Prevention of bacterial endocarditis: recommendations by the American Heart Association

Infective endocarditis risk in patients with bicuspid aortic valve: Systematic review and meta-analysis

Background

Antibiotic prophylaxis in bicuspid aortic valve patients is currently a matter of debate. Although it is no longer recommended by international guidelines, some studies indicate a high risk of infective endocarditis. We aim to evaluate the risk of native valve infective endocarditis in bicuspid aortic valve patients and compare to individuals with tricuspid aortic valve.

Methods

Study search of longitudinal studies regarding infective endocarditis incidence in bicuspid aortic valve patients (compared with tricuspid aortic valve/overall population) was conducted through OVID in the following electronic databases: MEDLINE, CENTRAL, EMBASE; from inception until October 2020. The outcomes of interest were the incidence rate and relative risk of infective endocarditis. The relative risk and incidence rate (number of cases for each 10 000 persons-year) with their 95 % confidence intervals (95 %CI) were estimated using a random effects model meta-analysis. The study protocol was registered at PROSPERO CRD42020218639.

Results

Eight cohort studies were selected, with a total of 5351 bicuspid aortic valve patients. During follow up, 184 bicuspid aortic valve patients presented infective endocarditis, with an incidence rate of 48.13 per 10,000 patients-year (95 %CI 22.24-74.02), and a 12-fold (RR: 12.03, 95 %CI 5.45-26.54) increased risk compared with general population, after adjusted estimates.

Conclusions

This systematic review and meta-analysis suggests that bicuspid aortic valve patients have a significant high risk of native valve infective endocarditis. Large prospective high-quality studies are required to estimate more accurately the incidence of infective endocarditis, the relative risk and the potential benefit of antibiotic prophylaxis.

Periodontal and dental health in inflammatory bowel diseases: a systematic review

Introduction: An increased risk of dental caries and periodontal diseases has been reported for inflammatory bowel disease (IBD) patients and are challenging conditions to manage.Areas covered: The authors searched international databases to find all studies assessing dental/periodontal outcomes in patients with IBD and other immune-mediated inflammatory disease (IMID), as well as the association between IMID medications and dental/periodontal status.Expert opinion: IBD are associated with a higher risk of both periodontitis and caries. Some evidence from rheumatoid arthritis suggests that periodontitis may be associated with a lower response to anti-TNF. There is no reliable evidence that IBD patients may be at greater risk of complications during routine dental care. On the basis of current data, guidelines can be proposed for the dental management focusing on the detection and eradication of infectious foci prior to the implementation of immunosuppressants/biologics and modified dental treatment protocol for invasive dental procedures that includes antibiotic prophylaxis.

Cranberry extract-based formulations for preventing bacterial biofilms

Generating formulations for the delivery of a mixture of natural compounds extracted from natural sources is a challenge because of unknown active and inactive ingredients and possible interactions between them. As one example, natural cranberry extracts have been proposed for the prevention of biofilm formation on dental pellicle or teeth. However, such extracts may contain phenolic acids, flavonol glycosides along with other constituents like coumaroyl iridoid glycosides, flavonoids, alpha-linolenic acid, n-6 (or n-3) fatty acids, and crude fiber. Due to the presence of a variety of compounds, determining which molecules (and how many molecules) are essential for preventing biofilm growth is nontrivial to ascertain. Therefore, a formulation that could contain natural, unrefined, cranberry extract (with all its constituent compounds) at high loading would be ideal. Accordingly, we have generated several candidate formulations including poly(lactic-co-glycolic) acid (PLGA)-based microencapsulation of cranberry extract (CE15) as well as formulations including stearic acid along with polyvinylpyrrolidone (PVP) or Ethyl lauroyl arginate (LAE) complexed with cranberry extracts (CE15). We found that stearic acid in combination with PVP or LAE as excipients led to higher loading of the active and inactive compounds in CE15 as compared with a PLGA microencapsulation and also sustained release of CE15 in a tunable manner. Using this method, we have been able to generate two successful formulations (one preventative based, one treatment based) that effectively inhibit biofilm growth when incubated with saliva. In addition to cranberry extract, this technique could also be a promising candidate for other natural extracts to form controlled release systems.Graphical abstract.

Dental Infection and Resistance-Global Health Consequences

Antibiotics are widely used in dental caries and another dental related issues, both for therapeutic and prophylactic reasons. Unfortunately, in recent years the use of antibiotics has been accompanied by the rapid emergence antimicrobial resistance. Dental caries and periodontal diseases are historically known as the top oral health burden in both developing and developed nations affecting around 20⁻50% of the population of this planet and the uppermost reason for tooth loss. Dental surgeons and family practitioners frequently prescribed antimicrobials for their patients as outpatient care. Several studies reported that antibiotics are often irrationally- and overprescribed in dental diseases which is the basis of antimicrobial resistance. The aim of this review is to evaluate the use of antibiotics in dental diseases. Almost certainly the promotion of primary oral health care (POHC) in primary health care program especially among the least and middle-income countries (LMIC) may be the answer to ensure and promote rational dental care.

Clinical, Radiographic, and Microbiologic Features of Infective Endocarditis in Patients With Hypertrophic Cardiomyopathy

Infective endocarditis (IE) is an infection of the inner lining of the heart with high morbidity and mortality despite medical and surgical advancements in recent decades. Hypertrophic cardiomyopathy (HC) is one of several medical conditions that have been linked to an increased risk of IE, but there is a paucity of data on this association. We therefore sought to define the clinical phenotype of IE in patients with HC at a single tertiary care center. A retrospective cohort of 30 adult patients with HC diagnosed with IE between January 1, 2006 and December 31, 2016 at Mayo Clinic Rochester were identified. Similar rates of aortic (n = 14) and mitral (n = 16) valve involvement by IE were noted (47% vs 53%). This finding persisted even in patients with left-ventricular outflow tract obstruction and systolic anterior motion of the mitral valve. Symptomatic embolic complications occurred in 10 cases (33%). Surgical intervention was performed in 11 cases (37%). One-year mortality was remarkably low at 7%. In conclusion, in the largest single-center cohort of IE complicating HC, there were similar rates of both mitral and aortic valve involvement regardless of the presence of left ventricular outflow tract obstruction, which is contrary to a long-standing tenet regarding the association of HC and IE. Moreover, no "high risk" IE subset was identified based on HC-related parameters.

Evaluation of Post-surgical Bacteremia with Use of Povidone-Iodine and Chlorhexidine During Mandibular Third Molar Surgery

BACKGROUND

Microorganisms may invade the blood stream by oral routes through surgical procedures like extractions, fractured teeth and periodontal pockets. The incidence of bacteremia is 70-80 % following tooth extraction, sub gingival scaling and intra ligament injection.

AIMS AND OBJECTIVES

Aim of study was to evaluate and compare the efficacy of two topical antimicrobial agents for the prevention of post-surgical bacteremia during mandibular third molar surgery. And objectives were to suggest need of proper topical antimicrobial agents and select proper antibiotics before oral surgical procedures in high risk cardiac patients.

MATERIALS AND METHODS

Thirty patients with Class 1, Position B mesioangular impacted mandibular third molar were randomly included in study and divided into 3 groups, each group containing 10 patients. Group I; sterile water group, Group II: povidone-iodine (5 %) group, Group III: chlorhexidine (Q, 2 %) group, pre and post-surgical blood samples were collected and Microbiological analyses of the blood samples were done. The organisms were identified by standard method on grams staining and identification of bacterial species by biochemical tests.

RESULTS

The clinical parameters like oral hygiene index simplified and periodontal index of Russel showed that all patients in three groups had fair oral hygiene with simple gingivitis on mean. In some individuals with slightly higher OHIS and PI scores, bacteremia was noted. All the pre surgical blood samples were negative for the growth of bacteria after 7 days of culture. In total 30 patients, 12 subjects had postoperative bacteremia. Out of those 12 patients 6 cases (60 %) of group I showed positive bacterial growth in the post surgical blood sample, while 4 cases in group III and 2 cases (20 %) in group II showed the same.

CONCLUSION

Use of povidone-iodine and chlorhexidine prior to the oral surgical procedures decreases the incidence of bacteremia as compared to sterile water irrigation. Povidone-iodine significantly reduces the incidence bacteremia and number of organisms compared to chlorhexidine and sterile water.

Low-cost periodontal therapy

Periodontitis is a complex infectious disease that affects low-income individuals disproportionately. Periodontitis is associated with specific bacterial species and herpesviruses, and successful prevention and treatment of the disease is contingent upon effective control of these pathogens. This article presents an efficacious, highly safe, minimally invasive, practical and low-cost periodontal therapy that involves professional and patient-administered mechanical therapy and antimicrobial agents. The major components are scaling for calculus removal, periodontal pocket irrigation with potent antiseptics, and treatment with systemic antibiotics for advanced disease. Povidone-iodine and sodium hypochlorite have all the characteristics for becoming the first-choice antiseptics in the management of periodontal diseases. Both agents show excellent antibacterial and antiviral properties, are readily available throughout the world, have been safely used in periodontal therapy for decades, offer significant benefits for individuals with very limited financial resources, and are well accepted by most dental professionals and patients. Four per cent chlorhexidine applied with a toothbrush to the most posterior part to the tongue dorsum can markedly reduce or eliminate halitosis in most individuals. Systemic antibiotics are used to treat periodontopathic bacteria that are not readily reached by topical therapy, such as pathogens within gingival tissue, within furcation defects, at the base of periodontal pockets, and on the tongue, tonsils and buccal mucosae. Valuable antibiotic therapies are amoxicillin-metronidazole (250 mg of amoxicillin and 250 mg of metronidazole, three times daily for 8 days) for young and middle-aged patients, and ciprofloxacin-metronidazole (500 mg of each, twice daily for 8 days) for elderly patients and for patients in developing countries who frequently harbor enteric rods subgingivally. Scaling to remove dental calculus and the prudent use of inexpensive antimicrobial agents can significantly retard or arrest progressive periodontitis in the great majority of patients.

Historical aspects of infective endocarditis

Infective endocarditis was a fatal disease three generations ago. Temporal evolution of knowledge made possible important advances in diagnostic techniques, especially in echocardiography, the possibility of cardiac surgery during the active infectious process and new guidelines for antibiotic prophylaxis before interventional procedures. Nowadays, infective endocarditis is curable. In this review, we describe historical aspects of endocarditis, from Osler's observations in the 19th century to the change from a "clinically possible" to a "clinically defined" disease.

Dentinal tubule disinfection with 2% chlorhexidine gel, propolis, morinda citrifolia juice, 2% povidone iodine, and calcium hydroxide

AIM

To investigate the antimicrobial activity of 2% chlorhexidine gel, propolis, Morinda citrifolia juice (MCJ), 2% povidone Iodine (POV-I), and calcium hydroxide on Enterococcus faecalis-infected root canal dentine at two different depths (200 microm and 400 microm) and three time intervals (day 1, 3 & 5).

METHODOLOGY

One hundred and eighty extracted human teeth were infected for 21 days with E. faecalis. Samples were divided into six groups. Group I (Saline) (Negative control), Group II (Propolis), Group III (MCJ), Group IV (2% Povidone Iodine), Group V (2% Chlorhexidine Gel), Group VI (Calcium hydroxide). At the end of 1, 3, and 5 days, the remaining vital bacterial population was assessed. Dentine shavings were collected at two depths (200 microm and 400 microm), and total numbers of colony forming units were determined. The values were analysed statistically with one-way analysis of variance followed by Tukey multiple comparison test. The paired t-test was used to check for differences in growth at different time intervals within groups and for differences at the two depths (P < 0.01)

RESULTS

The number of colony-forming units was statistically significant in all groups compared to the control group (Saline). Group V (chlorhexidine gluconate) (100%) produced better antimicrobial efficacy followed by 2% POV-I (87%), propolis (71%), MCJ (69%), and calcium hydroxide (55%). There was no significant difference between propolis and MCJ and no significant difference between data at 200 microm and 400 microm.

CONCLUSION

Propolis and MCJ were effective against E. faecalis in dentine of extracted teeth.

Antibiotic prophylaxis in oral healthcare - the agreement between Swedish recommendations and evidence

BACKGROUND

Almost all (17/20) Swedish counties have pharmaceutical committees that establish recommendations for the use of antibiotic prophylaxis in oral healthcare.Objective To evaluate the evidence for the use of antibiotic prophylaxis in oral healthcare and the agreement between Swedish recommendations and evidence.

MATERIAL AND METHODS

We conducted a systematic literature search in PubMed and the Cochrane Controlled Trials Register. The MeSH terms 'antibiotic prophylaxis' and 'dentistry' were used in the database search. Abstracts were reviewed according to specific inclusion and exclusion criteria. A total of 186 articles were read in full text by the four authors independently. Data extraction and interpretation of data was carried out using a pre-defined protocol. In the end, one case-control study was included for evaluation of evidence.

RESULTS

The case-control study included patients with specific cardiac conditions. The study reported a 49% protective efficacy (odds ratio: 0.51) of antibiotic prophylaxis for first-time episodes of endocarditis within 30 days of procedure. This result was not statistically significant. The quality of the evidence was low. No studies were evaluated on patients with other medical conditions. The recommendations included several cardiac and other medical conditions for which there is a lack of evidence or no evidence to support the use of antibiotic prophylaxis.

CONCLUSIONS

There is a lack of evidence to support the use of antibiotic prophylaxis. To avoid the risk of adverse events from antibiotics and the risk of developing resistant bacterial strains, the use of antibiotic prophylaxis should be minimised and recommendations in Sweden should be revised to be more evidence-based.

Risk Judgment by General Dental Practitioners: Rational but Uninformed

Background

Decisions by dentists to administer antibiotic prophylaxis to prevent infectious complications in patients involves professional risk assessment. While recommendations for rational use have been published, several studies have shown that dentists have low adherence to these recommendations.

Objective

To examine general dental practitioners’ (GDPs’) assessments of the risk of complications if not administering antibiotic prophylaxis in connection with dental procedures in patients with specific medical conditions.

Methods

Postal questionnaires in combination with telephone interviews. Risk assessments were made using visual analogue scales (VAS), where zero represented “insignificant risk” and 100 represented a “very significant risk”.

Results

Response rate: 51%. The mean risk assessments were higher for GDPs who administered antibiotics (mean = 54, SD = 23, range 26–72 mm on the VAS) than those who did not (mean = 14, SD = 12, range 7–31 mm) (P < 0.05). Generally, GDPs made higher risk assessments for patients with medical conditions that are included in recommendations than those with conditions that are not included. Overall, risk assessments were higher for tooth removal than for scaling or root canal treatment, even though the risk assessments should be considered equal for these interventions.

Conclusions

GDPs’ risk assessments were rational but uninformed. They administered antibiotics in a manner that was consistent with their risk assessments. Their risk assessments, however, were overestimated. Inaccurate judgments of risk should not be expected to disappear in the presence of new information. To achieve change, clinicians must be motivated to improve behaviour and an evidence-based implementation strategy is required.

Effect of betamethasone and diclofenac sodium on serum and tissue concentration of amoxicillin. In vivo study in rats

Objective:

Antimicrobial agents in combination with anti-inflammatory drugs have been usually prescribed in both Medicine and Dentistry. However, few scientific reports support this clinical practice. The aim of this study was to evaluate the effect of betamethasone and diclofenac sodium on serum and tissue concentration of amoxicillin in rats.

Methods:

Four polyurethane sponges were implanted in the back skin of 48 rats. After seven days the animals were divided into 6 groups (n=8). Group 1: amoxicillin (25 mg/kg); G2: diclofenac sodium (2.5 mg/kg); G3: betamethasone (0.1 mg/kg); G4: diclofenac sodium and amoxicillin; G5: betamethasone and amoxicillin; and G6: 0.9% sodium chloride solution (1.0 mL - control group). All drugs were administered in a single dose. After 90 minutes, the granulomatous tissues of each animal were surgically removed and weighed. Blood was collected from cervical plexus, centrifuged and 10μL of serum was placed on paper discs. In order to estimate amoxicillin concentration, serum and granulomatous tissues were separately submitted to microbiological assay, which used 10⁸cfu/mL of Staphylococcus aureus ATCC 25923 (penicillin-susceptible strain). After incubation (18 hours, 37°C) the inhibition zones were measured and compared to a regression curve.

Results:

No inhibition zones were observed for groups 2, 3 and 6. Tissue and serum concentrations of both G1 (4.14μg/g and 2.06μg/mL, respectively) and G5 (3.87μg/g and 1.70μg/mL, respectively) showed statistically significant differences (Kruskal-Wallis, p<0.05) in comparison to G4 (1.45μg/g and 0.41μg/mL, respectively). G1 and G5 did not differ significantly (p>0.05).

Conclusion:

Considering single doses, betamethasone did not interfere with amoxicillin levels but diclofenac sodium reduced both tissue and serum levels of amoxicillin in rats.

Periodontal health of older men: the MrOS dental study

OBJECTIVE

The purpose of this study was to evaluate the prevalence and severity of periodontitis in men of 65+ years and identify demographic and lifestyle factors associated with its presence.

METHODS

Participants were recruited from the Osteoporotic Fractures in Men Study, a longitudinal study of risk factors for fractures in older men. Dental measures included clinical attachment loss (CAL), pocket depth (PD), calculus, plaque and bleeding on a random half-mouth, plus a questionnaire regarding access to care, symptoms and previous diagnosis.

RESULTS

1210 dentate men completed the dental visit. Average age was 75 years, 39% reported some graduate school education, 32% smoked 20 + pack years and 88% reported their overall health as excellent/good. In terms of periodontal health, 38% had sub-gingival calculus, 53% gingival bleeding, 82% CAL > or =5 mm and 34% PD > or =6 mm. The prevalence of severe periodontitis was 38%. Significant demographic and lifestyle factors associated with severe periodontitis in multivariate analyses included age > or =75 (OR 1.4, 95% CI 1.1-1.7) non-white race (OR 1.9, 95% CI 1.3-2.8), less than an annual dental visit (OR 1.5, 95% CI 1.1-2.0), and 20 + pack years (OR 2.1, 95% CI 1.6-2.7).

CONCLUSION

A high proportion of healthy older men have evidence of periodontal destruction which could, given the growing ageing population, have a significant impact on the dental profession's ability to provide preventive and therapeutic care. The population at highest risk of periodontitis in MrOS is older minority men who smoke and do not have annual dental visits.

Cardiac risk factors for dental procedures: knowledge among dental practitioners in Wales

OBJECTIVES

To determine knowledge and educational needs of dental practitioners in Wales regarding congenital or acquired cardiac disease and the provision of antibiotic prophylaxis.

DESIGN

Self-administered postal questionnaire.

SETTINGS

Cardiff University Dental Hospital, district general hospitals (HDS), all general dental practices (GDP) and community dental service (CDS) clinics throughout Wales. Methods A questionnaire sent to 1,182 dentists in Wales in 2004-5.

RESULTS

528 questionnaires were returned (a response rate of 45%). These were analysed using one-way analysis of variance to compare summary scores between the occupation groups. Significant differences in knowledge of cardiac risk factors for infective endocarditis and for dental procedures requiring cover were observed between the occupation groups. The majority of dentists (92% GDPs, 94% CDS and 77% HDS) requested postgraduate education in cardiac risk factors and laminated flow diagrams for their surgeries as the preferred educational format.

CONCLUSION

The knowledge of Welsh dentists regarding cardiac conditions or procedures which are risk factors for paediatric and adult patients varied according to place of work. The study identified potential for under- and over-prescription of antibiotic prophylaxis within the current guidance. There was confusion as to which patient groups and cardiac conditions required prophylaxis and for which particular dental procedures. Postgraduate education detailing advances in cardiology practice is necessary for dentists.

Effect of the Diode Laser on Bacteremia Associated with Dental Ultrasonic Scaling: A Clinical and Microbiological Study

OBJECTIVE

The purpose of this study is to evaluate the potential use of diode lasers (DLs) to reduce bacteremia associated with ultrasonic scaling (US). Furthermore, the clinical efficacy of DLs as an adjunct to US in the treatment of gingivitis was investigated.

BACKGROUND DATA

Recently, lasers have found new applications in dental practice. The benefits of the use of DLs as an adjunct to US have not yet been determined.

METHODS

Twenty-two gingivitis patients were treated using a split-mouth study design in which each side was randomly treated by US alone or DL followed by US (DL + US). Blood samples were drawn just before and during US in each treatment step to detect induced bacteremia. Clinical parameters including plaque index, sulcus bleeding index, probing depth, and relative attachment level were recorded at baseline and 4 weeks postoperatively.

RESULTS

Bacteremia was detected in 15 patients (68%) after US alone, and in 8 patients following DL + US (36%). The reduction of the incidence of odontogenic bacteremia during US after the application of DL was statistically significant (p < 0.05). Clinical signs improved eventually, with no significant differences between the two treatment regimens (p > 0.05).

CONCLUSIONS

Application of DL energy can reduce bacteria in gingival crevices which may reduce bacteremia following US. The use of DL did not show additional clinical influence on gingival healing after treatment of gingivitis with US.

Effect of rinsing with povidone?iodine on bacteraemia due to scaling: a randomized-controlled trial

AIM

To investigate rinsing with povidone-iodine on bacteraemia caused by ultrasonic scaling.

MATERIAL AND METHODS

Sixty patients with gingivitis undertook a randomized, placebo-controlled trial in which 30 rinsed with 0.9% saline and 30 with 7.5% povidone-iodine for 2 min. before ultrasonic scaling of FDI teeth 31-35. Blood samples before and after 30 s and 2 min. of scaling were cultured by lysocentrifugation.

RESULTS

Oral bacteraemia occurred in 33.3% of the saline group and 10% of the povidone-iodine group. Regression analysis showed that rinsing with povidone-iodine was approximately 80% more effective than rinsing with saline in reducing the occurrence of bacteraemia, with a statistically significant odds ratio (OR) of 0.189 (95% confidence intervals, OR=0.043-0.827). There were 24 oral bacterial isolates in the saline group and 3 in the povidone-iodine group. Viridans streptococci comprised 11 of the isolates in the saline group and none in the povidone-iodine group. Bacteraemia magnitude was 0.1 colony-forming units/ml in the povidone-iodine subjects and 0.1-0.7 CFU/ml in the saline group.

CONCLUSIONS

Rinsing with 7.5% povidone-iodine reduced the incidence and magnitude of bacteraemia and eliminated viridans streptococci from such bacteraemia. Povidone-iodine rinsing may be helpful for ultrasonic scaling of gingivitis patients at risk of infective endocarditis.

Bone Healing at a Failed Implant Site in a Type II Diabetic Patient: Clinical and Histologic Evaluations: A Case Report

Placement of endosseous dental implants in diabetic patients may be compromised because of altered wound healing. Additionally there is no established timetable for implant healing in these patients. A case report is presented that evaluates implant healing at the site of a failed implant after its removal. This report documents bone remodeling in a diabetic patient 6 months after removing the failed implant. The prostheses was delivered within 4 months in the upper arch despite the complications during the healing period.

In vitro comparison of chlorhexidine and povidone-iodine on the long-term proliferation and functional activity of human alveolar bone cells

This work reports the behaviour of osteoblastic human alveolar bone cells (first subculture) in the presence of chlorhexidine (CHX) and povidone-iodine (PI). Short contact (2 min) of 24-h cultures with CHX, at 0.12 and 0.2%, and PI, at 5 and 10%, caused cell death within minutes; contact with 1% PI resulted in loss of the elongated characteristic cell shape. Cell adhesion was adversely affected at concentrations higher than 5 x 10(-5)% CHX or 0.05% PI. Long-term exposure to CHX at 10(-5) and 10(-4)% or PI at 10(-4)% had little effect on cell growth and caused an induction in the synthesis of alkaline phosphatase (ALP). Concentrations of CHX and PI similar and higher than, respectively, 5 x 10(-4)% or 0.05% caused dose-dependent deleterious effects. CHX affected mainly the cell growth, whereas the effects of PI were observed mostly in ALP production and matrix mineralization. Considering the levels of CHX and PI used routinely in the oral cavity, results suggest that CHX has a higher cytotoxicity profile than PI. This observation might have some clinical relevance regarding the potential utility of PI in the prevention of alveolar osteitis.

Antibiotic prevention of infective endocarditis due to oral procedures: myth, magic, or science?

Infective endocarditis (IE) can be induced by bacteremia attributable to dental procedures. To prevent this disease, prophylactic administration of antimicrobials prior to dental procedures has been recommended in several countries. However, no prospective study has proved its efficacy in a clinical setting. Recent recommendations from the American Heart Association (AHA) strongly suggested that dental work is not an important cause of IE; therefore, prophylactic use of antibiotics is of no use in most cases. Prevention of IE may be essential but its pathology and epidemiology remain unclear in various aspects. This article reviews the theoretical background of IE prophylaxis, and discusses how we should proceed when patients with a known cardiac disorder visit the dental clinic. The discussion includes antibiotics usage, daily maintenance procedures, and a possible new strategy with the use of antibacterial substances.

Ancillary therapy and supportive care of chronic graft-versus-host disease: national institutes of health consensus development project on criteria for clinical trials in chronic Graft-versus-host disease: V. Ancillary Therapy and Supportive Care Working Group Report

The Ancillary Therapy and Supportive Care Working Group had 3 goals: (1) to establish guidelines for ancillary therapy and supportive care in chronic graft-versus-host disease (GVHD), including treatment for symptoms and recommendations for patient education, preventive measures, and appropriate follow-up; (2) to provide guidelines for the prevention and management of infections and other common complications of treatment for chronic GVHD; and (3) to highlight the areas with the greatest need for clinical research. The definition of "ancillary therapy and supportive care" embraces the most frequent immunosuppressive or anti-inflammatory interventions used with topical intent and any other interventions directed at organ-specific control of symptoms or complications resulting from GVHD and its therapy. Also included in the definition are educational, preventive, and psychosocial interventions with this same objective. Recommendations are organized according to the strength and quality of evidence supporting them and cover the most commonly involved organs, including the skin, mouth, female genital tract, eyes, gastrointestinal tract, and lungs. Recommendations are provided for prevention of infections, osteoporosis, and steroid myopathy and management of neurocognitive and psychosocial adverse effects related to chronic GVHD. Optimal care of patients with chronic GVHD often requires a multidisciplinary approach.

Chewing fails to induce oral bacteraemia in patients with periodontal disease

AIM

To investigate whether chewing in patients with untreated chronic periodontitis or plaque-induced gingivitis causes bacteraemia of oral origin.

METHOD

Twenty-one patients with untreated chronic periodontitis (32-75 years old) and 20 with plaque-induced gingivitis (26-54 years old) chewed a standard wax medium for 4 min. Blood samples were drawn before, during and 5 min. post-chewing. Aerobic and anaerobic Bactec system culturing was performed for 21 days and positive bottles were subcultured and isolates were identified to genus level. A full periodontal analysis was performed on all teeth and included probing depths, recession, attachment levels, bleeding on probing, mobility plaque index and gingival index. Radiographs were assessed for the severity of alveolar bone loss.

RESULTS

No bacteraemia of oral origin was detected in any patient. Skin contaminants (Staphylococcus epidermidis, Propionibacterium spp.) were detected in blood samples from three patients (two periodontitis; one gingivitis).

CONCLUSION

Chewing did not cause bacteraemia in chronic periodontitis or plaque-induced gingivitis patients and may not be a risk factor for infective endocarditis in at-risk individuals with periodontal disease.

The outcome of a preventive dental care programme on the prevalence of localized aggressive periodontitis in Down's syndrome individuals

BACKGROUND

Periodontal disease in Down's syndrome (DS) individuals develops earlier and is more rapid and extensive than in age-matched normal individuals. The present study evaluated a group of DS patients, who had been participating in a 10-year preventive dental programme, for the impact of the programme on their periodontal status.

METHODS

Thirty DS patients (mean age 23.3 +/- 4 years) were compared with 28 age-matched healthy controls (mean age 22.8 +/- 5 years). The hygiene level, gingival condition and periodontal status (periodontal probing depth, clinical attachment level and radiographic alveolar bone loss) were determined.

RESULTS

In spite of similar oral hygiene and gingival measures, DS patients, as opposed to the control ones, had a severe periodontal disease. The prevalence, extent and severity of periodontitis in the DS group were significantly greater than in the control group. The teeth most commonly and severely affected were the lower central incisors and the upper first molars. DS patients lost significantly more teeth due to periodontitis.

CONCLUSIONS

The clinical and radiographic picture found in the present DS group is characteristic of localized aggressive periodontitis. Within the limitations of this study, it seems that the preventive dental programme had no effect on periodontal destruction progression of localized aggressive periodontitis in DS individuals and that impaired oral hygiene plays a relatively minor role in the pathogenesis of this disease. Future controlled studies are needed to assess the effectiveness of different preventive dental programmes in preventing the progression of periodontitis in DS patients.

Antibiotic prophylaxis in oral health care: administration strategies of general dental practitioners

OBJECTIVE

To examine the strategies that general dental practitioners (GDPs) use to administer antibiotic prophylaxis and to study the agreement between the administration strategies of GDPs and local recommendations.

METHODS

Postal questionnaires in combination with telephone interviews were used. Two hundred GDPs in two Swedish counties, Skåne and Orebro, were asked to participate. The response rate was 51% (n = 101). The GDPs were presented with eight simulated cases of patients with different medical conditions for which antibiotic prophylaxis might be considered necessary when performing dental procedures (scaling, tooth removal, root canal treatment). The administration strategies of the GDPs were compared with local recommendations.

RESULTS

In general, the variation in the administration strategies of the GDPs was large. For two medical conditions, type 1 diabetes that was not well controlled and hip prosthesis, significantly more GDPs in Skåne than in Orebro administered antibiotic prophylaxis for tooth removal. Agreement between the administration strategies of the GDPs and local recommendations was low. Differences between the two counties were non-significant. Furthermore, within Orebro, GDPs who did not have formal access to local recommendations did not differ in their administration strategies from those who did. The choice of substance was seldom in agreement with the substance recommended, while the majority followed the recommended duration of treatment.

CONCLUSION

Although recommendations existed, their impact appeared to be limited. This is significant, since the implementation of recommendations is crucial in making clinical practice more effective and in promoting the health of patients.

Takayasu's arteritis: what should the dentist know?

Takayasu's arteritis is a chronic inflammatory disease that affects large blood vessels, especially the aorta and/or its major branches. The condition presents with segmental lesions adjacent to normal, apparently unaffected, areas. The lesions include stenosis, occlusion, dilatations or aneurysm formations along the path of the affected artery. Because of the severity of the disease and the possibility of cardiovascular complications, patients with Takayasu's arteritis require medical treatment based on immunosuppressive and antihypertensive drugs, as well as regular follow up and surgical intervention in many instances. The aim of this paper was to describe the characteristics of Takayasu's arteritis, to report dental treatment carried out on an affected patient, and to discuss the main implications and care required during routine treatment for children in the dental office.

Mitral valve prolapse

Mitral valve prolapse is a common valvular abnormality that is the most common cause of severe non-ischaemic mitral regurgitation in the USA. The overall prognosis of patients with mitral valve prolapse is excellent, but a small subset will develop serious complications, including infective endocarditis, sudden cardiac death, and severe mitral regurgitation. We present a comprehensive review of mitral valve prolapse, examining normal mitral anatomy, the clinical and echocardiographic features of mitral valve prolapse, and the pathophysiology and genetics of the disorder. We discuss the contemporary management of both asymptomatic and symptomatic prolapse, with particular attention to the timing and technique of surgical repair. We conclude that echocardiography is the method of choice for diagnosing mitral valve prolapse, that clinical and echocardiographic features can predict which patients with prolapse are at highest risk for complications, and that mitral valve repair is the treatment of choice for symptomatic prolapse.

Endodontic considerations in the elderly

Tooth retention has increased significantly in older adults, and dentists are now challenged by the need to preserve critical teeth. There will be a need to consider endodontic therapy, and this paper describes how successful endodontics can be provided for elderly patients. Strategic treatment planning is essential, and preservation of key teeth will facilitate satisfactory oral function for elderly patients. These teeth may be important in achieving and maintaining an intact anterior dental arch, for removable partial denture retention or preservation of alveolar bone. In some cases, this can only be achieved if endodontic procedures are undertaken. When infection of a root canal is present, there is no reason why good quality endodontic therapy should not work in a healthy elderly patient. Elimination of infection can be challenging in narrow root canals, and a systematic approach for improving access into and negotiating these canals is outlined.

Isolation and characterization of subgingival staphylococci from periodontitis patients and controls

OBJECTIVES

To isolate and characterize subgingival staphylococci from patients with periodontal disease and from periodontally healthy controls, to evaluate the periodontal environment as a potential source for systemic staphylococcal infections.

METHODS

Periopaper strips were used to isolate subgingival staphylococci from 28 patients with chronic periodontitis and 28 periodontally healthy age and sex-matched controls. Staphylococci were identified by microbiological methods and antibiotic resistance profiles determined.

RESULTS

Staphylococci were isolated from 54% diseased subgingival and 43% healthy subgingival sites in over 50% periodontitis patients and from 29% healthy subgingival sites in 54% controls. No significant differences in the frequency of isolation or numbers of staphylococci isolated from diseased and healthy sites were noted. Staphylococcus epidermidis was the predominant oral species. Seventy per cent (115 of 165) of all isolates were penicillin-resistant.

CONCLUSIONS

Subgingival staphylococci are present in both periodontitis patients and controls. In periodontitis there is an increased risk of bacteraemia because of the increased dentogingival surface area. The dental and periodontal health of patients at risk from haematogenous infections should therefore be maintained at a high level. Antibiotic resistance profiles of the oral staphylococcal isolates suggest that amoxicillin may no longer be a suitable antibiotic for prophylaxis against systemic infections such as prosthetic valve endocarditis.

Hemostatic effect of n-butyl-2-cyanoacrylate (histoacryl) glue in warfarin-treated patients undergoing oral surgery

PURPOSE

Our goal was to evaluate the local hemostatic effect of n-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) glue in warfarin-treated patients who undergo outpatient oral surgery without a change in their level of anticoagulation.

MATERIALS AND METHODS

Thirty consecutive warfarin-treated patients randomly assigned to study and control groups and 10 patients who had never been on anticoagulant therapy serving as the negative control group were included in this trial. Before multiple teeth extractions, all patients had a prothrombin time and the international normalized ratio (INR) determined. To gain hemostasis and primary closure, gelatin sponge and multiple interrupted resorbable sutures were used in the control and negative control groups, and Histoacryl glue and the minimal number of interrupted resorbable sutures were used in the study group. Postoperatively, patients were to contact the oral surgeon if abnormal bleeding occurred. Patients who did not have postoperative bleeding were seen on the 10th postoperative day. Data were collected, and statistical differences in age and gender distributions, number of teeth extracted, INR levels, and bleeding that required treatment were analyzed with the Mantel-Haenzel test. Statistical significance was defined as a value of P <.05.

RESULTS

Local hemostasis was obtained immediately in study patients and only after 10 to 20 minutes in the control and negative control patients. In relation to bleeding complications, there were no cases of postoperative bleeding requiring treatment in both the negative control patients and study patients. In the control patients, 5 cases had postoperative spontaneous bleeding that required treatment. This difference was statistically significant. No patient had wound infection and the healing process appeared to be normal.

CONCLUSION

Multiple extractions can be performed in patients taking oral anticoagulant therapy without a change in their level of anticoagulation provided an efficient local hemostatic measure is instituted. And, in this regard, Histoacryl glue, used as a topical adhesive over approximated wound edges, is an effective and easily applicable local hemostatic for oral surgery in such patients.

Povidone-iodine as a periodontal pocket disinfectant

OBJECTIVES AND BACKGROUND

Povidone-iodine [polyvinylpyrrolidone-iodine complex (PVP-iodine)] might constitute a valuable adjunct to current periodontal therapy because of its broad-spectrum antimicrobial activity, low potential for developing resistance and adverse reactions, wide availability, ease of use, and low financial cost. This investigation employed a randomized, split-mouth study design to determine the microbiological and clinical effects of 10% PVP-iodine subgingival irrigation in periodontitis lesions showing radiographic evidence of subgingival calculus.

METHODS

Sixteen adults having at least one periodontal pocket of 6 mm or more in each quadrant of the dentition and harboring one or more periodontopathic bacteria participated in the study. In each subject, a study site in each quadrant was randomly chosen to receive either subgingival irrigation with 10% PVP-iodine together with scaling and root planing, scaling and root planing alone, subgingival irrigation with 10% PVP-iodine, or subgingival irrigation with sterile saline. Prior to therapy and at 5 weeks post-treatment, microbiological culture was carried out without knowledge of the clinical status or the type of treatment rendered. A blinded clinical examiner determined presence of dental plaque, probing pocket depth, and gingival bleeding on probing. Microbiological and clinical data were analyzed using a repeated measures analysis of variance and Kruskal-Wallis rank test with the Tukey and Mann-Whitney post hoc tests.

RESULTS

At 5 weeks post-treatment, subgingival irrigation with PVP-iodine together with scaling and root planing caused a 95% or greater reduction in total pathogen counts in 44% of pockets having >/= 6 mm depth whereas scaling and root planing alone, povidone-iodine irrigation alone and water irrigation alone caused 95% reduction of total pathogens only in 6-13% of similar study sites (P = 0.02). Reduction in mean pocket depth was 1.8 mm for the PVP-iodine/scaling and root planing group, 1.6 mm for the scaling and root planing group, and 0.9 mm for the PVP-iodine and the saline monotherapy groups, with statistical significance reached for the scaling and root planing group vs. the PVP-iodine group (P = 0.04) and for the scaling and root planing group vs. the saline group (P = 0.02). Reduction in visible dental plaque, which ranged from 38% to 62%, showed no significant differences among treatment groups.

CONCLUSIONS

The addition of subgingival PVP-iodine irrigation to conventional mechanical therapy may be a cost-effective means of reducing total counts of periodontal pathogens and helping control periodontal disease. However, subgingival irrigation with PVP-iodine without concomitant mechanical debridement might not improve microbiological and clinical variables in comparison with saline irrigation, at least not in sites with radiographic evidence of subgingival calculus.

The efficacy of azithromycin in the treatment of acute infraorbital space infection

PURPOSE

In this study, we aimed to evaluate the role of azithromycin in the treatment of acute infraorbital space infection.

MATERIALS AND METHODS

Sixty patients (39 men and 21 women; age range, 18 to 47 years) who had acute infraorbital space infection with pain, swelling, and general malaise were included in the study. After initial surgical therapy, patients were randomly allocated to receive either 500 mg azithromycin once daily for 3 days, 250 mg erythromycin stearate every 6 hours for 3 days, or no antibiotic. Patients were assessed at the time of admission and after 1, 2, 3, and 7 days. Pain, swelling, cervical lymphadenopathy, and sublingual temperature were assessed at each visit. Data were collected, and all groups were compared for differences in pain and swelling using the Mann-Whitney U test and for differences in lymphadenopathy and sublingual temperature using Fisher's exact test.

RESULTS

At the time of admission, no 2 groups were statistically different at the.05 level in relation to age, gender, and presenting clinical signs or symptoms. At days 2 and 3, patients who received azithromycin had a significant reduction in pain (P =.002 and P =.02, respectively) and swelling (P =.001 and P =.013, respectively) compared with those who received no antibiotic. At day 3, patients who received erythromycin had a significant reduction in pain (P =.03) and swelling (P =.046) compared with those who received no antibiotic. In a comparison of the patients who received azithromycin with those who received erythromycin, there was no significant difference (P >.05) in the reduction of pain at any time of the study. However, at day 2, patients who received azithromycin had a significantly greater reduction in swelling (P =.002) than those who received erythromycin. In relation to the percentage of the patients with cervical lymphadenopathy and raised sublingual temperature (>37.2 degrees C), no 2 groups were statistically different at any time of the study. After 3 days of treatment, patients who received the antibiotics were clinically improved, and all patients (n = 60 patients) reviewed after 7 days had resolution of their clinical signs and symptoms.

CONCLUSION

This study emphasizes the importance of surgical drainage and proves that both azithromycin and erythromycin are effective adjunctive treatments in the therapy of relatively mild odontogenic orofacial infections.

Congenital heart disease in adults: catheterization laboratory considerations

Congenital heart defects are the most common birth defects and represent an increasing proportion of adolescent and adult patients followed by cardiologists. While many of these patients have undergone successful palliative or corrective surgery with excellent functional results, most of them still require careful follow-up. Further, even complex lesions may first be diagnosed in adolescence and adulthood. Therefore, cardiologists caring for adults need to become more familiar with these defects. Assessment of the patient with known or suspected congenital heart defects requires a careful history, physical examination, and noninvasive assessment. In addition, the catheterization laboratory remains a critical venue for diagnosis and, increasingly, therapy. Pressure measurements, oximetry, and angiography remain cornerstones of diagnosis in selected patients and a variety of interventional procedures have become viable therapeutic alternatives in both pre- and postoperative patients.

Selection of antimicrobial agents in periodontal therapy

BACKGROUND

The recognition over the past 3 decades of microbial specificity in periodontitis has afforded dental practitioners the ability to prevent and treat the disease with a variety of antimicrobial drugs. These include systemic antibiotics, topical antibiotics and topical antiseptics.

RESULTS

Systemic antibiotic therapy can be essential in eliminating pathogenic bacteria that invade gingival tissue and in helping control periodontal pathogens residing in various domains of the mouth from where they may translocate to periodontal sites. Frequently used periodontal combination antibiotic therapies are metronidazole-amoxicillin (250-375 mg of each 3 x daily for 8 days) and metronidazole-ciprofloxacin (500 mg of each 2 x daily for 8 days). Microbiological analysis helps determine the optimal antibiotic therapy and effectiveness of treatment. Topical antibiotics that are commercially available as controlled release devices suffer from several potential problems, including insufficient spectrum of antimicrobial activity in some periodontal polymicrobial infections, risks of producing an antibiotic resistant microbiota, and high acquisition costs. Topical antiseptics of relevance in periodontal treatment include 10% povidone-iodine placed subgingivally by a syringe for 5 min, and 0.1% sodium hypochlorite solution applied subgingivally by patients using an irrigation device.

CLINICAL IMPLICATIONS

The present paper recommends periodontal treatment that includes a battery of professionally and patient-administered antimicrobial agents (properly prescribed systemic antibiotics, povidone-iodine and sodium hypochlorite subgingival irrigants, and chlorhexidine mouthrinse). Available chemotherapeutics can provide effective, safe, practical and affordable means of controlling subgingival colonization of periodontal pathogens and various types of periodontal disease.

Periodontal risk assessment, diagnosis and treatment planning

The prevention and treatment of the periodontal diseases is based on accurate diagnosis, reduction or elimination of causative agents, risk management and correction of the harmful effects of disease. Prominent and confirmed risk factors or risk predictors for periodontitis in adults include smoking, diabetes, race, P. gingivalis, P. intermedia, low education, infrequent dental attendance and genetic influences. Several other specific periodontal bacteria, herpesviruses, increased age, male, sex, depression, race, traumatic occlusion and female osteoporosis in the presence of heavy dental calculus have been shown to be associated with loss of periodontal support and can be considered to be risk indicators of periodontitis. The presence of furcation involvement, tooth mobility, and a parafunctional habit without the use of a biteguard are associated with a poorer periodontal prognosis following periodontal therapy. An accurate diagnosis can only be made by a thorough evaluation of data that have been systematically collected by: 1) patient interview, 2) medical consultation as indicated, 3) clinical periodontal examination, 4) radiographic examination, and 5) laboratory tests as needed. Clinical signs of periodontal disease such as pocket depth, loss of clinical attachment and bone loss are cumulative measures of past disease. They do not provide the dentist with a current assessment of disease activity. In an attempt to improve the ability to predict future disease progression, several types of diagnostic tests have been studied, including host inflammatory products and mediators, enzymes, tissue breakdown products and subgingival temperature. In general, the usefulness of these tests for predicting future disease activity remains to be established in terms of sensitivity, specificity and predictive value. Although microbiological analysis of subgingival plaque is not necessary to diagnose and treat most patients with periodontitis, it is helpful when treating patients with unusual forms of periodontal disease such as early-onset, refractory and rapidly progressive disease. There appears to be a strong genetic component in some types of periodontal disease and genetic testing for disease susceptibility has potential for future use, but more research is needed to determine its utility for use in clinical practice. Treatment of the periodontal diseases may be divided into four phases: systemic, hygienic, corrective and maintenance or supportive periodontal therapy. Regardless of the type of treatment provided, periodontal therapy will fail or will be less effective in the absence of adequate supportive periodontal therapy.

Topical antibiotic prophylaxis for bacteremia after dental extractions

OBJECTIVE

Current prophylaxis for endocarditis in patients undergoing dental procedures consists of oral administration of amoxicillin. There is concern that the risk of anaphylaxis from systemically administered antibiotics might approach the incidence of endocarditis. Emergence of resistance among bacteria is also favored by systemically administered antibiotics. The present study was designed to assess the efficacy of topical amoxicillin given prophylactically as a mouthwash in reducing the incidence of bacteremia after dental extraction.

STUDY DESIGN

Thirty-six outpatients in a dental clinic were randomized in a 3:2:2 ratio to experimental prophylaxis of topical amoxicillin (3 g per mouthwash rinse; 15 patients), standard prophylaxis of oral amoxicillin (3 g in a single dose; 11 patients), or no prophylaxis (10 patients), respectively. Patients were stratified by severity of periodontal disease and number of teeth extracted. Data were analyzed for differences in the incidence of bacteremia by means of the 2-tailed Fisher exact test.

RESULTS

Breakthrough bacteremia after dental extraction was observed in 60% (6 of 10 patients) who received topical amoxicillin and in 89% (8 of 9 patients) who received no prophylaxis (P =.30). By comparison, breakthrough bacteremia after dental extraction was observed in 10% (1 of 10 patients) who received standard prophylaxis with oral amoxicillin (60% vs 10%; P =.05).

CONCLUSIONS

Topical amoxicillin decreased the incidence of bacteremia in comparison with no prophylaxis, but statistical significance was not achieved (P =.30). Topical amoxicillin was significantly less effective than standard prophylaxis with oral amoxicillin in decreasing the incidence of bacteremia after dental extractions.

Bacteremia due to periodontal probing: a clinical and microbiological investigation

BACKGROUND

Infective endocarditis can occur in susceptible individuals due to bacteremia of oral origin. The aim of this study was to investigate the occurrence of bacteremia caused by full mouth periodontal probing.

METHODS

Forty patients, 20 with adult periodontitis (10 males, 10 females; mean age 43.0 years) and 20 with chronic gingivitis (11 males, 9 females; mean age 35.5 years) were investigated. Prior to and immediately following periodontal probing, 20 mL of venous blood were obtained from each patient and inoculated into aerobic and anaerobic blood culture bottles and incubated. Negative bottles were monitored continuously for 3 weeks before being discarded. Bottles which signalled positive were subcultured and isolates identified to genus level. Periodontal probing consisted of measuring pockets at 6 points around each tooth and recording the presence or absence of bleeding. A plaque index (PI) was assessed on the 6 Ramfjord teeth.

RESULTS

Probing caused bacteremia of oral origin in 8 (40%) of the periodontitis patients and 2 (10%) of the gingivitis patients. Streptococcus spp. were the most common isolates in both groups. Compared with the gingivitis group the odds ratio (OR) for bacteremia in the periodontitis group was 5.993 (95% CI 1.081 to 33.215). Bleeding on probing (OR 1.025, 95% CI 1.004 to 1.047) and mean probing depth per tooth (OR 1.444, 95% CI 1.055 to 1.977) were significantly associated with bacteremia. No significant correlations were found between bacteremia and age, number of teeth probed, smoking status, PI, or total probing depth.

CONCLUSIONS

Patients with untreated adult periodontitis are at greater risk of bacteremia due to periodontal probing than patients with chronic gingivitis. For individuals at risk of infective endocarditis, radiographic assessment prior to periodontal probing would be advisable to identify those with periodontitis so that appropriate antibiotic prophylaxis can be provided.

[The role of dentistry in the interdisciplinary team: contributing to comprehensive health care for the elderly]

This literature review focuses on dentistry's role in comprehensive health care for the elderly. The authors discuss the need for an interdisciplinary approach. They begin by analyzing the current situation in geriatric dentistry and related problems in Brazil, relating primarily to the lack of specific studies and human resources with training in geriatrics and gerontology. The authors emphasize interactions between dentistry and other health professions for health promotion, specific prevention, and rehabilitation of elderly patients, with special attention to the importance of communication and information exchange.