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Sinusitis and dental implants

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  Posted by: The Probe      14th April 2020

Rhinosinusitis is an inflammation of the nose and paranasal sinuses. For acute rhinosinusitis (ARS) symptoms usually resolve with 12 weeks of manifesting. Where symptoms continue beyond this point, it is diagnosed as chronic rhinosinusitis (CRS). The former is most often caused by bacterial or viral infection, while the latter has a less certain aetiology, but is generally believed to be multifactorial. CR is subcategorised depending on whether nasal polyps are present or not. Around 1 in 10 UK adults are affected by chronic rhinosinusitis.[i]

Sinusitis can have a number of unpleasant symptoms including: headaches, post-nasal drip, malodour, dental pain, fatigue, congestion and an impaired sense of smell.[ii] These symptoms are not only unpleasant in their own right, but they can also lead to further maladaptive strategies and consequences. For example, a patient with sinusitis induced halitosis may avoid speaking, or face social repercussions.

Congested sinuses can cause patients to breathe through their mouths more, which can lead to dental consequences. When we breath in the nose naturally and very efficiently warms and humidifies air. When breathing through the mouth we lose a lot more water in the air we breathe out, around 42% on average.[iii] Habitual mouth breathing has a significant drying effect on the oral cavity, particularly on the anterior teeth. Saliva has considerable protective effects; it shields tissues from desiccation, clears food particles, has antimicrobial properties, aids healing, remineralises teeth and works as a buffer to help normalise oral pH level.[iv], [v] As such, a dry mouth makes it more difficult to control plaque and can lead to gingival inflammation.[vi], [vii] In children, chronic mouth breathing may influence dental and facial growth, as well as encouraging gingivitis, plaque, caries and halitosis.[viii], [ix] One study comparing mouth and nose breathing in young adults, found that the risk of developing cariogenic S. mutans was four times as great in mouth breathers.[x] While AS is ultimately limited in duration, CR can result in extended, recurrent periods of sinusitis symptoms – allowing much more time for detrimental effects to take place.

Odontogenic sinusitis is dental in origin. It can be caused by infections and trauma of the maxillary dentition, as well as from iatrogenic injury. Endodontic infections and chronic periodontitis can disrupt and inflame the sinus lining, leading to mucosal inflammation of the maxillary sinus. Between 10-40% of all sinusitis cases are believed to have dental causes, though it appears that only around a third of these patients experience dental pain. Treatment can require medical and/or dental intervention, depending on the nature of the underlying pathology.[xi]

Dental implants

ARS and CRS are potential, though infrequent, complications that can arise following dental implant and sinus lift procedures.[xii], [xiii], [xiv], [xv] Odontogenic sinusitis symptoms generally occur within 3 months of the procedure.[xvi]

In rare instances, dental implants can be displaced into the maxillary sinus directly, during or after placement. This occurs more frequently in patients who have minimal alveolar bone available (particularly where it is less than 4mm), severe maxillary sinus pneumatisation, or require bone grafting. Surgical skill and experience is a noted influence on the likelihood of implant displacement, particularly regarding over-drilling and excessive force.[xvii] Where the implant penetrates into the sinus cavity less than 2mm, covering of the implants with sinus mucosa appears to occur; it is not unknown for new bone growth to cover over them. More than 2mm of extension, however, prevents healing and leads to debris accumulating on the exposed implant.[xviii] On the other hand Summers technique of closed sinus lift has been shown to be a highly successful treatment when carried out expertly in suitable patients where the residual bone height below the maxillary sinus is reduced.

It is usually recommended that displaced implants are immediately removed, though where a delay occurs, the sinus infection should be treated with antibiotics and/or endoscopic surgery. Once the offending implant is removed, implant replacement and grafting may be performed in stages.[xix]

With knowledge and precision, the risk of iatrogenic infections is reduced. Of crucial importance is to carry out a through clinical examination with appropriate 3D diagnostic imaging to evaluate the anatomy, identify existing pathology and to avoid collateral damage to the maxillary sinuses and the adjacent vital structures. Ucer Education offers courses providing clinical training, mentoring and support in all aspects of implant dentistry. Ucer Education’s PG Cert in Implant Dentistry will empower you with the training you need to confidently provide implants to the highest standard, while more advanced sinus lift and bone grafting courses offer experienced clinicians an opportunity to further refine their skills.

Sinusitis can reduce a patient’s quality of life and contribute to the development of oral health problems, which may ultimately lead to edentulism. If you believe a patient may be exhibiting CR, they should be advised of the potential risk to their oral hygiene and to seek treatment for the condition. Where you believe the patient is having to compensate for nasal congestion by breathing through their mouth, they may benefit from similar advice to a patient with xerostomia – chiefly they should ensure that they keep well hydrated by drinking plenty of water.

For some edentulous patients receiving implants and requiring sinus lifts, there is a small chance that the treatment could trigger chronic rhinosinusitis. However, this should not prevent patients from receiving implants, as for suitable candidates, the treatment provides a highly effective solution to edentulism. Alternatively, graftless extra-maxillary zygomatic ZAGA implants or the innovative technique of 3D printed customised subperiosteal implants could be considered with the advantages of less traumatic surgery and immediate loading. These techniques are routinely available at Prof Ucer’s Centre for Oral-Maxillofacial & Dental Implant Reconstruction and taught at his straightforward or advanced surgical courses.

 

Please contact Professor Ucer at

Centre for Oral-Maxillofacial & Dental Implant Reconstruction,

Manchester Postgraduate Dental Institute & ICE Hospital, Salford Quays, Manchester

 

Professor Ucer at ice@ucer.uk or Mel Hay at mel@mdic.co

Tel: 01612 371842

www.ucer.education

 

[i] ENT UK. Commissioning guide: chronic rhinosinusitis. Royal College of Surgeons. 2016. https://www.rcseng.ac.uk/standards-and-research/commissioning/commissioning-guides/topics/ December 10, 2019.

[ii] NHS. Sinusitis. NHS. 2017. https://www.nhs.uk/conditions/sinusitis-sinus-infection/ December 12, 2019.

[iii] Svensson S., Olin A., Hellgren J. Increased net water loss by oral compared to nasal expiration in healthy subjects. Rhinology. 2006; 44: 74-77. https://www.ncbi.nlm.nih.gov/pubmed/16550955 December 12, 2019.

[iv] Sharma S., Gaur P., Gupta S. Impact of saliva on health: an overview. European Journal of Biomedical and Pharmaceutical Sciences. 2018; 5(6): 202-204. https://pdfs.semanticscholar.org/322f/79fcba68e80e9fc33259a0fe741c788274b1.pdf December 12, 2019.

[v] Vila T., Rizk A., Sultan A., Jabra-Rizk M. The power of saliva: antimicrobial and beyond. PLoS Pathogens. 2019; 15(11): e1008058. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855406/ December 12, 2019.

[vi] Murakami S., Mealey B., Mariotti A., Chapple I. Dental plaque-induced gingival conditions.  Journal of Clinical Periodontology. 2018; 45(S20): 17-27. https://doi.org/10.1111/jcpe.12937 December 12, 2019.

[vii] Sharma R., Bhatia A., Tewari S., Narula S. Distribution of gingival inflammation in mouth breathing patients: an observational pilot study. Journal of Dentistry Indonesia. 2016; 23(2): 28-32. https://doi.org/10.14693/jdi.v23i2.981 December 12, 2019.

[viii] Valcheva Z., Arnautska H., Dimova M., Ivanova G., Atanasova I. The role of mouth breathing on dentition development and formation. Journal of IMAB. 2018; 24(1): 1878-1882. https://doi.org/10.5272/jimab.2018241.1878 December 12, 2019.

[ix] Triana B., Ali A., León I. Mouth breathing and its relationship to some oral and medical conditions: physiopathological mechanisms involved. Revista Habanera de Ciencias Médicas. 2016; 15(2): 200-212. http://www.redalyc.org/articulo.oa?id=180445640008 December 12, 2019.

[x] Mummolo S., Nota A., Caruso S., Quinzi V., Marchetti E., Marzo G. Salivary markers and microbial flora in mouth breathing late adolescents. BioMed Research International. 2018; 2018: 8687608. https://doi.org/10.1155/2018/8687608 December 12, 2019.

[xi] Little R., Long C., Loehri T., Poetker D. Odontogenic sinusitis: a review of the current literature. Laryngoscope Investigative Otolaryngology. 2018; 3(2): 110-114. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915825/ December 12, 2019.

[xii] Chirilä L., Rotaru C., Filipov I., Sändulescu M. Management of acute maxillary sinusitis after sinus bone grafting procedures with simultaneous dental implants placement – a retrospective study. BMC Infectious Diseases. 2016; 16(Suppl. 1): 94. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896248/ December 10, 2019.

[xiii] Jiam N., Goldberg A., Murr A., Pletcher S. Surgical treatment of chronic rhinosinusitis after sinus lift. American Journal of Rhinology & Allergy. 2017; 31(4): 271-275. https://journals.sagepub.com/doi/abs/10.2500/ajra.2017.31.4451 December 10, 2019.

[xiv] Rapsa K. Sinus lifts failure resulting in chronic sinusitis. Journal of Otolaryngology-ENT Research. 2017; 8(6): 00270. http://dx.doi.org/10.15406/joentr.2017.08.00270 December 10, 2019.

[xv] Little R., Long C., Loehri T., Poetker D. Odontogenic sinusitis: a review of the current literature. Laryngoscope Investigative Otolaryngology. 2018; 3(2): 110-114. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915825/ December 12, 2019.

[xvi] Jiam N., Goldberg A., Murr A., Pletcher S. Surgical treatment of chronic rhinosinusitis after sinus lift. American Journal of Rhinology & Allergy. 2017; 31(4): 271-275. https://journals.sagepub.com/doi/abs/10.2500/ajra.2017.31.4451 December 10, 2019.

[xvii] An J., Park S., Han J., Jung S., Kook M., Park H., Oh H. Treatment of dental implant displacement into the maxillary sinus. Maxillofacial Plastic and Reconstructive Surgery. 2017; 39: 35. https://link.springer.com/article/10.1186/s40902-017-0133-1 December 12, 2019.

[xviii] Ragucci G., Elnayef B., Suárez-López del Amo F., Wang H., Hernández-Alfaro F., Gargallo-Albiol J. Influence of exposing dental implants into the sinus cavity on survival and complications rate: a systematic review. International Journal of Implant Dentistry. 2019; 5: 6. https://journalimplantdent.springeropen.com/articles/10.1186/s40729-019-0157-7 December 12, 2019.

[xix] An J., Park S., Han J., Jung S., Kook M., Park H., Oh H. Treatment of dental implant displacement into the maxillary sinus. Maxillofacial Plastic and Reconstructive Surgery. 2017; 39: 35. https://link.springer.com/article/10.1186/s40902-017-0133-1 December 12, 2019.


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