FDC2018 Speaker Preview

Mandibular Osteomyelitis Associated to Candida Albicans in Marijuana and Heroin Abusers: Literature Review and Case Series

By Mikhail Daya, DMD*; Isabella Anderson, BS+; and, Jason Portnof, DMD, MD, FACS, FIDC**

Background: Osteomyelitis of the mandible is most commonly caused by bacterial infections and is rarely linked to fungal infections. Friedman et al. studied the relationship of multiple drugs, including marijuana, opioids, nicotine and alcohol, and its effect on the immune system. It’s important to consider potential risks and complications of patients who are immunocompromised and present a history of substance abuse. These complications include infections and osteomyelitis, which can be associated with multiple microorganisms, such as fungus. Candida albicans is commonly found in skin and mucosa of healthy individuals; however, it has been proven to cause disease in individuals who are immunocompromised.

Case Presentation: Two cases of mandibular osteomyelitis after routine dental extractions and a history of drug abuse, including heroin and marijuana, are presented in this case series. The patients were both male, ages included a 40-year-old (Patient A) and a 45-year-old (Patient B). Both patients underwent routine dental extractions performed by two different oral surgeons. Patient A underwent routine extraction of tooth No. 19 and Patient B had an extraction of erupted tooth No. 32. Due to recurrent infections and non-healing extraction sites, both patients were referred to the Department of Oral and Maxillofacial Surgery at Nova Southeastern University. Patients A and B underwent multiple courses of antibiotics as well as incision and drainage without resolution. Cultures of the infected sites were collected and analyzed for aerobes, anaerobes and fungus. In the final microbiology, both cases yielded positive results for Candida albicans.

Once the final microbiology yielded positive results for Candida albicans, Patient A was treated with irrigation and debridement, and Patient B underwent a right mandibular resection. Both patients also were treated in combination with antimicrobial therapy and fluconazole leading to complete resolution.

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Fig. 1: Patient A. – Initial presentation after extraction of tooth No. 19 (Note: penrose drain in left mandible).
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Fig. 2: Patient A. – Two-month follow-up, non-healing extraction site of tooth No. 19.
Fig. 3
Fig. 3: Patient B. – Non-healing extraction site of tooth No. 32, with radiolucent area affecting the inferior border and tooth No. 31.
Fig. 4
Fig. 4: Patient B. – Right mandibular resection due to chronic osteomyelitis, two-month follow-up with hardware in place, disease free.

 

Discussion: Osteomyelitis is defined as a progressive inflammatory condition of the bone and bone marrow.1,2 This rare condition can affect any bone, but is commonly seen in teeth bearing bones of the facial skeleton, due to direct access of microorganisms through infected teeth.5 In 2012, Slenker et al. studied 212 cases of Candida osteomyelitis. In this study, the most commonly affected sites were vertebrae and sternum. Interestingly, only six of them affected the facial skeleton.4

Infections of dental origin have been historically associated to bacterial microorganisms; however, in recent years there has been a trend in increasing infections associated to fungal pathogens.6 This increase in prevalence of Candida infections have been associated to contributing factors such as growth in population of immunosuppressed patients, invasive surgeries and overuse of broad-spectrum antibiotics.7

We show two cases of mandibular osteomyelitis after routine dental extraction in patients with a history of marijuana and heroin abuse as their only significant comorbidity. Friedman et al. demonstrated a correlation between marijuana and heroin abuse and a susceptibility to infections; this is due to the direct effect of these drugs over the immune response against pathogens.3 Marijuana is the common name given to Cannabis sativa; this plant has been widely used for recreational and medicinal purposes.3 Marijuana has been directly associated to increased susceptibility to infections because of its effect on immune cells, macrophages, lymphocytes and cytokines.9,10,11 On the other hand, heroin and other opioids have been linked to increase susceptibility to infection by direct exposure of pathogens through injections as well as their direct action in immune cells.12,13

Both cases presented here were treated with a combination of surgical debridement and fluconazole. The management of Candida osteomyelitis has not been well established due to the uncommon nature of this condition. Treatment recommendations for Candida osteomyelitis are based on case reports and case series. Amphotericin B (AmB) has been used widely in the past;14 however, more recent literature supports the use of fluconazole or echinocandin over AmB due to high toxicity rate.4,15,16 Recommendations of the Infectious Diseases Society of America include the use of different antifungal combinations and surgical debridement in selected cases.

Conclusion: Although mandibular osteomyelitis is most commonly caused by bacterial microorganisms, special attention must be given to patients with medical histories of immunosuppression and illicit drug use of cannabis and opiates. Patients who do not respond to broad-spectrum antibiotics might benefit from bacterial cultures, fungal cultures and sensitivity. In cases of positive fungal microorganisms, anti-fungal treatment with an antifungal agent such as oral fluconazole is indicated if fungal organisms are yielded in the culture.

 

*Oral and Maxillofacial Surgery Chief Resident at Nova Southeastern University, Broward Health Medical Center, Joe DiMaggio Children’s Hospital.
+Fourth-year Dental Student at Nova Southeastern University
**Oral and Maxillofacial Surgery Associate Professor and Craniofacial Director at Nova Southeastern University and Joe DiMaggio Children’s Hospital.

Dr. Portnof will be speaking at the 2018 Florida Dental Convention in Orlando in June. He is presenting his course, “Opioid Disorder in Dental Patients,” on Thursday, June 21 at 9:30 a.m. and 12:30 p.m. To register, go to floridadentalconvention.com.

 

References:

  1. Dym H, Zeidan J. Microbiology of Acute and Chronic Osteomyelitis and Antibiotic Treatment. Dent Clin North Am 2017; 61(2):271-282.
  2.  Kushner GM. Osteomyelitis and osteoradionecrosis. In: Miloro M, editor. Peterson’s principles of oral and maxillofacial surgery. Lewiston (ME): BC Decker; 2004. pp 300-324.
  3. Friedman H, Newton C, Klein TW. Microbial Infections, Immunomodulation, and Drugs of Abuse. Clin Microbiol Rev 2003; 16(2):209-219.
  4. Slenker AK, Keith SW, Horn DL. Two hundred and eleven cases of Candida osteomyelitis: 17 case reports and a review of the literature. Diagn Microbiol Infect Dis 2012; 73(1):89-93.
  5. Baur DA, Altay MA, Flores-Hidalgo A, Ort Y, Quereshy FA. Chronic osteomyelitis of the mandible: Diagnosis and management — an institution’s experience over 7 years. J Oral Maxillofac Surg 2015; 73(4):655-665.
  6. Sanz-Rodriguez C, Hernandez-Surmann F, Bueno AG, Goizueta C, Noguerado A. Candida and bacterial mandibular osteomyelitis in an AIDS patient. Eur J Clin Microbiol Infect Dis 1988; 17(7):531-532.
  7. Blumberg HM, Jarvis WR, Soucie JM, Edwards JE, Patterson JE, Pfaller MA, et al. Risk factors for candidal bloodstream infections in surgical intensive care unit patients: The NEMIS Prospective Multicenter Study. The National Epidemiology Mycosis Survey. Clin Infect Dis 2001; 33(2):177-186.
  8. Daya M, Mederos H, McClure S. Refractory Odontogenic Infection Associated to Candida Albicans: A Case Report. Clin Surg 2017; 2:1397.
  9. Baldwin GC, Tashkin DP, Buckley DM, Park AN, Dubinett SM, Roth MD. Marijuana and cocaine impair alveolar macrophage function and cytokine production. Am J Respir Crit Care Med 1997; 156(5):1606-1613.
  10. Derocq J, Segui M, Marchand J, LeFur G, Casellas P. Cannabinoids enhance human B-cell growth at low nanomolar concentrations. FEBS Lett 1995; 369:177-182.
  11. Srivastava MD, Srivastava BI, Brouhard B. Delta9 tetrahydrocannabinol and cannabidiol alter cytokine production by human immune cells. Immunopharmacology 1998; 40(3):179-185.
  12. Donahoe RM. Drug abuse and AIDS: causes for the connection. NIDA Res Monogr 1990; 96:181-191.
  13. McCarthy L, Wetzel M, Sliker JK, Eisenstein TK, Rogers TJ. Opioids, opioid receptors, and the immune response. Drug Alcohol Depend 2001; 62(2):111–123.
  14. Miller DJ, Mejicano GC. Vertebral osteomyelitis due to Candida species: case report and literature review. Clin Infect Dis 2001; 33(4):523-530.
  15. Neofytos D, Huprikar S, Reboli A, Schuster M, Azie N, Franks B, et al. Treatment and outcomes of Candida osteomyelitis: review of 53 cases from the PATH Alliance (R) registry. Eur J Clin Microbial Infect Dis 2014; 33(1):135-141.
  16. Mora-Duarte J, Betts R, Rotstein C, Colombo AL, Thompson-Moya L, Smietana J, et al. Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med 2002; 347(25):2020-2029.
  17. Pappas P, Kauffman C, Andes D, Clancy C, Marr K, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62(4): e1-e50.

 

ADA and CVS Collaborate on Three-year Oral Health Initiative

By Dr. Jeannette Peña Hall

CVS is renowned for promoting health and wellness. As an advocate for oral health, the American Dental Association (ADA) is committed to educating the public on the importance of oral health and the practice of good habits. The ADA has embraced an exciting three-year collaborative effort with CVS with product offerings and in-store education efforts that will reach hundreds of millions of people each year. The two organizations together will make a tremendous impact on how effectively oral health messages reach the public.

In January, flyers began to circulate announcing this promising affiliation. The ADA’s collaboration with CVS will be instrumental in creating awareness of the ADA and dental care products that have received the ADA Seal of Acceptance — from mouth rinses, toothbrushes, toothpastes, floss/interdental cleaners and sugar-free gum. CVS consumers visiting stores also will be provided with credible oral health information and encouraged to visit the dentist through the ADA’s Find-A-Dentist online resource.

These are exciting times for our ADA dentists as we embrace the renewed energy that comes with teamwork and networking. Kudos to CVS for valuing the role of oral health in the public’s overall health!

The three-year collaboration just launched, and we are in the planning process with CVS and manufacturers. As a result, there will be much more to come in stores and online.

  • We have already begun promoting the relationship at CVS to the public. The circular that ran from Jan. 28–Feb. 3 announced our relationship, highlighted ADA Seal products, educated the consumer on core daily hygiene habits and encouraged consumers to find an ADA dentist.
  • In March, permanent store signage will go up to educate the consumer about oral health and the ADA Seal of Acceptance. This signage will remain in place for a year.

Benefits of the Collaboration

How will this help me as an ADA/FDA member?
The collaboration will include signage that highlights the ADA Find-A-Dentist online search tool, which allows potential patients to easily find you, pending your profile is up to date. If you have not yet updated your ADA profile, now is a great time to do so. Click here to update your ADA profile.

When will we see promotions at CVS?
Promotions kicked off with a full-page ad in the Jan. 28 CVS circular that announced the collaboration to customers. In March, store signage promoting oral health information and ADA Seal products will go on display in the oral health aisle and other areas of the store. Seasonal programs to connect oral health with holidays and health awareness months will start this summer.

Dr. Peña Hall is an endodontist in Miami. She is on the FDA Board of Trustees, a member of the Florida Delegation and on the ADA Council on Communications. She can be reached at jhall@bot.floridadental.org.

The 3 Primary Ways You Are Abusing Your Email Inbox

By Randy Dean, MBA, The “Totally Obsessed” Time Management Tech Guy

As a time and productivity management speaker and author, I see it all the time. People just don’t use their inboxes properly. And these mistakes lead to significant distraction, lost time and rework. Most people use their email inbox in four specific ways, and only one of those ways is correct:

1. (The Correct Use): Receive and process new messages. The key reason you have an inbox is to receive new items in that inbox. Your goal is to quickly and efficiently figure out what those items are, and then properly process them. If you’ve ever attended one of my courses, you know that you handle the quick ones immediately, and you put the longer items on either your task list or your calendar, thus allowing you to plan and prioritize. After you either get them “done” or “tasked,” you can either delete those messages or file them for later reference. And if you don’t have a good place to file them, you make one and put it there. This is really the only way to use an inbox.

2. As your de facto, yet highly disorganized daily task list. So many people use their email inbox as their default task list. It isn’t at all built for that. It is hard to prioritize individual items in an inbox, so you end up looking at the same items multiple times, trying to figure out which ones are important and/or urgent, and which ones aren’t. Most tasking programs, including tools like MS Outlook, Toodledo and Google Tasks, allow you to see your tasks in priority order by either date or by project (I teach courses on this!). Very quickly, you can figure out what is either most urgent or important. (Even a properly designed paper task list can do this!) Thus, you can understand why I’m trying to get people out of the habit of “inbox tasking” and into the habit of building a smarter daily task list using an appropriate task tool each and every day.

3. As your de facto, yet highly disorganized general file box. The other thing people are doing with their inbox is using it to store everything — or nearly everything — with no consistent filing or organizational strategy. Most people have made a few folders, but they rarely file everything they should in the folders they have already created. And they leave literally hundreds of emails, many that have already been attended to, just sitting in their inbox for no good reason. The two big problems with leaving read emails in your inbox: 1) You’ll likely read them again, even if you’ve already dealt with them — a pure waste of time. 2) As you continue to add more and more emails into this inbox, you will lose more and more efficiency. You will “slog” to a halt. How about this instead: Once that email is “done,” put it away. If you can’t do it now, add it to your task list or calendar. Then, put it away — or delete it! It isn’t rocket science.

4. Final mistake: Checking that inbox far too often. A recent study I read found that somewhere between 20-25 percent of working professionals check their email 20 or more times per day! That’s every few minutes if you do the math! How can you possibly maintain any productivity or focus when you are literally distracting yourself every few minutes? Studies have shown that incessantly checking your email and other electronic inputs literally makes you stupid. You have to get off of these “crazy trains” or you will literally lose YEARS of productivity through these abusive inbox activities.

Here’s how:

  1. When checking email, process them the first time you look at them. If they are something you can handle quickly, do them now. If not, add them to your calendar or task list. Make decisions from your calendar and task list — NOT your inbox.
  2. Once you have that email either done or tasked, file it if you might need it for later reference, or delete it. And if there is no good place to file it, MAKE ONE and put it there.
  3. And, stop checking email so often! Get on some form of a regimen that balances your needs to be responsive with your needs to get things done.

This isn’t rocket science, but it does require some discipline, process management and a few new habits. With these new habits, you can get off the email “crazy train” and end your inbox abuse!

 

Randy Dean, MBA, The “Totally Obsessed” Time Management Technology Guy has been one of the most popular expert speakers on the conference, corporate, and university training and speaking circuit for several years. The author of the recent Amazon email bestseller, “Taming the Email Beast,” Randy is a popular and engaging time, email and technology management speaker and trainer. He brings 22 years of speaking and training experience to his programs, and has been popular with programs, including “Taming the Email Beast,” “Finding an Extra Hour Every Day,” “Optimizing Your Outlook,” “Time Management in ‘The Cloud’ Using Google and Other Online Apps,” and “Smart Phone Success and Terrific Tablets.” Learn more at http://www.randalldean.com.

Mr. Dean is an FDC2018 speaker, and will be presenting two courses on Saturday, June 23, 2018. “Smart Phone Success and Terrific Tablets: Finding More Productivity with Your Devices” will be at 9:30 a.m., and “Taming the Email Beast Using MS Outlook and/or Gmail: Key Strategies for Managing Your Email Overload” will be at 2 p.m.

Is Your Patient a Victim of Human Trafficking?

By Amy Wasdin, RN, CPHRM, Patient Safety Risk Manager II, The Doctors Company

Most health care providers are aware of their role and responsibility to identify and report victims of child abuse, elder neglect and domestic violence. However, there is another type of abuse that is on the rise and reported in every state throughout the nation. In 2016, human trafficking cases reported in the United States rose by more than 36 percent from 2015, according to the National Human Trafficking Hotline statistics.

Human trafficking occurs when a trafficker exploits another individual with force, fraud or coercion to make him or her perform labor or sexual acts. Victims can be any age (adults or minors), any gender, and from any cultural or ethnic group. The trafficker, or abuser, might be a stranger, family member or friend. This criminal industry is extremely profitable, generating billions of dollars worldwide. Lack of awareness and misconceptions by health care providers allow opportunities for identification of the victims to go unnoticed and unreported.

Victims of abuse rarely find opportunities to interact with other persons without approval from the abuser. A visit to a physician or dental practice may provide a rare opportunity for a patient to receive the help that he or she desperately needs. Research published in the Annals of Health Law in 2014 revealed that 87.8 percent of trafficking survivors reported that they were seen by a health care provider during their trafficking situation.

Human trafficking victims commonly are seen in medical and dental practices with the following conditions:

  • trauma such as broken bones, bruises, scars, burn marks or missing teeth
  • poor dental hygiene
  • pregnancy
  • gynecological trauma or multiple sexually transmitted infections (STIs)
  • anxiety, depression or insomnia

Victims usually are afraid to seek help for a variety of reasons that usually stem from fear, shame or language barriers. Health care providers and their staff should be trained to recognize the signs of human trafficking and know what steps to take.

Red flags to look for from the victim include:

  • fearful demeanor
  • depressed or flat affect
  • submissive to his or her partner or relative
  • poor physical health
  • suspicious tattoos or branding
  • lack of control with personal identification or finances
  • not allowed to speak for himself/herself
  • reluctant or unable to verify address or contact information
  • inconsistency with any information provided (medical, social, family, etc.)

Victims may be fearful and untrusting of their environment, so it is best not to directly ask an individual if they are a victim of human trafficking. Instead, the Department of Health and Human Services recommend questions such as the following:

  • Has anyone threatened you or your family?
  • Can you leave your job or home if you want to?
  • Are there locks on your doors and windows to keep you from leaving?
  • Do you have to get permission to eat, sleep or use the restroom?
  • Has someone taken your personal documents or identification?

Human trafficking is a federal crime and violators who are prosecuted receive prison sentences. The Trafficking Victims Protection Act was enacted in 2000 and provides tools to address human trafficking on a national and worldwide level. Many states also have laws and penalties for human trafficking.

If you suspect that a patient is a victim of human trafficking, please call the National Human Trafficking Hotline at 888.373.7888 or go to https://humantraffickinghotline.org/report-trafficking to report online. The hotline is not a law enforcement or investigative agency, but will take any possible steps to aid the victim and could result in a report to law enforcement.

Health care providers should follow state laws regarding mandatory reporting to provide notification of patient abuse or neglect situations. Unless calling the authorities is mandatory, it is recommended that you do not do so without the patient’s permission.

For resources and information on assessment tools, go to the National Human Trafficking Hotline’s Resources for Service Providers or Centers for Disease Control and Prevention.

 

Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.