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An endodontically induced maxillary sinusitis
0099-2399/84/1010-0504/$02.00/0 JOURNALOF ENDOF)ONTICS Copyright 9 1984 by The American Associationof Endodontists
Printed in U.SJe VOL. 10. No. 10, OCTOBER 198
CASE REPORT An Endodonticaily Induced Maxillary Sinusitis Sinusitis Debida a un Tratamiento Endodontico Robin B. Dodd, ODS, R. Nell Dodds, DOS, and John B. Holcomb, DDS
root canal treatment (2). The choice of materials and techniques available to the operator to achieve endodontic success are numerous (3) and success rates as high as 95% can be attained, if basic endodontic principles are followed (1,4). When these basic principles are violated, the preservation of the tooth in the dental arch and the health of the patient can be jeopardized. The purpose of this paper is to report a case in which an improperly treated maxillary first molar initiated a chronic sinusitis. A 25-yr-old female with an acute abscess of the maxillary right first molar was seen by her family dentist in September 1978. She became asymptomatic after emergency endodontic treatment and antibiotic therapy and a root canal filling was completed after several appointments using silver cones. Nine months later she began to have pain and pressure in the area of the treated tooth and sought the services of an oral surgeon who treated her for a maxillary sinusitis. During the next 2 yr infections of the sinus became increasingly frequent and more intense and were treated with antibiotics and analgesics. In 1981 a sinus series was taken by an ear, nose, and throat specialist and the CaldwellLuc procedure was performed on her maxillary right sinus. Multiple polyps were removed and a silver point was visualized protruding into the sinus. Her symptoms continued after the surgery and she presented in March 1983 to the endodontic department at Medical College of Virginia, Virginia Commonwealth University School of Dentistry for evaluation. Panorex radiographs (Fig. 1) revealed overextended silver points in the palatal and distobuccal canals and a mesiobuccal canal that did not appear to be obturated. The silver points were retrieved without undue difficulty through a normal access opening and were found to be corroded (Fig. 2). The canals were obturated with gutta-percha on the second visit (Fig. 3) and the patient has been asymptomatic since the treatment was completed. Radiographic evaluation after I yr confirmed the success of the treatment (Fig. 4).
A case report is presented in which a maxillary first molar was overfilled with silver cones, resulting in a chronic sinusitis. The etiology was initially undiagnosed and the patient was subjected to unnecessary surgery of the sinus. Proper retreatment of the case eliminated the patient's symptoms and returned the tooth to a state of health and function. Se presenta un caso de sinusitis cronica producida por la sobreobturacion con conos de plata en un primer molar superior. La etiologia de la sinusitis no se diagnostic6 inicialmente y se le hizo al paciente una innecesaria cirugia de seno. El retratamiento correcto del conducto elimino los sintomas del paciente y devolvio al molar a su estado de salud y funcion.
The ultimate goal of endodontic therapy is to return a pulpally compromised tooth to a state of health and function. According to Weine (1), endodontic therapy consists of three phases: a diagnostic and treatment planning phase, a preparatory phase which involves thorough debridement and shaping of the root canal system, and the final phase of hermetically sealing the root canal system by complete obturation ideally to the cementodentinal junction. Although endodontic therapy involves working within the confines of the tooth, it is the surrounding tissues and their response to treatment that determines success or failure (1). Success is primarily based on clinical and radiographic criteria. Clinical success should demonstrate that an involved tooth has been returned to normal masticatory usage and is free of sinus tracts, swelling, and symptoms. Radiographically, it should demonstrate periapical bone with normal appearance and structure and any radiolucency initially present should be reduced in size or absent. Success can al~o vary significantly between patients due to each patient's ability to tolerate diseases and their unique response to injury, periapical disease, and 504
Vol. 10, No. 10, October 1984
Maxillary Sinusitis
505
FIG 1. Panorex revealing overextended silver points. F~G4. Radiographic evaluation after I yr.
FIG 2. Corroded silver points.
FIG 3. Canals were obturated with gutta-percha.
DISCUSSION
It has been reported that pathosis of the maxillary sinus is dentally related in 10 to 15% of the cases (5). Because of the close relationship of the maxillary sinus to the apices of the maxillary posterior teeth, a direct relationship between dental sepsis and the maxillary sinus seems obvious. Pain and symptoms evolving from
the maxillary molar area can be ambiguous and may cause problems with diagnosis and treatment. Symptoms of maxillary sinusitis usually entail continuous dull aching pain over the cheeks and maxillary teeth on the affected side. The maxillary sinus varies widely in size and configuration with considerable bone between the apices of the teeth and the sinus in some patients. Hyperplasia of the antral mucosa may be induced from periapical osteitis and there is a relationship between the thickness of the overlying bone and the incidence of hyperplasia" the thinner the bone between the apices of the teeth and the sinus, the greater the incidence of hyperplasia. Repair of the mucosa usually ensues following adequate root canal treatment (6). However, some cases do not respond to treatment and these have been described as evidencing the endoantral syndrome requiring surgical intervention (7). In the present case, silver points were used to obturate the distobuccal and palatal canals. Silver points are difficult to use correctly but they have been clinically successful with careful case selection and proper adaptation. They are not advocated for palatal canals of maxillary molars because canal configuration does not allow for proper adaptation (4). Teeth with silver cones extending beyond the apical foramen are usually underfilled because space exists between the canal walls and the silver cones (8). Corrosion is a well known property of silver points and can also be a potential hazard in cases where the silver point is overextended. Seltzer et al. (9) found that silver points contacting tissue fluids became corroded with the formation of silver sulfide, silver sulfate, and silver carbonate. These corrosion products are known to be cytotoxic and silver cones pushed beyond the apex of the tooth are severely toxic to periapical tissue (9). The clinical success of silver points is enhanced when the points are seated entirely within the confines of the canal and surrounded by zinc oxide-eugenol sealer cement (10). Time has demonstrated that the silver point is not as effective an
506
Dodd et al.
Journal of EndodontJcs
apical seal as was once believed because the radiographic appearance is not always a true representation of the subtle changes taking place in the canal (2). In the present case the corrosive properties of the silver points, the intimate position of the maxillary sinus to the apices of the teeth, and the improper and inadequate root canal therapy jeopardized the health of the patient.
Richmond, VA. Dr. Dodds is assistant professor and director of postgraduate endodontics. Department of Endodontics, Medical College of Virginia. Virgmk3 Commonwealth University Dr. Holcomb is assJstant professor, SctKX~ Of Denbstry, Medical College of Virginia, Virginia Commonwealth Ufliversity, Richmond, VA 23298 Address requests for relents to Dr Robin B. Dodd.
SUMMARY
1, Weine FS. Endodontic therapy. 3rd (El. St. Louis: CV Mosby, 1982:2-4. 2. Frank AL, Simon JHS, Abou-Rass M, Glick DH Clinical and surgica~ endodontics, Concepts in practice. Philadelphia: JB IJppgrlcott, 1983:3-6, 80. 3. Schilder H. Filling root canals in three dimensions Dent Clin North Am 1967:723, 4. Ingle JI. Endedontncs. 2nd ed. Philadelphia: Lea & Febiger, 1976"34, 222 5, Kruger GO. Textboo~ of oral surgery. 3rd ed. St Louis: CV Mosby, 1968:254 6. Selden. HS The interrelatK:)nship between the maxillary sinus and en. dodonhcs. Oral Surg 1974:38:623, 7. Selden, HS. The efldo-antral syndrome. Oral Surg 1977;3:462. 8 Cohen S. Bums RC. Pathways of the pulp. 3rd ed St. Louis: CV Mosby, 1984:271. 275, 811 9. Seltzer S, Green DB, Weiner N, DeRenzis F A scanning electron mncroscope examination of sliver cones removed from endodontically treated teeth, Oral Surg 1972;33:589. 10 Gerstein H Techniques in clinK~.alendodontics. Philadelphia: WB Saunders. 1983263
A case report of a chronic sinusitis precipitated by inadequate and improper root canal treatment of a maxillary first molar is presented. Maxillary sinusitis and the corrosive properties of silver points are discussed. The proximity of the root apices to the maxillary sinus dictates prudent use of endodontic filling materials and proper technique. We thank Ms. Jane Tolker for pfepanng th~s manuscript. Dr Dodd was a second-year postgraduate endodontic student, Department of Endodontics, MedPcalCollege of Virginia, Virginia Commonwealth University,
References
Painting by David Solot, Pans, France.
Printed in U.SJe VOL. 10. No. 10, OCTOBER 198
CASE REPORT An Endodonticaily Induced Maxillary Sinusitis Sinusitis Debida a un Tratamiento Endodontico Robin B. Dodd, ODS, R. Nell Dodds, DOS, and John B. Holcomb, DDS
root canal treatment (2). The choice of materials and techniques available to the operator to achieve endodontic success are numerous (3) and success rates as high as 95% can be attained, if basic endodontic principles are followed (1,4). When these basic principles are violated, the preservation of the tooth in the dental arch and the health of the patient can be jeopardized. The purpose of this paper is to report a case in which an improperly treated maxillary first molar initiated a chronic sinusitis. A 25-yr-old female with an acute abscess of the maxillary right first molar was seen by her family dentist in September 1978. She became asymptomatic after emergency endodontic treatment and antibiotic therapy and a root canal filling was completed after several appointments using silver cones. Nine months later she began to have pain and pressure in the area of the treated tooth and sought the services of an oral surgeon who treated her for a maxillary sinusitis. During the next 2 yr infections of the sinus became increasingly frequent and more intense and were treated with antibiotics and analgesics. In 1981 a sinus series was taken by an ear, nose, and throat specialist and the CaldwellLuc procedure was performed on her maxillary right sinus. Multiple polyps were removed and a silver point was visualized protruding into the sinus. Her symptoms continued after the surgery and she presented in March 1983 to the endodontic department at Medical College of Virginia, Virginia Commonwealth University School of Dentistry for evaluation. Panorex radiographs (Fig. 1) revealed overextended silver points in the palatal and distobuccal canals and a mesiobuccal canal that did not appear to be obturated. The silver points were retrieved without undue difficulty through a normal access opening and were found to be corroded (Fig. 2). The canals were obturated with gutta-percha on the second visit (Fig. 3) and the patient has been asymptomatic since the treatment was completed. Radiographic evaluation after I yr confirmed the success of the treatment (Fig. 4).
A case report is presented in which a maxillary first molar was overfilled with silver cones, resulting in a chronic sinusitis. The etiology was initially undiagnosed and the patient was subjected to unnecessary surgery of the sinus. Proper retreatment of the case eliminated the patient's symptoms and returned the tooth to a state of health and function. Se presenta un caso de sinusitis cronica producida por la sobreobturacion con conos de plata en un primer molar superior. La etiologia de la sinusitis no se diagnostic6 inicialmente y se le hizo al paciente una innecesaria cirugia de seno. El retratamiento correcto del conducto elimino los sintomas del paciente y devolvio al molar a su estado de salud y funcion.
The ultimate goal of endodontic therapy is to return a pulpally compromised tooth to a state of health and function. According to Weine (1), endodontic therapy consists of three phases: a diagnostic and treatment planning phase, a preparatory phase which involves thorough debridement and shaping of the root canal system, and the final phase of hermetically sealing the root canal system by complete obturation ideally to the cementodentinal junction. Although endodontic therapy involves working within the confines of the tooth, it is the surrounding tissues and their response to treatment that determines success or failure (1). Success is primarily based on clinical and radiographic criteria. Clinical success should demonstrate that an involved tooth has been returned to normal masticatory usage and is free of sinus tracts, swelling, and symptoms. Radiographically, it should demonstrate periapical bone with normal appearance and structure and any radiolucency initially present should be reduced in size or absent. Success can al~o vary significantly between patients due to each patient's ability to tolerate diseases and their unique response to injury, periapical disease, and 504
Vol. 10, No. 10, October 1984
Maxillary Sinusitis
505
FIG 1. Panorex revealing overextended silver points. F~G4. Radiographic evaluation after I yr.
FIG 2. Corroded silver points.
FIG 3. Canals were obturated with gutta-percha.
DISCUSSION
It has been reported that pathosis of the maxillary sinus is dentally related in 10 to 15% of the cases (5). Because of the close relationship of the maxillary sinus to the apices of the maxillary posterior teeth, a direct relationship between dental sepsis and the maxillary sinus seems obvious. Pain and symptoms evolving from
the maxillary molar area can be ambiguous and may cause problems with diagnosis and treatment. Symptoms of maxillary sinusitis usually entail continuous dull aching pain over the cheeks and maxillary teeth on the affected side. The maxillary sinus varies widely in size and configuration with considerable bone between the apices of the teeth and the sinus in some patients. Hyperplasia of the antral mucosa may be induced from periapical osteitis and there is a relationship between the thickness of the overlying bone and the incidence of hyperplasia" the thinner the bone between the apices of the teeth and the sinus, the greater the incidence of hyperplasia. Repair of the mucosa usually ensues following adequate root canal treatment (6). However, some cases do not respond to treatment and these have been described as evidencing the endoantral syndrome requiring surgical intervention (7). In the present case, silver points were used to obturate the distobuccal and palatal canals. Silver points are difficult to use correctly but they have been clinically successful with careful case selection and proper adaptation. They are not advocated for palatal canals of maxillary molars because canal configuration does not allow for proper adaptation (4). Teeth with silver cones extending beyond the apical foramen are usually underfilled because space exists between the canal walls and the silver cones (8). Corrosion is a well known property of silver points and can also be a potential hazard in cases where the silver point is overextended. Seltzer et al. (9) found that silver points contacting tissue fluids became corroded with the formation of silver sulfide, silver sulfate, and silver carbonate. These corrosion products are known to be cytotoxic and silver cones pushed beyond the apex of the tooth are severely toxic to periapical tissue (9). The clinical success of silver points is enhanced when the points are seated entirely within the confines of the canal and surrounded by zinc oxide-eugenol sealer cement (10). Time has demonstrated that the silver point is not as effective an
506
Dodd et al.
Journal of EndodontJcs
apical seal as was once believed because the radiographic appearance is not always a true representation of the subtle changes taking place in the canal (2). In the present case the corrosive properties of the silver points, the intimate position of the maxillary sinus to the apices of the teeth, and the improper and inadequate root canal therapy jeopardized the health of the patient.
Richmond, VA. Dr. Dodds is assistant professor and director of postgraduate endodontics. Department of Endodontics, Medical College of Virginia. Virgmk3 Commonwealth University Dr. Holcomb is assJstant professor, SctKX~ Of Denbstry, Medical College of Virginia, Virginia Commonwealth Ufliversity, Richmond, VA 23298 Address requests for relents to Dr Robin B. Dodd.
SUMMARY
1, Weine FS. Endodontic therapy. 3rd (El. St. Louis: CV Mosby, 1982:2-4. 2. Frank AL, Simon JHS, Abou-Rass M, Glick DH Clinical and surgica~ endodontics, Concepts in practice. Philadelphia: JB IJppgrlcott, 1983:3-6, 80. 3. Schilder H. Filling root canals in three dimensions Dent Clin North Am 1967:723, 4. Ingle JI. Endedontncs. 2nd ed. Philadelphia: Lea & Febiger, 1976"34, 222 5, Kruger GO. Textboo~ of oral surgery. 3rd ed. St Louis: CV Mosby, 1968:254 6. Selden. HS The interrelatK:)nship between the maxillary sinus and en. dodonhcs. Oral Surg 1974:38:623, 7. Selden, HS. The efldo-antral syndrome. Oral Surg 1977;3:462. 8 Cohen S. Bums RC. Pathways of the pulp. 3rd ed St. Louis: CV Mosby, 1984:271. 275, 811 9. Seltzer S, Green DB, Weiner N, DeRenzis F A scanning electron mncroscope examination of sliver cones removed from endodontically treated teeth, Oral Surg 1972;33:589. 10 Gerstein H Techniques in clinK~.alendodontics. Philadelphia: WB Saunders. 1983263
A case report of a chronic sinusitis precipitated by inadequate and improper root canal treatment of a maxillary first molar is presented. Maxillary sinusitis and the corrosive properties of silver points are discussed. The proximity of the root apices to the maxillary sinus dictates prudent use of endodontic filling materials and proper technique. We thank Ms. Jane Tolker for pfepanng th~s manuscript. Dr Dodd was a second-year postgraduate endodontic student, Department of Endodontics, MedPcalCollege of Virginia, Virginia Commonwealth University,
References
Painting by David Solot, Pans, France.