Bacteremia after prophylaxis

A systematic review of professional mechanical plaque removal for prevention of periodontal diseases

AIM

To investigate the effect of professional mechanical plaque removal (PMPR) on the prevention of periodontal diseases.

METHODS

We searched for randomized controlled trials, controlled clinical trials and cohort studies from 1950 to October 2004. Screening and data abstraction were conducted independently and in duplicate. Critical appraisal of studies was based on objective criteria and evidence tables were constructed.

RESULTS

From 2179 titles and abstracts, 132 full-text articles were screened and 32 studies were relevant. Evidence exists that PMPR in adults, particularly in combination with oral hygiene instruction (OHI), may be more effective than no treatment judged by surrogate measures. The evidence for a benefit of PMPR+OHI over OHI alone is less clear. The optimum frequency of PMPR has not been investigated although more frequent PMPR is associated with improved markers of health. The strength of evidence for these results ranges from weak to moderate due to risk of bias, inconsistent results, lack of appropriate statistics and small sample size.

CONCLUSIONS

There appears to be little value in providing PMPR without OHI. In fact, repeated OHI might have a similar effect as PMPR. Some forms of PMPR might achieve greater patient satisfaction. There is little difference in beneficial or adverse effects of different methods of PMPR.

Clinical effectiveness of subgingival irrigation with a pulsated jet irrigator versus syringe

Previous studies have shown clinical and microbiological improvement with subgingival irrigation particularly after scaling and root planing. In this study we monitored the effects of saline irrigation on non-treated periodontal pockets. Ten subjects with severe periodontal disease and symmetrical lesions on multirooted teeth were selected. They had not received periodontal treatment or antibiotics for the previous 6 months. Patients were given simplified oral hygiene instructions. Neither scaling nor root planing was provided during the study. Two teeth were randomly selected per quadrant for subgingival irrigation with saline solution. One side was treated with a syringe and the other side with a pulsated jet irrigator with a modified tip, professionally administered. Clinical parameters (pocket depth, plaque index, gingival index, crevicular fluid, bleeding index, attachment level, and subgingival microflora) were evaluated on days 0, 15, 30, 60, and 90. Both subgingival irrigation products induced changes (reductions) in these indices during the study. Significant differences (P less than 0.001) with the oral irrigator were found for the following parameters: microscopy, pocket depth, crevicular fluid, and plaque index. In this study, professionally administered saline irrigation with a pulsated jet irrigator was more effective than syringe treatment with the same solution. Neither treatment resulted in a detectable gain in probing attachment level. Since gain in attachment level is achievable by other techniques, neither of these subgingival irrigation procedures alone can be considered adequate for periodontal therapy.

Bacteremia following subgingival irrigation and scaling and root planing

The purpose of this study was to determine the incidence of bacteremia after a single professional subgingival irrigation with a 0.12% chlorhexidine gluconate mouthrinse (CHX) as well as after a subsequent scaling and root planing (S/RP) during the same visit. Thirty subjects each with at least 1 site that probed 4 mm or more and bled on probing were randomly assigned to the following groups: 1) irrigation with 0.12% CHX; 2) irrigation with sterile water; and 3) non-irrigated controls. To begin the study blood was drawn just before and 2 minutes after irrigation. Thirty minutes later, blood was drawn again just before and 2 minutes after S/RP at the same site. Specimens were cultured for anaerobic and aerobic microorganisms using standard cultural techniques. Eighteen blood cultures from 15 subjects yielded positive cultures resulting in 23 isolates. Gram-positive rods comprised 34.8% of the total isolates; Gram-positive cocci 34.8%, Gram-negative rods 21.7%, and Gram-negative cocci 8.7%. In the CHX group, bacteremia was detected in 5 subjects after irrigation and in 2 other subjects after S/RP. In the water group, bacteremia was detected in one subject after irrigation and in 4 subjects after S/RP. The control group had 3 bacteremias after S/RP. There was no significant difference between the incidence of bacteremia associated with irrigation by CHX or sterile water (P = 0.141). There was also no significant difference in the incidence of bacteremia after S/RP between the CHX and sterile water irrigation groups and in patients who did not receive irrigation (control group) (P = 0.88).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of subgingival irrigation on bacteremia following scaling and root planing

The purpose of this study was to determine the effects of professional subgingival irrigation, together with subsequent patient administered home marginal irrigation, on the incidence of bacteremia after scaling and root planing (Sc/RP). A total of 60 periodontal maintenance patients were assigned to either Group 1: subgingival irrigation, with 0.12% CHX and daily marginal irrigation with 0.04% CHX; Group 2: subgingival irrigation with 0.12% CHX and daily marginal irrigation with water; Group 3: subgingival and daily marginal irrigation with water; Group 4: Non-irrigation (control). Patients entered the study after receiving a thorough periodontal maintenance appointment including a complete examination, Sc/RP, and standard oral hygiene instruction. Blood samples were taken at the 3-month visit before and after Sc/RP. Microbiological culturing was done using the Septi-Chek system, selective and non-selective media. Results from 54 patients showed that bacteremia was detected prior to Sc/RP in 2 patients and after Sc/RP in 10 patients. No significant effect by treatment regimens on post Sc/RP bacteremia could be detected. The organisms isolated included Eubacterium lentum, Propionibacterium acnes, Streptococcus species, Neisseria species, Candida albicans, Staphylococcus species, and un-identified Gram-negative rods.

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.

Bacteremia following dental cleaning in patients with and without penicillin prophylaxis

The rate, type, and magnitude of bacteremia were studied in 56 patients undergoing dental cleaning with and without penicillin prophylaxis. Sixty-one percent of patients without penicillin prophylaxis were bacteremic 5 minutes following the procedure. Although a significant decrease in detectable bacteremia occurred in patients receiving penicillin prophylaxis, the recovery of streptococci was not significantly different in the two groups. Using the present sample of patients as a basis for statistical inference, the true rate of bacteremia in such patients could be between 41% and 79% with 95% certainty. The magnitude of bacteremia was low and positive quantitative pour plates occurred at 5 minutes and only in patients without penicillin prophylaxis. Of the 71 total bacterial isolates, 53 (74.6%) were anaerobes and 18 (25.4%) were aerobes. This study indicates that parenteral penicillin prophylaxis for dental cleaning decreased detectable bacteremia rates significantly and could be recommended for patients with valvular heart disease who are known to be vulnerable to endocarditis.

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.

Ill effects of improper oral hygeine procedure

Improper use of the tools that prevent tooth decay and gingival disease can also produce harmful effects. For example, dental floss can cause inflammation; toothbrushes could cause abscesses; and water-irrigation devices might drive foreign material into soft tissue. This report discusses the effects of incorrect oral hygiene, the signs the practioner should notice, and the proper corrective steps. Although effective oral hygiene is essential for the maintenance of healthy teeth and supporting tissues, analysis of the literature and clinical observation suggested that six problem areas may be associated with common oral hygiene measures. --Overly vigorous toothbrushing or using the wrong type of brush for the technique often leads to cervical tooth abrasion, gingival irritation, and gingival recession, or all of these problems. --Uncontrolled or overly vigorous dental flossing may lead to irritation, ulceration, or defects of the gingiva. Proximal root surfaces are rarely abraded. --Dentifrices, mouthwashes, and chewing gum may elicit allergic or toxic reactions in susceptible persons. These reactions take a variety of traumatic injuries, especially if used at high pressure. Perhaps, detailed individual instruction should be given by dental personnel before use. --Abscess of gingival tissues may occur from implantation of fragments of such oral hygiene aids as toothbrush bristles and toothpicks. --Bacteria may enter the bloodstream during certain oral hygiene measures, especially in patients with advanced chronic gingival disease. The rate of occurrence is unknown because of conflicting results in different studies. These bacteremias are of concern to patients who have rheumatic heart disease, prosthetic heart valves, prosthetic joints, and renal dialysis shunts, or fistulas used in renal dialysis. A classification of oral hygiene-caused disorders is proposed, based on the injury and the causative agent.

Bacteremia associated with irreversible hydrocolloid dental impressions

A blood culturing technique was utilized to determine the incidence of bacteremia following the making of dental impressions with irreversible hydrocolloid (alginate). The results indicate that bacteremia is not produced by this impression procedure.

Relationship between bacterial contamination and alveolitis after third molar surgery

The frequency of alveolitis after third molar surgery was studied in three groups of 40 patients each. One group was premedicated with penicillin V, another with scopolamine, and the third group received no premedication. The respective frequencies of alveolitis were 5, 2.5 and 32.5 % (P less than 0.01 and P less than 0.001). The aerobic flora in blood sampled from the socket before suturing was significantly reduced (P less than 0.05) in the penicillin group as compared with the controls. In alveolar blood clot sampled 48 h postoperatively, both aerobes and anaerobes were significantly diminished (P less than 0.01). The concentration of penicillin V in alveolar blood ranged from 0.8 to 9.5 mg/l. The total bacterial content in alveolar blood before suturing showed poor correlation with the development of alveolitis. Abundant growth of aerobes was found, however, in 75 % of the patients with alveolitis, but in only 47 % of those without this complication.

Nitroblue tetrazolium and Limulus assays for bacteremia after dental extraction: effect of topical antiseptics

Bacteremia that occurs after dental extraction is common. This study assessed the effect of topical antisepsis on the incidence and magnitude of post-extraction bacteremia. On hundred patients scheduled for elective tooth extraction were randomized among four groups: contr-l, mouthrinsing with sodium-p-toluene sulfonchloramide (chloramine-T), toothbrushing with chloramine-T, and irrigation with Lugol's solution. The results showed that 84% of the control group and 59% of the treatment groups had positive blood cultures (290 organisms isolated) after dental extraction. The duration and magnitude of these bacteremias were diminutive as documented by the six serial blood cultures taken for each patient, colony counts per milliliter of blood, and nitroblue tetrazolium and Limulus assays. Brushing the teeth or rinsing the mouth with chloramine-T before dental extraction significantly reduced the incidence of bacteremia (P less than .025) and the number of different organisms recovered from each patient (P less than .05). Thus, topical treatment with chloramine-T is a simple and effective means of reducing the incidence of postextraction bacteremia.

Congenital neutropenia. Report of a case and a biorationale for dental management

Congenital neutropenia is characterized by a marked decrease in or lack of circulating PMN's in children with no prior history of drug intake. The neutropenia is persistent and the clinical course is one of early onset of severe, recurrent, and eventually fatal infections. Bone marrow studies show a maturation arrest of neutrophilic precursors. Because of their greatly increased susceptibility to infection, patients with congenital neutropenia present a difficult dental management problem. A case of congenital neutropenia has been presented, as well as a biorationale for dental treatment. On the basis of reports in the literature, the following recommendations for the management of patients with congenital neutropenia are made: 1. The prevention and control of infection and the interception of dental disease before surgical intervention becomes necessary should be the overriding considerations in the management of patients with congenital neutropenia. 2. The carious breakdown of teeth should be prevented by the daily application of a 0.4 per cent stannous fluoride gel in addition to oral hygiene and limitation of sucrose intake. 3. Periodontal therapy should be palliative only, since alveolar bone loss is progressive despite frequent oral hygiene instruction and prophylaxis. The goal of periodontal therapy for patients with congenital neutropenia should therefore be a decrease in gingival inflammation to make the patient's mouth more comfortable and to slow down alveolar bone loss. Periodontal surgery is contraindicated. 4. Bacteremia and subsequent septicemia should be prevented since a minor infection can become life threatening in patients with congenital neutropenia. The patient should rinse for 30 seconds and the gingival sulci should be irrigated with a phenolated antiseptic mouthwash prior to all dental manipulations of the soft tissue. This will significantly reduce the incidence of bacteremia. 5. Surgery should be avoided if at all possible because of the high risk of post-operative infection. All surgery sholld be performed in the hospital, and the patient should be given antibiotics as determined by his physician. Primary closure should be done with fine polyglycolic acid sutures to reduce the chance of infection. If postoperative infection can be prevented, wound healing will progress normally despite the complete absence of PMN's.

Effect of two antimicrobial rinses and oral prophylaxis on preoperative degerming of saliva

Two degerming mouthrinses, a 1% povidone-iodine and a 0.2% aqueous solution of chlorhexidine gluconate, were tested with regard to their degerming effect on the saliva. The study comprised two parts. In the first part 19 dental students with good oral hygiene rinsed their mouths at weekly intervals with 10 ml of the povidone-iodine and 10 ml of the chlorhexidine solution. A control group of 12 students and nurses with healthy teeth and gums rinsed their mouths with 10 ml of plain water. In the second part 11 adult patients with periodontal disease used the two test rinses at weekly intervals both before and after periodontal prophylaxis including scaling of the teeth. Non-stimulated saliva was simpled immediately before and 5, 30, 60, and 120 min after each rinse. Part of the saliva was cultured on blood agar plates to show the growth of aerobic microbes. The remainder of the saliva was poured over a Dentocult dip-slide for determination of the number of acidophilic bacteria. The results showed that in the water control group the bacterial count increased in spite of the rinse. When compared with the prerinse values, both test rinses clearly reduced the amounts of bacteria. Chlorhexidine reduced the bacterial count 5 min after the rinse about one logarithm more than povidone-iodine, did, and the degerming effect of chlorhexidine was also of longer duration than that of the povidone-iodine solution. The periodontal prophylaxis in the adult group did not seem to lower the pre-rinse bacterial counts but did slightly improve the duration of the effect of both test solutions. The dip-slide tests showed that 28% of the subjects had no growth of acidophilic bacteria. This absence was not dependent on the other bacterial flora of the saliva. In the cases with a positive dip-slide test, the number of acidophilic bacteria decreased with both test solutions according to the pattern revealed by the blood agar plate cultures.