Assessment of periodontitis and its role in viridans streptococcal bacteremia and infective endocarditis

Antimicrobial susceptibility of Viridians Group of Streptococci isolated from infective endocarditis patients from 2018 to 2023

INTRODUCTION

Viridans Group of Streptococci (VGS) are heterogeneous alpha hemolytic Streptococci that form commensal flora in the oral cavity, upper respiratory tract, gastrointestinal tract and female genital tract and are potential pathogens that can cause serious infections like infective endocarditis and bacteremia. Penicillin or Ceftriaxone is the recommended first line agent for definitive therapy of VGS endocarditis. Alteration in penicillin binding proteins can decrease the susceptibility of VGS to penicillin and other beta-lactam agents and complicate antimicrobial therapy for serious VGS infections like Infective endocarditis. The aim of our study was to determine the antimicrobial susceptibility pattern of viridians group Streptococci isolated from blood samples of infective endocarditis patients from April 2018 to September 2023 against betalactam and other agents.

MATERIAL AND METHODS

Three sets of blood cultures with 8-10 ml per bottle were collected from suspected infective endocarditis and incubated in automated blood culture system (BACTEC from BD diagnostics). The broth from positive bottles was streaked on Blood agar, Chocolate agar and MacConkey agar plates and incubated at 37°C. Alpha hemolytic Streptococci that grew after 24-48 h were further identified and antimicrobial susceptibility determined by Vitek 2 system.

RESULTS

A total of 100 VGS was isolated from blood samples of Infective endocarditis patients. The species most commonly isolated in our study was S. sanguinis (25%) and S.mitis/oralis group (23%) followed by Non speciated Viridans Streptococci (17%). The lowest penicillin susceptibility ie. PEN MIC <0.12 μg/ml of 40% was observed in S. alactolyticus group, followed by S. mitis (52%) and S. gallolyticus (56%). S. mitis/oralis group showed the lowest susceptibilities to betalactam antibiotics among all speciated and non speciated VGS.

CONCLUSION

Infective endocarditis carries a very high mortality and morbidity and the emergence of resistance to betalactam agents like penicillin will only narrow available therapeutic options and further challenge the treatment.

Infective endocarditis: prevention strategy and risk factors in an animal model

INTRODUCTION

Infective endocarditis is a serious infection of the endocardium, especially the heart valves, which is associated with a high mortality rate. It generally occurs in patients with altered and abnormal cardiac architecture combined with exposure to bacteria from trauma and other potentially high-risk activities with transient bacteremia.

Utilization of Prophylactic Antibiotics for Cardiac Patients Undergoing Dental Procedures in Saudi Arabia: A Retrospective Study

Objectives

This study aimed to determine the characteristics of antibiotic prophylaxis (AP) utilization and the level of adherence of King Saud University Medical City (KSUMC) staff to the latest American Heart Association (AHA) guidelines for AP for infective endocarditis (IE) in cardiac patients undergoing dental procedures.

Methods

The study was conducted as a retrospective cohort study to investigate the relationship between AP in dental procedures and cardiac patients admitted in the surgical wards of KSUMC between 2015 and 2021. All cardiac patients who underwent dental procedures were included in the study. We excluded patients with long-term or concurrent antibiotic use for other indications.

Results

Overall, 170 (69.4%) cardiac patients received AP before undergoing a dental procedure. The most common comorbidities were hypertension (39.1%) and diabetes (34.2%). Most of the low-risk (69.4%) and moderate-risk (70.5%) patients received AP, despite the guideline's recommendation to limit AP to high-risk patients only. Moreover, only 53.8% of high-risk patients were prescribed AP. In total, 95.9% of the 170 patients who received AP did so without following the recommendations. Only one patient developed IE during the 1-year follow-up. Tooth extraction was the only significant predictor of AP prescription in our study (P = 0.001; OR: 3.73; 95% CI; 1.678-8.298).

Conclusion

There was an exceeding level of inconsistency (95.9%) in AP utilization by cardiac patients in our sample compared with the recommendations of the latest AHA guidelines.

Complications and treatment errors in periodontal therapy in medically compromised patients

Patients who are medically compromised may be at an increased risk of complications and treatment errors following periodontal therapy. A review of the evidence on the topic is presented, in relation to the type of complication reported, of periodontal treatment, and of patients' medical status. Further, a framework for risk assessment and appropriate treatment modifications is introduced, with the aim of facilitating the management of patients with existing comorbidities and reducing the incidence of treatment complications.

Association between cardiovascular diseases and periodontal disease: more than what meets the eye

Cardiovascular diseases (CVDs) are inflammatory diseases of coronary arteries accompanying atheroma formation that can spawn impairment and, in severe cases, death. CVDs are the leading cause of death in the world. In recent decades, investigators have focused their impact on CVD by periodontal disease (PD). PD is a risk factor that can trigger the formation, maturation, and instability of atheroma in the arteries. Two mechanisms have been proposed to explain this relationship: periodontopathic pathogens explicitly invade the circulation or indirectly increase systemic levels of inflammatory mediators. It has been suggested that improvement in disease state has a positive effect on others. This review summarizes evidence from epidemiological studies as well as researches focusing on potential causation channels to deliver a comprehensive representation of the relationship between PD and CVD.

The Contribution of the Human Oral Microbiome to Oral Disease: A Review

The oral microbiome is an emerging field that has been a topic of discussion since the development of next generation sequencing and the implementation of the human microbiome project. This article reviews the current literature surrounding the oral microbiome, briefly highlighting most recent methods of microbiome characterization including cutting edge omics, databases for the microbiome, and areas with current gaps in knowledge. This article also describes reports on microorganisms contained in the oral microbiome which include viruses, archaea, fungi, and bacteria, and provides an in-depth analysis of their significant roles in tissue homeostasis. Finally, we detail key bacteria involved in oral disease, including oral cancer, and the current research surrounding their role in stimulation of inflammatory cytokines, the role of gingival crevicular fluid in periodontal disease, the creation of a network of interactions between microorganisms, the influence of the planktonic microbiome and cospecies biofilms, and the implications of antibiotic resistance. This paper provides a comprehensive literature analysis while also identifying gaps in knowledge to enable future studies to be conducted.

Infective endocarditis: association between origin of causing bacteria and findings during oral infection screening

Background

Oral streptococci represent the causing microorganism for infective endocarditis (IE) in many patients. The impact of oral infections is questioned, and it has been suggested that bacteraemia due to daily routines may play a bigger part in the aetiology of IE. The aim of this study was to examine the association between oral health and infective endocarditis caused by oral bacteria in comparison with bacteria of other origin than the oral cavity.

Methods

A retrospective study was conducted at Haukeland University Hospital from 2006- 2015. All consecutive adult patients admitted to hospital for treatment of IE and subjected to an oral focus screening including orthopantomogram, were included. The clinical, radiological and laboratory characteristics of the patients, collected during oral infectious focus screening, were analysed. Patient survival was calculated using Kaplan–Meier and mortality rates were compared using Cox-regression.

Results

A total of 208 patients were included, 77% (n = 161) male patients and 23% (n = 47) female, mean age was 58 years. A total of 67 (32%) had IE caused by viridans streptococci. No statistically significant correlation could be found between signs of oral infection and IE caused by viridans streptococci. The overall mortality at 30 days was 4.3% (95% CI: 1.6–7.0). There was no statistical difference in mortality between IE caused by viridans streptococci or S. aureus (HRR = 1.16, 95% CI: 0.57–2.37, p = 0.680).

Conclusion

The study indicates that the association between origin of the IE causing bacteria and findings during oral infection screening might be uncertain and may suggest that the benefit of screening and elimination of oral infections in patients admitted with IE might be overestimated. However, the results should be interpreted with caution and further studies are needed before any definite conclusions can be drawn.

Dietary magnesium intake is protective in patients with periodontitis

Background

Periodontitis is a chronic inflammatory disease of the oral cavity characterized by inflammation of the periodontal tissue and resorption of the alveolar bone, which has a high incidence and is the main cause of tooth loss in adults. In addition to its role in promoting osteogenesis, magnesium also has a role in regulating the inflammatory response, both systemically and locally. There is growing evidence that magnesium is an important factor in maintaining the normal functioning of the body's immune system. Hypomagnesaemia can lead to a variety of chronic inflammatory diseases throughout the body, including periodontitis. Two-thirds of the US population suffers from magnesium deficiency. The connection between dietary magnesium and periodontitis is unknown. As a result, we set out to investigate the link between dietary magnesium intake and periodontitis.

Methods

In this study, we collected data from the National Health and Nutrition Examination Survey (NHANES) database from 2013 to 2014. Through 24-h dietary recalls, information about food consumption was collected. We examined the association between the dietary magnesium and periodontitis using multivariable logistic regression model. Based on odds ratios (OR) and 95% confidence intervals (CIs), a strong association was detected.

Results

Multivariable logistic regression analysis showed that the OR for periodontitis comparing the highest to the lowest quintile of dietary magnesium intake was 0.69 (95% CIs = 0.52~0.92). The restricted cubic spline (RCS) analysis showed that the non-linear association between dietary magnesium and periodontitis was statistically significant and that dietary magnesium supplementation reduced the prevalence of periodontitis.

Conclusion

Dietary magnesium intake is associated with the prevalence of periodontitis. Dietary magnesium deficiency increases the prevalence of periodontitis.

Outer membrane vesicles of the oral pathogen Porphyromonas gingivalis promote aggregation and phagocytosis of Staphylococcus aureus

Staphylococcus aureus is an opportunistic Gram-positive bacterial pathogen that causes a wide variety of infectious diseases, including S. aureus bacteremia (SAB). Recent studies showed that rheumatoid arthritis (RA) is a risk factor for SAB, as RA patients appear to be more susceptible to SAB and display higher degrees of disease severity or complications, such as osteoarticular infections. On the other hand, Porphyromonas gingivalis is a Gram-negative bacterial oral pathogen, which is notable for its implication in the etiopathogenesis of RA due to its unique citrullinating enzyme PPAD and its highly effective proteases, known as gingipains. Both PPAD and gingipains are abundant in P. gingivalis outer membrane vesicles (OMVs), which are secreted nanostructures that originate from the outer membrane. Here we show that P. gingivalis OMVs cause the aggregation of S. aureus bacteria in a gingipain- and PPAD-dependent fashion, and that this aggregation phenotype is reversible. Importantly, we also show that the exposure of S. aureus to OMVs of P. gingivalis promotes the staphylococcal internalization by human neutrophils with no detectable neutrophil killing. Altogether, our observations suggest that P. gingivalis can eliminate its potential competitor S. aureus by promoting staphylococcal aggregation and the subsequent internalization by neutrophils. We hypothesize that this phenomenon may have repercussions for the host, since immune cells with internalized bacteria may facilitate bacterial translocation to the blood stream, which could potentially contribute to the association between RA and SAB.

The Clinical View on Streptococcus anginosus Group – Opportunistic Pathogens Coming Out of Hiding

Three distinct streptococcal species: Streptococcus anginosus, Streptococcus intermedius, and Streptococcus constellatus, belonging to the Streptococcus anginosus group (SAG), also known as Streptococcus milleri group, have been attracting clinicians and microbiologists, not only as oral commensals but also as opportunistic pathogens. For years they have been simply classified as so called viridans streptococci, and distinct species were not associated with particular clinical manifestations. Therefore, description of SAG members are clearly underrepresented in the literature, compared to other medically relevant streptococci. However, the increasing number of reports of life-threatening infections caused by SAG indicates their emerging pathogenicity. The improved clinical data generated with the application of modern molecular diagnostic techniques allow for precise identification of individual species belonging to SAG. This review summarizes clinical reports on SAG infections and systematizes data on the occurrence of individual species at the site of infection. We also discuss the issue of proper microbiological diagnostics, which is crucial for further clinical treatment.

Bloodstream infection in hospital therapeutic patients

Bloodstream infection (BI) is the cause of high mortality. Hospital bloodstream infection (HBI) complicates hemodialysis, pneumonia, oncohematological diseases. Positive hemoculture obtaining depends on the volume of blood inoculation, the number of blood samples, the incubation time. To test the principles of microbiological culturomics in the diagnosis BI of hospital patients with a therapeutic profile. 848 hospital cardiac patients with suspected BI were included. 10 ml of blood were taken intravenously with a syringe, blood was inoculated into 200 ml of the heart-brain medium (HBM) in an anaerobic bottle. It was incubated for 7 or more days in a thermostat at +37º C. The hemocultures were obtained in 64.3% of cases with paired blood sampling with an interval of 30 minutes whereas an increase in the number of blood samples reduced the effectiveness of obtaining hemocultures to 9.1%. When incubating bottles for more than 7 days there were obtained 200 additional hemocultures containing 239 strains of microorganisms. Episodes of HBI were observed more often in the cases of the circulatory system (77.8%), including infectious endocarditis (IE) (47.0%), rheumatism (22.1%), myocarditis (14.6%). Episodes of HBI occurred more often in men with IE and coronary heart disease, in women - with rheumatism and myocarditis. Patients aged 45-75 were in the group of risk with a probability of complications of HBI up to 73.7%. When examining the blood of 848 hospital patients of cardiological profile HBI was detected in 38.3% of cases. Among clinical isolates gram-positive cocci with a great number S.epidermidis prevailed. Polymicrobial hemocultures (16.3%) were characterized by two and three associates in one blood sample. Among the hematological indicators in HBI there were: leukocytosis, increased ESR, lymphocytosis, decreased hemoglobin; increased values of fibrinogen, CRP, γ-globulin, α2-globulin, low levels of total protein and A/G coefficient. The techniques of microbiological culturomics were used. HBI was diagnosed in 38.3% of the therapeutic patients of cardiological profile. The etiology of HBI was characterized by polymicrobicity in 16.3% of cases. Hematological markers of HBI were identified.

Streptococcus oralis Employs Multiple Mechanisms of Salivary Mucin Binding That Differ Between Strains

Streptococcus oralis is an oral commensal and opportunistic pathogen that can enter the bloodstream and cause bacteremia and infective endocarditis. Here, we investigated the mechanisms of S. oralis binding to oral mucins using clinical isolates, isogenic mutants and glycoconjugates. S. oralis bound to both MUC5B and MUC7, with a higher level of binding to MUC7. Mass spectrometry identified 128 glycans on MUC5B, MUC7 and the salivary agglutinin (SAG). MUC7/SAG contained a higher relative abundance of Lewis type structures, including Lewis b/y, sialyl-Lewis a/x and α2,3-linked sialic acid, compared to MUC5B. S. oralis subsp. oralis binding to MUC5B and MUC7/SAG was inhibited by Lewis b and Lacto-N-tetraose glycoconjugates. In addition, S. oralis binding to MUC7/SAG was inhibited by sialyl Lewis x. Binding was not inhibited by Lacto-N-fucopentaose, H type 2 and Lewis x conjugates. These data suggest that three distinct carbohydrate binding specificities are involved in S. oralis subsp. oralis binding to oral mucins and that the mechanisms of binding MUC5B and MUC7 differ. Efficient binding of S. oralis subsp. oralis to MUC5B and MUC7 required the gene encoding sortase A, suggesting that the adhesin(s) are LPXTG-containing surface protein(s). Further investigation demonstrated that one of these adhesins is the sialic acid binding protein AsaA.

Applications of Novel and Nanostructured Drug Delivery Systems for the Treatment of Oral Cavity Diseases

PURPOSE

Novel drug delivery systems (DDSs) hold great promise for the treatment of oral cavity diseases. The main objective of this article was to provide a detailed overview regarding recent advances in the use of novel and nanostructured DDSs in alleviating and treating unpleasant conditions of the oral cavity. Strategies to maximize the benefits of these systems in the treatment of oral conditions and future directions to overcome these issues are also discussed.

METHODS

Publications from the last 10 years investigating novel and nanostructured DDSs for pathologic oral conditions were browsed in a systematic search using the PubMed/MEDLINE, Web of Science, and Scopus databases. Research on applications of novel DDSs for periodontitis, oral carcinomas, oral candidiasis, xerostomia, lichen planus, aphthous stomatitis, and oral mucositis is summarized. A narrative exploratory review of the most recent literature was undertaken.

FINDINGS

Conventional systemic administration of therapeutic agents could exhibit high clearance of drugs from the bloodstream and low accumulation at the target site. In contrast, conventional topical systems face problems such as short residence time in the affected region and low patient compliance. Novel and nanostructured DDSs are among the most effective and commonly used methods for overcoming the problems of conventional DDSs. The main advantages of these systems are that they possess the ability to protect active agents from systemic and local clearance, enhance bioavailability and cellular uptake, and provide immediate or modified release of therapeutic agents after administration. In the design of local drug delivery devices such as nanofiber mats, films, and patches, components and excipients can significantly affect factors such as drug release rate, residence time in the oral cavity, and taste in the mouth. Choosing appropriate additives is therefore essential.

IMPLICATIONS

Local drug delivery devices such as nanofiber mats, nanoparticles, liposomes, hydrogels, films, and patches for oral conditions can significantly affect drug efficacy and safety. However, more precise clinical studies should be designed and conducted to confirm promising in vitro and in vivo results. In recent years, novel and nanostructured DDSs increasingly attracted the attention of researchers as a means of treatment and alleviation of oral diseases and unpleasant conditions. However, more clinical studies should be performed to confirm promising in vitro and in vivo results. To transform a successful laboratory model into a marketable product, the long-term stability of prepared formulations is essential. Also, proper scale-up methods with optimum preparation costs should be addressed.

Type IV Pili of Streptococcus sanguinis Contribute to Pathogenesis in Experimental Infective Endocarditis

Streptococcus sanguinis is a common cause of infective endocarditis (IE). Efforts by research groups are aimed at identifying and characterizing virulence factors that contribute to the ability of this organism to cause IE. This Gram-positive pathogen causes heart infection by gaining access to the bloodstream, adhering to host extracellular matrix protein and/or platelets, colonizing the aortic endothelium, and incorporating itself into the aortic vegetation. While many virulence factors have been reported to contribute to the ability of S. sanguinis to cause IE, it is noteworthy that type IV pili (T4P) have not been described to be a virulence factor in this organism, although S. sanguinis strains typically encode these pili. Type IV pili are molecular machines that are capable of mediating diverse virulence functions and surface motility. T4P have been shown to mediate twitching motility in some strains of S. sanguinis, although in most strains it has been difficult to detect twitching motility. While we found that T4P are dispensable for direct in vitro platelet binding and aggregation phenotypes, we show that they are critical to the development of platelet-dependent biofilms representative of the cardiac vegetation. We also observed that T4P are required for in vitro invasion of S. sanguinis into human aortic endothelial cells, which indicates that S. sanguinis may use T4P to take advantage of an intracellular niche during infection. Importantly, we show that T4P of S. sanguinis are critical to disease progression (vegetation development) in a native valve IE rabbit model. The results presented here expand our understanding of IE caused by S. sanguinis and identify T4P as an important virulence factor for this pathogen.

IMPORTANCE This work provides evidence that type IV pili produced by Streptococcus sanguinis SK36 are critical to the ability of these bacteria to attach to and colonize the aortic heart valve (endocarditis). We found that an S. sanguinis type IV pili mutant strain was defective in causing platelet-dependent aggregation in a 24-h infection assay but not in a 1-h platelet aggregation assay, suggesting that the type IV pili act at later stages of vegetation development. In a rabbit model of disease, a T4P mutant strain does not develop mature vegetations that form on the heart, indicating that this virulence factor is critical to disease and could be a target for IE therapy.

Periodontitis and cardiovascular disease: A literature review

BACKGROUND

Cardiovascular diseases (CVDs) are in charge of many deaths worldwide including myocardial infarction (MI), hypertension (HTN), coronary atherosclerosis (CAS), infective endocarditis (IE), heart failure (HF), arterial fibrillation (AF), and peripheral artery disease (PAD). Besides, periodontitis is the sixth prevalent disease among humans and it seems that there are common risk factors between these diseases which are creating communication between prevalence and treatment. The purpose of this study is to assess the articles that reviewed the relationship between heart diseases and periodontitis.

METHODS

Three databases, including PubMed, Scopus, and Web of Science were searched until November 2020. The search terms "periodontal disease, periodontitis, oral health, cardiovascular disease, atherosclerosis, myocardial infarction, hypertension, coronary heart disease, angina pectoris, arterial fibrillation, arrhythmia, and peripheral artery disease" were used in combination to identify the publications providing data.

RESULTS

MI, HTN, atherosclerosis diseases for coronary artery, IE, HF, AF, and PAD were associated with periodontitis. It seems that the treatment of periodontitis may help to improve the state of mentioned heart-related diseases. However, more studies are needed to prove this relationship.

CONCLUSION

The prevalence of heart diseases is more common in individuals with periodontitis.

Influence of periodontal treatment on blood microbiotas: a clinical trial

Objective

To investigate the effects of periodontal treatment on the abundance and diversity of blood microbiota.

Methods and Materials

Twenty-seven periodontitis patients were randomly allocated to a control group (A) and two test groups (B1 and B2). Group A patients received full-mouth scaling and root planing (SRP), group B1 patients received subgingival glycine air polishing (GAP) right after SRP, and group B2 patients received subgingival glycine air polishing right before SRP. Peripheral blood samples were obtained at the baseline, the day after periodontal treatment, and 6 weeks after treatment and evaluated using nested polymerase chain reaction and 16SrRNA Gene Sequencing (Miseq platform).

Results

All participants exhibited significant improvements in the clinical parameters evaluated at the 6-week follow-up visit compared to the values at the baseline, but no significant differences were observed between the three groups. The total bacterial count was lowest in group B2. The bacterial species diversity (α-diversity) in group B1 was significantly higher (Chao-1 index, P = 0.03) and Porphyromonas and Pantoea were the dominant genera (linear discriminant analysis (LDA > 2)) in this group the day after treatment compared to the baseline. No significant difference was detected in the relative abundance and α-diversity of blood microbiota between the baseline and 6 weeks after treatment.

Conclusion

Local periodontal treatment merely disrupts the stability of blood microbiota in the short term. Periodontitis treatment using full-mouth SRP followed by adjunctive GAP is a promising approach to reduce the introduction of bacteria into the bloodstream during the procedure.

Association Between Periodontal Disease and Atherosclerotic Cardiovascular Diseases: Revisited

Atherosclerotic cardiovascular disease (ACVD) is an inflammatory disease of the coronary arteries associated with atheroma formation, which can cause disability and often death. Periodontitis is ranked as the sixth most prevalent disease affecting humans affecting 740 million people worldwide. In the last few decades, researchers have focused on the effect of periodontal disease (PD) on cardiovascular disease. The aim of this review was to investigate the association between these two diseases. PD is a potential risk factor that may initiate the development, maturation, and instability of atheroma in the arteries. Two mechanisms were proposed to explain such association, either periodontal pathogens directly invade bloodstream or indirectly by increasing systemic level of inflammatory mediators. Interestingly, it has been suggested that improvement in the condition of one disease positively impact the condition of the other one. Highlighting the association between these two diseases, the importance of early diagnosis and treatment of PD and its impact on cardiovascular status may be of great value in reducing the complications associated with ACVDs. Further in vitro and in vivo studies with longer follow up are necessary to confirm the causal relationship between PD and ACVDs.

Antimicrobial susceptibility pattern of oral viridans group Streptococci in children at risk of infective endocarditis

Infective endocarditis (IE) is an important clinical disease in children with a mortality rate of 11.6%. Prophylaxis with antibiotics is one of the most commonly used methods in children at risk of IE; therefore, the evaluation of antibiotic resistance seems necessary in view of its increasing trend. This study aimed to determine the antibiotic susceptibility pattern of oral viridans group streptococci (VGS) isolated from the dental plaque of children at risk of IE. Fifty-one plaque samples were obtained from children aged 3 to 12 years old in the period from April to July 2018. Samples were obtained with sterile swabs and were transferred to the laboratory in Brain Heart Infusion (BHI) Broth. Samples were immediately cultivated on Columbia blood agar. After identifying VGS, antimicrobial susceptibility test (AST) was performed using Mueller-Hinton agar (MHA) with sheep's blood and E-test strips for selected antibiotics. The minimum inhibitory concentration (MIC) was determined for each isolate and the results were reported as sensitive, intermediate and resistant. Fifty-one VGS bacteria were isolated from children with an average age of 7.3 ± 2.5 years. The highest resistance was observed for azithromycin in 36 (70.6%) isolates and then cefazolin in 35 (68.6%) isolates. The highest susceptibility was observed for amoxicillin in 46 (90.2%) isolates. Based on the findings of this study, amoxicillin is the most effective option for prophylaxis in children. Furthermore, cefazolin should be used with caution because bacteria resistant to this antibiotic can transfer resistance genes to other bacteria.

Association between Perceived Oral Symptoms and Presence of Clinically Diagnosed Oral Diseases in a Sample of Pregnant Women in Malaysia

The integration of oral health into primary health care denotes the important role of medical counterparts as the front liners in antenatal care to help screen mothers for oral symptoms and refer them to dentists accordingly. However, the validity of self-perceived oral health status is inconclusive. This study determined the association between self-perceived oral symptoms and the presence of clinically diagnosed oral diseases in a sample of pregnant women. A total of 192 pregnant women participated in this cross-sectional study. Clinical oral examinations were performed to record dental caries experience, gingival health and periodontal health. The women were also asked about their oral symptoms. Most women had at least one oral symptom (84.9%): cavitated tooth (62.0%), bad breath (38.5%), bleeding gums (28.6%), and toothache (22.9%). About half of the women had untreated dental caries (58.9%), and the odds were significantly higher in women who complained of having cavitated tooth. About half of the women had moderate to severe gingivitis (53.7%), and the odds were significantly higher in women who complained of bleeding gums. About half had periodontal pockets (46.3%), and the odds were higher in women who complained of bleeding gums and bad breath although lower in women who complained of swollen gums. In conclusion, the prevalence of dental caries and periodontal disease among pregnant women in this study were relatively high. The presence of untreated dental caries, moderate and severe gingivitis, and periodontal pockets were significantly associated with their corresponding oral symptoms.

Effect of silica nano-spheres on adhesion of oral bacteria and human fibroblasts

OBJECTIVE

This study investigated the effect of surface nano-patterning on adhesion of an oral early commensal colonizer, Streptococcus mitis and the opportunistic pathogen Staphylococcus aureus and human fibroblasts (HDFa) in a laminar flow cell.

METHODS

Nanostructured surfaces were made by functionalizing glass substrates with 40 nm SiO2 nanoparticles. Gradients in nanoparticle surface coverage were fabricated to study the effect of nanoparticle spacing within a single experiment. Bacterial adhesion was investigated after 5 min of contact time by subjecting surfaces to a flow in a laminar flow cell. In addition, to examine the particles effect on human cells, the establishment of focal adhesion and spreading of primary human dermal fibroblasts (HDFa) were investigated after 4 and 24 h.

RESULTS

Adhesion of both S. aureus and S. mitis decreased on surfaces functionalized with nanoparticles and coincided with higher nanoparticle surface coverage on the surface. Both strains were tested on three separate surfaces. The regression analysis showed that S. mitis was influenced more by surface modification than S. aureus. The establishment of focal adhesions in HDFa cells was delayed on the nanostructured part of the surfaces after both 4 and 24 h of culturing.

SIGNIFICANCE

In the current manuscript, we have used a flow cell to investigate the effect of nanotopographies on S. aureus and S. mitis adhesion. The present findings are of relevance for design of future implant and prostheses surfaces in order to reduce adhesion of bacteria.

Periodontal diseases and adverse pregnancy outcomes: Mechanisms

Adverse pregnancy outcomes (APOs) have been defined as (a) pre-term birth, when there is a delivery before 37 completed weeks (<259 days); (b) pre-eclampsia, which is a multisystem disorder of pregnancy characterized by maternal hypertension and proteinuria after the 20th gestational week; (c) low and very low birthweight, depending on whether the weight of the baby is less of 2500 g or <1500 g and (d) the spontaneous death of the fetus with <20 weeks (miscarriage) or between 20 and 36 weeks (stillbirth). In 2012, during the Consensus Report from the Joint EFP/AAP workshop on periodontitis and systematic diseases the role of periodontal diseases on APOs was reviewed. Some years later, this evidence has grown, and an update on the literature regarding the mechanisms related to this potential association (APOs and periodontal diseases) needs to be presented. The two major pathways (direct and indirect) already accepted in 2012 are still valid nowadays. Most evidence published in the last 5 years deals with a strong and solid evidence coming from the direct pathway while there is as scarce new evidence regarding indirect pathway. In this direct pathway, the haematological dissemination of oral microorganisms and their products, would later induce an inflammatory/Immune response in the foetal-placental unit. The most plausible route for this direct pathway is the hematogenous transmission through dental bacteremia, although not many new studies dealing with bacteremia has been performed lately.

Periodontal diseases and association with atherosclerotic disease

Cardiovascular diseases still account for the majority of deaths worldwide, although significant improvements in survival, after being affected by cardiovascular disease, have been achieved in the last decades. Periodontal diseases are also a common global burden. Several studies have shown a link between cardiovascular disease and periodontitis, although evidence is still lacking regarding the direct cause-effect relation. During the 2012 "Periodontitis and systemic diseases" workshop, the available evidence on the association between cardiovascular and periodontal diseases was discussed, covering biologic plausibility and clinical studies. The objective of the present narrative review was to update the previous reviews presented at the 2012 workshop, following similar methodological approaches, aiming to critically assess the available evidence. With regard to biologic plausibility, two aspects were reviewed: (a) for microbiologic mechanisms, assessing periodontal bacteria as a contributing factor to atherosclerosis based on seven "proofs," substantial evidence was found for Proofs 1 through 6, but not for Proof 7 (periodontal bacteria obtained from human atheromas can cause atherosclerosis in animal models), concluding that periodontal pathogens can contribute to atherosclerosis; (b) mechanistic studies, addressing five different inflammatory pathways that could explain the links between periodontitis and cardiovascular disease with the addition of some extra pathways , suggest an association between both entities, based on the presence of higher levels of these inflammatory markers in patients with periodontitis and cardiovascular disease, vs healthy controls, as well as on the evidence that periodontal treatment reduces serum levels of these mediators. When evidence from clinical studies was analyzed, two aspects were covered: (a) epidemiologic studies support the estimation that the incidence of atherosclerotic disease is higher in individuals with periodontitis than in individuals with no reported periodontitis, irrespective of many common risk factors, but with a substantial variability in the definitions used in reporting of exposure to periodontal diseases in different studies; (b) intervention trials have shown that periodontal therapy can reduce serum inflammatory mediators, improve the lipids profile, and induce positive changes in other cardiovascular disease surrogate measures, but no evidence is available to support that adequate periodontal therapy is able to reduce the risk for cardiovascular diseases, or the incidence of cardiovascular disease events in periodontitis patients.

A comparison of different antibiotic regimens for the treatment of infective endocarditis

BACKGROUND

Infective endocarditis is a microbial infection of the endocardial surface of the heart. Antibiotics are the cornerstone of treatment, but due to the differences in presentation, populations affected, and the wide variety of micro-organisms that can be responsible, their use is not standardised. This is an update of a review previously published in 2016.

OBJECTIVES

To assess the existing evidence about the clinical benefits and harms of different antibiotics regimens used to treat people with infective endocarditis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase Classic and Embase, LILACS, CINAHL, and the Conference Proceedings Citation Index - Science on 6 January 2020. We also searched three trials registers and handsearched the reference lists of included papers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of antibiotic regimens for treating definitive infective endocarditis diagnosed according to modified Duke's criteria. We considered all-cause mortality, cure rates, and adverse events as the primary outcomes. We excluded people with possible infective endocarditis and pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment, and data extraction in duplicate. We constructed 'Summary of findings' tables and used GRADE methodology to assess the quality of the evidence. We described the included studies narratively.

MAIN RESULTS

Six small RCTs involving 1143 allocated/632 analysed participants met the inclusion criteria of this first update. The included trials had a high risk of bias. Three trials were sponsored by drug companies. Due to heterogeneity in outcome definitions and different antibiotics used data could not be pooled. The included trials compared miscellaneous antibiotic schedules having uncertain effects for all of the prespecified outcomes in this review. Evidence was either low or very low quality due to high risk of bias and very low number of events and small sample size. The results for all-cause mortality were as follows: one trial compared quinolone (levofloxacin) plus standard treatment (antistaphylococcal penicillin (cloxacillin or dicloxacillin), aminoglycoside (tobramycin or netilmicin), and rifampicin) versus standard treatment alone and reported 8/31 (26%) with levofloxacin plus standard treatment versus 9/39 (23%) with standard treatment alone; risk ratio (RR) 1.12, 95% confidence interval (CI) 0.49 to 2.56. One trial compared fosfomycin plus imipenem 3/4 (75%) versus vancomycin 0/4 (0%) (RR 7.00, 95% CI 0.47 to 103.27), and one trial compared partial oral treatment 7/201 (3.5%) versus conventional intravenous treatment 13/199 (6.53%) (RR 0.53, 95% CI 0.22 to 1.31). The results for rates of cure with or without surgery were as follows: one trial compared daptomycin versus low-dose gentamicin plus an antistaphylococcal penicillin (nafcillin, oxacillin, or flucloxacillin) or vancomycin and reported 9/28 (32.1%) with daptomycin versus 9/25 (36%) with low-dose gentamicin plus antistaphylococcal penicillin or vancomycin; RR 0.89, 95% CI 0.42 to 1.89. One trial compared glycopeptide (vancomycin or teicoplanin) plus gentamicin with cloxacillin plus gentamicin (13/23 (56%) versus 11/11 (100%); RR 0.59, 95% CI 0.40 to 0.85). One trial compared ceftriaxone plus gentamicin versus ceftriaxone alone (15/34 (44%) versus 21/33 (64%); RR 0.69, 95% CI 0.44 to 1.10), and one trial compared fosfomycin plus imipenem versus vancomycin (1/4 (25%) versus 2/4 (50%); RR 0.50, 95% CI 0.07 to 3.55). The included trials reported adverse events, the need for cardiac surgical interventions, and rates of uncontrolled infection, congestive heart failure, relapse of endocarditis, and septic emboli, and found no conclusive differences between groups (very low-quality evidence). No trials assessed quality of life.

AUTHORS' CONCLUSIONS

This first update confirms the findings of the original version of the review. Limited and low to very low-quality evidence suggests that the comparative effects of different antibiotic regimens in terms of cure rates or other relevant clinical outcomes are uncertain. The conclusions of this updated Cochrane Review were based on few RCTs with a high risk of bias. Accordingly, current evidence does not support or reject any regimen of antibiotic therapy for the treatment of infective endocarditis.

Lack in Periodontal Care of Patients Suffering from Severe Heart Diseases-Results after 12 Months Follow-Up

BACKGROUND

To assess whether the standardized recommendation of patients with heart failure (HF), left-ventricular assist device (LVAD) and heart transplantation (HTx) to visit their dentist leads to improved oral conditions after 12 months.

METHODS

Patients from the Department of Cardiothoracic Surgery, Leipzig Heart Centre, Germany were examined at baseline and after 12 months. A dental (decayed-, missing-, and filled-teeth index (DMF-T)) and periodontal examination (periodontal probing depth, clinical attachment loss) was performed. At baseline, patients received a standardized recommendation to visit their dentist. At follow-up, a standardized questionnaire regarding the dental consultation was applied.

RESULTS

Eighty-eight participants (HTx: 31, LVAD: 43, HF: 14) were included. The majority of patients (79.5%) followed the recommendation to visit their dentist. Within the total cohort, periodontal treatment need was significantly reduced from 91% (baseline) to 75% (follow-up; p < 0.01). Only 10% of total cohort stated that they received periodontal treatment. The outcome in periodontal and dental treatment need at follow-up appointment revealed no statistically significant associations to the questionnaire regarding dentist consultation (p > 0.05). Conclusions: The simple recommendation to visit the dentist appears not enough to obtain sufficient dental and periodontal conditions in patients with severe heart diseases. Thereby, a lack in periodontal treatment of patients with HF, HTx and LVAD was identified, making interdisciplinary dental special care programs recommendable.

Periodontal Disease in Association with Systemic Diseases in the Dog

Periodontal disease (PD) is the second most common disease affecting dogs in UK veterinary practices. Veterinary and human literature suggests that periodontal disease may be associated with bacteraemia and a chronic, systemic release of inflammatory mediators which produce direct or immune-mediated changes elsewhere in the body. Thirty canine periodontal patient’s electronic medical histories were analysed for comorbidities. The findings were analysed overall to identify any possible associations. Seventy three percent of these dogs had comorbidities, most commonly haematopoietic, cardiovascular, musculoskeletal and hepatic systems were involved. The most prevalent comorbidities were: high liver enzymes, heart murmur, mitral valve disease, and monocytosis. Other interesting comorbidities were: endocarditis, neutrophilia, submandibular lymph node enlargement and arthritis. Periodontal disease patients had a higher prevalence of disease when compared to the disease prevalence data for UK pet dogs in general. Mitral valve disease was over 17 times more likely in the periodontal disease patients. Comorbidity disease prevalence also increased with more severe periodontal disease stages. This study supports an association between periodontal disease and systemic diseases in the dog. Further studies should focus on confirming a cause and effect relationship. Until then, these data may be useful for veterinarians to examine periodontal patients for concurrent diseases and can be used as a tool to promote dental disease prevention to pet owners.

Preterm birth associated with periodontal and dental indicators: a pilot case-control study in a developing country

Introduction: Preterm delivery is a multifactorial health problem that represents a serious public health problem around the world. In recent years, there has been an increase in scientific evidence suggesting associations between oral health status (mainly periodontal disease and tooth loss) and an increased risk of systemic diseases and various adverse pregnancy outcomes. This study explores the association between indicators of oral health and preterm delivery in a sample of Mexican pregnant women.Materials and methods: A case-control study was carried out with 111 pregnant (36 cases, 75 controls) who received prenatal care and delivered in an obstetric hospital in Pachuca, Mexico. Clinical files were reviewed to obtain the necessary information for the variables studied. The dependent variable was preterm delivery and the independent variables were gingivitis, periodontitis, DMFT index and its components, the number of decayed teeth with pulpal exposure or endodontic lesions, age of the mother, education, alcohol use, smoking status, number of gestations, and sex of the newborn.Results: The average ages were similar between the cases and the controls (24.29 ± 5.42 versus 24.89 ± 5.67, p = .5781). Significant differences were observed with gingivitis (p < .01) and periodontitis (p < .001). In addition, when the severity of gingivitis or periodontitis increased, the percentage of cases of preterm delivery increased (p < .01). The average number of teeth lost was higher among the cases than among the controls (1.33 ± 1.89 versus 0.81 ± 1.82, p < .05).Conclusions: It was found that gingivitis, periodontitis, and tooth loss were associated with preterm delivery. It is necessary to carry out actions aimed at the preservation of oral health in pregnant patients to avoid adverse results. These findings indicate a likely association, but it needs to be confirmed by large and well-designed studies.