When seasons change, it is not uncommon for dental offices to be filled with mysterious aches and pains that seem to be related to the upper teeth.

These symptoms are more likely to be related to inflamed sinus mucosal pressure on the maxillary nerves running along the sinus floor. Headaches may be an accompanying complaint, but the most frequent complaint is simply a toothache.

mucosal contact headache figure 1
Figure 1. Mucosal response to periapical lesion on the second molar

Some signs and symptoms that may assist in reaching a diagnosis of dentalgia secondary to sinusitis, which is a form of headache, include:

  • Decentralized toothache
  • “Wandering toothache,” where the tooth that hurts varies at different times of the day
  • Positional dependent tooth pain
  • No evidence of pulpal, dental or periapical pathology
  • Variable response to electronic pulp testing and percussion
  • Positive response to both cold and hot
  • Transillumination negative

Healthy sinuses are important for general health because humans are obligate nasal breathers. The sinus cavities are lined with pseudostratisfied columnar cells and goblet cells that produce mucous, which traps junk and bacteria from the air we breathe. Little moving hairs, called cilia, move the mucous and trapped debris toward our throat to get it away from our lungs.

There are several different sinus cavities: 

  • 2 maxillary sinuses that are divided into “rooms” by structures called conchae (also called turbinates) and the nasal septum
  • two frontal sinuses
  • a sphenoid sinus
  • ethmoid air cells (a group of small-medium hollow areas encased in the skull behind the top of the nose)

All of these chambers have a primary purpose to warm and moisturize the air that we breathe. When we breathe through the nose, nitrous oxide is produced that circulates around the turbinates, creating an antibacterial effect that controls bacteria in our sinuses.

Infections, including some dental infections, allergic reactions, and reactions to chemicals such as those found in cigarette smoke, can cause the specialized cells within the sinuses to not function properly. This can lead to headaches. When pressure is applied to the nerves that go to the upper teeth, toothaches can occur.

When the ethmoidal air cells are inflamed, headaches can present themselves as double vision and painful eyes. If the mucosa covering the turbinates is so swollen that layers of mucosa contact each other, painful headaches that seem to come from behind the nose can occur, which is typically a seasonal phenomenon. 

mucosal contact headache figure 2
Figure 2. Mucosal contact: If the right inferior concha causes pain behind the eyes, mucosal inflammation is likely related to the periapical lesion on the maxillary right bicuspid.

Seasonal allergies can often be managed with over-the-counter medications, but bacterial or even fungal infections of the sinuses can be serious and even deforming, and, therefore, require medical treatment. When CBCTs are taken, mucosal thickening can often be seen in the maxillary sinuses. When more than one sinus cavity is involved with mucosal thickening, a medical diagnosis that definitely requires medical intervention exists called pansinusitis.

Localized radiographic mucosal thickening over a tooth may suggest pathology with that tooth with or without the presence of periapical radiolucency as a reactive response to bacterial invasion.

While seasonal allergic reactions may be manageable with over-the-counter medications, a good rule of thumb would be that if improved symptoms do not resolve within a week or so to refer the patient to an otolaryngologist for evaluation and appropriate management. It is important to remember that in many jurisdictions management of sinusitis falls outside the scope of care of general dentists.

(Click this link to read more dentistry articles by Dr. Kevin Huff.)

Kevin D. Huff, D.D.S., Spear Moderator and Contributing Author - www.doctorhuff.net