歯原性副鼻腔炎の臨床的進展における歯内病変の影響-コホート研究

The Influence of Endodontic Lesions on The Clinical Evolution of Odontogenic Sinusitis-A Cohort Study.

抄録

歯根膜周囲病変（PAL）の形成を伴う歯内療法は、慢性歯原性副鼻腔炎（ODS）の最も一般的な原因の1つである。この場合、耳鼻咽喉科医と歯科医の緊密な連携が必要であるが、最適な管理順序は未だ不明である。本研究の目的は、PALおよび根管治療（RCT）既往のある歯のX線学的特徴が疾患の臨床的進展にどのように影響するかを明らかにし、さらなる外科的介入の必要性を決定する際のX線学的特徴および内視鏡的特徴の予測価値を定義することである。PALを伴うODSの症候性患者68名を本研究に組み入れた。評価は、問診、鼻内視鏡検査、寒冷歯髄検査、断層撮影画像に基づき、耳鼻咽喉科医と歯科医が行った。患者は少なくとも12ヵ月間前向きに追跡され、その間、鼻腔ステロイド、生理食塩水灌流、RCTが投与された。疾患改善の基準は、症状の軽減、内視鏡検査での副鼻腔粘膜の治癒、X線透視検査での副鼻腔周囲X線透視と副鼻腔炎症の消失であった。その結果、9例（13％）が保存的治療で改善し、59例（87％）がさらなる外科的介入を要した。内科的治療およびRCT後に改善した患者は、年齢が若く( = 0.043)、智歯周囲病変の上端から上顎洞底までの距離が長かった( = 0.003)。X線画像でPALの拡大と上顎洞側への骨破壊が観察された場合（= 0.041）、および複数の歯根が侵された場合（= 0.004）、患者は外科的介入を必要とする可能性が高かった。結論として、侵された歯根の数が多いほど、またPALの上端が上顎洞底に近いほど、内科的治療やRCT失敗の可能性が高くなる。骨破壊が上顎洞に及ぶと、ODSを完全に解決するために、患者は最終的に抜歯とFESSの両方を必要とする。

Endodontic disease with formation of periapical lesions (PALs) is one of the most common causes of chronic odontogenic sinusitis (ODS). It requires close collaboration between otolaryngologists and dentists, but the best sequence of management is still unknown. The aim of the present study is to clarify how radiological characteristics of teeth with PALs and previous root-canal treatment (RCT) influence the clinical evolution of the disease and to define the predictive value of its radiological and endoscopic features in determining the need for further surgical intervention. A total of 68 symptomatic patients with ODS with PALs were included in the study. The evaluation was performed by an otolaryngologist and a dentist based on a medical interview, nasal endoscopy, cold pulp testing and tomography images. Patients were prospectively followed for at least 12 months, during which nasal steroids, saline irrigations and RCT were administered. The criteria of disease improvement were: decrease of symptoms, healed sinonasal mucosa in endoscopy and radiological resolution of periapical radiolucency and sinus inflammation. Results showed that 9 (13%) patients improved after conservative treatment and 59 (87%) required further surgical intervention. Patients who improved after medical treatment and RCT were younger ( = 0.043) and had a greater distance from the top of the periapical lesion to the maxillary sinus' floor ( = 0.003). When expansion of PALs and bone destruction toward the maxillary sinus was observed on radiological imaging ( = 0.041), and when more than one tooth root was affected ( = 0.004), patients were more likely to require surgical intervention. In conclusion, the more roots that are affected and the closer the top of the PAL is to the maxillary sinus' floor, the greater the possibility of medical treatment and RCT failure. When the bone destruction extends into the maxillary sinus, patients eventually require both tooth extraction and FESS in order to resolve ODS completely.