Reduction of bacteremia after oral manipulations

Transient bacteremia induced by dental cleaning is not associated with infection of central venous catheters in patients with cancer

OBJECTIVE

The aim of this study was to determine the incidence of bacteremia resulting from dental cleaning and of subsequent established bloodstream infection (BSI) caused by oral microorganisms in patients with cancer with central venous catheters (CVCs).

STUDY DESIGN

Twenty-six patients with cancer with CVCs and absolute neutrophil count over 1000 cells/µL received dental cleaning without antibiotic prophylaxis. Periodontal status was assessed at baseline by using the Periodontal Screening and Recording (PSR) score. Blood cultures were drawn via the CVCs at baseline, 20 minutes into cleaning, and 30 minutes and 24 hours after cleaning. Medical records were monitored for 6 months.

RESULTS

Baseline blood culture results were negative in 25 patients. Nine of 25 patients (36%) had positive blood culture 20 minutes into cleaning, all associated with at least 1 microorganism typically found in the mouth. These 9 patients had significantly higher mean PSR score (3.22) compared with the other 16 (2.56; P = .035). These expected bacteremias did not persist, with blood culture results (0/25) at 30 minutes and 24 hours after cleaning showing no positivity (P = .001). There were no cases of CVC-related infection or BSI attributable to dental cleaning.

CONCLUSIONS

Bacteremia resulting from dental cleaning is transient and unlikely to cause CVC-related infection or BSI in patients with absolute neutrophil count greater than 1000 cells/µL.

An investigation of the frequency of bacteraemia following dental extraction, tooth brushing and chewing

Abstract

We conducted a study to determine the frequency of bacteraemias following dental extraction and common oral procedures, namely tooth brushing and chewing, and the relationship between bacteraemia and oral health in black patients. Positive blood cultures were detected in 29.6% of patients after dental extraction, in 10.8% of patients after tooth brushing and in no patients after chewing. No relationship between the state of oral health, which was assessed using the plaque and gingival indices, and the incidence of bacteraemia was found. The duration of bacteraemia was less than 15 minutes. One patient had a positive blood culture prior to dental extraction; his oral health status was poor. Our study confirmed that bacteraemia occurs after tooth brushing.

Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

BACKGROUND

The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997.

METHODS AND RESULTS

A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) with liaison members representing the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on IE. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization and bacteremia. The reference lists of the identified articles were also searched. The writing group also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The article subsequently was reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

CONCLUSIONS

The major changes in the updated recommendations include the following. (1) The committee concluded that only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective. (2) IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE. (3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when IE prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

Effect of the Diode Laser on Bacteremia Associated with Dental Ultrasonic Scaling: A Clinical and Microbiological Study

OBJECTIVE

The purpose of this study is to evaluate the potential use of diode lasers (DLs) to reduce bacteremia associated with ultrasonic scaling (US). Furthermore, the clinical efficacy of DLs as an adjunct to US in the treatment of gingivitis was investigated.

BACKGROUND DATA

Recently, lasers have found new applications in dental practice. The benefits of the use of DLs as an adjunct to US have not yet been determined.

METHODS

Twenty-two gingivitis patients were treated using a split-mouth study design in which each side was randomly treated by US alone or DL followed by US (DL + US). Blood samples were drawn just before and during US in each treatment step to detect induced bacteremia. Clinical parameters including plaque index, sulcus bleeding index, probing depth, and relative attachment level were recorded at baseline and 4 weeks postoperatively.

RESULTS

Bacteremia was detected in 15 patients (68%) after US alone, and in 8 patients following DL + US (36%). The reduction of the incidence of odontogenic bacteremia during US after the application of DL was statistically significant (p < 0.05). Clinical signs improved eventually, with no significant differences between the two treatment regimens (p > 0.05).

CONCLUSIONS

Application of DL energy can reduce bacteria in gingival crevices which may reduce bacteremia following US. The use of DL did not show additional clinical influence on gingival healing after treatment of gingivitis with US.

Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

BACKGROUND

The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997.

METHODS AND RESULTS

A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

CONCLUSIONS

The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

BACKGROUND

The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997.

METHODS AND RESULTS

A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

CONCLUSIONS

The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

The impact of oral disease and nonsurgical treatment on bacteremia in children

BACKGROUND

The authors examine the role of dental disease and nonsurgical dental procedures in the incidence and duration of bacteremia in children.

METHODS

The authors randomized a group of children to receive amoxicillin or a placebo before dental rehabilitation in an operating room setting. They collected eight blood draws at the following times: two minutes after intubation (draw 1); after dental restorations, pulp therapy and cleaning (draw 2); 10 minutes later (draw 3); and five draws during and after dental extractions (draws 4-8). The authors compared dental disease parameters and the type of dental procedures performed with the incidence and duration of bacteremia.

RESULTS

The authors enrolled 100 children (aged 1-8 years) in the study. The incidence of bacteremia from draw 2 was 20 percent in the placebo group and 6 percent in the amoxicillin group (P = .07), and the incidence from draw 3 was 16 percent in the placebo group and zero percent in the amoxicillin group (P = .03). Subjects with higher gingival scores were more likely to have a bacteremia for draw 2 (P = .01). The authors found that subjects in the group with bacteremia for draw 3 had undergone more pulpotomies than did subjects in the group without bacteremia for draw 3 (3 +/- 2.5 standard deviation [SD] versus 1.5 +/- 1.6 SD, P = .04), while they found almost no differences for draw 2.

CONCLUSIONS

This study suggests that gingival disease has an impact on bacteremia after dental restorations and prophylaxis. Although antibiotics have an impact, they do not eliminate bacteremia altogether.

Endodontics and infective endocarditis – is antimicrobial chemoprophylaxis required?

The purpose of this review is to evaluate the evidence implicating nonsurgical endodontic procedures in inducing infective endocarditis (IE). The literature is reviewed and findings about dental procedures that elicit bacteraemia [in particular root canal treatment (RCT)], sequelae of bacteraemia, relationship between IE and RCT and variation between antibiotic prophylaxis (AP) guidelines are highlighted. At present, there is still significant debate as to which dental procedures require chemoprophylaxis and what antibiotic regimen should be prescribed. Currently, there are insufficient primary data to know whether AP is effective or ineffective against IE. Practitioners are bound by current guidelines and medico-legal considerations. Thus, the profession requires clear, uniform guidelines that are evidence-based.

Bacteraemia following periodontal procedures

INTRODUCTION

Transient bacteraemias are frequently detected following dental manipulation. Infective endocarditis (IE) can arise in susceptible individuals and antibiotic prophylaxis is routinely performed for certain procedures considered to be "at risk" of IE. Evidence is emerging that periodontal disease may be a significant risk factor for the development of certain systemic diseases such as cardiovascular disease. These systemic conditions could be initiated or detrimentally influenced by the repeated entry of bacteria into the bloodstream.

MATERIALS AND METHODS

The present study comprised a single blind parallel study of 2 weeks duration. A baseline blood sample was obtained from 30 volunteers with untreated periodontal disease following which a periodontal probing depth chart was collected. A further blood sample was taken following this procedure, and each subject was recalled 2 weeks later. A blood sample was collected, the subject carried out toothbrushing and a further blood sample taken. Full-mouth ultrasonic scaling was then performed and a final blood sample taken. Blood samples were analysed for bacteraemia using conventional microbiological culture and polymerase chain reaction (PCR) using universal bacterial primers that target the 16S ribosomal RNA gene of the vast majority of bacteria.

RESULTS

Using culture methods, the incidence of bacteraemias was as follows: following ultrasonic scaling (13%), periodontal probing (20%) and toothbrushing (3%). PCR analysis revealed bacteraemia incidences following ultrasonic scaling, periodontal probing and toothbrushing of 23%, 16% and 13%, respectively.

CONCLUSION

These findings suggest that detectable dental bacteraemias induced by periodontal procedures are at a lower level than previously reported.

Incidence of bacteremia after routine tooth brushing

BACKGROUND

The American Heart Association first developed recommendations on antibiotic prophylaxis against infective endocarditis during dental procedures more than 50 years ago. These recommendations were partly based on the fact that bacteremia occurs with dental procedures. Previous studies in the 1970s and earlier demonstrated that patients become bacteremic after tooth brushing. Improved culture techniques suggest that these rates could be higher now. The objective of this study was to determine the current incidence of bacteremia after routine tooth brushing.

METHODS

Thirty military beneficiaries were enrolled in a prospective, institutional review board-approved study after providing informed consent. The incidence of bacteremia after routine tooth brushing for 1 minute using a standardized soft-bristle toothbrush was prospectively measured in 30 healthy adults at three different time points (at baseline and 30 seconds and 20 minutes after brushing). Periodontal Screening and Recording (PSR) scores were recorded for each patient to assess periodontal disease.

RESULTS

Three of 180 blood cultures were positive for Propionibacterium acnes (a known contaminant). The remaining blood cultures were all negative. The average PSR score was 9.8 (standard deviation 3.17) for 17 of 30 subjects.

CONCLUSIONS

The rate of true bacteremia in this study was zero, which is much lower than previous studies. Bacteremia after tooth brushing in a healthy population is a rare occurrence. Data from previous studies may no longer apply to the current population. Results similar to the ones found in this study during other dental procedures could be an impetus to reevaluate infective endocarditis prophylaxis guidelines.

Topical antibiotic prophylaxis for bacteremia after dental extractions

OBJECTIVE

Current prophylaxis for endocarditis in patients undergoing dental procedures consists of oral administration of amoxicillin. There is concern that the risk of anaphylaxis from systemically administered antibiotics might approach the incidence of endocarditis. Emergence of resistance among bacteria is also favored by systemically administered antibiotics. The present study was designed to assess the efficacy of topical amoxicillin given prophylactically as a mouthwash in reducing the incidence of bacteremia after dental extraction.

STUDY DESIGN

Thirty-six outpatients in a dental clinic were randomized in a 3:2:2 ratio to experimental prophylaxis of topical amoxicillin (3 g per mouthwash rinse; 15 patients), standard prophylaxis of oral amoxicillin (3 g in a single dose; 11 patients), or no prophylaxis (10 patients), respectively. Patients were stratified by severity of periodontal disease and number of teeth extracted. Data were analyzed for differences in the incidence of bacteremia by means of the 2-tailed Fisher exact test.

RESULTS

Breakthrough bacteremia after dental extraction was observed in 60% (6 of 10 patients) who received topical amoxicillin and in 89% (8 of 9 patients) who received no prophylaxis (P =.30). By comparison, breakthrough bacteremia after dental extraction was observed in 10% (1 of 10 patients) who received standard prophylaxis with oral amoxicillin (60% vs 10%; P =.05).

CONCLUSIONS

Topical amoxicillin decreased the incidence of bacteremia in comparison with no prophylaxis, but statistical significance was not achieved (P =.30). Topical amoxicillin was significantly less effective than standard prophylaxis with oral amoxicillin in decreasing the incidence of bacteremia after dental extractions.

Root canal treatment and general health: a review of the literature

REVIEW

The focal infection theory was prominent in the medical literature during the early 1900s and curtailed the progress of endodontics. This theory proposed that microorganisms, or their toxins, arising from a focus of circumscribed infection within a tissue could disseminate systemically, resulting in the initiation or exacerbation of systemic illness or the damage of a distant tissue site. For example, during the focal infection era rheumatoid arthritis (RA) was identified as having a close relationship with dental health. The theory was eventually discredited because there was only anecdotal evidence to support its claims and few scientifically controlled studies. There has been a renewed interest in the influence that foci of infection within the oral tissues may have on general health. Some current research suggests a possible relationship between dental health and cardiovascular disease and published case reports have cited dental sources as causes for several systemic illnesses. Improved laboratory procedures employing sophisticated molecular biological techniques and enhanced culturing techniques have allowed researchers to confirm that bacteria recovered from the peripheral blood during root canal treatment originated in the root canal. It has been suggested that the bacteraemia, or the associated bacterial endotoxins, subsequent to root canal treatment, may cause potential systemic complications. Further research is required, however, using current sampling and laboratory methods from scientifically controlled population groups to determine if a significant relationship between general health and periradicular infection exists.

Oral microflora as a cause of endocarditis and other distant site infections

Bacteremia originating from the oral cavity is common, but the role of bacteremia in the genesis of infective endocarditis and other distant site infections is unclear. Only a small percentage of oral flora have been associated with distant site infection. Important issues remain unresolved concerning the identification of patients at risk, the relative risk from invasive dental procedures versus naturally occurring bacteremia, and the impact of prophylactic antibiotics on the incidence, nature, magnitude, and duration of bacteremia from the oral cavity. This article addresses the controversies in infection management in patients at risk for distant site infection.

Risks for and prevention of infective endocarditis

It is accepted medical practice to prevent bacterial endocarditis in patients with susceptible congenital or acquired cardiac malformations who are likely to experience predictable procedure-related bacteremia. Patients in general, those with congenital heart disease specifically, are insufficiently aware of the need for such prophylaxis. It is responsibility of the physician to determine which patients are susceptible to endocarditis and the need for endocarditis prophylaxis for each patient for any given instance and to educate the patient as to this need. The American Heart Association provides wallet-sized cards that may be given to each patient. Those patients not previously known to have heart disease are, of course, not eligible for chemoprophylaxis. Because these represent many of the patients with endocarditis each year, it can be argued that only a minority of patients have preventable cases. Regarding the clinical application of anti-infective endocarditis prophylaxis, the American Heart Association gives this perspective: This statement represents recommended guidelines to supplement practitioners in the exercise of their clinical judgement and is not intended as a standard of care for all cases.... Because no adequate, controlled clinical trials of antibiotic regimens for the prevention of bacteria endocarditis in humans have been done, recommendations are based on vitro studies, clinical experience, data from experimental animal models, and assessment of both the bacteria most likely to produce bacteremia from a given site and those most likely to result in endocarditis. Bacterial endocarditis is one of the few infectious disease that almost always result in death unless treated. The dramatic nature of the morbidity and mortality of infective endocarditis in those so afflicted makes the prevention of even a few cases worth the effort.

Preventing post-treatment bacteremia: comparing topical povidone-iodine and chlorhexidine

It is well known that the occurrence of bacteremia after dental procedures can place certain patients at risk for bacterial endocarditis. The authors compared the efficacy of two antiseptic agents in the prevention of post-treatment bacteremia in 120 dental patients. Before treatment, dentists irrigated the gingival sulcus of each patient with 10 percent povidone-iodine, 0.2 percent chlorhexidine or sterile water. The authors report lower levels of bacteremia among patients treated with the povidone-iodine solution.

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.

Modes of application of anti-plaque chemicals

Because interdental and subgingival sites are relatively inaccessible to mouthrinsing, they necessitate alternative methods of application of anti-plaque chemicals. These include routine oral hygiene aids, surfactants to enhance uptake and retention of antimicrobials, gels and periodontal dressings. The principal modes of application that have received attention recently, apart from the systemic route, are syringe and pulsated jet irrigation and slow release compounds. Slow release devices currently receiving attention may be classified as membrane diffusion, solution of drug in polymer and solid drug dispersed in polymer matrix. The most widespread dental instance of a slow release device appears to be the use of varnishes and resins to carry fluoride. Recent attempts at devising improved methods of antimicrobial application include the testing of materials for their biodegradability or for their potential to adhere to mucosal surfaces. It is concluded that the potential exists for antimicrobials applied directly to the site of intended action to contribute significantly to dental health, particularly when employed as components of practical oral hygiene regimes.

Dental bacteremia--a neglected cause of arthroplasty infections? Three hip cases

We report on three patients with late hip replacement infection. The micro-organism was microaerophilic Streptococcus viridans, an oral organism, in all patients. Dental procedures had preceded the onset of the hip infection in all cases, and severe periodontal disease was observed on subsequent admissions.

How important are dental procedures as a cause of infective endocarditis?

Eighteen pediatric patients with infective endocarditis (IE) were reviewed for "failure" of chemoprophylaxis; none had had a previous dental procedure. Surprisingly, published reports reveal a similarly low prevalence of dental extractions preceding IE, only 3.6% for 1,322 cases. Although bacteremia was associated with 40% of 2,403 reported extractions, it also was found in 38% of patients after mastication, and in 11% of patients with oral sepsis and no intervention. In a hypothetical month, ending with a single dental extraction, the cumulative exposure to these "physiologic" sources of bacteremia is nearly 1,000 times greater than it is from extraction. The current American Heart Association recommendations for intramuscular or intravenous chemoprophylaxis are impractical, and the discomfort and inconvenience may impede good dental care. The Committee also implies that gingival bleeding allows bacterial access to the blood stream, whereas experimental studies establish the lymphatics as the only access. Although oral chemoprophylaxis for major dental procedures appears prudent, the British regimen of a single dose of amoxicillin administered orally is much simpler and probably more effective. However, scrupulous oral and dental hygiene is undoubtedly superior in preventing IE than any chemoprophylaxis regimen.

Effect of a local germicide on the occurrence of bacteremia during subgingival scaling

The purpose of this investigation was to determine the effectiveness of irrigating periodontal pockets with povidone-iodine in reducing the incidence of bacteremia found during subgingival scaling. Twenty male patients requiring subgingival scaling had the following factors recorded on two contralateral groups of three posterior teeth: age, race, mean pocket depth, mobility, and scores of gingival, plaque, calculus, bleeding indices. In control areas, 5 ml blood samples were taken before, during and after scaling through an in dwelling Minicath. In experimental areas, the patients first rinsed with a povidone-iodine mouthwash for 1 minute, and the teeth then received a 3-minute sulcus irrigation with 10% povidone-iodine. Blood samples were taken as with the controls, and also 2 minutes after the irrigation. Blood samples were anaerobically cultured, and isolates were classified by Gram staining and cellular morphology. No significant difference in factors between control and experimental areas was noted. All preoperative blood cultures, including those taken 2 minutes after irrigation, were negative. In the 11 patients (55%0 who showed positive cultures during the scaling, cultures were positive in both control and experimental areas. None of the preoperatively recorded factors in either control or experimental ares were significantly correlated with the occurrence of bacteremia. Local degerming by mouthrinsing and sulcus irrigation with povidone-iodine prior to subgingival scaling seems neither to increase nor decrease the incidence of bacteremia.

Experimental transient bacteraemias in human subjects with clinically healthy gingivae

Thirty-six subjects with no evidence of clinical gingival inflammation underwent a standardized toothbrushing procedure. Blood specimens, obtained from a vein in the antecubital fossa during the last 30 seconds of brushing, were cultured under aerobic and stringent anaerobic conditions. Three subjects exhibited detectable bacteraemias, Propionibacterium sp. being isolated from two of the subjects, while Actinomyces sp., Streptococcus sanguis and Streptococcus mitis were isolated from the third. The implications of these results are discussed.

Experimental transient bacteraemias in human subjects with varying degrees of plaque accumulation and gingival inflammation

Ninety-six subjects were assigned to one of four groups according to severity of gingival inflammation and bacterial plaque accumulation on the teeth. Following a standardized toothbrushing procedure, blood specimens from a vein in the antecubital fossa were cultured under aerobic and stringent anaerobic conditions. The percentage of positive cultures increased significantly with increasing severity of gingival inflammation, as did the number of species of organisms isolated. Thirty different microbial species indigenous to the oral cavity, including many strict anaerobes, were recovered. The study has implications for standards of oral health which might be considered necessary in patients with congenital or acquired endocardial defects or cardiovascular prostheses.

Dental management of patients undergoing bone marrow transplantation for aplastic anemia

Acquired aplastic anemia is a rare hematologic disease characterized by a hypoplastic bone marrow and peripheral pnacytopenia. In severe cases, where conservative medical management has been unsuccessful, bone marrow transplantation is now being performed. Between the years 1971 and 1975, twenty-two patients with severe aplastic anemia were seen at the Children's Hospital Medical Center. This article discusses the oral presentations of aplastic anemia and the dental management of nine patients without and thirteen with transplantations.

A quantitative measurement of bacteremia and its relationship to plaque control

Despite the improvement in the patients' oral hygiene, there was no significant decrease in the frequency of bacteremia. There was no significant difference in bacteremia between brushing, flossing, or deplaquing either before or after initial periodontal preparation and plaque control in 21 healthy subjects. Utilizing more sophisticated bacteriologic techniques for the cultivation of obligate anaerobes, a relatively high frequency of anaerobic bacteremia was found.

Infected total hip replacement after dental procedures

Three cases are reported in which there was a worrisome association between dental work and an infected total hip replacement. The patients had long asymptomatic intervals subsequent to implantation of prosthetic hip joints. After dental procedures, infections became apparent in these hips. Such infections carry an enormous and crippling morbidity. The potential complications of transient bacteremia in the patient with a cardiac valvular prosthesis are appreciated and the importance of prophylactic antibodies for dental work in such patients is well known. Although we emphasize that there is no proof that the infections in our patients were metastatic from the mouth, the sequence of events is suggestive. We recommend prophylactic antibiotics for dental work in the patient with a total hip replacement.