Page 11 - GP Spring 2024

After the radiography was evaluated, the patient was asked about sinus problems. The patient reported consistent, chronic sinus problems
that were alternately treated by decongestants, antihistamines, and rarely antibiotics. After much reflection, she remembered one occasion
when she presented to her primary care physician with soreness in her cheek and was put on a course of antibiotics, which resolved the
problem. She was told it may be related to dry winter conditions.
On the panoramic view, fine vertical opacifi-
cations (halos) superior to the posterior max-
illary teeth, bilaterally, indicated a possible
anomaly and additional maxillary posterior
periapical radiographs were taken (Figures
4, 5). The radiographs revealed several teeth
with full coverage crowns and extensive core
build-ups. The margins and cement seals were
intact; there were no secondary caries; the pa-
tient reported no sensitivity to percussion or
chewing, no discomfort to hot or cold, and no
Figure 4. Periapical x-ray, right side. Figure 5. Periapical x-ray, left side. sensation to electrical stimulation for vitality
testing. She also reported normal for her si-
nus conditions, which meant typical seasonal
allergies and post-nasal drip. However, on the
panoramic radiographs, the apical region of the
maxillary teeth revealed mild, lace-like halo
arcs with discontinuous boundaries 2-3 mm
from the apices of teeth 2, 3, and 14, with the
root apices as the center of the arc.
The patient was advised that while the periapi-
cal and panorex images did not demonstrate
clear pathology, there was a high degree of sus-
picion about the vitality of teeth #2, 3, and 14
and their contribution to her sinus condition. A
CBCT was recommended (Figures 6 - 10). In
Figure 6, cross-section view, tooth #3 has sig-
nificant periapical pathology associated with
the palatal root, causing the expansion of the
cortical plate into the maxillary sinus. Tooth
#14 demonstrates a disruption in the cortical
plate shared with the floor of the maxillary si-
Figure 6. CBCT cross section view of bilateral teeth #3, 14. The arrow depicts nus and expansion of the inflammation into the
periapical pathology. sinus. In Figure 7, axial view, tooth #3, palatal
root demonstrates the expansion of the defect
into the sinus along the medial wall of the left
sinus. In Figure 8, a panoramic view of tooth
#3, palatal root, demonstrates the expansive na-

Figure 7. CBCT axial view of tooth #3. Figure 8. CBCT panoramic view of tooth #3.

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