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.
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Fig. 3: Patient B. – Non-healing extraction site of tooth No. 32, with radiolucent area affecting the inferior border and tooth No. 31.
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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.

 

2018 Florida Mission of Mercy

By DentalPC

What happens when you need a dental cleaning, you’re experiencing tooth pain or worse? Most of our readers own dental practices or they are staff members who assist in a dental practice, which should make the entire process of going to the dentist very simple.

For most people who do not work in the world of dentistry, typically you’ll make a dental appointment and see your dentist as soon as possible, but what if it wasn’t that simple for others? Thankfully, DentalPC partners with life-changing foundations like the Florida Dental Association Foundation’s Florida Mission of Mercy (FLA-MOM) to help make this process a little easier for some of our Floridians.

What is the FLA-MOM?

The FLA-MOM is a two-day clinic which provides free dental care to the under-served and under-insured in Florida – those that would otherwise go without dental care. The FLA-MOM is a first-come, first-served event with a goal of treating 2,000 patients in two days. Every year, the FLA-MOM event is held in a different location throughout the state.

Services provided include cleanings, fillings, extractions, pediatric dentistry and limited root canal therapy.

How is DentalPC Involved?

DentalPC had the honor of sponsoring the FLA-MOM as the Presenting Benefactor for the fourth consecutive year. Clay Archer (CEO) and his team of knowledgeable technicians traveled to Fort Myers for this years big event. It was a busy couple of days in Fort Myers at the Lee Civic Center last weekend! The FLA-MOM provided 11,899 procedures to 1,906 patients with a value of more than $1.7 million!

 

Take a Walk Down Memory Lane With Us:

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Behind the Scenes: Jacob and David working hard to get all of the workstations set up!
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Day 2 in full effect … 200 veterans are about to walk in for their pre-screening.
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Veterans pre-screened, meetings done, we are locked and loaded to start seeing 2,000 patients and provide high quality dental care to those in need. It all starts bright and early at 5 a.m. and won’t stop until a little after noon on Saturday!
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Our CTO, Marty Cortines and Project Lead, Jacob!
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Of course, we have a little fun along the way! Thanks for all your hard work, Clay (CEO)!
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#DPCteam
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Last day, patients coming in.
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And just like that, it ends … 1900 patients in 2 days.

Thank you to all the volunteers who selflessly dedicated their time and skills to the 2018 FLA-MOM! We could not have done this without your help and support!

We’ll see you in Orlando for the next FLA-MOM on March 22-23, 2019.

Reprinted with permission. This article first appeared on DentalPC’s blog and can be found at http://www.dentalpc.com/2018/03/2018-florida-mission-of-mercy/.

The Smile was Free, But the Hug was Priceless

By Dr. Paul Palo

As I stood with a badly aching back and feet that felt as if they had been beaten from continuously standing for 12 hours two days straight on a concrete floor, a woman appeared and briskly walked toward me. Her look was determined and a little concerned.

First, let me explain my location: I was at the Lee County Civic Center Arena. This is where I’ve just spent three days volunteering for the Florida Dental Association Foundation’s (FDA Foundation) fourth annual Florida Mission of Mercy (FLA-MOM) dental clinic. Last weekend, me and my fellow dentists, hygienists, assistants, laboratory technicians and lay volunteers provided nearly 2,000 patients with more than $1.7 million worth of dentistry at no charge to them. Hard work? You bet it is. But worth every ache and blister.

So, back to the distressed woman who approached me. I was the lead volunteer in charge of overseeing dental triage, so I was frequently singled out by many people with questions and concerns. This young woman certainly looked concerned. She introduced herself as an advocate for a group of people staying in a drug addiction treatment facility in Naples. Dr. Leo Cullinan had arranged to bus them over to our event to take advantage of the treatment we were providing. She explained that one of her charges, a 24-year-old young woman, had come in the day before with many painful, bad teeth. It was determined that her remaining teeth were so badly decayed, none could be saved. She was taken to oral surgery where a skilled surgeon removed her remaining teeth. The caregiver’s reason for concern was because she could sense the despair in this young woman’s eyes at now not having any teeth to present herself with for future employment. I calmly explained that our clinic had no provisions to make immediate dentures, but she was not deterred. So, at this point, I brought in Dr. Cullinan to see if there were any available resources in Naples to help this young woman out. And that’s where I left her — in Dr. Cullinan’s capable hands. I moved on to other problems that needed to be solved and completely forgot about the situation.

Fast-forward 24 hours to Saturday afternoon, when I was helping break down the clinical equipment and box it up to transport out when again, who do I see but the advocate bounding straight for me — this time with a huge smile on her face.  She thanked me profusely for helping the young woman the day before, and told me that due to Dr. Cullinan’s persistence, she was fitted for a same-day denture courtesy of Dr. Reza Iranmanesh, our wonderful lead prosthodontist. “This will change her life!” she proudly exclaimed as my eyes began to mist over. She then embraced me in a wonderful heartfelt hug of thanks —  more payment than I ever expected, but so gladly accepted.

If you’re looking to help change the lives of so many in need as well as receive much more payment than you would ever get in a typical week at the office, I urge you to join us in Orlando in March 2019 for the FDA Foundation’s next FLA-MOM. It will change your life, too.

 

Dr. Palo is a member of the FDA Board of Trustees and an alternate to the American Dental Association 17th District Delegation. He is a general dentist in Winter Haven, Fla. and can be reached at ppalo@bot.floridadental.org.

 

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.