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Endodontics & Dental Traumatology

ISSS (Il(l'>-2^(I2

Case report

Periapicai actinomycosis: report of a case and review of the literature

Sakellariou PL, Periapicai aclinoniycosis: lepcirl ol a case and review of the lileiatiue, Endod I^enl Traumatol 1996; 12: 151-154, Munksgaard, 1996 Abstract - This case of )3eriapical actiuomycosi.s presented the clinical pictttre of chronic periapicai inllammation. The diagnosis was based on die histological examination ol the periapicai lesions suggesting the necessity for routine histological exatninalion. Although root canals pro\ide a piimai)' jDort ol entry the Acti)iomyfe.s orgcXnisuK into the periapicai tisstte, periapicai actinomycosis, is considered exlremcly rare. This ma)- be due to the omission of rotitine histological examination oi peria])ical lesions and the clinical l^ehavior of the disease. The large nutiiber of cases reported dtiring tlie last decade itidicates that periapicai actinomycosis is moi e freqtient than what it is believed and lliis is important in the daily denial practice. The maiti etiological agent ol htiman actinomycosis is Aciinoinyces israelii, followed by Aradmia }>roj)ionica, A. naeslundU, A. xnsco.ms atid A. odoniolyticus
P, L, Sakellariou
Athens, Greece

Key words: actinomycosis: periapicai actinomycosis: periapicai inflammation: periapicai infection Piiiiip Sai<enarioLi, 31 Diligianni St., f45 62 Kifissia, Afliens, Greece Accepted October 2.1995

in descending order (1-S), The aclinomya's are normal saptophytes iti the oral cavity. The pathogenesis of actinomycosis is not clear. It is believed, however, that actinomyces enter the tissues following trauma and become pathogenic (4), The ttstial location of actinc:)mycosis is the cetvicofacial region in 60% of cases, followed by the abdotninal in 20%, thoracic in 15% (5) and the cerebral in 5% (6), Periapicai actinomycosis is considered extremely rare (3), Aciinomycps are found in 10,6 to 17,2 of infected root canals (7, 8) which are tlie primary port of entry for Actinomyces organisms into the periapicai tissue, Hardwick & Newman (9), atid Villa (10) liave found colonies of Actinomyces in the pulp chambeis of teeth with cornual absesses. Howevet; tlie largest number of cases reported to date, arc of actinomycosis of i^etiapical granttloiiias. Weir & Buck (11) report a case of periapicai actinomycosis and in reviewing the literattiie ttntil 1982 they found 20 cases includiug dieir own.

A teview of the literatttre from 1982 till now reveals 25 additional cases including the present one, A series of 16 cases is teported by Happonen et al, (1, 2), The diaguc:>sis was conlhmed bv inimtitiocytochemical histologica! examination of the periapicai lesions in which the presence of ,4rtinomyces israelii atid in descetiditig order A. propionicadwA A. iiaesluiidriwere fbuud. Two cases were t eported by Nair c*v: Schroedcr (3) in a histological examination of 45 cases of periapicai lesions, Perna et al, (6) report one case of actitiomycotic granuloma of the right Gasserian ganglioti, with the primary site an actinomycotic periapicai granuloma of the right thiid inferior molar. Five isolated cases are reported by Martin & Harrison (12), Craig et al, (13), Nishimura (14), O'Grady & Reade (15), Figttres & Dottgias (16), Review of the literature shows that the cases of periapicai actinotnycosis teported until toda)' total 45 inchtding this one. The purpose of this study was to show tJiat the pei-iapical actinomycosis, a disease that may cavise serious complications (6), is involved in the aiea of the dentist's dailv practice and is not extremely rare, as is commonlv believed.
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spond to eiectrie and diermal pulp testing. Tbe teeth weie slightly sensitive to percussion. Tlie patient had never before complained oi diseotnfort from this area or leported any injuries. Tine lesion was operated Ijased on the radiological diagnosis of iniected periapical cyst. Undei- inferior dental nerve block anesthesia, an incision was made along the nuicogingival junction from 47 to 45. A mucoperiosteal flajj was reflected and the cortical bone was exposed. Tbe cortical bone corresjDonding to the apex of 46 was papyraceous witb a j^erfbration of 1 mm. The perforation was enlarged atid revealed the entire cavity. Teeth 47, 46 and 45 were extracted and a granular tnass which filled the etitire periapical cavity and was not attached to the bone was removed. The flap was stUured with silk, a rubl^er dam drain inserted aud the patient was placed on a l egime of 500 nig penieifliu three times a day for 6 days. The next day tlie drain was remo\ed and the suttnes were removed on tlie 6th ]5ost-operative day. The liealingwas uneventful. As the histological examination revealed actinomycosis, tbe admini.stration of peiiieillin was prolonged for two additional weeks. The histologieal examination (Fig. 3) of tlie material from tbe pei iapical fesions consisted of granular tisstie with dense inflammatory infiltration composed of polymorphonuclear leucocytes, some lymphocytes and many plasma cells (3). The sttrface was partly tilcet ated and pat tly covered by fiyi)er]3fastic squamous epithelium without celfulai- atypia. Among exudative elements some typical colonies of actinoniyces were present. Diagnosis: "periapical actinomycosis". Radiographs taken three years after oiJeration showed cotnplete regenetation of the bone in the peria])icaf region (Fig. 4); 5 years postopei atively there was no sign of recttrrence.

I. R i t d i o g r a p h s h o w i n g h u g e c o i i l i n u o u s nals lining o l l l i c molars.

nidiolucency

a l o n g i h e upict-s of -1."), -Ki a n d 17 a n d llif i n c o n i p k i c r o o t ca-

Case report
A 56-year old while man was referred with tbe diagnosis of peria|)ical cyst of tbe right mandible. Twenty days prior to the rcleiTal the ]3atient developed a .swelling of tlie liglil mandibular vestibule. The swelling was redueed wilhin a week with antibiotic treatment (tetracycline 250 mg four times a day for 10 days) ]3rescribed by the denlist. Tlie patient had an tnireniarkable medical history. On examiniition the swelling had disappeared and palpation of ilu- right mandibtilar vestibule was painless and listula tree. The radiograpiis (Fig. 1-2) revealed a large radiolucent ])eriai3icii! area extending from the apex ol 47 to and including the apex of 45. Teeth 46 and 47 showed incomplete filling of the root canals. Tooth 45 was non-caritjus and did not le-

Discussion
This case presented the clinical picture of usual chronic jjeriapical inflammation. Tbe diagnosis was accidental from the histological exatninatioti of the periapical lesion, in which tfie characteristic colonies of the cictinomyce.s constituted an uncontroveisiaf proof of actinomycosis. Tbe farge osteolytic periapical area (Fig. 1, 2) sttggested that the symptomless disease had been piesent for a long time before the recent exacerbatioti. In the jaws actinomycosis may occur as a central fesion or it may occur in the soft tissue arottnd the niatidible. In the central type of actinomycosis of tbe jaw, as in the present case, the bone destruction may exist for a long time liefore symptoms appear; fre-

I'iir. 2. t^aleral l a d i o g i a p l i ol t h e r i g h t m a n d i b l e , s h o w i n g I h e liinils o/ i h c l a d i o h n e i n p e r i a p i c a l a r e a .

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Periapical actinomycosis ment lhat the endodontic therapy had been peribrmed se\eral years ago without the patient having complained ever since. The exacerbation appeared 20 da)s prior to the referral. Withotit excluding the possibility of hematogenic spreading to an already established periapical lesion, the most propable wa)' for aetinoittyre.s to be introciticed to the periapical region is through the root canal. Unfortunately, in this case, as in all pi e\dous cases, we do not know whether the artiuornyees were intiodticed before the endodontic therapy or were advanced as a result of stich tlierap). We know, however, that endodontic therapy alone fails in cases of periapical lesions in which actinomycosis is in\ olved. In such cases surgical cm ettage of the periapical lesion is recjuired too (1, 11). Fis;. 3. l'hotoniiero<;ta|)h ol ti.s.stie .seclion showitig colony ol It is strange that the periapical actinomycosis is actinoniycete.s .stirtouiuled In inllaniniatory cells. (I Ieiiiatoxvconsidered extremely larc^ since the root canals lin atid eositi staiti X 2.'iO). provide the primar\' port of entry for the AetinomyT organisms inlo the periapical tissues. In the ceiM qucnlly it i.s by roenlgcn diagnosi.s lliat an o.steitic vicofacial actinomycosis which accotmts for 60% defecl is discovered which, when ojjeraled npon, of all cases, the clinical picture is very obviotis: proves lo be due to aclinoniycosis (4). hi such .swelling, itidttration of soft tissues, abscesses, cases lhe soft tissues are not necessarily involved draining sinuses and fislulae. With this clinical pic(4). The .syniptoniless clinical bahavior in the lure, it is essential for lhe clinician to suspect acpresent case suggested tlial the aetiitotnyres are of tinomycosis and look for the laboiatoi)- proof of low virulence. These organisms also lack tissue the disease in the pus of the abscesses and fistiilae. decomposing enzymes (hyaluronidases) and so On the contrary, in the periapical actinomycosis require the aid of other partly aerobic, partly the clinical picture is at)pical, as in the present anaerobic noti-specillc bacteria, particularly stacase, and it is confused with the tisual and more phyloroeei and streptoeoeei lo achieve ]3alhogenecily freqtient chronic periapical inflammations. (5). In addition, these organisms may establish au Rotitine microscopy periapical lesions, espeeqtiilibiitim with the ho.st tissue without necessarcially tliose which resist endodontic theiap)' may ily causing an acute resjjonse or undue discomlbrt lead lo a re\ised understanding of the occurrence to the host (3). of actinomycosis in periapical lesions. This reIn the present case, as in most pre\ious cases of search may be done also with the help of inmiunoperiapical actiuomycosis, the diagnosis followed cytochemical histological methods (1, 2, 17), endodontic. In this case, the diOerence was treatwhich identify the species oi' aetiitoinyee.sdnd reveal small colonies that are not morphologically characteristic and are easily oxeiiooked in routine histopathological examination (2). This is supported by the impressive series of 16 cases of periapical actinomycosis reported by Happonen et al. (1,2) and by the reported 2 cases of periapical actinomycosis by Nair & Schroeder (3) in histological examination of 45 cases of periapical lesion, while thoiLsands of periapical lesions are encountered daily without histological examination. Tlie belief tliat "a tootli with a granulotna may have an infected root canal, but a sterile periapical tisstie" (18, 19) pre\'ailed fbr nian\' years and stopped the microbiological research of periapical lesions, because such a tesearch was consideied to be done in vain. However, the presence of coloh'ig. 4. Radiogtapli of the right tiiandible, thtee years alter O|> eration, .showiiij; cotiiplete tegetietation of the bone in the nies of (letiitomyces in periapical lesions, as in the periapical region. present case (Fig. 3), and other microorganisms

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Sakellariou (20-22), changed tlic bcliel that pciiapical lesions arc free o( microorganisms and proved that ticlinomycc.s s])ecies and other microorganisms may stirvive in periapical lesions. As a result, the signiiicancc of the lact that microorganisms are incltided and stirvive in the living tissues of the periapical lesions and not only in tlic dead and inaccessible to the circulation root canal mtisl be Itirther considered and cvahiated. References
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