Prevalence, etiology, diagnostic approaches, and imaging evaluation of odontogenic sinusitis. A comprehensive review

 

 

Nº de DOI: 10.34896/RSI.2026.65.42.001

 

 

AUTHORS

1. Domenica Corina Mazzilli Drouet. General Practitioner and Master’s Degree in Hospital Management. Attached to Private Clinics of Ecuador. Graduate of the Catholic University of Santiago of Guayaquil. (Guayaquil, Ecuador). https://orcid.org/0009-0007-1808-4344
2. Obed Febles Matos. General Dentist. Attached to Private Clinics in Ecuador. Graduate of the University of Medical Sciences of Matanzas. Cuba. (Ibarra, Ecuador). https://orcid.org/0009-0004-8731-6629
3. Celia Belén Ortega Almendariz. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the University of Cuenca. (Quito, Ecuador). https://orcid.org/0009-0008-3547-5029
4. Luis Roberto Ordeñana Robles. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the State University of Guayaquil. (Guayaquil, Ecuador). https://orcid.org/0009-0004-9359-8386
5. Nohelia Maricela Feijóo Villa. General Practitioner. Attached to Teófilo Dávila General Hospital. Graduate of the University of Guayaquil. (Piñas, Ecuador). https://orcid.org/0000-0001-5641-3515

 

ABSTRACT

The diagnosis of ODS requires a multi-disciplinary approach that includes an otolaryngologist and a dental specialty, as patients tend to present with sinonasal symptoms but do not have dental pain. Cone Beam Computed Tomography (CBCT) is the gold standard to assess the dental-sinus interface and demonstrate superior sensitivity over traditional radiography. Treatment most effectively involves treatment of the dental source and appropriately targeting the sinus to prevent recurrence. ODS is highlighted further, as these patients represent a relatively frequent practice to assess dental pathology, and monthly treatment is discussed, suggesting a conscious effort towards increased clinical suspicion, especially in unilateral sinusitis, and the importance of utilizing medical-dental diagnostic protocols.

KEY WORDS

Maxillary sinusitis, odontogenic, periapical periodontitis and dental image.

RESUMEN

El diagnóstico de la sinusitis odontogénica (ODS) requiere un enfoque multidisciplinario que incluya un otorrinolaringólogo y un especialista dental, ya que los pacientes suelen presentar síntomas sinonasales sin dolor dental. La tomografía computarizada de haz cónico (CBCT) es el estándar de oro para evaluar la interfaz diente-seno, mostrando una sensibilidad superior a la radiografía tradicional. El tratamiento más eficaz consiste en abordar la fuente dental y tratar adecuadamente el seno para prevenir recurrencias. La ODS se destaca por ser relativamente frecuente en la práctica clínica, y se sugiere un esfuerzo consciente hacia una mayor sospecha clínica, especialmente en casos de sinusitis unilateral, así como la importancia de utilizar protocolos diagnósticos médico-dentales.

PALABRAS CLAVE

Sinusitis maxilar, odontogénica, periodontitis periapical, imagen dental.

INTRODUCTION

Odontogenic sinusitis (ODS) is a unique clinical concept defined as inflammation of the maxillary sinus as a consequence of dental pathology, or more specifically from iatrogenic sequela from dental procedures. ODS has historically been documented to constitute 10% of chronic rhinosinusitis (CRS), but more recent studies with the benefit of advanced imaging suggest prevalence rates should be approximately 40%. The current systematic review summarizes the available evidence regarding the prevalence, etiology, and diagnostic dilemmas associated with ODS. The pathophysiology usually involves a disruption of the Schneiderian membrane due to periapical infections, periodontal disease, and iatrogenic trauma, such as tooth extractions and dental implants. A definitive characteristic of ODS is that it is nearly always unilateral (in over 90% of cases). Microbiologically, ODS has a greater prevalence of anaerobic organisms and particular organisms that differentiate ODS from rhinogenic sinusitis (RS), such as the presence of Staphylococcus species.

OBJECTIVE

The objective of this systematic review is to provide a comprehensive analysis of Odontogenic Sinusitis (ODS)

METHODOLOGY

Search Strategy and Information Sources:

In an effort to provide a thorough review of the literature, a comprehensive search strategy was developed using various electronic databases, including PubMed/MEDLINE, Scopus, Embase, and Google Scholar. The search was devised to identify peer-reviewed articles published between the years 2000 and 2024 that focused on the prevalence, etiology, pathophysiology, and diagnostic imaging associated with odontogenic sinusitis. Terms and MeSH terms used in the search included «maxillary sinusitis», «odontogenic», «periapical periodontitis», «CBCT», «dental implants», and «Schneiderian membrane». Additionally, to capture the iatrogenic causes, phrases such as «sinus lift complications» and «foreign bodies in maxillary sinus» were also utilized.

Inclusion and Exclusion Criteria:

Studies were included based on a set of criteria that were communicated to the reviewers. Studies were included in review if they had: (1) an original description focused maxillary sinusitis of odontogenic origin, (2) included diagnostic imaging data (specifically CBCT or MDCT), (3) assessed epidemiological trends or etiological factors, and (4) were published in English. Studies were excluded if they met any of the following criteria: (1) focused only on rhinogenic or fungal sinusitis without dental involvement, (2) had fewer than five subjects in case reports, (3) were not peer-reviewed studies, and (4) diagnosis of ODS was not verified by clinical and radiographic findings. The search strategy aimed to prioritize interdisciplinary research studies that linked otorhinolaryngology and dentistry.

Data Extraction and Quality Assessment:

Data extraction focused on relevant variable dimensions such as demographics, unilateral or bilateral involvement, dental pathology items (e.g., periapical lesions, periodontitis), and microbiological findings (8). Quality of the reviewed studies was determined by quality metrics, sample size, and outcome measures (6). Further, the «diagnostic silo» effect was specifically noted in terms of studies published from dental clinic settings, reporting different outcomes than studies published from ENT cohorts. Synthesis of this information creates a well-rounded view of the current state of the literature and identifies areas that exhibit a need for research⁹.

RESULTS

The maxillary sinus is the largest paranasal sinus and has a complex anatomical relationship to the oral cavity when considering the roots of the maxillary posterior teeth¹. Odontogenic sinusitis (ODS) is defined as inflammation of the Schneiderian membrane (the respiratory epithelium lining the maxillary sinus) from dental infection, trauma, or dental procedure complication². In contradistinction, rhinogenic sinusitis is often caused by a viral infection or allergic reaction affecting the ostiomeatal complex that leads to sinus blockage but is of non-infectious origin. ODS is a contagious infectious process of dental origin.

The anatomical proximity of the roots of the maxillary molars and premolars to the floor of the sinus is regarded as the primary predisposing factor in ODS¹. Many people have a layer of cortical bone separating the apices of the maxillary posterior teeth to the sinus mucosa. In some situations, the roots will extend into the antrum of the sinuses³. This anatomical arrangement provides a path of least resistance of the microorganisms from the periapical lesion or periodontal conditions and into the sinus cavity⁴. Although prevalent, ODS is under-represented in the literature that covers sinusitis, which leads to delays in diagnosis and treatment failure².

Clinically, ODS is a diagnostic frustration, as «silent» infections of the dental etiology generally, means that dental pain is not reported, leading patients to a primary care physician or an otolaryngologist, rather than dentists to manage their primary care⁵. Lastly, the medical management of sinusitis treatment, which is directed towards aerobic organisms (as that is the primary responsible pathogen in rhinogenic cases), is generally ineffective in ODS, due more to the unique anaerobic flora that is often the case in ODS⁶. Understanding the prevalence and etiological mechanisms of ODS is essential for developing multidisciplinary intervention treatment protocols that address the underlying inflammation in the sinus and any underlying dental disease⁷.

Prevalence and Epidemiological Trends:

Global Incidence in Chronic Rhinosinusitis Populations:

Reports of prevalence of odontogenic sinusitis has been discussed as a general upward revision of prevalence rates in the literature². In the past, ODS was thought to comprise 10% of all maxillary sinusitis, however, recent studies using new imaging technologies, including CBCT demonstrate this number could be 30% to 40% among chronic rhinosinusitis patients¹⁰. This variability in point prevalence is primarily due to the detection of subtle dental pathologies that would have previously remained undetected with 2D images³.

In populations with unilateral maxillary sinus opacification, this incidence of ODS is even more notable². Studies have shown that in cases of maxillary sinusitis that is confined to a single sinus has an odontogenic origin in upwards of 75% of particpants⁸. Geographic locations report relatively uniform incidence rates, but the incidence is a factor of local dental health and procedures (e.g., sinus lifts, implants) ¹¹.

Demographic Variations and Patient Risk Factors:

Demographic data of ODS patients indicates a wide range of age, generally peaking during the 4th to 6th decades of life⁸. This peak is correlated with the increased cumulative incidence of chronic dental conditions, such as periodontitis, failed endodontic treatments, and teeth lost to disease, that will be replaced with implants in a higher percentage of the population¹¹. Some studies have suggested a slight male or female predominance, however, large case series demonstrate a relatively balanced gender distribution with one major report documenting 44% men and 56% women⁸.

Patient risk factors are primarily associated with dental health and history⁴. Variables that are correlated with higher incidence of ODS include: periapical lesions, severe periodontal bone loss, and a history of complicated surgical dental treatment³. Anatomical factors are highly influential in ODS, patients with a short distance from the root apices to the sinus floor are significantly more vulnerable to the route of infection¹. Aging is also a risk factor since it is associated with atrophic alveolar process and a higher chance of foreign materials (e.g., fillings or implants) next to the sinus⁴.

Frequency of Unilateral vs. Bilateral:

Another of the most prominent epidemiological features of ODS is the consistently predominant unilateral disease process². In a retrospective case series of 480 patients, approximately 94.5% demonstrated unilateral maxillary opacification⁸. This is in direct contrast to rhinogenic or allergic sinusitis which is much more likely to develop into simultaneous multiple sinus involvement bilaterally⁶. This is adaptive to the pathological presentation of the dental infection, which is usually localized to a single tooth or quadrant of the mouth¹.

Bilateral ODS is uncommon and occurs in only approximately 5.4% of cases⁸. In instances of bilateral ODS, it occurs most likely due to independent odontogenic foci on the left and right side of the maxilla⁸. Interestingly, a small portion of unilateral dental pathology patients may simultaneously develop bilateral sinus inflammation due to a route of infection via the nasal cavity or perhaps a ruling adjunct of a rhinogenic condition that is worsened by the odontogenic insult⁸. Furthermore, the most important clinical sign to for clinicians to consider the odontogenic origin, is the persistent unilateral symptoms².

Pathophysiology and Etiological Mechanisms:

Periapical and Periodontal Pathologies:

The pathophysiology associated with ODS appears to be the direct or indirect spread of oral bacteria and inflammatory mediators into the maxillary sinus¹⁰. Periapical pathology, more specifically apical periodontitis arising from pulpal necrosis, is the predominating cause¹¹. In these cases, the infection moves through the root canal system to the apex where it provokes an inflammatory response in the host bone¹². If the apex is close to the floor of the sinus, the periapical lesion may erode the cortical bone and subsequently thicken or perforate the Schneiderian membrane³.

Periodontal disease is another major etiological pathway, accounting for almost 47.1% of dental factors in certain cohorts¹¹. In chronic periodontitis, the destruction of the periodontal ligament and alveolar bone creates deep pockets that may extend to the sinus floor⁴. This enables pathogens to bypass the tooth itself and access the sinus through porous bone, or via the venous and lymphatic systems³. The extent of sinus membrane thickening is directly proportional to the degree of periodontal bone loss and size of periapical lesions³.

Iatrogenic Factors in Oral Surgery and Implantology:

With the increase in advanced dental procedures, iatrogenic complications have gained recognition as causes of ODS⁸. Tooth extraction is commonly implicated, particularly when involving the development of an oroantral communication (OAC)¹¹. Once an OAC is formed and not recognized and surgically closed, it may progress to an oroantral fistula (OAF) that establishes a mode of communication into the maxillary sinus. This allows oral flora and food debris to repeatedly enter the maxillary sinus, leading to chronic infection⁷.

Dental implant placement also has the potential for ODS, especially when the implant penetrates the sinus floor¹¹. Usually, any protocols that elevate the maxillary sinus floor during implant placement can be intentional, but iatrogenic complications can arise from improper technique, or by utilizing a non-biocompatible material, establishing a chronic inflammatory response⁷. Iatrogenic ODS is particularly challenging because complications generally include a foreign body, i.e. the dental implant, that can act as a nidus for biofilm development to resist standard antibiotic therapy⁸.

Foreign Bodies and Maxillary Sinus Floor Elevation:

Maxillary sinus floor elevation (sinus lift) procedures aim to increase bone volume for placement of an dental implant but have associated complications¹¹. Any time a material, in this case, a graft material, is introduced to the antrum, a complication of sinusitis can occur, especially related to perforating the Schneiderian membrane during elevation or if the graft was infected⁷. These cases demonstrate severe, recalcitrant sinusitis that necessitates surgical intervention to remove incompletely implanted graft material⁸.

Other foreign bodies that may contribute to ODS include endodontic materials, i.e. guttapercha or sealer that extruded beyond the root apex into the sinus¹. These materials twill can a induce both a chemical irritation to the sinus as well as a microbiological challenge¹². Additional foreign bodies may consist of displaced tooth roots or fragments during extraction with may established localized inflammation and eventual generalized opacification of the maxillary sinus¹.

Microbiological Profile of Odontogenic Infections:

The microbiological profile of ODS is different that from rhinogenic sinusitis, and is notable for the oral cavity’s unique flora². Rhinogenic cases are predominantly aerobic species, among which Streptococcus pneumoniae and Haemophilus influenzae are the most common¹⁰. ODS, however, is polymicrobial, with a predominance of anaerobes¹⁰. Prevotella, Fusobacterium, and Peptostreptococcus species are commonly isolated in ODS⁶.

Recently published comparative studies have also identified Staphylococcus species to be significantly more prevalent in ODS than in CRS⁶. Oral pathogens contribute to the presence of «cacosmia» (foul smell), which is a pathognomonic feature of odontogenic infections². Because empirical antibiotics for sinusitis may not cover this anaerobic spectrum, identification of the odontogenic source is imperative for antimicrobial selection⁶. Clinically, if a patient fails to respond to standard sinus medications, it is often the first clinical indicator that the course of infection is from dental pathology².

Clinical Diagnostic Approaches:

Symptomatology and Distinctive Clinical Features:

The clinical manifestation of odontogenic sinusitis (ODS) often resembles that of chronic rhinosinusitis (CRS), it nonetheless has recognizable pathognomonic clinical features that require a high level of suspicion on the part of the otolaryngologist and the dental practitioner. Studies show that a primary feature which differentiates from rhinosinusitis is the symptom’s unilateral nature. While rhinogenic sinusitis can occur bilaterally, ODS is most often unilateral, reflecting the localized nature of dental disease. Patients generally report a clinical picture consisting of one-sided nasal obstruction, facial pressure/pain over the maxillary sinus, and purulent nasal drainage.

A key symptom of ODS is cacosmia, a foul or rotten smell perceived by the patient, which seems to be reported more frequently in ODS than in other sinusitis classifications. This is a subjective phenomenon attributed to the presence of anaerobic bacteria typically associated with a dental infection and the production of volatile sulfur compounds. Data suggests that the presence or absence of a toothache does not rule out odontogenic disease and that many patients with ODS are «dentally asymptomatic.» This is because chronic periapical infections can drain into the sinuses without pressure build-up in the alveolar bone. Therefore, the clinician cannot rely solely on the patient’s report of toothache to prompt the dental evaluation. European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020) further asserts that any case of unilateral maxillary sinusitis that does not resolve with clinical therapy should be considered odontogenic in nature¹³.

Nasal Endoscopy and Physical Examination:

Nasal endoscopy is a crucial part of the evaluation of ODS and can allow for direct visualization of the middle meatus and ostiomeatal complex. During the endoscopic evaluation, purulent secretions or «pus» coming from the maxillary ostium may be one of the first signs of the active disease in the sinuses. The mucosa of the middle meatus in ODS often demonstrates mucosal edema or polypoid changes, which may be more prominent or obvious on the affected side.

The physical examination should also include an intraoral evaluation, however, the examination may prove less sensitive without specialized dental tools. During the intraoral examination the clinician should attempt to note any advanced caries, periodontal disease, or signs of implants and fixed prosthodontics. Tenderness to percussion of the maxillary premolars/molars, or the presence of vestibular swelling and/or fistula tracts can provide immediate indications of a dental complaint. However, as noted during multidisciplinary consensus statements, a negative physical examination of the oral cavity by an otolaryngologist does not conclusively rule out ODS, as the causative pathology may lie deep or be iatrogenic¹⁴.

The Role of Dental Consultation in Diagnosis:

An accurate diagnosis of ODS requires a collaborative diagnostic framework. As per an international multidisciplinary consensus, confirming the diagnosis typically requires that the otolaryngologist confirm sinusitis while a dental provider simultaneously confirms the presence of a maxillary odontogenic pathology¹⁴. The «dual-confirmation» model addresses the «diagnostic silo» problem, in which the patient may fall between specialties.

The dental consultation is fundamental in recognizing more subtle pathologies (e.g., failed endodontic therapy, periapical granulomas, and subclinical periodontal disease) that may be overlooked in standard imaging of the sinuses. Dental providers utilize clinical techniques, including vitality testing and periodontal probing, to evaluate the health/condition of the teeth adjacent to the floor of the sinus. In addition to clinical findings, it is agreed that dental and otolaryngology providers should refer patients to each other when ODS is suspected, based on clinical signs such as unilateral symptoms or foul-smelling discharge¹⁴. The collaborative care pathway is important for ensuring the odontogenic source of the infection is addressed instead of just treating the sinonasal symptoms.

Thorough Imaging Assessment:

Disadvantages of Typical Intraoral Radiography:

Previously, the diagnosis of dental pathology largely depended on two-dimensional (2D) imaging, such as periapical radiographs and orthopantomograms (OPGs). Regarding ODS, these images have many shortcomings. The biggest drawback of 2D imaging is anatomical structures being superimposed on each other, for example, the zygomatic buttress and the roots of adjacent teeth often interfere with seeing the apex of a tooth in relation to the maxillary sinus floor.

Studies indicate that periapical radiographs have an extremely high false-negative rate for detecting periapical lesions that have perforated the sinus cortex. In 2D, the anatomy that exists in three dimensions is compressed into a flat ‘snapshot’ image. Therefore, it is entirely possible that small areas of bone destruction or subtle mucosal thickening (the «halo sign») are invisible. Further, while OPGs give a large view of the teeth and maxillary sinuses, it lacks the spatial resolution needed to accurately evaluate the relationship between dental roots and the Schneiderian membrane. Ultimately, the use of 2D imaging leads to underassessing the odontogenic contribution to maxillary sinusitis.

Cone Beam Computed Tomography (CBCT) as the Diagnostic Benchmark:

Cone Beam Computed Tomography (CBCT) has rapidly become the preferred imaging technology for the diagnostic evaluation of the maxilla and associated pathologies. In terms of three-dimensional radiographic imaging, CBCT delivers high-quality, high-resolution images of the maxillary anatomy, including the height and width of bone above the maxillary sinus, and the spatial relationship between dental roots and the sinus floor¹⁵.

The clinical application of CBCT in diagnosing ODS has many aspects. It allows for the identification of important anatomical landmarks and the detection of more subtle periapical radiolucencies that would not been seen in 2D films. For patients who are candidates for dental implant surgery, CBCT is beneficial and more predictable for clinical planning since it can assess the bone and the health of the sinus prior to the planned intervention¹⁵. In the case of ODS, because CBCT can provide sub-millimeter spatial resolution, it has become the «gold standard» image for a «bone-to-membrane interface» assessment. CBCT offers clinical providers the ability to visualize the exact location of a dental infection, as it exits the root and breaches the maxillary sinus.

Multidetector Computed Tomography (MDCT) and Soft Tissue Assessment:

MDCT is a useful imaging tool despite its limitations in providing detail when compared to CBCT. MDCT is especially valued when the sinusitis is no longer limited to the maxillary sinus and has begun to extend into the ethmoid, frontal or sphenoid sinuses. MDCT is useful for assessing osseous structures and soft tissue for a global assessment of the paranasal sinus system.

Radiographic Signs of Odontogenic Maxillary Sinusitis:

The radiographic evidence of ODS consists of several key indicators. The most obvious sign is the unilateral maxillary sinus opacification or significant thickening of mucosa adjacent to a dental pathosis. A specific radiographic marker is the «halo sign», which is a localized, dome-shaped radiopacity representing a mucosal elevation over a tooth with periapical pathology.

Some of the other critical signs seen radiographically are the disturbance of the maxillary sinus cortical floor, periapical radiolucency, and foreign bodies such as endodontic filling material or displaced dental roots within the sinus antrum. In the case of Sinonasal Complications of Dental Disease and Treatment (SCDDT), the imaging may show dislodged dental implants or bone graft material into the sinus¹⁶. Detection of these complications using 3D imaging is very accurate so the surgical approach may then be guided by the culprit etiological factor.

DISCUSSION

Differentiating ODS from other rhinosinusitis conditions is a clinical necessity, as the treatment approaches are very different. Rhinogenic sinusitis (RS) is generally treated with intranasal steroids, saline irrigations, and/or systemic antibiotics aimed against common respiratory pathogens, such as Streptococcus pneumoniae. On the other hand, ODS is treated by eradication of the dental source of infection.

Differential diagnosis should also include rare entities like Silent Sinus Syndrome (SSS). SSS is a rare condition characterized by unilateral enophthalmos and diplopia secondary to chronic maxillary sinus atelectasis¹⁷. SSS is not inflammatory or infectious as is ODS, rather SSS involves bone resorption, with progressive displacement of the orbital floor over time¹⁷. Fungal rhinosinusitis should also be ruled out. For example, allergic fungal rhinosinusitis (AFRS) represents a unique type of chronic polypoid rhinosinusitis characterized by eosinophilic mucin and fungal hyphae¹⁸. ODS and fungal sinusitis can occur unilaterally, however, the radiographic appearance of fungal «hyperdensities» and the immunological profile associated with AFRS facilitate differentiation¹⁸. Diagnosis is crucial to limit disease progression and also to ensure that Functional Endoscopic Sinus Surgery (FESS) is appropriately utilized to stop the progression of the disease¹⁷.

Management of ODS and its related sequelae, or SCDDT, requires a multidisciplinary approach combining endoscopic endonasal surgery (EES) and, at times, an intraoral approach¹⁹. Research on SCDDT demonstrates that a treatment protocol utilizing a classification system can achieve rates of success of up to nearly 98%¹⁶.

The surgical approach utilized is dependent on location and type of dental pathology. If the infection is limited to the sinus, and the dental source can be endodontically treated or extracted, EES may sufficient to drain the sinus. If, however, there is a foreign body (displaced root or implant) or the pathology involves the anterior wall of the maxilla, a combined approach may be necessary¹⁹. In fact, studies suggest a significant proportion of patients (up to 38.7%) are treated with the combined approach to achieve early recovery and prevent recurrence¹⁹. This collaborative model allowed for simultaneous treatment of sinonasal symptoms and the underlying dental origin, providing the most effective means to avoid the chronic recurrence of the disease.

Despite the growing awareness of ODS, current systematic literature has glaring limitations. One major issue is the lack of standardized diagnostic criteria across medical and dental specialties. Many existing studies are retrospective studies guided by differing definitions of «odontogenic origin,» which generates confusion and inconsistency in reporting prevalence and outcomes.

Much existing research is focused on either the otolaryngological or the dental perspective, with only a handful of studies taking the truly multidisciplinary perspective recommended by international consensus¹⁴. Moreover, there is geographic variation in both the incidence and epidemiology of related conditions, such as fungal sinusitis, preventing the synthesis of ODS data on a global scale¹⁸. Future research should aim to present more definitive evidence-based recommendations and integrated care pathways similar to the work done in EPOS 2020, in order to unify the management of ODS across diverse clinical settings¹³.

CONCLUSIONS

1. Odontogenic sinusitis (ODS) is a multifaceted and often under-recognized ailment that exists at the entanglement of otolaryngology and dentistry. This systematic review has demonstrated that the diagnosis of ODS relies upon the recognition of certain clinical features, specifically unilateral symptoms and cacosmia, and is diagnosed in a multidisciplinary manner with both ENT and dental professionals. The shift in practice from 2D conventional radiography to 3D imaging modalities with high resolution, specifically cone beam computed tomography (CBCT), has altered the practice of noting the dental-sinus interface, and is now the gold standard on examining the maxilla.
2. The management of ODS is predicated on an etiology-based model which treats the dental cause and the sinonasal infection. Whether through EES, intraoral, or combined approaches, the factor of eliminating the source of the pathogens and restoring the physiological function of the maxillary sinus is fundamental. As a rare but growing prevalence of iatrogenic ODS increases with the rise of dental implantology, the need for integrated care pathways will be paramount. Standardizing clear diagnostic pathways and encouraging collaborative care will remain the most effective methods for optimizing patient care and minimizing recurrence of this challenging disease.

 

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