visit approach can be as effective as multivisit RCT in MSEO management The cooperation between ENT specialists, maxillofacial surgeons, and endodontists is crucial for good diagnostics and treatment of maxillary sinusitis
Statement of ethics
Patient 1 involved in the study has given his written informed consent to publish his case (including publication of images).
Patient 2 involved in the study has given his written informed consent to publish his case (including publication of images).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.