actinomycosis is an uncommon chronic granulomatous disease that presents as a slowly progressive , indolent , indurated infiltration with multiple abscesses , fistulas , and sinuses .
the purpose of this article is to report on a case of actinomycosis with clinical findings similar to periodontitis .
a 46-year - old female presented with recurrent throbbing pain on the right first and second molar of the mandible three weeks after root planing .
exploratory flap surgery was performed , and the bluish - gray tissue fragment found in the interproximal area between the two molars was sent for histopathology .
the patient did not report any symptoms , and she is scheduled for a follow - up visit .
actinomycosis should be included in the differential diagnosis in cases with periodontal pain and inflammation that do not respond to nonsurgical treatment for periodontitis .
more routine submissions of tissue removed from the oral cavity for biopsies may be beneficial for differential diagnosis .
actinomycosis is an uncommon , indolent , slowly progressive infection caused by anaerobic or microaerophilic bacteria that normally colonize the mouth , colon , and vagina .
actinomycosis occurs rarely in humans , but occurs more frequently in cattle as a disease called lumpy jaw .
it often presents as a slowly progressive , indolent , indurated infiltration with multiple abscesses , fistulas , and sinuses .
four clinical forms of actinomycosis account for most of these human infections : the cervicofacial , thoracic , abdominopelvic , and cerebral .
actinomyces exist in normal oral flora , and they can be found in calculus , periodontal pockets , carious lesions , and oral mucosal surfaces .
the bacteria do not cause any pathology as long as they stay on the surface of the mucosa , but they become pathogenic and can initiate a prolonged chronic inflammatory process if the integrity of the mucosal barrier is compromised and access to the oral tissues or jawbones is gained .
actinomycosis of the jaws and oral tissues has been considered for a long time to be a rare disease ; therefore , it has not generated much interest in research .
other types of actinomycosis in oral tissues , such as periapical actinomycosis , are relatively well documented in the literature , but reports of actinomycosis with clinical and radiographic findings similar to periodontitis are limited . one case has been reported of a regional alveolar bone actinomycosis with a related juvenile - periodontitis - like lesion .
a patient was diagnosed with actinomycosis without abscess formation or desquamation based on a biopsy during a periodontal flap procedure .
this article reports a case of actinomycosis - mimicking periodontitis , and provides a review of the literature related to actinomycosis .
a 46-year - old female was referred to the department of periodontics of seoul st .
mary 's hospital ( seoul , korea ) for treatment of chronic periodontitis , particularly in the mandibular molar area ( fig .
1 ) . she complained of throbbing pain on the right first and second molars of the mandible .
the patient 's medical and dental histories were taken , and clinical assessments and examination , including probing depths , tooth mobility , and bleeding on probing , were performed .
the patient was a nonsmoker and went to the department of cardiology of seoul st .
mary 's hospital for rheumatic mitral insufficiency ; she had been taking an anticoagulant ( warfarin , 2 mg cuparin tablets ; hana pharm co. , seoul , korea ) for 3 years .
intraoral examination revealed generalized chronic periodontitis and particularly deep probing pocket depths : 7 to 8 mm on the distal area of the left second molar , right first molar , and right second molar of the mandible .
her cardiologist was consulted for operability , and the cardiologist recommended continuing anticoagulant therapy . the initial cause - related therapy consisted of thorough full - mouth scaling and root planing in the quadrants under local anesthesia .
three weeks after her final root planing treatment , she made an unscheduled visit to the clinic .
she complained of recurrence of throbbing pain on the right first molar of the mandible .
the right first and second molars of the mandible had positive responses for percussion , cold , and electric pulp testing .
she complained of an unusual throbbing pain , which was relieved when she bit tightly .
the probing pocket depth of the distal area on the right first molar was 7 mm .
the right first and second molars of the mandible had positive responses for percussion , cold , and electric pulp testing .
a sulcular incision was made around the right posterior teeth of the mandible to preserve the papillae , and the mucoperiosteal buccal and lingual access flaps were elevated ( fig .
2 ) . granulation tissue adherent to the teeth and the alveolar bone was removed . a round , hard , floating , bluish - gray fragment in the interproximal area between the right first and second molar of the mandible was seen .
the resulting interproximal crater defect was filled with a xenograft bone material ( bio - oss , geistlich pharma ag , wolhusen , switzerland ) .
an analgesic ( 300 mg acetaminophen , 300 mg endapen tablet ; chodang pharm co. , seoul , korea ) at 3 times a day , and an antimicrobial drug ( 625 mg amoxicillin with clavulanate , 625 mg moxicle tablet ; daewoong co. , seoul , korea ) , 3 times a day , were prescribed for 5 days .
the patient was also instructed to abstain from brushing and flossing around the surgical area for 2 weeks , to use a 0.1% chlorhexidine ( hexamedine solution , bukwang pharm co. , seoul , korea ) solution rinse , and to consume a diet of soft food until suture removal .
the follow - up visits after the surgical procedure were scheduled for each week of the first month after surgery .
the mass removed from the interproximal alveolar bone was stored in 10% formalin , and was sent to the department of pathology of seoul st .
five days after biopsy , the pathologist concluded that the fragment was aggregates of bacterial colonies and needed a special stain for diagnosis .
after one week , the results of the gram , silver , and periodic acid - schiff ( pas ) stain were positive , and the differential diagnosis was actinomycosis ( figs
the actinomycotic aggregate presented an isolated mass of bacterial filaments in the center and periphery , the so - called sun - ray effect ( figs . 4 and 5 ) .
the healing was uneventful , and the patient reported mild discomfort , but was satisfied with the absence of throbbing pain . based on the histologic result , the patient was prescribed to continue taking amoxicillin and clavulanate ( 625 mg three times a day for 4 weeks ) .
the patient was monitored weekly for the first month and then monthly for four months .
the patient did not report any symptoms , and she is now scheduled for ongoing follow - up .
a previous case reported on an adult patient who presented with periodontitis with a diffuse and atypical actinomycotic lesion that was limited to the gingiva and had an abscess formation , a large desquamation , and subsequent exposure of the alveolar bone in the involved region .
actinomyces colonies can be identified using hematoxylin - eosin , gram , pas stains , and silver stain , exhibiting filamentous morphology with color variation between the center and periphery .
the colonies have a basophilic center with eosinophilic rays terminating in pear - shaped clubs , the so - called sun - ray effect . in this case , gram , pas , and silver stains were performed , and the results were positive .
infection by actinomyces may initiate complications , which may not be diagnosed correctly unless the tissue is biopsied and the actinomyces colonies are identified . in the clinical practice of periodontology ,
tissue is not routinely submitted for histopathologic analysis , and the authors would like to suggest more routine submissions of tissue removed from the oral cavity , especially during the treatment of periodontal disease .
moreover , due to the opportunistic characteristics of the actinomycotic infection , early and adequate differential diagnosis of actinomycosis , prior to attempts at therapy and management steps , is of great importance in the oral cavity because it can prevent the spread of the disease . in a previous report , the majority of cases of actinomycosis were asymptomatic , with only 18% presenting symptoms such as pain and sensory disturbances ( 80% and 20% of the symptomatic cases , respectively ) . in this case , the patient had a recurrence of throbbing pain .
actinomycotic patients have often been afflicted by more than one medical condition . won et al .   have described actinomycosis as an opportunistic infection , suggesting cancer , immunodeficiency steroids taken over a long period of time , and malnutrition as possible contributing factors . however , most of the actinomycotic patients from the indian subcontinent have been systemically healthy
. extended antimicrobial therapy has been recommended for patients with any clinical form of actinomycosis to prevent disease recrudescence . however , individualization of therapy is recommended whether the duration of antibiotics depends on the initial burden of disease , the site of infection , or the clinical and radiological response to treatment .
actinomyces are sensitive to a number of antibiotics , and penicillin is the drug of choice for treating an infection caused by any of the actinomyces . in this report , the combination of penicillin ( amoxicillin ) and a beta - lactamase inhibitor ( clavulanate )
are recommended because this offers the advantage of coverage against penicillin - resistant aerobic and anaerobic copathogens .
the density of actinomyces colonies , representing the bacterial load in the tissue , may also be considered because the length of antibiotic treatment may be modified according to the density . surgical excision or debridement
may be desired as well , especially if extensive necrotic tissue , fistulas , or a neoplasm is present .
the patient did not present any recurrence of actinomycosis after a short course of amoxicillin - clavulanate because the infected tissue was totally excised .
actinomycosis should be included in the differential diagnosis in cases where pain has not responded to the appropriate periodontal treatment and the periapical lesion has not been detected .
more routine submissions of tissue removed from the oral cavity may be beneficial for differential diagnosis .
 purposeactinomycosis is an uncommon chronic granulomatous disease that presents as a slowly progressive , indolent , indurated infiltration with multiple abscesses , fistulas , and sinuses . 
 the purpose of this article is to report on a case of actinomycosis with clinical findings similar to periodontitis.methodsa 46-year - old female presented with recurrent throbbing pain on the right first and second molar of the mandible three weeks after root planing . 
 exploratory flap surgery was performed , and the bluish - gray tissue fragment found in the interproximal area between the two molars was sent for histopathology.resultsthe diagnosis from the biopsy was actinomycosis . 
 the clinical and radiographic manifestations of this case were clinically indistinguishable from periodontitis . 
 the patient did not report any symptoms , and she is scheduled for a follow - up visit.conclusionsthe present study has identified periodontitis - mimicking actinomycosis . 
 actinomycosis should be included in the differential diagnosis in cases with periodontal pain and inflammation that do not respond to nonsurgical treatment for periodontitis . 
 more routine submissions of tissue removed from the oral cavity for biopsies may be beneficial for differential diagnosis . 
Purpose
Methods
Results
Conclusions
INTRODUCTION
CASE REPORT
DISCUSSION