bacteremia tooth brushing
Blood samples were cultured in BACTEC Plus Aerobic/F and LYTIC/10 Anaerobic/F (BD Diagnostics). Amoxicillin resulted in a significant decrease in positive cultures (P<0.0001). Our prior work suggested that the incidence of bacteremia from single-tooth extraction would be between 70% and 100%.7 There was no consensus opinion available on the incidence of bacteremia after toothbrushing in adults; estimates ranged from 30% to >60%. For example, tooth brushing and flossing (20-68%), using toothpicks (20-40%), consuming chewable foods (7-51%) have a risk of temporary bacteremia [5,6]. Two percent of the placebo group (n=2) and 9% of subjects in the brushing group (n=9) were still bacteremic at 60 minutes after the procedure. In healthy individuals, bacteremias can be qualified as transient. J Am Dent Assoc. Patients randomized to the brushing group had their dental extraction accomplished at the end of the study period, after the last blood draw, or on a subsequent visit. This is consistent with another study reporting the incidence and the magnitude of bacteremia induced by chewing, tooth brushing, and invasive dental procedures to be associated with gingival inflammation rather than with pocket depths . Local Info The relative risk for infective endocarditis from bacteremia during invasive office procedures such as dental extractions versus routine daily events such as toothbrushing is unknown. 1-800-242-8721 Michael Brennan Two subjects (2%) in the extraction-amoxicillin group were positive at 40 minutes. The incidence of bacteremia after routine tooth brushing for 1 minute using a standardized soft-bristle toothbrush was prospectively measured in 30 healthy adults at three different time points (at baseline and 30 seconds and 20 minutes after brushing). Study groups and reasons for exclusion. Numbered boxes represent the number of positive cultures for that species at that time point. Tooth brushing with a powered toothbrush is more likely to result in a transient bacteraemia than brushing with either a conventional toothbrush or an ultrasonic toohbrush which might have implications for susceptible individuals with congenital heart defects at risk of bacterial endocarditis. Ten (31%) of the 32 IE-associated oral bacterial species were (viridans) streptococci (Table 2). We are also grateful to Larry Baddour, MD, Stanford Shulman, MD, Brian Strom, MD, MPH, and Kathryn Taubert, PhD, for their helpful comments on this manuscript. Improving oral hygiene may be associated with a decreased risk of occurrence of new-onset diabetes. Each tooth was measured from the mesial and mesiobuccal sites, with the average representing the tooth score. Study protocol time line. The magnitude of bacteremia for all 3 study groups was <104 colony-forming units per milliliter of blood, which suggests that brushing and single-tooth extraction are similar from the standpoint of magnitude. The Risk of Bacterernia Procedure … The present data suggest that brushing and single-tooth extraction, generally thought to be at different ends of the spectrum of invasiveness, are similar from the standpoint of magnitude. The duration of bacteremia likely reflects the nature and number of bacteria that enter the circulation, as well as multiple other host factors such as immune responses. Background— Antibiotic prophylaxis recommendations for the prevention of infective endocarditis are based in part on studies of bacteremia from dental procedures, but toothbrushing may pose a greater threat. Update on bacteraemia related to dental procedures. They occur frequently and have no infectious and clinical consequences as the bacteria are rapidly eliminated. Therefore, given the far greater frequency for oral hygiene than for dental office procedures, toothbrushing appears to be a greater threat for individuals at risk for infective endocarditis. Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. Periodontal disease may affect the incidence, magnitude, duration and bacterial spectrum of bacteremia. Therefore, all we can say is that the magnitude of bacteria in the blood cultures was <104 CFU/mL. All false-positive bottles (ie, bottles that were signaled positive but for which the subculture was negative) were further incubated for a total of 2 weeks. Identification of strains was based on comparisons of the first 500 bases with Database Project (RDP [Ribosomal Database Project]; http://wdcm.nig.ac.jp/RDP/htlm/index.htlm) and GenBank by BLAST http://ncbi.nlm.nih.gov/BLAST.cgi). People in good health rarely develop BAC because their immune systems eliminate the potentially-harmful bacteria. Demographic and baseline clinical characteristics of participants are reported as means and SDs or frequencies and percentages. Periodontal Disease and Atherosclerotic Vascular Disease: Does the Evidence Support an Independent Association? After brushing, rinse your toothbrush with warm water and store it upright to air-dry. It is difficult to quantify the magnitude of bacteria that initially gain entrance to the circulation after dental procedures owing to factors such as heart rate, blood volume, proximity of the blood collection site to the source of the bacteremia, and the rapid bacterial clearance by the reticuloendothelial system. Additional blood samples (20 mL) were drawn 20, 40, and 60 minutes after the end of the procedure. 1-800-AHA-USA-1 Our literature search revealed 275 species of bacteria reported to cause IE. Tooth brushing can cause bacteremia even in healthy individuals. During the 3-year study period, we screened 600 patients and subsequently randomized 290 patients to 1 of 3 groups (Figure 2). Given the unfeasible concept of advocating antibiotic coverage for toothbrushing, we suggest that a controlled clinical trial is indicated to resolve this longstanding issue. The majority of the nonstreptococcal species occurred in the extraction groups. We established standard curves for the seeded pathogens and calculated the levels of bacteria in subject blood cultures. Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. If this is the case, there is less of an impact from amoxicillin than Figure 3 suggests. The timing for the steps in the brushing and extraction procedures was strictly controlled. Incidence figures for bacteremia in adults range from 0% to 100% for single-tooth extractions5,7,20–22 and from 0% to 57% for toothbrushing.13–15,17,19 There is no large, prospective comparison study of the incidence, duration, nature, and magnitude of bacteremia from procedures with these perceived extremes of invasiveness. We are also grateful to Larry Baddour, MD, Stanford Shulman, MD, Brian Strom, MD, MPH, and Kathryn Taubert, PhD, for their helpful comments on this manuscript. KEYWORDS: BACTEREMIA, TOOTHBRUSHING, ELECTRIC TOOTHBRUSH Received October 26, 2001 Revision Accepted April 8, 2002 T ransient bacteremias may occur after certain medi-cal and dental procedures. The highest incidence of positive cultures occurred in the first 5 minutes of the procedures (combining draws 2 and 3), with incidence figures of 19%, 33%, and 58% for the brushing, extraction-amoxicillin, and extraction-placebo groups, respectively. Our comprehensive search of the literature provided a list of 275 species of bacteria reported to cause IE, which we compared with the list of bacterial species identified in the present study. They occur frequently and have no infectious and clinical consequences as the bacteria are rapidly eliminated. Therefore, given the far greater frequency for oral hygiene than for dental office procedures, toothbrushing appears to be a greater … Second, although the number of bacterial CFU per milliliter of blood was always below 10 000, this does not exclude the possibility of significant differences in bacterial CFU per milliliter of blood below this threshold between the 3 groups, which might be important in terms of risk of heart valve colonization. PubMed journal article: Transient bacteremia consequent to tooth brushing in orthodontic patients. Patients presented to our urgent care service with the need for extraction of at least 1 erupted tooth. 2009;140:1238-1244. During dental procedures, even tooth brushing, these bacteria and their components, such as endotoxin, can easily disseminate into the systemic circulation through minor or major gingival injuries. Manual versus powered toothbrushing for oral health. Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. All baseline blood cultures were negative, with the exception of 1 patient (with 2 species) in the brushing group (Figure 3; Table 2). Finally, we identified 71 species and subspecies of bacteria not previously reported in blood cultures after extractions or toothbrushing, 30 of which are novel. Little is known about the incidence, nature, and duration (IND) of bacteremia resulting from dental extractions or tooth brushing, either in the presence or absence of prophylactic antibiotic coverage. Numbers at the baseline represent the time points for the 6 blood draws: (1) baseline and (2) 1.5 minutes and (3) 5 minutes after initiation of brushing or extraction; and (4) 20 minutes, (5) 40 minutes, and (6) 60 minutes after completion of the brushing or extraction. use prohibited. Given the frequency of routine tooth brushing, antimicrobial prophylaxis is impractical in any case. However, data on the incidence, duration, nature, and magnitude of bacteremia from non–IE-associated species and bacteria identified by nonmolecular means are of little or no help to clinicians or policy makers.31 We focused on the 32 bacterial species identified in the present study that were also on our list of 275 bacteria reported to cause IE, 11 (34%) of which have not been reported previously in studies of brushing or extractions. Of the 98 bacterial species identified, 32 species overlapped with our list of 275 species reported to cause IE, and the following results focus on these 32 oral bacterial species. This might contribute to the increased incidence and duration of bacteremia in the placebo group, and this would likely explain the (nonsignificant) increased extraction time for the placebo group. READ PAPER. Four surfaces (mesial, distal, facial, and lingual) were recorded, with the average value calculated for each tooth. This suggests that brushing poses a risk for bacteremia similar to that of a dental extraction, given professional guidelines that recommend toothbrushing at least twice per day. Tooth extractions almost always cause bacteremia due to the large presence of bacteria in the oral cavity. The overall incidence of bacteremia at any of the 6 draws was 32%, 56%, and 80% for the brushing, amoxicillin, and placebo groups, respectively (χ2P<0.0001). Introduction . Our comprehensive search of the literature provided a list of 275 species of bacteria reported to cause IE, which we compared with the list of bacterial species identified in the present study. Department of Periodontology, University of Copenhagen, Copenhagen, Denmark . Patients in the extraction arms of the study were anesthetized with 1.8 mL of 2% lidocaine with 1:100 000 epinephrine ≈15 minutes before surgery. Although there is a strong emphasis on prevention of bacteremia in the dental office setting, the relative risk for IE from dental procedures versus routine daily events such as toothbrushing is unknown. Study groups and reasons for exclusion. Identification of strains was based on comparisons of the first 500 bases with Database Project (RDP [Ribosomal Database Project]; http://wdcm.nig.ac.jp/RDP/htlm/index.htlm) and GenBank by BLAST http://ncbi.nlm.nih.gov/BLAST.cgi). All analyzed samples were below the detection threshold of 104 CFU per milliliter of blood. However, no meaningful differences were found in extraction times or in the incidence of bacteremia between those with simple and complex extractions in the relevant study arms. Incidence figures for bacteremia in adults range from 0% to 100% for single-tooth extractions5,7,20–22 and from 0% to 57% for toothbrushing.13–15,17,19 There is no large, prospective comparison study of the incidence, duration, nature, and magnitude of bacteremia from procedures with these perceived extremes of invasiveness. The highest incidence occurred at the time of the procedures in the placebo group (79%), followed by the extraction-amoxicillin (56%) and brushing (28%) groups. Comparisons by study arm at each blood draw and a summary comparison by study arm that combined all draws were made with χ2 tests. The 16S ribosomal RNA (rRNA) sequencing method was used for bacterial identification. The cumulative incidence of bacteremia from all 6 blood draws was 23%, 33%, and 60% for the brushing, extraction-amoxicillin, and extraction-placebo groups, respectively (P<0.0001). No bacteraemia was detected prior to tooth brushing. P.G. This pattern persisted to 40 minutes. The literature suggests that the detection of bacteria after a tooth extraction drops off sharply after 10 minutes, and isolated reports indicate that positive blood cultures can be detected for as long as 30 minutes after a dental procedure.8,12,20,23 Finally, the extent to which systemic antibiotics reduce the incidence, duration, nature, and magnitude of bacteremia from dental procedures is controversial as well.5,24. Relationship of bacteremia to toothbrushing in patients with periodontitis. Publish date: May 15, 2007 By Bruce Jancin Don't cover your toothbrush or place it in a closed container until it is completely dry. The human oral cavity is colonized by a larger variety of bacterial flora than any other anatomic area. Study protocol time line. Periodontal Screening and Recording (PSR) scores were recorded for each patient to assess periodontal disease. Five percent of subjects in the extraction-placebo group and 2% of the brushing group were still bacteremic at 60 minutes. Patients who met the inclusion/exclusion criteria were informed of the study, and institutional review board–approved consent was obtained. The mean of all tooth scores represents the calculus index. Duration to specific intervals by study arm was compared with χ2 tests. Dental scaling and extraction lead to bacteremia in 70% - 100% and tooth brushing leads to bacteremia in 40% of the children, where VGS were found in 50% of the cases (67, 68). Circulation, 2008. Although toothbrushing does not have the same incidence, duration, nature, or likely magnitude of bacteremia as a dental extraction, we found a substantial incidence of bacteremia (23%) of infective endocarditis–causing species of bacteria from brushing. E-mail. The American Heart Association is qualified 501(c)(3) tax-exempt Amoxicillin resulted in a significant reduction in the incidence of positive cultures at draws 2, 3, and 4 (P<0.0001), and it reduced the incidence of positive cultures by 69% (from 151 to 47) for all species and by 78% (106 to 23) for (viridans) streptococci (Table 2). Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. An extensive search of the literature yields a common list of 126 individual bacteria reported in blood cultures after extractions (n=131) or toothbrushing (n=26), all identified by conventional clinical laboratory methods. Bruce Paster. Although the 2007 AHA recommendations call for far fewer people to receive antibiotic prophylaxis than in earlier guidelines, these recommendations have been adopted for more than 20 groups of noncardiac patients as well.36 The incidence, duration, nature, magnitude, and daily occurrence of bacteremia from toothbrushing and other routine daily events (eg, chewing food) calls into question the appropriateness and emphasis on prophylaxis for periodic dental procedures. Therefore, there is the potential for bacteremia from tooth brushing alone to occur over two hundred times per year, by comparison with an average of less than two dental office visits per year per person in the United States. 28 These percentages are similar to other self-care devices: tooth brushing and flossing (20% to 68%), use of wooden toothpicks or sticks (20% to 40%), and mastication (7% to 51%). The results indicate that methodology used for oral care before the HSCT and the practice of tooth brushing during the period were effective in preventing streptococcal bacteremia. Thirteen (48%) of 27 positive cultures in the brushing group were (viridans) streptococci compared with 23 (49%) of 47 in the extraction-amoxicillin group and 106 (70%) of 151 in the extraction-placebo group. Bacteremia may result from ordinary activities (such as vigorous toothbrushing), dental or medical procedures, or from infections (such as pneumonia or a urinary tract infection). https://doi.org/10.1161/CIRCULATIONAHA.107.758524, National Center Amoxicillin resulted in a significant decrease in positive cultures (P<0.0001). The frequency of bacteremia was 46% with manual brushing: 18% aerobic, 9% anaerobic and 73% both. Robinson, S.A. Deacon, C. Deery, et al. However, no meaningful differences were found in extraction times or in the incidence of bacteremia between those with simple and complex extractions in the relevant study arms. Second, although the number of bacterial CFU per milliliter of blood was always below 10 000, this does not exclude the possibility of significant differences in bacterial CFU per milliliter of blood below this threshold between the 3 groups, which might be important in terms of risk of heart valve colonization. A mean score for these 4 areas was obtained for each tooth. The duration of bacteremia for some pathogenic species persisted for at least 60 minutes after brushing and extraction without antibiotic prophylaxis. The authors had full access to the data and take full responsibility for its integrity. They occur frequently and have no infectious and clinical consequences as the bacteria are rapidly eliminated. Sconyers JR, Crawford JJ, Moriarty JD. 8 The gingiva being highly vascularized, the irritation induced by the toothbrush can enable bacteria to go to the systemic circulation. Dental and periodontal disease parameters included mean periodontal pocket depths for all remaining teeth, calculus scores (range 0 to 3), gingival erythema scores (range 0 to 3), and plaque scores (range 0 to 3; Table 1). Given the unfeasible concept of advocating antibiotic coverage for toothbrushing, we suggest that a controlled clinical trial is indicated to resolve this longstanding issue. Various studies have shown positive cultures after tooth brushing,In the use of dental floss,16 the use of oral irrigation devices,3and chewing bubble gum,' although the incidence is J. Customer Service The baseline blood sample (20 mL) was then drawn, and 7 to 8 mL was inoculated directly into both aerobic and anaerobic BACTEC bottles (BD Diagnostics, Sparks, Md) for bacterial culturing. All baseline blood cultures were negative, with the exception of 3 instances, likely from skin contamination (eg, Staphylococcus epidermidis).27,28. All authors have read and agree to the manuscript as written. Lone Forner. Patients presented to our urgent care service with the need for extraction of at least 1 erupted tooth. © American Heart Association, Inc. All rights reserved. Incidence and duration of bacteremia at 6 time points from IE-related bacterial species. Tooth brushing can cause bacteremia even in healthy individuals. Incidence and duration of bacteremia at 6 time points from IE-related bacterial species. Intravascular Constant, positive blood cultures. The risk of transient bacteremia following gastrointestinal endoscopic procedures is lower than that caused by many routine activities in daily life. Patients who met the inclusion/exclusion criteria were informed of the study, and institutional review board–approved consent was obtained. The sensitivity of the method was 25 colony-forming units (CFU) per polymerase chain reaction, which corresponds to 103 to 104 CFU per milliliter of blood. Baseline data included demographics, medical history, and a thorough clinical and radiographic examination of the teeth and periodontium. This study assessed bacteremia levels after brushing with either the Sonicare electric toothbrush or a manual toothbrush. ¶Plaque index: 0=no plaque in the gingival area; 1=no plaque visible to the unaided eye, but plaque is visible on the probe after being moved across the gingival crevice; 2=gingival area covered with a thin to moderately thick layer of plaque visible to the naked eye; and 3=heavy plaque accumulation and soft debris in the interdental area. Frequent Tooth Brushing Tied to Lower Diabetes Risk. For real-time quantitative polymerase chain reaction, TaqMan technology and probes (Biosearch Technologies, Novaro, Calif) and universal 16S rRNA primers (Integrated DNA Technologies, Coralville, Iowa) conserved among oral pathogens were used with the SmartCycler system (Cepheid, Sunnyvale, Calif). This lack of 100% efficacy alters the per-dose risk-benefit ratio, increasing the number needed to treat to avert a distant site infection. Four surfaces (mesial, distal, facial, and lingual) were recorded, with the average value calculated for each tooth. Michael Brennan. In accordance with AHA recommendations, the extraction began 1 hour after ingestion of the amoxicillin or placebo. The authors wish to thank Jenene Noll, RN, and Louise Kent, RN, for their dedicated effort with subject enrollment and data collection; Shirley Coleman, MS, and Jignya Ashar, MS, for their contribution to bacterial isolation; Tainika Williams for her skills with manuscript preparation; Bridget Loven, MLIS, for her skills with biomedical information; and Anne Olson for her Adobe Illustrator skills. Although toothbrushing does not have the same incidence, duration, nature, or likely magnitude of bacteremia as a dental extraction, we found a substantial incidence of bacteremia (23%) of infective endocarditis–causing species of bacteria from brushing. Two subjects (2%) in the extraction-amoxicillin group were positive at 40 minutes. Circulation, 2008. The baseline blood sample (20 mL) was then drawn, and 7 to 8 mL was inoculated directly into both aerobic and anaerobic BACTEC bottles (BD Diagnostics, Sparks, Md) for bacterial culturing. The major purposes of this prospective, randomized, clinical study are to: Determine and compare the true incidence, nature, magnitude, and duration (INMD) of bacteremia (bacteria found in the bloodstream) resulting from a highly invasive dental office procedure (tooth extraction) and a minimally invasive and naturally occurring source of bacteremia (tooth brushing); The organisms cultured after tooth brushing are listed in Table 4. The highest incidence occurred at the time of the procedures in the placebo group (79%), followed by the extraction-amoxicillin (56%) and brushing (28%) groups. Forner L, Larsen T, Kilian M, Holmstrup P. J Clin Periodontol, 33(6):401-407, 01 Jun 2006 Cited by: 242 articles | PMID: 16677328. Work was performed at Virginia Commonwealth University … Incidence and duration of bacteremia at 6 time points from IE-related bacterial species. Patients randomized to the brushing group had their dental extraction accomplished at the end of the study period, after the last blood draw, or on a subsequent visit. We identified 98 bacterial species, 32 of which are reported to cause endocarditis. More than 700 species of bacteria have already been identified, 400 of which were found in the periodontal pocket adjacent to teeth.30 Streptococci represent a significant proportion of the flora around the teeth, especially in the supragingival plaque, and they are frequently associated with IE. Although toothbrushing does not have the same incidence, duration, nature, or likely magnitude of bacteremia as a dental extraction, we found a substantial incidence of bacteremia (23%) of infective endocarditis–causing species of bacteria from brushing. Our review of the literature identified 170 species of bacteria that have been isolated from blood after dental procedures and 275 species of bacteria that have been reported to cause IE; however, there are no studies that focus on the subset of bacteria that are common to both of these groups. Dallas, TX 75231 We identified 98 different bacterial species, the most common of which belonged to the genera Streptococcus (49%), Prevotella (9%), Actinomyces (5%), and Fusobacterium (5%). However, data on the incidence, duration, nature, and magnitude of bacteremia from non–IE-associated species and bacteria identified by nonmolecular means are of little or no help to clinicians or policy makers.31 We focused on the 32 bacterial species identified in the present study that were also on our list of 275 bacteria reported to cause IE, 11 (34%) of which have not been reported previously in studies of brushing or extractions. Our literature search revealed 275 species of bacteria reported to cause IE. There is ongoing debate concerning the health risks, cost-effectiveness, and practicality of the routine use of prophylactic antibiotics.3,4,33–35 The lack of efficacy data for this practice must be weighed against risk factors (eg, drug reactions), potential for resistant strains, and various economic costs to society from the routine use of antibiotics for common dental procedures. Search for more papers by this … Old nonbacterial vegetation may be a predisposing factor in the valvular heart disease, a locus minoris Dallas, TX 75231 Contact Us, Correspondence to Dr Peter B. Lockhart, Chair, Department of Oral Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232-2861. The mean value of all tooth scores represents the gingival index.
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