(TC49) Conservative Management of Periapical Actinomycosis when Apicoectomy is Contraindicated

Periapical actinomycosis is a rare presentation of chronic infection caused by the Actinomyces species. Treatment options differ across case studies, but generally suggest favorable outcomes when managed with apicoectomy or tooth extraction followed by curettage, sometimes supplemented with short-term or long-term antibiotic treatment. However, there are no established guidelines on the conservative management of actinomyces when apicoectomy is contraindicated.

This case describes a 30-year-old immunocompetent female presenting with a large, fluctuant, non-ulcerated palatal swelling near the apices of previously treated teeth #7 and #8. Emergency management involved I&D of purulent exudate with curettage of yellow-white granules and a 7-day course of Amoxicillin. Biopsy confirmed presence of sulfur granules consistent with actinomycosis. CBCT revealed extensive bone loss palatally, and communication to the nasal cavity. Follow-up showed significant reduction of patient’s symptoms, and root canal retreatment of teeth #7 and #8 was performed. 

Surgical intervention was considered due to the risk of persistent extraradicular infection and the potential for osteomyelitis. After consultation with oral surgery, the decision was made to closely monitor the patient without surgical intervention at this time, as the management of complications near vital structures — such as the risk of excessive bleeding and the potential need for nasal floor reconstruction — rendered apicoectomy unfeasible in our clinic. The patient had a rapid and complete resolution of all clinical signs and symptoms and six-month radiographs showed early signs of bone remodeling. This table clinic highlights the potential for conservative management of actinomycosis when apicoectomy is contraindicated.