Does chlorhexidine reduce bacteremia following tooth extraction? A systematic review and meta-analysis

Localised 0.2% chlorhexidine irrigation delivery system versus oral antibiotics in reducing postoperative complications in the surgical extraction of impacted mandibular third molar (IMTM). - a randomised controlled trial

BACKGROUND

The purpose of the study was to compare the efficacy of the use of 0.2% chlorhexidine irrigation and the oral antibiotics for the prevention of postoperative complication like pain, trismus, swelling and infection after the surgical extraction of IMTM.

MATERIAL AND METHODS

A randomised, double blinded clinical trial was planned with two equal groups. Patients were randomly divided into two groups using computer-generated codes with an allocation ratio of 1:1. Group I (Control): Standard preoperative and postoperative systemic oral antibiotics and Group II (Study): No systemic antibiotics and Chlorhexidine irrigation local delivery. The primary outcomes evaluated were postoperative pain, mouth opening, swelling and infection. The secondary outcome variables were the number of analgesics and antibiotics taken by the patient in the postoperative period, the satisfaction of the patient and adverse events, were followed up regulary for 7 days postoperatively.

RESULTS

A total of 84 patients, divided into two equal groups participated in the study. In intergroup comparison of swelling, the difference was non-significant on postoperative day (POD) 1 and 7, except for POD 3, where it showed significantly lower results in the antibiotic group (p = 0.012). However, there was no significant difference in pain found between both groups at any of the postoperative time points, and the study group had a lesser need for rescue analgesics than the control group. A statistically significant difference in incidence of dry socket was observed (p = 0.03) and gastrointestinal adverse symptoms, but it showed insignificant results for wound dehiscence and pus discharge. Also, patient satisfaction was higher in the study group.

CONCLUSIONS

both antibiotics and localised delivery demonstrated comparable results in terms of swelling, pain and trismus. However, with lesser adverse events, the localised chlorhexidine delivery with curved tips outperformed the antibiotic group.

Stroke Caused by Vasculitis Induced by Periodontitis-Associated Oral Bacteria after Wisdom Teeth Extraction

Invasive dental procedures, such as wisdom teeth removal, have been identified as potential triggers for vascular events due to the entry of oral bacteria into the bloodstream, leading to acute vascular inflammation and endothelial dysfunction. This study presents the case of a 27-year-old healthy male who developed ischemic stroke resulting from bacteremia after undergoing wisdom teeth extraction. Initially, the patient experienced fever and malaise, which were followed by right-sided hemiplegia. Diagnostic imaging, including a CT scan, identified a subacute infarction in the posterior crus of the left internal capsule, and MRI findings indicated inflammatory changes in the masticatory muscles. Further investigations involving biopsies of the masticatory muscles, along with blood and cerebrospinal fluid samples, confirmed bacterial meningitis with associated vasculitis. Notably, oral bacteria linked to periodontitis, including Porphyromonas gingivalis, Fusobacterium nucleatum, Tannerella forsythia, and Parvimonas micra, were found in the biopsies and microbiological analyses. To the best of our knowledge, this is the first reported case showing that bacteremia following dental procedures can lead to such severe neurological outcomes. This case underscores the importance of recognizing bacteremia-induced vasculitis in patients presenting with neurological symptoms post-dental procedures, emphasizing the broader implications of oral infections in such pathologies.

Prophylactic therapy for prevention of surgical site infection after extraction of third molar: An overview of reviews

BACKGROUND

To compare the effect of different prophylactic therapies on prevention of surgical site infection after extraction of third molars with different degree of impaction.

MATERIAL AND METHODS

Systematic reviews and meta-analyses evaluating the effect of different prophylactic therapies on prevention of surgical site infection after extraction of third molars were included. An electronic search was performed in PubMed, EMBASE, and the Cochrane Database of Systematic reviews. AMSTAR 2 tool was used to evaluate the confidence in results from the included reviews. Descriptive analyses were performed.

RESULTS

Six reviews were included. A significant benefit of different antibiotics to the prevention of site infection after extraction of third molars was reported. Amoxicillin/amoxicillin clavulanic acid could significantly reduce the rate of surgical site infection versus placebo. Chlorhexidine gel could significantly reduce the frequency of alveolar osteitis versus placebo.

CONCLUSIONS

Based on the limited evidence, there is a significant benefit of prophylactic therapy while the comparative effect of different types of prophylactic regimes are controversial.

Efficacy of mouthwash on reducing salivary SARS-CoV-2 viral load and clinical symptoms: a systematic review and meta-analysis

BACKGROUND

COVID-19 has been a public health emergency of international concern (PHEIC) for a lengthy period of time. The novel coronavirus is primarily spread via aerosols at a short distance, with infected individuals releasing large amounts of aerosols when speaking and coughing. However, there is an open question regarding whether mouthwash could effectively reduce virus transmission during the COVID-19 pandemic and support the prevention of infection among medical workers.

METHODS

Cochrane Library, PubMed, Web of Science, and Embase databases were systematically searched from the inception of each database to January 12, 2023 for currently available randomized clinical trials (RCTs) on the effect of mouthwash on novel coronavirus load in the oral cavity in COVID-19 patients. The treatment group received mouthwash for rinsing the mouth, while the control group received a placebo or distilled water for COVID-19 patients. The primary outcomes were CT value and viral load. Odds ratios (ORs) were estimated using a random-effects model. Subgroup and sensitivity analyses were performed to minimize the bias and the impact of heterogeneity.

RESULTS

Thirteen RCTs were included. Seven studies reported the intervention effect of mouthwash on the CT value of novel coronavirus. The analysis results showed that the mouthwash group had a positive impact on the CT value of novel coronavirus [ SMD = 0.35, 95% CI (0.21, 0.50)] compared with the control group. In addition, subgroup analysis showed a significant positive effect of mouthwash on CT values in the treatment group compared with the control group, with chlorhexidine (CHX) [SMD = 0.33, 95% CI (0.10, 0.56)], povidone-iodine (PVP-I) [SMD = 0.61, 95% CI (0.23, 0.99)], or hydrogen peroxide (HP) [SMD = 1.04, 95% CI (0.30, 1.78)] as an ingredient of the mouthwash. Six studies reported the intervention effect of mouthwash on the viral load, 263 cases in the treatment group and 164 cases in the control group. The analysis results showed that there was no statistical difference between the mouthwash group and the control group in the viral load of novel coronavirus [SMD = -0.06, 95% CI (-0.18, 0.05)]. In the subgroup analysis by measurement time, there were statistically significant differences between the mouthwash and control groups for CT values [SMD = 0.52, 95% CI (0.31, 0.72)] and viral load [SMD =  - 0.32, 95% CI (- 0.56, - 0.07)] within 30 min of gargling.

CONCLUSIONS

In summary, mouthwash has some efficacy in reducing the viral load of novel coronavirus, especially within 30 min after rinsing the mouth. Mouthwash containing CHX, PVP-I and HP all had significant positive effects on CT values, and PVP-I-containing mouthwash may be a promising option to control novel coronavirus infections and relieve virus-related symptoms. However, studies on the dose and frequency of use of mouthwash for infection control are still lacking, which may limit the clinical application of mouthwash.

TRIAL REGISTRATION

Protocol registration: The protocol was registered at PROSPERO (CRD42023401961).

Dental Treatment Under General Anesthesia With Nasal Intubation in a Patient With Selective Immunoglobulin A Deficiency

Immunoglobulin A (IgA) deficiency is one of the most common immune disorders characterized by increased susceptibility to infections, especially involving the respiratory tract and mucosal surfaces of the mouth, gingiva, and nasal sinus. Because dental surgery and general anesthesia may pose an increased risk for systemic infections, management of IgA-deficient patients requires caution during dental procedures and intubated general anesthesia. We report a 5-year-old female patient with IgA deficiency who underwent extraction of 18 deciduous teeth under general anesthesia. Antibiotic prophylaxis and antiseptic mouthwash were used perioperatively to reduce bacteremia risks. Nasotracheal intubation was carefully performed after applying topical disinfectants and epinephrine-containing gauze packing into the nasal cavity to minimize trauma. The patient was carefully monitored overnight in the hospital and discharged without any signs or symptoms of infection the next day. Dental anesthesia providers must be aware of the potential implications for safe practice when managing patients with IgA deficiency.

Bacterial exclusion and wound healing potential of horizontal platelet-rich fibrin (H-PRF) membranes when compared to 2 commercially available collagen membranes

OBJECTIVES

The aim of the present study was to compare the barrier function during bacterial invasion and wound healing properties of 3 commonly used membranes including horizontal platelet-rich fibrin (H-PRF) against two commercially available resorbable collagen membranes.

MATERIALS AND METHODS

H-PRF membranes were prepared by collecting venous blood from 3 healthy volunteers using a 700 g for 8-min centrifugation protocol followed by compression into membranes. To evaluate their barrier function, 3 groups (H-PRF membrane, collagen membrane A (Bio-Gide, Geistlich), collagen membrane B (Megreen, Shanxi Ruisheng Biotechnology Co) were placed between an inner chamber and outer chamber and inoculated with S. aureus. At 2 h, 24 h, and 48 h post-inoculation, cultures from the inner and outer chambers were assessed for bacterial CFUs. Then, scanning electron microscope (SEM) was utilized to visualized the morphological destruction by bacteria of the inner and outer surfaces of the membranes. To assess the wound healing properties of each membrane, leachates from each group were applied to human gingival fibroblasts (HGF) and a scratch assay was performed at 24 h and 48 h.

RESULTS

S. aureus showed a minimal bacterial attachment or invasion rate through either collagen membranes at 2 h post-inoculation, yet over time demonstrated rapid degradation, especially on the rougher surface. While PRF demonstrated higher number of CFUs after 2 h, no significant penetration/degradation of the H-PRF membranes was observed at 24 h and 48 h in the H-PRF group. Both collagen membranes demonstrated significant morphological changes 48 h post-bacterial innoculation, while minimal obvious morphological changes were observed in the H-PRF group. The wound healing assay also demonstrated significantly better wound closure rates in the H-PRF group.

CONCLUSION

H-PRF membranes exhibited better barrier function towards S. aureus over 2 days of innoculation and better wound healing ability when compared to two commercially available collagen membranes.

CLINICAL RELEVANCE

This study provides further evidence for the application of H-PRF membranes during guided bone regeneration by minimizing bacterial invasion. Furthermore, H-PRF membranes have significantly better ability to promote wound healing.

Is Antibiotic Prophylaxis Necessary before Dental Implant Procedures in Patients with Orthopaedic Prostheses? A Systematic Review

As the population ages, more and more patients with orthopaedic prostheses (OPs) require dental implant treatment. Surveys of dentists and orthopaedic surgeons show that prophylactic antibiotics (PAs) are routinely prescribed with a very high frequency in patients with OPs who are about to undergo dental procedures. The present study aims to determine the need to prescribe prophylactic antibiotic therapy in patients with OPs treated with dental implants to promote their responsible use and reduce the risk of antimicrobial resistance. An electronic search of the MEDLINE database (via PubMed), Web of Science, LILACS, Google Scholar, and OpenGrey was carried out. The criteria used were those described by the PRISMA® Statement. No study investigated the need to prescribe PAs in patients with OPs, so four studies were included on the risk of infections of OPs after dental treatments with varying degrees of invasiveness. There is no evidence to suggest a relationship between dental implant surgeries and an increased risk of OP infection; therefore, PAs in these patients are not justified. However, the recommended doses of PAs in dental implant procedures in healthy patients are the same as those recommended to avoid infections of OPs.

Virucidal efficacy of chlorhexidine: a systematic review

This study aimed to systematically review the literature about the virucidal efficacy of CHX in comparison to other substances used in the oral cavity. Electronic searches were performed in four databases (PubMed, Scopus, Embase, and Web of Science). Only studies that presented the following characteristics were included: (1) verified virucidal efficacy of CHX against Herpes Simplex Type-1 (HSV-1), any Influenza, or any human coronavirus (HcoV); and (2) compared the virucidal efficacy of CHX with essential oils (Listerine^®), quaternary ammonium compounds, povidone-iodine, hydrogen peroxide, negative control substance, and absence of therapy. Two researchers independently selected the studies, extracted data and evaluated the risk of bias. A narrative data synthesis was used. Twenty-five studies were included, of which 21 were in vitro and four were randomized clinical trials (RCT). Studies assessed the virucidal efficacy of CHX against Herpes Simplex Type-1 (HSV-1) (10 studies), Influenza A (InfluA) (4 studies), human coronavirus (HCoV) (4 studies) and Severe Acute Respiratory Syndrome-Related Coronavirus (SARS-CoV-2) (11 studies). Most studies demonstrated that CHX has a positive virucidal efficacy against HSV-1 and InfluA strains. However, lower efficacy was shown to InfluA strain in comparison to povidone-iodine. Lower to none virucidal efficacy of CHX is expected for HCoV and SARS-CoV-2 strains for in vitro studies. Three RCT demonstrated that CHX was able to significantly reduce the viral load of SARS-CoV-2 for a short period. CHX may present an interesting virucidal efficacy against HSV-1 and InfluA viruses. CHX also presents transient efficacy against SARS-CoV-2 when used as a mouthwash.

Antibiotika im Rahmen der Endokarditisprophylaxe – Risiko und Nutzen

Für die Effektivität und Effizienz einer antibiotischen Prophylaxe vor zahnmedizinischen Eingriffen zum Schutz vor einer infektiösen Endokarditis liegt nur eine geringe Evidenz vor, die keine Rechtfertigung zur generalisierten Therapie von Patienten mit einem erhöhten Endokarditisrisiko darstellt. Aktuelle Leitlinien empfehlen daher, Antibiotika im Rahmen der Endokarditisprophylaxe auf Patienten zu beschränken, die zum einen ein hohes Risiko für die Entstehung einer infektiösen Endokarditis aufweisen und die sich zum anderen zahnärztlichen Eingriffen mit höchstem Endokarditisrisiko unterziehen. Einen hohen Stellwert besitzen allerdings auch Mund- und Hauthygienemaßnahmen, die nicht nur auf Risikopatienten, sondern auch auf die Allgemeinbevölkerung angewendet werden sollten, da die Inzidenz der infektiösen Endokarditis bei Patienten ohne anamnestisch bekannte Herzerkrankung zunehmend ansteigt.

Current uses of chlorhexidine for management of oral disease: a narrative review

OBJECTIVES

Chlorhexidine (CHX) is a commonly used antiseptic mouthwash, used by dental practitioners and the public, due to its antimicrobial effects. The aim of this article was to provide a narrative review of current antimicrobial uses of CHX relevant to dentistry in the context of oral diseases, highlighting need for further studies to support its safe and appropriate use.

STUDY SELECTION, DATA AND SOURCES

Randomised controlled trials, systematic reviews and national (UK and US) guidelines were consulted where available, with search terms for each subject category entered into MEDLINE, PubMed, Google Scholar and the Cochrane database.

RESULTS

Some evidence existed to support adjunctive short-term use of CHX to manage dental plaque, and reduce clinical symptoms of gingivitis, dry socket, as well as reduce aerosolisation of bacteria. However, use must be weighed alongside the less desirable effects of CHX, including extrinsic staining of teeth, antimicrobial resistance to antiseptic agents and the rare, but fatal, allergic reactions to CHX. Conversely, evidence for the effectiveness of chlorhexidine to manage or prevent periodontitis, dental caries, necrotising periodontal diseases, peri-implantitis, and infections associated with extraction and aerosolised viruses remains less certain.

CONCLUSIONS

The use of CHX in dentistry and oral healthcare continues to be widespread and thus it is important that dental practitioners understand that, based on its differential mechanisms of action on different microbes, appropriate clinical and dental use of CHX should be oral disease specific. However, further scientific and clinical research is required before full recommendations can be made.

Antibacterial activity of viable and heat-killed probiotic strains against oral pathogens

Probiotics can stabilize gut flora, regulate intestinal immunity and protect the host from enteric diseases; however, their roles in oral health have received little attention compared to their roles in gut health. Nowadays, the prevalence of sugar-sweetened foods and abuse of antibiotics contribute towards dysbiosis of oral microbiota and drug resistance development in oral pathogens, resulting in various intractable oral diseases. We screened the antibacterial activities of viable and heat-killed probiotic strains against the oral pathogens Streptococcus mutans, Porphyromonas gingivalis, Fusobacterium nucleatum and Aggregatibacter actinomycetemcomitans. The probiotic strains Lactobacillus salivarius subsp. salicinius AP-32, L. rhamnosus CT-53, L. paracasei ET-66 and Bifidobacterium animalis subsp. lactis CP-9 displayed strong antipathogenic activities, whereas heat-killed AP-32, CT-53 and ET-66 displayed high levels of pathogen inhibition. The antibacterial activities of these probiotics were not associated with their H₂ O₂ production; L. acidophilus TYCA02 produced high levels of H₂ O₂ but merely exhibited moderate antibacterial activities. Oral tablets containing probiotics showed positive inhibitory effects against oral pathogens, particularly those containing viable probiotics. Our results indicate that probiotics prevent the growth of oral pathogens and improve oral health, providing insights into the antipathogenic efficacy of different probiotic species and their potential role in functional foods that improve oral health. SIGNIFICANCE AND IMPACT OF THE STUDY: Our study provides insights into the antipathogenic efficacy of different probiotic species and their potential roles in developing functional foods to improve oral health. We showed that the probiotic strains Lactobacillus salivarius subsp. salicinius AP-32, L. rhamnosus CT-53, L. paracasei ET-66 and Bifidobacterium animalis subsp. lactis CP-9 have great potential for use in the development of functional foods to improve oral health. Since active probiotics may provide strong and long-term protection, the development of functional food products should favour the use of viable bacteria.

Surgical Wound Healing in the Oral Cavity: a Review

Wound healing is a fundamental survival mechanism, largely taken for granted. It consists of four intricately tuned phases: haemostasis, inflammation, proliferation and remodelling. Successful wound healing only occurs if each phase occurs in the correct sequence and timeframe. Moreover, the oral cavity serves as a unique and remarkable setting whereby wound healing takes place in a saliva-filled environment containing millions of micro-organisms. Many local and systemic factors can impair oral wound healing. This article provides an overview of the wound healing process, with a discussion of these respective local and systemic factors, along with the potential cellular and/or molecular mechanisms involved.

CPD/Clinical Relevance: On a daily basis, dentists perform procedures such as exodontia and implant placement that rely on adequate wound healing. An improved understanding of the local and systemic factors that can impair oral wound healing can help clinicians to control these factors more accurately, resulting in improved patient outcomes.

Prevention of Postdental Procedure Bacteremia: A Network Meta-analysis

Postdental procedure bacteremia is common and troublesome. The comparative efficacy of multiple prophylactic interventions is unclear. We compared the efficacy of interventions for the prevention of postdental procedure bacteremia. We conducted a review of ClinicalKey, Cochrane CENTRAL, Embase, ProQuest, PubMed, ScienceDirect, Web of Science, and ClinicalTrials.gov from inception to December 4, 2018. Randomized controlled trials that evaluated prophylactic interventions for the prevention of postdental procedure bacteremia were eligible. The primary outcome was the incidence of postdental procedure bacteremia. A total of 24 trials were included with 2,147 participants. Our network meta-analysis demonstrated that intravenous administration of 1,000/200 mg of amoxicillin/clavulanate provided the least incidence of postdental procedure bacteremia among all the prophylactic interventions (odds ratio = 0.03, 95% CI = 0.00 to 0.63) as compared with the placebo/controls. Oral 3 g of amoxicillin had the least incidence of postdental procedure bacteremia among all oral or topical forms of prophylactic interventions (odds ratio = 0.10, 95% CI = 0.02 to 0.44) as compared with the placebo/controls. No serious adverse events, such as anaphylactic shock, mortality, and the development of antibiotic-resistant bacteria, were reported. None of the included subjects were of high risk of infectious endocarditis. Our network meta-analysis demonstrates that intravenous amoxicillin/clavulanate and oral amoxicillin might be the best prophylactic interventions in preventing postdental procedure bacteremia among all the oral/topical forms of interventions for the overall populations.