Periapical actinomycosis An unusual

case

report

Steven Oppenheimer, D.D.S., * Gary Scott Miller, D.D.S., * Kenneth Knopf, D.D.S.,** and Harry Blechman, D.D.S.,*** New York, N. Y. DEPARTMENT COLLEGE

OF OF

ENDODONTICS,

NEW

YORK

UNIVERSITY

DENTISTRY

An unusual case of actinomycosis in the oral cavity is reported. The strict anaerobic qualities of Actinomyces israelii make laboratory culturing and growing of this organism difficult. Accordingly, the diagnosis was based on the histopatbologic report. Because of the atypical clinical presentation, i.e., lack of any discharging sinus tract on the skin surface, and the histopathologic reports, it was postulated that the actinomycosis was superimposed on an existing granulomatous tissue.

A lthough actinomycetes

are often found in the oral cavity,’ actinomycosis is a relatively uncommon infection.‘, 2 Sixty percent of the reported cases occur in the cervicofacial region, 20 percent in the abdomen, and 15 percent in the thorax.2 It is often caused by the gram-positive, anaerobic organism Actinomyces israelii, which has been variously referred to as commensa12 and saprophytic.3 Recently, A. naeslundii has been implicated in the orofacial form.’ The actinomycetes are often referred to as fungi (which they superficially resemble), but are clearly related to true bacteria (corynebacteria and mycobacteria).4 This infection occurs most often in young adults,2 and classically presents as “a brawny, submandibular swelling which, if untreated, discharges through multiple sinuses onto the skin surface. “j Actinomycetes lack tissue-decomposing enzymes (hyaluronidases) and so require the aid of other party aerobic, partly anaerobic nonspecific bacteria, particularly staphylococci and streptococci.3 Accordingly, this predilection for a mixed infection, coupled with the strict anaerobic qualities of A. israelii, makes laboratory culturing and growing of this organism difficult. It is not unusual for the diagnosis to depend on the demonstration of the *Formerly postgraduate endodontic students, New York practice of Endodontics, North Miami Beach, Fla. **Clinical Associate Professor. ***Professor and Chairman.

University

0030.4220/78/0146-0101$00.60/0

Co.

6

1978 TheC.

V. Mosby

College of Dentistry.

Presently

in the private

101

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et al.

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1978

Fig. 1. I, Pre-endodontic therapy roentgenogram; 2, postendodontic therapy roentgenogram; 3, one year postendodontic therapy roentgenogram; 4, 2 year postendodontic therapy roentgenogram. Note apparent increase in size of periapical radiolucency.

characteristic granule with gram-positive filaments in tissue specimensof suspectedlesions6 Indeed, a histopathologic report of actinomycosis may be the only verification possible. Actinomycetes, as previously mentioned, are a constituent of normal oral flora, but may also be found in dental pulps and periapical granulomasand cysts.” However, it is rare for colonies of actinomycetes to be seen on histologic examination of periapical tissues.7 The following caSe report illustrates a case of actinomycosis that presented in an unusualmanner. CASE REPORT R. B., a 3 l-year-old Indian man, presented at the Endodontia clinic of New York University College of Dentistry with the chief complaint of infrequent, vague pain in the anterior mandible. The patient reported having a great deal of discomfort and swelling in the apical area of the mandibular incisors while visiting India 3 years prior to this presentation. At that time his mother recommended a native remedy, which was to place large pieces of rock salt in the vestibule over the swelling and to press on the swollen area. The patient reported that in time a hole was opened in the tissue and pus drained from the area. He was then comfortable and sought no further treatment in India or upon his return to the United States. One year later, because of a recurrence of pain and swelling in the same area, the patient sought the services of a general dentist, who referred him to an

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Periapicalactinomycosis 103

Fig. 2. Panorex film taken upon presentation at Endodontia Note extent of anterior mandibular radiolucency.

Fig. 3. Photomicrograph

of incisional

biopsy

Clinic,

specimen.

New York

(Original

University

magnification,

College

x

of Dentistry.

IO.)

endodontist. The endodontist subsequently performed root canal therapy for the lower right lateral incisor, which manifested a periapical radiolucent area (see Fig. 1). When the symptoms subsided, the patient next sought the services of an orthodontist, as he desired to have his mandibular anterior teeth realigned. The orthodontist took a roentgenogram of the area and insisted that the patient consult an oral surgeon for further evaluation of the apparent enlargement of the mandibular lesion. The oral surgeon suggested total excision of the lesion. The

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Fig. 4. Postexcisional

Fig. 5. Excisional

biopsy

biopsy

1978

roentgenograms.

specimen.

patient reported that he was unsure of the proper course and, after consultation with his brother, a physician, he was referred to the New York University College of Dentistry Endodontia Clinic. Physical findings were within normal limits except for a palpable bilateral lingual mandibular concavity in the premolar region (Fig. 2). Concomitant buccal and lingual palpation revealed a firm but yielding segment of the anterior mandible between the mandibular canines and apical to the incisors. Perforation of the facial and lingual cortical plates was suspected. The overlying mucosa, however, was intact. The mandibular anterior teeth were malposed. All teeth except the lower right laterial incisor tested vital with a Digilog electric pulp tester.* A complete blood count and differential blood analysis were within normal limits, as was the chest roentgenogram. The patient denied any history of trauma. It was decided to perform an incisional biopsy because of the size of the radiolucency (Fig. 3). A 0.5 cm. horizontal incision was made in the soft tissue in the area of the lower central incisors. A defect was felt in the cortical plate and a small piece of paper-thin cortical plate was removed. A billowing, yellowish lesion protruded

*Demetron

Research

Corp.

Danbury,

Conn.

Volume 46 Number I

Fig.

6. Four-month

postoperative

roentgenograms.

Note appearance

of bone regeneration.

from this defect. An I I-gauge needle was inserted, and approximately 6 C.C. of a bloody exudate was aspirated. A piece of the lesion was removed for histopathologic study. The area was closed with 3-O black silk sutures (Figs. 4 and 5). The pathology report received from the Department of Pathology of New York University College of Dentistry read as follows: “There are several small fragments of granulation tissue, fibrous tissue, and a large area of fungus surrounded by pus. The fungus appears to be actinomycosis. Diagnosis: Actinomycosis with pus and granulation tissue, labial plate.” The patient was subsequently placed on 500 mg. of penicillin V by mouth, four times a day. He remained on this regimen for 2 weeks until admission to Bellevue Hospital. The medical work-up proved unremarkable. The antibiotic regimen was raised to 2 million units, intravenously, every 4 hours. With the patient under intravenous sedation, supplemented by local anesthesia, the chief oral surgery resident removed the lesion, which measured approximately 2 cm. An anaerobic culture was made by the Department of Infectious Diseases. The patient responded well, and was discharged on the day after the operation on an antibiotic regimen of 3 Cm. of penicillin V, by mouth, per day. This regimen lasted for 2 months. Upon discharge, the patient complained of slight paresthesia in the lip symphysis region in the area of the lower left canine. Electric pulp testing at I and 4 months postoperatively revealed an unresponsive the lower left canine and a questionable response for the lower left lateral incisor. It was felt at the time of operation that the lower left canine might require root canal therapy secondary to the extent of the manipulation in removing the lesion. The histopathologic findings on the excisional biopsy reported the presence of granulomatous tissue. The attempts to grow actinomycetes from the cultures taken at the time of operation were not productive. The 4-month postoperative roentgenograms (Fig. 6) illustrate the appearance of bone regeneration.

DISCUSSION

It is often difficult to culture the anaerobicA. israelii for a variety of reasonspreviously noted. Diagnosismay be dependentupon histologic evidence. Actinomycetes have been isolated in dental pulps and have been reported to be a constituent of oral flora. An infected root canal, therefore, may be considereda portal of entry for actinomycetes. Thus, introduction of the organism via the root canal with the subsequentsuperimpositionof an actinomycosis infection over an existing granulomatous lesion cannot be ruled out. In addition, introduction of the organismdirectly from the oral

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cavity Aikat7 tologic In lesion

should be considered. In reviewing the literature, however, Samanta, Malik, and found only fifteen cases on record revealing colonies of actinomycetes on hisexamination, accordance with accepted therapy, treatment consisted of surgical removal of the along with high doses of penicillin.‘~ 2, 7

REFERENCES

I. Stenhouse, D.: Intraoral Actinomycosis, ORAL SURG. 39: 547-552, 1975. 2. Williams, F. B.: Cervicofacial Actinomycosis: In the Presence of Mandibular Bone Loss, Br. Dent. J. 140: 145-146, 1976. 3. Kruger, E.: Clinical Aspects and Therapy of Cervicofacial Actinomycosis, Quientessence Int. 10: I I- 18, 1974. 4. Jarvetz, E., Melnick, J., and Adelberg, E.: Review of Medical Microbiology, ed. 9, Los Altos, Calif., 1970, Lange Medical Publications, pp. 227-228. 5. Stenhause, D., MacDonald, D., and MacFarlan, T.: Cervicofacial and Irma-Oral Actinomycosis: A 5 Year Retrospective Study, Br. J. Oral Surg. 13: 172- 182, 1975. 6. Samuels, H., Bravham, G., Vogt, T., and Peterson, L.: Actinomycosis of the Mandible, J. Oral Surg. 32: 679-681, 1974. 7. Samanta, A., Malik, C., and Aikat, B.: Periapical Actinomycosis, ORAL SURG. 39: 458-462, 1975. Reprint

requests

to:

Dr. Steven Oppenheimer 951 N.E. 167th St. North Miami Beach, Fla. 33 I62

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Periapical actinomycosis. An unusual case report.

Periapical actinomycosis An unusual case report Steven Oppenheimer, D.D.S., * Gary Scott Miller, D.D.S., * Kenneth Knopf, D.D.S.,** and Harry Blech...
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