Next Article in Journal
Main Findings from Retrospective Studies on the Comorbidity of Asthma and Sinusitis and Their Implications for Clinical Practice
Previous Article in Journal
Cholesterol Granuloma of the Frontal Sinus Complicated by Mycetoma: A Rare Case Report
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Sinusitis
Volume 9
Issue 2
10.3390/sinusitis9020016
sinusitis-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Apical Periodontitis and Maxillary Sinus Alterations: Results of an Exploratory Cross-Sectional Tomographic In Vivo Study

by
Thaïs Coutinho
1,
Lucio Gonçalves
2,
Marilia Fagury Videira Marceliano-Alves
1,
Vivian Ronquete Figueiredo
1,
Josué da Costa Lima Junior
2,
Rafael Vidal Peres
2 and
Fábio Vidal
2,3,*
1
Post Graduation Program in Dentistry, Iguaçu University, Nova Iguaçu 26275-580, RJ, Brazil
2
Post Graduation Program in Dentistry, Faculty of Dentistry, Estácio de Sá University, Rio de Janeiro 22640-100, RJ, Brazil
3
Department of Periodontology, Dental School, Rio de Janeiro State University, Rio de Janeiro 20551-030, RJ, Brazil
*
Author to whom correspondence should be addressed.
Sinusitis 2025, 9(2), 16; https://doi.org/10.3390/sinusitis9020016
Submission received: 11 December 2024 / Revised: 20 August 2025 / Accepted: 21 August 2025 / Published: 26 August 2025
Browse Figures
Versions Notes

Abstract

Odontogenic sinusitis is a highly prevalent yet frequently overlooked condition. Since anatomically, the roots of the upper molars and premolars may be in proximity to the maxillary sinus, apical periodontitis affecting these teeth may lead to the development of sinus membrane thickening suggestive of odontogenic sinusitis. The present cross-sectional study aimed to investigate the relationship between images suggestive of apical periodontitis and alterations in the maxillary sinus. One hundred and thirty Cone Beam Computed Tomographies (CBCTs) of the posterior maxilla were examined for the presence of apical radiolucent lesions and thickening of the sinus membrane. The relationship between the distance of the lesions from the sinus and the prevalence of sinus alterations was described and compared using a chi-squared test and logistic regression models. In the sample studied, 16.12% and 45.96% of the sinus images suggested mucositis and sinusitis, respectively. The mere presence of radiolucent apical lesions was not related to sinus alterations. However, lesions breaking through the cortical floor of the sinus were associated with a larger mucosal thickness, reaching statistical significance on the left side. Estimation of the magnitude showed that increasing the sample size would lead to a statistical difference on the right side as well. Thus, it can be concluded that, in cases where lesions suggesting apical periodontitis are closely related to the sinus floor, breaking though the cortical bone of the maxillary sinus floor, the prevalence of sinus mucosal thickening, indicating mucositis or sinusitis, is greater.

1. Introduction

Maxillary sinus pathosis is a frequently described imaging finding, even in asymptomatic individuals [1]. Mucosal thickening (MT) is the most common alteration [2,3,4,5], with a prevalence ranging from 23.7% [6] in young patients to up to 74.3% in dentate elders [7]. Although definitions may vary among authors, it is accepted that a normal, healthy sinus presents no MT or only mild thickening (<2 mm) with a flat characteristic [8] while MT of >6 mm indicates mucosal pathology [9].
Rhinosinusitis is the main cause of mucosal thickening in symptomatic individuals [1,10], while in asymptomatic patients, allergic problems are possible culprits [11]. Since both rhinosinusitis and allergic conditions usually present as bilateral alterations, Otolaryngologists recognize that whenever unilateral mucosal thickening or sinus opacification is found, or in cases of chronic rhinosinusitis that do not respond to antibiotics, patients must be referred to a Dentist, and a dental cause must be sought [12,13].
Although odontogenic sinusitis (OS) is a long-known condition, it is frequently underdiagnosed, lacking a detailed and broadly agreed-upon definition [14]. Although comprehensive reviews have addressed this topic [15,16] and retrospective studies have estimated that more than 70% of cases of unilateral maxillary sinusitis have an odontogenic etiology [17,18], OS has been briefly described in many guidelines for rhinosinusitis, such as the EPOS (European Position Paper on Rhinosinusitis and Nasal Polyps) [19].
Regardless of the lack of consensus, based on the current knowledge, OS can be defined as “predominantly unilateral sinus opacification and sinus symptoms related to a history of dental disease or dental treatment on the upper jaw (at the same side) in temporal relation to the symptoms onset and CT findings” [20].
The biological rationale supporting the etiological role of odontogenic infections in the development of MT and OS is based on the well-described anatomical proximity of the apices of the maxillary premolars and molars to the maxillary sinus floor [10,21]. Often, the roots of maxillary teeth may disrupt the contours of the sinus floor [10], leaving only the mucoperiosteum between the roots and the sinus [21]. Such a relation allows the inflammatory exudate from periapical or periodontal infection to erode through the bone and drain into the sinus, causing OS [21]. In milder cases, the bacterial/inflammatory challenges can stimulate a response from the sinus membrane, leading to MT [22].
Three-dimensional imaging techniques, such as computed tomography (CT) and cone beam CT (CBCT), are the most accurate imaging exams used to assess the spatial relationship between the teeth and the maxillary sinus and detect the presence of sinus alterations and their possible causes. Also, they allow Dentists to prevent iatrogenic events leading to oroantral communication and the intrusion of dental materials or roots into the sinus [1,23,24,25,26,27,28]. However, the European Society of Endodontology (ESE)’s joint position statement from 2019 pointed out that CBCT must not be used routinely for endodontic diagnosis or screening purposes [29], and thus, Specialists and General Practitioners must request CT and/or CBCT only in specific clinical situations, such as when OS is suspected [29].
Anatomically, the first and second molars are the teeth most closely related to the maxillary sinus floor [23,25,30], and the palatal root of the first molar is more prone to being related to MT and OS since it penetrates the sinus in 34.2% of cases [30].
Even though the concept of OS is established and well accepted in both the medical and dental literature [5,10,14,21,31,32], there is still some controversy among studies regarding the main cause of maxillary diseases of dental origin. Severe periodontal bone loss [1,11,31,32] and chronic apical periodontitis [3,4,10,23,32,33] are the dental conditions most frequently associated with maxillary sinus pathosis. However, some of these studies failed to find such an association between endodontic lesions and sinus pathosis [1,31].
Several other conditions have been cited as being the cause of MT and/or OS, such as a periapical abscess [32]; peri-implantitis [34]; an oroantral fistula [35]; dento-alveolar surgery [18]; overextension of endodontic material [34,36]; and dental implant-related complications [37].
Identifying the dental causes of MT and OS is of the utmost importance, since such conditions do not respond to the conventional therapy used to treat rhinosinusitis [10], frequently leading to recalcitrant disease [14] and unsuccessful or unnecessary sinus surgery [23,38]. In addition, maxillary sinus infections can eventually evolve into potentially serious conditions, such as orbital and intracranial abscesses [39,40,41].
The proper diagnosis and treatment of OS frequently requires collaboration between the Otolaryngologist and the Dentist [14,17]. The dental cause should be removed prior to [34] or concomitantly with endoscopic sinus surgery [14], and in some cases, dental treatment alone is enough to resolve OS [16,38].
Despite the recognition of MT and OS as frequently found conditions, affecting up to 90% of patients with periapical and/or periodontal bone loss and corresponding to about 40% of cases of unilateral sinus disease [42], there are some controversies, yet to be cleared up, regarding the role of chronic apical periodontitis in the etiology of MT and OS.
Thus, the present study aimed to investigate the relationship between CBCT images suggesting chronic apical periodontitis (CAP), MT, and maxillary sinus opacification using CBCT in a population of asymptomatic individuals referred to dental treatment.

2. Materials and Methods

Study sample: This study was approved by the Research Ethics Committee of the Health Sciences Center at Estácio de Sá University (protocol number 50594215.8.0000.5284). A total of 130 posterior maxilla CBCTs, obtained between August 2014 and July 2015, from patients referred to a private radiology clinic (ODT Digital Diagnostics, Rio de Janeiro, Brazil) were randomly selected and screened for the presence of images suggestive of chronic apical periodontitis (primary or secondary) in at least 1 posterior tooth (premolars and/or molars). A previously trained assessor, specializing in both endodontics and radiology, was responsible for the evaluations. For screening purposes, apical periodontitis was defined based on the criteria proposed by Bornstein et al. (2012) [43], which define CAP as a hypodense lesion, twice the width of the periodontal ligament space, closely associated with the apex. All images were acquired with the PreXion Elite 3D (PreXion, Inc., San Mateo, CA, USA) using a field of view of 8 × 8 cm and operating at 4.0 mA, 90 kV, a 0.1–0.15 mm voxel size, and a 37 s acquisition time in a high resolution. Then, the images were reconstructed in a high resolution, with 0.5 mm thin slices. A total of 100 exams from patients without a previous diagnosis of rhinosinusitis were included in the study and were further analyzed using open-access software for medical image viewing (InVesalius 3.0, Centro de Tecnologia da Informação Renato Archer, Campinas, SP, Brazil) and a 20-inch LCD screen. The exclusion criteria were the presence of metal artifacts impairing the adequate visualization of the posterior maxilla and whole maxillary sinus; the presence of images suggesting non-odontogenic sinus pathologies, such as solid tumors; the presence of a foreign body inside the sinus; and evidence of sinus lifting, orthognathic surgery, or corrective surgeries for the treatment of complex maxillofacial fractures.
Selection of the slices, analysis of the anatomic relationship between the teeth and maxillary sinus, and assessment of sinus alterations: After the whole tomographic volume had been analyzed in the sagittal and coronal views, the sagittal slice that allowed for the clearest visualization of the relationship between the apex and the maxillary sinus floor was selected and the linear distance between the 2 structures measured (Figure 1). The width of the sinus membrane was measured, whenever it was apparent, in the area immediately adjacent to each tooth. The parameters set by Nurbakhsh et al. (2011) [44] to classify the sinus mucosa status were used as follows: normal = a membrane up to 1 mm thick; mucositis = a membrane width of up to 3.54 mm; and sinusitis = a width of above 3.54 mm. (Figure 2). Additionally, the maxillary sinus condition was assessed using the LUND–MACKAY SCORE [45], with which the maxillary sinus can be grouped into 3 categories according to the opacification detected in an image, with 0 = a completely clean sinus; 1 = partial opacification; and 2 = complete opacification.

2.1. Evaluation of Dental Parameters

The distance between the most apical part of the apical radiolucent lesion (ARL) at each apex and the maxillary sinus floor cortical bone was measured, and the teeth were divided into 5 categories: 0 = absent; 1 = an ARL below the sinus floor cortical bone; 2 = an ARL in contact with the intact cortical bone; 3 = an ARL in contact with the sinus membrane, with an eroded cortical wall; 4 = teeth without an ARL (Figure 3).
Additionally, the presence of endodontic treatment was recorded, and a subdivision was made: 0 = teeth without endodontic treatment and no image suggesting apical periodontitis; 1 = teeth without endodontic treatment and an image suggesting apical periodontitis; 2 = teeth with endodontic treatment and no image suggesting apical periodontitis; 3 = teeth with endodontic treatment and an image suggesting apical periodontitis.
All the CBCTs were evaluated by the same, previously calibrated investigator (TMC) with an excellent intra-class correlation coefficient (ICC = 0.91). The age and gender of the patients were also obtained from the files.

2.2. Statistics

The data were tabulated, and descriptive statistics were presented: the distances from the apex of each root to the maxillary sinus floor cortical bone; the sinus membrane’s thickness in the area above each root; the prevalence of maxillary sinuses with images suggesting good health, mucositis, or sinusitis; the prevalence of each Lund–McKay score; and the prevalence of teeth with images suggesting apical periodontitis (ARL).
The association between ARLs and maxillary sinus alterations (MT) was investigated using a logistic regression model that included gender, age, and the spatial relationship between the ARL and maxillary sinus as variables and MT as the outcome. The chi-squared distribution was used to compare the frequencies, with the level of significance set at 5%.

3. Results

We assessed 100 CBCTs, totaling 76 unilateral and 24 bilateral images. A total of 124 maxillary sinuses presenting at least 1 adjacent tooth with a hypodense lesion, suggestive of CAP (ARL), were included in the study.
The mean age of the patients was 54.6 years (range: 17–86 years), and 62% of the patients were female (Table 1).
Regarding the maxillary sinus membrane’s thickness, on the right side, the images suggested mucositis and sinusitis in 22.03% and 35.59% of the sinuses, respectively. On the left side, the images suggested mucositis in 10.76% of the cases and sinusitis in 55.38%.
When the total sample was included, the images suggested mucositis and sinusitis in 16.12% and 45.96% of the sinuses, respectively. When only the images of teeth suggesting apical periodontitis were evaluated, the prevalence of mucositis was 13.69% and that of sinusitis was 41.92%, with no significant differences between the groups (p > 0.05). A chi-squared test failed to find statistically significant differences between ages, genders, and the presence of an ARL protruding into the sinus regarding MT when analyzing the sinuses on the right side of the maxilla. On the other hand, for the left side of the maxilla, the presence of an ARL protruding into the sinus showed a statistically significant association with increased MT (p = 0.005, Cramer’s V effect magnitude = 0.346).
For teeth with lesions that were not touching the sinus floor, there was a prevalence of 7.25% of mucositis and 9.67% of sinusitis, while in the group with lesions touching the preserved cortical floor bone, the prevalence of mucositis was 4.03% but that of sinusitis was higher (20.16%) (p < 0.01). In the group where the lesion was close to the eroded cortical wall, there were prevalences of 2.41% for mucositis and 12.09% for sinusitis (Table 2).
Mann–Whitney’s test was used to compare the mean MT (mm) between maxillary sinuses associated with an ARL protruding into the sinus and those in which an ARL did not disrupt the cortical bone floor of the sinus. On the right side, the mean MT was 3.89 mm for sinuses with a preserved cortical bone floor versus 6.02 mm for those with an ARL protruding into the sinus (p = 0.24). On the other hand, on the left side, the mean MT was 4.07 mm for sinuses with a preserved cortical bone floor versus 9.74 mm for those with an ARL protruding into the sinus (p = 0.01).
Additionally, the regression model adjusted for age, gender, and the ARL position failed to find differences between the groups regarding MT.

4. Discussion

In the present study, a higher frequency of female patients was observed (62%), in agreement with the findings of previous studies [18,46,47]. The average age of the sample evaluated was 54.6 years, and such findings are consistent with the prevalence of AP described in the literature [18,48].
The maxillary sinus is an anatomical structure localized between the nasal cavity and the oral cavity, causing greater vulnerability to the invasion of microorganisms [21]. The roots of the premolars and molars are located below the floor of the maxillary sinus; however, the greatest anatomical proximity to the maxillary sinus was found in the roots of the second upper molar, with an average distance of 1.97 mm from the root apex to the floor of the sinus. Such a distance is similar to the results described by previous studies [21,23,29].
It is noteworthy that in the present study, a large range was observed for each root, highlighting the importance of individualized assessment for the diagnosis, planning, and execution of endodontic treatments, as well as surgical procedures performed adjacent to the floor of the sinus. In a study by Maillet et al. (2011) [23], molars were 11 times more likely to be associated with odontogenic sinusitis than premolars. This data is comparable with the findings of the present study. Thus, we suggest that second molars should be approached in a more cautious manner, to prevent the overflow of filling material or an irrigation solution into the maxillary sinus. In this study, the bilateral first and second premolars showed a higher frequency of healthy periradicular regions. Furthermore, the premolars did not present lesions in close contact with the maxillary sinus. This last finding was basically due to their anatomical position, further away from the cortical bone of the maxillary sinus [21].
In agreement with the current literature [24,49,50], the high percentage of periradicular lesions can be attributed to the sensitivity of the imaging technique used, since CBCT is a three-dimensional examination that minimizes the limitations of the conventional radiographic technique normally used for endodontic treatments. The images suggestive of periradicular lesions associated with endodontically treated teeth observed in this study could not be classified into images showing secondary or persistent periradicular lesions, or even repair, due to the cross-sectional design of the study. Additionally, in this study, the quality of the endodontic treatment performed was not evaluated.
Of all the lesions observed, 18.93% were located below the cortex of the floor of the maxillary sinus; 12.25% were in close contact with the cortex of the floor of the maxillary sinus, which was still intact; and at a lower prevalence, we observed that 4.36% of images were suggestive of a periradicular lesion with discontinuity of the maxillary sinus cortex. The findings of this study can be compared to literature reports [23,29] which associate the low incidence of odontogenic sinusitis, even with the high frequency of dental infections, due to the thickness of the cortical bones that constitute an effective barrier to the penetration of odontogenic infections.
To analyze the thickness of the sinus membrane and its possible relationship with sinus diseases, the measurements proposed by Nurbakhsh et al. (2011) [44] were used, and we observed a high prevalence of images in which the sinus membrane was thickened, with 16.12% showing characteristics compatible with mucositis and 45.96% showing characteristics compatible with sinusitis.
The relationship between a periradicular lesion and the cortical bone of the floor of the maxillary sinus, triggering possible sinus alterations/pathology, is directly related to its spatial location. In this regard, the results of our study showed that the smaller the distance between the periradicular lesion and the cortical bone of the floor of the maxillary sinus, the greater the changes in the adjacent maxillary sinuses. When only the dental elements that were present in an image suggestive of a periradicular lesion were evaluated, the prevalence of images suggestive of mucositis was 13.69% and that of images suggestive of sinusitis was 41.92%, with no statistical differences from the total sample regarding the prevalence of the different groups of lesions and the general prevalence (p > 0.05 for both).
Comparing the findings of the present study with those described by Nurbakhsh et al. (2011) [44], who conducted a study in which only images showing apical periodontitis were evaluated, a lower prevalence of cases of thickening, suggestive of mucositis, was observed in our sample (13.69% versus 56%).
However, when evaluating teeth with lesions, considering the relationship between the periradicular lesion and the maxillary sinus, it was observed that in cases where the lesion was in closer contact with the maxillary sinus, there was greater thickening of the sinus membrane, with an image suggestive of sinusitis. Another interesting finding was the fact that, when evaluating only cases in which the sinus membrane measured 10 mm or more (n = 28 maxillary sinuses or 22.58% of cases), it was observed that in 92.85% of these cases (28 sinuses) there was at least one tooth with an associated periradicular lesion.
Despite the numerical differences found, the logistic regression model failed to find statistically significant differences between the MT in sinuses with and without an ARL protruding into the sinus. Such results may be explained by the sample size, since the magnitude effect test (Cramer’s V = 0.346) showed that increasing the number of sinuses would result in statistical significance.
Of the total number of sinuses, 19 maxillary sinuses (67.85% of the total number of sinuses with extensive opacification) were associated with the presence of teeth with lesions that reached the cortical bone of the maxillary sinus. It is noteworthy that in only two cases where there was a large thickening of the sinus membrane, there was no associated periradicular lesion.
Regarding mucous thickening, the literature reports that thickening of the sinus membrane is almost 10 times more common in individuals with periradicular lesions, with the main cause being endodontic or periodontal infection of the posterior teeth of the maxilla [15]. However, a study by Phothikhun et al. (2012) [1] found no association between periapical lesions and endodontic treatment and mucosal thickening, suggesting that periodontal bone loss alone could play a role in the etiology of odontogenic sinusitis. These results differ from those of other studies [32,43] which observed that roots with periradicular lesions tend to have thicker sinus membranes adjacent to them when compared to roots without periapical pathology. Bornstein et al. (2012) [43] found in their study that in a group that presented periradicular lesions, the thickening of the sinus membrane was statistically greater in relation to that in a group that did not present periradicular lesions. Therefore, it was concluded that conditions that violate the integrity of the maxillary sinus bone and the sinus membrane considerably increase the risk of odontogenic sinusitis. The authors also observed that the thickening most frequently found was of the flat and shallow type.
The Lund-McKay score was used in the present study because it is a simple way to categorize sinus condition, is frequently used and requires virtually no previous training [51]. A very recently published study in a Brazilian population found that patients with AP were 15.63 times (7.576; 32.268) and 25.97 times (16.22, 41.56) more likely to have MT and opacification of the maxillary sinus, respectively [52].
It is noteworthy that the present study presents limitations inherent to its cross-sectional design and the fact that CBCT is not the standard imaging technique used to evaluate the maxillary sinus. Additionally, it must be pointed out that other imaging modalities can be used for assessing sinus pathology. However, since in dentistry, CBCT is the most accurate 3D imaging exam used for diagnostic purposes, it has become a useful tool to evaluate the maxillary sinus, allowing for the screening of sinus pathology.

5. Conclusions

The present study failed to find an association between the mere presence of a periradicular lesion itself and changes in the sinus membrane or sinus pathologies, probably due to the great variability in the distances observed between the periapex and the maxillary sinus and the sample size (beta error). The cross-sectional design and the lack of clinical information related to the patients’ sinus conditions are limitations that must be addressed in future studies. Nevertheless, the results suggest that apical periodontitis in close proximity to the sinus may lead to repercussions as a result of an infection of dental origin. These findings have significant clinical implications, as they underscore the importance of an interdisciplinary approach and dental examination in managing non-responsive chronic sinusitis. In summary, when an infection or the inflammatory tissue associated with it is located within the maxillary sinus, the prevalence of sinus mucosa thickening/sinus pathology is greater.

Author Contributions

Conceptualization, T.C. and F.V.; methodology, T.C. and F.V.; software, R.V.P.; validation, T.C., M.F.V.M.-A. and V.R.F.; formal analysis, L.G.; investigation, T.C.; resources, J.d.C.L.J.; data curation, T.C.; writing—original draft preparation, T.C. and F.V.; writing—review and editing, T.C., F.V. and L.G.; supervision, L.G.; project administration, F.V. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was approved by the Research Ethics Committee of the Health Sciences Center of Estácio de Sá University (protocol number 50594215.8.0000.5284) on 10 December 2015.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. At the time of the acquisition of the tomographic data, the patients signed an informed consent form allowing the use of the images for research and didactic purposes.

Data Availability Statement

The raw data is unavailable due to privacy restrictions.

Acknowledgments

The authors acknowledge the radiology team at ODT radiology for their acquisition of the images and provision of access to the database.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

CBCTCone Beam Computed Tomography
MTMucosal thickening
OSOdontogenic sinusitis
EPOSEuropean Position Paper on Rhinosinusitis and Nasal Polyps
CTComputed tomography
ESEEuropean Society of Endodontology
CAPChronic apical periodontitis

References

  1. Phothikhun, S.; Suphanantachat, S.; Chuenchompoonut, V.; Nisapakultorn, K. Cone-Beam Computed Tomographic Evidence of the Association Between Periodontal Bone Loss and Mucosal Thickening of the Maxillary Sinus. J. Periodontol. 2012, 83, 557–564. [Google Scholar] [CrossRef]
  2. Schneider, A.C.; Bragger, U.; Sendi, P.; Caversaccio, M.D.; Buser, D.; Bornstein, M.M. Characteristics and Dimensions of the Sinus Membrane in Patients Referred for Single-Implant Treatment in the Posterior Maxilla: A Cone Beam Computed Tomographic Analysis. Int. J. Oral Maxillofac. Implant. 2013, 28, 587–596. Available online: http://search.ebscohost.com/login.aspx?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=08822786&AN=86217694&h=kIJ9v9tFXs%2FvIdK7K00x51uU6bZLmsUO6o%2BOK4r7JHqiJWnZC%2Bfd4QyVEtH7A4pF7lksMZ%2BUYAj971Y6sWcQbg%3D%3D&crl=c (accessed on 12 November 2024). [CrossRef] [PubMed]
  3. Shanbhag, S.; Karnik, P.; Shirke, P.; Shanbhag, V. Association between periapical lesions and maxillary sinus mucosal thickening: A retrospective cone-beam computed tomographic study. J. Endod. 2013, 39, 853–857. Available online: https://www.sciencedirect.com/science/article/pii/S0099239913003221 (accessed on 12 November 2024). [CrossRef]
  4. Nunes, C.A.B.C.M.; Guedes, O.A.; Alencar, A.H.G.; Peters, O.A.; Estrela, C.R.A.; Estrela, C. Evaluation of Periapical Lesions and Their Association with Maxillary Sinus Abnormalities on Cone-beam Computed Tomographic Images. J. Endod. 2016, 42, 42–46. [Google Scholar] [CrossRef]
  5. Siddiqui, F.; Smith, R.V.; Yom, S.S.; Beitler, J.J.; Busse, P.M.; Cooper, J.S.; Hanna, E.Y.; Jones, C.U.; Koyfman, S.A.; Quon, H.; et al. ACR appropriateness criteria® nasal cavity and paranasal sinus cancers. Head Neck 2017, 39, 407–418. [Google Scholar] [CrossRef] [PubMed]
  6. Pazera, P.; Bornstein, M.M.; Pazera, A.; Sendi, P.; Katsaros, C. Incidental maxillary sinus findings in orthodontic patients: A radiographic analysis using cone-beam computed tomography (CBCT). Orthod. Craniofacial Res. 2011, 14, 17–24. [Google Scholar] [CrossRef] [PubMed]
  7. Mathew, A.L.; Sholapurkar, A.A.; Pai, K.M. Maxillary sinus findings in the elderly: A panoramic radiographic study. J. Contemp. Dent. Pract. 2009, 10, 41–48. Available online: http://www.thejcdp.com/journal/ (accessed on 24 October 2024).
  8. Zhang, J.; Liu, L.; Yang, L.; Wang, J.; Tan, X.; Huang, D. Diagnosis of Odontogenic Maxillary Sinusitis by Cone-beam Computed Tomography: A Critical Review. J. Endod. 2023, 49, 1445–1456. [Google Scholar] [CrossRef]
  9. Savolainen, S.; Eskelin, M.; Jousimies-Somer, H.; Ylikoski, J. Radiological findings in the maxillary sinuses of symptomless young men. Acta Otolaryngol. 1997, 117 (Suppl. S529), 153–157. [Google Scholar] [CrossRef]
  10. Ferguson, M. Rhinosinusitis in oral medicine and dentistry. Aust. Dent. J. 2014, 59, 289–295. [Google Scholar] [CrossRef]
  11. Chen, H.J.; Chen HSen Chang, Y.L.; Huang, Y.C. Complete unilateral maxillary sinus opacity in computed tomography. J. Formos. Med. Assoc. 2010, 109, 709–715. Available online: https://www.sciencedirect.com/science/article/pii/S0929664610601155 (accessed on 7 September 2024). [CrossRef]
  12. Longhini, A.B.; Branstetter, B.F.; Ferguson, B.J. Otolaryngologists’ perceptions of odontogenic maxillary sinusitis. Laryngoscope 2012, 122, 1910–1914. [Google Scholar] [CrossRef]
  13. Pokorny, A.; Tataryn, R. Clinical and radiologic findings in a case series of maxillary sinusitis of dental origin. Int. Forum Allergy Rhinol. 2013, 3, 973–979. [Google Scholar] [CrossRef] [PubMed]
  14. Patel, N.A.; Ferguson, B.J. Odontogenic sinusitis: An ancient but under-appreciated cause of maxillary sinusitis. Curr. Opin. Otolaryngol. Head Neck Surg. 2012, 20, 24–28. [Google Scholar] [CrossRef]
  15. Vidal, F.; Coutinho, T.M.; Carvalho Ferreira Dde Souza RCde Gonçalves, L.S. Odontogenic sinusitis: A comprehensive review. Acta Odontol. Scand. 2017, 75, 623–633. [Google Scholar] [CrossRef] [PubMed]
  16. Simuntis, R.; Kubilius, R.; Vaitkus, S. Odontogenic maxillary sinusitis: A review. Stomatologija 2014, 16, 39–43. [Google Scholar] [PubMed]
  17. Matsumoto, Y.; Ikeda, T.; Yokoi, H.; Kohno, N. Association between odontogenic infections and unilateral sinus opacification. Auris Nasus Larynx 2015, 42, 288–293. Available online: https://www.sciencedirect.com/science/article/pii/S0385814615000048 (accessed on 7 September 2024). [CrossRef] [PubMed]
  18. Troeltzsch, M.; Pache, C.; Troeltzsch, M.; Kaeppler, G.; Ehrenfeld, M.; Otto, S.; Probst, F. Etiology and clinical characteristics of symptomatic unilateral maxillary sinusitis: A review of 174 cases. J. Cranio-Maxillofac. Surg. 2015, 43, 1522–1529. Available online: https://www.sciencedirect.com/science/article/pii/S1010518215002474 (accessed on 10 September 2024). [CrossRef]
  19. Fokkens, W.J.; Lund, V.J.; Hopkins, C.; Hellings, P.W.; Kern, R.; Reitsma, S.; Toppila-Salmi, S.; Bernal-Sprekelsen, M.; Mullol, J.; Alobid, I.; et al. European position paper on rhinosinusitis and nasal polyps 2020. Rhinology 2020, 58 (Suppl. S29), 1–464. [Google Scholar] [CrossRef]
  20. Ly, D.; Hellgren, J. Is dental evaluation considered in unilateral maxillary sinusitis? A retrospective case series. Acta Odontol. Scand. 2018, 76, 600–604. Available online: https://www.tandfonline.com/action/journalInformation?journalCode=iode20 (accessed on 2 October 2024). [CrossRef]
  21. Mehra, P.; Murad, H. Maxillary sinus disease of odontogenic origin. Otolaryngol. Clin. N. Am. 2004, 37, 347–364. [Google Scholar] [CrossRef] [PubMed]
  22. Maloney, P.L.; Doku, H.C. Maxillary sinusitis of odontogenic origin. J. Can. Dent. Assoc. 1968, 34, 591. [Google Scholar]
  23. Maillet, M.; Bowles, W.R.; McClanahan, S.L.; John, M.T.; Ahmad, M. Cone-beam computed tomography evaluation of maxillary sinusitis. J. Endod. 2011, 37, 753–757. Available online: https://www.sciencedirect.com/science/article/pii/S0099239911002524 (accessed on 2 October 2024). [CrossRef]
  24. Kruse, C.; Spin-Neto, R.; Wenzel, A.; Kirkevang, L.L. Cone beam computed tomography and periapical lesions: A systematic review analysing studies on diagnostic efficacy by a hierarchical model. Int. Endod. J. 2015, 48, 815–828. [Google Scholar] [CrossRef]
  25. Shahbazian, M.; Vandewoude, C.; Wyatt, J.; Jacobs, R. Comparative assessment of periapical radiography and CBCT imaging for radiodiagnostics in the posterior maxilla. Odontology 2015, 103, 97–104. [Google Scholar] [CrossRef] [PubMed]
  26. Campello, A.; Gonçalves, L.; Guedes, F.; Marques, F. Cone-beam computed tomography versus digital periapical radiography in the detection of artificially created periapical lesions: A pilot study of the diagnostic accuracy of endodontists using both techniques. Imaging Sci. Dent. 2017, 47, 25–31. [Google Scholar] [CrossRef] [PubMed]
  27. Patel, S.; Brown, J.; Semper, M.; Abella, F.; Mannocci, F. European society of endodontology position statement: Use of cone beam computed tomoraphy in endodontics. Int. Endod. J. 2019, 52, 1675–1678. [Google Scholar] [CrossRef]
  28. de Lima, C.O.; Devito, K.L.; Baraky Vasconcelos, L.R.; Prado Mdo Campos, C.N. Correlation between Endodontic Infection and Periodontal Disease and Their Association with Chronic Sinusitis: A Clinical-tomographic Study. J. Endod. 2017, 43, 1978–1983. [Google Scholar] [CrossRef]
  29. Brook, I. Sinusitis of odontogenic origin. Otolaryngol. Head Neck Surg. 2006, 135, 349–355. [Google Scholar] [CrossRef] [PubMed]
  30. Ok, E.; Güngör, E.; Colak, M.; Altunsoy, M.; Nur, B.G.; Ağlarci, O.S. Evaluation of the relationship between the maxillary posterior teeth and the sinus floor using cone-beam computed tomography. Surg. Radiol. Anat. 2014, 36, 907–914. [Google Scholar] [CrossRef]
  31. Sheikhi, M.; Pozve, N.J.; Khorrami, L. Using cone beam computed tomography to detect the relationship between the periodontal bone loss and mucosal thickening of the maxillary sinus. Dent. Res. J. 2014, 11, 495–501. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4163829/ (accessed on 15 October 2024).
  32. Vallo, J.; Suominen-Taipale, L.; Huumonen, S.; Soikkonen, K.; Norblad, A. Prevalence of mucosal abnormalities of the maxillary sinus and their relationship to dental disease in panoramic radiography: Results from the Health 2000 Health Examination Survey. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endodontol. 2010, 109, e80–e87. [Google Scholar] [CrossRef]
  33. Hoskison, E.; Daniel, M.; Rowson, J.E.; Jones, N.S. Evidence of an increase in the incidence of odontogenic sinusitis over the last decade in the UK. J. Laryngol. Otol. 2012, 126, 43–46. Available online: https://www.researchgate.net/publication/51657360 (accessed on 20 October 2024). [CrossRef]
  34. Costa, F.; Emanuelli, E.; Robiony, M.; Zerman, N.; Polini, F.; Politi, M. Endoscopic Surgical Treatment of Chronic Maxillary Sinusitis of Dental Origin. J. Oral Maxillofac. Surg. 2007, 65, 223–228. Available online: https://www.sciencedirect.com/science/article/pii/S0278239106013991 (accessed on 20 October 2024). [CrossRef]
  35. Akhlaghi, F.; Esmaeelinejad, M.; Safai, P. Etiologies and treatments of odontogenic maxillary sinusitis: A systematic review. Iran. Red Crescent Med. J. 2015, 17, e25536. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4706849 (accessed on 20 October 2024). [CrossRef]
  36. Badarne, O.; Koudstaal, M.J.; van Elswijk, J.F.; Wolvius, E.B. Odontogenic maxillary sinusitis based on overextension of root canal filling material. Ned. Tijdschr. Tandheelkd. 2012, 119, 480–483. Available online: https://www.ncbi.nlm.nih.gov/pubmed/23126175 (accessed on 21 October 2024). [CrossRef]
  37. Lee, K.C.; Lee, S.J. Clinical features and treatments of odontogenic sinusitis. Yonsei Med. J. 2010, 51, 932–937. [Google Scholar] [CrossRef] [PubMed]
  38. Longhini, A.B.; Branstetter, B.F.; Ferguson, B.J. Unrecognized odontogenic maxillary sinusitis: A cause of endoscopic sinus surgery failure. Am. J. Rhinol. Allergy 2010, 24, 296–300. [Google Scholar] [CrossRef] [PubMed]
  39. Akhaddar, A.; Elasri, F.; Elouennass, M.; Mahi, M.; Elomari, N.; Elmostarchid, B.; Oubaaz, A.; Boucetta, M. Orbital abscess associated with sinusitis from odontogenic origin. Intern. Med. 2010, 49, 523–524. Available online: http://www.naika.or.jp/imindex.html (accessed on 21 October 2024). [CrossRef]
  40. Hoxworth, J.M.; Glastonbury, C.M. Orbital and intracranial complications of acute sinusitis. Neuroimaging Clin. N. Am. 2010, 20, 511–526. Available online: https://www.neuroimaging.theclinics.com/article/S1052-5149(10)00076-6/abstract (accessed on 24 October 2024). [CrossRef] [PubMed]
  41. Martines, F.; Salvago, P.; Ferrara, S.; Mucia, M.; Gambino, A.; Sireci, F. Parietal subdural empyema as complication of acute odontogenic sinusitis: A case report. J. Med. Case Rep. 2014, 8, 282. [Google Scholar] [CrossRef]
  42. Vestin Fredriksson, M.; Öhman, A.; Flygare, L.; Tano, K. When Maxillary Sinusitis Does Not Heal: Findings on CBCT Scans of the Sinuses with a Particular Focus on the Occurrence of Odontogenic Causes of Maxillary Sinusitis. Laryngoscope Investig. Otolaryngol. 2017, 2, 442–446. [Google Scholar] [CrossRef]
  43. Bornstein, M.M.; Wasmer, J.; Sendi, P.; Janner, S.F.M.; Buser, D.; Von Arx, T. Characteristics and dimensions of the Schneiderian membrane and apical bone in maxillary molars referred for apical surgery: A comparative radiographic analysis using limited cone beam computed tomography. J. Endod. 2012, 38, 51–57. [Google Scholar] [CrossRef] [PubMed]
  44. Nurbakhsh, B.; Friedman, S.; Kulkarni, G.V.; Basrani, B.; Lam, E. Resolution of maxillary sinus mucositis after endodontic treatment of maxillary teeth with apical periodontitis: A cone-beam computed tomography pilot study. J. Endod. 2011, 37, 1504–1511. [Google Scholar] [CrossRef] [PubMed]
  45. Lund, V.J.; Mackay, I.S. Staging in rhinosinusitis. Rhinology 1993, 31, 183. [Google Scholar] [PubMed]
  46. Little, R.E.; Long, C.M.; Loehrl, T.A.; Poetker, D.M. Odontogenic sinusitis: A review of the current literature. Laryngoscope Investig. Otolaryngol. 2018, 3, 110–114. [Google Scholar] [CrossRef]
  47. Souza-Nunes, L.A.; Verner, L.S.; Rosado, L.P.L.; Aquino, S.N.; Carvalho, A.C.P.; Junqueira, R.B. Periapical and endodontic status scale for endodontically treated teeth and their association with maxillary sinus abnormalities: A cone-beam computed tomographic study. J. Endod. 2019, 45, 1479–1488. [Google Scholar] [CrossRef]
  48. Psillas, G.; Papaioannou, D.; Petsali, S.; Dimas, G.G.; Constantinidis, J.J. Odontogenic maxillary sinusitis: A comprehensive review. J. Dent. Sci. 2021, 16, 474–481. [Google Scholar] [CrossRef]
  49. Lima, A.D.; Benetti, F.; Ferreira, L.L.; Dezan-Júnior, E.; Gomes-Filho, J.E.; Cintra, L.T.A. Endodontic applications of cone-beam computed tomography. Braz. J. Surg. Clin. Res. 2014, 6, 30–39. [Google Scholar]
  50. Ponce, J.B.; Guimarães, B.M.; Pinto, L.C.; NIshiyama, C.K.; Almeida, A.L.P.F. Tamanho do voxel no diagnóstico tomográfico em endodontia. Salusvita 2014, 33, 257–267. [Google Scholar]
  51. Hopkins, C.; Browne, J.P.; Slack, R.; Lund, V.; Brown, P. The Lund-Mackay staging system for chronic rhinosinisitis: How is it used and what does it predict? Otolaryngol. Head Neck Surg. 2007, 137, 555–561. [Google Scholar] [CrossRef] [PubMed]
  52. Castro, C.J.M.; Junqueira, J.L.C.; Rodrigues, C.D.; Santos, G.N.M.; Martinez, C.R.; Panzarella, F.K. Dental maxillary sinus pathology: A CBCT-based case-control study. Odontology 2025, 113, 1269–1277. [Google Scholar] [CrossRef] [PubMed]
Sinusitis 09 00016 g001
Figure 1. Linear measurements from the periapex to the cortical bone of the maxillary sinus floor.
Figure 1. Linear measurements from the periapex to the cortical bone of the maxillary sinus floor.
Sinusitis 09 00016 g001
Sinusitis 09 00016 g002
Figure 2. Example of thickened sinus mucosa.
Figure 2. Example of thickened sinus mucosa.
Sinusitis 09 00016 g002
Sinusitis 09 00016 g003
Figure 3. Summary of the evaluation of the sinuses’ conditions.
Figure 3. Summary of the evaluation of the sinuses’ conditions.
Sinusitis 09 00016 g003
Table 1. Description of the population studied.
Table 1. Description of the population studied.
GenderMaleFemale
38%62%
Age (years/SD)54.66/12.02
years old
Maxillary sinusRight side Left side
MucositisSinusitisMucositis Sinusitis
(22.03%)(35.59%)(10.76%)(55.38%)
Table 2. Prevalence of maxillary sinus alterations according to the anatomical relation between CAP and the sinus floor.
Table 2. Prevalence of maxillary sinus alterations according to the anatomical relation between CAP and the sinus floor.
IP1 *IP2 **IP3 **
MUCOSITIS7.25%4.03%2.41%
SINUSITIS 9.67%20.16%12.09%
IP1—Image suggestive of a periradicular lesion not touching the cortical bone of the maxillary sinus floor. IP2—Image suggestive of a periradicular lesion in close contact with the cortical bone of the maxillary sinus. IP3—Image suggestive of a periradicular lesion promoting disruption of the cortical bone of the maxillary sinus. Statistical analysis was carried out using the chi-squared test. ** p < 0.01/* p > 0.05.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Coutinho, T.; Gonçalves, L.; Marceliano-Alves, M.F.V.; Figueiredo, V.R.; Lima Junior, J.d.C.; Peres, R.V.; Vidal, F. Apical Periodontitis and Maxillary Sinus Alterations: Results of an Exploratory Cross-Sectional Tomographic In Vivo Study. Sinusitis 2025, 9, 16. https://doi.org/10.3390/sinusitis9020016

AMA Style

Coutinho T, Gonçalves L, Marceliano-Alves MFV, Figueiredo VR, Lima Junior JdC, Peres RV, Vidal F. Apical Periodontitis and Maxillary Sinus Alterations: Results of an Exploratory Cross-Sectional Tomographic In Vivo Study. Sinusitis. 2025; 9(2):16. https://doi.org/10.3390/sinusitis9020016

Chicago/Turabian Style

Coutinho, Thaïs, Lucio Gonçalves, Marilia Fagury Videira Marceliano-Alves, Vivian Ronquete Figueiredo, Josué da Costa Lima Junior, Rafael Vidal Peres, and Fábio Vidal. 2025. "Apical Periodontitis and Maxillary Sinus Alterations: Results of an Exploratory Cross-Sectional Tomographic In Vivo Study" Sinusitis 9, no. 2: 16. https://doi.org/10.3390/sinusitis9020016

APA Style

Coutinho, T., Gonçalves, L., Marceliano-Alves, M. F. V., Figueiredo, V. R., Lima Junior, J. d. C., Peres, R. V., & Vidal, F. (2025). Apical Periodontitis and Maxillary Sinus Alterations: Results of an Exploratory Cross-Sectional Tomographic In Vivo Study. Sinusitis, 9(2), 16. https://doi.org/10.3390/sinusitis9020016

Article Metrics

Back to TopTop