OralMedicine-UpdatefortheDentalTeam
David H Felix
Jane Luker
Crispian Scully
This series provides an overview of current thinking in the more relevant areas of Oral Medicine, for primary care practitioners. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders. Approaching the subject mainly by the symptomatic approach, as it largely relates to the presenting complaint, was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made, along with guidance on management and when to refer, in addition to relevant websites which offer further detail.
Oral Medicine: 17. Radiolucencies and Radio-opacities. D. Antral Disease Specialist referral may be indicated if the Practitioner feels: The diagnosis is unclear; A serious diagnosis is possible; Systemic disease may be present; Unclear as to investigations indicated; Complex investigations unavailable in primary care are indicated; Unclear as to treatment indicated; Treatment is complex; Treatment requires agents not readily available; Unclear as to the prognosis; The patient wishes this.
Antral disease Paranasal sinuses are air-filled cavities in the dense portions of the bones of the skull lined with a ciliated mucosa, the mucus from which drains via openings (ostia) into the nose. The main sinuses are frontal, ethmoid, sphenoid and maxillary.
David H Felix, BDS, MB ChB, FDS RCS(Eng), FDS RCPS(Glasg), FDS RCS(Ed), FRCP(Edin), Postgraduate Dental Dean, NHS Education for Scotland, Jane Luker, BDS, PhD, FDS RCS , DDR RCR, Consultant and Senior Lecturer, University Hospitals Bristol NHS Foundation Trust, Bristol, Professor Crispian Scully, CBE, MD, PhD, MDS, MRCS, BSc, FDS RCS, FDS RCPS, FFD RCSI, FDS RCSE, FRCPath, FMedSci, FHEA, FUCL, DSc, DChD, DMed(HC), Dr HC, Emeritus Professor, University College London, Hon Consultant UCLH and HCA, London, UK.
370 DentalUpdate
Their main disorders are inflammatory and neoplastic. This section focuses on the maxillary sinus (antrum). The floor of the maxillary antrum will be visualized in maxillary intra-oral films and in DPTs – where the medial and posterior wall can also be assessed (Figure 1).
Sinusitis Definition: inflammation of the sinus mucosa. Sinusitis most commonly affects the ethmoid sinuses, which then causes a secondary maxillary sinusitis. As a result of later development of the sinuses, sphenoid sinusitis is unusual in children under age 5 years and frontal sinusitis is unusual before age 10. Maxillary sinusitis is subdivided into acute and chronic sinusitis, the differential being a 3-month time period. Prevalence (approximate): common; (15–20% of the population at some point); Age mainly affected: any; Gender mainly affected: M = F.
Allergic (vasomotor) rhinitis and nasal polyps; Viral upper respiratory tract infection (URTI); Diving or flying; Nasal foreign bodies; Periapical infection of maxillary posterior teeth; Oro-antral fistula; Prolonged endotracheal intubation. Table 1. Factors predisposing to paranasal
sinusitis.
Aetiopathogenesis: cilia damage (eg tobacco smoke exposure), or impaired mucociliary clearance as when ostia are obstructed (eg allergic or infective rhinitis, foreign bodies, polyps). A change in sinus air pressure may cause pain (eg from ostia obstruction, increased mucus production, or air pressure changes such as flying or diving)(Table 1). Bacteria are most commonly the cause, and incriminated are: In acute sinusitis: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Staphylococcus aureus and Streptococcus pyogenes may also be involved. In chronic sinusitis, also anaerobes, especially Porphyromonas (Bacteroides); In some circumstances, Grampositive cocci and bacilli as well as Gram-negative bacilli may also be found – especially after prolonged endotracheal intubation, and in HIV/ AIDS. In many immunocompromised persons, fungi (mucor, aspergillus or others) may be involved and, in cystic fibrosis, Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae are often implicated. Diagnostic features History
Symptoms can include nasal drainage (rhinorrhea or post nasal drip), nasal blockage, the sensation of swelling in nose or sinuses, ear symptoms, pain in teeth worse on biting or leaning over, halitosis, headache, fever, cough, malaise, etc (Table 2). Symptoms are typically less severe in chronic sinusitis. May 2014
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 29, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
OralMedicine-UpdatefortheDentalTeam
Location
Location of pain
Other features
Maxillary
Cheek and/or upper teeth
Tenderness over antra
Frontal
Over frontal sinuses
Tenderness of sides of nose
Ethmoidal
Between eyes
Anosmia, eyelid swelling
Sphenoidal
Ear, neck, and at top or centre of head
Table 2. Features of paranasal sinusitis
Dome-shaped soft tissues opacity (mucus retention)
Medial wall of maxillary antrum
Figure 2. Half DPT (left side) showing antral anatomy and dome-shaped soft tissue opacity of a mucous retention cyst.
a
Floor of maxillary antrum
Posterior wall of the maxillary antrum
Figure 1. Anatomy of the maxillary antrum imaged in a DPT.
Clinical features
There may be nasal turbinate swelling, erythema and injection (dilated blood vessels), mucus, sinus tenderness, allergic ‘shiners’ (dark circles around eyes), pharyngeal erythema, otitis, etc. Diagnosis is from the history, plus sinus tenderness and dullness on transillumination. Nasendoscopy can visualize the mucosal surface inside the maxillary or sphenoid sinus in over 50% of patients. Nasal cytology with a rhinoprobe may help and ear examination is important. Acute sinusitis is diagnosed and treated clinically and does not require imaging. If symptoms persist after 10 days of treatment, CT is recommended when the results may affect management. Plain films are not recommended as the findings May 2014
are usually non-specific. Differentiating between sinusitis and URTI is difficult. Antral radio-opacities in children under age b 6 years can be difficult to evaluate since they are seen in up to 50%. In adults, a sinus radio-opacity may be due to mucosal thickening or a mucous retention cyst (Figures 2 and 3) but a fluid level is highly suggestive of acute sinusitis. Corticated opacities occurring in the maxillary antrum indicate that the aetiology of the opacity is extrinsic to the antrum, eg an apical radicular cyst (Figure 4). MRI may be recommended if there are complications such as peri-orbital infection, or to rule out malignancy. It may sometimes be necessary Figure 3. (a) Coronal CT of maxilla showing rightto perform a needle aspiration sinus to sided benign mucous retention cyst. (b) Axial CT confirm the diagnosis, and sample infected of (a). material to culture to determine what DentalUpdate 371 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 29, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
OralMedicine-UpdatefortheDentalTeam
a
Figure 4. Section of DPT showing antral opacity with corticated margin indicating aetiology extrinsic to the antrum, in this case an apical radicular cyst associated with the upper right first molar.
b
micro-organism is responsible. In patients with recurrent or recalcitrant sinusitis, cystic fibrosis and immunodeficiencies may need to be excluded. Management
Acute sinusitis resolves spontaneously in about 50%, but analgesics are often indicated and other therapies may be required, especially if symptoms persist or there is a purulent discharge. Intranasal steroids are helpful in many patients, although studies evaluating the efficacy have not been conclusive. Antihistamines are used for patients with significant allergic symptoms. Oral decongestants help, but typically may be used for 3–7 days only as longer use may cause rebound and rhinitis medicamentosa. Guaifenesin helps thin and increase clearance of secretion. Buffered saline lavage may help in clearing secretions. Hot steam is often helpful. Antibiotic treatment for at least two weeks in acute sinusitis and at least three weeks in chronic sinusitis is commonly required. Treatment for acute sinusitis is amoxicillin, ampicillin or co-amoxiclav (erythromycin if penicillin-allergic), or a tetracycline such as doxycycline or clindamycin. Chronic sinusitis responds better to drainage by functional endoscopic sinus surgery (FESS), plus antimicrobials (metronidazole with
372 DentalUpdate
Figure 5. (a) DPT showing radiological features of a malignancy of the right antrum – opacity and bony destruction of the floor of the antrum. (b) Section of an occipito-mental radiograph, showing loss of lateral wall of the right maxillary antrum, a feature that is highly suspicious of malignant disease.
Definition: usually squamous carcinoma Prevalence (approximate): rare; Age mainly affected: older people; Gender mainly affected: M > F. Aetiopathogenesis: the only identified predisposing factors are smoking and occupational exposure to wood dust.
the effects of expansion and infiltration of adjacent tissues become apparent as intra-oral alveolar swelling, ulceration of the palate or buccal sulcus; swelling of the cheek; unilateral nasal obstruction often associated with a blood-stained discharge; obstruction of the nasolacrimal duct with epiphora; hypo- or anaesthesia of the cheek; proptosis and ophthalmoplegia consequent on invasion of the orbit and trismus from infiltration of the muscles of mastication. Diagnosis is supported by endoscopy, radiography (Figures 5a and b), magnetic resonance imaging and biopsy.
Diagnostic features
Management
These tumours can remain undetected until late. When they infiltrate branches of the trigeminal nerve they cause maxillary pain. As the tumour expands
Combinations of surgery and radio-chemotherapy are usually required. Prognosis is poor with a < 30% 5-year survival.
amoxicillin, erythromycin, clindamycin or a cephalosporin). Open procedures including the classical Caldwell-Luc operation are generally outmoded.
Neoplasms
May 2014 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 29, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
David H Felix
Jane Luker
Crispian Scully
This series provides an overview of current thinking in the more relevant areas of Oral Medicine, for primary care practitioners. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders. Approaching the subject mainly by the symptomatic approach, as it largely relates to the presenting complaint, was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made, along with guidance on management and when to refer, in addition to relevant websites which offer further detail.
Oral Medicine: 17. Radiolucencies and Radio-opacities. D. Antral Disease Specialist referral may be indicated if the Practitioner feels: The diagnosis is unclear; A serious diagnosis is possible; Systemic disease may be present; Unclear as to investigations indicated; Complex investigations unavailable in primary care are indicated; Unclear as to treatment indicated; Treatment is complex; Treatment requires agents not readily available; Unclear as to the prognosis; The patient wishes this.
Antral disease Paranasal sinuses are air-filled cavities in the dense portions of the bones of the skull lined with a ciliated mucosa, the mucus from which drains via openings (ostia) into the nose. The main sinuses are frontal, ethmoid, sphenoid and maxillary.
David H Felix, BDS, MB ChB, FDS RCS(Eng), FDS RCPS(Glasg), FDS RCS(Ed), FRCP(Edin), Postgraduate Dental Dean, NHS Education for Scotland, Jane Luker, BDS, PhD, FDS RCS , DDR RCR, Consultant and Senior Lecturer, University Hospitals Bristol NHS Foundation Trust, Bristol, Professor Crispian Scully, CBE, MD, PhD, MDS, MRCS, BSc, FDS RCS, FDS RCPS, FFD RCSI, FDS RCSE, FRCPath, FMedSci, FHEA, FUCL, DSc, DChD, DMed(HC), Dr HC, Emeritus Professor, University College London, Hon Consultant UCLH and HCA, London, UK.
370 DentalUpdate
Their main disorders are inflammatory and neoplastic. This section focuses on the maxillary sinus (antrum). The floor of the maxillary antrum will be visualized in maxillary intra-oral films and in DPTs – where the medial and posterior wall can also be assessed (Figure 1).
Sinusitis Definition: inflammation of the sinus mucosa. Sinusitis most commonly affects the ethmoid sinuses, which then causes a secondary maxillary sinusitis. As a result of later development of the sinuses, sphenoid sinusitis is unusual in children under age 5 years and frontal sinusitis is unusual before age 10. Maxillary sinusitis is subdivided into acute and chronic sinusitis, the differential being a 3-month time period. Prevalence (approximate): common; (15–20% of the population at some point); Age mainly affected: any; Gender mainly affected: M = F.
Allergic (vasomotor) rhinitis and nasal polyps; Viral upper respiratory tract infection (URTI); Diving or flying; Nasal foreign bodies; Periapical infection of maxillary posterior teeth; Oro-antral fistula; Prolonged endotracheal intubation. Table 1. Factors predisposing to paranasal
sinusitis.
Aetiopathogenesis: cilia damage (eg tobacco smoke exposure), or impaired mucociliary clearance as when ostia are obstructed (eg allergic or infective rhinitis, foreign bodies, polyps). A change in sinus air pressure may cause pain (eg from ostia obstruction, increased mucus production, or air pressure changes such as flying or diving)(Table 1). Bacteria are most commonly the cause, and incriminated are: In acute sinusitis: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Staphylococcus aureus and Streptococcus pyogenes may also be involved. In chronic sinusitis, also anaerobes, especially Porphyromonas (Bacteroides); In some circumstances, Grampositive cocci and bacilli as well as Gram-negative bacilli may also be found – especially after prolonged endotracheal intubation, and in HIV/ AIDS. In many immunocompromised persons, fungi (mucor, aspergillus or others) may be involved and, in cystic fibrosis, Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae are often implicated. Diagnostic features History
Symptoms can include nasal drainage (rhinorrhea or post nasal drip), nasal blockage, the sensation of swelling in nose or sinuses, ear symptoms, pain in teeth worse on biting or leaning over, halitosis, headache, fever, cough, malaise, etc (Table 2). Symptoms are typically less severe in chronic sinusitis. May 2014
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 29, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
OralMedicine-UpdatefortheDentalTeam
Location
Location of pain
Other features
Maxillary
Cheek and/or upper teeth
Tenderness over antra
Frontal
Over frontal sinuses
Tenderness of sides of nose
Ethmoidal
Between eyes
Anosmia, eyelid swelling
Sphenoidal
Ear, neck, and at top or centre of head
Table 2. Features of paranasal sinusitis
Dome-shaped soft tissues opacity (mucus retention)
Medial wall of maxillary antrum
Figure 2. Half DPT (left side) showing antral anatomy and dome-shaped soft tissue opacity of a mucous retention cyst.
a
Floor of maxillary antrum
Posterior wall of the maxillary antrum
Figure 1. Anatomy of the maxillary antrum imaged in a DPT.
Clinical features
There may be nasal turbinate swelling, erythema and injection (dilated blood vessels), mucus, sinus tenderness, allergic ‘shiners’ (dark circles around eyes), pharyngeal erythema, otitis, etc. Diagnosis is from the history, plus sinus tenderness and dullness on transillumination. Nasendoscopy can visualize the mucosal surface inside the maxillary or sphenoid sinus in over 50% of patients. Nasal cytology with a rhinoprobe may help and ear examination is important. Acute sinusitis is diagnosed and treated clinically and does not require imaging. If symptoms persist after 10 days of treatment, CT is recommended when the results may affect management. Plain films are not recommended as the findings May 2014
are usually non-specific. Differentiating between sinusitis and URTI is difficult. Antral radio-opacities in children under age b 6 years can be difficult to evaluate since they are seen in up to 50%. In adults, a sinus radio-opacity may be due to mucosal thickening or a mucous retention cyst (Figures 2 and 3) but a fluid level is highly suggestive of acute sinusitis. Corticated opacities occurring in the maxillary antrum indicate that the aetiology of the opacity is extrinsic to the antrum, eg an apical radicular cyst (Figure 4). MRI may be recommended if there are complications such as peri-orbital infection, or to rule out malignancy. It may sometimes be necessary Figure 3. (a) Coronal CT of maxilla showing rightto perform a needle aspiration sinus to sided benign mucous retention cyst. (b) Axial CT confirm the diagnosis, and sample infected of (a). material to culture to determine what DentalUpdate 371 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 29, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
OralMedicine-UpdatefortheDentalTeam
a
Figure 4. Section of DPT showing antral opacity with corticated margin indicating aetiology extrinsic to the antrum, in this case an apical radicular cyst associated with the upper right first molar.
b
micro-organism is responsible. In patients with recurrent or recalcitrant sinusitis, cystic fibrosis and immunodeficiencies may need to be excluded. Management
Acute sinusitis resolves spontaneously in about 50%, but analgesics are often indicated and other therapies may be required, especially if symptoms persist or there is a purulent discharge. Intranasal steroids are helpful in many patients, although studies evaluating the efficacy have not been conclusive. Antihistamines are used for patients with significant allergic symptoms. Oral decongestants help, but typically may be used for 3–7 days only as longer use may cause rebound and rhinitis medicamentosa. Guaifenesin helps thin and increase clearance of secretion. Buffered saline lavage may help in clearing secretions. Hot steam is often helpful. Antibiotic treatment for at least two weeks in acute sinusitis and at least three weeks in chronic sinusitis is commonly required. Treatment for acute sinusitis is amoxicillin, ampicillin or co-amoxiclav (erythromycin if penicillin-allergic), or a tetracycline such as doxycycline or clindamycin. Chronic sinusitis responds better to drainage by functional endoscopic sinus surgery (FESS), plus antimicrobials (metronidazole with
372 DentalUpdate
Figure 5. (a) DPT showing radiological features of a malignancy of the right antrum – opacity and bony destruction of the floor of the antrum. (b) Section of an occipito-mental radiograph, showing loss of lateral wall of the right maxillary antrum, a feature that is highly suspicious of malignant disease.
Definition: usually squamous carcinoma Prevalence (approximate): rare; Age mainly affected: older people; Gender mainly affected: M > F. Aetiopathogenesis: the only identified predisposing factors are smoking and occupational exposure to wood dust.
the effects of expansion and infiltration of adjacent tissues become apparent as intra-oral alveolar swelling, ulceration of the palate or buccal sulcus; swelling of the cheek; unilateral nasal obstruction often associated with a blood-stained discharge; obstruction of the nasolacrimal duct with epiphora; hypo- or anaesthesia of the cheek; proptosis and ophthalmoplegia consequent on invasion of the orbit and trismus from infiltration of the muscles of mastication. Diagnosis is supported by endoscopy, radiography (Figures 5a and b), magnetic resonance imaging and biopsy.
Diagnostic features
Management
These tumours can remain undetected until late. When they infiltrate branches of the trigeminal nerve they cause maxillary pain. As the tumour expands
Combinations of surgery and radio-chemotherapy are usually required. Prognosis is poor with a < 30% 5-year survival.
amoxicillin, erythromycin, clindamycin or a cephalosporin). Open procedures including the classical Caldwell-Luc operation are generally outmoded.
Neoplasms
May 2014 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 29, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
