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 Table of Contents  
SYSTEMATIC REVIEW AND META-ANALYSIS
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 348-353

Association of maxillary sinus mucosal thickening and peri-apical lesion in cone-beam computed tomographic images: A systematic review and meta-analysis


Department of Oral Medicine and Radiology, VSPM'S Dental College and Research Centre, Nagpur, Maharashtra, India

Date of Submission29-Jan-2022
Date of Decision14-Mar-2022
Date of Acceptance20-May-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
Apeksha Dhole
Department of Oral Medicine and Radiology, VSPMfS Dental College and Research Centre, Nagpur - 440 019, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_37_22

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   Abstract 


Maxillary sinusitis is one of the most common pathologies worldwide and a substantial cause of sinus mucosal thickening. Around 10–86% of maxillary sinusitis reported odontogenic origin. A systematic review and meta-analysis were designed and aimed to evaluate the association of maxillary sinus mucosal thickening and peri-apical lesions using cone-beam computed tomography (CBCT). An extensive bibliographic search with directed vocabulary (MeSH terms in PubMed) and free-text terms were used in databases such as PubMed, Google Scholar, and EBSCO. A total one 8427 articles were identified through the electronic database [Pubmed (34), Ebscohost (0), Google Scholar]. For the meta-analysis, six articles were selected following PRISMA guidelines. One of the major causes of sinus mucosal thickening is reported to be periapical lesions, and the results of the review and meta-analysis concluded that maxillary mucosal sinus thickening was associated with periapical lesions evaluated by CBCT. The results put forward by this review are of utmost importance in treating patients with regenerative and implant procedures related to the posterior maxillary region.

Keywords: CBCT, maxillary sinus mucosal thickening, maxillary sinusitis, peri-apical lesions


How to cite this article:
Dhole A, Dube D, Motwani M. Association of maxillary sinus mucosal thickening and peri-apical lesion in cone-beam computed tomographic images: A systematic review and meta-analysis. J Indian Acad Oral Med Radiol 2022;34:348-53

How to cite this URL:
Dhole A, Dube D, Motwani M. Association of maxillary sinus mucosal thickening and peri-apical lesion in cone-beam computed tomographic images: A systematic review and meta-analysis. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Nov 30];34:348-53. Available from: http://www.jiaomr.in/text.asp?2022/34/3/348/356967




   Introduction Top


One of the paired anatomical structures occupying the maxilla is the maxillary sinuses. A pseudo-stratified columnar ciliated cell along with lamina propria lines the maxillary sinus. Sinus mucosal thickening is considered one of the causative factors for maxillary sinusitis, which is a common pathology worldwide.[1] In the literature, about 10–86% of maxillary sinusitis outlines odontogenic origin.[2],[3] The vicinage of premolar and molar roots with the floor of the maxillary sinus explains the correspondence between dental pathology and pathologies of the maxillary sinus. Three-dimensional imaging, that is, cone beam computed tomography (CBCT), is notably more sensitive in identifying the expansion of periapical lesions into maxillary sinuses.[4],[5]

A prevalence of up to 90% has been reported for basal mucosal thickening, which is considered one of the prominent radiographic findings reported for sinus pathology.[6] An important indicator for maxillary sinusitis radiographically is mucosal sinus thickening of more than 2 mm thickness.[2]

Till date, no systematic review has been performed with regard to this association. It holds an important significance for clinicians to accomplish surgical and regenerative procedures, particularly the posterior maxillary region. Hence, the current systematic review and meta-analysis were designed to identify and elucidate the outcome of studies that assessed the association of maxillary sinus mucosal thickening and peri-apical lesions CBCT images.


   Materials and Methods Top


Study protocol

The current study was performed under PRISMA criteria (http://www.prismastatement.org) and was registered on the PROSPERO on 10/05/2021. The PROSPERO number of the present systematic review is CRD42021239845.

Focused question

The review aims to answer the following deterministic question in Population, Exposure, and Outcome (PEO) format.

“In dentulous patients (P) subjected to CBCT evaluation, whether peri-apical lesions (E) and the appearance of the maxillary sinus membrane thickening (O) are related?”

  • Eligibility Criteria


Inclusion Criteria

  1. Randomized controlled trials; retrospective studies; and analytical, observational, and cross-sectional studies that assessed the association of maxillary mucosal sinus thickening and periapical lesions in CBCT images.
  2. Studies published in the period from the year 2010 to 2020.
  3. Original research articles.
  4. Articles in the English language.


Exclusion Criteria

  1. Retrospective and analytical CBCT studies evaluating the association of maxillary mucosal sinus thickening with other than peri-apical lesions.
  2. Studies of 2-D imaging modalities and computed tomography (CT) scans.
  3. Animal studies, clinical case reports or case series, book reports, other language articles, letters to the editor, literature reviews, and studies with unavailable data.


    • Information sources and search strategy
    • An extensive bibliographic search with directed vocabulary (MeSH terms in PubMed) and free terms was used in databases such as PubMed, Google Scholar, and EBSCO.
    • Keywords and MeSH terms used were periapical lesions AND maxillary mucosal sinus thickening cbct, periapical lesion, AND maxillary sinusitis CBCT.


A total of 8427 articles were identified through the electronic database [PubMed (34), Ebscohost (0), Google Scholar (8390), and others (3)]. A total of 102 articles remained after duplicate removal and after a thorough review of titles and abstracts. Therefore, finally, 28 articles were excluded out of 34 full-text articles, which were assessed for eligibility for no detailed description of the methodology, bias, and specified outcome.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] Finally, the remaining six studies were selected, which met the inclusion criterion [Figure 1].[1],[25],[26],[27],[28],[29]
Figure 1: Flow chart showing systematic literature search for the present review

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Data Collection Process

To perform the quantitative meta-analysis, all reported study results were transformed into standardized extraction forms, and systematically, the required data were collected from each included study [Table 1].
Table 1: Characteristics of studies included in the systematic review

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Risk of bias assessment

The assessment of the qualitative analysis was carried out in accordance with Higgins, JPT, Green, S [editors: the Cochrane Handbook for the systematic review of Interventions Versions 5.1,0 (updated March 2011) independently by two reviewers DD and AD]. The disparity during this phase was resolved by consulting an expert.


   Results Top


The descriptive statistics for mucosal sinus thickness were obtained in six studies, along with the relative risk ratio difference and weight of each study in the analysis. The complete number of studies combined is 6; the total number of observations is 525 with a total event of 291 [Table 2].
Table 2: Comparison of mucosal sinus thickness in association with peri-apical lesions across different studies

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From the studies included, because of heterogeneity, there is a variation in percentage across the studies. The I2 indicates the level of heterogeneity. The estimate of measure of heterogeneity for mucosal sinus thickness based on six studies was I2 = 98.3%.

Confidence interval (CI) reports the uncertain inherent in this estimate and recounts a range of values in which the true effect actually lies, where CI is 97.6–98.8%.

The ratio of the standard deviation of the estimated overall effect size from a random-effect meta-analysis compared to the standard deviation from a fixed-effect meta-analysis (where H = 7.71, 95% CI: 6.39–9.30) is elucidated as H statistic.

The test for heterogeneity, described by Cochran's Q test, is based on a Chi-square distribution that leads to a probability. A larger probability indicates a larger variation across studies rather as compared to within. Heterogeneity resulted in a Q-statistic of 297.31, indicating statistical significance.

The objective of meta-analysis is to secure a more exact evaluation of the complete proportion for a definite case or incident. Each study is represented by a line in the plot. The event rates of each study are listed. Effect estimates and weights of each study are given in the table. All this information is presented in the forest plot. If the weight is bigger than the study, the box is also bigger, and the smaller the box, the smaller the weight. 95% CI for that particular study is represented by a line. Therefore, for example, in the first study, a dot represents the point estimation of that proportion of that study, that is, 0.311, and the line represents the 95% CI, that is, 0.244–0.384 and so on. The proportions of fixed effects and random effects were 0.613 (95% CI: 0.570–0.655) and 0.721 (95% CI: 0.381–0.961), respectively.

For the visualization of proportions among the studies, a forest plot was graphed [Figure 2]. Effect estimates and weights of each study are given in [Table 2]. All this information is presented in the forest plot. The proportions of fixed effects and random effects were 0.613 (95% CI: 0.570–0.655) and 0.721 (95% CI: 0.381–0.961), respectively, with P value <0.0001 for each, which showed the statistical significance also shown in the forest plot using the black diamond shape.
Figure 2: Forest plot

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The funnel plot was used to assess the possible publication bias [Figure 3].
Figure 3: Funnel plot

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The intervention effect estimates were linearly regressed on the corresponding standard errors weighted by their inverse variance using Egger's test. Test result t = 2.73 with P value = 0.0527, indicating that possible publication bias is present. Bias = 41.074 with a standard error of bias = 15.069 with intercept = -0.6925 (intercept = 0.5055).


   Discussion Top


The propinquity of the floor of the maxillary sinus to the alveolar process causes maxillary sinusitis from peri-apical lesions and is often associated with significant complication if undiagnosed. A 3-D imaging modality plays an essential role in diagnosing these sinus pathologies because of its high resolution as compared to other imaging modalities.

For the qualitative analysis, a search of electronic databases was carried out, and after the removal of the duplicates, eligibility criteria were checked for 34 articles. Finally, quantitative analysis was carried out to evaluate the association between peri-apical lesions and maxillary mucosal sinus thickening, including six studies [Figure 1]. To assess the association between peri-apical lesions and sinus mucosal thickening, certain diagnostic criteria were employed.

The Cone-Beam Computed Tomography Peri-apical Index (CBCTPAI) was employed to assess peri-apical lesions.[25],[26],[27],[28] The CBCTPAI was evolved on the basis which was established from the measurements obtained from peri-apical radiolucency and elucidated on CBCT scans.

The measurement of the peri-apical lesion was performed in three dimensions in CBCT scans, mesiodistal, Bucco palatal, and diagonal, and the greatest extension of the lesion governed the CBCTPAI.

Assessment of mucosal sinus thickening was performed by classifying mucosal thickening into five classes according to severity,[25],[26],[27],[28] whereas direct observation methods were employed by others to assess the association.[1],[27],[29]

This quantitative analysis aims to investigate the association between maxillary mucosal sinus thickening and peri-apical lesions through the CBCT imaging technique.

A valuable diagnostic basis was obtained for the evaluation of maxillary mucosal sinus thickening and peri-apical lesions through CBCT. The current study provides a first quantitative referring to sinus pathology, along with the association between the presence of peri-apical lesions and maxillary mucosal sinus thickening.

Of the included publications (6), all the studies evaluated the association between peri-apical lesions and maxillary sinus mucosal thickening (Yu Lu et al., 31.1%; Carla, 38.4%; Hooman, 100%; Sohleah, 70.6%; preeti, 100%; Gisa, 100%), with the total number of observations being 525 and with the total events being 291 [Table 2].

Following the analysis, we observed heterogeneity of the selected articles (I2 = 98.3%, H = 7.71) (95% CI: 6.39–9.30) because of variation in assessing both mucosal sinus thickening and peri-apical lesions and also taking into consideration variation in sample size. The presence of heterogeneity resulted was statistically significant (Q-statistic, 297.31; P value < 0.0001).

Taking into consideration the heterogeneity where I2 >50%, a random-effect model was used in the forest plot [Figure 2], which signifies that underlying true effects differ across all the studies and are statistically significant (P value < 0.0001).

The funnel plot was used to assess the possible publication bias in the study. The possible reasoning for this bias in the study is probably because of selective reporting of positive outcomes in all the studies considered in the meta-analysis [Figure 3].

The results put forward by this review are of high significance for different dental fraternities, particularly those involving the treatment of patients with regenerative and implant procedures related to the maxillary posterior region.

Maxillary mucosal sinus thickening has multiple causative factors. This systematic review as well as meta-analysis has taken only a single causative factor for maxillary mucosal sinus thickening, that is, peri-apical lesion, which is considered one of the limitations of the study. Future research may emphasize multiple factors causing maxillary mucosal sinus thickening.


   Conclusion Top


The current study presents a systematic review along with a meta-analysis that was designed and focused to assess the association between maxillary sinus mucosal thickening and peri-apical lesion using CBCT. The present review was performed following the PRISMA guidelines and was registered on PROSPERO on 10/05/2021 under Protocol number CRD42021239845. A strategic search was carried out with relevant MeSH terms and keywords on different databases from which a total of six publications were included in the meta-analysis.

The results of the quantitative analysis concluded that there was heterogeneity and possible publication bias among the studies. The cause of maxillary sinus mucosal thickening is multi-factorial, and one of the major causes of this is reported to be peri-apical lesions. The results of the quantitative and qualitative analysis concluded that maxillary mucosal sinus thickening was associated with peri-apical lesions evaluated by CBCT and was found to be statistically significant. Therefore, this association can be considered useful among the dental fraternity while dealing with peri-apical lesions and maxillary sinus pathologies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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