“Holes” in the Jaw—A Report of Two Cases of Periapical Actinomycosis

Abstract

Periapical actinomycosis is a relatively rare form of cervicofacial actinomycosis, which typically involves the periapical region with subsequent potential spread to the jaw bones. We hereby present two cases of periapical actinomycosis. Both patients presented with jaw pain and “holes” in their gum and lacked the characteristic clinical features commonly seen in cervicofacial actinomycosis such as jaw mass, draining ulcers, sinuses and fistulae. The first patient was an immunocompetent host with chronic stable medical conditions but with a rather bad dentition requiring multiple recent teeth extractions. The second patient was edentulous, had refractory multiple myeloma, was on low-dose chronic steroids and pomalidomide therapy and therefore relatively immunocompromised. Both cases of actinomycosis were diagnosed by jaw bone histopathology, which showed characteristic sulfur granules and embedded Actinomyces-like organisms. The two patients had excellent clinical response to six months of penicillin therapy without any need for surgical intervention. The cases remind clinicians of including actinomycosis in the differential diagnosis of periapical lesions and illustrates the possibility of achieving cure with non-surgical treatment.

Diagnosis and Management of Cervicofacial Actinomycosis: Lessons from Two Distinct Clinical Cases

“…The patient was treated with high-dose penicillin for 4 weeks and made a complete recovery [22]. Ayoade et al reported two distinct cases of periapical actinomycosis, which is a very rare presentation of the cervicofacial form [12]: both of these patients had no history of dental procedures but presented with underlying immunosuppression (due to type 2 diabetes and multiple myeloma, respectively) and they were over 60 years of age. In both cases, the diagnosis was based on histopathological examination using hematoxylin and eosin and Gomori-Grocott methenamine silver stains, where both the bacteria and the sulfur granules were shown [12].…”

“…Ayoade et al reported two distinct cases of periapical actinomycosis, which is a very rare presentation of the cervicofacial form [12]: both of these patients had no history of dental procedures but presented with underlying immunosuppression (due to type 2 diabetes and multiple myeloma, respectively) and they were over 60 years of age. In both cases, the diagnosis was based on histopathological examination using hematoxylin and eosin and Gomori-Grocott methenamine silver stains, where both the bacteria and the sulfur granules were shown [12]. In the case series presented by Moghimi et al [23], 19 cases of cervicofacial actinomycosis cases were characterized: all patients complained of swelling, while 17 also had severe pain.…”

“…Cervicofacial actinomycosis was reported more frequently in patients living in rural areas, compared to people living in urban environments (the observed prevalence was 10:1); this difference was usually attributed to poor hygiene, neglected health status, low socioeconomic status and close contact with animals [11]. Histopathological examinations, microbiological culture, and consideration of the patient's medical history and underlying illnesses, together with imaging methods are all important components for the definitive diagnosis of actinomycoses [12][13][14]. However, in some instances and for many healthcare-settings, histopathology is not available or not routinely performed; thus, a presumptive diagnosis is carried out from the symptomatology and microbiological findings.…”

Palatal actinomycosis osteomyelitis–Complication of impacted tooth in a diabetic

“…Actinomycosis is diagnosed by jaw bone histopathology, which showed characteristic sulfur granules and embedded actinomyces‐like organisms. The patients have excellent clinical response to 6 months of penicillin therapy without any need for surgical intervention, as is reported in literature …”

“…The patients have excellent clinical response to 6 months of penicillin therapy without any need for surgical intervention, as is reported in literature. 12 Any unidentified mass, facial swelling, or persistent infection particularly after endodontic therapy or tooth extraction, regardless of its nontraumatic history is suggestive of actinomycosis. 13 Diagnosis should be actively attempted in all instances of persistent oral infections because progressive actinomycosis, particularly in the maxilla, is likely to have relatively serious consequences if it is not diagnosed.…”