Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2014; 59: 289–295

doi: 10.1111/adj.12193

Rhinosinusitis in oral medicine and dentistry

M Ferguson*
*Marfleet Primary Healthcare Centre, Hull, United Kingdom.

ABSTRACT
Rhinosinusitis is a very common condition which is normally readily recognizable. Given the intimate anatomic relation-
ship between the antrum and the posterior maxillary teeth, maxillary sinusitis can present as odontalgia. Distinguishing
between odontogenic orofacial pain and pain associated with maxillary sinusitis is important to prevent unnecessary
dental intervention and to direct patients to medical colleagues. Conversely, odontogenic infection can spread to involve
the antrum, termed odontogenic sinusitis, or maxillary sinusitis of dental origin. Odontogenic sinusitis accounts for
about 10–40% of all cases of sinusitis, and usually requires combined dental and medical treatment. Maxillary sinusitis
can also be a complication of exodontia, resulting from tuberosity fractures, displaced teeth or root fragments and the
creation of oroantral communications and fistulae. Dental implants and endodontic materials can also impinge on the
maxillary sinus, and are rare causes of sinusitis. Often it is stated that rhinosinusitis may contribute to a halitosis com-
plaint, and widely used diagnostic protocols for rhinosinusitis sometimes list halitosis as a minor criterion. However,
gold standards in halitotosis research such as organoleptic assessment or gas chromatography have not been used to vali-
date a correlation between objective (genuine) halitosis and sinusitis. The pathophysiology of this mechanism is unclear,
and the relative importance of this alongside other causes of extraoral halitosis is debated.
Keywords: Halitosis, maxillary sinusitis, odontogenic sinusitis, oronantral communication, rhinosinusitis, sinusitis.
Abbreviations and acronyms: ARS = acute rhinosinusitis; CRS = chronic rhinosinusitis; FESS = functional endoscopic sinus surgery;
OAC = oroantral communication; OAF = oroantral fistula; URTI = upper respiratory tract infection; VSC = volatile sulfur compound.
(Accepted for publication 24 October 2013.)

halts with eruption of the permanent teeth, the roots

INTRODUCTION
The maxillary antrum is often described as a four-
sided pyramid, the base orientated vertically, lateral
to the nasal cavity, and the apex extending into the
zygomatic bone. Relatively thin bony walls divide the
sinus from the orbit superiorly and the oral cavity
inferiorly. The cartilaginous medial wall divides the
antrum from the nasal cavity. Beyond the posterior
wall lies the pterygomaxillary fossa medially and the
infratemporal fossa laterally. The maxillary alveolar
process forms the antral floor, which often lies at a
more inferior position relative to the nasal cavity floor
in adults. The antral floor is intimately related to the
roots of the maxillary teeth, particularly the first
molar and second premolar. The morphology and
degree of pneumatization is subject to significant
interpersonal variation. The antral floor may extend
as far anteriorly as the canine, or as posteriorly as the
third molar. Bony irregularities, such as conical pro-
cesses or dehiscences, are fairly commonly associated
with the periapices of maxillary teeth in the antral
floor.1 Whilst pneumatization of the sinus generally
© 2014 Australian Dental Association
of maxillary teeth may disrupt the contours of the
antral floor. This is seen in healthy individuals, indi-
cating that pneumatization has continued to some
degree around the teeth. Edentulism triggers resorp-
tion of the alveolar ridge but also increased pneumati-
zation of the sinus.
The posterior, middle and anterior superior alveolar
nerves are all associated with the walls of the antrum,
and they may all be involved in its innervation.2 The
mucoperiosteal lining of the antrum (the Schneiderian
membrane) is respiratory epithelium. A mucocillary
clearance mechanism keeps mucous secretions slowly
moving, at about 6 mm/min, towards the ostium.3 As a
result of this, in health the microbiota is largely con-
trolled, although the sinus is not sterile as was once
believed. The osteomeatal complex is a collective term
for the final common route of drainage of the maxil-
lary, frontal and anterior and middle ethmoid sinuses
into the middle meatus, between the middle and infe-
rior nasal conchae. The ostium of the maxillary sinus is
situated superomedially. This is significant because the
drainage of secretions is against gravity, meaning there
289
M Ferguson
is no redundancy mechanism if dysfunction of mucocil-
lary clearance occurs.1 The function of the paranasal
air sinuses is open to debate, but generally speaking the
sinonasal apparatus as a whole is adapted to warming
and adding moisture to inspired air, as well as filtering
any particulate suspension (Fig. 1).
Rhinosinusitis: background
Sinusitis is inflammation of the mucosal lining of one
or more of the paranasal sinuses,4 and it is a very
common trigger to seek health care advice. It is esti-
mated about 50 patients with sinusitis will be seen by
the average primary care physician annually,5 making
it one of the top 10 diagnoses made in ambulatory
patients.6 ‘Rhinosinusitis’ is becoming an increasingly
preferred term,7 since it is argued there is mucosal
continuity between the paranasal sinuses and the nasal
cavity proper, and inflammation is generalized over
these arbitrary anatomic boundaries. The ICD-10
describes a dichotomy between acute rhinosinusitis
(ARS) if the condition lasts for less than 12 weeks,
and chronic rhinosinusitis (CRS) if it lasts for more.
However, many define ARS as lasting less than four
weeks, and use the term subacute rhinosinusitis if the
condition lasts between 4 and 12 weeks.8 Some also
distinguish between recurrent acute rhinosinusitis and
CRS, in which the latter lacks any symptoms of CRS
between acute symptomatic episodes.7
Most ARS represents extension of a viral upper
respiratory tract infection (URTI) into the sinuses,7
usually caused by rhinoviruses. Viral URTI or allergic
rhinitis may lead to secondary bacterial infection of
the sinuses. Viral URTI or allergic rhinitis may lead to
secondary bacterial infection of the sinuses in about
0.5–2% of cases (6–13% in children).4,8,9 In bacterial
sinusits, Streptococcus pneumoniae, Haemophilus
influenzae, and/or Moraxella catarrhalis are common
causative organisms.8 CRS is a multifactorial chronic
inflammatory disorder in which allergy, bacterial and
fungal infection may be involved.10 Polypoid and non-
Fig. 1 Anatomic relations of the maxillary sinus.
290
polypoid forms of CRS are recognized.11 Obstruction
of the osteomateal unit is thought to be pivotal in the
development and persistence of sinusitis.1
The cardinal features of ARS are purulent nasal dis-
charge (anterior and/or posterior); nasal obstruction/
congestion; facial pain/pressure/fullness in the anterior
face, periorbital region or headache.7 The cardinal
features of CRS include those described for ARS in
addition to olfactory chemosensory dysfunction
(dysosmia or total anosmia). Minor diagnostic criteria
for CRS are said to be headache, halitosis, fatigue,
dental pain, cough and ear pressure/fullness.12 By tra-
dition the signs and symptoms of maxillary sinusitis
(antritis) are distinguished from ethmoid sinusitis
(ethmoiditis), frontal sinusitis, etc (Fig. 2).
Viral URTI tends to be self-limiting, and the treat-
ment is symptomatic (analgesics, antipyretics and/or
decongestants).7 There is widespread over-prescription
of antibiotics in ARS,9 which are usually ineffective
since most cases represent viral URTI. One evidence-
based protocol advocated that clinicians assume the
aetiology of rhinosinusitis is viral if symptoms have
been present for less than 10 days and are not wors-
ening. If symptoms persist, or there is double worsen-
ing (worsening after an initial improvement), then
acute bacterial rhinosinusitis is presumed.7 CRS tends
to be managed with nasal irrigation and topical and
systemic pharmacotherapies including corticosteroids,
decongestants, antihistamines, antibiotics and antifun-
gals.13 Functional endoscopic sinus surgery (FESS) is
used in cases recalcitrant to non-surgical treatment.
This technique aims to restore sinus ventilation and
drainage.12
Maxillary sinusitis masquerading as odontalgia
Maxillary sinusitis is not uncommonly perceived as
pain originating in the maxillary molar and premolar
teeth, which may trigger patients to seek dental care.
This is an example of so called non-odontogenic
toothache.14 In one report, 11% of patients with
Fig. 2 CT showing maxillary sinusitis (image courtesy of Murat Aydin
DDS, PhD).
© 2014 Australian Dental Association
 Rhinosinusitis in oral medicine and dentistry

sinusitis reported maxillary toothache.15 In maxillary Odontogenic maxillary sinusitis

sinusitis, the posterior maxillary teeth may be tender
By tradition, odontogenic infection is considered a
to percussion,16 and hypersensitive to cold stimuli.
rare cause of sinusitis, said to account for about
This is secondary hyperalgesia (i.e. concentric spread
10–12% of cases.3,19 In 1986, a study of 200 patients
of pain beyond the area of tissue injury), rather than
with sinusitis reported that 40% were odontogenic in
true referred pain. There may also be mucosal tender-
nature.20 More recently in 2010, a study of 411
ness, oedema and erythema in the area over the sinus
patients with CRS reported that 25% were odonto-
intraorally.14 This clinical presentation may prompt
genic.21 Thickening of the sinus mucosa is almost 10
consideration of dental pathoses. If periapical radio-
times more commonly demonstrated in individuals
graphs are carried out, artifactual widening of the
with periapical lesions.22 The cause of odontogenic
periodontal ligament space may occur where the api-
maxillary sinusitis is usually periapical or periodontal
ces are superimposed on the sinus. In heavily restored
infection of a maxillary posterior tooth, where the
quadrants which may provide multiple apparent
inflammatory exudate has eroded through the bone
causes of dental pain, busy dentists may be motivated
superiorly to drain into the maxillary sinus. Less com-
to carry out dental treatment in such a scenario.
monly, dentoalveolar trauma or surgery involving the
Differentiation between odontalgia from maxillary
posterior maxillary teeth results in infection which
sinusitis and dental causes of odontalgia (e.g. pulpitis
spreads to the sinus.
or a dentoalveolar abscess) is achieved mainly through
The displacement of tooth apices or other foreign
a careful history and examination. The cardinal signs
bodies into the sinus can cause sinusitis. Dental
and symptoms of rhinosinusitis have been described
implants which penetrate the sinus membrane are
above, including purulent nasal discharge and nasal
sometimes cited as a potential cause of sinusitis. How-
obstruction/congestion. Classically, sinusitis pain
ever, in a longitudinal study of 70 patients with
increases during head movements (particularly when
implants perforating the sinus, none had evidence of
the head is placed below the level of the heart), or dur-
sinusitis after an average review period of 10 years.23
ing valsalva manoeuvre. The pain is worse when the
Dental implants can be entirely lost into the sinus dur-
head is held upright compared to when lying supine.17
ing their placement and act as a foreign body.24 End-
The explanation for this feature is related to local
odontic materials can also be extruded into the sinus.
increases in blood pressure which accompany postural
Aspergillosis sinusitis is a recognized complication of
changes. However, pain intensity modulation with pos-
zinc oxide eugenol materials (e.g. obturation paste)
tural changes may also accompany an acute dentoalve-
being left in the antrum25–27 (See Fig. 3).
olar abscess. In sinusitis, there may be tenderness to
The causative organisms in odontogenic sinusitis
palpatation in the infraorbital region.14 Potentially use-
tend to differ from non-odontogenic sinusitis. In the
ful diagnostic aids are provided by the fact that local
latter, normal nasal cavity commensals are frequently
anesthetic given intraorally will not relieve sinusitis
implicated, whereas in the former, the infection may
pain (whereas topical nasal anesthetic will).14 Intraoral
involve oral commensals and is most commonly a pre-
transillumination of the sinuses in a darkened room
dominantly anaerobic, polymicrobial infection of
may show reduced transillumination of the involved
anaerobic streptococci spp., gram-negative bacilli, and
side, caused by the presence of fluid and thickening of
Enterobacteriaceae.29 Once odontogenic infection
the Schneiderian membrane.3 With the patient’s head
involves the maxilary sinus, if untreated or inade-
held upright, a fluid level may even be demonstrable.16
quately treated, it may progress to pansinusitis. Rare
Several teeth tend to be tender to percussion rather than
a single tooth, although generalized tenderness to per-
cussion can also be seen in dental conditions such as
bruxism. A dental panoramic radiograph may show
obvious pathology such as mucosal thickening or a
fluid level in the inferior part of the sinus,3 appearing as
radiopaque areas relative to the contralateral side. In a
panoramic, the focal trough corresponds to the dental
arches, and therefore it imperfectly images the sinus.
Other features of acute maxillary sinusitis are non-
specific (e.g. pyrexia, elevated erythrocyte sedimenta-
tion rate and elevated C-reactive protein),18 and not
particularly helpful in ruling out odontogenic infec-
tion. If a patient’s pain is suspected to originate from
the sinus rather than a dental cause, referral to a med- Fig. 3 CT showing Aspergillosis sinusitis of right maxillary sinus
ical colleague is indicated. (image courtesy of Murat Aydin DDS, PhD).
© 2014 Australian Dental Association 291
M Ferguson
complications include osteomyelitis, orbital celulitis,
cavernous sinus thrombosis, meningitis, subdural
empyema, or intracranial abscess. There have been
reported cases of blindness, paralysis or death result-
ing from complications of odontogenic sinusitis.3,30,31
In a review of 33 cases of odontogenic sinusitis, the
clinical features commonly found were sinus pain,
postnasal drip, congestion and maxillary toothache.
Over half the cases demonstrated a periapical abscess
on CT, but in 12 cases there was no obvious dental
pathology. Odontogenic sinusitis and non-odontogenic
sinusitis present with similar clinical features, but the
former is usually unilateral and may be present in the
absence of obstruction to the drainage of the
sinus.19,32
Odontogenic maxillary sinusitis may be resistant to
conventional sinusitis therapy.29 Rather, management
of both the sinusitis and the dental cause is required
to resolve the condition. Dental management is by
extraction or endodontic treatment of the causative
tooth. Antibiotics are usually required, and cover for
both oral and sinus flora should be prescribed.34 In
the case of foreign bodies, their location should be
confirmed radiographically and then removed by
either a Caldwell-Luc or endoscopic approach.
Maxillary sinusitis secondary to oroantral
communications and fistulae
Sinusitis can occur secondary to an oroantral commu-
nication (OAC) created during exodontia. Fractures of
the maxillary tuberosity may create OAC, especially if
the tuberosity is completely removed. OAC are more
commonly created than is generally realized, although
most small defects tend to close spontaneously with-
out any intervention. If a patent communication per-
sists, mucosal epithelia proliferate from the sinus
lining and the oral mucosa, taking about a week to
fully line the defect, which is then termed an oroantral
fistula (OAF). Classically, OAC/OAF present with a
complaint of beverages entering the nose when
drinking, a bad, salty taste or the inability to draw on
a cigarette or to inflate the cheeks.33 These features
are mixed on a background of the usual sinonasal
symptoms if acute sinusitis develops. On examination,
a prolapse of antral lining may be visible in the tooth
socket. Immediately following extraction, it has been
suggested that asking the patient to blow through
their nose while occluding their nares, and observing
the socket for escaping bubbles can confirm the pres-
ence of an OAC. However, this risks creation of an
OAC where it did not exist before and is an inadvis-
able diagnostic test.
Depending upon the experience of the clinician,
management of this complication may warrant refer-
ral to a specialist in oral surgery. However, measures
292
to prevent OAC/OAF should be common knowledge
to all clinicians carrying out exodontia. Firstly, the
risk assessment on all maxillary posterior teeth for
extraction should include consideration of the possi-
bility or creating an OAF. Example factors which pre-
dispose to OAC/OAF are listed in Table 1. About
50% of reported OAF are associated with the maxil-
lary first molar, most commonly in middle aged
males.28 The maxillary first molar region often corre-
sponds to the most inferior position of the antral floor
and hence the closest part of the antrum to the oral
cavity. Also, the maxillary first molar is a large tooth,
leaving a large socket after extraction, and making it
less likely that a thrombus will be retained and orga-
nize. Teeth which are deemed to be at high risk may
be more appropriately extracted by a specialist in oral
surgery, or the surgical plan amended to reduce the
risk. For example, sectioning of the tooth carries less
risk of OAF creation than extraction with forceps and
elevators. Similarly, curettage of lesions such as peri-
apical granulomata risks creation of an OAC if in
close proximity to the antrum. Following the extrac-
tion, postoperative advice (e.g. avoid blowing the
nose, drinking through a straw or sucking at or other-
wise disturbing the extraction site, which risks loss of
the thrombus), should be given to the patient.
Sinusitis secondary to OAF tends not to resolve until
the defect is closed. Detailed descriptions of the surgi-
cal management of OAF are outside the scope of this
review. The treatment options for established defects
are flap closure (buccal or palatal mucoperiosteal flap,
or buccal fat pad), or minimally invasive techniques
utilizing bioresorbable root analogues or haemostatic
gauze. A systematic review held these to have com-
parable reliability.35 The buccal advancement flap
Table 1. Oroantral communication, predisposing
factors
Local factors
• Intimate relationship between tooth apices and antral floor
• Widely divergent root morphology – more likely to remove a
section of bone
• Tooth size – large teeth more prone
• Tooth position – maxillary first molar most common
• Periapical lesions – lead to bony remodelling of the contour of
the antral floor and weakness
• Hypercementosis
• Ankylosis
Systemic factors
• Patient age – middle aged and elderly patients more
predisposed
• Impaired wound healing – e.g. smoking
• Predisposition to infection – e.g. diabetes
• Systemic bone disorder – especially alterations in bone density
© 2014 Australian Dental Association

technique may result in loss of sulcus depth, but is
favoured by some. Other sources also state excision of
the epithelial lining of the tract is indicated to prevent
inclusion of epithelia which may later proliferate and
cause the OAF to persist. Immediately following
closure of an OAF, an antral regime is indicated,
aiming to avoid increased pressure in the sinus. A
typical antral regime consists of nasal decongestants
(e.g. ephedrine), implicit instructions not to blow the
nose, antibiotics and antiseptic mouthwash (e.g.
chlorhexidine).
Displacement of root into the antrum
Most often, this occurs with the palatal root of the
maxillary first molar, or an impacted maxillary third
molar, and is due to excessive vertical force applied to
the tooth with forceps or elevators, combined with
predisposing anatomic factors such as a thin or other-
wise structurally weakened floor of the antrum. As
with the risk factors for OAC/OAF creation, periapi-
cal lesions are sometimes responsible.
The sudden disappearance of a tooth or root during
the extraction, combined with a routine check that
the apices of extracted teeth are intact means this
complication is usually detected immediately by the
dentist. Root fracture is a common occurrence in
tooth extraction, but is generally preventable with due
care. Most root fractures occur with premature
attempts to deliver the tooth, before sufficient luxa-
tion has been carried out, or movements made with-
out regard for the root morphology, e.g. rotational
movements in a tooth with a sharp apical bend. How-
ever, there will always be some teeth which are
impossible to extract whole. Some are of the opinion
if there is only a small fragment of root left in the
socket and no periapical pathology present, then the
root can be left as its retrieval would cause more
harm than good. Such retained roots may spontane-
ously erupt or sequestrate in later years, where their
removal will be much easier. However, if a fractured
root from a maxillary posterior tooth is not visible in
the socket, it cannot be left and it must be located.
This commonly occurs in addition to the creation of
an OAC, but the mucosal lining of the antrum may
not necessarily be penetrated since the root can be
pushed submucosally under the lining rather than
being displaced to lie free in the antrum.
Again, depending upon the setting and the clini-
cian’s experience, this complication may warrant
referral to a specialist. The management involves ini-
tially locating the fragment radiographically, ideally in
two different views so the exact position can be deter-
mined via parallax. Attempts to remove the fragment
can be exacted via the tooth socket if an OAC has
been created, or via a Caldwell–Luc approach if no
© 2014 Australian Dental Association
Rhinosinusitis in oral medicine and dentistry
OAC exists. If these attempts fail, intranasal antrosto-
my may be required.
Rhinosinusitis as a cause of halitosis
There is general agreement that about 10% of all
objective (genuine) halitosis complaints are caused by
extraoral processes; however, their relative importance
is debated. One research group report that halitosis
caused by the blood-borne mechanism is the most
common,36–38 whilst others state tonsillar pathology
is the most common.39 Sinusitis is sometimes cited as
a possible cause of halitosis.40–43 Indeed, the RSTF
1996 criteria lists halitosis as a minor clinical feature
of chronic sinustitis,44 and one source reported 50%–
70% of chronic sinusitis patients will complain of hal-
itosis,45 which may be present even when features
such as nasal obstruction, postnasal exudate, pain,
sneezing and secretion are clinically absent.46
Sources listing halitosis as a possible symptom of
sinusitis must be interpreted with caution. Clinicians
and researchers unfamiliar with gold standard tech-
niques such as organoleptic assessment or analysis of
breath gases with gas chromatography may utilize
unreliable methods of halitosis detection, e.g. ques-
tionnaires and patient self reports. Subjective (non-
genuine) halitosis complaints may account for
between 5% and 71% of all patients who complain
of halitosis, and these are explained in the large part
by psychologic factors, but also by retronasal olfac-
tion or neurologic factors such as chemosensory dys-
function.36,47 A marked lack of standardization of
research methodologies has led to some authors call-
ing for greater efforts in standardizing protocols in
halitosis research.48 Many reported correlations
between halitosis and various ailments may prove to
be uncorroborated by studies with more reliable
methodologies. For example, upon reviewing the
literature one will find several studies which report a
correlation between halitosis and Heliobacter pylori
infection, and yet when researchers specializing in
halitosis carried out a study using gas chromatogra-
phy, no such association was demonstrated.49 Unfor-
tunately, researchers unfamiliar with the complexity
of the halitosis topic readily accept self reported hali-
tosis as a reliable measure of objective halitosis.
To the author’s knowledge there is no available evi-
dence of the exact pathophysiologic mechanism by
which sinusitis may cause either an objective or sub-
jective halitosis complaint. Therefore, several possible
mechanisms are suggested here. Some claim halitosis
secondary to sinonasal pathoses is more strongly
detectable on the nose breath while the mouth is
closed than on the mouth breath when the nares are
occluded.50 Stasis and stagnation of secretions, the
result of mucosal inflammation which obstructs
293
M Ferguson
drainage, will likely be associated with increased bac-
terial load. Consequently, increased volatile sulfur
compound (VSC) release may occur, along with other
volatiles. In purulent sinusitis, the presence of pus
may contribute to the malodour, particularly in anaer-
obic infections. The so-called post-nasal drip syn-
drome is postulated to be caused by sinusitis among
other things, and in addition, is said to be a cause of
halitosis. In post-nasal drip, mucus drains onto the
posterior dorsal tongue via the nasopharynx.51 How-
ever, it has been argued nasal mucus dripping down
the back of the throat occurs in normal, healthy peo-
ple, and furthermore there are no pathologic or bio-
chemical tests for this condition.52 Also, the
relationship between post-nasal drip and halitosis has
not been formally investigated. Some have suggested
obstructive nasal pathology can cause mouth breath-
ing, which results in oral malodor (intraoral halitosis)
secondary to xerostomia.53,54 Xerostomia reduces the
mechanical cleansing and antimicrobial action of
saliva and results in a sharp increase in bacterial
growth in the mouth. The higher the bacterial load,
the more VSC are released with bacterial putrefaction.
The nasal congestion which accompanies sinusitis is
readily imagined as a cause of nasal obstruction.
However, to contradict this possible mechanism, oth-
ers report mouth breathing is not associated with hali-
tosis.55 On the other hand, subjective halitosis (odour
perceived only by the patient) could be explained by
dysosmia, retronasal olfcation, or a foul taste caused
by posterior nasal discharge.
CONCLUSIONS
Rhinosinusitis may present as maxillary toothache and
such patients may present to the dentist. In this sce-
nario, differentiation between dental causes of odontal-
gia and maxillary sinusitis can be challenging, requiring
a careful history and examination. Odontogenic maxil-
lary sinusitis has a higher incidence than is traditionally
recognized, and requires joint dental and medical man-
agement once established. Although rhinosinusitis is
frequently described as causing halitosis, it is unclear if
this constitutes an objective or subjective halitosis com-
plaint since the evidence of a relationship is performed
in the absence of gold standards for halitology research.
Theoretically, both objective and subjective halitosis
may be caused by several mechanisms in rhinosinusitis.
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Address for correspondence:
Dr Matthew Ferguson
Marfleet Primary Healthcare Centre
Hull HU9 5HH
United Kingdom
Email: ferguson.mmx@gmail.com
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