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.

 

Come for the CE, Stay for the Fun at FDC2018!

The 2018 Florida Dental Convention (FDC) will be held June 21-23 at the Gaylord Palms Resort & Convention Center in Orlando. As a member benefit, Florida Dental Association (FDA) members can pre-register for FREE and earn up to 18 hours FREE continuing education (CE) credit.

This year’s theme, “Elevate Your Game,” is designed to assist the entire dental team with furthering their professional knowledge by offering more than 95 lectures and 30 workshops. FDC2018 has placed a conscious effort in specialty care CE, as well as focusing on complications that may arise during dental treatment.

Back by popular demand are “live dentistry” courses, designed for you to observe in-office operatory procedures firsthand. Course topics include orthodontic black triangles, CEREC and dental implant surgery.

Take advantage of free course tuition at FDC2018 and apply to be a speaker host. Lecture hosts will receive free course tuition for the hosted course and a lunch voucher for Exhibit Hall concessions. Workshop and certification hosts will receive free course tuition for an AM or PM lecture course of their choice and a lunch voucher for Exhibit Hall concessions. As a speaker host, you will introduce the speaker, make course announcements, pass out and collect surveys, and assist the speaker, if necessary. Click here to apply today!

Connect with more than 300 leading dental exhibitors at FDC2018. The Exhibit Hall will feature exhibitors ready to show you the latest technology, materials and instrumentation for your dental practice.

FDC offers fun for everyone! End each day with fun-filled and family-friendly events. On Thursday, sing along to Dueling Pianos, and on Friday, flashback in time at “80s Flashback!” If you are looking for nightlife, join the new dentists Friday night for “The After Party.”

Click here to register for FDC2018 today!

For questions or more information, email fdc@floridadental.org or call 850.681.3629.

 

 

 

10 Helpful Tips for License Renewal

The Florida Department of Health (DOH) now reviews your continuing education (CE) records in the DOH’s electronic tracking system, powered by CE Broker, at the time of license renewal. It will happen automatically when you renew your license. It is mandatory that all Florida licensed dentists renew their license through CE Broker for the 2016-2018 biennium by midnight on Feb. 28, 2018.

1. You must have 30 hours of CE to renew.

  • 28 general hours, which include 2 hours of Domestic Violence and no more than 3 hours of practice management
  • 2 hours of Medical Errors

2. NEW! Mandatory Survey. You must complete the mandatory telehealth survey when renewing your license. No license will be issued without this mandatory survey being completed!

3. First Year Renewing? If this is the first year renewing your license, you must have an additional 2 hours of HIV/AIDS along with the 30 hours of CE to renew your license.

4. CPR Certification. Along with the 30 hours needed to renew, you must have an up-to-date CPR certificate reported. You do not need to upload your CPR certificate to CE Broker. You will simply select that you have an updated certificate prior to renewing your license.

5. CE Credit Category. When reporting your CE credit, each type of CE credit, such as Domestic Violence, Medical Errors, HIV/AIDS, etc. must be reported in the correct category.

6. CE Provider. CE credit also must be reported under the correct CE provider. Click here to see the full list of BOD-approved CE providers.

7. Pro Bono Hours. To receive credit for pro bono dental services, the services must have been for the indigent residing in Florida (1 CE credit equals 1 hour of service). Only 7 hours of pro bono services can go toward your license renewal. If you volunteered at the 2017 Florida Mission of Mercy, an email was sent to you on how to report your service hours to CE Broker.

8. Free CE Broker Account. If you have the free CE Broker account, you must keep track of the CE courses you have taken and what you need for renewal. CE Broker will not keep track of what CE courses you are missing unless you have the professional or concierge accounts.

9. FDC Credit is Reported for You! CE credit for courses taken at FDC2016 or FDC2017, except for NC courses, have been reported to CE Broker on your behalf.

10. CE Broker App. If you upload CE courses on the CE Broker app, you must log out and then back into the app for the credit to show. The credits will not show up automatically or by refreshing the page.

For more information on the renewal process, CE Broker or FDA online CE, or courses taken at the 2016 or 2017 conventions, contact the Florida Dental Association at 800.877.9922 or fda@floridadental.org.

Are You Renewal Ready?

As a Florida Dental Association (FDA) member, you have access to exclusive benefits to help you through the license renewal process for the upcoming 2016-2018 biennium. Membership has its perks, and we want to make your renewal process as seamless as possible! Below are some of the benefits the FDA offers to assist you in the renewal process.

CE Broker
The Florida Department of Health (DOH) now automatically reviews your continuing education (CE) records in the DOH’s electronic tracking system — powered by CE Broker — at the time of license renewal. It is mandatory for all Florida-licensed dentists to renew their license through CE Broker for the 2016-2018 biennium by midnight on Feb. 28, 2018.

The FDA provides an exclusive members-only discount for CE Broker accounts.

  • Basic Account: FREE
  • Professional Account: $24 (non-members $29)
  • Concierge Account: $90 (non-members $99)

Click here to learn more about your account options. Contact the FDA office at fda@floridadental.org or 850.681.3629 for the discount code. Did you know you can update your CE credits on the go? Click here to download the FREE iPhone CE Broker app today.

NEW! Mandatory Survey
You must complete the mandatory Telehealth Survey when renewing your license. No license will be issued without this mandatory survey being completed!

Renewal by Mail
Your license should be renewed online through CE Broker. However, certain situations require you to renew by mail:

  • You need to change the status of your license.
  • You do NOT have a credit card or debit card to complete the transaction online and need to pay using a cashier’s check or money order.
  • Your license is in an Active Military status.
  • Your license is in a Volunteer status.
  • You need to request a name change.

To renew by mail, you must properly log into www.FLHealthsource.gov and print your renewal notice by selecting the Renew License link, then click on the Renew by Mail option.

Online CE
The FDA offers bimonthly “Diagnostic Discussion” articles from Today’s FDA and two Legal CE Guides that members can read and take an accompanying quiz for to earn CE credit. To access these articles, you will need to log into the member-only section of the FDA website. CE credit for these articles will be reported to CE Broker on your behalf.

Click here to directly access the “Diagnostic Discussions” and Legal CE Guides available to FDA-member dentists.

FDA CE Courses
All CE-eligible courses taken at FDC2016 and FDC2017 have been automatically reported to CE Broker on your behalf. FDA “Diagnostic Discussion” and Legal CE Guide credit is reported to CE broker the first Friday of each month.

CE@RENEWAL
The Florida DOH is a great source for renewal information! Click here to access a helpful 30-minute webinar to learn more about how to report your CE credits through CE Broker as well as other useful information. Don’t have time to join the webinar? Click here to learn more about the renewal process, how to report CE credits, the benefits CE Broker has to offer and much more!

Questions?
For the FDA CE Broker discount code, information on the biennium, the renewal process, CE Broker or your FDA-earned CE credits, contact the FDA office at fda@floridadental.org or 850.681.3629.