Since 1992 I have had yearly sinus infections on the left side which have caused pain in the back teeth on the upper left side. The first time this was treated with amoxicilin. Six months later it came back and I had to have a root canal done in an upper left side tooth. I took a year for the teeth to settle down. The tooth was still sensitive even after the root canal. One of the three roots was bad. Now I am having the same problem again. The tooth behind the one that had the root canal is sensitive. Two months ago I took 1000 mg per day of amoxicilin for 21 days and the problem was corrected. A rather bad pollen season in May has brought the problem back again and amoxicilin does not seem to be working as well this time. A CT scan showed heavy sinus infection 2 months ago. A tooth x-ray shows the upper left back two teeth roots extend into the sinus cavity. Any suggestions.
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First of all, it is important to note that sinus pain or discomfort may be referred to the teeth of the upper jaw and is commonly confused as originating in the teeth.
The symptoms you describe are consistent with a diagnosis of chronic sinusitis. Chronic sinusitis is generally defined by the length of time that sinus disease persists (most define it as sinus disease lasting >8-12 weeks). The bacteriology of chronic sinusitis is different than that of acute sinusitis and commonly requires "extended spectrum" antibiotics and greater durations of treatment (eg 4-6 weeks).
Chronic sinusitis is typically associated with significant swelling of the lining of the sinuses particularly near the drainage channels of the sinuses. This swelling helps to perpetuate the condition by interfering with the normal pathways of drainage of mucous which is produced in the sinuses as well as disturbing the ventilation of the sinuses. This creates a stagnant environment inside the sinuses creating a favorable situation for bacterial growth. The ventilation disturbance causes the resorbtion of gases in the sinuses which are replaced by fluid and mucous, providing nutrients for bacteria.
Thus resolution of chronic sinusitis not only requires long- term antibiotic therapy, but also therapy directed towards restoration of the normal ventilation and drainage of the sinuses. Adjuvant medications typically used are decongestants such as those containing the ingredient pseudoephedrine. These medications are somewhat variable in effect and have some potential side effects such as insomnia, palpitations, etc. An alternative means of reducing mucosal swelling involves the use of steroids either in the form of pills or topical spray used in the nose. Steroid medications taken by mouth such as prednisone are generally reserved for severe cases and are used only for short periods of time to avoid potential adverse side effects. Topical nasal steroids are very commonly used in the treatment of chronic sinusitis (Flonase, Beconase, Nasacort, Rhinocort, Vancenase, etc). They are designed to be used for long periods of time (eg daily for weeks to months) and are very safe as they are not significantly absorbed into the blood stream. Finally, medication to "thin" mucous secretions are helpful to facilitate drainage and are known as expectorants. These medications contain the ingredient guaifenesin.
While allergy may be implicated as a factor in the development of chronic sinusitis, once sinus disease becomes chronic, the most commonly used allergy medications - antihistamines - can actually work against resolution of the condition by interfering with mucous drainage. I therefore recommend avoidance of antihistamines (Seldane, Hismanal, Claritin,etc) during treatment of chronic sinusitis. However, allergy assessment is important.
Occasionally, the condition fails to respond to the most aggressive medication regimens. This may be due to certain anatomical factors such as a deviated septum, obstructive polyps, etc. When symptoms persist despite appropriate medical treatment, and at the conclusion of that treatment, sinus CT scans demonstrate persistence of significant swelling or opacification of the sinuses, I generally recommend surgery known as endoscopic sinus surgery. This type of surgical intervention is directed at restoring the normal sinus drainage channels.
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Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
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