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Actinomycosis of the mandible
ACTINOMYCOSIS NICHOLAS
OF THE MANDIBLE
C. CH~IJKAS, -
l).D.S.,
CHICAGO,
ILL.
is an infection that is encountered infrequently in the CTINOMYCORIS mantlible, although the number of reported cases indicates-that the possibility of t)hc presence of actinomycosis must always be considered in any infection of the jaws. Tt is necessary, therefore, to include actinomycosis in the differctntial diagnosis. One should be acquainted with the clinical and pathologic picture ill order to recognize and treat actinomycosis rationally and cff ectively. The genus Actinomyces is the most important member of the family Actinomycetaceac. These arc mainly soil types of organisms which have an important, function in agriculture. The great majority of actinomycetes are aerobic, but the pathogenic forms are anaerobic and have to be cultivated under reduced oxygen tension. Bollingerl discovered the most important type of actinomyces while studying lesions of cattle suffering from actinomycosis. The term “ actinomycosis ” refers to an infection with an actinomycete, although it usually is thought of in connection with Actinomyces bovis or RCtinomyces isrncli. The actinomyccs discovered by Kollinger and Harz” has been definitely established as the same organism isolated by Wolf and Israel, In the opinion of some workers, which is sometimes called Actinomyccs isrncli. there are two distinct types of actinomyces : Actinomyces israeli which is thought to be responsible for human actinomycosis, and Ilctinomyces bovis, the usual cause of actinomycosis in cattle.” Because of the lack of general agreement,, the two actinomyces will be considered as one species, namely, Actinomyces bovio. The actinomyces are typically filamcntous, branched forms, which are closely related to the fungi. They are very pleomorphic, and cultures rcvcal all sorts of shapes and sizes. Actinomyces bovis, which is anaerobic, produces “lumpy jaw,” or actinomycosis, in cattle.* The term “lumpy jaw” is derived from the fact that the destruction of the interior of the bone is compensated by the addition of bone on its surface, which at times causes monstrous swelling of the jawbones.” Actinomyces bovis grows in a typical raylike arrangement, which appears The presence of the sulfur granules clinically as a small yellowish granule. is a definite diagnostic criterion for establishing a diagnosis of actinomycosis. Initial failure to locate sulfur granules should not discourage one from conRepeated examination may bc in tinuing the examination for actinomycosis. order, and a culture for the fungus may be necessary.
A
From
the Department
of Oral
Surgery
of the School of Dentistry, 14
Loyola
University.
Volume I I
ACTINOMYCOSIS
Number 1
OF
MANDIBLE
15
Infection of the cervicofacial area by Actinomyces bouis may take place via the pulp chamber of a carious tooth, a recent extraction site,6 or a cut or abrasion of the mucous membrane. The development may be slow and there may be a long period of incubation. The submandibular area is a The surrounding areas are involved by direct exfavorite site of invasion. tension along the cervical facial planes. The area of involvement is characterized by a hard, boardlike swelling with little or no fluctuation. The body temperature remains normal or low, and the patient’s general health is not affected to any great extent.7 The muscles of mastication are invariably involved, and this gives rise to trismus. Extension of the infection may cause respiratory embarrassment. Acute pain is uncommon, and the swelling eventually breaks down to discharge a yellowish fluid which contains the sulfur granules. In advanced cases fistulas form in the areas of lumpy swellings. From these fistulas there is a typical yellowish discharge containing the characteristic sulfur granules. The skin overlying the area involved will also assume a characteristic purple or bluish red color. The treatment of actinomycosis is still indefinite ; however, adequate surgiBefore the introduction of the sulfa drugs cal drainage is always indicated. and antibiotics, potassium iodide was the popular drug for the treatment of actinomycosis. Clinicians today use the sulfonamides and various other antibiotics, with varying results. Penicillin therapy combined with accepted surgical procedures appears to be the treatment of choice in all cases of actinomycosis.8 Dobson and Cutting,8 in an analysis of sixteen cases of actinomycosis, found that both the sulfonamides and penicillin are highly effective drugs in treating actinomycosis. Case Report Chief
Complaint.-Pain
in the jaw.
Onset and Course.-The patient, a white woman, had a lower left third molar extracted by a dentist. She developed considerable postoperative swelling and pain. When she returned to the dentist, she was assured that all was well and that the pain and swellThe pain and swelling persisted, however, and the paing would disappear in due time. tient began to experience difficulty in opening and closing her mouth. Becoming alarmed, she sought the advice of another dentist who took a roentgenogram of the area and discovered a retained root tip. She was then referred to me for consultation and treatment. She was seen in our office three weeks after the attempted extraction. Another roentgenogram was taken of the area involved and the described root tip The patient was now in excruciating pain and the swelling was was noted (Fig. 1). spreading into the cervical areas. It was thought advisable to place her in a hospital for further evaluation and therapy. She was admitted to the hospital and placed on 600,000 units of Abbocillin daily and 50 mg. Demerol as needed for pain. Past history and systemic review were noncontributory. Physical Examinatdon.-Examination revealed a well-developed, well-nourished, white woman who was unable to open her mouth more than 2 mm. and who complained of intense pain in her jaw. Over the body of the left mandible and the submaxillary region, there was a firm swelling which was not fluctuant and which had a boardlike consistency. The swelling extended into the submental and sublingual regions, and there appeared to be an
0. S.. 0. M., & 0. P. January, 1958
CHOUKAS
16 early invasion of the left supraclavicular had difficulty in swallowing and talking. tially negative.
area of the neck. The patient was afebrile and The remaining physical examination was essen-
Roentgenographic Examination.-An unextracted fragment of the root of the lower left molar remained in the socket of the recently extracted tooth. There was probably a tiny sequestrum involving the alveolar margin of the socket. Otherwise, the mandible showed nothing of significance.
Fig. l.-Preoperative
radiograph
of retained
root tip in mandible.
hematocrit-40 per cent; red blood Laboratory Data.-Laboratory findings included: cells-4,290,000 ; white blood cells-13,700 ; hemoglobin-13 grams; platelets-adequate ; containing 3 to 8 white blood cells and a moderate chest x-ray-negative; urine-yellow, number of epithelial cells, and specific gravity-1.005, few bacteria, character-hazy. Impression.-The impression, after evaluation of all the clinical and laboratory data, was that there was some sort of infection of the mandible. The fact that the patient was afebrile was puzzling. If she had osteomyelitis, as was suspected, she should have had an elevated temperature and a more marked increase in her white blood cell count. Treatment.-The patient was placed on continued for surgery on the morning of Aug. 14, 1956.
antibiotic
therapy
and scheduled
Volume 11
ACTINOMYCOSIS
Number I
OF
17
MANDIBLE
Operation.-Under general endotracheal anesthesia, the mouth was opened to a slight degree. With retraction, the extraction site could be approached. An incision was made, mucoperiosteal flap was retracted, and considerable amounts of granulative tissues and fragments of bone were removed. The root fragment was also located and removed. The area was packed with iodoform gauze and one silk suture was placed through the flap, suturing it to its original position. Through a submandibular approach, a second incision, overlying the swelling, was made. By means of sharp and dull dissection, a cavity containing pus was entered on the Several cubic centimeters of creamy pus medial aspects of the body of the left mandible. was found to escape. The pus was placed in a sterile tube for laboratory analysis. The area was cleaned out and a rubber drain was inserted. The skin was closed with 0000 black silk, and a pressure dressing was applied over the area (Fig. 2).
Fig. Z.-Postoperative Pathologic
photograph
showing
drain
in place
and
area
of incision.
Report.-
Culture report from surgery specimen (Aug. 14, 1956): Examination of the specimen revealed pus from the neck; green stain. The specimen was loaded with white blood cells and histiocytes in varied stages of degeneration. Many of the histiocytes had inclusion of phagocytized gram-positive organisms that showed a filamentary and branching form. Some branching forms were extracellular. Other organisms present were secondary invaders and were true bacteria. Friedlander’s pseudomonas and a gram-negative micrococcus could be identified. The pathologist’s impression of the branching forms was that it was quite probably actinomycosis. Culture report from surgical drain (Aug. 18, 1956): Direct culture of pus salvaged from the surgical dressing and cultivated anaerobically on a microscopic slide revealed, in seventy-two hours, many sulfur granules or ray fungi of microscopic size. These findings, together with the fact that the organism was an anaerobe and that its colonies on solid media were smooth, uniform, and soft, establish its specific identity as Actinomyces bovk. Course.-The patient was discharged from the hospital within in our office twice a week for dressing changes and observat.ion. taken of the material draining from the incision.
the week, and was seen Repeated cultures were
L8
0. S., 0. M., k 0. P. January, 1958
CHOUKAS
All drainage ceased on October 22, sixty-eight days after surgery, and the subsequent r*ulture reports were negative for act~inomycosis. The patient had been kept on a minimum units of penicillin daily for the entire period of treatment. of 300,000 therapeutic The area of incision has remained asymptomatic
healed
satisfartorily
and all the smrlling
resolved.
The patient
to date.
Discussion The chief interest in the foregoing case lies in the fact that the clinical picture rcsemblad a nonspecific osteomyelitis which proved to be actinomycosis. All the symptoms ant1 laboratory examination, with the exception of the patient’s afehrile condition and only a slight increase in the W.B.C. count, indicatecl a nonspecific osteomyelitis of the mandible. The presence of the root tip and the sudden onset of pain and swelling also fitted into the picture of nonspecific osteomyelitis of the mandible. Although Actinomyces bovis is considered to be present naturally in the oral cavity of many persons, it is not always pathogenic to the host. It seems that Actinomyces bovis, which is transplanted from one patient to another, might be more pathogenic. It is not unreasonable to assume that improperly sterilized instruments in the dental office might serve to transfer the organism to a second patient. The ext,raction site could very well be an easy avenue of entry for the invading organism. We can only speculate on the etiology of the origin of the actinomycosis infection. The clinician has a responsibility to his patient to USC all the diagnostic tools at his command in making a differential diagnosis in order t.o establish rational and effective treatment.
Summary 1. Actinomycosis of the mandible can be easily misdiagnosed in its acute or early stage. 2. Improperly st,erilized dental instruments may bc the source of crosscontamination in actinomycosis. 3. Actinomycosis is not restrict,ed to rural folk or to t,hosc who have a history of chewing grass or straw. 4. The diagnostician should avail himself of the full use of all the culture and sensitivity tests in order to confirm an early diagnosis and thereby improve the prognosis of the case. 5. Actinomycosis should always be considered in a differential diagnosis of all infections of the cervicofacial area. 6. Adequate therapy for cervicofacial actinomycosis involves prompt and adequate incision and drainage and penicillin in sufficient doses.
References A Clinical, Pathological and Bac1. Bollinger, cited by Jacobson, H. P.: Actinomycosis: teriological Study, M. J. & Rec. 132: 342, 1930. 2. Burrows, W.: Textbook of Bacteriology, ccl. 16, Philadelphia, 1954, W. B. Saunders Company, pp. 568-569. Textbook of Bacteriology, New York, 1942, Paul B. Hoeber, Inc., pp. 200-202. 3. Leifson, E.:
Volume II Number 1
ACTINOMYCOSIS
OF
MANDIBLE
19
4. Weinmann, J. P., and Sicher, H.: Bone and Bones, ed. 2, St. Louis, 1955, The C. V. Mosby Company, p. 354. 5. Thoma, K. H.: Oral Diagnosis, ed. 2, Philadelphia, 1943, W. B. Saunders Company, p. 407. 6. Rash, Rieva, and Seldin, H. M.: Actinomycosis: The Treatment of Five Cases, J. Oral Surg. 6: 2, 1948. 7. Eli Lilly Company: Antibiotic Therapy and Sulfonamide Therapy, Indianapolis, 1956, Eli Lilly Company? p. 43. 8. Dobson, L., and Cutting, W.: Penicillin and Sulfonamides in Therapy of Aetinomycosis, J. A. M. A. 128: 856, 1945.
OF THE MANDIBLE
C. CH~IJKAS, -
l).D.S.,
CHICAGO,
ILL.
is an infection that is encountered infrequently in the CTINOMYCORIS mantlible, although the number of reported cases indicates-that the possibility of t)hc presence of actinomycosis must always be considered in any infection of the jaws. Tt is necessary, therefore, to include actinomycosis in the differctntial diagnosis. One should be acquainted with the clinical and pathologic picture ill order to recognize and treat actinomycosis rationally and cff ectively. The genus Actinomyces is the most important member of the family Actinomycetaceac. These arc mainly soil types of organisms which have an important, function in agriculture. The great majority of actinomycetes are aerobic, but the pathogenic forms are anaerobic and have to be cultivated under reduced oxygen tension. Bollingerl discovered the most important type of actinomyces while studying lesions of cattle suffering from actinomycosis. The term “ actinomycosis ” refers to an infection with an actinomycete, although it usually is thought of in connection with Actinomyces bovis or RCtinomyces isrncli. The actinomyccs discovered by Kollinger and Harz” has been definitely established as the same organism isolated by Wolf and Israel, In the opinion of some workers, which is sometimes called Actinomyccs isrncli. there are two distinct types of actinomyces : Actinomyces israeli which is thought to be responsible for human actinomycosis, and Ilctinomyces bovis, the usual cause of actinomycosis in cattle.” Because of the lack of general agreement,, the two actinomyces will be considered as one species, namely, Actinomyces bovio. The actinomyces are typically filamcntous, branched forms, which are closely related to the fungi. They are very pleomorphic, and cultures rcvcal all sorts of shapes and sizes. Actinomyces bovis, which is anaerobic, produces “lumpy jaw,” or actinomycosis, in cattle.* The term “lumpy jaw” is derived from the fact that the destruction of the interior of the bone is compensated by the addition of bone on its surface, which at times causes monstrous swelling of the jawbones.” Actinomyces bovis grows in a typical raylike arrangement, which appears The presence of the sulfur granules clinically as a small yellowish granule. is a definite diagnostic criterion for establishing a diagnosis of actinomycosis. Initial failure to locate sulfur granules should not discourage one from conRepeated examination may bc in tinuing the examination for actinomycosis. order, and a culture for the fungus may be necessary.
A
From
the Department
of Oral
Surgery
of the School of Dentistry, 14
Loyola
University.
Volume I I
ACTINOMYCOSIS
Number 1
OF
MANDIBLE
15
Infection of the cervicofacial area by Actinomyces bouis may take place via the pulp chamber of a carious tooth, a recent extraction site,6 or a cut or abrasion of the mucous membrane. The development may be slow and there may be a long period of incubation. The submandibular area is a The surrounding areas are involved by direct exfavorite site of invasion. tension along the cervical facial planes. The area of involvement is characterized by a hard, boardlike swelling with little or no fluctuation. The body temperature remains normal or low, and the patient’s general health is not affected to any great extent.7 The muscles of mastication are invariably involved, and this gives rise to trismus. Extension of the infection may cause respiratory embarrassment. Acute pain is uncommon, and the swelling eventually breaks down to discharge a yellowish fluid which contains the sulfur granules. In advanced cases fistulas form in the areas of lumpy swellings. From these fistulas there is a typical yellowish discharge containing the characteristic sulfur granules. The skin overlying the area involved will also assume a characteristic purple or bluish red color. The treatment of actinomycosis is still indefinite ; however, adequate surgiBefore the introduction of the sulfa drugs cal drainage is always indicated. and antibiotics, potassium iodide was the popular drug for the treatment of actinomycosis. Clinicians today use the sulfonamides and various other antibiotics, with varying results. Penicillin therapy combined with accepted surgical procedures appears to be the treatment of choice in all cases of actinomycosis.8 Dobson and Cutting,8 in an analysis of sixteen cases of actinomycosis, found that both the sulfonamides and penicillin are highly effective drugs in treating actinomycosis. Case Report Chief
Complaint.-Pain
in the jaw.
Onset and Course.-The patient, a white woman, had a lower left third molar extracted by a dentist. She developed considerable postoperative swelling and pain. When she returned to the dentist, she was assured that all was well and that the pain and swellThe pain and swelling persisted, however, and the paing would disappear in due time. tient began to experience difficulty in opening and closing her mouth. Becoming alarmed, she sought the advice of another dentist who took a roentgenogram of the area and discovered a retained root tip. She was then referred to me for consultation and treatment. She was seen in our office three weeks after the attempted extraction. Another roentgenogram was taken of the area involved and the described root tip The patient was now in excruciating pain and the swelling was was noted (Fig. 1). spreading into the cervical areas. It was thought advisable to place her in a hospital for further evaluation and therapy. She was admitted to the hospital and placed on 600,000 units of Abbocillin daily and 50 mg. Demerol as needed for pain. Past history and systemic review were noncontributory. Physical Examinatdon.-Examination revealed a well-developed, well-nourished, white woman who was unable to open her mouth more than 2 mm. and who complained of intense pain in her jaw. Over the body of the left mandible and the submaxillary region, there was a firm swelling which was not fluctuant and which had a boardlike consistency. The swelling extended into the submental and sublingual regions, and there appeared to be an
0. S.. 0. M., & 0. P. January, 1958
CHOUKAS
16 early invasion of the left supraclavicular had difficulty in swallowing and talking. tially negative.
area of the neck. The patient was afebrile and The remaining physical examination was essen-
Roentgenographic Examination.-An unextracted fragment of the root of the lower left molar remained in the socket of the recently extracted tooth. There was probably a tiny sequestrum involving the alveolar margin of the socket. Otherwise, the mandible showed nothing of significance.
Fig. l.-Preoperative
radiograph
of retained
root tip in mandible.
hematocrit-40 per cent; red blood Laboratory Data.-Laboratory findings included: cells-4,290,000 ; white blood cells-13,700 ; hemoglobin-13 grams; platelets-adequate ; containing 3 to 8 white blood cells and a moderate chest x-ray-negative; urine-yellow, number of epithelial cells, and specific gravity-1.005, few bacteria, character-hazy. Impression.-The impression, after evaluation of all the clinical and laboratory data, was that there was some sort of infection of the mandible. The fact that the patient was afebrile was puzzling. If she had osteomyelitis, as was suspected, she should have had an elevated temperature and a more marked increase in her white blood cell count. Treatment.-The patient was placed on continued for surgery on the morning of Aug. 14, 1956.
antibiotic
therapy
and scheduled
Volume 11
ACTINOMYCOSIS
Number I
OF
17
MANDIBLE
Operation.-Under general endotracheal anesthesia, the mouth was opened to a slight degree. With retraction, the extraction site could be approached. An incision was made, mucoperiosteal flap was retracted, and considerable amounts of granulative tissues and fragments of bone were removed. The root fragment was also located and removed. The area was packed with iodoform gauze and one silk suture was placed through the flap, suturing it to its original position. Through a submandibular approach, a second incision, overlying the swelling, was made. By means of sharp and dull dissection, a cavity containing pus was entered on the Several cubic centimeters of creamy pus medial aspects of the body of the left mandible. was found to escape. The pus was placed in a sterile tube for laboratory analysis. The area was cleaned out and a rubber drain was inserted. The skin was closed with 0000 black silk, and a pressure dressing was applied over the area (Fig. 2).
Fig. Z.-Postoperative Pathologic
photograph
showing
drain
in place
and
area
of incision.
Report.-
Culture report from surgery specimen (Aug. 14, 1956): Examination of the specimen revealed pus from the neck; green stain. The specimen was loaded with white blood cells and histiocytes in varied stages of degeneration. Many of the histiocytes had inclusion of phagocytized gram-positive organisms that showed a filamentary and branching form. Some branching forms were extracellular. Other organisms present were secondary invaders and were true bacteria. Friedlander’s pseudomonas and a gram-negative micrococcus could be identified. The pathologist’s impression of the branching forms was that it was quite probably actinomycosis. Culture report from surgical drain (Aug. 18, 1956): Direct culture of pus salvaged from the surgical dressing and cultivated anaerobically on a microscopic slide revealed, in seventy-two hours, many sulfur granules or ray fungi of microscopic size. These findings, together with the fact that the organism was an anaerobe and that its colonies on solid media were smooth, uniform, and soft, establish its specific identity as Actinomyces bovk. Course.-The patient was discharged from the hospital within in our office twice a week for dressing changes and observat.ion. taken of the material draining from the incision.
the week, and was seen Repeated cultures were
L8
0. S., 0. M., k 0. P. January, 1958
CHOUKAS
All drainage ceased on October 22, sixty-eight days after surgery, and the subsequent r*ulture reports were negative for act~inomycosis. The patient had been kept on a minimum units of penicillin daily for the entire period of treatment. of 300,000 therapeutic The area of incision has remained asymptomatic
healed
satisfartorily
and all the smrlling
resolved.
The patient
to date.
Discussion The chief interest in the foregoing case lies in the fact that the clinical picture rcsemblad a nonspecific osteomyelitis which proved to be actinomycosis. All the symptoms ant1 laboratory examination, with the exception of the patient’s afehrile condition and only a slight increase in the W.B.C. count, indicatecl a nonspecific osteomyelitis of the mandible. The presence of the root tip and the sudden onset of pain and swelling also fitted into the picture of nonspecific osteomyelitis of the mandible. Although Actinomyces bovis is considered to be present naturally in the oral cavity of many persons, it is not always pathogenic to the host. It seems that Actinomyces bovis, which is transplanted from one patient to another, might be more pathogenic. It is not unreasonable to assume that improperly sterilized instruments in the dental office might serve to transfer the organism to a second patient. The ext,raction site could very well be an easy avenue of entry for the invading organism. We can only speculate on the etiology of the origin of the actinomycosis infection. The clinician has a responsibility to his patient to USC all the diagnostic tools at his command in making a differential diagnosis in order t.o establish rational and effective treatment.
Summary 1. Actinomycosis of the mandible can be easily misdiagnosed in its acute or early stage. 2. Improperly st,erilized dental instruments may bc the source of crosscontamination in actinomycosis. 3. Actinomycosis is not restrict,ed to rural folk or to t,hosc who have a history of chewing grass or straw. 4. The diagnostician should avail himself of the full use of all the culture and sensitivity tests in order to confirm an early diagnosis and thereby improve the prognosis of the case. 5. Actinomycosis should always be considered in a differential diagnosis of all infections of the cervicofacial area. 6. Adequate therapy for cervicofacial actinomycosis involves prompt and adequate incision and drainage and penicillin in sufficient doses.
References A Clinical, Pathological and Bac1. Bollinger, cited by Jacobson, H. P.: Actinomycosis: teriological Study, M. J. & Rec. 132: 342, 1930. 2. Burrows, W.: Textbook of Bacteriology, ccl. 16, Philadelphia, 1954, W. B. Saunders Company, pp. 568-569. Textbook of Bacteriology, New York, 1942, Paul B. Hoeber, Inc., pp. 200-202. 3. Leifson, E.:
Volume II Number 1
ACTINOMYCOSIS
OF
MANDIBLE
19
4. Weinmann, J. P., and Sicher, H.: Bone and Bones, ed. 2, St. Louis, 1955, The C. V. Mosby Company, p. 354. 5. Thoma, K. H.: Oral Diagnosis, ed. 2, Philadelphia, 1943, W. B. Saunders Company, p. 407. 6. Rash, Rieva, and Seldin, H. M.: Actinomycosis: The Treatment of Five Cases, J. Oral Surg. 6: 2, 1948. 7. Eli Lilly Company: Antibiotic Therapy and Sulfonamide Therapy, Indianapolis, 1956, Eli Lilly Company? p. 43. 8. Dobson, L., and Cutting, W.: Penicillin and Sulfonamides in Therapy of Aetinomycosis, J. A. M. A. 128: 856, 1945.