tologic T Steven Levine, D.M.D.,* Steven Friedman, D.D.S.,” and Alan J. Nevins, D.D.S.,** East Meadow, N.Y.

hASSAU COUhTY MEDlCAL CENTER

Histologic examination of a necrotic pulp from a traumatized tooth revealed mycotic organisms which could be identified morphologically. Actinomyces has been identified as part of the normal oral ftora but has not been identified in necrotic pulp tissue histologically. The present case report is of interest because it showed the ability of autolytic pulp tissue to support mycotic growth. The tooth also gave a positive response to pulp-testing procedures, even though no new tissue could be demonstrated histologically. (ORAL SURG. ORAL MED. ORAL PATHOL. 59:414-417, 1984)

t has been demonstrated that necrotic pulps may become infected with various microorganisms,’ including several species of mycosis.2 Two of the most prevalent mycotic organisms that have been cultured from necrotic root canals are Candida and Actinomyces. The present case is of interest because the organism could be identified morphologically within the necrotic pulp on histologic sections.

CASE REPORT

A 12-year-old boy came to the dental clinic with a history of luxation of the two maxillary central incisors with alveolar fracture. At the initial visit the upper left central incisor exhibited a periapical radiolucency and did not respond to electric pulp testing. Root canal therapy was initiated and subsequently completed.

The upper right central incisor was sensitive at approx- imately midrange to electric pulp testing? and aiso revealed a periapical radiolucency with apical root resorp- tion (Fig. 1). Upon opening of the tooth, a solid necrotic- appearing piece of tissue was removed, immediately placed in 10% neutral buffered formalin, and submitted to the hospital’s Department of Pathology for biopsy. As a control for the fixation and staining technique, a biopsy specimen was taken from a tooth which had pulp-tested sensitive and exhibited early carious exposure (Fig. 5). After the initial instrumentation, the patient exhibited a slight fluctuant swelling in the mucobuccal fold above the upper right central incisor, at which time the tooth was opened, drainage was encountered, and the patient was placed on a regimen of 500 mg phenoxymethyl penicillin four times per day for 1 week. Calcium hydroxide therapy

*Endodontic Resident. **Director of Dental Research. tAnalytic Technology pulp tester, Redmond, Wash.

Fig. I. Preoperative radiograph of upper right central incisor.

was initiated 1 week after symptoms subsided. Root canal therapy was completed 2 months later (Fig. 2).

Biopsy report

Sections of the necrotic-appearing pulp demonstrated pale-staining, indistinct, fibrocollagenous tissue with no

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Mycotic infection in necrotic pulp tissue 415

Fig. 2. Postoperative radiograph of upper right central incisor.

cells evident (Fig. 3). Bodian stain failed to demonstrate conclusively the presence of nerve fibers (Fig. 4). Periodic acid-Schiff stain (Fig. 6) and Gomori’s methenamine silver stain (Fig. 7) demonstrated clusters of branching filaments morphologically consistent with Actinomyces sps3 IBrown and Brenn stain revealed gram-positive cocci (Fig. 8). The sections of the control specimen demonstrated intact pulp tissue with nerve fibers present (Fig. 5).

DISCUSSION

Sections stained with routine hematoxylin and eosin and sections stained with silver stains failed to demonstrate conclusively the presence of nerve fibers in a necrotic pulp within a tooth that was sensitive to pulp tests. In a study by Mullaney and associateSq4 in which pulps were evaluated histologically from teeth that were nonsensitive to pulp tests,, forty three teeth were found to be histologically vital and five were partially vital. Nerve fibers were not evident in thirty four specimens. Degenerating nerve fibers were found in only twelve specimens, and normal-appear- ing fibers were found in only two specimens. In contrast with these findings, Langeland and col- leagues,5 using light microscopy, demonstrated struc- turally intact nerve fibers persisting in severely inflamed pulp tissue within the apical third of root canals.

Fig. 3. Section of pulp stained with hematoxylin and eosin. (Magnification, X50.)

Fig. 4. Bodian nerve fiber stain of necrotic pulp from upper right central incisor. (Magnification, X300.)

416 Levine, Z;riedman, and Nevins Oral Surg. April, 1985

Fig. 5. Bodian stain of normal control puip demonstrat- ing nerve fiber bundles. (Magnification, X300.)

Fig. 7. GMS stain demonstrating branching filaments oi‘ mycotic organism. (Magnification, X600.)

Fig. 6. Periodic acid-Schiff stain demonstrating mycotic Fig. 6. Brown and Brenn stain demonstrating gram- organism. (Magnification, X300.) positive cocci. (Magnification, X600.)

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In our report we have demonstrated that a tooth can give a sensitive pulp-test response withou.t exhib- iting intact nerve fibers histologically. Apical granu- lation tissue with inflammatory cells and nerve fibers might have been left in the resorbing apical portion of the root. Diffusable products of necrotic pulp tissue or the presence of microorganisms might be responsible for periapical pathosis. Since no opening was made directly into the pulp chamber by trauma or caries, it is possible that organisms infected the pulp via anachoresis through the bloodstream6, 7 or through spaces in disrupted periodontal ligament occurring during the trauma.* It is established that Actinomyces sp is part of the normal oral flora and is present within tonsillar crypts and dental calculus.

The authors thank. Dr. A. Loesevitz for reviewing the histologic slides and Mrs. Sheila Slezak for preparing the manuscript.

REFERENCES

1. Sunqvist G: Bacteriological studies of necrotic dental pulps, Umea University Odontological Dissertations, No. 7, 1976.

2. Borssen E, Sunqvist G: Actinomyces of infected dental root canals. ORAL SURC ORAL MED ORAL PATHOL 51: 643-641, 1981.

3.

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Burnett GW, Schuster GS: Oral microbiology and infectious disease. Baltimore, 1978, Williams & Wilkins Company, p. 153. Mullaney TP, Howell RM, Petrich JD: Resistance of nerve fibers to pulpal necrosis. ORAL SURG ORAL MED ORAL PATHOL JO: 690-693, 1970. Langeland K, Yagi T: Investigations on the innervation of teeth. Int Dent J 22: 240-269, 1972. Torabinejad M, Bakland LK: Immunopathogenesis of chronic periapical lesions. ORAL SURG ORAL MED ORAL PATHOL 46: 685-698, 1978. Gier RE, Mitchell DF: Anachoretic effect of pulpitis. J Dent Res 47: 564-570, 1968. Robinson HBG, Baling LB: The anachoretic effect in pulpitis. I. Bacteriologic studies. J Am Dent Assoc 38: 268-282, 1941. Grossman LI: Origin of micro-organisms in traumatized pulpless sound teeth. J Dent Res 46: 551-553, 1967. Topazian R, Goldberg M: Management of infections of the oral and maxillofacial regions. Philadelphia, 1981, W. B. Saunders Company, p. 50.

Reprint requests to: Dr. Steven Levine Division of Endodontics Department of Dentistry Nassau County Medical Center 2201 Hempstead Turnpike East Meadow, NY 11554