Oral actinomycosis in children: case reports.

Actinomycosis of the oral cavity, specifically at the crown level of teeth, is rare in children. If left untreated, the disease can be fatal. The lesion is a granuloma in which suppuration has occurred with the Actinomyces israelii bacterium as the primary causative organism. There are distinct granules visible clinically in the lesion which are microcolonies of the bacteria. The lesion may appear as an acute abscess for which there is no apparent reason and teeth adjacent to the lesion may be caries and restoration free. The abscess contains an abundance of lymphocytes, plasma cells, macrophages, and occasional multinucleated giant cells. The disease is treated by excision biopsy and large, long-term doses of penicillin or tetracycline. Proper management involves a team approach with the patient’s pediatrician. The diagnosis, treatment, and management of 2 female patients, ages 9 and 10 years, are described. Oral actinomycosis in children is rare due to the prevalent use of antibiotics. Before 1950 it was seen more frequently in male patients, 20 years or older.1 Prior to antibioti.cs, the organism Actinomyces bovis was found in orofacial lesions. The predominant organism now seen in patients is Actinomyces israelii, with a few lesions containing A. naeslundi, A. eriksonii, A. dentolyticus, and A. propionica, which cannot be distinguished histopathologically from A. israelii. 2 In children, tonsil and adenoid problems, dental calculus, epuli, trauma, and deep dental caries have been described in tlhe literature as endogenous sources from which a lesion may arise. Actinomyces organisms can be isolated in 11-14% of excised tonsils. If an oral lesion is left untreated, it can become resistant to therapy and the outcome may be fatal. 3"4 VonLangerbeck in 1845 was the first to discover this fungus-like bacterium, and Israel, in 1878, recognized and described the actinomycete in human disease. 1 The lesion is a granuloma in which suppuration has occurred and the pus contains visible granules which microscopically show a center of closely meshed filamentous networks with a border of radially arranged structures often ending in club-shaped bodies which are regarded as hyaline thickening of the sheaths of the threads. The lesion varies from that of an acute abscess with an abundance of lymphocytes, plasma cells, macrophages, and occasional multinucleated giant cells. The more chronic lesion contains proliferating connective tissue as the .most conspicuous feature. Bony involvement may occur with trismus and swelling in the region of the angle or ramus of the mandible. Abscess formation with erosion of the cortex leads to bone resorption. The skin, neck, scalp, pleura, lungs, and the abdomen may develop lesions. Tokiwa and Yoshiya in 1950 described a case of actinomycosis of the jaw with metastases to the braino s Actinomycosis may occur at any age, but it is most frequently reported in young adults and is more than twice as prevalent in males than in females. 2 Case Report: Patient 1 A 10-year-old Caucasian female was seen for posterior orthodontic banding and anterior bracket bonding. The patient had been seen 3 weeks prior for a routine dental checkup. At the visit, a soft tissue mass of about 8 mm extended over the distobuccal cusp of the mandibular right first permanent molar. The patient was unaware of its presence. The visit was interrupted to take a panoramic radiograph which disclosed a radiolucent area at the distogingival margin of the crown (Fig 1). Bite-wing radiographs taken 3 weeks prior were negative for caries and pathology. The dental and medical history of the patient was reviewed, and a parent noted that the patient’s first permanent molars erupted at age 8 years with some 312 ORAL ACTINOM¥COSIS IN CHILDREN -CASE REPORTS: Glenn and Doughty FIG 1. Radiograph of lesion, case 1. difficulty. At that age there were 4 restored primary molars, but the adjacent second primary molar and all 4 first permanent molars were caries free. The patient had a history of frequent strep throats and high fever episodes since age 10 months, but had not had tonsil and adenoid surgery. The patient was referred to an oral surgeon for an excision biopsy. The diagnosis of actinomycosis was confirmed by the pathologist who found distinct sulphur granules (Fig 2). A culture was positive for A. ismelii. The patient received oral penicillin V. 500 mg/ qid 6 hr after surgery for 4 weeks. Healing progressed and orthodontic banding was completed 3 months after diagnosis. At this appointment, the parent stated that the patient's grandfather had been treated for actinomycosis several years ago. There has been no oral recurrence during the 3-year follow-up of this patient, however, routine panoramic radiographs show the mandibular right second permanent molar erupting ectopically. Thirty-four months after the excision the patient required an appendectomy, but the surgeon failed to have the organ cultured for actinomyces. Case Report: Patient 2 A 9-year-old female of Chinese ancestry was seen for initial dental examination; intraoral, bite-wing, and panoramic radiographs were taken. No caries or restorations were present, and resorption of the mandibular first primary molars was noted. Mandibular second premolars were congenitally missing with a Class II, Division 1 malocclusion and a history of airway problems and mouthbreathing. A painless, 9 mm mass containing granules was present at the distobuccal gingival area of the mandibular right first permanent molar. A careful history review with the parent revealed that the patient's primary incisors erupted at 4 months and her first permanent molars at 5 years. There was no history of trauma, and her tonsils and adenoids were present. The patient was referred to the second author for an excision biopsy. The pathology report was as follows: Actinomycosis — the specimen consists of squamous epithelium with pseudoepitheliomatous hyperplasia and severe acute and chronic inflammation associated with "sulphur granules." The gram stain revealed that the granules are composed of interlacing branching gram-positive filamentous organisms consistent with actinomycosis FIG 2. Histology of lesion of c?se 1 demonstrating "sulpher granules" in the upper left and right. Fig 3. (center) Histology of case 2 showing "sulpher granules" at lower right; (right) Histology of case 2 showing interlacing filamentous branches of A. israelii. PEDIATRIC DENTISTRY: December 1985/Vol. 7 No. 4 313 (Fig 3). This patient was treated at the time of surgery with 4 M units of procaine penicillin a day intraveneously for 7 days,; then oral penicillin V 500 mg/qid for 5 weeks. Healing was uneventful and no lesion recurrence has been noted to date.