Unknown to a rare known: A case report of apical actinomycosis

Krishtipati Suhasini; Koppolu Madhusudhana; Chinni Suneelkumar; Anumula Lavanya

doi:10.4103/0976-433X.195639

CASE REPORT

Year : 2016 | Volume : 7 | Issue : 4 | Page : 248-251

Unknown to a rare known: A case report of apical actinomycosis

Krishtipati Suhasini, Koppolu Madhusudhana, Chinni Suneelkumar, Anumula Lavanya
Department of Conservative Dentistry and Endodontics, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication

13-Dec-2016

Correspondence Address:
Koppolu Madhusudhana
Department of Conservative Dentistry and Endodontics, Narayana Dental College and Hospital, Nellore, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0976-433X.195639

Abstract

Actinomycosis is a rare infection caused by filamentous Actinomyces, which form club-shaped filaments arranged in a radiating pattern and rarely infects jawbone. Due to its nonspecificity from its clinical features, it has been considered as a challenging diagnosis. This case report describes a case of periapical cyst which was diagnosed as actinomycosis based on histopathological examination. Periapical actinomycosis is one of the most important reasons for the failure of nonsurgical treatment. Clinically, if the periapical lesion is largely associated with weeping canals, surgical debridement of granulation tissue is mandatory. In this case, surgical intervention and adjunctive platelet rich fibrin with osseograft provided successful healing.

Keywords: Actinomycosis, periapical lesion, platelet rich fibrin, weeping canals

How to cite this article:
Suhasini K, Madhusudhana K, Suneelkumar C, Lavanya A. Unknown to a rare known: A case report of apical actinomycosis. SRM J Res Dent Sci 2016;7:248-51

How to cite this URL:
Suhasini K, Madhusudhana K, Suneelkumar C, Lavanya A. Unknown to a rare known: A case report of apical actinomycosis. SRM J Res Dent Sci [serial online] 2016 [cited 2023 May 30];7:248-51. Available from: https://www.srmjrds.in/text.asp?2016/7/4/248/195639

Introduction

Microorganisms play a vital role in the development of periapical lesions. According to the literature review, failure of 10% of well-treated cases was mainly due to persistent infection within the root canal system and persistent extraradicular infection in the tissue mainly by Actinomyces israelii. Periapical actinomycosis is defined as a nonresolving periapical lesion associated with actinomycotic infection and has been suggested as a contributing factor in the perpetuation of periapical radiolucencies after endodontic treatment. ^[1]

Wide circumferential apical defects caused by endodontic infection needs surgical intervention for a successful outcome. Periapical surgery has continued to evolve into a precise, biologically-based adjunct to nonsurgical root canal therapy in eliminating the bacteria and other microbial irritants in the root canal space. It has been reported that treatment of 24.5% of the cases was only possible with surgical therapy. ^[2]

This article reports a case of a periapical lesion with actinomycotic infection and its treatment strategies.

Case Report

A 19-year-old South Indian female came to the Department of Conservative Dentistry with a chief complaint of palatal swelling in the upper right front and back tooth region since 2 years that was started as small one and attained the present size. She had a history of trauma 7 years back which is asymptomatic, and there was a swelling in the upper palatal region since 2 years. The patient was physically healthy, with no other remarkable features in her past medical history. On examination, extraorally, there were no observable abnormalities. Intraorally, there was an oblique fracture involving incisal third toward distal side seen with slight discoloration in relation to 11. Swelling measuring about 3 cm × 3 cm in the palatal aspect of 11-15, extending anteroposteriorly and mediolaterally 0.5 cm crossing away the mid-palatine raphe and 1 cm away from the marginal gingiva of premolar (palatal) was seen. The mucosa over the swelling was normal. The swelling was non tender and soft in consistency.

On intraoral periapical radiographic interpretation, there was a radiolucency extending from mesial aspect of 11 to distal aspect of 13 measuring 3 cm × 3 cm. There was no response in relation to 11, 12, 13 on vitality testing (thermal, cold, and electrical pulp testing).

The treatment planned was conventional root canal therapy for 11, 12, 13. Access cavity preparation and working length was determined after isolation by rubber dam, copious irrigation was done with 2.5% NaOCl (Novo Dental Products Pvt., Ltd., Mumbai, India), 17% ethylenediaminetetraacetic acid (B.N. Laboratories, Mangalore, India) and 0.2% chlorhexidine (Vishal Dentocare Pvt., Ltd., Ahmedabad, India) within between saline flush to remove the necrotic debris from the pulp space.

The access cavity was sealed with zinc oxide eugenol temporary restoration (Dental Products of India, Mumbai, India). The next day, the patient returned with severe pain with respect to both teeth 11, 12. On examination, it was seen that both 11 and 12 were severely tender on percussion. It was assumed as a case of mid-treatment flare up, and the canals were reopened. Pus discharge was allowed to drain; canals were dried and closed dressing was given. Systemic antibiotics (amoxicillin; Amox 500 mg 3 times daily 5 days) and analgesics (ibuprofen; brufen 400 mg twice daily for 3 days) were advised. On the recall visit after 4 days, mild tenderness was present, and the canals were still weeping on the removal of the temporary restoration. The canals were once again irrigated with chlorhexidine, and calcium hydroxide intracanal medicament was placed and sealed temporarily by an intermediate restorative material. The patient recalled after 2 weeks, cleaning and shaping was done in relation to 11, 12, 13 as canals were free of exudate, obturation was performed in relation to 12, 13 except 11 because of weeping canal. Furthermore, intracanal medicament was placed and closed dressing had given in relation to 11.

After 2 weeks, exudate was still present, hence, apical surgery was planned. On the day of surgery, Obturation was done in relation to 11 and an intra crevicular incision was given from the distal aspect of tooth 13 to the distal aspect of tooth 21. A full thickness mucoperiosteal rectangular flap was elevated, with releasing incisions in the distal area of tooth 13 and distal aspect of 21. Degranulation of the defect revealed the presence of yellowish granules, black-blue granules. A tissue sample obtained was placed in 10% formalin solution and sent it for biopsy. The apical 3 mm of roots of 11, 12, 13 was resected and restored with mineral trioxide aggregate as root-end filling. Bone graft (osseograft demineralized bone matrix) placed along with platelet rich fibrin (PRF) in the residual bony crypt and the flap was reapproximated with 5-0 silk sutures. The patient was given a prescription for medication and postsurgical instructions. After 1 week, the patient was asymptomatic, and sutures were removed. All the radiographic pictures were represented in [Figure 1], and clinical photographs were represented in [Figure 2].

Figure 1: (a) pre operative radiograph. (b) post obturation radiograph. (c) Bone graft placed after surgery. (d) Healing after 6 months

Click here to view

Figure 2: (a) Pre operative photograph. (b) Palatal Swelling pre operative. (c) Incision and flap reflection with defect. (d) Bone graft and platelet rich fibrin placement. (e) Suture placement

Click here to view

Histopathological examination revealed small/large filamentous colonies surrounded by many neutrophils. The colonies were basophilic in the center and eosinophilic at the periphery and composed of many radiating filaments with neutrophils clinging to their borders. Some bits show edematous connective tissue with intense mixed inflammatory changes, hemorrhage, fibrous areas with occasional multinucleated giant cells. Based on biopsy report, the case was diagnosed as radicular cyst with actinomycotic infection. Histopathological findings were shown in [Figure 3].

Figure 3: (a) Filamentous colonies surrounded by neutrophils colonies were basophilic in the center and (b) eosinophilic at the periphery and (c) composed of many radiating filaments with neutrophils clinging to their borders

Click here to view

After 6-month follow-up, the patient is completely asymptomatic and patient is kept under observation.

Discussion

Actinomycosis is an infection caused by a non motile, non spore forming Gram-positive, anaerobic to microaerophilic filamentous bacterial rods. It is subacute to chronic bacterial infection characterized by contiguous spread, suppurative, and granulomatous inflammation by forming multiple abscesses and sinus tracts that may discharge sulfur granules. ^[3],[4]

Actinomycosis is a Greek word comprising of "Aktino" meaning radiating appearance of sulfur granules and "mykos" meaning mycotic disease.

Actinomyces microorganisms are commensal in the oral cavity, with a low potential for virulence or invasion. Other bacteria in a synergistic ecosystem are required for their proliferation. Mucosal disruption is a pre requisite for the establishment of infection. Oral trauma, dental extraction, or a dental abscess are the most common predisposing factors. ^[5],[6] Kuklani et al. stated that periapical lesions with Actinomyces were more prevalent in older age groups and females, with the predilection of anterior maxilla. ^[1]

Sinus tracts are more commonly seen in the actinomycosis cases but in this case, there was no sinus tract seen.

Most reported cases of periapical actinomycosis in the literature are associated with a long and complicated endodontic history but in this case, periapical actinomycosis had seen in the absence of root canal therapy. According to Nair and Schroeder, actinomycotic infection was seen in 2 out of 45 periapical lesions, with no history of previous endodontic treatment. ^[7]

In this case, periapical surgery was planned immediately after nonsurgical root canal treatment, as there was wide periapical lesion which attained a large size within a short duration in a young patient, despite normal systemic conditions.

PRF forms a strong natural fibrin matrix, which concentrates almost all the platelets and leucocytes of the blood harvest and creates a complex architecture as a healing matrix. Bone graft enhanced tissue regeneration with osteoinductive capabilities and promote remodeling of an osseous defect. Hence, in the present case to facilitate faster healing by bone formation, both PRF and bone graft placed concomitantly. ^[8],[9]

As apical actinomycosis was more prevalent than commonly believed and incidence of about 2-4% was reported, and conservative surgical curettage along with short-term antibiotic treatment was considered as an appropriate treatment option. ^[10] Histologic examination of all periapical lesions that are surgically curetted is mandatory as a case like an actinomycosis can only be identified through histological examination.

Conclusion

As actinomycotic infection would not be healed without surgical intervention, in the present case, a nonsurgical treatment followed by surgical intervention and adjunctive PRF with osseograft provided successful healing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Kuklani RM, Bhattacharyya I, Nair MK. Radiographic evaluation of periapical lesions with and without biopsy-proven Actinomyces: A pilot study. Quintessence Int 2011;42:301-6.
2.	Singh S, Singh A, Singh S, Singh R. Application of PRF in surgical management of periapical lesions. Natl J Maxillofac Surg 2013;4:94-9. [PUBMED]
3.	Hirshberg A, Tsesis I, Metzger Z, Kaplan I. Periapical actinomycosis: A clinicopathologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:614-20.
4.	Rush JR, Sulte HR, Cohen DM, Makkawy H. Course of infection and case outcome in individuals diagnosed with microbial colonies morphologically consistent with Actinomyces species. J Endod 2002;28:613-8.
5.	Tseng SK, Tsai YL, Li UM, Jeng JH. Radicular cyst with actinomycotic infection in an upper anterior tooth. J Formos Med Assoc 2009;108:808-13.
6.	Siqueira JF Jr., Rôças IN, Souto R, de Uzeda M, Colombo AP. Actinomyces species, streptococci, and Enterococcus faecalis in primary root canal infections. J Endod 2002;28:168-72.
7.	Weir JC, Buck WH. Periapical actinomycosis. Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol 1982;54:336-40.
8.	Zhao JH, Tsai CH, Chang YC. Management of radicular cysts using platelet-rich fibrin and bioactive glass: A report of two cases. J Formos Med Assoc 2014;113:470-6.
9.	Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44.
10.	Ricucci D, Siqueira JF Jr. Apical actinomycosis as a continuum of intraradicular and extraradicular infection: Case report and critical review on its involvement with treatment failure. J Endod 2008;34:1124-9.