AAE Position Statement Maxillary Sinusitis of Endodontic Origin Pag e 1AAE Position Statement [607432]

AAE Position Statement – Maxillary Sinusitis of Endodontic Origin | Pag e 1AAE Position Statement
Introduction
The American Association of Endodontists is dedicated to excellence in
endodontics and promoting the highest standards of patient care. This
following position statement is intended to define and outline Maxillary
Sinusitis of Endodontic Origin (MSEO), deliver guidelines for its diagnosis
and appropriate treatment, and provide a standard for all dental and medical
practitioners who undertake the responsibility of managing patients with
this condition.
The relationship between dental infections and sinus disease is widely
recognized in both the dental and medical literature. Despite extensive
scientific recognition and reported high prevalence, periapical infection
manifesting in the maxillary sinus remains under-appreciated and frequently
goes undiagnosed by dentists, otolaryngologists, and radiologists alike,
with its sequelae often misdiagnosed as sinogenic sinusitis. Recognition of
MSEO is critical as failure to identify and properly manage the endodontic
source pathology will result in the persistence of sinus disease, the failure of
medical sinus therapies, and the potential advancement to more serious or
even life-threatening cranio-facial infections.
Incidence and Recognition
The pathological extension of dental disease into the maxillary sinus
is well documented in the dental and medical literature and was first
referred to by Bauer in 1943 as maxillary sinusitis of dental origin (MSDO).1
Numerous investigators since have discovered that this is a prevalent
and common disease process.2-23,25 Abrahams et al.2 have reported that
infections of maxillary posterior teeth show maxillary sinus pathology in
60% of the cases, while Mattila3 found sinus mucosal hyperplasia present
in approximately 80% of teeth with periapical osteitis. Obayashi et al.4
found maxillary sinus mucosal changes in 71.3% of patients with infections
originating in the maxillary canines, premolars and molars.About This Document
The following statement
was prepared by a special
committee and approved by
the AAE Board of Directors in
April 2018.
©2018Distribution Information
AAE members may reprint
this position statement for
distribution to patients or
referring dentists.Maxillary Sinusitis of
Endodontic Origin
The guidance in this
statement is not intended
to substitute for a clinician’s
independent judgment in
light of the conditions and
needs of a specific patient.

Access additional resources at aae.orgWhile it has often been quoted and generally accepted that
dental infections account for approximately 10 to 12% of
all cases of maxillary sinusitis,5-9 the primary source for this
figure provides no epidemiological data to support it.5,10
More recent literature strongly supports the conclusion that
the incidence of MSDO, also termed odontogenic sinusitis,
is likely much higher, particularly in chronic cases. Melen
et al.11, in a study of 198 patients with 244 cases of chronic
bacterial maxillary sinusitis, found a dental etiology in
40.6% of the cases. Maillet et al.12 reviewed 82 cone beam
computed tomography (CBCT) scans that had findings
consistent with maxillary sinusitis for evidence of a dental
pathology and concluded that over 50% of these cases were
of dental etiology. Bomeli et al.13 found that the more severe
the sinus disease, the more likely it was to be associated
with dental pathology, with up to 86% of severely affected
maxillary sinuses having a dental etiology for the infection.
Matsumoto et al.14 found that 72% of unilateral sinusitis
cases had an odontogenic source.
Despite the reported high prevalence of MSDO, and the
persistence of sinus disease if the odontogenic source
remains, this condition frequently goes unrecognized by
radiologists, dentists, and otolaryngologists – Ear, Nose
and Throat (ENT) specialists.15 In two separate case series
evaluating odontogenic sinusitis, approximately two-thirds
of the identifiable dental pathology went unreported by
radiologists on sinus computed tomography (CT) scans.16,17
It was also found that routine general dental examination
using periapical radiographs failed to diagnose odontogenic
maxillary sinusitis in 86% of the cases.16 Melen et al.11
similarly reported that 56 out of 99 (55%) odontogenic
maxillary sinusitis cases were missed on routine dental
examination and dental radiography.Although the medical literature provides ample studies and
review articles regarding the high prevalence of odontogenic
sinusitis with the specific recommendation for dental or
endodontic examination and treatment, published guidelines
for the management of sinusitis rarely address the need
to rule out or treat a potential odontogenic source. The
current Clinical Practice Guidelines for the Management of
Adult Rhinosinusitis , published by The American Academy
of Otolaryngology – Head and Neck Surgery Foundation,
makes no mention of the potential for an odontogenic
cause for sinusitis, nor does it make any recommendation
for a dental or endodontic examination to rule out or treat
an odontogenic source for sinusitis.24 Out of 85 sinusitis
guidelines, published between 1998 and 2010, only eleven
mentioned an odontogenic cause for sinusitis and only three
gave a recommendation for a dental examination.16 None of
the published sinusitis guidelines made the recommendation
to refer to endodontic specialists, who are uniquely trained
and equipped to diagnose and treat odontogenic infections.
Presentation and Definitions
Inflammatory responses of the maxillary sinus to dental
infection can present with varied symptoms, clinical
progression, and radiographic presentations. Odontogenic
sinus infections may produce only a minimal, often
asymptomatic local reaction in the antral floor periosteum
and/or mucosa for months or even years.25 However, a
pathologically altered mucosa is impaired and less resistant
than an intact one to infection, and is a pathogenic factor in
the progression to rhinosinusitis.26,27 Depending on dental
pathogenicity, anatomic factors, the extent of mucosal
edema, and sinus ostial patency, periradicular inflammation
may progress beyond the antral floor causing a partial or
total obstruction of the maxillary sinus with symptoms and
radiographic presentation common to sinogenic sinusitis.
The condition can further ascend to involve the nasal cavity,
ethmoid, and frontal sinuses, and in rare, severe cases can
spread via the maxillary sinus causing orbital cellulitis,
blindness, meningitis, subdural empyema, brain abscess and
life-threatening cavernous sinus thrombosis.4,28-31

AAE Position Statement – Maxillary Sinusitis of Endodontic Origin | Pag e 3The terms MSDO, odontogenic sinusitis, odontogenic
rhinosinusitis, and odontogenic maxillary sinusitis are all
used synonymously in the current literature to describe
various levels of mucosal inflammation and symptoms,
caused by multiple odontogenic etiologies, including
periodontal disease, endodontic disease, root fractures,
dental implants, dental extractions, oro-antral fistulae,
and iatrogenic causes such as extruded dental materials,
displaced teeth and foreign bodies.2,6,7,25,32-35 While these
are all odontogenic sources for sinusitis, it is important
to distinguish these etiologies from maxillary sinusitis of
endodontic origin (MSEO), as they each require markedly
different clinical treatments. Furthermore, combining these
very different etiologies under a single term can create
confusion that may impede understanding of the disease
processes and potential post-treatment management.
MSEO is a new term, coined with this document, and
refers specifically to sinusitis secondary to periradicular
disease of endodontic origin, excluding sinusitis secondary
to other dental etiologies. Previously termed “the endo-
antral syndrome” by Seldon,18-20 MSEO requires an accurate
diagnosis of the condition followed by appropriate
endodontic treatment or extraction to remove the source of
endodontic pathogens associated with the periapical disease
and secondary sinus infection.
Diagnosis of MSEO
1. Dental and Sinonasal History and Symptoms
Diagnosis of MSEO begins with a thorough medical and
dental history. The clinician must recognize that patients
with MSEO may experience a wide variation of dental and
sinonasal symptoms including no symptoms. Common
sinonasal symptoms include congestion, rhinorrhea,
retrorhinorrhea, facial pain, and foul odor.36,37 Typical
endodontic symptoms such as thermal pain, periapical
sensitivity, swelling, and/or draining intraoral sinus tract are
often not present with MSEO. Thermal pain is not typically
present because source teeth for MSEO are either necrotic
or have failing endodontic therapy. Periapical tenderness
is typically absent in MSEO because periapical infection is
essentially draining into the sinus via fistula, eliminating
pressure. For this same reason, swelling or intraoral sinus
tracts rarely form. There are of course no absolutes, as
multi-rooted teeth have the potential for both sinus and
intraoral presentations.Patients with primary sinonasal symptoms and without
localized dental pain will typically first seek care from
their primary care physician or ENT specialist who may
misdiagnose and treat MSEO as a primary sinus infection
since dental infections are easily overlooked during routine
ENT examinations.15,16,37 Physicians must always be aware
that a lack of dental symptoms or complaint does not
rule out dental etiology for sinusitis, and recognize that
current clinical guidelines for the medical management of
rhinosinusitis do not offer guidance in this area.24 Physicians
must also recognize that lack of sinonasal symptoms does
not rule out a dental etiology for mucosal abnormalities or
sinus obstruction. Rhinosinusitis is defined as symptomatic
inflammation of the paranasal sinuses and nasal cavity, and
therefore management of rhinosinusitis is based primarily
on patient symptoms rather than imaging findings.24
Considering this, mucosal changes and periradicular
findings seen on imaging that are not coupled with patient
symptoms may be dismissed as incidental, to the detriment
of patients exhibiting dental abscesses and/or associated
periapical mucositis. If periapical findings are noted on
sinus CT imaging, or sinus floor mucosal changes appear
to have potential dental etiology, these patients should be
referred to an endodontist for evaluation to rule out or
resolve any dental pathology, even if the patient is dentally
asymptomatic.17
Findings that should raise the suspicion of MSEO are a
history of repeated episodes of unilateral maxillary sinus
infections, particularly when associated with a patent
sinus ostium or previously unsuccessful sinus surgery.17
A cooperative relationship between endodontists and
ENT specialists is imperative for diagnosing MSEO and
distinguishing it from sinogenic sinusitis. Endodontists
should keep sinonasal disease in mind when diagnosing
and treating MSEO, and should not attempt to make a
final diagnosis of non-odontogenic sinus disease, nor offer
treatment that is outside the scope of dental practice.

Access additional resources at aae.org2. Radiographic Examination
While periapical radiographs are the most widely used
imaging modality in endodontics, the posterior maxilla
presents significant and unique interpretation challenges
when using conventional 2-D imaging.38 Anatomic structures
such as the zygomatic and palatal processes, maxillary
sinus cortical floor, and buccal cortical plate are often
superimposed onto the dental roots, obscuring or concealing
periradicular inflammatory changes. Visualizing the apices
of the maxillary posterior teeth is further obscured when
maxillary sinus mucosal thickening is present. Conventional
periapical radiographs also do not consistently reveal
mucosal soft tissue changes or air-fluid levels in the sinus,
which are of great diagnostic value in MSEO.39
Limited field CBCT imaging has been shown to significantly
improve the ability to detect odontogenic sources for
sinusitis. In a study by Low et al.40, comparing periapical
radiography and CBCT for preoperative diagnosis in 74
posterior maxillary teeth consecutively referred for apical
surgery, CBCT revealed 34% more lesions than periapical
radiography, as well as significantly more expansion
of lesions into the maxillary sinus, sinus membrane
thickening, and untreated canals. The same investigation
also showed that with the use of CBCT imaging, mucosal
changes associated with dental infections were found
with a prevalence of 77%, compared to only 19% using
conventional radiographs. Lofthag-Hansen et al.39 compared
CBCT and intraoral radiography for the diagnosis of
periapical pathology and found that thickening of the
mucous membrane of the maxillary sinus was identified
more than four times as often with CBCT imaging than with
periapical radiographs, and all observers agreed that in 70%
of the cases CBCT provided clinically relevant information
not found in the periapical radiographs. Shahbazian et
al.41, examining 145 dental records, found that periapical
radiography could only identify approximately 40% of apical
periodontitis on posterior maxillary teeth, and 3% of all
apical infections extending into the sinus that were seen
on CBCT . They also concluded that periapical radiographs
are not adequate in observing the anatomical relationship
between maxillary molars and the sinus floor. Periapical inflammation is often responsible for distinct
maxillary sinus radiographic changes that differ
significantly from typical periradicular radiolucencies
observed in alveolar bone.42 Two unique radiographic
findings associated with periradicular inflammation of the
sinus mucoperiosteum are periapical osteoperiostitis and
periapical mucositis .43 Both conditions can progress further
to a partial or total sinus obstruction.
Periapical Osteoperiostitis (PAO)
The presence of apical periodontitis adjacent to the
maxillary sinus cortical floor will often expand the
sinus periosteum, displace it upward into the sinus, and
subsequently induce a periosteal reaction that continues
to deposit a thin layer of new bone on the inner periphery
of the periosteum as it expands. This reactive osteogenesis,
termed periapical osteoperiostitis (PAO), forms a thin, hard-
tissue dome on the sinus floor and presents on radiographs
and CT images as a radiopaque “halo” appearance.43 (Fig 1)
If the inflammatory process continues, the bone deposits can
become thicker and expand deeper into the maxillary sinus.
PAO lesions may or may not be symptomatic and may be
accompanied by varying degrees of adjacent mucosal edema
and sinus fluid levels, particularly if a perforation occurs in
the periosteum and osseous tissue.44,45
Figure 1. Periapical osteoperiostitis. A. Periapical radiograph of the posterior left
maxilla. Clinical exam confirmed a necrotic maxillary left second molar, however any
periapical and sinus abnormalities are obscured by the zygoma. B. CBCT image of
the same necrotic left maxillary second molar displaying an osteoperiostitis or “halo”
lesion (arrow) with associated mucosal edema of the left maxillary sinus.A B

AAE Position Statement – Maxillary Sinusitis of Endodontic Origin | Pag e 5
Figure 3. Periapical mucositis. A. Periapical radiograph of a failing root canal
therapy of the maxillary second bicuspid. B. CBCT image of the apical periodontitis
perforating the antral cortical floor and associated periosteum causing a localized,
dome-shaped inflammatory edema of the sinus mucosal tissue (arrow).A BPeriapical Mucositis (PAM)
It is not uncommon for the root apices of maxillary
posterior teeth to project through the maxillary sinus
cortical floor and directly contact the antral mucosa, or for
periapical abscesses to perforate the sinus cortical floor
and periosteum. Symptomatic or asymptomatic apical
periodontitis in direct contact with or adjacent to the
antral mucosa will typically produce a localized mucosal
tissue edema termed periapical mucositis (PAM), which
appears on CT imaging as a mucosal thickening or dome-
shaped soft tissue expansion in the floor of the sinus
directly adjacent to the infected root apex.43 (Figs 2 and 3)
Periradicular inflammation from dental roots not directly
adjacent to the sinus mucosa can also cause PAM without
any evident inflammatory bone resorption via extension
of inflammatory mediators through bone marrow, blood
vessels, and lymphatics.1 Because there is often no evident
osseous destruction or PAO halo, PAM is more difficult to
recognize radiographically than typical endodontic lesions
and may be misinterpreted as an insignificant or incidental
finding. Mucosal edema on the sinus floor and particularly
dome-shaped mucosal swellings directly over dental root
apices should raise the suspicion of a dental etiology.
Clinicians should be mindful, however, that PAM may have
a similar appearance to mucous retention cysts, antral
polyps, mucosal thickening caused by periodontal disease,
and sinogenic mucosal thickening. As with all endodontic
diagnoses, a determination of etiology cannot be made based
on radiographic examination alone. Careful endodontic
clinical examination of pulpal status is imperative to
distinguish PAM from other mucosal abnormalities.
Figure 2. Periapical mucositis. A. Periapical radiograph of the posterior left
maxilla. Clinical exam confirmed a necrotic maxillary left second molar. B. CBCT
image reveals mucosal edema on the floor of the left maxillary sinus (arrow) with no
evident osseous lesion. C. Periapical radiograph following endodontic treatment of
the second molar. D. 3-month post-operative CBCT image showing full resolution
of the mucosal edema.A B
C D

Access additional resources at aae.orgSinus Obstruction from MSEO
Full or partial sinus obstruction is very evident on sinus
CT imaging, but may be more difficult to recognize as
having an endodontic etiology. (Fig 4) Careful radiographic
examination for evidence of PAO is helpful in making this
determination but, as seen with PAM lesions, periapical
radiolucencies or osseous changes do not always exist.
A history of unilateral sinus obstruction, particularly if
recurrent and/or associated with a patent infundibulum is
a strong indicator for possible MSEO. Clinical endodontic
examination, however, is essential to confirm or rule out a
potential endodontic source.173. Clinical Examination
When diagnosing a possible endodontic etiology in patients
with rhinosinusitis, the clinician must perform a thorough
clinical endodontic examination to evaluate for any pulpal
necrosis and periapical disease, while carefully evaluating
all prior endodontic treatments for possible failure in the
suspected quadrant. Endodontic evaluation of pulpal and
periapical tissues includes thermal testing, electric pulp
vitality testing, percussion, palpation, periodontal probing
and mobility tests. A healthy vital pulp will not contribute
to any periradicular or odontogenic sinus inflammation.
While an inflamed vital pulp with root apices proximal
to the sinus floor may generate enough inflammatory
mediators to induce minor sinus mucosal changes, it is
unlikely to contribute to any significant sinonasal disease
or sinonasal symptoms.45 For a periapical infection to occur,
microorganisms must be present.46 Only those teeth with
an infected necrotic pulp or failing endodontic treatment
will generate MSEO. When examining maxillary posterior
teeth with existing root canal treatment, one must carefully
examine for any untreated or sub-optimally filled canals,
inadequate core restorations, or leaking coronal restorations
that may provide evidence of endodontic failure and a
bacterial source for MSEO.4
Treatment of MSEO
Successful management of MSEO, as with any infection
of endodontic origin, is focused on removing the nidus
of infection and preventing reinfection. The objectives
for treatment of MSEO are removal of the pathogenic
microorganisms, their by-products, and pulpal debris from
the infected root canal system that are causing the sinus
infection. Appropriate treatment options include non-
surgical root canal therapy, periradicular surgery when
indicated, intentional replantation, or extraction of the
infected tooth. Patients should be informed of all treatment
options and the prognosis of each option, to include risks of
no treatment.
Figure 4. MSEO sinus obstruction. A. Coronal CT image of a fully obstructed
right maxillary sinus (large arrow). The patient had experienced recurrent right
maxillary sinus infections and nasal congestion for more than four years with no
resolution despite multiple antibiotic regimens and adjunctive sinus treatments.
An associated periapical osteoperiostitis lesion is evident over the palatal root apex
of the necrotic right maxillary first molar (small arrow). B. 3-month postoperative
coronal CT image showing full resolution of the maxillary rhinosinusitis following
endodontic therapy of the maxillary first molar. No other sinus treatment was
performed, nor antibiotics administered.A B

AAE Position Statement – Maxillary Sinusitis of Endodontic Origin | Pag e 7Clinicians performing endodontic treatment in the
posterior maxillary dentition should have extensive
knowledge of maxillary root canal anatomy, the necessary
armamentarium, and requisite clinical skill considering
the anatomic complexities and challenges in this region.
Endodontists are specialists in managing complex root
canal systems, and maxillary molars typically have the most
complex anatomy in the dentition. Inadequate root canal
treatment, particularly missed mesio-buccal canal systems,
is a common cause of endodontic failure in maxillary
molars.48-51 The close anatomic proximity of maxillary molar
root apices to the floor of the maxillary sinus can lead to
persistent or progressive MSEO if canals are left untreated
or root canal failure occurs in these teeth. Clinicians should
realize that persistent sinus infection following endodontic
treatment may be due to deficiencies in endodontic or
restorative treatment, or due to periodontal disease52,53, and
should critically evaluate these potential sources of sinusitis
prior to concluding that other forms of medical or surgical
intervention are indicated.
Use of systemic antibiotics to manage MSEO should follow
the guidelines set forth in the AAE Guidance on the Use of
Systemic Antibiotics in Endodontics .54 Apart from spreading
infections, antibiotic therapy is unwarranted in the
treatment of MSEO and utterly ineffective as a definitive
solution. While antibiotic therapy may offer temporary
relief of symptoms by improving sinus clearing, and may
be indicated for rapidly spreading infections, their sole
use is inappropriate without definitive debridement and
disinfection of the root canal system. In cases of MSEO,
antibiotic therapy should not be used in lieu of endodontic
treatment or removal of the infected root canal system.
Similarly, surgical intervention of the maxillary sinus that
is focused strictly on removing diseased sinus tissue and
establishing drainage is inadequate if the endodontic
component is neglected. Although these procedures are
performed with the goal of re-establishing sinus aeration
and drainage, and may provide relief of some symptoms,
it is well documented that neglecting the dental etiology
and focusing only on medical and surgical therapies of the
ostiomeatal complex (OMC) will not resolve MSEO.15,55-57The dental literature provides numerous case reports
showing full resolution of MSEO following endodontic
treatment.2,16,19-22,58-62 It should be noted, however, that
thorough dental treatment alone may not resolve all cases
of MSEO, therefore clinical and radiological follow-up is
essential as concomitant management of the associated
rhinosinusitis by an ENT specialist may be necessary in
some cases.15,37,59,60,63-66 Tomamatsu60 et al. evaluated 39
patients with MSEO associated with full unilateral maxillary
sinus obstruction who underwent initial treatment of
endodontic therapy or extraction. Twenty patients showed
full resolution of maxillary sinus obstruction and sinusitis
symptoms without requiring sinus surgery. The remaining
19 patients required adjunctive sinus surgery which
resolved the sinusitis. The primary finding in this study
was that the non-effective group displayed a significantly
narrower aperture width of the OMC, suggesting it may be
a predictor of the effectiveness of initial dental treatment
of MSEO. In contrast to earlier studies that recommend
contemporaneous dental treatment and sinus surgery for
management of all cases of odontogenic sinusitis67-69, the
Tomamatsu study strongly supports the AAE’s position
for managing MSEO by treating the primary endodontic
infection first, followed by clinical and radiological
assessment, and then proceeding with additional sinus
surgical procedures only for recalcitrant cases, even in
cases of total sinus obstruction. Contemporaneous dental
and surgical sinus treatment with appropriate antibiotics
should only be considered in severely acute cases requiring
immediate drainage.
Collectively, the literature strongly supports the need for a
collaborative effort and open referral relationship between
the ENT surgeon and the endodontic specialist to achieve
the best outcomes for patients with MSEO. Directions for
future research may include the incidence and progression
of sinus disease in MSEO, specific pathological alterations to
sinus mucosal tissues induced by endodontic disease, and
potential indicators for adjunctive antibiotic use, medical
treatments, or surgical sinus treatment following endodontic
therapy in the management of MSEO.

Access additional resources at aae.orgConclusion
It is important to recognize that MSEO is fundamentally
an endodontic infection manifesting in the maxillary sinus.
This condition is different from sinogenic sinusitis, with
an entirely different pathogenesis and treatment regimen.
Although the symptoms and radiographic signs of MSEO
may mimic sinogenic sinusitis and lead patients to first seek
care from their primary care physicians or ENT specialists,
medical treatment will not resolve MSEO if the endodontic
source is overlooked. MSEO is also frequently overlooked
in general dental practice due to a lack of dental symptoms
and an obscured or atypical radiographic presentation.
The increased availability of in-office CBCT has increased
clinicians’ recognition and ability to diagnose MSEO. Clinical
endodontic examination, however, remains essential for
correct diagnosis. Endodontists are uniquely trained and
equipped to diagnose and properly manage endodontic
disease that manifests in the maxillary sinus. Improved
communication and referral relationships between ENT
surgeons and endodontic specialists are essential to provide
appropriate patient care when managing MSEO.
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Thank you to the Special Committee to Develop a Position
Statement on Maxillary Sinusitis of Endodontic Origin:
Roderick W. Tataryn, Chair
Michael J. Lewis
Anthony L. Horalek
Chase G. Thompson
Bruce Y. Cha, Board Liaison
Alan T . Pokorny, Physician (ENT) Consultant