Prior Dental Procedures Research Articles

Preliminary Analysis of Incidence, Risk Factors, and Management of Medication-Related Osteonecrosis of the Jaw in Cancer Patients

Preliminary Analysis of Incidence, Risk Factors, and Management of Medication-Related Osteonecrosis of the Jaw in Cancer Patients

Occipital Lobe Abscess Causing Homonymous Hemianopsia After a Dental Procedure

Background: A homonymous hemianopsia visual field defect is defined as vision loss on the same side of the vertical midline in both eyes. Although the vast majority are caused by an ischemic stroke, other neurologic etiologies must be considered and ruled out. This case highlights the importance of a rapid and thorough investigation of a patient’s symptoms using both clinical examination and imaging to reduce the risk of permanent complications and potential fatality. Case Report: A 67-year-old Caucasian male presented to the eye clinic with sudden onset reduced peripheral vision to his right side in both eyes. Entering visual acuities were 20/40 OD and 20/60 OS. Humphrey visual field (HVF) testing confirmed a complete right homonymous hemianopsia. Magnetic resonance imaging (MRI) revealed a large, left occipital lobe intracranial mass. Neurosurgical intervention was necessary to confirm the diagnosis of a brain abscess, thought to be related to a prior dental procedure with tooth extraction. Conclusion: A brain abscess is a focal area of necrosis within the brain parenchyma that typically results from an infectious process. Though rare, the condition has potentially devastating neurologic complications which can be mitigated with early detection and treatment. In this case, the abscess caused a right homonymous hemianopsia field defect, which prompted his urgent request for an appointment with the eye clinic.

Actinomyces naeslundii Bacteremia in an Elderly Woman With Type 2 Diabetes Mellitus

To the Editor: Actinomyces naeslundii is a gram-positive, rod-shaped, non–spore-forming, facultative anaerobe, which is present as a normal commensal of human oral cavity, intestines, vagina, and upper respiratory system.1 Bacteremia due to A. naeslundii is rare and poses an increased risk of subacute and chronic granulomatous inflammation, which can affect any organ system via hematogenous spread.1 Infections due to A. naeslundii has been mainly reported in cases of periodontitis and few others in endocarditis, septic arthritis, pelvic inflammatory disease, cholecystitis, liver abscess, cervical actinomycosis, mediastinitis, and pulmonary infection. We present the case of a 70-year-old woman who complained of a fall due to lower-limb weakness. She reported generalized fatigue, polyuria, and lower abdominal pain several days before the episode of falling. She had a history of recurrent urinary tract infection, diabetes mellitus type 2, hypertension, hysterectomy, and osteoarthritis. On admission, she was febrile (38°C), tachycardic (108 beats/min), and hypertensive (174/70 mm Hg). She was alert and oriented to person, place, and time with no focal or meningeal signs. She had multiple noninfected abrasions over her knees. Laboratory studies were significant for anemia (10.6 g/dL) and hyperglycemia (342 mg/dL). Urine examination showed pyuria (>1163 white blood cells), hematuria (15 red blood cells), and positive leukocyte esterase. Blood cultures were obtained, and she was empirically administered vancomycin and cefepime. Four days later, blood cultures grew gram-positive rods, which were further identified as A. naeslundii by matrix-assisted laser desorption ionization time of flight. As urine culture was taken after initiation of antibiotics, no growth was obtained. However, there was significant improvement in pyuria with resolution of her urinary symptoms. As part of the bacteremia workup, the patient underwent dental evaluation, which showed moderate to severe generalized chronic periodontitis and dental caries extending into the pulp. Abdominal and pelvic computed tomography and echocardiogram all did not show abnormalities. Her antibiotic treatment was switched from vancomycin and cefepime to piperacillin-tazobactam. Blood cultures cleared within 4 days of antibiotic therapy. After completing a week of intravenous piperacillin-tazobactam, the patient was discharged on oral amoxicillin-clavulanate for a duration of 1 month. In addition, she was scheduled for multiple dental extractions following discharge. Actinomyces naeslundii is the second most common cause of actinomycosis (median, 7.0%) after Actinomyces israelii (median, 72.7%). Distant infections are usually related to prior dental procedures or poor dental hygiene. It is well known that chronic hyperglycemia in diabetic patients is an element that increases the rates of infection due to structural changes in tissue and impaired wound healing.2 We believe that our patient developed Actinomyces bacteremia from chronic periodontitis precipitated by chronic hyperglycemia and poor oral hygiene. This species is usually susceptible to a great variety of antibiotics including penicillin, ceftriaxone, vancomycin, and linezolid.3 The duration of treatment has not been standardized and ranges from 2 weeks to 1 year.4,5 Although we could not obtain antimicrobial susceptibilities in our patient, we expected this strain to be sensitive to penicillin. However, we chose β-lactam/β-lactamase inhibitor antibiotics to cover potential anaerobes that might have been present in the oral cavity. Infection with A. naeslundii should be considered in every patient who presents with a mucosal barrier breach in oral cavity or gastrointestinal system where tissue healing might be impaired by age, chronic hyperglycemia, or trauma. Appropriate investigation is warranted to rule out causes or mucosal breach. Our case illustrates the pathogenic potential of A. naeslundii and highlights the importance of its treatment in elderly patients with diabetes mellitus. Keshav Bhandari, MBBS All India Institute of Medical Sciences New Delhi, IndiaJose Armando Gonzales Zamora, MD Division of Infectious Diseases Department of Medicine University of Miami Miller School of Medicine Miami, FL [email protected]

Predisposing cardiac conditions, interventional procedures, and antibiotic prophylaxis among patients with infective endocarditis

Efficacy and safety of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) in patients with predisposing cardiac condition (PCC) undergoing invasive procedures is still debated. We sought to assess the prevalence of PCC, the type of interventional procedures preceding the onset of symptoms, and the usefulness of AP in a large cohort of consecutive patients with definite IE. We examined 677 (median age 65.34 years; male 492 [73%]) consecutive patients with IE enrolled from July 2007 through 2010 into the Italian Registry of Infective Endocarditis. Predisposing cardiac condition was present in 341 patients (50%).Thirty-two patients (4.7%) underwent dental procedures. Of 20 patients with PCC undergoing dental procedure, 13 had assumed AP. Viridans group streptococci were isolated from blood cultures in 8 of 20 patients with PCC and prior dental procedure. Nondental procedures preceded IE in 139 patients (21%). They were significantly older and had more comordibities compared with patients undergoing dental procedures. Predisposing cardiac condition was identified in 91 patients. Perioperative antimicrobial prophylaxis was administered to 67 patients. Staphylococcus aureus was the most frequent causative agent. Cardiac surgery was necessary in 85 patients (20 with prior dental and 65 with nondental procedure). Surgical mortality (12% vs 0%, P = .03) and hospital mortality (23% vs 3%, P = .001) were significantly larger among patients with nondental procedures. In a large unselected cohort of patients with IE, the incidence of preceding dental procedures was minimal. The number of cases potentially preventable by means of AP was negligible. Nondental procedures were more frequent than dental procedures and were correlated with poorer prognosis.

Predictive factors in patients undergoing endoscopic sinus surgery for odontogenic sinusitis.

Odontogenic sinusitis (OS) presents a therapeutic dilemma. Evidence is lacking whether dental treatment alone is sufficient or whether patients will eventually require endoscopic sinus surgery (ESS). Our aim was to identify predictors of OS patients undergoing ESS. Retrospective review performed of OS patients (n = 43) analyzing multiple factors including age, sex, symptoms, prior dental procedures, treatment, diabetes, immunosuppression, smoking history, retained dental hardware, oral-antral fistula (OAF), and Lund-Mackay scores (LMSs). Descriptive statistics, Wilcoxon rank sum, and logistic regression analyses were performed. Common presenting symptoms included facial pressure, discolored nasal drainage, and foul smell/taste. Half of patients presented either after a recent dental procedure or with dental complaints. Forty-eight percent required ESS after failing medical and dental therapy alone. Total LMS was significantly higher in the group undergoing ESS (8.3 vs 3.7; p = 0.0003). Multivariate analysis showed 2 significant predictors of undergoing ESS: (1) OMC involvement (OR 37.3, p = 0.003) and prior dental procedure (OR 7.4, p = 0.03). All patients with OAF or retained dental hardware required ESS. Forty-eight percent of patients who presented with OS underwent ESS for symptom control and prevention of complications. Patients who underwent ESS had significantly higher total LMS than those who did not. In multivariate analysis, prior dental procedures and OMC involvement significantly increased the likelihood of requiring ESS.

Prevalence of hepatitis B and C virus infections among military personnel

BackgroundData regarding Hepatitis B and C viruses (HBV and HCV) prevalence among military personnel in Brazil are lacking, but the work-related risk of exposure can be high. The objective of this study was to estimate the seroprevalence of HBV and HCV and the risk factors associated to HBV exposure among Brazilian military personnel.MethodsA cross-sectional study was conducted and included 433 male military adults aged 18–25 years old working in Rio de Janeiro during October 2013. All individuals completed a questionnaire to assess their risk of exposure and provided a blood sample to HBV and HCV testing.ResultsNone of the participants presented HBsAg or anti-HBc IgM, 18 (4.1%) were positive for total anti-HBc, 247 (57.0%) were positive for anti-HBs, and 3 (0.7%) were anti-HCV reactive. The majority of military personnel with past HBV infection (anti-HBc reactive) and HBV immunity (anti-HBs reactive) had a history of prior dental procedures (88.9% and 77.3%), consumption of alcohol at least once a week (50% and 55.9%), and practiced oral sex (61.1% and 58.3%, respectively). In addition, anti-HBc positivity was common among individuals with a history of surgery (44.4%) and practice of anal sex (50%). At univariate analysis, age group was associated to anti-HBc and anti-HBs positivity.ConclusionsLow rates of HBV and HCV infection were observed among Brazilian military personnel in comparison to the general Brazilian population. HBV immunity rates were relatively low indicating the need for vaccination campaigns in this group.

Changing Spectrum of Infective Endocarditis in Children

The epidemiology of infective endocarditis (IE) changes with the medical advances. This study aimed to evaluate the trends in a pediatric cohort. From hospital database (1983-2011), patients <18 years who fulfilled the modified Duke criteria of IE were identified. We enrolled 112 patients (M/F 57/55) with 116 IE episodes. About 86 patients (74.1%) had preexisting cardiac lesions and 23 patients (19.6%) were immunocompromised hosts. Prior dental procedure was noted in 12 (10.3%) patients, including 4 with simple ventricular septal defect. The overall mortality was 10.7%. The risk factors included vegetations in both ventricles (odds ratio = 7.81, P = .019) and prior use of broad-spectrum antibiotics (odds ratio = 3.75, P = .055). Approximately one-third of the patients (29.3%) required surgical intervention. We identified an increasing trend in the proportion of hospital-acquired IE (from 12% during 1983-1991 to 39% during 2002-2011), and the spectrum of offending pathogens showed a trend for fewer Streptococcus species, more Staphylococcus aureus and increased pathogen diversity. The leading pathogens were Gram-negative bacilli in hospital-acquired IE and Streptococcus species in community-acquired IE. Hospital-acquired IE was associated with younger age, a higher proportion of immunocompromised patients, a history of central line indwelling and higher mortality. In contrast, more surgical intervention and embolic events occurred in community-acquired IE patients. The mortality of pediatric IE remains high. Dental procedures were noted in one-tenth of the patients. Although increased S. aureus-caused episodes and pathogen diversity were noted, Streptococcus species remain the most common pathogen.

Dysphagia due to Retropharyngeal Abscess that Incidentally Detected in Subarachnoid Hemorrhage Patient

Cerebral hemorrhage is one of the most common causes of dysphagia. In many cases, dysphagia gets better once the acute phase has passed. Structural lesions such as thyromegaly, cervical hyperostosis, congenital web, Zenker's diverticulum, neoplasm, radiation fibrosis, and retropharyngeal abscess must be considered as other causes of dysphagia as well. Retropharyngeal abscess seldom occur in adults and if it does so, a search for a prior dental procedure, trauma, head and neck infection is needed. The symptoms may include neck pain, dysphagia, sore throat, and in rare cases, dyspnea accompanied by stridor. We present a case and discuss a patient who had dysphagia and neck pain after a cerebral hemorrhage. Testing revealed a retropharyngeal abscess. The symptoms were successfully treated after the administration of antibiotics.

Osteonecrosis of the Jaw in Multiple Myeloma Patients: Incidence and Characteristics in Korean Patients.

Abstract Abstract 4956 Introduction Osteonecrosis of the Jaw (ONJ) is a potentially serious complication of bisphosphonate (BP) therapy in multiple myeloma (MM). Despite of current update about bisphosphonate related ONJ (BRONJ), only a few Asian BRONJ cases were reported and incidence of BRONJ in Asian MM patients has not yet been definitively estimated. The purpose of this study was to determine incidence and characteristics of BRONJ in Korean MM patients who were receiving BP therapy. Patients and Methods We invited 9 hospitals of Korean Multiple Myeloma Working Group (KMMWP) to participate in a retrospective multicenter study on BRONJ in MM patients. To defined BRONJ incidence, we reviewed the data from 130 MM patients treated with BP in one hospital. We also reviewed the medical records of MM patients with BRONJ treated in 9 hospitals to know the patterns of disease. We analyzed patient and disease characteristics, type and number of BP infusions, previous history of dental procedures, locations of osteonecrosis, clinical symptoms, treatment and outcome. ONJ was defined as clinical evidence of exposed bone in the jaw, which has been present for more than 8 weeks. Results Nine of 130 MM patients (6.9%) treated with BP developed BRONJ in the hospital. Twenty-two patients with MM developed BRONJ after a median number of 17 BP infusions (range 6 - 50) in all 9 hospitals. None of the patients had been irradiated to the jaw. There were 14 male and 8 female patients. The median age was 62 years (range 46 – 75). Median time from MM diagnosis to BRONJ was 2.8 years (range 0.6 – 15.6). The MM isotype was IgG in 9, IgA in 8, IgM in 1, light chain in 3 and non-secretory myeloma in 1 patient. BP therapy included zoledronate (n = 2) or pamidronate (n = 4) and both drugs as sequential treatment (n = 16). Fifteen patients had recent problems in oral cavity (72.7%) and 14 had prior dental procedures (63.6%). The mandible was involved in 14 patients (63.6%), the maxilla in 7 (31.8%), and both the maxilla and mandible in 1 (4.5%). Patients usually presented with pain and soft tissue swelling. ONJ staging (Khan et al. Canadian consensus practice guidelines of Bisphosphonate associated ONJ. J Rheumatol 2008;35:1391-7) was used to define the severity, there were 5 patients in stage I, 14 in stage II and 1 in stage III. Because of the limitation of retrospective study, the stage of 2 patients could not be confirmed. Management of these established cases were discontinuation of BP and medical treatment including antibiotics and pain killer. Surgical debridement of necrotic bone was performed in 12 patients. From onset of exposed bone in jaw, patients were followed for median 11 months (range 4.2 - 42). Wounds of 10 patients were healed at median 175 days (range 60 – 404) after bone exposure. In 8 patients, lesions had persisted over 154 days (range 66 – 425). Evaluation was impossible for 4 patients due to loss of follow up. Four patients were dead because of disease progression (n = 3) or concomitant infection. BRONJ was healed in 2 of them. Conclusions To the best of our knowledge, this is the largest retrospective study ever reported about BRONJ in Asian MM patients. The incidence of BRONJ in Korean MM patients was 6.9% and this is similar with data in western countries. Clinical manifestations and outcome of BRONJ in Korean patients were not different from previously reported data, but no risk factors could be definitively identified with our retrospective analysis. In the name of KMMWP, prospective trials are ongoing to define incidence and risk factors of BRONJ in Korean MM patients. Disclosures No relevant conflicts of interest to declare.

Bisphosphonate‐related osteonecrosis of the jaw and its associated risk factors: A belgian case series

Bisphosphonate-related osteonecrosis of the jaw (BROJ) is a serious oral complication of bisphosphonate (BP) treatment involving the exposure of necrotic maxillary or mandibular bone. Our purpose is to describe the clinical presentation of 34 cases of BROJ and to identify potential risk factors. A retrospective study was performed in four Belgian institutions. Complete medical histories were recorded and analyzed. These data include age, gender, initial disease requiring BP, type and duration of BP treatment, symptomatology and location of BROJ, prior dental procedures, treatment of the BROJ and treatment outcome, and radiographic, histological, and microbiological data. Bisphosphonates (BP) were used in the management of disseminated cancers in 30 patients (88.5% of total studied), while four patients received BP due to osteoporosis (11.5%). The most frequently used BP was zoledronic acid in 29 patients (83%). Microbiological data obtained in 25 patients demonstrated that 72% of these patients were infected or colonized by an actinomyces. Eight of the 14 patients (57%) who received only medical treatment were cured. Of the 20 patients who underwent surgical treatments, only four were completely cured (20%). BROJ lesions smaller than 1 cm are associated with better prognosis in terms of treatment outcomes (P = .0009). Local treatments combined with long-term antibiotics are also correlated with better prognosis (P = .02). Lesions smaller than 1 cm and lesions that were subject to medical treatments are associated with a better outcome. Surgical treatments appear to be non-beneficial for BROJ.

市中総合病院における感染性心内膜炎症例の検討

There have been few reports on the clinical features of infective endocarditis (IE) in Japan. We clinically investigates 45 episodes (36 cases) of definite IE that were experienced from January 1985 to March 1997 at a community hospital, Okinawa Chubu Hospital, Okinawa, Japan. Regarding age, prior dental procedure, causative organisms and sites of infection, analyses and comparison were performed on a total of 94 episodes, by adding another 49 episodes of IE that were experienced between 1977 and 1984 at our hospital. The mean age was 47 years and majority of patients in the recent 12 years were older than 50 years of age. Mortality of all 94 episodes was 20%, while that of recent 45 cases was 13%. Eight % of all episodes had history of recent dental treatment but significance of the finding remains unclear. Alpha streptococci were most common (33%) and Staphylococcus aureus was the second most common organism (17%). Eleven % of all episodes were culture-negative and there was a statistically significant difference in the histories of prior antibiotic therapy between culture-negative and culture-positive episodes. Regarding sites of infection, 27% of all episodes involved mitral valves, while 24% involved aortic valves. Prosthetic valves were involved in 12%. Ninety-eight % of the recent episodes had fever, 98% had cardiac murmurs and 27% had characteristic mucocutaneous lesions. Heart failure was the most common complication (27%) and half of the cases with prosthetic valve infection had heart failure. Cerebral embolism was most frequently seen among the major arterial embolic complications. Our results were similar to those which were previously reported from other countries. We should have a high index of suspicion for endocarditis whenever we see patients who present various clinical manifestations and fever of which origin remains unclear. Willingness to obtain blood culture before starting antibiotics is most important.

Facial edema, oral ulcers, and a cutaneous eruption following a dental procedure utilizing diflunisal and mepivacaine

HISTORY OF PRESENT ILLNESS A 48-year-old Asian male was referred to our outpatient allergy clinic after experiencing oral ulcers, angioedema, and a penile skin eruption following tooth extraction and gum irrigation. Less severe reactions had occurred following two prior dental procedures. These reactions consisted of painful buccal blisters developing within 3 hours of each procedure, progressing over the next 3 days to extensive oral ulcerations. Penicillin was given before the first dental procedure in 1990. Ciprofloxacin was given before the second procedure in 1994. He did not receive any antibiotics before the third extraction in 1997. Thirty minutes before all procedures, the patient was pre-medicated with 1000 mg of oral diflunisal. During each procedure, 5.5 mL of the local anesthetic mepivacaine (2%) with the sympathomimetic vasoconstrictor neo-cobefin (1 20,000) was administered by injection. Within 1 hour following the third dental procedure, the patient complained of lip and facial swelling accompanied by burning eyes. Eighty milligrams of triamcinolone and 50 mg of diphenhydramine were given intramuscularly with moderate relief of facial swelling. He was sent home on a regimen of oral dexamethasone 1 mg tid and oral diphenhydramine 50 mg tid. Approximately 3 hours after the procedure, the patient noted the appearance of painful blisters on the buccal mucosa. The blisters progressed to oral ulcers in a manner and time course similar to that following the two prior dental procedures. On the third day post-procedure, the patient complained of severe dysphagia and noted a painful bullous, erythematous penile lesion. Neosporin ointment along with fluocinolone .025% ointment was applied topically to the penile lesion each day. Corticosteroid eye drops were also used daily. The symptoms continued to persist throughout the next 2 months, gradually diminishing in severity, and completely resolving within 3 months.

Septic Pulmonary Embolism Due to Periodontal Disease

Three weeks following a toothache, a 56-year-old man developed cough, sputum, fever, and pleuritic chest pain. He had mild periodontal disease and his chest radiographs and chest computed tomographic (CT) scans showed multiple pulmonary nodules. The CT scan strongly suggested septic pulmonary embolism. Aspirated pus from one of the nodules yielded pure growth of Streptococcus intermedius. Lesions resolved with antimicrobial therapy. The usual predisposing factors for septic pulmonary embolism were absent, and, the isolation of S intermedius from the pus, the antecedent toothache, and periodontal disease all suggested the gingiva as the source. We hypothesize that periodontal infection led to bacteremia, seeding of the lungs, and multiple anaerobic pulmonary abscesses, akin to reported instances of infective endocarditis from dental foci without any prior dental procedures. To our knowledge, this presentation of septic pulmonary embolism is unprecedented.

Antibiotic prophylaxis for endocarditis in patients with a prosthetic heart valve

A review of the types of organisms and their sensitivities to antibiotics, as well as the source of infection, was carried out for 11 patients who had late onset infective endocarditis and a prosthetic heart valve. Candida organisms were isolated from two patients. In nine patients with late onset bacterial endocarditis, the organisms isolated were five streptococci and four staphylococci. Their sensitivities to antibiotics were penicillin, five of eight; erythromycin, eight of eight; and cephalothin, six of seven. Two patients with endocarditis had ulcerations beneath their dentures, and one had undergond a prior dental procedure. Of 52 healthy patients with prosthetic valves who were interviewed, only 18 had visited a dentist during the previous year, and six did not receive antibiotic prophylaxis for endocarditis. It is concluded that patients with prosthetic heart valves do not practice good oral hygiene and, if they do visit the dentist, some may not receive antibiotics for endocarditis prevention. An antibiotic regimen for endocarditis is presented that is consistent with the organisms found in the oral cavity and those found in patients with endocarditis who have a prosthetic valve.