ORLI 2025 Volume 55 No.
1 : 52-59
Prognostic factors for medicamentous and dental treatment failure Case Report Prognostic factors for medicamentous and dental treatment failure in odontogenic sinusitis Kartika Dwiyani*.
Eka Dian Safitri**.
Josua Manalu*** *Department of Otolaryngology Head and Neck Surgery.
Faculty of Medicine.
Universitas Indonesia/ Persahabatan Hospital.
Jakarta **Clinical Epidemiology and Evidence Based Medicine Unit.
Faculty of Medicine.
Universitas Indonesia/ Dr.
Cipto Mangunkusumo National General Hospital.
Jakarta ***Department of Otolaryngology Head and Neck Surgery.
Faculty of Medicine.
Universitas Indonesia/ Dr.
Cipto Mangunkusumo National General Hospital.
Jakarta
ABSTRACT
Background: Odontogenic sinusitis refers to bacterial maxillary sinusitis caused by maxillary dental pathology, or complications from dental procedures.
The therapeutic algorithm usually has two stages:
conservative and surgical.
If conservative therapy alone is successful in curing sinusitis, unnecessary sinus surgery can be avoided.
But if conservative therapy fails, sinus surgery is usually required to remove the cause of the pathology.
The effectiveness of conservative therapy varies in the range from 36 to 95%.
Purpose: To investigate prognostic factors for medicamentous and dental treatment failure in odontogenic sinusitis.
Case illustration: A 27 years old male with odontogenic sinusitis should undergo endoscopic sinus surgery although he had already received optimal conservative therapy.
Clinical question: In patients with odontogenic sinusitis treated by conservative therapy, are smoking habits, high total Lund-Mackay score including osteomeatal complex (OMC) blockage, and history of dental procedure contribute as prognostic factors for medicamentosa and dental treatment failure? Method:
Literature searching was performed through PubMed.
Cochrane database and Hand-searching using keyword Auodontogenic sinusitisAy.
Result: Three valid prognostic cohort articles were appraised for the validity, importance, and applicability in our clinical scenario.
The precision prognostic factor is high total Lund-Mackay score with odd ratio (OR) 95%, and confidence interval (CI) 2.
0, 1.
Conclusion:
High total Lund-Mackay score is an important prognostic factor for conservative therapy failure, so that the sinus surgery should be performed.
Keywords: odontogenic sinusitis, conservative treatment, sinus surgery.
Lund-Mackay score
ABSTRAK
Latar belakang: Sinusitis odontogenik mengacu pada infeksi bakteri pada sinus maksilaris yang disebabkan oleh kuman, atau komplikasi tindakan pada gigi.
Algoritma terapeutik biasanya memiliki dua tahap yaitu konservatif dan bedah.
Efektivitas terapi konservatif bervariasi berkisar di antara 36 hingga 95%.
Jika terapi konservatif berhasil menyembuhkan sinustis, maka bedah sinus dapat dihindari.
tetapi jika terapi konservatif gagal, bedah sinus dibutuhkan untuk menghilangkan penyebabnya.
Tujuan: Mengetahui faktor prognostik yang mempengaruhi kegagalan terapi medikamentosa dan pengobatan gigi pada sinusitis odontogenik.
Ilustrasi kasus: Seorang laki-laki berusia 27 tahun dengan diagnosis sinusitis odontogenik harus menjalani operasi sinus endoskopi, walaupun telah mendapatkan terapi konservatif yang optimal.
Pertanyaan klinis: Pada pasien sinusitis odontogenik telah diterapi konservatif, apakah kebiasaan merokok, skor total Lund-Mackay tinggi termasuk adanya penyumbatan kompleks osteomeatal (KOM), dan riwayat tindakan pada gigi, memengaruhi kegagalan terapi konservatif? Metode: Pencarian literatur dilakukan melalui PubMed.
Cochrane dan Hand-searching ORLI 2025 Volume 55 No.
Prognostic factors for medicamentous and dental treatment failure dengan menggunakan kata kunci Ausinusitis odontogenikAy.
Hasil: Tiga artikel kohort prognostik yang didapatkan, ditelaah kritis untuk dinilai validitas, esensi, dan kemampuan untuk dapat diaplikasikan dalam skenario klinis.
Faktor prognostik yang presisi adalah skor total Lund-Mackay tinggi dengan odd ratio (OR) 95% dan confidence interval (CI) 2,0/1,04-3,79.
Kesimpulan: Skor total Lund-Mackay yang tinggi adalah faktor prognostik penting dalam kegagalan terapi konservatif, sehingga bedah sinus harus dilakukan.
Kata kunci: sinusitis odontogenik, terapi konservatif, bedah sinus, skor Lund-Mackay Correspondence address: Josua Manalu.
Department of Otolaryngology Head and Neck Surgery.
Faculty of Medicine.
Universitas Indonesia/ Dr.
Cipto Mangunkusumo National General Hospital.
Jakarta
INTRODUCTION
Odontogenic sinusitis (OS), also known as odontogenic maxillary sinusitis or maxillary sinusitis of dental origin, refers to bacterial maxillary sinusitis, with or without extension to other paranasal sinuses, secondary to either adjacent infectious maxillary dental pathology, or following complications from dental procedures.
OS accounts for 10Ae14% of the total maxillary sinusitis.
From all the total number of unilateral maxillary sinusitis.
OS accounts for 75% of cases.
The floors of maxillary sinus are close to molar roots, and varies in thickness up to 12 It can be interrupted with exposed tooth roots in patients with bone loss.
The respiratory epithelium .
lso known as the Schneiderian membran.
of the maxillary sinus can be in direct contact with periodontal membrane of the tooth roots, which provide a potential source of contamination.
2 From anatomical perspective, the second molarAos roots are the closest to the sinus floor measuring an average 97 mm, nevertheless some studies had concluded that the first molars are the most commonly affected by periodontal disease, and endodontic pathology as the cause of sinus infections.
Iatrogenic injury is the most frequent cause of OS .
round 56%), and majority of cases arise in people who have had dental procedures, such as dental extractions, and endodontic treatments.
It can also result from odontogenic infections, for instance dental caries, endodontic infections, periapical lesions, etc.
), and traumatic injuries of the maxillary bone.
3 Anaerobic bacteria, such as Fusobacterium.
Prevotella, and Porphyromonas, are the majorities of the nasal microbiome of OS.
Peptostreptococcus was also found in other studies.
The important aspects of diagnosing OS are suspecting OS based on typical clinical features such as patient complaint of foulsmelling, purulent secretion from middle meatus on nasal endoscopic examination, unilateral maxillary sinus opacification, and possible dental pathology on CT scan, and odontogenic bacteria in sinus culture.
Subsequently, the otorhinolaryngologist will confirm sinusitis, and dental provider will confirm odontogenic pathology as the sources of sinusitis.
The radiological examination is important in the diagnosis of OS.
Limited efficacy of two-dimentional .
D) imaging can be used, include periapical, panoramic, and Waters radiographs.
All 2D studies frequently degrades anatomic relationships due to superimposition.
By far, the most common imaging study currently used is a non-contrast computed tomography (CT) scan of the paranasal sinuses.
2,5 CT imaging of OS presents with unilateral maxillary ORLI 2025 Volume 55 No.
Prognostic factors for medicamentous and dental treatment failure sinus changes marked by mucosal thickening, or total opacification.
Regarding dental imaging, multiple studies have demonstrated cone-beam CT being superior to periapical radiography, for detecting periapical lesions from apical periodontitis.
However, conebeam CT is more costly, and is not as widely The target of therapy in OS is to eliminate the underlying cause, relieve symptoms, and restore the normal function of the The therapeutic algorithm usually includes two stages: conservative and 2,5 Conservative therapy consists of antibiotics, nasal steroids, decongestants, saline nasal irrigation, and dental treatments.
Among the results of studies examining the effectiveness of conservative therapy, there was a significant variation, with the results ranging between 36% and 95%.
The duration of antibiotic treatment in OS should be at least 14 days, or at least 7 days after the resolution of symptoms, but some authors recommended antibiotic treatment for 21Ae28 1 Appropriate antibiotic therapy for OS should initially be given targeting aerobe and anaerobe bacteria.
For this reason, amoxicillin combined with clavulanate, which is a beta lactamase inhibitor, is preferred.
If conservative therapy is successful in curing sinusitis, unnecessary sinus surgery can be avoided, which lowers the risk of perioperative complications and discomfort associated with sinus surgery, as well as overall medical costs.
But, if conservative therapy fails, sinus surgery is usually required to remove the cause of the pathology, to allow the correct drainage and ventilation of the sinus, and to prevent disease recurrence.
In the past, the classical Caldwell-Luc procedure was the main surgical management of maxillary sinus disease, but associated with the disadvantages of large trauma and many complications.
At present, endoscopic sinus surgery (ESS) is regarded as the gold standard surgery.
It has shown excellent effect, especially when the osteomeatal complex (OMC) is blocked.
ESS provides a large middle meatal antrostomy, which improves visualization for the entire maxillary sinus through a smaller surgical window.
It has small surgical trauma and optimal exposure, and provides maximum elimination of infection in maxillary sinus by opening OMC, and removing sinus lesion to restore normal drainage and ventilation, while preserving the healthy mucosa, thereby reducing possible However, because the management protocol of OS is not well established, and there is no consensus for the optimal timing of endoscopic sinus surgery (ESS) for OS, doctors are often unsure about the best treatment strategy to follow Ae dental treatment first.
ESS first, or both simultaneously.
7 The necessity to undergo ESS in the early stages is controversial, because some cases have been reported to be cured with just medical management and dental Moreover, if the causative teeth were not treated, sinusitis might persist after ESS.
This study was aimed to identify prognostic factors in patients with OS that increase the likelihood of undergoing ESS after conservative treatment failure.
We formulated our clinical question as P (Populatio.
: Odontogenic sinusitis patients treated by conservative Intervention/Comparation (I/C):
Prognostic factors such as smoking history, high Lund-Mackay Score, ostiomeatal complex blockage, history of dental procedure prior to OS.
and Outcome (O): no clinical improvement.
The proposed question in this study were the prognostic factors such as smoking habits, high Lund-Mackay score, ostiomeatal complex blockage, and history of dental procedure prior to OS.
Did these factors affect medicamentosa and dental treatment failure in OS? CASE ILLUSTRATION A 27 years old male, after being treated by antibiotic, decongestant, and anti-inflammation.
ORLI 2025 Volume 55 No.
Prognostic factors for medicamentous and dental treatment failure was referred to ENT Department of Persahabatan Hospital with chief complaint foul-smelling purulent rhinorrhea and post nasal drip, along with nasal blockage, hyposmia and left maxillary facial pain for about 1 year.
He was an active smoker since his adolescence, with the smoking frequency of around 8-10 cigarettes/day.
History of dental cavities, implants, dental extractions, and trauma at dental region were all denied.
Extraction of left upper third molar was already performed 1 month previously by dentoalveolar surgeon under local anesthesia.
On general physical examinations, no significant abnormalities were found.
In the right nasal endoscopy examination, all within normal limits, while on the left nasal endoscopy examination it was found narrowed nasal cavity, inferior turbinate edema, purulent and pulsating discharge from middle meatus, bulging and edematous uncinate process, and occluded ostiomeatal Patient was treated by conservative treatments included oral antibiotic, saline nasal irrigation, intranasal corticosteroid, and and CT scan of paranasal sinuses was performed.
From the CT scan of paranasal sinuses there were total opacification in the left maxillary sinus, partial opacification of anterior ethmoid sinus, obstructed ostiomeatal complex and periapical lucency at left second molar.
Endoscopic sinus surgery was scheduled, and the patient was re-consulted the patient to the dentoalveolar surgeon for evaluation whether they had further Afterwards, they diagnosed the patient with irreversible pulpitis and planned for conservative treatment.
The endoscopic sinus surgery was There was no complication during Three weeks after surgery, sinus ostium was broad opened and no purulent secretion was found.
METHOD
We defined the keywords based on PICO and searched the evidence through bibliographic database (PubMed.
Cochrane, and Hand-searchin.
and selected with eligibility criteria.
We included this study with a systematic review design, or prospective or retrospective cohort study.
The study must be published in English between the year of Odontogenic sinusitis (OS) only mentioned minimally in sinusitis guidelines.
The recent 2020 European Position Paper on Rhinosinusitis (EPOS) briefly discussed OS as the cause of sinusitis, but did not discuss diagnostic or therapeutic recommendations.
According to the consensus on diagnosing OS by Craig et al.
OS had received significantly less attention in the literature compared to rhinosinusitis, so this study covered the newest literatures in the past 10 years.
The inclusion criteria were: .
a clinical diagnosis of sinusitis of suspected odontogenic origin, supported either by endoscopy or .
ENT specialist and dentist agreement on the odontogenic focus.
had underwent conservative treatment e.
antibiotic, steroid, and dental treatment.
The exclusion criteria were: complicated odontogenic sinusitis .
rbital, osseous, or intracranial involvemen.
Type of prognostic factors in odontogenic sinusitis with conservative treatment, were all factors such as history of high LundMackay score including ostiomeatal complex involvement, smoking, history of dental procedure prior to developing odontogenic Type of outcome should be observed on how was the clinical improvement after medical and dental treatment.
After a period of at least 2-4 weeks, a follow-up examination should be conducted to assess the healing progress of the odontogenic sinusitis.
If there were no signs of healing, or if the symptoms persisted, sinus surgery might be required.
ORLI 2025 Volume 55 No.
Prognostic factors for medicamentous and dental treatment failure The evidence selected was appraised by at least two research members, using Oxford Centre for Evidence-based Medicine (CEBM) worksheet for prognostic study.
RESULT
Since the issue of OS was underreported, we expanded the method of literature searching by using only one term Auodontogenic sinusitisAy, and all its synonyms.
After conducting literature searching on two large data base Medline and Cochrane, also Handsearching, it was found 309 articles related to our term.
A screening of duplication and title/ abstract were performed.
Studies that did not match with the inclusion criteria were In the end, the authors obtained three studies to be appraised that fit to our clinical settings: Yoo et al.
Mattos et al.
and Kim et al.
Two of three studies design were prospective cohort studies, and all of them evaluated prognostic factors that affected the failure of medical and dental treatment in OS.
Yoo et al.
8 in their study evaluated 33 patients with OS due to dental caries and periapical They were initially managed with dental treatment, along with medication and saline nasal irrigation without ESS.
They also evaluated smoking status and total Lund-Mackay score in two groups according to the results of medical management and dental treatment.
After duration of antibiotic use of 23.
95A11.
32 days, and the time taken to cure was 37.
23A26.
07 days, twenty-two patients .
%) were cured by medication and dental treatment without ESS, while 11 patients .
%) had to undergo ESS.
Patients with smoking habits and high Lund-Mackay score were recommended to undergo early ESS.
Mattos et al.
9 collected data from previously constructed database and found 43 patients underwent treatment for OS.
They were treated medically and referred to dental evaluation prior to pursuing ESS.
They also evaluated Lund-Mackay score and the history of dental procedure as prognostic factors that contributed to the failure of conservative treatment in OS.
Lund-Mackay scores were analyzed by each components, and OMC involvement was the only statistically Twenty-one patients .
%) with OMC involvement and prior dental procedure had to undergo ESS.
The last.
Kim et al.
in their study, compared conservative and surgical groups for analysis.
Nineteen patients who were treated for OS developing in relation to dental implant: 4 patients .
%) were successfully treated conservatively, while 15 patients .
%) underwent surgical They concluded that longer symptom duration, high LundAeMackay CT score, complete obstruction of the ostiomeatal unit (OMU), and the damaged of maxillary sinus floor on coronal CT images, were significantly more severe conditions in the surgical group.
In this evidence-based case report, there were 3 prognostic studies for the failure of medical and dental treatment in patients with OS.
All of these were the representative samples of patient with OS who underwent sinus surgery.
DISCUSSION
Odontogenic sinusitis (OS) is an inflammatory condition of the maxillary, or extended paranasal sinuses, that has a dental etiology.
During conservative therapy, besides medical treatment, any dental hygiene treatment, treatment of dental pockets, root canal treatment, caries removal, and tooth extraction, must be performed if necessary.
Sinus surgical treatment is advised if conservative treatment is ineffective.
2-4 In our Evidence Based Case Report (EBCR), high Lund-Mackay score, with a narrow range of confidence interval, was the most precision prognostic factor that contributed to the conservative treatment ORLI 2025 Volume 55 No.
Prognostic factors for medicamentous and dental treatment failure failure in OS.
In contrast, there was a wide range of contraindication in smoking.
OMC involvement, history of dental procedure in those studies.
However, these factors could have a role as potential prognostic factors although precision was not obtained, that could be caused by a too few numbers of research subjects.
The Lund-Mackay score is the most common method used for evaluating sinus CTscans according to the location of the lesions in the sinuses, depending on partial or complete opacification.
It is used to assess the extent and degree of disease in chronic In the Lund-Mackay system, each sinus .
axillary, anterior ethmoid, posterior ethmoid, sphenoid, and fronta.
is scored between 0 and 2 .
: no abnormality.
1: partial 2: total opacificatio.
The ostiomeatal complex was scored as 0 .
o obstructio.
or 2 .
8,11
Study by Yoo et al.
8 concluded the mean of Lund-Mackay in non-ESS group was 36A1.
22, which inline with another study by Mattos et al.
9 concluded that the non-ESS group mean score of 3.
Both of their studies showed that there was a significant relationship between the Lund-Mackay score based on CT scan findings with patientsAo clinical status and treatment response.
The Lund-Mackay was significantly higher in patients who did not respond well to medication .
fterward requiring surgical treatmen.
, than in patients who responded well to medication.
Since a high Lund-Mackay score indicated that more sinuses were involved beyond the maxillary sinus, describing the extent of sinus involved were severe and wide, so ESS was required to achieve a complete cure.
8,9,12
The frontal, maxillary, and anterior ethmoid air cells, ultimately share a common channel for drainage and ventilation, which is represented by the OMC.
An extension of inflammation from the maxillary sinus to the OMC may lead to other sinuses becoming Anatomic variations also can impair mucous drainage or narrow the OMC, which predispose the development of sinusitis and treatment failure.
The understanding of the complex and variable anatomy of the sinuses and their drainage pathways is therefore imperative in successful management of OS.
11,12 Furthermore, the finding of OMC blockage may represent advanced or severe disease, that will be more difficult to treat with only conservative treatments.
The OMC obstruction can be a consideration for clinician, concerning the potential need for ESS to relieve symptoms, and allowing a better treatment planning.
Study of Yoo et al.
8 found that smoking patients with odontogenic sinusitis were the ones who eventually underwent ESS.
Tobacco smoke stimulates the nasal mucosa, increases intranasal air resistance, and causes physiological responses such as nasal congestion and rhinorrhea.
Study of Christensen et al.
13 summarized prominent findings about the possible effects of smoking on the sinonasal mucosa, from available in vitro and in vivo studies.
In vitro studies had suggested number of possible mechanisms with smoking causing alterations in chloride ion transport, reduced mucociliary clearance, and/or reduced ciliary generation.
In vivo results were also supporting with possible changes in histology, mucociliary transport and inflammatory cytokines underlying disease development.
Finally, more recent studies had evaluated how smoking affects the microbiome of the sinonasal mucosa, and had shown that smoking both altered the sinonasal microbiome and increased the risk of biofilm Lieu and FeinsteinAos research cited by Yoo et al.
8, also conducted a study on the prevalence of smoking and sinusitis, and found that smokers showed a significantly higher prevalence of sinusitis when compared with non-smokers.
These results strengthened the possibility that smokers were more likely to require ESS after the failure of dental ORLI 2025 Volume 55 No.
Prognostic factors for medicamentous and dental treatment failure Various odontogenic pathologies can cause OS, including pulpitis, periapical lesions, periodontitis, oroantral fistulas, or foreign bodies in the sinus related to dental The most common cause is periapical lesions .
following root canal treatment .
When the root canals of teeth are incompletely filled with a filling material during endodontic treatment, insufficient root canal treatment causes pulpitis and pulp necrosis in the root canal at the root apex.
The pathological studies of the causative teeth showed pulpal necrosis and apical lesions after the root canal treatment.
The pulp inflammation causes apical lesions .
pical periodontiti.
, consequently, odontogenic infection such as alveolar ostitis occurs.
When the odontogenic inflammation is constantly presented at the floor of the maxillary sinus, the maxillary sinus is at risk of becoming inflamed.
7 Patients who had underwent a dental procedure prior to presenting to otolaryngologists with OS, may represent patients who either have a severe odontogenic infection, or may have had an iatrogenic etiology to their infection.
These individuals may represent a population with more severe or recalcitrant disease, that requires ESS for symptoms resolution.
In conclusion, high total Lund-Mackay is an important precision prognostic factor that contributed for medicamentous and dental treatment failure in odontogenic This is a crucial information for clinician, concerning the potential need for ESS, allowing an early better treatment planning for the patients.
However, for the applicability, paranasal sinus CT at early phase for odontogenic sinusitis in our clinical setting is still become a consideration.
depends on health provider resources.
As the answer to our clinical question, the total Lund-Mackay score in our patient was 5, appreciably higher than those who did not need ESS, besides he had smoking history and OMC blockage.
These could be the prognostic factors that might cause the failure of medicamentous and dental treatment, so that the ESS had to be performed in our patient.
However, we recommended further research with suitable method to obtain accurate result.
REFERENCE