maxillary sinus disease and salivary gland disease

lecture given 10/6/2026

why is the maxillary sinus important for dentists to know about?

anatomical proximity to the posterior maxillary teeth

dental infections can lead to odontogenic sinusitis

diagnostic considerations- commonly reveals incidental sinus disease

differentiation is critical to distinguish between odontogenic vs rhinogenic sinusitis for proper treatment

implantology- sinus augmentation, knowledge of sinus anatomy, septa, and vascular structures is crucial to avoid complications

shape and location of maxillary sinus

pyramidal-shaped cavity within the maxilla, adjacent to the nasal cavity

largest of the paranasal sinuses

superior boundary of the maxillary sinus

orbital floor

medial boundary of the maxillary sinus

lateral wall of the nasal cavity

anterior boundary of the maxillary sinus

facial surface of the maxilla

posterior boundary of the maxillary sinus

infratemporal surface of the maxilla

inferior boundary of the maxillary sinus

alveolar process of the maxilla

what is the average volume of the maxillary sinus?

12.5 mL (range of 5-22mL)

semilunar hiatus located ~25.6mm above the nasal floor

ostium

drains into the middle meatus of the nasal cavity

located in the anterior third of the ethmoid infundibulum

where is the maxillary sinus in relation to teeth?

roots of the maxillary molars/premolars often protrude into the sinus

risk of odontogenic sinusitis from dental infections

how commonly are septa in maxillary sinuses?

~27%, mainly near molars and premolars

clinical implications for surgical procedures

when does the maxillary sinus start to develop and pneumatize?

prenatally (~10th week) and continues to pneumatize into adulthood

variations influences by genetics, trauma, and surgical history

what is the recommended procedure to examine the sinus cavity?

CBCT

highly accurate for evaluating both odontogenic and non-odontogenic sinusitis and is particularly useful for preoperative assessment in dental implant planning and sinus lift

what is the flowchart for radiographic examination of maxillary sinus?

periapical x-ray

pano

CBCT

medical CT

odontogenic sinusitis

an inflammation of the maxillary sinus primarily caused by dental infections or procedures

apical periodontitis

common etiology of ODS

often results from untreated dental caries leading to root canal infections

oroantral communication/fistula

common etiology of ODS

occurs following dental extractions, allowing direct communication between the oral cavity and sinus

endo-periodontal lesion

involve both endodontic and periodontal issues

can penetrate the maxillary sinus floor significantly

periodontitis

advanced periodontitis may cause mucosal thickening, leading to purulent ODS due to destruction of supporting tissues

odontogenic cysts

types include dentigerous cysts, radicular cysts, and odontogenic keratocysts

may require surgical management, often involving both intraoral and endoscopic techniques

dental procedure complications

issues from oroantral communications, sinus bone grafting, or dental implants can lead to ODS, especially if implants dispalce into the sinus or infections occur

mucosal thickening

generalized and localized MT often linked to periodontal bone loss and periapical lesions

what are clinical manifestations of ODS

unilateral sinus symptoms- nasal obstruction, purulent nasal discharge, and postnasal drip

facial pain or pressure, particularly over the affected maxillary sinus

dental pain or discomfort, which can be exacerbated by chewing or palpation of the affected teeth

dental treatment for ODS

crucial and involves procedures like RCT or dental extraction to eliminate source of infection

antibiotic therapy for ODS

3-4 week course of antibiotics targeting both aerobic and anaerobic bacteria is recommended

common pathogens include anaerobic strep, bacteroides, proteus, and coliform bacili

choice of antibiotics should cover these organisms effectively

nasal saline irrigation for ODS treatment

can help in clearing the sinus and reducing symptoms

often used in conjunction with antibiotics and dental treatment

what specific antibiotics should be prescribed for someone with mild ODS who have not received antibiotics in previous 4-6 weeks?

amox/calv or amox

alternative cefpodoxime proxetil, cefuroxime axetil, or cefdinir

what specific antibiotics should be prescribed for someone with ODS AND b lactam allergies?

doxycycline or respriatory fluoroquinolones (not recommended as first line due to higher adverse event rate)

what specific antibiotics should be prescribed for someone with moderate ODS or who have received antibiotics in previous 4-6 weeks?

high dose amox/clav or a respiratory fluoroquinolone

surgical interventions for ODS

endoscopic sinus surgery is widely used to remove inflamed sinus mucosa, foreign bodies, and displaced teeth while preserving the physiological function of sinus

for cases with odontogenic cysts- a combined approach of transnasal endoscopic sinus surgery and intraoral surgery is recommended

parotid gland

just in front of and below each ear

well encapsulated by tight fascia (superficial musculo aponeurotic system)

wraps around the mandibular ramus and the tail extends into the neck

superficial and deep lobes are separated by the facial nerve branches

produces serous saliva which contains enzymes like amylase that aid in digestion

parotid duct / stensen’s duct

transports saliva from the gland into the mouth and exists at the second molars

sharp bend at the anterior border of the masseter muscles

opens at the second molar

submandibular gland / whartons duct

gland is located in the neck and posterior floor of mouth

separated by the mylohyoid muscle- bimanual palpation

duct is 5cm long and 2-4mm in diameter

opens at the anterior floor of the mouth

lingual nerve transverses the path of the duct

sublingual gland / bartholin’s duct

located beneath the tongue, on either side of the floor of the mouth

ducts are small and numerous ducts of rivinus which open directly into the floor of the mouth

lingual nerve transverses beneath the submandibular duct anterior to the first molar

bartholins usually opens alongside the submandibular duct

primarily produce saliva which is thick and sticky, helping to lubricate the mouth and facilitate the movement of food

less to the volume of saliva and the mucous secretion is crucial for maintaining the mucous membrane’s moisture

minor salivary glands

palate, upper lip, lower lip, buccal mucosa, retromolar trigone, tongue

what are the major functions of saliva?

lubrication and protection- keeps the mouth moist, protecting tissues from drying out and helping prevent injury

digestion- enzymes like amylase begin digestion by breaking down food

taste- dissolves food chemicals so that they can be tasted by taste buds

antimicrobial action- substances like lysozyme, lactoferrin, immunoglobulins help control bacterial growth in the mouth

buffering- maintains pH balance, neutralizing acids produced by bacteria in the plaque

what are the minor functions of saliva?

maintenance of tooth integrity- provides calcium and phosphate ions that help in remineralization of teeth

tissue repair- contains growth factors and proteins that can help in the healing of oral wounds

formation of pellicle- forms a protective layer on the teeth, which protects against acids and dental caries

aids in speech- lubricates the oral tissues, smooth movement and articulation with the tongue during speech

what alters the production of saliva?

aging, hormonal changes, diet, taste, chewing, smell, medications, dehydration, stress and anxiety, autoimmune conditions (diabetes), radiation therapy, trauma, inflammatory/neoplastic disease

obstructive salivary disorders

sialolithiasis, ductal stenosis, mucoceles, ranulas

infection salivary disorders

viral (mumps), bacterial, fungal

autoimmune disorder salivary disorders

sjogren’s syndrome

neoplastic salivary disorders

benign and malignant

developmental salivary disorders

aplasia, hyperplasia, atresia

functional salivary disorders

sialorrhea (excessive salivation), xerostomia (dry mouth)

what is the diagnostic imaging for salivary gland disorders?

plain radiography

sialography (conventional, CT, MRI)

high resolution ultrasonography

computed tomography (CT)

magnetic resonance imaging (MRI)

radionuclide scintigraphy

mucocele

lower lip ~70%, other locations floor of mouth or ventral surface of tongue

translucent

minor salivary gland

trauma or iatrogenic

excision with gland

laser

branches of mental nerve

not a true cyst, no epithelial lining

mucous retention phenomenom, mucus extravasation phenomenon

ranula

mucous retention or extravasation in the floor of the mouth

lateral to midline

plunging- violates the muscles of the floor of mouth

treatment- spontaneous resolution / marsupualization- unroof and suture the oral mucosa and place a dressing to prevent collapse

high (50-60%) rate of recurrance

removal of sublingual gland- risk of injury to vital structures like lingual nerve and submandibular duct

sialolithiasis

salivary stones

formation of calcified stones within the salivary ducts, most commonly in the submandibular glands

more common in submandibular gland

distal or proximal duct or gland

subsequent infection/inflammation of the gland

mucous plugs

accumulation of thick mucous that blocks the salivary ducts

ductal strictures

narrowing of the salivary ducts, often due to scarring or inflammation

ductal stenosis

similar to ductal strictures, involves a narrowing of the ducts, which can impede saliva flow

sialadenitis

etiology- bacterial (staph, strep), viral (mumps), obstruction (mucous plugs, sialoliths, strictures), autoimmune

risk factors- aging, medication that cause xerostomia, dehydration, malnutrition, XRT

pain, episodic swelling during eating, swelling and redness, purulent discharge, fever

acute sialadenitis

acute bacterial sialadenitis (nonobstructive)

obstructive sialadenitis

autoimmune sialadenitis

subacute necrotizing sialadenitis

chronic sialadenitis

chronic (not recurrent) <3 times a year / not severe

chronic (recurrent) >3 times a year / severe

what tests should you consider for sialadenitis

labs- CBC, chem 7, culture of discharge from duct

imaging- ultrasound, CT scan neck with contrast, MR sialography, digital subtraction sialography

diagnosis for sialolithadenitis

physical examination

imaging studies- ultrasound or CT scan with contrast

lab tests- CBC with diff, CRP, ESR

treatment for sialolithadenitis

hydration, massage, sialogogues (agents that stimulate saliva flow), antibiotics for infection, surgical removal of the stones

what are sialoliths composed of?

organic- bacteria, glycoproteins, cellular debris

inorganic- calcium carbonates, calcium phosphates, other minerals

sialendoscopy

a thin, flexible tube with a camera and light is inserted into the salivary duct to visualize the inside of the glands

helps diagnose and treat conditions like salivary stones, strictures, and chronic inflammation

minimally invasive- involves smaller incisions leading to quicker recovery and less risk of complications

effective treatment- for the removal of stones and treatment of ductal strictures without sigificant damage to the surrounding tissue

what are the uses of sialendoscopy?

diagnosing obstructions- identifying and locating salivary stones or other blockages

treating infections- addressing chronic infections by removing obstructions and improving saliva flow

managing strictures- treating narrowed ducts to restore normal saliva flow

recovery- most pts can resume normal acitivities shortly after procedure with minimal discomfort

sjogren’s syndrome

autoimmune disorder

lupus

rheumatoid arthritis

women around menopause

dry eyes (keratoconjunctivitis sicca), dry mouth (xerostomia), enlarged salivary glands, fatigue, joint pain

what specialists and tests are needed for a sjogren’s diagnosis

rheumatologist, ophthalmologist, oral medicine specialist

CBC, urine, schirmer’s test (eyes), conjunctival staining, lip biopsy, CT scan of salivary glands

effects of radiation on saliva

xerostomia- most common, significant reduction in saliva production

altered saliva composition- increased viscosity, higher concentrations of Na/Cl/lactoferrin, and decreased levels of Ca and amylase

lowered pH and buffering capacity- can lower pH of saliva, reducing its ability to neutralize acids

increased osmolality- saliva becomes more concentrated, leading to a higher osmolality

mucosal changes- mucous membranes become dry, atrophic, leading to difficulties in chewing, swallowing, and speaking

dental impairment- increased risk of dental caries, periodontal disease due to the lack of protective saliva

malignant tumors are (more/less) common in minor salivary glands

benign tumors are (more/less) common in major salivary glands

signs and symptoms are…

more

more

palatal mass, facial swelling, neck swelling / malignancy- facial nerve weakness, palate numbness

pleomorphic adenoma

most common benign tumor, accounting for about 50% of all salivary gland tumors

usually occurs in the parotid gland

found in minor and major salivary glands

warthin’s tumor (papillary cystadenoma lymphomatosum)

benign

bilateral, can be unilateral

common in parotid

mucoepidermoid carcinoma

most common malignant tumor of the salivary glands

makes up about 30% of malignant cases

adenoid cystic carcinoma

another malignant tumor, known for slow growth but potential for perineural invasion and distant metastasis

located on palate

adenocarcinoma

another malignant tumor that can occur in the minor salivary glands

malignant mixed tumor

a rare but aggressive tumor that contains both epithelial and mesenchymal components

where do minor salivary gland neoplasms present?

lumps in palate, cheek, lower lip, occasionally upper lip

what should you do if a pt has a palatal swelling?

duration?

location?

overlying mucosa?

neurosensory disturbance?

mobility of teeth?

nasal congestion?