Dental sources of infection can produce acute and chronic maxillary sinusitis. In some cases, the source of the infection may be related to the presence of endodontic materials in the oral cavity. In this article, we report a case of retained gutta-percha in the maxillary sinus resulting in chronic sinusitis

Ferguson, Berrylin

Hodnett, Benjamin L.

F1000Research

PubMed

Benjamin L. Hodnett

Berrylin Ferguson

Crossref

 Open Peer ReviewAny reports and responses or comments on thearticle can be found at the end of the article.CASE REPORTCase Report: retained gutta-percha as a cause for persistent maxillary sinusitis and pain [version 1; peer review: 2 approved,1 approved with reservations]Benjamin L. Hodnett , Berrylin Ferguson2Department of Otolaryngology, University of Pittsburgh Medical Center Eye and Ear Institute, Pittsburgh, PA, 15213, USADepartment of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, 15219, USAAbstractDental sources of infection can produce acute and chronic maxillarysinusitis. In some cases, the source of the infection may be related to thepresence of endodontic materials in the oral cavity. In this article, we reporta case of retained gutta-percha in the maxillary sinus resulting in chronicsinusitis.112     Reviewer Status  Invited Reviewers   version 2published29 Apr 2014version 1published31 Mar 2014   1 2 3reportreportreport report, Northwestern University,Rakesh K ChandraChicago, Il, USA1, Royal Adelaide Hospital,Alkis PsaltisAdelaide, SA, Australia2, Boston University School ofMichael P. PlattMedicine, Boston, MA, USA3 31 Mar 2014,  :81 (First published: 3)https://doi.org/10.12688/f1000research.3791.1 29 Apr 2014,  :81 (Latest published: 3)https://doi.org/10.12688/f1000research.3791.2v1Page 1 of 8F1000Research 2014, 3:81 Last updated: 16 MAY 2019  Berrylin Ferguson ( )Corresponding author: fergusonbj@upmc.edu No competing interests were declared.Competing interests: The author(s) declared that no grants were involved in supporting this work.Grant information: © 2014 Hodnett BL and Ferguson B. This is an open access article distributed under the terms of the Copyright: Creative Commons Attribution, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associatedLicencewith the article are available under the terms of the   (CC0 1.0 Public domain dedication).Creative Commons Zero "No rights reserved" data waiver Hodnett BL and Ferguson B. How to cite this article: Case Report: retained gutta-percha as a cause for persistent maxillary sinusitis and F1000Research 2014,  :81 (pain [version 1; peer review: 2 approved, 1 approved with reservations] 3)https://doi.org/10.12688/f1000research.3791.1 31 Mar 2014,  :81 ( ) First published: 3 https://doi.org/10.12688/f1000research.3791.1Page 2 of 8F1000Research 2014, 3:81 Last updated: 16 MAY 2019IntroductionForeign bodies in soft tissues can often occur as a result of trauma. There are multiple case reports in the otolaryngology literature of projectiles that have become lodged in the paranasal sinuses1. Retained packing gauze from endoscopic sinus surgery has also been reported in the paranasal sinuses2. In the endodontic literature, many reports and reviews have described various materials that can cause disease of the maxillary sinuses3. In this case report, we present an interesting case of a patient who presented with recalci-trant maxillary sinusitis that was ultimately found to be related to retained endodontic material in her maxillary sinus.Case reportA 26-year-old Caucasian woman presented with a chief complaint of left-sided maxillary pain with intermittent, discoloured nasal drainage. Seven years prior to current presentation, the patient had reported a history of headaches, nasal congestion and bilateral discolored drainage refractory to prednisone, antibiotics, and endo-scopic sinus surgery at an outside facility. Revision endoscopic sinus surgery one year after the initial surgery provided partial relief. Two years prior to current presentation, her left maxillary pain recurred, and a computed tomography (CT) scan revealed a left wisdom tooth projecting into her maxillary sinus. Following wisdom teeth extrac-tion, she had marked improvement in pain and nasal drainage; how-ever 8 weeks later, left maxillary pain returned and was associated with left-sided yellow nasal discharge. Her oral surgeon discovered an infection in the molar adjacent to the extracted wisdom tooth and performed a root canal.Two weeks following the root canal, she presented with continued left maxillary tooth pain and left-sided discolored nasal discharge. Extraction of the molar failed to resolve her pain, and she was sub-sequently referred to the facial pain/headache clinic by her dentist where she was prescribed gabapentin 300 mg TID, which was inef-fective. Her dentist also prescribed her multiple courses of clin-damycin 150 mg TID and guaifenesin 600 gm QID, which would improve her pain and discoloured drainage. However, her symp-toms would return after completing the antibiotics. On examination with rigid endoscopy, she had widely patent maxillary, ethmoid, and frontal sinus ostia with no purulence or polyposis. On flexible endoscopic examination of the floor of her left maxillary sinus, white to slightly yellow mucus was found. Aspiration of the mucus relieved the patient’s discomfort. Maxillary sinus cultures revealed few polymorphonuclear leukocytes, few mononuclear cells, and no microorganisms. Her most recent CT scan from two years prior to presentation at our facility was remarkable for minimal mucosal thickening of the floor of the left maxillary sinus was otherwise normal (Figure 1). An occult dental infection was considered high in the differential diagnosis; however, because no actual dental infection could be demonstrated, a medial maxillectomy was con-sidered in order to facilitate topical washing of the left maxillary sinus. Follow-up appointments in the facial pain/headache clinic found “some features of migraine, but it is unclear whether head-aches represent primary or secondary headaches with migraine features”. Repeat evaluations by her dentist found no evidence of a dental infection. Because of past improvement on an 8-week course of clindamycin 300 mg TID, she was prescribed a 12-week course of clindamycin 300 mg TDI before surgery was considered, and she was referred to an infectious disease specialist.Figure 1. Non-contrasted coronal CT scan from two years prior to patient presentation. Only mild mucosal thickening of the floor of the left maxillary sinus and post-surgical changes related to endoscopic sinus surgery were noted.Clindamycin initially improved her symptoms, but midway through the course her congestion returned. A bone scan was positive in the region of the left maxilla; however, a repeat indium scan was negative. Her CT scan was repeated and she was referred to an oral surgeon for evaluation (Figure 2–Figure 4).Figure 2. Repeat non-contrasted coronal CT scan. Retained gutta-percha (white arrow) noted in left maxillary sinus.Page 3 of 8F1000Research 2014, 3:81 Last updated: 16 MAY 2019Figure 3. Axial section of non-contrasted CT scan shows two retained remnants of gutta-percha (white arrow) in the left posterior maxillary sinus.Figure 4. Sagittal section of non-contrasted CT scan shows two retained remnants of gutta-percha (white arrow) in the left maxilla in the location of previous dental extractions.The CT scan was evaluated by an oral and maxillofacial surgeon who noted that there were two small remnants of the prior left max-illary root canal that had been performed two and half years ago (Figure 2–Figure 4). A combined endoscopic and Caldwell-Luc approach under computer-assisted navigation to drill out retained gutta-percha in the maxillary sinus resolved the patient’s pain and drainage immediately, without recurrence at her three month follow-up.DiscussionGutta-percha, a product of tropical rubber plants, has been used since the mid-1800s as an endodontic filling material following root canal procedures4. The chemical structure of gutta-percha is a trans-isomer of poly-isoprene, or natural rubber; however it is more crystalline than natural rubber and often is formulated with medi-cations such as zinc oxide, iodoform, chlorhexidine and calcium hydroxide, which contribute to both the antibacterial and antifungal activity4–7. Animal studies have shown that gutta-percha becomes encapsulated by fibrous connective tissue with little inflammatory reaction8.Maxillary sinus complications from gutta-percha from root canals are rare. According to a previous case report, gutta-percha from a maxillary tooth root canal can migrate to and obstruct the maxil-lary ostium9. Gutta-percha has also been reported to migrate into the ethmoid sinus10. In the current patient, retained gutta-percha in the maxillary sinus resulted in chronic inflammation and a persistent sinusitis-type picture with nasal congestion, pain and drainage. Her symptoms preceding the sinus surgery may or may not have been related to dental infection, but she clearly improved following wis-dom teeth extraction, and she relapsed due to the infection of the adjacent molar. The retained gutta-percha prevented the resolution of infection and symptoms, even following extraction of the affected tooth. Partial improvement with antibiotics directed to usual dental pathogens provided some evidence that the etiology of her symp-toms was a dental infection. In patients with persistent sinusitis and a history of endodontic procedures, an evaluation for dental mate-rials retained in or near the sinuses may be warranted to rule out an additional source of infection. Removal of these retained dental materials may require an external approach with drilling, which can be facilitated by endoscopic visualization through the Caldwell-Luc procedure.A review of the otolaryngology literature did not provide any addi-tional case reports on retained gutta-percha. In fact, only two case reports were found in the oral and maxillofacial surgery literature that described retained gutta-percha in the paranasal sinuses. In the oral surgery and endodontic literature, there are multiple reports of aspergillosis occurring in the maxillary sinus as a result of overex-tension of root canals of maxillary teeth, especially using materials containing zinc oxide or formaldehyde3,11. One case series of asper-gillosis of the maxillary sinus was found in the otolaryngology liter-ature. In this series, 85 cases of aspergillosis of the maxillary sinus in non-immunosuppressed patients were reviewed. Of these, 94% Page 4 of 8F1000Research 2014, 3:81 Last updated: 16 MAY 2019Author contributionsBenjamin Hodnett wrote the manuscript. Berrylin Ferguson revised the manuscript. All authors approved the final manuscript for publication.Competing interestsNo competing interests were declared.Grant informationThe author(s) declared that no grants were involved in supporting this work.presented evidence of a radio-opaque foreign body in the maxillary sinus, with 85% of the cases related to endodontic dental paste12.Our case report highlights the importance of investigating alterna-tive sources of infection in cases of recalcitrant sinusitis. Dental sources of infection as well as retained or overextended endodon-tic materials should be investigated in patients with unexplained, chronic sinusitis.ConsentWritten informed consent for publication of clinical details and clinical images was obtained from the patient.References1. Yarlagadda B, Jalisi S, Burke P, et al.: Retrieval of projectile foreign bodies from the paranasal sinuses and skull base. Am J Rhinol Allergy. 2012; 26(3): 233–236. PubMed Abstract | Publisher Full Text 2. Gotwald TF, Sprinzl GM, Fischer H, et al.: Retained packing gauze in the ethmoidal sinuses after endonasal sinus surgery: CT and surgical appearances. AJR Am J Roentgenol. 2001; 177(6): 1487–9. PubMed Abstract | Publisher Full Text 3. Hauman CH, Chandler NP, Tong DC: Endodontic implications of the maxillary sinus: a review. Int Endod J. 2002; 35(2): 127–141. PubMed Abstract | Publisher Full Text 4. Friedman CM, Sandrik JL, Heuer MA, et al.: Composition and mechanical properties of gutta-percha endodontic points. J Dent Res. 1975; 54(5): 921–925. PubMed Abstract | Publisher Full Text 5. Bodrumlu E, Alaçam T: The antimicrobial and antifungal activity of a root canal core material. J Am Dent Assoc. 2007; 138(9): 1228–1232. PubMed Abstract | Publisher Full Text 6. Tanomaru JM, Pappen FG, Tanomaru Filho M, et al.: In vitro antimicrobial activity of different gutta-percha points and calcium hydroxide pastes. Braz Oral Res. 2007; 21(1): 35–39. PubMed Abstract | Publisher Full Text 7. Bodrumlu E, Alaçam T: Evaluation of antimicrobial and antifungal effects of iodoform integrating gutta-percha. J Can Dent Assoc. 2006; 72(8): 733. PubMed Abstract 8. Sugawara A, Nishiyama M, Kusama K, et al.: Histopathological reactions of calcium phosphate cement. Dent Mater J. 1992; 11(1): 11–16. PubMed Abstract | Publisher Full Text 9. Costa F, Robiony M, Toro C, et al.: Endoscopically assisted procedure for removal of a foreign body from the maxillary sinus and contemporary endodontic surgical treatment of the tooth. Head Face Med. 2006; 2: 37. PubMed Abstract | Publisher Full Text | Free Full Text 10. Ishikawa M, Mizuno T, Yamazaki Y, et al.: Migration of gutta-percha point from a root canal into the ethmoid sinus. Br J Oral Maxillofac Surg. 2004; 42(1): 58–60. PubMed Abstract | Publisher Full Text 11. Giardino L, Pontieri F, Savoldi E, et al.: Aspergillus mycetoma of the maxillary sinus secondary to overfilling of a root canal. J Endod. 2006; 32(7): 692–694. PubMed Abstract | Publisher Full Text 12. Legent F, Billet J, Beauvillain C, et al.: The role of dental canal fillings in the development of Aspergillus sinusitis. A report of 85 cases. Arch Otorhinolaryngol. 1989; 246(5): 318–320. PubMed Abstract | Publisher Full Text Page 5 of 8F1000Research 2014, 3:81 Last updated: 16 MAY 2019 Open Peer Review   Current Peer Review Status:Version 1 16 April 2014Reviewer Reporthttps://doi.org/10.5256/f1000research.4060.r4315© 2014 Platt M. This is an open access peer review report distributed under the terms of the Creative Commons, which permits unrestricted use, distribution, and reproduction in any medium, provided the originalAttribution Licencework is properly cited. Michael P. PlattDepartment of Otolaryngology, Boston University School of Medicine, Boston, MA, USAThis is an interesting case that highlights the importance of identifying odontogenic causes for chronicmaxillary sinusitis. No competing interests were disclosed.Competing Interests:I have read this submission. I believe that I have an appropriate level of expertise to confirm thatit is of an acceptable scientific standard. 09 April 2014Reviewer Reporthttps://doi.org/10.5256/f1000research.4060.r4314© 2014 Psaltis A. This is an open access peer review report distributed under the terms of the Creative Commons, which permits unrestricted use, distribution, and reproduction in any medium, provided the originalAttribution Licencework is properly cited. Alkis PsaltisDepartment of Otolaryngology, Royal Adelaide Hospital, Adelaide, SA, AustraliaThe value of single patient case reports to the scientific literature is debatable. Other than facilitating thedocumentation of rare conditions or experimental techniques, they are usually just articles of interest.Having said this, this well written article describing an odontogenic cause of refractory left maxillarysinusitis does highlight the importance of a broad differential when treating patients with sinus symptoms.My only criticism is the imaging provided and its purpose. The arrows used to highlight the foreignmaterial, particularly in the coronal CT scan, appear to be pointing into space. Furthermore, there is littleevidence of mucosal inflammation or osteitis, that one would expect to see in a patient with a foreign bodyreaction with symptoms of nasal discharge. Nevertheless, the significant improvement the patientPage 6 of 8F1000Research 2014, 3:81 Last updated: 16 MAY 2019 reaction with symptoms of nasal discharge. Nevertheless, the significant improvement the patientexperienced on removal of the retained gutta-percha does suggest that this was indeed the underlyingcause of her symptoms. No competing interests were disclosed.Competing Interests:I have read this submission. I believe that I have an appropriate level of expertise to confirm thatit is of an acceptable scientific standard, however I have significant reservations, as outlinedabove.Author Response 11 Apr 2014, University of Pittsburgh Medical Center Eye and Ear Institute, Pittsburgh, PA,Benjamin HodnettUSAThis CT scan was performed at the completion of an antibiotics course, which may explain the lackof inflammation. The radiology reports minimal inflammation as well.  The patient had been onmultiple courses of antibiotics with symptomatic improvement for a period of time after eachtreatment. The lack of osteitis is interesting. However, as stated in the discussion, gutta-percha inanimals becomes encapsulated by fibrous connective tissue with little inflammatory response. Themechanism by which an encapsulated foreign body with little surrounding inflammation mayprecipitate a chronic sinus infection is indeed unusual.  We will also provide additional imageswhich should better illustrate the foreign material.  NoneCompeting Interests: 09 April 2014Reviewer Reporthttps://doi.org/10.5256/f1000research.4060.r4316© 2014 Chandra R. This is an open access peer review report distributed under the terms of the Creative Commons, which permits unrestricted use, distribution, and reproduction in any medium, provided the originalAttribution Licencework is properly cited. Rakesh K ChandraDepartment of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School ofMedicine, Chicago, IL, USAAn interesting case that creates awareness about odontogenic sources of maxillary sinusitis. the authorsshould describe any histopathology findings - what type of inflammation was seen - eg  neutrophilic,eosinophilic, histiocytes, foreign body giant cell, etc. No competing interests were disclosed.Competing Interests:I have read this submission. I believe that I have an appropriate level of expertise to confirm thatit is of an acceptable scientific standard.Author Response 11 Apr 2014Page 7 of 8F1000Research 2014, 3:81 Last updated: 16 MAY 2019 Author Response 11 Apr 2014, University of Pittsburgh Medical Center Eye and Ear Institute, Pittsburgh, PA,Benjamin HodnettUSANo pathological specimen was available. The foreign material was embedded in the bone anddrilled out by the oral surgeons.  NoneCompeting Interests:The benefits of publishing with F1000Research:Your article is published within days, with no editorial biasYou can publish traditional articles, null/negative results, case reports, data notes and moreThe peer review process is transparent and collaborativeYour article is indexed in PubMed after passing peer reviewDedicated customer support at every stageFor pre-submission enquiries, contact   research@f1000.comPage 8 of 8F1000Research 2014, 3:81 Last updated: 16 MAY 2019

English

Case report: retained gutta-percha as a cause for persistent maxillary sinusitis and pain

Dental sources of infection can produce acute and chronic maxillary sinusitis. In some cases, the source of the infection may be related to the presence of endodontic materials in the oral cavity. In this article, we report a case of retained gutta-percha in the maxillary sinus resulting in chronic sinusitis.</ns4:p

Case Report: retained gutta-percha as a cause for persistent maxillary sinusitis and pain

Directory of Open Access Journals

Case Report: retained gutta-percha as a cause for persistent maxillary sinusitis and pain [v1; ref status: indexed, http://f1000r.es/34s]

D-Scholarship@Pitt

F1000ResearchOpen Peer Review, NorthwesternRakesh K ChandraUniversity USA, Royal Adelaide HospitalAlkis PsaltisAustralia, Boston University SchoolMichael P. Plattof Medicine USADiscuss this article (0)Comments321CASE REPORTCase Report: retained gutta-percha as a cause for persistent maxillary sinusitis and pain [v1; ref status: indexed, http://f1000r.es/34s]Benjamin L. Hodnett , Berrylin Ferguson2Department of Otolaryngology, University of Pittsburgh Medical Center Eye and Ear Institute, Pittsburgh, PA, 15213, USADepartment of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, 15219, USAAbstractDental sources of infection can produce acute and chronic maxillary sinusitis. Insome cases, the source of the infection may be related to the presence ofendodontic materials in the oral cavity. In this article, we report a case ofretained gutta-percha in the maxillary sinus resulting in chronic sinusitis.112   Referee Status: Invited Referees   version 2published29 Apr 2014version 1published31 Mar 2014  1 2 3reportreportreport report 31 Mar 2014, :81 (doi: )First published: 3 10.12688/f1000research.3791.1 29 Apr 2014, :81 (doi: )Latest published: 3 10.12688/f1000research.3791.2v1Page 1 of 7F1000Research 2014, 3:81 Last updated: 05 MAR 2015F1000Research Berrylin Ferguson ( )Corresponding author: fergusonbj@upmc.edu Hodnett BL and Ferguson B. How to cite this article: Case Report: retained gutta-percha as a cause for persistent maxillary sinusitis and  2014, :81 (doi: )pain [v1; ref status: indexed, ]http://f1000r.es/34s F1000Research 3 10.12688/f1000research.3791.1 © 2014 Hodnett BL and Ferguson B. This is an open access article distributed under the terms of the Copyright: Creative Commons Attribution, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associatedLicencewith the article are available under the terms of the  (CC0 1.0 Public domain dedication).Creative Commons Zero "No rights reserved" data waiver The author(s) declared that no grants were involved in supporting this work.Grant information: Competing interests: No competing interests were declared. 31 Mar 2014, :81 (doi: ) First published: 3 10.12688/f1000research.3791.1 16 Apr 2014, :81 (doi: )First indexed: 3 10.12688/f1000research.3791.1Page 2 of 7F1000Research 2014, 3:81 Last updated: 05 MAR 2015IntroductionForeign bodies in soft tissues can often occur as a result of trauma. There are multiple case reports in the otolaryngology literature of projectiles that have become lodged in the paranasal sinuses1. Retained packing gauze from endoscopic sinus surgery has also been reported in the paranasal sinuses2. In the endodontic literature, many reports and reviews have described various materials that can cause disease of the maxillary sinuses3. In this case report, we present an interesting case of a patient who presented with recalci-trant maxillary sinusitis that was ultimately found to be related to retained endodontic material in her maxillary sinus.Case reportA 26-year-old Caucasian woman presented with a chief complaint of left-sided maxillary pain with intermittent, discoloured nasal drainage. Seven years prior to current presentation, the patient had reported a history of headaches, nasal congestion and bilateral discolored drainage refractory to prednisone, antibiotics, and endo-scopic sinus surgery at an outside facility. Revision endoscopic sinus surgery one year after the initial surgery provided partial relief. Two years prior to current presentation, her left maxillary pain recurred, and a computed tomography (CT) scan revealed a left wisdom tooth projecting into her maxillary sinus. Following wisdom teeth extrac-tion, she had marked improvement in pain and nasal drainage; how-ever 8 weeks later, left maxillary pain returned and was associated with left-sided yellow nasal discharge. Her oral surgeon discovered an infection in the molar adjacent to the extracted wisdom tooth and performed a root canal.Two weeks following the root canal, she presented with continued left maxillary tooth pain and left-sided discolored nasal discharge. Extraction of the molar failed to resolve her pain, and she was sub-sequently referred to the facial pain/headache clinic by her dentist where she was prescribed gabapentin 300 mg TID, which was inef-fective. Her dentist also prescribed her multiple courses of clin-damycin 150 mg TID and guaifenesin 600 gm QID, which would improve her pain and discoloured drainage. However, her symp-toms would return after completing the antibiotics. On examination with rigid endoscopy, she had widely patent maxillary, ethmoid, and frontal sinus ostia with no purulence or polyposis. On flexible endoscopic examination of the floor of her left maxillary sinus, white to slightly yellow mucus was found. Aspiration of the mucus relieved the patient’s discomfort. Maxillary sinus cultures revealed few polymorphonuclear leukocytes, few mononuclear cells, and no microorganisms. Her most recent CT scan from two years prior to presentation at our facility was remarkable for minimal mucosal thickening of the floor of the left maxillary sinus was otherwise normal (Figure 1). An occult dental infection was considered high in the differential diagnosis; however, because no actual dental infection could be demonstrated, a medial maxillectomy was con-sidered in order to facilitate topical washing of the left maxillary sinus. Follow-up appointments in the facial pain/headache clinic found “some features of migraine, but it is unclear whether head-aches represent primary or secondary headaches with migraine features”. Repeat evaluations by her dentist found no evidence of a dental infection. Because of past improvement on an 8-week course of clindamycin 300 mg TID, she was prescribed a 12-week course of clindamycin 300 mg TDI before surgery was considered, and she was referred to an infectious disease specialist.Figure 1. Non-contrasted coronal CT scan from two years prior to patient presentation. Only mild mucosal thickening of the floor of the left maxillary sinus and post-surgical changes related to endoscopic sinus surgery were noted.Clindamycin initially improved her symptoms, but midway through the course her congestion returned. A bone scan was positive in the region of the left maxilla; however, a repeat indium scan was negative. Her CT scan was repeated and she was referred to an oral surgeon for evaluation (Figure 2–Figure 4).Figure 2. Repeat non-contrasted coronal CT scan. Retained gutta-percha (white arrow) noted in left maxillary sinus.Page 3 of 7F1000Research 2014, 3:81 Last updated: 05 MAR 2015Figure 3. Axial section of non-contrasted CT scan shows two retained remnants of gutta-percha (white arrow) in the left posterior maxillary sinus.Figure 4. Sagittal section of non-contrasted CT scan shows two retained remnants of gutta-percha (white arrow) in the left maxilla in the location of previous dental extractions.The CT scan was evaluated by an oral and maxillofacial surgeon who noted that there were two small remnants of the prior left max-illary root canal that had been performed two and half years ago (Figure 2–Figure 4). A combined endoscopic and Caldwell-Luc approach under computer-assisted navigation to drill out retained gutta-percha in the maxillary sinus resolved the patient’s pain and drainage immediately, without recurrence at her three month follow-up.DiscussionGutta-percha, a product of tropical rubber plants, has been used since the mid-1800s as an endodontic filling material following root canal procedures4. The chemical structure of gutta-percha is a trans-isomer of poly-isoprene, or natural rubber; however it is more crystalline than natural rubber and often is formulated with medi-cations such as zinc oxide, iodoform, chlorhexidine and calcium hydroxide, which contribute to both the antibacterial and antifungal activity4–7. Animal studies have shown that gutta-percha becomes encapsulated by fibrous connective tissue with little inflammatory reaction8.Maxillary sinus complications from gutta-percha from root canals are rare. According to a previous case report, gutta-percha from a maxillary tooth root canal can migrate to and obstruct the maxil-lary ostium9. Gutta-percha has also been reported to migrate into the ethmoid sinus10. In the current patient, retained gutta-percha in the maxillary sinus resulted in chronic inflammation and a persistent sinusitis-type picture with nasal congestion, pain and drainage. Her symptoms preceding the sinus surgery may or may not have been related to dental infection, but she clearly improved following wis-dom teeth extraction, and she relapsed due to the infection of the adjacent molar. The retained gutta-percha prevented the resolution of infection and symptoms, even following extraction of the affected tooth. Partial improvement with antibiotics directed to usual dental pathogens provided some evidence that the etiology of her symp-toms was a dental infection. In patients with persistent sinusitis and a history of endodontic procedures, an evaluation for dental mate-rials retained in or near the sinuses may be warranted to rule out an additional source of infection. Removal of these retained dental materials may require an external approach with drilling, which can be facilitated by endoscopic visualization through the Caldwell-Luc procedure.A review of the otolaryngology literature did not provide any addi-tional case reports on retained gutta-percha. In fact, only two case reports were found in the oral and maxillofacial surgery literature that described retained gutta-percha in the paranasal sinuses. In the oral surgery and endodontic literature, there are multiple reports of aspergillosis occurring in the maxillary sinus as a result of overex-tension of root canals of maxillary teeth, especially using materials containing zinc oxide or formaldehyde3,11. One case series of asper-gillosis of the maxillary sinus was found in the otolaryngology liter-ature. In this series, 85 cases of aspergillosis of the maxillary sinus in non-immunosuppressed patients were reviewed. Of these, 94% Page 4 of 7F1000Research 2014, 3:81 Last updated: 05 MAR 2015Author contributionsBenjamin Hodnett wrote the manuscript. Berrylin Ferguson revised the manuscript. All authors approved the final manuscript for publication.Competing interestsNo competing interests were declared.Grant informationThe author(s) declared that no grants were involved in supporting this work.presented evidence of a radio-opaque foreign body in the maxillary sinus, with 85% of the cases related to endodontic dental paste12.Our case report highlights the importance of investigating alterna-tive sources of infection in cases of recalcitrant sinusitis. Dental sources of infection as well as retained or overextended endodon-tic materials should be investigated in patients with unexplained, chronic sinusitis.ConsentWritten informed consent for publication of clinical details and clinical images was obtained from the patient.References1. Yarlagadda B, Jalisi S, Burke P, et al.: Retrieval of projectile foreign bodies from the paranasal sinuses and skull base. Am J Rhinol Allergy. 2012; 26(3): 233–236. PubMed Abstract | Publisher Full Text 2. Gotwald TF, Sprinzl GM, Fischer H, et al.: Retained packing gauze in the ethmoidal sinuses after endonasal sinus surgery: CT and surgical appearances. AJR Am J Roentgenol. 2001; 177(6): 1487–9. PubMed Abstract | Publisher Full Text 3. Hauman CH, Chandler NP, Tong DC: Endodontic implications of the maxillary sinus: a review. Int Endod J. 2002; 35(2): 127–141. PubMed Abstract | Publisher Full Text 4. Friedman CM, Sandrik JL, Heuer MA, et al.: Composition and mechanical properties of gutta-percha endodontic points. J Dent Res. 1975; 54(5): 921–925. PubMed Abstract | Publisher Full Text 5. Bodrumlu E, Alaçam T: The antimicrobial and antifungal activity of a root canal core material. J Am Dent Assoc. 2007; 138(9): 1228–1232. PubMed Abstract | Publisher Full Text 6. Tanomaru JM, Pappen FG, Tanomaru Filho M, et al.: In vitro antimicrobial activity of different gutta-percha points and calcium hydroxide pastes. Braz Oral Res. 2007; 21(1): 35–39. PubMed Abstract | Publisher Full Text 7. Bodrumlu E, Alaçam T: Evaluation of antimicrobial and antifungal effects of iodoform integrating gutta-percha. J Can Dent Assoc. 2006; 72(8): 733. PubMed Abstract 8. Sugawara A, Nishiyama M, Kusama K, et al.: Histopathological reactions of calcium phosphate cement. Dent Mater J. 1992; 11(1): 11–16. PubMed Abstract | Publisher Full Text 9. Costa F, Robiony M, Toro C, et al.: Endoscopically assisted procedure for removal of a foreign body from the maxillary sinus and contemporary endodontic surgical treatment of the tooth. Head Face Med. 2006; 2: 37. PubMed Abstract | Publisher Full Text | Free Full Text 10. Ishikawa M, Mizuno T, Yamazaki Y, et al.: Migration of gutta-percha point from a root canal into the ethmoid sinus. Br J Oral Maxillofac Surg. 2004; 42(1): 58–60. PubMed Abstract | Publisher Full Text 11. Giardino L, Pontieri F, Savoldi E, et al.: Aspergillus mycetoma of the maxillary sinus secondary to overfilling of a root canal. J Endod. 2006; 32(7): 692–694. PubMed Abstract | Publisher Full Text 12. Legent F, Billet J, Beauvillain C, et al.: The role of dental canal fillings in the development of Aspergillus sinusitis. A report of 85 cases. Arch Otorhinolaryngol. 1989; 246(5): 318–320. PubMed Abstract | Publisher Full Text Page 5 of 7F1000Research 2014, 3:81 Last updated: 05 MAR 2015F1000ResearchOpen Peer Review   Current Referee Status:Version 1 16 April 2014Referee Reportdoi:10.5256/f1000research.4060.r4315 Michael P. PlattDepartment of Otolaryngology, Boston University School of Medicine, Boston, MA, USAThis is an interesting case that highlights the importance of identifying odontogenic causes for chronicmaxillary sinusitis.I have read this submission. I believe that I have an appropriate level of expertise to confirm thatit is of an acceptable scientific standard. No competing interests were disclosed.Competing Interests: 09 April 2014Referee Reportdoi:10.5256/f1000research.4060.r4314 Alkis PsaltisDepartment of Otolaryngology, Royal Adelaide Hospital, Adelaide, SA, AustraliaThe value of single patient case reports to the scientific literature is debatable. Other than facilitating thedocumentation of rare conditions or experimental techniques, they are usually just articles of interest.Having said this, this well written article describing an odontogenic cause of refractory left maxillarysinusitis does highlight the importance of a broad differential when treating patients with sinus symptoms.My only criticism is the imaging provided and its purpose. The arrows used to highlight the foreignmaterial, particularly in the coronal CT scan, appear to be pointing into space. Furthermore, there is littleevidence of mucosal inflammation or osteitis, that one would expect to see in a patient with a foreign bodyreaction with symptoms of nasal discharge. Nevertheless, the significant improvement the patientexperienced on removal of the retained gutta-percha does suggest that this was indeed the underlyingcause of her symptoms.I have read this submission. I believe that I have an appropriate level of expertise to confirm thatit is of an acceptable scientific standard, however I have significant reservations, as outlinedabove. No competing interests were disclosed.Competing Interests:Author Response 11 Apr 2014, UPMC, USABenjamin HodnettPage 6 of 7F1000Research 2014, 3:81 Last updated: 05 MAR 2015F1000ResearchAuthor Response 11 Apr 2014, UPMC, USABenjamin HodnettThis CT scan was performed at the completion of an antibiotics course, which may explain the lackof inflammation. The radiology reports minimal inflammation as well.  The patient had been onmultiple courses of antibiotics with symptomatic improvement for a period of time after eachtreatment. The lack of osteitis is interesting. However, as stated in the discussion, gutta-percha inanimals becomes encapsulated by fibrous connective tissue with little inflammatory response. Themechanism by which an encapsulated foreign body with little surrounding inflammation mayprecipitate a chronic sinus infection is indeed unusual.  We will also provide additional imageswhich should better illustrate the foreign material.  NoneCompeting Interests: 09 April 2014Referee Reportdoi:10.5256/f1000research.4060.r4316 Rakesh K ChandraDepartment of Otolaryngology, Northwestern University, Chicago, Il, USAAn interesting case that creates awareness about odontogenic sources of maxillary sinusitis. the authorsshould describe any histopathology findings - what type of inflammation was seen - eg  neutrophilic,eosinophilic, histiocytes, foreign body giant cell, etc.I have read this submission. I believe that I have an appropriate level of expertise to confirm thatit is of an acceptable scientific standard. No competing interests were disclosed.Competing Interests:Author Response 11 Apr 2014, UPMC, USABenjamin HodnettNo pathological specimen was available. The foreign material was embedded in the bone anddrilled out by the oral surgeons.  NoneCompeting Interests:Page 7 of 7F1000Research 2014, 3:81 Last updated: 05 MAR 2015

http://dx.doi.org/10.12688/f1000research.3791.1

Case report: retained gutta-percha as a cause for persistent maxillary sinusitis and pain

Abstract

Similar works

Full text

Available Versions

Crossref

Crossref

Crossref

Crossref

Crossref

Directory of Open Access Journals

Crossref

D-Scholarship@Pitt