Toothbrushing and transient bacteremia in patients undergoing orthodontic treatment Richard A. Schlein, DDS," Earl M. Kudlick, DDS, MSD, b C. A. Reindorf, MD, FRCP, c J. Gregory, PhD, d and George C. Royal, PhD"
Washhzgton, D.C. This study was made to determine whether and to what extent bacteremia occurred after toothbrushing in patients undergoing orthodontic treatment with fixed appliances. Twenty patients were selected, all with negative history of heart or hematologic disorders. These patients had not taken antibiotics or had a history of a cold in the previous 30 days. Blood samples of 20 ml were drawn before and 5 minutes after brushing. The immune status of the patients was tested by measurerrlent of isohemagglutins and immunoglobulin levels. Blood samples were incubated in paired culture bottles containing trypticase soy broth (TSB) with an agar paddle and Columbia broth. All samples taken before brushing were negative for bacteria. Five of the 20 patients (25% of the sample) had positive blood tests after brushing. Both anaerobic and aerobic bacteria were identified from the blood samples. Those patients who were found to have a bacteremia did not display poor oral hygiene. (AMJ ORTHODDENTOFACORTHOP1991;99:466"723
T h e microflora of the oral cavity can be a source of bacteremia after disruption of capillaries in the gingival tissues. In normal persons, the episodes of bacteremia are brief because of the efficient clearance by the host's immune system. However, in persons with a history of rheumatic heart disease, infective endocarditis, congenital heart defects, prosthetic valve replacement, organic heart murmurs, and aortic valve disease, transient bacteremia increases the risk of infective endocarditis. Bacterial endocarditis has a high mortality rate) and successfully treated bacterial endocarditis has a high rate of recurrence (8.5%) 2 of bacterial reinfection and limitation of activity as a result of cardiac decompensation. The 5-year survival rate has been reported at 69% with congestive failure as the principal cause of death. Originally, a study entitled "A Survey to Evaluate the Management of Orthodontic Patients With a History of Rheumatic Fever or Congenital Heart Disease" was published) This article logically led to the question: If the presence of fixed orthodontic appliances increases From ttoward University 'Private practice, White River Junction, Vt. ~Associate Professor, College of Dentistry. ¢Associate Professor, Sickle Cell Center. dAssociate Professor, College of Medicine 'Professor, College of Medicine. A thesis submitted by Dr. Schlein to the Department of Orthodontics, Howard University College of Dentistry, in partial fulfillment of the requirement for a Certificate of Proficiency in Orthodontics in 1987. 811119659
466
the risk of plaque retention, will toothbrushing give rise to bacteremia? The present article represents the third study in a series involving toothbrushing and bacteremia in orthodontic patients that was performed at Howard University College of Dentistry Orthodontic Department. In the initial study, Chung et al. 4 recovered anaerobes in 10 of 16 patients. Unexpectedly, these 10 patient~ had positive blood cultures before brushing, while only three had positive cultures after brushing. In a second study, Petrovitch et al.,5 using similar techniques, did not detect any bacterial growth in blood samples taken from 26 patients. The second study demonstrated the elusive nature and difficulty of isolating bacteria from the bloodstream because of the following factors: (1) the concentration of bacteria entering the bloodstream, (2) the rate of dispersion of circulating bacteria, (3) the site of blood sampling, (4) the time between inoculation and blood sampling, and (5) culturing techniques. All of these factors were carefully evaluated, and a third study was developed with major revisions in blood sampling and culturing techniques to improve the ability to isolate bacteria from the bloodstream to determine whether bacteremia could be detected after toothbrushing in normally healthy orthodontic patients. REVIEW OF THE LITERATURE Site of blood withdrawal
Beeson et al. 6 compared sites of removal of bacteria from the blood of patients with bacterial endocarditis.
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Quantitative arterial and venous blood cultures were taken from the following peripheral locations: the femoral artery and vein and the antecubital vein as well as the right auricle, vena cavae, hepatic, and renal veins. Blood collected from the antecubital fossa had colony counts only slightly lower than arterial blood. The femoral vein had appreciably less bacterial-invasion and the hepatic vein had the smallest bacterial count. Timing of blood withdrawal Berger et al. 7 showed that blood cultures taken immediately after extraction were 81.4% "positive but decreased to only 48.8% in cultures taken 10 minutes after extraction. Cobe 8 found that intravenous inoculations of orhemolytic streptococci in rabbits were recovered in blood cultures taken by means of cardiac puncture at 1 minute and 3 minuteg. Minimal amounts were detected at 5 minutes, and none after 10 minutes. Bender et al. 9 observed bacteremia immediately after light scaling and 10 minutes afterward. Initial cultures were positive for 30% of subjects tested, but after 10 minutes only 5% of cultures were positive. These researchers also found positive cultures in 48 cases in which instruments had extended beyond the apex during endodontic therapy. Immediately after manipulation, 31.2% of the subjects had positive cultures, but cultures taken 10 minutes later were all negative. Blood volume sample Hall et al) ° compared 5 ml and 10 ml blood-volume samples in 50 ml and 100 ml soybean-casein digest broth culture bottles (tryptic soy broth (TSB), Difco Laboratories, Detroit, Mich.). A larger number of microorganisms was isolated with significant growth of gram-negative bacilli in the 100 ml bottles. Loesche '~ also strongly advocated increasing the volume of blood samples to increase the isolation of bacteria. Tenney et al. '2 found a microorganism yield from 7 ml samples 29% greater than from 2 ml samples. This supports the theory that the volume of blood cultured is critical in the detection of septicemia. Washington .3 suggested that the volume of blood is relatively more important than the medium or the atmosphere of incubation in the detection of sepsis. Salventi et al.~4 recommended a blood-to-broth ratio of 1:5 to 1 : 10. A blood-to-broth ratio between 1:2 and 1 : 5 may result in an overall decreased number of positive cultures, according to Relier.'5
Culturing medium Pfaller et al.~6 compared conventional TSB blood culture bottles with a combiuation of TSB and an agar-
coated slide attachment (Septi-Chek, Roche Diagnostic Systems, Montclair, N.J.) in 2662 sets of blood cultures. Significantly more gram-positive and gramnegative bacteremias were detected in the slide culture bottle than in the conventional bottles. Growth of grampositive organisms (particularly Staphylococcus) was detected in 24 to 48 hours earlier in the slide culture bottle. Henry et a l ) 7 found that Roche Septi-Chek blood culture was superior to the vented brain heart infusion biphasic medium bottle when both were tested in 5121 culture sets. Weinstein et al) s detected 99.7% of clinically important organisms in TSB with agar slides (BBL Microbiology Systems, Cockeysville, Md.) but only 82% in conventional blood culture systems. It was concluded that the biphasic system was superior to the conventional system, but this group recommended the use of a complementary anaerobe bottle. Weinstein et al., 19 in a subsequent study, rated the Septi-Check biphasic blood culture system with TSB superior to conventional peptone broth in 6956 filledblood culture sets. However, the benefit of a paired anaerobic bottle was reemphasized. Thiemke and Wicher 2° found the use of a radiometric blood culture system (Bactec-Johnson Laboratories Inc., Towson, Md.) valuable in early detection of bacteremias. Thompson 2' found the two-bottle Septi-Chek system less expensive than the Bactec radiometric blood culture system. Weinstein et al. 22 found the TSB with slide (SeptiChek) equal to the Bactec in most respects except for the growth of more fungi in the Septi-Chek bottles. METHODS AND MATERIALS Twenty patients who were undergoing treatment in the Howard University Orthodontic clinic were selected according to the following criteria. The patients were 15 years of age or older with no history of rheumatic fever, rheumatic heart disease, congenital heart birth defects, cardiac surgery (prosthetic valves), sickle cell disease, arteriosclerotic heart disease, or hematologic disorders. Patients were rejected if they had taken antibiotics within the last 30 days. All patients stated that they were in good general health. Once these criteria were fulfilled, the patients signed consent forms and were instructed not to brush their teeth, eat, or chew gum or hard candy for 2 hours before their appointments for the blood drawing. Each participant's gingival condition was evaluated at least 20 minutes before sampling with the Silness and Loe 23 Gingival and Plaque Index System. The gin-
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gival index measured the degree of inflammation and the tendency for bleeding in response to probing on a scale of 0 to 3. Measurements were taken on the buccal, mesial, and lingual gingival surfaces of the crowns of the maxillary right molar, right central incisor, left canine, mandibular right canine, left central incisor, and mandibular left first molar. The doubled scores for the buccal, lingual, and doubled mesial surfaces were summed and divided by 24 in the calculation of the index score. The nonbrushing arm of the patient was selected, and the median cubital vein'area was prepared with a povidone-iodine solution. A scalp vein needle, 21 or 23 gauge, with 12 inches of tubing was inserted. Twenty-one milliliters of blood was withdrawn into a 25 ml syringe. The first syringe was removed and replaced with a syringe containing 1.0 ml of Hep-Lock (Elkin, Sire, Cherry Hill, N.J.), a heparin-lock flush solution (10 units per ml). A 21-gauge x 1V2-inch needle was attached to the syringe with the blood sample, allowing 10 ml to be injected directly into a blood culture bottle which contained 70 ml of Columbia broth culture medium (Septi-Chek, Roche Diagnostic Systems, Montclair, N.J.). This medium was selected to support anaerobic growth. The second I0 ml of blood was injected into a Septi-Chek blood culture bottle containing 70 ml of trypticase soy broth (TSB). The final 1 ml was deposited into a sterile Kahn tube for testing immunologic competency. The needle and heparin sytinge were secured, and the patient was given a new toothbrush and instructed to brush for 2 minutes without dentrifice and then to rinse. Three minutes after the brushing, the heparin solution was retracted, the final 20 ml of blood was taken, and the scalp vein needle with withdrawn. This second blood sample was equally divided into a second pair of Septi-Chek blood culture bottles. This procedure was followed for all 20 patients. All samples were transported to the laboratory. The 1 ml blood sample was allowed to clot. The clot was rimmed before centrifuging to maximize yield of serum. The serum was pipetted and transferred to a second tube for storage at - 2 0 ° C until all samples had been collected. The RBCs were typed for the ABO system. The patients' RBCs were mixed with anti-A and anti-B typing serum and identified by the agglutination pattern. A Septi-Chek slide containing three agar media was attached to the TSB culture bottle. It contained chocolate agar, MacConkey agar, and malt agar, which were suitable for subculture of bacterial and fungal growth. The culture bottles were inverted to mix the broth and to inoculate the slide. The slide facilitated early identification of aerobic growth. The bottles were incubated
Am. J. Orthod. Denlofac. Orthop. May 1991
at 37 ° C and checked daily for 7 days for turbidity and growth on the agar slide. Subcultures were performed wherever turbidity occurred or after 7 days if turbidity did not occur. Subcultures were obtained by insertion of a sterile cotton-tipped applicator into the broth, which was then stretched across trypticase soy agar with 5% sheep blood. Subcultures from the anaerobic bottles of Columbia broth were placed into an acti~'ated Gaspak anaerobic jar (Baltimore Biological Laboratory, Cockeysville, Md.). Both aerobic and anaerobic subcultures were incubated at 37 ° C for 48 hours and then examined for bacterial growth. Positive subcultures were examined for growth patterns, and a representative colony was transferred to a glass slide and Gram stained for examination under the microscope (magnification ×1000). Speciation of Staphylococcus was performed by means of the coagulase test and the Minitek system (Becton Dickinson and Company) with substrates of mannitol, maltose, and trehalose. A plate of TSA ~vas inoculated, a 5microgram novobiocin disk was placed in the center, and the plate was incubated for 24 hours and examined for sensitivity. All tubes of stored serum were thawed and tested for isohemagglutinin levels (anti-A, anti-B, and antiAB). A volume of 0.025 ml of saline solution was pippetted into each well of the MicroTiter plate (GIBCO Laboratories, Grand Island, N.Y.). To the first well, 0.025 ml of patient serum was pipetted and serially diluted to 1:128. Known A and B cells were washed and prepared as a 1% suspension with a graduated centrifuge tube. Then a volume of 0.025 ml of the standardized cells (group A cells if type B, group B cells if type A, or both if type O) were added to each well. Agglutination patterns were read after 3 hours and the titers were recorded. Quantitative determination of immunoglobulin G,M,A levels in the patient's serum was performed with Kallestad single radial immunodiffusion plates (Helena Laboratories, Beaumont, Tex.) Each endoplate contained buffered aga.rose antiserum mixture with 16 wells for depositing.patient and reference samples. Five microliters of serum from each patient was placed into a well of each type of endoplate and read after 24 hours. The diameter of the immunoprecipitin ring was measured with the aid of an ocular magnifying glass with a 0.1 m scale. Using known serum as a reference, we plotted a reference curve on two-cycle semilogarithmic graph paper. We determined test sample concentrations by locating the sample ring diameter on the reference curve. Patient serum concentration was then compared to normally accepted serum levels.
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Table I. Toothbrushing and transient bacteremia in patients undergoing orthodontic treatment Turbidity
Oral hygeine
After
Before Subject
GI,
GI
l
.
2
.
3
.
4
.
5
.
6
-
7
.
8
.
9
.
10
.
PI
AER
.
.
.
.
.
.
.
.
.
.
.
.
.
. .
. .
+
.
.
.
.
.
. .
.
.
. .
12
--
-I-
13
--
--
14
--
+
15
--
+
16
--
--
R
17
+
+
D
18
--
--
i
--
-
--
--
G i n g i v a l i n d e x ( A p p e n d i x Ill);
PI,
A N A , A n a e r o b i c a t m o s p h e r e in culture;
.
+
Gram + cocci in chains
+
Gram
-
+
Gram
+ c o c c i in s h o r t
bacilli
+
chains Gram + (aerobic)pleomorphic rods diphtheroids Gram + (anaerobic) cocci in clusters
m
m
M
p l a q u e i n d e x ( A p p e n d i x III); 0 . 0 0 -
AER,
+
.
.
19
+ c o c c i in c l u s t e r s
.
II
20
-
.
.
.
Gram
.
-
.
Smear
. .
-
.
ANA
+*
.
.
AER
.
.
.
ANA
1.50 = negative; 1.50 -
3.00 = positive
A e r o b i c a t m o s p h e r e in culture
* o n l y c u l t u r e w i t h p o s i t i v e g r o w t h o n the S e p t i - C h e k a g a r Slide ( c h o c o l a t e a g a r m e d i u m )
RESULTS Bacteriologic studies All cultures were negative in samples taken before brushing. Five of the 20 patients had detectable bacteremia after brushing, with a total of six positive cultures. Two gram-positive aerobic cocci, three grampositive anaerobic coccis, and one gram-negative anaerobic coccus were identified. Growth on the chocolate agar subculture of the Sept-check slide was present on only one of the two positive aerobic slides. No growth occurred on the malt or Macconkey agar (Table I). The following samples produced detectable bacteremia: In sample 2 turbidity and hemolysis were present in the postbrushing aerobic bottle. They were evident in large, chalky white, smooth, nonhemolytie colonies on an agar slide and plate under aerobic conditions. These colonies tested coagulase-negative and used only the maltose substrate in the Minitek system. Subcultures were inhibited by novobiocin. Smears showed gram-
positive cocci in clusters. The bacterium was identified as Staphylococcus epidermidis. In sample 6 turbidity and hemolysis were present in the postbrushing anaerobic bottle. It contained grayish white, smooth, nonhemolytic colonies that grew under anaerobic conditions. Smears showed grampositive cocci in chains culturally and morphologically consistent with the genus Peptostreptococcus. In sample 8 slight turbidity was present in the postbrushing anaerobic bottle, It contained medium-sized, round, chalky white, 13-hemolytic colonies that also grew under anaerobic conditions. Smears revealed gram-negative non-spore-forming rods that were culturally and morphologically consistent with the family Bacteroidaceae. In sample 10 turbidity was present in the postbrushing anaerobic bottle. It contained medium-sized, grayish white, nonhemolytic colonies that grew under anaerobic conditions. A strong, foul odor exuded from the broth and the agar. Smears showed gram-positive
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Schlein et al.
Am. J. Orthod. Dentofac. Orthop. May 1991
Table II. Indices of oral hygiene Subject
Gingival index
Plaque index
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1718 19 20
0.96 1.37 1.13 1.5 1.38 1.17 1.125 '.71 '.83 .13 .04 .21 .25 .25 .58 .38 .87 .21 .38 .25
0.75 0.96 1.17 1.42 1.09 1.54 1.0 1.75 1.29 1.04 1~21 1.13 1.46 1.71 1.75 1.33 1.96 1.67 2.0 0.92
0.00-1.50 - good oral hygiene 1.50-3.00 - poor oral hygiene
cocci in chains culturally and morphologically consistent with the genus Peptostreptococcus. In sample 11 turbidity was evident in both aearobic and anaerobic postbrushing culture bottles. It contained medium-sized, greyishwhite, nonhemolytic colonies that grew under aerobic conditions. Smears revealed gram-positive pleomorphic rods (diphtheroids). Also, sample 11 contained large, chalky white, smooth nonhemolytic colonies that grew under anaerobic conditions. These were gram-positive cocci in clusters culturally and morphologically consistent with the genus Peptococcus.
Oral hygiene studies All patients with positive cultures had a gingival score below 1.50. Only two of these patients had plaque scores above 1.50 (see Table II).
Immunologic studies All isohemagglutinin titers that were tested were within the normal acceptable range. Two patients had AB-positive blood and therefore could not be tested. All immunoglobulin levels measured with the normally accepted values of IgG, IgA, and IGM.
DISCUSSION The results of this study conflict with the study of Chung et al.4 in two principal areas. First, Chung found positive cultures t/efore the subjects brushed, and, second, aerobes were not recovered in that study. He ex-
plained that prebrushing bacteremia was possibly caused by eating or brushing just before blood-drawing appointments. The patients in the present study were carefully screened to confirm that these activities had not occurred in the 2 hours before their appointments. Recovery of aerobic bacteria in the present study may be attributed to the selection of paired culture bottles. The TSB culture bottles were vented and favored growth and early detection of aerobic and facultative bacteria; the unvented Columbia broth culture bottles were selective for anaerobic growth. Pfaller et al. ~6 showed that paired culture-bottle-system subculturing of unvented thiol broth had limited value for detection of additional isolates because such isolates tended to be contaminants or were facultative and already present in the vented bottle before the initiation of the study. Chung 4 employed a single-blood-culture bottle of brain heart infusion broth per blood sample. The blood volume in his sample was 4 ml per culture. This sample was later subcultured in aerobic and anaerobic conditions. Petrovitch et a12 controlled prebrushing activity 2 hours before blood sampling and followed the same blood-culturing techniques as.Chung for the first 10 patients. The blood volume sample, however, was increased to 10 ml per sample. The samples from the next eight patients were vented, which would favor aerobic and facultative growth. The samples taken from the last eight patients were divided in half and placed into vented and unvented culture bottles. Petrovitch suggested that the complete absence of growth was probably a result of the efficient reticuloendothelial system in removing circulating bacteria. Several factors in the present study may be considered responsible for the recovery of bacteria in blood samples after brushing: (1) favorable timing of the blood sampling (5 minutes after brushing), (2) increased blood-volume sample (20 ml), (3) paired culture bottles, and (4) the presence of 0.05% sodium polyanethol sulfonate (SPS) in the broth of all the culture bottles. Petrovitch did add SPS to the last eight samples; however, these co.ntained half the blood volume sample. Bender et al. 29 found that SPS increased the sensitivity of blood-culturing techniques. Blood remains actively phagocytic for 24 hours. Sodium polyanethol sulfonate is a polyanionic anticoagulant that also inhibits complement, lysozyme, and phagocytosis of the blood, improving recovery of bacteria. The gingival index of all patients with positive cultures was below 1.50. The plaque index of only one patient with a positive culture exceeded 1.50 at 1.54. The plaque index was not an accurate indication of oral hygiene in this study because the patients were required not to brush for at least 2 hours before their appoint-
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Toothbrushing and transient bacteremia in patients undergoing treatment
ments. Collection of patients with poor oral hygiene who were willing to participate in this study was a difficult task, as the previous researchers have stated. Durack et al. 3° (1983) found that in 52 cases of endocarditis, 92% were linked directly to an episode of dental treatment. Only 12% of these patients were covered by the American Heart Association (AHA) guidelines. Premedication requiring parenteral injection for dental procedures has been identified as a significant problem 31 in compliance with AHA recommendations. A controversy exists concerning the use of safe and convenient alternatives to parenteral injection. The advantages of oral prophylaxis are expected to increase compliance and reduce the incidence of bacterial endocarditis. For example, the literature in England 3-"and Israel 33 has shown recent support for the use of amoxicillin for prevention of bacterial efidocarditis outside the hospital. A single dose of 3 gm of amoxicillin is given orally I hour before the dental procedure. For patients under age 10, one half of the dose is prescribed, for patients under age 5, one quarter the adult dose. This dosage will achieve adequate serum levels for the critical 9hour period in which surviving bacteria begin to multiply on the endocardium. In addition to the bactericidal activity of amoxicillin, Glauser et al. 34 showed that this antibiotic inhibits the adherence of bacteria to the thrombotic vegetations on affected heart valves. Neu 35 found Streptococcus in 42% of nonpremedicated patients. However, this figure was reduced to 12% in those premedicated with penicillin V and further reduced to 5% in those given amoxicillin. Littner et al. 33 demonstrated amoxicillin as a simplified and appropriate regimen for chemoprophylaxis in high-risk as well as low-risk patients. The authors believe that since orthodontic appliances increase the incidence of gingival hypertrophy and make home care procedures more difficult, the subject of transient bacteremia should be discussed with patients who are at risk. These patients and their parents must be advised of the importance of removing plaque on a daily basis to reduce the incidence of gingival hypertrophy and reduce or prevent gingival bleeding, the cause of bacteremia from home care procedures. It must be emphasized that patients in this study with adequate home care procedures nevertheless had transient bacteremia after tooth-brushing. Patients at risk will also encounter transient bacteremia. Like Chung 4 and Petrovitch, ~ we also found it difficult or impossible to isolate bacteria from the blood of patients after toothbrushing--a result that indicates the efficiency of a properly functioning immune system. The question that must be asked is whether the patient at risk has a greater chance to experience bacterial endocarditis as a
471
result of home care procedures. Unfortunately, very little is known about the consequences of bacteremia generated from toothbrushing, flossing, or loss of deciduous teeth in actual cases of bacterial endocarditis. It could be argued that the lack of information may be attributed to the lack of incidence, but until a definitive statement can be made the recommendations of the American Heart Association should be accepted. Dajani, 36 a member of the American Heart Association, stated in a personal communication that if the standard premedication recommended by the American Heart Association is given to the patient, and if the orthodontic procedure does not cause bleeding, the followup dose 6 hours later need not be taken. Both Dajani and Millard 37 stated in personal communications that perhaps antibacterial mouthwashes such as chlorhexidine can be used by the at-risk orthodontic patient before banding and debanding so that the orthodontist can reduce the risk of the treatment for which he is responsible. The American Heart Association's pamphlet entitled Dental Care f o r Children With Heart Disease 36 states, in reference to heart disease: "Applicances can cause tissue injury during vigorous activitieg, such as contact sports like football. Children participating in contact sports should wear mouth guards to protect their teeth and prevent tissue damage. Your dentist and orthodontist can offer other suggestions to avoid injury." This pamphlet should be given to all patients who are at risk and who are undergoing any type of dental treatment. CONCLUSIONS
1. Samples taken from 25% of the patients after brushing revealed bacteremia. 2. Those patients with bacteremia developed had been identified as having good oral hygiene. 3. The orthodontist should evaluate the level of risk of the patient and consider consultation with the patient's internist or cardiologist. 4. Premedication should be given at the time of banding and bracketing and again at debanding and debracketing. 5. The orthodontist should be more conscious of the size and sharp edges on the appliance to minimize gingival hypertrophy and mucosal irritation. Special attention should be given to reducing the size of brackets; to smoothing of tubes, hooks, and bracket wings; and to the avoidance of fixed acrylic appliances such as the Haas rapid palatal expander and the Nance palatal button. 6. The orthodontist should take into consideration neuromuscular patterns that affect the pressure and posture of the cheek, lip, and tongue along with the effects of mouth breathing on the gingiva.
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Am. J. Orthod. Dentofae. Orthop. MaS' 1991
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35. 36.
37. 38. 39.
metric method for detecting bacteria. J Clin Microbiol 1975; 1:302-8. Thompson RB Jr, File TM Jr, Evans BL. Comparison of yield, clinical significance, and cost of a 20 ml and 20 ml Blood Volume Cultured by Bactec plus Septi-Chek system [Abstract]. American Society for Mierobiol~y, 86th Annual Meeting, Washington, D.C., March 23-28, 1986. Weinstein hiP, Relier LB, Mirrett S, Stratton CW, Reimer LG, Wang WL. Controlled evaluation of the agar-slide and radioactive blood culture systems for the detection of bacteremia and fungemia. J Clin Microbiol 1986;23-221-5. Loe H. The gingival index, the plaque index and the retention index system. J Periodont 1967;38[suppl]:610. Cassell GH. Staphylococci. In: McGhee JR, Michalek SM, Cassell GH eds. Dental microbiol~y, Philadelphia: tlarper & Row, 1982:404-15. Cassell GH. Other bacteria of medical importance. In: McGhee JR, hlichalek SM, Cassell GH eds. Dent Microbiol, Philadelphia: Harper & Row, 1982:492-504. Holdeman LV, Kelley RW, Moore WEC. In: Krieg NR, Holt JH, eds. Bergey's manual of systematic bacteriology, Baltimore: Williams & Wilkins, 1984:602-62. Louis DS, Smith LDS. The anaerobic bacteria, In: McGhee JR, Michalek, S, Cassel GH. Dental microbiology, Philadelphia: Harper & Row, 1982:450-60. Pfaller MA, Westfall LM, Murray PR. Value of routine aerobic subculturing of unvented blood culture bottles. J Clin Microbiol 1983;17:601-4. Bender IB, Seltzer S, Meloff (3, Pressman RS. Conditions affecting sensitivity of techniques for detection of bacteremia. J Dent Res 1961;40:951-9. Durack DT, Kaplan EL, Bmno AL. Apparent failures of endocarditis prophylaxis: analysis of 52 cases submitted to a national registry. JAMA 1983;250:2318-22. Holbrook WP, Wiley RF, Shaw TRD. Prophylaxis of infective endocarditis. Br Dent J 1983;154:36-9. Shanson DC. The prophylaxis of infective endocarditis. J Antimicrob Chemother 1978;4:2-4. Littner hiM, Kaffe I, Tamse H, Buchner A. New concepts in chemoprophylaxis of bacterial endocarditis resulting from dental treatment. Oral Surg Oral Med Oral Pathol 1986;61:338-42. Glauser MP, Bernard JP, Morelillon P, Francioli P. Successful single dose amoxicillis prophylaxis against experimental endocarditis, evidence for two mechanisms of protection. J Infect Dis 983; 147:568-75. Neu HC. Amoxicillin. Ann Intern bled 1979;90:356-60. Dajani A. Personal communication. Committee on Rheumatic Fever, Endocarditis, Kawaski Disease, Council on Cardiovascular Disease in the Young. Millard HD. Personal communication. University of hlichigan. Tauber KA. Personal communication. American Heart Association. American Heart Association. Dental care for children with heart disease [pamphlet]. Committee on Rheumatic Fever and Infective Endocarditis of the Council on Cardiovascular Disease in the Young of the American Heart Association. 1986.
Reprint requests to: Dr. Earl M. Kudlick Department of Orthodontics College of Dentistry Howard University 600 W St. NW Washington, D.C. 20059
Washhzgton, D.C. This study was made to determine whether and to what extent bacteremia occurred after toothbrushing in patients undergoing orthodontic treatment with fixed appliances. Twenty patients were selected, all with negative history of heart or hematologic disorders. These patients had not taken antibiotics or had a history of a cold in the previous 30 days. Blood samples of 20 ml were drawn before and 5 minutes after brushing. The immune status of the patients was tested by measurerrlent of isohemagglutins and immunoglobulin levels. Blood samples were incubated in paired culture bottles containing trypticase soy broth (TSB) with an agar paddle and Columbia broth. All samples taken before brushing were negative for bacteria. Five of the 20 patients (25% of the sample) had positive blood tests after brushing. Both anaerobic and aerobic bacteria were identified from the blood samples. Those patients who were found to have a bacteremia did not display poor oral hygiene. (AMJ ORTHODDENTOFACORTHOP1991;99:466"723
T h e microflora of the oral cavity can be a source of bacteremia after disruption of capillaries in the gingival tissues. In normal persons, the episodes of bacteremia are brief because of the efficient clearance by the host's immune system. However, in persons with a history of rheumatic heart disease, infective endocarditis, congenital heart defects, prosthetic valve replacement, organic heart murmurs, and aortic valve disease, transient bacteremia increases the risk of infective endocarditis. Bacterial endocarditis has a high mortality rate) and successfully treated bacterial endocarditis has a high rate of recurrence (8.5%) 2 of bacterial reinfection and limitation of activity as a result of cardiac decompensation. The 5-year survival rate has been reported at 69% with congestive failure as the principal cause of death. Originally, a study entitled "A Survey to Evaluate the Management of Orthodontic Patients With a History of Rheumatic Fever or Congenital Heart Disease" was published) This article logically led to the question: If the presence of fixed orthodontic appliances increases From ttoward University 'Private practice, White River Junction, Vt. ~Associate Professor, College of Dentistry. ¢Associate Professor, Sickle Cell Center. dAssociate Professor, College of Medicine 'Professor, College of Medicine. A thesis submitted by Dr. Schlein to the Department of Orthodontics, Howard University College of Dentistry, in partial fulfillment of the requirement for a Certificate of Proficiency in Orthodontics in 1987. 811119659
466
the risk of plaque retention, will toothbrushing give rise to bacteremia? The present article represents the third study in a series involving toothbrushing and bacteremia in orthodontic patients that was performed at Howard University College of Dentistry Orthodontic Department. In the initial study, Chung et al. 4 recovered anaerobes in 10 of 16 patients. Unexpectedly, these 10 patient~ had positive blood cultures before brushing, while only three had positive cultures after brushing. In a second study, Petrovitch et al.,5 using similar techniques, did not detect any bacterial growth in blood samples taken from 26 patients. The second study demonstrated the elusive nature and difficulty of isolating bacteria from the bloodstream because of the following factors: (1) the concentration of bacteria entering the bloodstream, (2) the rate of dispersion of circulating bacteria, (3) the site of blood sampling, (4) the time between inoculation and blood sampling, and (5) culturing techniques. All of these factors were carefully evaluated, and a third study was developed with major revisions in blood sampling and culturing techniques to improve the ability to isolate bacteria from the bloodstream to determine whether bacteremia could be detected after toothbrushing in normally healthy orthodontic patients. REVIEW OF THE LITERATURE Site of blood withdrawal
Beeson et al. 6 compared sites of removal of bacteria from the blood of patients with bacterial endocarditis.
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Quantitative arterial and venous blood cultures were taken from the following peripheral locations: the femoral artery and vein and the antecubital vein as well as the right auricle, vena cavae, hepatic, and renal veins. Blood collected from the antecubital fossa had colony counts only slightly lower than arterial blood. The femoral vein had appreciably less bacterial-invasion and the hepatic vein had the smallest bacterial count. Timing of blood withdrawal Berger et al. 7 showed that blood cultures taken immediately after extraction were 81.4% "positive but decreased to only 48.8% in cultures taken 10 minutes after extraction. Cobe 8 found that intravenous inoculations of orhemolytic streptococci in rabbits were recovered in blood cultures taken by means of cardiac puncture at 1 minute and 3 minuteg. Minimal amounts were detected at 5 minutes, and none after 10 minutes. Bender et al. 9 observed bacteremia immediately after light scaling and 10 minutes afterward. Initial cultures were positive for 30% of subjects tested, but after 10 minutes only 5% of cultures were positive. These researchers also found positive cultures in 48 cases in which instruments had extended beyond the apex during endodontic therapy. Immediately after manipulation, 31.2% of the subjects had positive cultures, but cultures taken 10 minutes later were all negative. Blood volume sample Hall et al) ° compared 5 ml and 10 ml blood-volume samples in 50 ml and 100 ml soybean-casein digest broth culture bottles (tryptic soy broth (TSB), Difco Laboratories, Detroit, Mich.). A larger number of microorganisms was isolated with significant growth of gram-negative bacilli in the 100 ml bottles. Loesche '~ also strongly advocated increasing the volume of blood samples to increase the isolation of bacteria. Tenney et al. '2 found a microorganism yield from 7 ml samples 29% greater than from 2 ml samples. This supports the theory that the volume of blood cultured is critical in the detection of septicemia. Washington .3 suggested that the volume of blood is relatively more important than the medium or the atmosphere of incubation in the detection of sepsis. Salventi et al.~4 recommended a blood-to-broth ratio of 1:5 to 1 : 10. A blood-to-broth ratio between 1:2 and 1 : 5 may result in an overall decreased number of positive cultures, according to Relier.'5
Culturing medium Pfaller et al.~6 compared conventional TSB blood culture bottles with a combiuation of TSB and an agar-
coated slide attachment (Septi-Chek, Roche Diagnostic Systems, Montclair, N.J.) in 2662 sets of blood cultures. Significantly more gram-positive and gramnegative bacteremias were detected in the slide culture bottle than in the conventional bottles. Growth of grampositive organisms (particularly Staphylococcus) was detected in 24 to 48 hours earlier in the slide culture bottle. Henry et a l ) 7 found that Roche Septi-Chek blood culture was superior to the vented brain heart infusion biphasic medium bottle when both were tested in 5121 culture sets. Weinstein et al) s detected 99.7% of clinically important organisms in TSB with agar slides (BBL Microbiology Systems, Cockeysville, Md.) but only 82% in conventional blood culture systems. It was concluded that the biphasic system was superior to the conventional system, but this group recommended the use of a complementary anaerobe bottle. Weinstein et al., 19 in a subsequent study, rated the Septi-Check biphasic blood culture system with TSB superior to conventional peptone broth in 6956 filledblood culture sets. However, the benefit of a paired anaerobic bottle was reemphasized. Thiemke and Wicher 2° found the use of a radiometric blood culture system (Bactec-Johnson Laboratories Inc., Towson, Md.) valuable in early detection of bacteremias. Thompson 2' found the two-bottle Septi-Chek system less expensive than the Bactec radiometric blood culture system. Weinstein et al. 22 found the TSB with slide (SeptiChek) equal to the Bactec in most respects except for the growth of more fungi in the Septi-Chek bottles. METHODS AND MATERIALS Twenty patients who were undergoing treatment in the Howard University Orthodontic clinic were selected according to the following criteria. The patients were 15 years of age or older with no history of rheumatic fever, rheumatic heart disease, congenital heart birth defects, cardiac surgery (prosthetic valves), sickle cell disease, arteriosclerotic heart disease, or hematologic disorders. Patients were rejected if they had taken antibiotics within the last 30 days. All patients stated that they were in good general health. Once these criteria were fulfilled, the patients signed consent forms and were instructed not to brush their teeth, eat, or chew gum or hard candy for 2 hours before their appointments for the blood drawing. Each participant's gingival condition was evaluated at least 20 minutes before sampling with the Silness and Loe 23 Gingival and Plaque Index System. The gin-
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gival index measured the degree of inflammation and the tendency for bleeding in response to probing on a scale of 0 to 3. Measurements were taken on the buccal, mesial, and lingual gingival surfaces of the crowns of the maxillary right molar, right central incisor, left canine, mandibular right canine, left central incisor, and mandibular left first molar. The doubled scores for the buccal, lingual, and doubled mesial surfaces were summed and divided by 24 in the calculation of the index score. The nonbrushing arm of the patient was selected, and the median cubital vein'area was prepared with a povidone-iodine solution. A scalp vein needle, 21 or 23 gauge, with 12 inches of tubing was inserted. Twenty-one milliliters of blood was withdrawn into a 25 ml syringe. The first syringe was removed and replaced with a syringe containing 1.0 ml of Hep-Lock (Elkin, Sire, Cherry Hill, N.J.), a heparin-lock flush solution (10 units per ml). A 21-gauge x 1V2-inch needle was attached to the syringe with the blood sample, allowing 10 ml to be injected directly into a blood culture bottle which contained 70 ml of Columbia broth culture medium (Septi-Chek, Roche Diagnostic Systems, Montclair, N.J.). This medium was selected to support anaerobic growth. The second I0 ml of blood was injected into a Septi-Chek blood culture bottle containing 70 ml of trypticase soy broth (TSB). The final 1 ml was deposited into a sterile Kahn tube for testing immunologic competency. The needle and heparin sytinge were secured, and the patient was given a new toothbrush and instructed to brush for 2 minutes without dentrifice and then to rinse. Three minutes after the brushing, the heparin solution was retracted, the final 20 ml of blood was taken, and the scalp vein needle with withdrawn. This second blood sample was equally divided into a second pair of Septi-Chek blood culture bottles. This procedure was followed for all 20 patients. All samples were transported to the laboratory. The 1 ml blood sample was allowed to clot. The clot was rimmed before centrifuging to maximize yield of serum. The serum was pipetted and transferred to a second tube for storage at - 2 0 ° C until all samples had been collected. The RBCs were typed for the ABO system. The patients' RBCs were mixed with anti-A and anti-B typing serum and identified by the agglutination pattern. A Septi-Chek slide containing three agar media was attached to the TSB culture bottle. It contained chocolate agar, MacConkey agar, and malt agar, which were suitable for subculture of bacterial and fungal growth. The culture bottles were inverted to mix the broth and to inoculate the slide. The slide facilitated early identification of aerobic growth. The bottles were incubated
Am. J. Orthod. Denlofac. Orthop. May 1991
at 37 ° C and checked daily for 7 days for turbidity and growth on the agar slide. Subcultures were performed wherever turbidity occurred or after 7 days if turbidity did not occur. Subcultures were obtained by insertion of a sterile cotton-tipped applicator into the broth, which was then stretched across trypticase soy agar with 5% sheep blood. Subcultures from the anaerobic bottles of Columbia broth were placed into an acti~'ated Gaspak anaerobic jar (Baltimore Biological Laboratory, Cockeysville, Md.). Both aerobic and anaerobic subcultures were incubated at 37 ° C for 48 hours and then examined for bacterial growth. Positive subcultures were examined for growth patterns, and a representative colony was transferred to a glass slide and Gram stained for examination under the microscope (magnification ×1000). Speciation of Staphylococcus was performed by means of the coagulase test and the Minitek system (Becton Dickinson and Company) with substrates of mannitol, maltose, and trehalose. A plate of TSA ~vas inoculated, a 5microgram novobiocin disk was placed in the center, and the plate was incubated for 24 hours and examined for sensitivity. All tubes of stored serum were thawed and tested for isohemagglutinin levels (anti-A, anti-B, and antiAB). A volume of 0.025 ml of saline solution was pippetted into each well of the MicroTiter plate (GIBCO Laboratories, Grand Island, N.Y.). To the first well, 0.025 ml of patient serum was pipetted and serially diluted to 1:128. Known A and B cells were washed and prepared as a 1% suspension with a graduated centrifuge tube. Then a volume of 0.025 ml of the standardized cells (group A cells if type B, group B cells if type A, or both if type O) were added to each well. Agglutination patterns were read after 3 hours and the titers were recorded. Quantitative determination of immunoglobulin G,M,A levels in the patient's serum was performed with Kallestad single radial immunodiffusion plates (Helena Laboratories, Beaumont, Tex.) Each endoplate contained buffered aga.rose antiserum mixture with 16 wells for depositing.patient and reference samples. Five microliters of serum from each patient was placed into a well of each type of endoplate and read after 24 hours. The diameter of the immunoprecipitin ring was measured with the aid of an ocular magnifying glass with a 0.1 m scale. Using known serum as a reference, we plotted a reference curve on two-cycle semilogarithmic graph paper. We determined test sample concentrations by locating the sample ring diameter on the reference curve. Patient serum concentration was then compared to normally accepted serum levels.
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Table I. Toothbrushing and transient bacteremia in patients undergoing orthodontic treatment Turbidity
Oral hygeine
After
Before Subject
GI,
GI
l
.
2
.
3
.
4
.
5
.
6
-
7
.
8
.
9
.
10
.
PI
AER
.
.
.
.
.
.
.
.
.
.
.
.
.
. .
. .
+
.
.
.
.
.
. .
.
.
. .
12
--
-I-
13
--
--
14
--
+
15
--
+
16
--
--
R
17
+
+
D
18
--
--
i
--
-
--
--
G i n g i v a l i n d e x ( A p p e n d i x Ill);
PI,
A N A , A n a e r o b i c a t m o s p h e r e in culture;
.
+
Gram + cocci in chains
+
Gram
-
+
Gram
+ c o c c i in s h o r t
bacilli
+
chains Gram + (aerobic)pleomorphic rods diphtheroids Gram + (anaerobic) cocci in clusters
m
m
M
p l a q u e i n d e x ( A p p e n d i x III); 0 . 0 0 -
AER,
+
.
.
19
+ c o c c i in c l u s t e r s
.
II
20
-
.
.
.
Gram
.
-
.
Smear
. .
-
.
ANA
+*
.
.
AER
.
.
.
ANA
1.50 = negative; 1.50 -
3.00 = positive
A e r o b i c a t m o s p h e r e in culture
* o n l y c u l t u r e w i t h p o s i t i v e g r o w t h o n the S e p t i - C h e k a g a r Slide ( c h o c o l a t e a g a r m e d i u m )
RESULTS Bacteriologic studies All cultures were negative in samples taken before brushing. Five of the 20 patients had detectable bacteremia after brushing, with a total of six positive cultures. Two gram-positive aerobic cocci, three grampositive anaerobic coccis, and one gram-negative anaerobic coccus were identified. Growth on the chocolate agar subculture of the Sept-check slide was present on only one of the two positive aerobic slides. No growth occurred on the malt or Macconkey agar (Table I). The following samples produced detectable bacteremia: In sample 2 turbidity and hemolysis were present in the postbrushing aerobic bottle. They were evident in large, chalky white, smooth, nonhemolytie colonies on an agar slide and plate under aerobic conditions. These colonies tested coagulase-negative and used only the maltose substrate in the Minitek system. Subcultures were inhibited by novobiocin. Smears showed gram-
positive cocci in clusters. The bacterium was identified as Staphylococcus epidermidis. In sample 6 turbidity and hemolysis were present in the postbrushing anaerobic bottle. It contained grayish white, smooth, nonhemolytic colonies that grew under anaerobic conditions. Smears showed grampositive cocci in chains culturally and morphologically consistent with the genus Peptostreptococcus. In sample 8 slight turbidity was present in the postbrushing anaerobic bottle, It contained medium-sized, round, chalky white, 13-hemolytic colonies that also grew under anaerobic conditions. Smears revealed gram-negative non-spore-forming rods that were culturally and morphologically consistent with the family Bacteroidaceae. In sample 10 turbidity was present in the postbrushing anaerobic bottle. It contained medium-sized, grayish white, nonhemolytic colonies that grew under anaerobic conditions. A strong, foul odor exuded from the broth and the agar. Smears showed gram-positive
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Schlein et al.
Am. J. Orthod. Dentofac. Orthop. May 1991
Table II. Indices of oral hygiene Subject
Gingival index
Plaque index
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1718 19 20
0.96 1.37 1.13 1.5 1.38 1.17 1.125 '.71 '.83 .13 .04 .21 .25 .25 .58 .38 .87 .21 .38 .25
0.75 0.96 1.17 1.42 1.09 1.54 1.0 1.75 1.29 1.04 1~21 1.13 1.46 1.71 1.75 1.33 1.96 1.67 2.0 0.92
0.00-1.50 - good oral hygiene 1.50-3.00 - poor oral hygiene
cocci in chains culturally and morphologically consistent with the genus Peptostreptococcus. In sample 11 turbidity was evident in both aearobic and anaerobic postbrushing culture bottles. It contained medium-sized, greyishwhite, nonhemolytic colonies that grew under aerobic conditions. Smears revealed gram-positive pleomorphic rods (diphtheroids). Also, sample 11 contained large, chalky white, smooth nonhemolytic colonies that grew under anaerobic conditions. These were gram-positive cocci in clusters culturally and morphologically consistent with the genus Peptococcus.
Oral hygiene studies All patients with positive cultures had a gingival score below 1.50. Only two of these patients had plaque scores above 1.50 (see Table II).
Immunologic studies All isohemagglutinin titers that were tested were within the normal acceptable range. Two patients had AB-positive blood and therefore could not be tested. All immunoglobulin levels measured with the normally accepted values of IgG, IgA, and IGM.
DISCUSSION The results of this study conflict with the study of Chung et al.4 in two principal areas. First, Chung found positive cultures t/efore the subjects brushed, and, second, aerobes were not recovered in that study. He ex-
plained that prebrushing bacteremia was possibly caused by eating or brushing just before blood-drawing appointments. The patients in the present study were carefully screened to confirm that these activities had not occurred in the 2 hours before their appointments. Recovery of aerobic bacteria in the present study may be attributed to the selection of paired culture bottles. The TSB culture bottles were vented and favored growth and early detection of aerobic and facultative bacteria; the unvented Columbia broth culture bottles were selective for anaerobic growth. Pfaller et al. ~6 showed that paired culture-bottle-system subculturing of unvented thiol broth had limited value for detection of additional isolates because such isolates tended to be contaminants or were facultative and already present in the vented bottle before the initiation of the study. Chung 4 employed a single-blood-culture bottle of brain heart infusion broth per blood sample. The blood volume in his sample was 4 ml per culture. This sample was later subcultured in aerobic and anaerobic conditions. Petrovitch et a12 controlled prebrushing activity 2 hours before blood sampling and followed the same blood-culturing techniques as.Chung for the first 10 patients. The blood volume sample, however, was increased to 10 ml per sample. The samples from the next eight patients were vented, which would favor aerobic and facultative growth. The samples taken from the last eight patients were divided in half and placed into vented and unvented culture bottles. Petrovitch suggested that the complete absence of growth was probably a result of the efficient reticuloendothelial system in removing circulating bacteria. Several factors in the present study may be considered responsible for the recovery of bacteria in blood samples after brushing: (1) favorable timing of the blood sampling (5 minutes after brushing), (2) increased blood-volume sample (20 ml), (3) paired culture bottles, and (4) the presence of 0.05% sodium polyanethol sulfonate (SPS) in the broth of all the culture bottles. Petrovitch did add SPS to the last eight samples; however, these co.ntained half the blood volume sample. Bender et al. 29 found that SPS increased the sensitivity of blood-culturing techniques. Blood remains actively phagocytic for 24 hours. Sodium polyanethol sulfonate is a polyanionic anticoagulant that also inhibits complement, lysozyme, and phagocytosis of the blood, improving recovery of bacteria. The gingival index of all patients with positive cultures was below 1.50. The plaque index of only one patient with a positive culture exceeded 1.50 at 1.54. The plaque index was not an accurate indication of oral hygiene in this study because the patients were required not to brush for at least 2 hours before their appoint-
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Toothbrushing and transient bacteremia in patients undergoing treatment
ments. Collection of patients with poor oral hygiene who were willing to participate in this study was a difficult task, as the previous researchers have stated. Durack et al. 3° (1983) found that in 52 cases of endocarditis, 92% were linked directly to an episode of dental treatment. Only 12% of these patients were covered by the American Heart Association (AHA) guidelines. Premedication requiring parenteral injection for dental procedures has been identified as a significant problem 31 in compliance with AHA recommendations. A controversy exists concerning the use of safe and convenient alternatives to parenteral injection. The advantages of oral prophylaxis are expected to increase compliance and reduce the incidence of bacterial endocarditis. For example, the literature in England 3-"and Israel 33 has shown recent support for the use of amoxicillin for prevention of bacterial efidocarditis outside the hospital. A single dose of 3 gm of amoxicillin is given orally I hour before the dental procedure. For patients under age 10, one half of the dose is prescribed, for patients under age 5, one quarter the adult dose. This dosage will achieve adequate serum levels for the critical 9hour period in which surviving bacteria begin to multiply on the endocardium. In addition to the bactericidal activity of amoxicillin, Glauser et al. 34 showed that this antibiotic inhibits the adherence of bacteria to the thrombotic vegetations on affected heart valves. Neu 35 found Streptococcus in 42% of nonpremedicated patients. However, this figure was reduced to 12% in those premedicated with penicillin V and further reduced to 5% in those given amoxicillin. Littner et al. 33 demonstrated amoxicillin as a simplified and appropriate regimen for chemoprophylaxis in high-risk as well as low-risk patients. The authors believe that since orthodontic appliances increase the incidence of gingival hypertrophy and make home care procedures more difficult, the subject of transient bacteremia should be discussed with patients who are at risk. These patients and their parents must be advised of the importance of removing plaque on a daily basis to reduce the incidence of gingival hypertrophy and reduce or prevent gingival bleeding, the cause of bacteremia from home care procedures. It must be emphasized that patients in this study with adequate home care procedures nevertheless had transient bacteremia after tooth-brushing. Patients at risk will also encounter transient bacteremia. Like Chung 4 and Petrovitch, ~ we also found it difficult or impossible to isolate bacteria from the blood of patients after toothbrushing--a result that indicates the efficiency of a properly functioning immune system. The question that must be asked is whether the patient at risk has a greater chance to experience bacterial endocarditis as a
471
result of home care procedures. Unfortunately, very little is known about the consequences of bacteremia generated from toothbrushing, flossing, or loss of deciduous teeth in actual cases of bacterial endocarditis. It could be argued that the lack of information may be attributed to the lack of incidence, but until a definitive statement can be made the recommendations of the American Heart Association should be accepted. Dajani, 36 a member of the American Heart Association, stated in a personal communication that if the standard premedication recommended by the American Heart Association is given to the patient, and if the orthodontic procedure does not cause bleeding, the followup dose 6 hours later need not be taken. Both Dajani and Millard 37 stated in personal communications that perhaps antibacterial mouthwashes such as chlorhexidine can be used by the at-risk orthodontic patient before banding and debanding so that the orthodontist can reduce the risk of the treatment for which he is responsible. The American Heart Association's pamphlet entitled Dental Care f o r Children With Heart Disease 36 states, in reference to heart disease: "Applicances can cause tissue injury during vigorous activitieg, such as contact sports like football. Children participating in contact sports should wear mouth guards to protect their teeth and prevent tissue damage. Your dentist and orthodontist can offer other suggestions to avoid injury." This pamphlet should be given to all patients who are at risk and who are undergoing any type of dental treatment. CONCLUSIONS
1. Samples taken from 25% of the patients after brushing revealed bacteremia. 2. Those patients with bacteremia developed had been identified as having good oral hygiene. 3. The orthodontist should evaluate the level of risk of the patient and consider consultation with the patient's internist or cardiologist. 4. Premedication should be given at the time of banding and bracketing and again at debanding and debracketing. 5. The orthodontist should be more conscious of the size and sharp edges on the appliance to minimize gingival hypertrophy and mucosal irritation. Special attention should be given to reducing the size of brackets; to smoothing of tubes, hooks, and bracket wings; and to the avoidance of fixed acrylic appliances such as the Haas rapid palatal expander and the Nance palatal button. 6. The orthodontist should take into consideration neuromuscular patterns that affect the pressure and posture of the cheek, lip, and tongue along with the effects of mouth breathing on the gingiva.
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Am. J. Orthod. Dentofae. Orthop. MaS' 1991
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