Cervico-Facial and Intra-Oral Actinomycosis

Stenhouse, David (1976) Cervico-Facial and Intra-Oral Actinomycosis. Master of Dental Surgery thesis, University of Glasgow.

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Actinomycosis was first recognized as a specific disease late in the 19th century. Confusion os to the nature of the infecting micro-organism and the mode of its entry into soft tissue led to two diverse theories on the pathogenesis. On the one hand it was believed that the microbe was an aerobic species which grew on agricultural land and which was introduced to the body from the habit of grass or straw chewing, whilst on the other hand the organism was held to exist as a commensal in the oral cavity which could under certain circumstances become an active pathogen. Many investigators contributed to these basic arguments, but the overwhelming weight of evidence came down on the side of the endogenous theory. Despite this, many texts still perpetuate this misconception. Cervico-facial actinomycosis is the most common site of the disease, and it is most prevalent in the second and third decades affecting males more frequently than females in a ratio of approximately 2 to 1. There is a close association between the teeth and cervicofacial actinomycosis. The vast majority of cases are related either to an apical dental abscess or follow some form of oral trauma, usually an extraction. Two clinical variants of the disease can be recognized. The acute infection is often related to a septic tooth and is shown to affect a younger age group, whereas the chronic infection more often is a sequel to an extraction and affects an older age group. In both groups, the lower molar region is predominantly involved. The diagnosis of actinomycosis involves a combination of astute clinical awareness and microbiological technique. The use of specific fluorescent antiserum in the diagnosis of cervicofacial actinomycosis is shown to be of value in the early recognition of the disease, thus allowing the clinician to formulate and implement correct therapeutic drug regimes at an early stage. The value of bacteriological examination of intra-oral specimens is highlighted as is the limitation of diagnosis from formalin fixed material. Treatment of cervico-facial actinomycosis involves a combination of surgery and antibiotic therapy, normally penicillin. The difficulty of laying down rules on the duration of therapy is clear, since each case requires individual assessment. The host reaction to actinomycotic infection is a fibrosis which may lead to scar formation on resolution. Investigations into the occurrence of actinomyces in relation to bony sequestra may be an indication of the mechanism by which the organisms gain access to the soft tissues, and the frequency with which the lower molar region is implicated. Although actinomycosis in bone is rare, the sequestrum may provide a suitable environment for these bacteria to thrive before invading the soft tissues which have been opened to the infection by the fracture of the buccal or lingual alveolar bone which originally provided the sequestrum. Logically, the bacterial population of the dental plaque in the lower molar area must be considered and investigations showed that A. israelii is present in larger numbers in this area than in the anterior region of the mouth. This study also indicated that A. israelii is more prevalent than A. naeslundii per unit volume of plaque in both anterior and posterior regions and in total numbers. A. naeslunaii showed no significant difference in numbers anteriorly compared with posteriorly. Studies on the flora obtained from the fitting surfaces of upper dentures in edentulous subjects confirmed the close relationship between actinomyces and the natural dentition. Finally, it was shown that in vitro, polymorphonuclear leucocytes were able to ingest both cocco-bacillary and filamentous forms of actinomyces. The impediment to more rapid resolution of the infection would hence appear to lie elsewhere. Excessive fibrous walling off by the host tissue does offer one explanation for this slow healing response particularly in the more chronic form of the disease. Furthermore, the "sulphur granule" itself may act as an effective barrier to successful phagocytosis. Actinomycosis in the oro-facial region remains a fascinating disease to the medical and dental professions. It is one of the few pyogenic infections in the area which can be attributed to a specific bacterium. Most abscesses of the jaws are found to be due to a mixture of pathogens, and actinomycosis is no exception. The isolation of actinomyces, however, forewarns the clinician of the likelihood of persistence and a marked fibrotic reaction from the host tissues. Its early diagnosis is of paramount importance to treatment, and although the disease is comparatively rare, in the words of W. D. Miller written as long ago as 1890 "We consequently have here again another dangerous source of infection in the human mouth, which the dentist and physician do well not to lose sight of.".

Item Type: Thesis (Master of Dental Surgery)
Qualification Level: Doctoral
Keywords: Dentistry
Date of Award: 1976
Depositing User: Enlighten Team
Unique ID: glathesis:1976-78740
Copyright: Copyright of this thesis is held by the author.
Date Deposited: 30 Jan 2020 14:57
Last Modified: 30 Jan 2020 14:57
URI: https://theses.gla.ac.uk/id/eprint/78740

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