The incidence of bacteremia in endodontic manipulation

Association between Endodontic Infection, Its Treatment and Systemic Health: A Narrative Review

The 'Focal Infection Era in Dentistry' in the late 19th and early 20th century resulted in widespread implementation of tooth extraction and limited the progress of endodontics. The theory proposed that bacteria and toxins entrapped in dentinal tubules could disseminate systemically to remote body parts, resulting in many types of degenerative systemic diseases. This theory was eventually refuted due to anecdotal evidence. However, lately there has been increased interest in investigating whether endodontic disease could have an impact on general health. There are reviews that have previously been carried out on this subject, but as new data have emerged since then, this review aims to appraise the available literature investigating the dynamic associations between apical periodontitis, endodontic treatment, and systemic health. The available evidence regarding focal infection theory, bacteraemia and inflammatory markers was appraised. The review also collated the available research arguing the associations of apical periodontitis with cardiovascular diseases, diabetes mellitus, adverse pregnancy outcome and autoimmune disorders, along with the effect of statins and immunomodulators on apical periodontitis prevalence and endodontic treatment prognosis. There is emerging evidence that bacteraemia and low-grade systemic inflammation associated with apical periodontitis may negatively impact systemic health, e.g., development of cardiovascular diseases, adverse pregnancy outcomes, and diabetic metabolic dyscontrol. However, there is limited information supporting the effect of diabetes mellitus or autoimmune disorders on the prevalence and prognosis post endodontic treatment. Furthermore, convincing evidence supports that successful root canal treatment has a beneficial impact on systemic health by reducing the inflammatory burden, thereby dismissing the misconceptions of focal infection theory. Although compelling evidence regarding the association between apical periodontitis and systemic health is present, further high-quality research is required to support and establish the benefits of endodontic treatment on systemic health.

A Review of Guidelines for Antibiotic Prophylaxis before Invasive Dental Treatments

Bacteraemia associated with invasive dental treatments can propagate infective endocarditis in high-risk cardiac patients. Over the past decade, antibiotic prophylaxis before dental treatment has been questioned. This review aims to compare the variations between the UK, European and American antibiotic prophylaxis guidelines before dental treatments. Antibiotic prophylaxis guidelines by the National Institute for Health and Care Excellence (NICE)—Clinical Guideline 64, Scottish Dental Clinical Effectiveness Programme (SDCEP), American Heart Association (AHA), European Society of Cardiology (ESC), European Society of Endodontology (ESE) and Belgian Health Care Knowledge Centre (KCE) position statements were compared regarding the indications, high-risk patients and prophylaxis regimens before dental treatments. In the United Kingdom, the NICE—Clinical Guideline 64 and SDCEP—Implementation Advice do not advise the prescription of prophylactic antibiotics for the majority of high-risk cardiac patients undergoing routine dental treatments. On the contrary, the AHA, ESC and KEC recommend the prescription of antibiotics prior to invasive dental procedures in high-risk cardiac individuals. The ESE also indicates prophylaxis before endodontic procedures for patients with other conditions, including impaired immunologic function, prosthetic joint replacement, high-dose jaw irradiation and intravenous bisphosphonates. Among these guidelines, there are variations in antibiotic prophylaxis regimens. There are variations regarding the indications and antibiotic prophylaxis regimens before invasive dental treatments among these available guidelines.

Severity of dental caries and risk of coronary heart disease in middle-aged men and women: a population-based cohort study of Korean adults, 2002-2013

We aimed to evaluate the risk of coronary heart disease (CHD) according to dental caries status in middle-aged patients using a population-based cohort database containing medical/dental claims, health examination, and death records in the Republic of Korea. A total of 234,597 patients were identified in the database who were without history of cardiovascular disease, including 104,638 patients without dental caries, 41,696 with incipient/moderate stage dental caries, and 88,262 advanced/severe dental caries. We used Cox proportional hazards model adjusted for sociodemographic, lifestyle, and medical characteristics to compute hazard ratio (HR) and 95% confidence intervals (95% CI) for CHD according to severity of dental caries. During 1,491,190 person-years of follow-up, there were a total of 6,015 CHD events. After adjustment for potential confounders, patients in the highest quartile of outpatient visits for advanced/severe stage dental caries was associated with an increase in CHD risk (HR = 1.13; 95% CI: 1.04-1.22) as compared with patients without dental caries. When the analysis was restricted to the patients with advanced/severe dental caries, dose-response relationship between number of outpatient visits for dental caries and risk of CHD was observed (Ptrend: <0.001). Prevention and control of dental caries might be worth promoting in clinical practice to prevent CHD.

Bacteremia after Endodontic Procedures in Patients with Heart Disease: Culture and Molecular Analyses

INTRODUCTION

Infective endocarditis (IE) is still associated with high mortality, and antibiotic prophylaxis strategies are under intense debate. We evaluated the incidence of bacteremia after root canal preparation in teeth with necrotic pulps and apical periodontitis.

METHODS

Blood samples were taken before and 5 and 30 minutes after endodontic treatment in teeth with apical periodontitis from individuals at high (n = 21) or no risk (n = 11) for IE. The former received prophylactic antibiotic therapy. Bacteriologic samples were taken from root canals before chemomechanical preparation to confirm pulp infection. Samples were subjected to aerobic and anaerobic culture and quantitative real-time polymerase chain reaction (qPCR), the latter to determine the total bacterial and streptococcal levels.

RESULTS

Culture revealed no bacteremia in all individuals. Analysis by qPCR showed that bacterial DNA occurred in all root canal samples. qPCR showed a similar incidence of bacteremia between patients who received or did not receive prophylactic antibiotic therapy (P > .05). In blood samples taken 5 minutes after endodontic procedures, bacteria were detected in 2 of 11 (18%) individuals not taking antibiotics and in 4 of 21 (19%) patients under prophylaxis. After 30 minutes, the incidence of bacteremia decreased to 2 of 21 (10%) in patients taking antibiotics and was undetectable in patients at no risk of IE. The incidence of bacteremia by streptococci was identical as that for total bacteria.

CONCLUSIONS

No detectable bacteremia was evident by culture after treatment of infected root canals. Molecular analysis revealed bacterial DNA and streptococci in blood from some patients without a significant difference between individuals receiving or not receiving antibiotic prophylaxis.

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.

Detection of bacteraemias during non-surgicalroot canal treatment

Some dental procedures initiate a bacteraemia. In certain compromised patients, this bacteraemia may lead to distant site infections, most notably infective endocarditis.

OBJECTIVE

To investigate whether a detectable bacteraemia was produced during non-surgical root canal therapy.

METHODS

Thirty patients receiving non-surgical root canal therapy were studied. Three blood samples were taken per patient: pre-operatively, peri-operatively and post-operatively. In addition, a paper point sample was collected from the root canal. The blood samples were cultured by pour plate and blood bottle methods. The isolated organisms were identified by standard techniques. Blood samples were analysed for the presence of bacterial DNA by the polymerase chain reaction (PCR). In two cases where the same species of organism was identified in the root canal and the bloodstream, the isolates were typed by pulsed field gel electrophoresis (PFGE).

RESULTS

By conventional culturing, a detectable bacteraemia was present in 9 (30%) of the 30 patients who had no positive pre-operative control blood sample. In 7 (23.3%) patients, the same species of organism was identified in both the bloodstream and in the paper point sample from the root canal system. Overall, PCR gave lower detection rates compared with conventional culture, with 10 of 90 (11%) of the blood samples displaying bacterial DNA. PFGE typing was undertaken for two pairs of culture isolates from blood and paper points; these were found to be genetically identical.

CONCLUSIONS

Non-surgical root canal treatment may invoke a detectable bacteraemia.

Infective endocarditis, dentistry and antibiotic prophylaxis; time for a rethink?

OBJECTIVE

To provide a critical review of the current evidence that links dental treatment to infective endocarditis (IE) and appraise the risks of antibiotic chemoprophylaxis.

DESIGN

Retrospective analysis

SETTING

Mainly hospital based patients or subjects

OUTCOME MEASURES

The interrelationship between infective endocarditis and dental treatment is complex and in many instances uncertain. The risk from antibiotic chemoprophylaxis appear greater than the risk of contracting IE.

RESULTS

There is increasing evidence that spontaneous bacteraemia are more likely to cause IE in at risk patients than specific episodes of dental treatment. Antibiotic chemoprophylaxis may not necessarily reduce dental-induced bacteraemia and the protective effect if any from antibiotic cover may arise from an inhibitory action upon bacterial colonisation on the compromised cardiac valves.

CONCLUSION

There is increasing concern over the misuse of antibiotics in general and this has focused attention on chemoprophylaxis in dentistry to prevent IE. New evidence on dental-induced bacteraemia and the prevalence of IE in association with dental treatment raises further questions on the need to provide antibiotic cover in at risk patients. More prescriptive guidelines to define who is at risk from IE and what procedures require cover will help to reduce overprescribing of antibiotics and reduce the risks of their unwanted effects.

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.

The prevention of infective endocarditis-paedodontic considerations. British Society for Antimicrobial Chemotherapy

This review of the literature considers the pathology and epidemiology of infective endocarditis (IE), dental procedures that may precipitate IE and prophylaxis against dentally induced IE. The most recent recommendations published in May 1992 by the British Society for Antimicrobial Chemotherapy are outlined and discussed.

Antibiotics and endodontics

Antibiotics can be used as an adjunct to endodontic treatment in a number of ways--locally, systemically and prophylactically. The local or intra-canal use of antibiotics in the form of medicaments is common. However, the commercially available agents for this purpose may not be the ideal mixtures. Systemic antibiotics should be restricted to patients who have local signs of infection, malaise and elevated body temperature. Prophylactic use of antibiotics has been recommended for patients 'at risk' of infective endocarditis, in some pre-surgical situations and following avulsion and replantation of teeth. The tendency towards indiscriminate antibiotic use should be discouraged. The use of broad spectrum drugs should be restricted so that these medications remain effective in serious situations.

Brain abcess following dental infection

A 48-year-old woman underwent root canal treatment of the upper left lateral incisor and lower right second premolar. Close to the conclusion of the endodontic treatment she complained about headaches. Later on, because of aggravation of her condition, with headaches, fever, malaise, weakness, and numbness of the right limbs, she was admitted to the hospital. The disease progressed to an epileptic state, with appearance of a right hemiparesis. A brain scan and carotid arteriogram revealed the presence of a mass occupying the left parietal space. Craniotomy disclosed an abscess containing yellow pus from which Streptococcus viridans was cultured. After thorough surgical cleansing of the area, removal of the bone for decompression, and treatment with ampicillin the patient improved gradually and slowly regained the mobility of her right side.

Evaluation of techniques and material used in pulpal therapy based on a review of the literature: part II

A healthy and functional dental pulp is the goal of any treatment procedure, but at present there does not seem to be any material that will regularly induce dentinal bridge formation and healing of an exposed, inflamed pulp. The usefulness of various capping agents, including corticosteroids and isobutyl cyanoacrylates, is interpreted. In determining treatment, all the clinician's experience is needed in correlating clinical evidence, history, size of the filling in relation to the tooth crown and periodontal condition.