The Incidence of Transient Bacteremia During Periodontal Dressing Change
multifilament sutures within tissues were contaminated by particles interpreted to be bacteria. The subsequent removal of these sutures from the highly vascular tissue following periodontal surgery may create transient bac teremia. The purpose of this study was to investigate the inci dence of transient bacteremias during the first dressing change 7 days after periodontal surgery.
by H.
SCOTT WAMPOLE,
ANDREW ARTHUR
L. ALLEN,
MATERIALS AND METHODS
D.D.S., M.S.* D.M.D.,
M.s.†
GROSS, D.D.S., M.S ‡
have profound medical signif icance in the patient with a history of rheumatic heart defects, valvular prosthesis, or a previous episode of endocarditis. Alterations in the heart valves of these individuals predispose them to subacute bacterial endo carditis following dental manipulations. Studies have implicated toothbrushing, mastica tion, prophylaxis, use of stimudents, gingival massage combined with tooth rocking, oral irrigation devices, " root planing, scaling, gingivectomy, flap surgery and/or osteoplasty, and exodontia, as sources of transient bacteremias. For a comprehensive review of transient bacteremia and endocarditis prophy laxis, the reader is referred to the paper by Everett and Hirschmann. The American Heart Association has recommended a prescribed antibiotic regimen for prevention of subacute bacterial endocarditis to include antibiotic coverage 1 hour prior to, the day of, and for 2 days after the surgical procedure (or longer in case of delayed healing). The latter portion of this recommendation by The American Heart Association generates several questions. What cri teria are to be utilized in the determination of delayed healing? Should the surgical site be evaluated prior to termination of prophylactic antibiotic therapy? Is it pos sible to determine the probability of delayed healing 2 days after the procedure? Assuming that healing is pro gressing normally, could therapeutic postoperative care produce a bacteremia? A search of the literature revealed no studies relating to the incidence of transient bacteremia during dressing changes following periodontal surgery. It would seem that sutures in an area of relatively undisturbed bacterial colonization such as found under a periodontal dressing might be highly contaminated. Lilly has shown that TRANSIENT BACTEREMIAS
1,2
1,3,4
1,5,6
7
3
8
10
11
12,13
711
7
14-17
18
19
20
* Major DC, USA. Department of Periodontics, Dental Activities, MEDDAC, Fort Leonard Wood, Mo 65473. †Assistant Professor, Department of Periodontics, Baltimore Col lege of Dental Surgery, Dental School, University of Maryland at Baltimore, Baltimore, Md 21201. % Colonel, DC, USA. Chief, Division of Oral Biology, U.S. Army Institute of Dental Research, Walter Reed Army Medical Center, Washington, DC 20012. 462
Twenty patients undergoing treatment for periodontal disease volunteered to participate in this study and were selected utilizing the following criteria: 1. Only patients treated with full thickness mucoperiosteal facial and lingualflapprocedures were accepted for study. 2. Patients who required prophylactic antibiotics or who received antibiotics prior to or during the postop erative interval were excluded from the study. 3. Only patients who presented 1 week postoperatively with intact, well adapted periodontal dressings were investigated. Management of the surgical area 1 week after surgery was based on the findings of a survey of 46 periodontists attending a meeting of the Greater Washington Society of Periodontology.§ Questions were asked in reference to postoperative procedures following full-thickness fa cial and lingual flaps and osseous recontouring exclusive of new attachment and grafting procedures. The survey indicated that 100% of periodontists surveyed used a periodontal dressing following osseous resection. Sixtynine percent used a noneugenol formulation, and of those, 94% used Coe-pac. || Antibiotics were prescribed routinely for osseous recontouring procedures by 33% of the respondents. The sutures and dressings were removed an average of 7.26 days following periodontal surgery and the area was cleansed most often using a cotton tip applicator and water spray syringe. The venipuncture site was cleansed and disinfected as described by the American Association of Blood Banks, using prepared, individually wrapped, medicated swabs4 Blood was cultured both aerobically and anaerobically using commercially prepared media. A prereduced brain-heart infusion broth with 0.01% sodium polyanethol sulfonate (SPS) supplemented with Vitamin K, Hemin and Resazurin** was used as the anaerobic media. A brain-heart infusion broth with 0.01% SPS (not prereduced) was used as an aerobic media. " Blood was withdrawn utilizing a Difco 20 gauge, double-needle blood collecting unit in conjunction with the commercially prepared vacuum-packed culture bot tles. This procedure allowed blood toflowdirectly from the subject to the culture media. Two 20-ml specimens 21
22,28
22
§ 12 December 1974, Washington, DC, || Coe-pac, Coe Laboratories, Inc., Chicago, 111. \ Clinswab—The Clinipad Corp., Stamford, Conn. ** Robbins Laboratories, Inc., Chapel Hill, N.C.
25
Volume 49 Number 9
Incidence of Transient Bacteremia 463
of blood were obtained: one prior to dressing change to establish an absence of bacteremia and one during the suture removal. Venipuncture for obtaining the latter sample was made 60 seconds after the first suture was cut and removed. Five ml of blood were collected in the aerobic bottle containing 90 ml of BHI. The remaining 15 ml were divided into three equal aliquots in bottles containing 45 ml of prereduced brain-heart infusion broth. All cultures were immediately incubated at 37°C. As growth became apparent, specimens were subcultured as follows: 1. Specimens from aerobic bottles were aspirated into a syringe and placed on blood agar plates. 2. Samples from anaerobic prereduced bottles were similarly transferred to prereduced BHI agar roll tubes. Oxygen was kept from entering the roll tubes by inserting a canula carrying a stream of oxygen-free C 0 into the neck of each tube when the stopper was removed. 3. Specimens from anaerobic bottles were also placed on blood agar plates in Brewer jars. Disposable hydrogen carbon dioxide generators ("Gaspak," BBL) were used to produce anaerobic conditions in the Brewer jars. If no growth was apparent after 2 weeks, subcultures of each "negative" bottle were made. A l l bottles were incubated for 4 weeks before discarding. All isolates were gram stained, subcultured on Mitis Salivarius Agar* and incubated aerobically at 37°C. Colonial morphology was studied on Mitis Salivarius Agar after 1 day of anaerobic incubation followed by 1 day at room temperature in air. Hemolysis was determined from blood agar plates. Ex tracellular polysaccharide and acid production were de termined* following the methods of Carlsson. 2
26,28
29
RESULTS
was selected for statistical analysis. A Chi-square value of 3.65 (df = 1) was obtained. Although not statistically significant, the obtained value approached statistical sig nificance at the 0.05 level (3.84). DISCUSSION
In all five cases of transient bacteremia, some degree of gingival hemorrhage was noted during the dressing and suture removal. Thus, the potential for bacteremia was evident. However, other cases exhibiting hemor rhage during dressing change showed no evidence of bacteremia. This does not necessarily mean that no bacteria entered the blood stream. Detection is depend ent on many factors. The number of bacteria present in the blood may be extremely small, and appears to be related to the degree of trauma applied to the tissue. Since dressing and suture removal is generally much less traumatic than tooth extraction, it might be suspected that insufficient numbers of bacteria gain entrance into the bloodstream for detection. Bender et al. concluded that bacteremia occurs in all patients following extrac tion, even through they were able to demonstrate only an 83.3% occurrence. Results of other investigators studying bacteremia during tooth extraction show a wide range of occurrence, varying from 15% to 92%. Many of the lower percentages reported possibly may have resulted from less sensitive culture techniques. Therefore, the sensitivity of the culture technique is extremely crit ical. 24
23,27
The incidence of endocarditis in man following bac teremia appears to be very low. Two studies undertaken before antibiotics became available indicate that the incidence may be as low as 1%. Schwartz and Salman reported no cases of bacterial endocarditis in 98 patients with chronic rheumatic heart disease subjected to a total of 403 extractions. Taran reported four cases (1.1%) of endocarditis among 350 rheumatic children subjected to extractions without antibiotic prophylaxis. Any inci dence of endocarditis following toothbrushing, mastica tion, periodontal dressing change and suture removal, and other minor oral manipulations could be expected to be very low. The results of this study have demonstrated clearly the potential for bacteria to gain entrance to the vasculature through direct channels when hemorrhage occurs during the postoperative dressing change. There were sufficient numbers of bacteria in the bloodstream so that detection was possible in 25% of the patients studied. The significance of this transient bacteremia as well as those during mastication, toothbrushing, and other oral manipulations has yet to be determined. Intuitively, one would expect the intensity of bacteremia to be an impor tant factor in endocarditis. However, this remains unproven in human subjects and is likely to remain so, since a controlled study of this nature certainly would be unethical. The significance of these bacteremias will depend upon further research and case reports in the literature. 30
31
Of the 20 patients participating in this study, none demonstrated a bacteremia prior to the dressing change, while five patients produced blood samples which con tained bacteria following the dressing and suture re moval. Microorganisms from positive cultures were iso lated and identified as a-hemolytic facultative strepto cocci. One culture was lost during transfer and could be identified only as a gas-producing coccus. Three cultures contained only one streptococcus strain (pure cultures) and the fourth contained two different strains of strep tococci. One of the streptococcal strains in pure cultures was identified as Streptococcus sanguis. The other two belonged to group IV and group VB of Carlsson. Two strains isolated from blood of the fourth patient (mixed culture) closely resembled the streptococcal species of group IV and VB. The relation of strains of group IV to recognized species of genus streptococcus is uncertain. The strains of group V B resemble Streptococcus mitis. Because of the nature of the data and size of the population, the Chi-square test with a Yates correction 29
29
* BBL—Cockeysville, Md.
464
Wampole, Allen, Gross
J. Periodontol. September, 1978
bacteremia after the use of an oral irrigation device in subjects with periodontitis. J Periodontol 42: 785, 1971. 11. Korn, N. A., and Schaffer, E. M.: A comparison of the postoperative bacteremias induced following different peri odontal procedures. J Periodontol 13: 226, 1962. 12. Bandt, C. L., Korn, N. A., and Schaffer, E. M.: Bacter emia from ultrasonic and hand instrumentation. J Periodontol 35:214, 1964. 13. Conner, H. D., Haberman, S., Collings, C. K., and Winford, T. E.: Bacteremias following periodontal scaling in patients with healthy appearing gingiva. J Periodontol 38: 446, SUMMARY 1967. Twenty patients undergoing treatment for periodontal 14. Bender, I. B., and Pressman, R. S.: Factors in dental disease and not receiving antibiotics, volunteered to do bacteremia. J Am Dent Assoc 32: 836, 1945. nate blood for culture studies to determine the incidence 15. Okell, C. C , Camb, M. B., and Elliot, S. D.: Bacteremia of transient bacteremia during the dressing change and and oral sepsis with special reference to the etiology of sub acute bacterial endocarditis. Lancet 329: 1869, 1935. suture removal 1 week after periodontal surgery. Each 16. Burket, L. W., and Burn, C. G.: Bacteremias following patient contributed 20 ml of blood prior to the dressing dental extraction. Demonstration of source of bacteria by change and an additional 20 ml during suture removal. means of a non-pathogen (Serratia Marcesens). J Dent Res 16: The samples were cultured both aerobically and anaer521, 1937. obically. 17. Hopkins, J. A.: Streptococcus viridans: Bacteremia fol lowing extraction of teeth. J Am Dent Assoc 26: 2002, 1939. Bacteria were demonstrated in five out of 20 postop 18. Everett, E. D., and Hirschmann, J. V.: Transient bacter erative cultures (25%). This incidence approached statis emia and endocarditis prophylaxis. A review. Medicine 56: 61, tical significance at the 0.05 level using Chi-square anal 1977. ysis with a Yates correction. A l l species were identified 19. Council on Dental Therapeutics, American Dental As sociation and American Heart Association: Prevention of bac as belonging to the genus streptococcus. None of the terial endocarditis. J Am Dent Assoc 85: 1377, 1972. blood specimens obtained prior to dressing change ex 20. Lilly, G. E., Salem, J. E., Armstrong, J. H., and Cutcher, hibited bacterial growth. J. L.: Reaction of oral tissues to suture material, Part III. Oral Although the incidence of bacteremia in this study Surg 28: 432, 1969. was not statistically significant at the 0.05 level, it may 21. Technical Methods and Procedures of the American As sociation of Blood Banks, ed 5, pp 3-29, 1970. be clinically significant that five out of 20 patients dem 22. Robinson, L., Kraus, F. W., Lazansky, J. P., Wheeler, R. onstrated transient bacteremia. E., Gordon, S., and Johnson, V.: Bacteremias of dental origin Commercial materials and equipment are identified in II—A study of factors influencing occurrence and detection. this report to specify the investigative procedures. Such Oral Surg 3: 923, 1950. identification does not imply recommendation or en 23. Robinson, L., Kraus, F. W., Lazansky, J. P., Wheeler, R. E., Gordon, S., and Johnson, V.: Bacteremias of dental origin dorsement or that the materials and equipment are nec I—A review of the literature, Oral Surg 3: 519, 1950. essarily the best available for the purpose. Furthermore, 24. Bender, I. B., Seltzer, S., Meloff, G., and Pressman, R. the opinions expressed herein are those of the author S.: Conditions affecting sensitivity of techniques for detection and are not to be construed as those of the Army Medical of bacteremia. / Dent Res 40: 951, 1961. Department. 25. Minkus, R., and Moffet, H. L.: Detection of bacteremia in children with sodium polyanethol sulfonate: A prospective REFERENCES clinical study. Appl Microbiol 22: 805, 1971. 1. Cobe, H. M.: Transitory bacteremia. Oral Surg 7: 609, 26. Moore, W. E., Cato, E. P., Cummins, C. S., Holdeman, 1954 L. F., Johnson, J. L., Smilbert, R. M., Smith, L., and Wilkins, 2. Sconyers, J. R., Crawford, J. J., and Moriarty, J. D.: T. D.: Anaerobe Laboratory Manual Holdeman, L. V. and Relationship of bacteremia to toothbrushing in patients with Moore, W. E., (eds). Blacksburg, Va., Southern Printing Com periodontitis. J Am Dent Assoc 87: 616, 1973. pany, 1972. 3. Richards, J. H.: Bacteremia following irritation of foci of 27. Crawford, J. J., Sconyers, J. R., Moriarty, J. D., King, R. infection. J Am Dent Assoc 99: 1495, 1932. C , and West, J. F.: Bacteremia after tooth extractions studied 4. Murray, M., and Moosnick, F.: Incidence of bacteremia with the aid of pre-reduced anaerobically sterilized culture in patients with dental disease. J Lab Clin Med 26: 801, 1941. media. Appl Microbiol 27: 927, 1974. 5. Winslow, M. B., and Kobernick, S. D.: Bacteremia after 28. McMinn, M. T., Crawford, J. J.,: Recovery of anaerobic prophylaxis. J Am Dent Assoc 61: 69, 1960. micro-organisms from clinical specimens in pre-reduced media 6. DeLeo, A. A., Schoenknecht, F. D., Anderson, M. W., versus recovery by routine clinical laboratory methods. Appl and Peterson, J. C : The incidence of bacteremia following oral Microbiol 19: 207, 1970. prophylaxis on pediatric patients. Oral Surg 37: 36, 1974. 29. Carlsson, J.: A numerical taxonomic study of human 7. Lineberger, L. T., and DeMarco, T. J.: Evaluation of oral streptococci. Odontol Revy 19: 137, 1968. transient bacteremia following routine periodontal procedures. 30. Schwartz, S. P., and Salman, I.: The effects of oral J Periodontol 44: 757, 1973. surgery on the course of treatment of patients with diseases of 8. Kancir, S. L., and Krajewski, J. J.: The relation of water the heart. Am J Ortho 28: 331, 1942. pressure cleansing to the reticuloendothelial system. J Perio 31. Taran, L. M.: Rheumatic fever in its relation to dental dontol 43: 696, 1972. disease. NY J Dent 14: 107, 1944. 9. Romans, A. R., and App, G. R.: Bacteremia, a result from 32. Davis, B. D., Dulbecco, R, Eisen, H. N., Ginsberg, H. oral irrigation in subjects with gingivitis. J Periodontol 42: 757, S., Wood, W. B. Jr., and McCarthy, M.: Microbiology, ed 2, p 1971. 958. New York, Harper & Row, 1973. 10. Felix, J. E., Rosen, S., and App, G. R.: Detection of The recovery of streptococci from all bacteremia cases was not surprising considering that they are the most common and most numerous inhabitants of the oral cavity. However, it does seem likely that the protected area beneath a periodontal dressing would serve as an excellent anaerobic environment. It would be interesting to culture the underside of dressings to determine what organisms commonly inhabit this area. 32
multifilament sutures within tissues were contaminated by particles interpreted to be bacteria. The subsequent removal of these sutures from the highly vascular tissue following periodontal surgery may create transient bac teremia. The purpose of this study was to investigate the inci dence of transient bacteremias during the first dressing change 7 days after periodontal surgery.
by H.
SCOTT WAMPOLE,
ANDREW ARTHUR
L. ALLEN,
MATERIALS AND METHODS
D.D.S., M.S.* D.M.D.,
M.s.†
GROSS, D.D.S., M.S ‡
have profound medical signif icance in the patient with a history of rheumatic heart defects, valvular prosthesis, or a previous episode of endocarditis. Alterations in the heart valves of these individuals predispose them to subacute bacterial endo carditis following dental manipulations. Studies have implicated toothbrushing, mastica tion, prophylaxis, use of stimudents, gingival massage combined with tooth rocking, oral irrigation devices, " root planing, scaling, gingivectomy, flap surgery and/or osteoplasty, and exodontia, as sources of transient bacteremias. For a comprehensive review of transient bacteremia and endocarditis prophy laxis, the reader is referred to the paper by Everett and Hirschmann. The American Heart Association has recommended a prescribed antibiotic regimen for prevention of subacute bacterial endocarditis to include antibiotic coverage 1 hour prior to, the day of, and for 2 days after the surgical procedure (or longer in case of delayed healing). The latter portion of this recommendation by The American Heart Association generates several questions. What cri teria are to be utilized in the determination of delayed healing? Should the surgical site be evaluated prior to termination of prophylactic antibiotic therapy? Is it pos sible to determine the probability of delayed healing 2 days after the procedure? Assuming that healing is pro gressing normally, could therapeutic postoperative care produce a bacteremia? A search of the literature revealed no studies relating to the incidence of transient bacteremia during dressing changes following periodontal surgery. It would seem that sutures in an area of relatively undisturbed bacterial colonization such as found under a periodontal dressing might be highly contaminated. Lilly has shown that TRANSIENT BACTEREMIAS
1,2
1,3,4
1,5,6
7
3
8
10
11
12,13
711
7
14-17
18
19
20
* Major DC, USA. Department of Periodontics, Dental Activities, MEDDAC, Fort Leonard Wood, Mo 65473. †Assistant Professor, Department of Periodontics, Baltimore Col lege of Dental Surgery, Dental School, University of Maryland at Baltimore, Baltimore, Md 21201. % Colonel, DC, USA. Chief, Division of Oral Biology, U.S. Army Institute of Dental Research, Walter Reed Army Medical Center, Washington, DC 20012. 462
Twenty patients undergoing treatment for periodontal disease volunteered to participate in this study and were selected utilizing the following criteria: 1. Only patients treated with full thickness mucoperiosteal facial and lingualflapprocedures were accepted for study. 2. Patients who required prophylactic antibiotics or who received antibiotics prior to or during the postop erative interval were excluded from the study. 3. Only patients who presented 1 week postoperatively with intact, well adapted periodontal dressings were investigated. Management of the surgical area 1 week after surgery was based on the findings of a survey of 46 periodontists attending a meeting of the Greater Washington Society of Periodontology.§ Questions were asked in reference to postoperative procedures following full-thickness fa cial and lingual flaps and osseous recontouring exclusive of new attachment and grafting procedures. The survey indicated that 100% of periodontists surveyed used a periodontal dressing following osseous resection. Sixtynine percent used a noneugenol formulation, and of those, 94% used Coe-pac. || Antibiotics were prescribed routinely for osseous recontouring procedures by 33% of the respondents. The sutures and dressings were removed an average of 7.26 days following periodontal surgery and the area was cleansed most often using a cotton tip applicator and water spray syringe. The venipuncture site was cleansed and disinfected as described by the American Association of Blood Banks, using prepared, individually wrapped, medicated swabs4 Blood was cultured both aerobically and anaerobically using commercially prepared media. A prereduced brain-heart infusion broth with 0.01% sodium polyanethol sulfonate (SPS) supplemented with Vitamin K, Hemin and Resazurin** was used as the anaerobic media. A brain-heart infusion broth with 0.01% SPS (not prereduced) was used as an aerobic media. " Blood was withdrawn utilizing a Difco 20 gauge, double-needle blood collecting unit in conjunction with the commercially prepared vacuum-packed culture bot tles. This procedure allowed blood toflowdirectly from the subject to the culture media. Two 20-ml specimens 21
22,28
22
§ 12 December 1974, Washington, DC, || Coe-pac, Coe Laboratories, Inc., Chicago, 111. \ Clinswab—The Clinipad Corp., Stamford, Conn. ** Robbins Laboratories, Inc., Chapel Hill, N.C.
25
Volume 49 Number 9
Incidence of Transient Bacteremia 463
of blood were obtained: one prior to dressing change to establish an absence of bacteremia and one during the suture removal. Venipuncture for obtaining the latter sample was made 60 seconds after the first suture was cut and removed. Five ml of blood were collected in the aerobic bottle containing 90 ml of BHI. The remaining 15 ml were divided into three equal aliquots in bottles containing 45 ml of prereduced brain-heart infusion broth. All cultures were immediately incubated at 37°C. As growth became apparent, specimens were subcultured as follows: 1. Specimens from aerobic bottles were aspirated into a syringe and placed on blood agar plates. 2. Samples from anaerobic prereduced bottles were similarly transferred to prereduced BHI agar roll tubes. Oxygen was kept from entering the roll tubes by inserting a canula carrying a stream of oxygen-free C 0 into the neck of each tube when the stopper was removed. 3. Specimens from anaerobic bottles were also placed on blood agar plates in Brewer jars. Disposable hydrogen carbon dioxide generators ("Gaspak," BBL) were used to produce anaerobic conditions in the Brewer jars. If no growth was apparent after 2 weeks, subcultures of each "negative" bottle were made. A l l bottles were incubated for 4 weeks before discarding. All isolates were gram stained, subcultured on Mitis Salivarius Agar* and incubated aerobically at 37°C. Colonial morphology was studied on Mitis Salivarius Agar after 1 day of anaerobic incubation followed by 1 day at room temperature in air. Hemolysis was determined from blood agar plates. Ex tracellular polysaccharide and acid production were de termined* following the methods of Carlsson. 2
26,28
29
RESULTS
was selected for statistical analysis. A Chi-square value of 3.65 (df = 1) was obtained. Although not statistically significant, the obtained value approached statistical sig nificance at the 0.05 level (3.84). DISCUSSION
In all five cases of transient bacteremia, some degree of gingival hemorrhage was noted during the dressing and suture removal. Thus, the potential for bacteremia was evident. However, other cases exhibiting hemor rhage during dressing change showed no evidence of bacteremia. This does not necessarily mean that no bacteria entered the blood stream. Detection is depend ent on many factors. The number of bacteria present in the blood may be extremely small, and appears to be related to the degree of trauma applied to the tissue. Since dressing and suture removal is generally much less traumatic than tooth extraction, it might be suspected that insufficient numbers of bacteria gain entrance into the bloodstream for detection. Bender et al. concluded that bacteremia occurs in all patients following extrac tion, even through they were able to demonstrate only an 83.3% occurrence. Results of other investigators studying bacteremia during tooth extraction show a wide range of occurrence, varying from 15% to 92%. Many of the lower percentages reported possibly may have resulted from less sensitive culture techniques. Therefore, the sensitivity of the culture technique is extremely crit ical. 24
23,27
The incidence of endocarditis in man following bac teremia appears to be very low. Two studies undertaken before antibiotics became available indicate that the incidence may be as low as 1%. Schwartz and Salman reported no cases of bacterial endocarditis in 98 patients with chronic rheumatic heart disease subjected to a total of 403 extractions. Taran reported four cases (1.1%) of endocarditis among 350 rheumatic children subjected to extractions without antibiotic prophylaxis. Any inci dence of endocarditis following toothbrushing, mastica tion, periodontal dressing change and suture removal, and other minor oral manipulations could be expected to be very low. The results of this study have demonstrated clearly the potential for bacteria to gain entrance to the vasculature through direct channels when hemorrhage occurs during the postoperative dressing change. There were sufficient numbers of bacteria in the bloodstream so that detection was possible in 25% of the patients studied. The significance of this transient bacteremia as well as those during mastication, toothbrushing, and other oral manipulations has yet to be determined. Intuitively, one would expect the intensity of bacteremia to be an impor tant factor in endocarditis. However, this remains unproven in human subjects and is likely to remain so, since a controlled study of this nature certainly would be unethical. The significance of these bacteremias will depend upon further research and case reports in the literature. 30
31
Of the 20 patients participating in this study, none demonstrated a bacteremia prior to the dressing change, while five patients produced blood samples which con tained bacteria following the dressing and suture re moval. Microorganisms from positive cultures were iso lated and identified as a-hemolytic facultative strepto cocci. One culture was lost during transfer and could be identified only as a gas-producing coccus. Three cultures contained only one streptococcus strain (pure cultures) and the fourth contained two different strains of strep tococci. One of the streptococcal strains in pure cultures was identified as Streptococcus sanguis. The other two belonged to group IV and group VB of Carlsson. Two strains isolated from blood of the fourth patient (mixed culture) closely resembled the streptococcal species of group IV and VB. The relation of strains of group IV to recognized species of genus streptococcus is uncertain. The strains of group V B resemble Streptococcus mitis. Because of the nature of the data and size of the population, the Chi-square test with a Yates correction 29
29
* BBL—Cockeysville, Md.
464
Wampole, Allen, Gross
J. Periodontol. September, 1978
bacteremia after the use of an oral irrigation device in subjects with periodontitis. J Periodontol 42: 785, 1971. 11. Korn, N. A., and Schaffer, E. M.: A comparison of the postoperative bacteremias induced following different peri odontal procedures. J Periodontol 13: 226, 1962. 12. Bandt, C. L., Korn, N. A., and Schaffer, E. M.: Bacter emia from ultrasonic and hand instrumentation. J Periodontol 35:214, 1964. 13. Conner, H. D., Haberman, S., Collings, C. K., and Winford, T. E.: Bacteremias following periodontal scaling in patients with healthy appearing gingiva. J Periodontol 38: 446, SUMMARY 1967. Twenty patients undergoing treatment for periodontal 14. Bender, I. B., and Pressman, R. S.: Factors in dental disease and not receiving antibiotics, volunteered to do bacteremia. J Am Dent Assoc 32: 836, 1945. nate blood for culture studies to determine the incidence 15. Okell, C. C , Camb, M. B., and Elliot, S. D.: Bacteremia of transient bacteremia during the dressing change and and oral sepsis with special reference to the etiology of sub acute bacterial endocarditis. Lancet 329: 1869, 1935. suture removal 1 week after periodontal surgery. Each 16. Burket, L. W., and Burn, C. G.: Bacteremias following patient contributed 20 ml of blood prior to the dressing dental extraction. Demonstration of source of bacteria by change and an additional 20 ml during suture removal. means of a non-pathogen (Serratia Marcesens). J Dent Res 16: The samples were cultured both aerobically and anaer521, 1937. obically. 17. Hopkins, J. A.: Streptococcus viridans: Bacteremia fol lowing extraction of teeth. J Am Dent Assoc 26: 2002, 1939. Bacteria were demonstrated in five out of 20 postop 18. Everett, E. D., and Hirschmann, J. V.: Transient bacter erative cultures (25%). This incidence approached statis emia and endocarditis prophylaxis. A review. Medicine 56: 61, tical significance at the 0.05 level using Chi-square anal 1977. ysis with a Yates correction. A l l species were identified 19. Council on Dental Therapeutics, American Dental As sociation and American Heart Association: Prevention of bac as belonging to the genus streptococcus. None of the terial endocarditis. J Am Dent Assoc 85: 1377, 1972. blood specimens obtained prior to dressing change ex 20. Lilly, G. E., Salem, J. E., Armstrong, J. H., and Cutcher, hibited bacterial growth. J. L.: Reaction of oral tissues to suture material, Part III. Oral Although the incidence of bacteremia in this study Surg 28: 432, 1969. was not statistically significant at the 0.05 level, it may 21. Technical Methods and Procedures of the American As sociation of Blood Banks, ed 5, pp 3-29, 1970. be clinically significant that five out of 20 patients dem 22. Robinson, L., Kraus, F. W., Lazansky, J. P., Wheeler, R. onstrated transient bacteremia. E., Gordon, S., and Johnson, V.: Bacteremias of dental origin Commercial materials and equipment are identified in II—A study of factors influencing occurrence and detection. this report to specify the investigative procedures. Such Oral Surg 3: 923, 1950. identification does not imply recommendation or en 23. Robinson, L., Kraus, F. W., Lazansky, J. P., Wheeler, R. E., Gordon, S., and Johnson, V.: Bacteremias of dental origin dorsement or that the materials and equipment are nec I—A review of the literature, Oral Surg 3: 519, 1950. essarily the best available for the purpose. Furthermore, 24. Bender, I. B., Seltzer, S., Meloff, G., and Pressman, R. the opinions expressed herein are those of the author S.: Conditions affecting sensitivity of techniques for detection and are not to be construed as those of the Army Medical of bacteremia. / Dent Res 40: 951, 1961. Department. 25. Minkus, R., and Moffet, H. L.: Detection of bacteremia in children with sodium polyanethol sulfonate: A prospective REFERENCES clinical study. Appl Microbiol 22: 805, 1971. 1. Cobe, H. M.: Transitory bacteremia. Oral Surg 7: 609, 26. Moore, W. E., Cato, E. P., Cummins, C. S., Holdeman, 1954 L. F., Johnson, J. L., Smilbert, R. M., Smith, L., and Wilkins, 2. Sconyers, J. R., Crawford, J. J., and Moriarty, J. D.: T. D.: Anaerobe Laboratory Manual Holdeman, L. V. and Relationship of bacteremia to toothbrushing in patients with Moore, W. E., (eds). Blacksburg, Va., Southern Printing Com periodontitis. J Am Dent Assoc 87: 616, 1973. pany, 1972. 3. Richards, J. H.: Bacteremia following irritation of foci of 27. Crawford, J. J., Sconyers, J. R., Moriarty, J. D., King, R. infection. J Am Dent Assoc 99: 1495, 1932. C , and West, J. F.: Bacteremia after tooth extractions studied 4. 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P., and Salman, I.: The effects of oral J Periodontol 44: 757, 1973. surgery on the course of treatment of patients with diseases of 8. Kancir, S. L., and Krajewski, J. J.: The relation of water the heart. Am J Ortho 28: 331, 1942. pressure cleansing to the reticuloendothelial system. J Perio 31. Taran, L. M.: Rheumatic fever in its relation to dental dontol 43: 696, 1972. disease. NY J Dent 14: 107, 1944. 9. Romans, A. R., and App, G. R.: Bacteremia, a result from 32. Davis, B. D., Dulbecco, R, Eisen, H. N., Ginsberg, H. oral irrigation in subjects with gingivitis. J Periodontol 42: 757, S., Wood, W. B. Jr., and McCarthy, M.: Microbiology, ed 2, p 1971. 958. New York, Harper & Row, 1973. 10. Felix, J. E., Rosen, S., and App, G. R.: Detection of The recovery of streptococci from all bacteremia cases was not surprising considering that they are the most common and most numerous inhabitants of the oral cavity. However, it does seem likely that the protected area beneath a periodontal dressing would serve as an excellent anaerobic environment. It would be interesting to culture the underside of dressings to determine what organisms commonly inhabit this area. 32
