SURGICAL TREATMENT AND DIAGNOSIS OF AN ACTINOMYCOSIS INFECTION IUSD Department of Graduate Endodontics A. Griglione, Y. Ehrlich, K. Spolnik, M. Vail, C. Kutanovski

Abstract

Persistent or secondary infections are a major causes of endodontic treatment failure. Bacteria that survive treatment

and resist intracanal disinfection procedures can adapt to the drastically changed environment (1, 2). Actinomyces

and Propionibacterium species can invade the apical tissues and form apical periodontitis (AP) by self sustained

extraradicular colonies - apical actinomycosis. We report the treatment of a refractory AP diagnosed as granuloma

with colonies consistent with actinomycosis. Non-surgical root canal treatment failed to resolve the apical

periodontitis. An apicoectomy using microscopic surgical techniques was done to remove the lesion and resect the

infected roots. EndoSequence Root Repair Material™ a calcium silicate based material was used to seal the resected

roots. Emdogain, demineralized freeze dried bone allograft and calcium sulfate were used to graft the residual bony

crypt. Following surgery the patient was given amoxicillin, Peridex 0.12% and warm salt water rinses. Healing was

uneventful and after four months clinical and radiographic evaluation show evidence of hard and soft tissue repair.

This report describes the successful diagnosis and treatment of refractory endodontic infection with periapical

actinomycosis.

.

Treatment Evaluation – 11-4-11

• Examination was performed to determine teeth #s 7 and 8 were both necrotic with symptomatic apical periodontitis.

Treatment plans were discussed and the decision was made to perform nonsurgical endodontic therapy with inter-

appointment intra-canal calcium hydroxide medication, short-term follow up and surgical endodontic therapy as

needed.

Nonsurgical endodontic treatment 1st visit – 3-12-12

• Nonsurgical endodontic treatment was initiated on teeth #7 and 8. Due to the unpredictability to properly debride the

apical portion of tooth #7 due to the nondeveloped apex, a CBCT was taken and surgical debridement was

recommended with apicoectomy of teeth #s 7 and 8. Calcium hydroxide was placed and the patient was given a

prescription for amoxicillin 500 mg, 21 tabs tid.

Nonsurgical endodontic treatment 2nd visit– 4-30-12

• Patient returned for obturation of teeth #s 7 and 8 stating he was asymptomatic. Tooth #7 was obturated apically with

MTA followed by a backfill of gutta-percha/roth’s sealer. Tooth #8 was obturated with gutta percha/roth’s sealer.

Surgical endodontic treatment – 10-16-12

• The patient presented for surgical debridement/apicoectomy/retrofill. An intrasulcular incision was made with vertical

releasing incision distal to teeth #s 5 and 10. Osteotomy was created, the lesion was excised and sent for biopsy.

The apical segment of tooth #7 was resected and already had MTA in the apically prepared segment for adequate

seal. Tooth #8 was retro-prepared with a #1 and #2 surgical ultrasonic tip and brasseler ERRM putty was used as

retro-filling material. Emdogain, DFDBA, and calcium sulfate were used to graft the residual bony crypt. 5-0 silk

sutures were used to reapproximate the flap. The patient was given prescriptions for amoxicillin 500 mg 21 tabs 1 tab

q8h, vicodin 5/500 20 tabs 1-2 q6h and ibuprofen 600 20 tabs 1 q6h and placed on peridex 0.12% bid and advised

warm saltwater rinses qid.

1 Week Suture Removal/Follow-up – 10-24-12

• Sutures were removed and soft tissue healing was WNL. Biopsy report histological diagnosis: RIGHT ANTERIOR

MAXILLA, APICAL REGION OF TEETH #s 7 AND 8, PERIAPICAL GRANULOMA WITH FIBROUS CONNECTIVE

TISSUE SCAR, ABSCESS AND BACTERIAL COLONIES MORPHOLOGICALLY CONSISTENT WITH

ACTINOMYCES SPECIES

1 Month Surgical Follow-up – 11-27-12

• Soft tissue healing WNL, PD’s 2-3 mm.

4 Month Surgical Follow-up – 11-27-12

• PA taken (Figure 4.). Hard tissue healing progressing WNL, soft tissue healed WNL, appearance of intact periodontal

ligament development. No pathosis detected.

• No swelling or sinus tract clinically present, teeth #s 7 and 8 asymptomatic to percussion and palpation. Probing 2-3

mm and no mobility.

Background Endodontic therapy is used to prevent or eliminate apical periodontitis. Root-end surgery may be indicated when

persistent or refractory periradicular pathosis exists after nonsurgical treatment (3). The present case focuses on

persistent extraradicular infection, specifically with an etiology of actinomycosis, which has not healed after non-

surgical treatment.

Actinomyces species are normal inhabitants of the oral cavity which are found in high prevalence in carious dentin.

Some argue that they are the first colonizers of exposed dentinal pulp in endodontic infections (18). Evidence

suggests that the main bacterial species implicated in exclusively extra-radicular infections are of the genera

Actinomyces and Propionibacteri (specific species examples include Actinomyces israelii and Propionibacterium

propionicum) (11-14). There are three main portals of entry into extraradicular space: 1) apical extrusion of debris

2) direct advance from the infected canal into the lumen of pocket cysts; or 3) previous participation in acute

periapical abscesses (16-18). Once in the extraradicular space these two species are able to flourish in host

tissues for long periods of time without causing symptoms. In order to effectively treat this extraradicular infection,

root end surgery may be indicated.

Microsurgical success rates have collectively been reported to have a 94% success rate (5). These success rates

have been attributed in part to the technical advances in microsurgery. Microsurgical technique requires a

microscope or endoscope, the use of ultrasonic tips and micro-instruments as well as a more biologically

acceptable root-end filling material (4). Mineral trioxide aggregate (MTA) has produced the most favorable results

in root-end filling materials in terms of lack of inflammation, biocompatibility, superiority in sealing, and the

presence of cementum and hard tissue formation (6-9). When comparing MTA to ERRM putty they display in-vitro

similar biocompatibilites (24). In this case guided tissue regeneration (GTR) was used to help with healing of the

large PA lesion. The current data supports GTR in cases with large PA lesions, and through-and-through lesions to

improve bone regeneration after surgical endodontic treatment (10). Local growth factors have been shown to

improve endodontic and periodontic healing. Emdogain consists of amelogenin and enamel matrix proteins. A

systematic review by Giannobile and Somerman (23) suggested that EMD and growth factors are promising in

terms of their ability to promote tissue/bone regeneration, but long-term data and sufficient evidence were still

lacking. Contrary to systemic actinomycosis antibiotic treatment, prolonged systemic antibiotic therapy is not the

treatment of choice with periapical actinomycosis (13). The vast majority of reported cases of periapical

actinomycosis have been successfully treated by either apical surgery or extraction of the affected tooth; with no

antibiotic therapy the healing went uneventful (13,19-20).

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Patol Oral Cir Bucal 2008;13:E180–E185.

10. Tsesis, Igor; Rosen, Eyal; Tamse, Aviad; Taschieri, Silvio; Del Fabbro, Massino. Effect of guided tissue regeneration on the outcome of

surgical endodontic treatment: a systematic review and meta analysis. J Endod 2011; 37,8: 1039-45.

11. Sjo¨gren U, Happonen RP, Kahnberg KE, Sundqvist G. Survival of Arachnia propionica in periapical tissue. Int Endod J 1988: 21:

277–82.

12. Sundqvist G, Reuterving C-O. Isolation of Actinomyces israelii from periapical lesion. J Endod 1980: 6: 602–6.

13. Happonen R-P. Periapical actinomycosis: a follow-up study of 16 surgically treated cases. Endod Dent Traumatol 1986: 2: 205–9.

14. Happonen RP, Soderling E, Viander M, Linko-Kettunen L, Pelliniemi LJ. Immunocytochemical demonstration of Actinomyces species

and Arachnia propionica in periapical infections. J Oral Pathol 1985: 14: 405–413.

15. Hoshino E, Ando N, Sato M, Kota K. Bacterial invasion of nonexposed dental pulp. Int Endod J 1992: 25: 2–5.

16. Sjo¨gren U, Happonen RP, Kahnberg KE, Sundqvist G. Survival of Arachnia propionica in periapical tissue. Int. Endod J 1988: 21:

277–82.

17. Pulverer G, Schutt-Gerowitt H, Schaal KP. Human cervicofacial actinomycoses: microbiological data for 1997 cases. Clin Infect Dis

2003: 37: 490–7.

18. 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.

19. Bystro¨m A, Happonen R-P, Sjo¨gren U, Sundqvist G. Healing of periapical lesions of pulpless teeth after endodontic treatment with

controlled asepsis. Endod Dent Traumatol 1987: 3: 58–63.

20. Sjo¨gren U, Happonen RP, Kahnberg KE, Sundqvist G. Survival of Arachnia propionica in periapical tissue. Int Endod J 1988: 21:

277–82.

21. Pulverer G, Schutt-Gerowitt H, Schaal KP. Human cervicofacial actinomycoses: microbiological data for 1997 cases. Clin Infect Dis

2003: 37: 490–7.

22. Heijl L, Heden G, Svardstrom G, Ostgren A. Enamel matrix derivative (EMDOGAIN) in the treatment of intrabony periodontal

defects. J Clin Periodontol 1997;24(Pt 2):705–14.

23. Giannobile WV, Somerman MJ. Growth and amelogenin-like factors in periodontal wound healing: a systematic review. Ann

Periodontol. 2003;8:193–204

24. Jingzhi Ma, Ya Shen, Sojia Stojicic, Markus Happaslo. Biocompatibility of Two Novel Root Repair Materials. J. Endod 2011; 793-

8.

Case Report Dental History/Sensibility testing

A 34 year old male with unremarkable medical history presented to the graduate endodontics clinic referred for

evaluation of an asymptomatic lesion apical to teeth #7 and 8 with a history of trauma to the face when he fell at 8

years old. Upon clinical exam and testing the finding were no response to cold (nonvital) on teeth #s 7 and 8 with pain

to palpation at the apices at 7 and 8. There was no pain to percussion, class 1 mobility was noted on teeth #s 7 and 8

and probing depths were 2-3 mm. Radiographic exam revealed a 2 x 1.5 cm solitary periapical radiolucent lesion

with well defined borders encompassing the apices of teeth #s 7 and 8. Tooth #7 appeared to have an

underdeveloped root apex and tooth #8 had a coronal pin resin restoration.

Conclusions The treatment of localized actinomycosis with surgical debridement has been recommended with no need

for long-term antibiotics. Due to the large size of the lesion as well as the understanding of the

anatomical constraints to properly debride the apical segment of tooth #7, surgical endodontics was

warranted. It can be presumed that without surgical intervention, the extraradicular actinomycotic

infection would not have healed. The six month delay between completion of nonsurgical and initiation of

surgical treatment exemplified this. This case report confirmed that successful treatment of localized

actinomycosis with the combination of nonsurgical and surgical endodontics with a one week course of

antibiotics and adjunctive GTR provided successful clinical and radiographic healing at four months.

Figure 8. Actinomycosis colonies

Figure 1. Pre-op 11-4-11 Figure 2. Obturation #7 & 8 4-30-12

Figure 3. Six mo. Post-op of

Nonsurgical / Pre-op surgical 10-16-12

Figure 4. Apical Surgery 10-16-12

Figure 5. Lesion removal

Figure 6. Crypt after lesion removal

Figure 10. Actinomycotic Colony

Figure 11. Live bacteria/abscess, PMNs,

dead bacterial nidus

Figure 9. Immune cells, RBCs,

Granulation tissue

Figure 7. Four mo Post-Op 2-5-13

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