Download Bacterial endocarditis prevention

Detailed Protocol for Anti-Infective Periodontal Treatment
And Prevention of Bacteremia
David Kennedy, DDS
Periodontitis or gum disease is a chronic infectious transmissible disease present
in the majority of adults. It can be caused by many different species of organisms
usually anaerobes or facultative anaerobes and one-celled parasitic animals. The
best and most logical approach to treatment is to disinfect the gum tissues and
destroy the infectious organisms prior to dental intervention and thus and avoid
further systemic spread of these common organisms.
Bacterial Endocarditis can result from pathogenic bacteria spread into the blood
stream during many common dental procedures. Oral bacteria can travel to the
heart from the mouth thereby causing an infection on one or more of the valves.
During dental procedures if the organisms are present a large volume of
pathogenic bacteria are spread to the circulation. This is especially true when
teeth are deep scaled, cleaned by hand or with an ultrasonic cleaner and or
water irrigated. In a comprehensive review by Xialojing Li in 2000 it was shown
that pathogenic oral bacteria have been linked to bacteria endocarditis,
metastatic infections, aortic aneurisms, cardiovascular disease, myocardial
infarction, low birth weight babies, bacterial pneumonia, diabetes mellitus, and
many other adverse health effects.1 Xialojing states that, “The incidence of
bacteremias following dental procedures such as tooth extraction, endodontic
treatment, periodontal surgery, and root scaling have been well documented.”
Bacteremias after dental extraction third-molar surgery, dental scaling, and
endodontic treatment has been studied by means of lysis-filtration of blood
samples with subsequent anaerobic and aerobic incubation. 2 Bacteremia was
observed in 100% of the patients after extraction, in 70% after dental scaling, in
55% after third-molar surgery, in 20% after endodontic treatment. Anaerobes
were isolated more frequently than facultative anaerobic bacteria.3 4 5 6 7 8 9 10 11
Brushing and chewing in an infected state has also been shown to spread
bacteria to the blood stream. It is apparent then that the best policy is to prevent
the spread of these organisms into the blood stream during dental procedures
and ultimately eliminate them from the oral cavity.
Since it is not possible to determine in advance if the existing oral flora has the
potential for harm the best policy is to simply disinfect the oral sulcus prior to
mechanical intervention for operative dentistry, oral surgery or dental cleanings.
This precaution is similar to requiring doctors to wash their hands prior to
delivering a baby.
The International Academy of Oral Medicine and Toxicology’s non-surgical
biocompatible periodontal treatment will accomplish this goal.
The following patient protection and treatment guideline is proposed.
1. Prior to intervening in the oral cavity with any invasive procedure the
clinician or appropriate technician should identify the oral bacteria present.
Three common methods are available for this analysis.
a. In order to rapidly screen the oral flora a wet mount of the
subgingival plaque using a phase contrast or dark field microscope
is the fastest screening method currently available. If motile
organisms are seen then a culture may be made and the gums
disinfected prior to treatment of any kind.
b. If antibiotic use is anticipated prior to disinfection an anaerobic
bacterial sample should be taken under a nitrogen drape and sent
for culture and sensitivity testing.
c. Another chairside method of determining the nature of the
periodontal (gum) infection is tests such as BANNA and DNA
analysis.
2. Once the presence of motile organisms has been determined, the gums
should be disinfected as rapidly and thoroughly as possible through the
topical application of disinfectants. Disinfection is not possible with oral
antibiotics because only minimal amounts of systemic antibiotics are
excreted in saliva and crevicular fluids.
3. When amoebas or trichomonads are identified during the initial
microscopic evaluation it will be necessary to use topical disinfectants,
topical antibiotics and systemic antibiotics. (Note: it is not possible to
culture these two organisms as they are animals and not bacteria)
a. Treatment for oral amoebiasis with an antibiotic: Amoebas are onecelled animals and their presence in gum pockets produces severe
inflammation and greatly accelerates bone loss and periodontal
destruction. In situations where amoebas are present they should
be treated both topically and systemically with metronidazole if
possible.
b. First the oral flora should killed be irrigating with a rapidly lethal
antiseptic such as chloramine-T or Povidone Iodine. NOTE: Both
these products are for external use only therefore; every effort
should be made to prevent the patient from swallowing them. An
oral irrigator with a 25 gage or smaller cannula can be used to
introduce the solutions into the sulcus around each tooth. The
whole mouth should be treated at each intervention. After irrigation
another bacterial sample should be taken to visually confirm the
eradication of the motile organisms.
c. A syringe may also be used to apply the solution but is somewhat
less desirable since manipulating a small cannula while pressing on
a syringe is not as simple as an oral irrigator and some have
expressed concerns about the amount of pressure a syringe can
generate. Nevertheless a syringe with a 12” flexible tubing attached
has been successfully used to disinfect gums and is an acceptable
method of treatment.
d. Prior to the use of any antibiotic a careful medical history and any
allergies or personal habits that might make antibiotic use
contraindicated should be taken. Of particular concern would be
allergy to the medication and in the case of metronidazole
determine through interview any history of continued chronic
alcohol use. Metronidazole and alcohol will rapidly produce nausea
this includes use of alcohol based mouthwash.
e. Once the oral flora has been disinfected the hygienist, dentists or
physician should introduce ophthalmic metronidazole (a liquid
suspension of metronidazole) into the gum collar of each tooth. A
small syringe with a 25g cannula can be used to introduce the
solution into the gum collar sulcus.
f. Systemic antibiotics should start within the next 4 hours and
continuously taken for the next 7 days.
g. After 7 days the oral flora should be reevaluated and again
disinfected.
h. Ophthalmic metronidazole should again be applied.
i. If no amoebas were seen during the microscopic evaluation there is
no need to continue systemic metronidazole. If amoebas are
present another week of metronidazole is indicated. Interview the
patient for any possible sources of infection, spouse, dog, and other
intimate personal contacts.
j. Several follow up visits for disinfection should be made at
approximately 2 week intervals until no more infective organisms
are present on two sequential visits. This is often somewhat difficult
in advanced cases of periodontal infection, as research has
confirmed the presence of pathogenic bacteria from the sulcus in
the pulp and dentin of teeth. Repeatedly applying liquid antiseptic to
the sulcus both in the dental office and at home will eventually
destroy these organisms but a single visit of disinfection seldom
produces the desired result. Generally speaking it takes between 4
and 6 visits of disinfection to effectively eradicate the pathogens.
4. Long term follow up visits should be schedule no later than 3 months to
confirm the removal of pathogenic bacteria and healing of the periodontal
pockets.
5. The depth of the pocket should be measured annually and monitored for
healing.
6. The presence of bleeding, swelling or pus is a definitive sign that the
infection is not completely controlled and retreatment is necessary.
Xiaojing, Li et al Systemic Diseases Caused by Oral Infections Clinical Microbiology Reviews, Vol. 13 pp.
547-558 Oct. 2000 (PDF Available upon request)
1
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