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Endodontics &Dental Traumatology

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Case report

Periapicai actinomycosis: report of a case andreview of the literatureSakellariou PL, Periapicai aclinoniycosis: lepcirl ol a case and re-view of the lileiatiue, Endod I^enl Traumatol 1996; 12: 151-154,© Munksgaard, 1996

Abstract - This case of )3eriapical actiuomycosi.s presented theclinical pictttre of chronic periapicai inllammation. The diagno-sis was based on die histological examination ol the periapicai le-sions suggesting the necessity for routine histological exatnina-lion. Although root canals pro\ide a piimai)' jDort ol entry theActi)iomyfe.s orgcXnisuK into the periapicai tisstte, periapicai actin-omycosis, is considered exlremcly rare. This ma)- be due to theomission of rotitine histological examination oi peria])ical le-sions and the clinical l^ehavior of the disease. The large nutiiberof cases reported dtiring tlie last decade itidicates that periapicaiactinomycosis is moi e freqtient than what it is believed and lliis isimportant in the daily denial practice.

P, L, SakellariouAthens, Greece

Key words: actinomycosis: periapicaiactinomycosis: periapicai inflammation: periapicaiinfection

Piiiiip Sai<enarioLi, 31 Diligianni St.,f45 62 Kifissia, Afliens, Greece

Accepted October 2.1995

The maiti etiological agent ol htiman actinomyco-sis is Aciinoinyces israelii, followed by Aradmia }>roj)i-onica, A. naeslundU, A. xnsco.ms atid A. odoniolyticusin descending order (1-S), The aclinomya's arenormal saptophytes iti the oral cavity. The patho-genesis of actinomycosis is not clear. It is believed,however, that actinomyces enter the tissues follow-ing trauma and become pathogenic (4),

The ttstial location of actinc:)mycosis is the cetvi-cofacial region in 60% of cases, followed by the ab-dotninal in 20%, thoracic in 15% (5) and the cere-bral in 5% (6), Periapicai actinomycosis is consid-ered extremely rare (3), Aciinomycps are found in10,6 to 17,2 of infected root canals (7, 8) which aretlie primary port of entry for Actinomyces organismsinto the periapicai tissue,

Hardwick & Newman (9), atid Villa (10) liavefound colonies of Actinomyces in the pulp cham-beis of teeth with cornual absesses. Howevet; tlielargest number of cases reported to date, arc of ac-tinomycosis of i^etiapical granttloiiias.

Weir & Buck (11) report a case of periapicai ac-tinomycosis and in reviewing the literattiie ttntil1982 they found 20 cases includiug dieir own.

A teview of the literatttre from 1982 till now re-veals 25 additional cases including the presentone, A series of 16 cases is teported by Happonenet al, (1, 2), The diaguc:>sis was conlhmed bv ini-mtitiocytochemical histologica! examination ofthe periapicai lesions in which the presence of ,4r-tinomyces israelii atid in descetiditig order A. propi-onicadwA A. iiaesluiidriwere fbuud. Two cases weret eported by Nair c*v: Schroedcr (3) in a histologicalexamination of 45 cases of periapicai lesions,Perna et al, (6) report one case of actitiomycoticgranuloma of the right Gasserian ganglioti, withthe primary site an actinomycotic periapicai gran-uloma of the right thiid inferior molar. Five iso-lated cases are reported by Martin & Harrison(12), Craig et al, (13), Nishimura (14), O'Grady &Reade (15), Figttres & Dottgias (16), Review of theliterature shows that the cases of periapicai actino-tnycosis teported until toda)' total 45 inchtdingthis one. The purpose of this study was to showtJiat the pei-iapical actinomycosis, a disease thatmay cavise serious complications (6), is involved inthe aiea of the dentist's dailv practice and is notextremely rare, as is commonlv believed.

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I. R i td iograph s h o w i n g h u g e c o i i l i n u o u s n i d i o l u c e n c y

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 root ca-

na ls l i n ing o l l l i c m o l a r s .

Case report

A 56-year old while man was referred with tbediagnosis of peria|)ical cyst of tbe right mandible.Twenty days prior to the rcleiTal the ]3atient devel-oped a .swelling of tlie liglil mandibular vestibule.The swelling was redueed wilhin a week with anti-biotic treatment (tetracycline 250 mg four times aday for 10 days) ]3rescribed by the denlist. Tliepatient had an tnireniarkable medical history. Onexaminiition the swelling had disappeared andpalpation of ilu- right mandibtilar vestibule waspainless and listula tree.

The radiograpiis (Fig. 1-2) revealed a large ra-diolucent ])eriai3icii! area extending from the apexol 47 to and including the apex of 45. Teeth 46and 47 showed incomplete filling of the root ca-nals. Tooth 45 was non-caritjus and did not le-

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

liinils o/ ihc l a d i o h n e in pe r iap ica l a rea .

spond to eiectrie and diermal pulp testing. Tbeteeth weie slightly sensitive to percussion. Tlie pa-tient had never before complained oi diseotnfortfrom this area or leported any injuries. Tine lesionwas operated Ijased on the radiological diagnosisof iniected periapical cyst.

Undei- inferior dental nerve block anesthesia,an incision was made along the nuicogingivaljunction from 47 to 45. A mucoperiosteal flajj wasreflected and the cortical bone was exposed. Tbecortical bone corresjDonding to the apex of 46 waspapyraceous witb a j^erfbration of 1 mm. The per-foration was enlarged atid revealed the entire cav-ity. Teeth 47, 46 and 45 were extracted and a gran-ular tnass which filled the etitire periapical cavityand was not attached to the bone was removed.The flap was stUured with silk, a rubl^er dam draininserted aud the patient was placed on a l egime of500 nig penieifliu three times a day for 6 days. Thenext day tlie drain was remo\ed and the suttneswere removed on tlie 6th ]5ost-operative day.

The liealingwas uneventful. As the histologicalexamination revealed actinomycosis, tbe admini.s-tration of peiiieillin was prolonged for two addi-tional weeks.

The histologieal examination (Fig. 3) of tlie ma-terial from tbe pei iapical fesions consisted of gran-ular tisstie with dense inflammatory infiltrationcomposed of polymorphonuclear leucocytes,some lymphocytes and many plasma cells (3). Thesttrface was partly tilcet ated and pat tly covered byfiyi)er]3fastic squamous epithelium without celfu-lai- atypia. Among exudative elements some typicalcolonies of actinoniyces were present. Diagnosis:"periapical actinomycosis".

Radiographs taken three years after oiJerationshowed cotnplete regenetation of the bone in theperia])icaf region (Fig. 4); 5 years postopei ativelythere was no sign of recttrrence.

Discussion

This case presented the clinical picture of usualchronic jjeriapical inflammation. Tbe diagnosiswas accidental from the histological exatninatiotiof the periapical lesion, in which tfie characteristiccolonies of the cictinomyce.s constituted anuncontroveisiaf proof of actinomycosis. Tbe fargeosteolytic periapical area (Fig. 1, 2) sttggested thatthe symptomless disease had been piesent for along time before the recent exacerbatioti. In thejaws actinomycosis may occur as a central fesion orit may occur in the soft tissue arottnd the niatidi-ble. In the central type of actinomycosis of tbe jaw,as in the present case, the bone destruction mayexist for a long time liefore symptoms appear; fre-

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Fis;. 3. l'hotoniiero<;ta|)h ol ti.s.stie .seclion showitig colony olactinoniycete.s .stirtouiuled In inllaniniatory cells. (I Ieiiiatoxv-lin atid eositi staiti X 2.'iO).

qucnlly it i.s by roenlgcn diagnosi.s lliat an o.steiticdefecl is discovered which, when ojjeraled npon,proves lo be due to aclinoniycosis (4). hi suchcases lhe soft tissues are not necessarily involved(4). The .syniptoniless clinical bahavior in thepresent case suggested tlial the aetiitotnyres are oflow virulence. These organisms also lack tissuedecomposing enzymes (hyaluronidases) and sorequire the aid of other partly aerobic, partlyanaerobic noti-specillc bacteria, particularly sta-phyloroeei and streptoeoeei lo achieve ]3alhogenecily(5). In addition, these organisms may establish aueqtiilibiitim with the ho.st tissue without necessar-ily causing an acute resjjonse or undue discomlbrtto the host (3).

In the present case, as in most pre\ious cases ofperiapical actiuomycosis, the diagnosis followedendodontic. In this case, the diOerence was treat-

h'ig. 4. Radiogtapli of the right tiiandible, thtee years alter O|>eration, .showiiij; cotiiplete tegetietation of the bone in theperiapical region.

ment lhat the endodontic therapy had been per-ibrmed se\eral years ago without the patient hav-ing complained ever since. The exacerbation ap-peared 20 da)s prior to the referral. Withotit ex-cluding the possibility of hematogenic spreadingto an already established periapical lesion, themost propable wa)' for aetinoittyre.s to be introciticedto 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 in-tiodticed before the endodontic therapy or wereadvanced as a result of stich tlierap). We know,however, that endodontic therapy alone fails incases of periapical lesions in which actinomycosisis in\ olved. In such cases surgical cm ettage of theperiapical lesion is recjuired too (1, 11).

It is strange that the periapical actinomycosis isconsidered extremely larc^ since the root canalsprovide the primar\' port of entry for the Aetinomy-TM organisms inlo the periapical tissues. In the cei-vicofacial actinomycosis which accotmts for 60%of all cases, the clinical picture is very obviotis:.swelling, itidttration of soft tissues, abscesses,draining sinuses and fislulae. With this clinical pic-lure, it is essential for lhe clinician to suspect ac-tinomycosis and look for the laboiatoi)- proof ofthe disease in the pus of the abscesses and fistiilae.On the contrary, in the periapical actinomycosisthe clinical picture is at)pical, as in the presentcase, and it is confused with the tisual and morefreqtient chronic periapical inflammations.

Rotitine microscopy periapical lesions, espe-cially tliose which resist endodontic theiap)' maylead lo a re\ised understanding of the occurrenceof actinomycosis in periapical lesions. This re-search may be done also with the help of inmiuno-cytochemical histological methods (1, 2, 17),which identify the species oi' aetiitoinyee.sdnd revealsmall colonies that are not morphologically char-acteristic and are easily oxeiiooked in routine his-topathological examination (2). This is supportedby the impressive series of 16 cases of periapicalactinomycosis reported by Happonen et al. (1,2)and by the reported 2 cases of periapical actino-mycosis by Nair & Schroeder (3) in histological ex-amination of 45 cases of periapical lesion, whilethoiLsands of periapical lesions are encountereddaily without histological examination.

Tlie belief tliat "a tootli with a granulotna mayhave an infected root canal, but a sterile periapicaltisstie" (18, 19) pre\'ailed fbr nian\' years andstopped the microbiological research of periapicallesions, because such a tesearch was consideied tobe done in vain. However, the presence of colo-nies of (letiitomyces in periapical lesions, as in thepresent case (Fig. 3), and other microorganisms

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(20-22), changed tlic bcliel that pciiapical lesionsarc free o( microorganisms and proved that ticlino-mycc.s s])ecies and other microorganisms may stir-vive in periapical lesions.

As a result, the signiiicancc of the lact that mi-croorganisms are incltided and stirvive in the liv-ing tissues of the periapical lesions and not only intlic dead and inaccessible to the circulation rootcanal mtisl be Itirther considered and cvahiated.

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