The Journal of the American Dental Association
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

J Am Dent Assoc, Vol 138, No 1, 80-85.
© 2007 American Dental Association
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Brennan, M. T.
Right arrow Articles by Lockhart, P. B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Brennan, M. T.
Right arrow Articles by Lockhart, P. B.
Related Collections
Right arrow Infection Control

RESEARCH

JADA Continuing Education

The impact of oral disease and nonsurgical treatment on bacteremia in children



Michael T. Brennan, DDS, MHS, M. Louise Kent, RN, Philip C. Fox, DDS, H. James Norton, PhD and Peter B. Lockhart, DDS


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. The authors examine the role of dental disease and nonsurgical dental procedures in the incidence and duration of bacteremia in children.

Methods. The authors randomized a group of children to receive amoxicillin or a placebo before dental rehabilitation in an operating room setting. They collected eight blood draws at the following times: two minutes after intubation (draw 1); after dental restorations, pulp therapy and cleaning (draw 2); 10 minutes later (draw 3); and five draws during and after dental extractions (draws 4–8). The authors compared dental disease parameters and the type of dental procedures performed with the incidence and duration of bacteremia.

Results. The authors enrolled 100 children (aged 1–8 years) in the study. The incidence of bacteremia from draw 2 was 20 percent in the placebo group and 6 percent in the amoxicillin group (P = .07), and the incidence from draw 3 was 16 percent in the placebo group and zero percent in the amoxicillin group (P = .03). Subjects with higher gingival scores were more likely to have a bacteremia for draw 2 (P = .01). The authors found that subjects in the group with bacteremia for draw 3 had undergone more pulpotomies than did subjects in the group without bacteremia for draw 3 (3 ± 2.5 standard deviation [SD] versus 1.5 ± 1.6 SD, P = .04), while they found almost no differences for draw 2.

Conclusions. This study suggests that gingival disease has an impact on bacteremia after dental restorations and prophylaxis. Although antibiotics have an impact, they do not eliminate bacteremia altogether.

Key Words: Bacteremia; infective endocarditis; pediatric dental care; gingival diseases

Abbreviations: AHA: American Hospital Association • IE: Infective endocarditis • IND: Incidence, nature (species of bacteria) and duration • OR: Operating room

Studies have demonstrated a wide range of incidence, nature (species of bacteria) and duration (IND) of bacteremia after dental office procedures that are both minimally invasive (for example, tooth brushing) and more invasive (for example, dental extractions).1–6 The impact of bacteremia from dental procedures on the risk of developing infective endocarditis (IE) remains controversial, as the American Heart Association (AHA) guidelines for prevention of IE from dental procedures are not based on prospective clinical trials.7

The impact of dental disease on the IND of bacteremia after dental procedures still is unclear; no associations are found in some studies,8,9 and a significant effect is found in others.1,10–13 Similar to the literature on adults, investigators have reported a wide range of IND of bacteremia in children,8,12,14–18 and the role of dental disease in IND is poorly understood. In a study by Lockhart and colleagues,14 the investigators randomized 100 children to receive an antibiotic or a placebo before dental rehabilitation in an operating room (OR) setting.1 They reported the role of the AHA-recommended dose of amoxicillin in moderating the IND of bacteremia in children younger than 8 years and demonstrated that the incidence of bacteremia was reduced significantly in the amoxicillin group compared with the placebo group (33 percent versus 84 percent, P < .0001). The species of bacteria and duration of bacteremia also were affected. The severity of dental disease did not affect the incidence of bacteremia shortly after extractions, but increases in age and number of teeth extracted were associated with higher incidence levels of bacteremia.

The goal of our study was to examine the role of dental disease and nonsurgical dental procedures on the incidence and duration of bacteremia in children.


   SUBJECTS, MATERIALS AND METHODS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We enrolled 100 children who required dental treatment in an OR setting owing to uncooperative behavior, young age or the extent of treatment needs. We obtained consent from each child’s parent or legal guardian as approved by the institutional review board at Carolinas Medical Center, Charlotte, N.C. We randomized the subjects using a computer-generated random number scheme, and used identical-appearing syringes to administer the placebo or the amoxicillin. All of the investigators were blinded to the assigned treatment.

The subjects received the AHA-recommended dose of an amoxicillin elixir (50 milligrams/kilogram) or a placebo one hour before dental rehabilitation in an OR setting (FigureGo). We then sedated the subjects with midazolam and brought them to the OR, where we performed a mask induction and placed an intravenous line for anesthetic administration purposes. For blood culture draws, we placed a large-bore (18–22 grams) angiocath needle with a line in the antecubital fossa or dorsum of the hand, after we prepared the skin in the usual manner with alcohol, followed by povidoneiodine (10 percent).


Figure 1
View larger version (29K):
[in this window]
[in a new window]

  		Figure. Study timeline. * In cases of single tooth extractions, the fifth blood draw took place three minutes after the initiation of the first extraction. Adapted and modified with permission by Lippincott Williams and Wilkins from Lockhart and colleagues.14

 
We drew 6 milliliters of blood (draw 1) two minutes after we initiated intubation. After placing throat packs, we took dental radiographs and conducted a thorough oral examination. After we completed dental restorations, pulp therapy and prophylaxis, we drew a second 6-mL blood sample (draw 2). Ten minutes later, we drew a third 6-mL blood sample (draw 3) to determine the duration of bacteremia after the procedures were performed and as a baseline culture before dental extractions were performed. We have reported data from draw 1 and draws 4 to 8 after dental extractions.14

We flushed the angiocath needle and line with 3 cubic centimeters of saline after each blood draw, and we drew and discarded 2 cm3 of blood before each draw. The order of dental procedures was completion of the dental restoration followed by dental prophylaxis. Therefore, we performed draw 2 immediately after the dental cleaning; however, the incidence and duration of bacteremia likely also were influenced by the restorative treatment.

In addition to recording demographic variables (age, sex, ethnic group), we recorded the following for each subject:

– periodontal status (gingival score [0 = normal, 1 = mild inflammation, 2 = moderate inflammation, 3 = severe inflammation],19 gingival size [0 = normal, 1 = slight enlargement, 2 = moderate enlargement, 3 = gross enlargement] and periodontal disease present with any probing depths > 3 millimeters [yes/no]);
– mixed dentition versus primary dentition;
– caries present (yes/no);
– depth of caries (0 = none, 1 = to dentin, 2 = to pulp, 3 = gross);
– periapical radiolucency present (yes/no);
– the size of the radiolucency (in mm);
– swelling present (yes/no);
– suppuration present (yes/no);
– type of dental procedure performed:
– prophylaxis completed (yes/no);
– number of amalgam restorations, resin-based composites, sealants and stainless steel crowns placed;
– number of pulpectomies (removal of pulpal tissue from pulp chamber and roots) and pulpotomies (removal of pulpal tissue from pulp chamber only) performed;
– time required to complete dental restorations.

Microbial analysis. We divided each blood sample into 2-mL pediatric BACTEC aerobic (PEDS PLUS) (Becton Dickinson, Sparks, Md.) and 4-mL adult BACTEC anaerobic bottles, per the manufacturer’s recommendation. After we collected the last draw, we transported all 16 aerobic and anaerobic bottles to the microbiology laboratory for incubation and processing according to standard methods.20 We gram-stained cultures with evidence of bacterial growth and subcultured them onto appropriate media. We continuously monitored blood cultures for growth using an automated microbiology analyzer system (Microscan, Baxter, West Sacramento, Calif.) and manually completed standard biochemical tests for species identification. We incubated blood cultures for up to 14 days to ensure identification of more slow-growing species.

Data analysis. We examined the role of demographics, dental disease and types of dental procedures on the incidence of bacteremia for blood draws 2 and 3. We calculated descriptive statistics, including means and standard deviations, counts and percentages. For continuous data, we used a Student t test or a Wilcoxon rank sum test. We used a {chi}2 or Fisher exact test for nominal data. We used computer software (SAS, Version 8.2, SAS Institute, Cary, N.C.) for all analyses. We considered a P value of less than .05 to be statistically significant.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We enrolled 100 children (age range, 1–8 years) in the study. We randomized the subjects to receive a placebo (51) or amoxicillin (49). We did not collect draw 2 from one subject, and we did not collect draw 3 from six subjects. We dropped these subjects from the data analyses.

The incidence of bacteremia from draw 2 was 20 percent in the placebo group and 6 percent in the amoxicillin group (P = .07). The incidence of bacteremia from draw 3 was 16 percent in the placebo group and zero percent in the amoxicillin group (P = .03), as we reported previously.14

We noted no statistically significant differences in baseline characteristics between subjects in the placebo and amoxicillin groups (Table 1Go). We compared demographic, dental disease and type of restorative treatment data for bacteremia incidence groups for draws 2 and 3. For draw 2, we found that the mean age of the subjects in the group with bacteremia was 4.1 ± 1.3 standard deviation (SD) years and the mean age of the subjects in the group without bacteremia was 3.4 ± 1.2 SD years (P = .06). We also found that two (15 percent) of 13 subjects in the group with bacteremia had a mixed dentition compared with two (2 percent) of the 86 subjects in the group without bacteremia (P = .08) (Table 2Go, page 84).


View this table:
[in this window]
[in a new window]

  		TABLE 1 Baseline characteristics of 100 subjects randomized to receive amoxicillin or a placebo.*

 

View this table:
[in this window]
[in a new window]

  		TABLE 2 Relationship between baseline demographic and odontogenic findings and bacteremia incidence for draws 2 and 3.

 
When we compared dental disease and incidence of bacteremia, we found that subjects with higher gingival scores were significantly more likely to have a bacteremia for draw 2 (P = .01). No other dental disease parameters had a statistically significant association with a bacteremia.

We found that subjects in the group with bacteremia for draw 3 had undergone more pulpotomies than did subjects in the group with no bacteremia for draw 3 (3 ± 2.5 SD versus 1.5 ± 1.6 SD, P = .04), while we found almost no differences for draw 2. We did not perform pulpectomies in the subjects who had a bacteremia in draws 2 and 3; we performed 0.3 ± 1.0 SD pulpectomies in subjects in the no bacteremia group (P = .01).


   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
A variety of dental procedures have been associated with bacteremia in children, but few studies have assessed bacteremia after nonsurgical procedures. Incidence rates after oral prophylaxis in children range from 0 to 40 percent,15,17,18 while studies in adults have shown incidence rates of 15 to 61 percent.21,22 Minimal information is available for incidence rates associated with other types of dental procedures in children. One study reported a higher incidence of bacteremia with rubber dam placement (31 percent) and a matrix band with a wedge (32 percent) compared with baseline (9 percent) and removal of tooth structure with a dental drill (4–12 percent).23 Although the incidence and nature figures for bacteremia are varied, largely owing to different study methodologies, there have been no large studies concerning the duration of bacteremia in children.

Our study demonstrated an incidence of bacteremia after dental restorations and cleaning of 20 percent in the placebo group (draw 2), which falls within the range of previous studies of dental cleaning in children.17,18,24,25 Sixteen percent of the subjects in the placebo group still had bacteremia 10 minutes later (draw 3). As expected, this bacteremia incidence was lower than that from dental extractions (76 percent).6,14

A comparison of the amoxicillin and placebo groups did not show statistically significant differences at draw 2 (P = .07), but it did at draw 3 (P = .03). For draw 2, three subjects in the amoxicillin group had a bacteremia. This demonstrates that amoxicillin does not completely eliminate bacteremia after dental restorations and prophylaxis in children. However, no subjects in the amoxicillin group had a bacteremia 10 minutes later (draw 3). Therefore, the duration of bacteremia did not linger beyond 10 minutes with antibiotic prophylaxis.14

We found that only one parameter of dental disease—higher gingival scores—was associated with a higher incidence of bacteremia at draw 2. One pediatric study reported that gingival disease is related to the bacteremia incidence after dental extraction,12 while other pediatric studies found no relationship between dental disease factors and extractions, oral prophylaxis or noninvasive dental procedures.8,17,23 In a previous study, we found that older age was associated with bacteremia after dental extractions,14 but this finding was not statistically significant for draws 2 or 3. Older children have more teeth and different oral bacterial flora than do younger children, which likely results in a different IND of bacteremia.

We found that subjects in the group with bacteremia for draw 3 had undergone more pulpotomies than did subjects in the group without bacteremia for draw 3, while we found almost no differences for draw 2. We also found that pulpectomies were more common in the no bacteremia group for both draws 2 and 3. No subjects in the group with bacteremia underwent pulpectomies. As these findings are contradictory, it is unclear if these types of procedures have any role in the incidence or duration of bacteremia in children, or if these findings resulted from the small number of pulpectomies performed overall.

A limitation of our study is the small number of subjects in the group with bacteremia for draws 2 and 3, which allowed for only univariate analyses. Multivariate regression analysis, controlling for the impact of amoxicillin, would have been more appropriate. In addition, multiple comparisons can produce type I errors, which might account for the finding of a lower incidence of bacteremia after pulpectomies. Similarly, because of the low incidence of bacteremia, a type II error may have occurred with differences between the amoxicillin and the placebo at draw 2.


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Few studies have addressed the role of dental disease and dental procedures in children. Our study suggests that gingival disease has an effect on bacteremia after dental restorations and prophylaxis. Although antibiotics have an impact, they do not eliminate bacteremia.


   FOOTNOTES
 

Dr. Brennan is the oral medicine residency director, Department of Oral Medicine, Carolinas Medical Center, P.O. Box 32861, Charlotte, N.C. 28232, e-mail "mike.brennan{at}carolinas.org". Address reprint requests to Dr. Brennan.


Ms. Kent is the clinical coordinator, Department of Oral Medicine, Carolinas Medical Center, Charlotte, N.C.


Dr. Fox is the clinical research director, Department of Oral Medicine, Carolinas Medical Center, Charlotte, N.C.


Dr. Norton is the director of biostatistics, Department of Biostatistics, Carolinas Medical Center, Charlotte, N.C.


Dr. Lockhart is chairman, Department of Oral Medicine, Carolinas Medical Center, Charlotte, N.C.


The authors would like to acknowledge Drs. Margaret Lochary, Kelly Zukaitis and Carlton V. Winter for their participation in this study. In addition, the authors thank David Weinrib, MD, and David Rupar, MD, for their help with the microbiology data, and William T. Williams, MD, for his instrumental and longstanding support of this effort.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Silver JG, Martin AW, McBride BC. Experimental transient bacteraemias in human subjects with varying degrees of plaque accumulation and gingival inflammation. J Clin Periodontol 1977;4(2):92–9.[Medline]

  2. Faden HS. Dental procedures and bacteremia (letter). Ann Intern Med 1974;81(2):274.[Medline]

  3. Rise E, Smith JF, Bell J. Reduction of bacteremia after oral manipulations. Arch Otolaryngol 1969;90(2):198–201.[Medline]

  4. Lockhart PB. An analysis of bacteremias during dental extractions: a double-blind, placebo-controlled study of chlorhexidine. Arch Intern Med 1996;156(5):513–20.[Abstract]

  5. Bhanji S, Williams B, Sheller B, Elwood T, Mancl L. Transient bacteremia induced by toothbrushing: a comparison of the Sonicare toothbrush with a conventional toothbrush. Pediatr Dent 2002;24(4):295–9.[Medline]

  6. Roberts GJ, Radford P, Holt R. Prophylaxis of dental bacteraemia with oral amoxycillin in children. Br Dent J 1987;162(5):179–82.[Medline]

  7. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277(22):1794–801.[Abstract]

  8. Peterson LJ, Peacock R. The incidence of bacteremia in pediatric patients following tooth extraction. Circulation 1976;53(4):676–9.

  9. Daly C, Mitchell D, Grossberg D, Highfield J, Stewart D. Bacteraemia caused by periodontal probing. Aust Dent J 1997;42(2):77–80.[Medline]

  10. Otten JE, Pelz K, Christmann G. Anaerobic bacteremia following tooth extraction and removal of osteosynthesis plates. J Oral Maxillofac Surg 1987;45(6):477–80.[Medline]

  11. Okabe K, Nakagawa K, Yamamoto E. Factors affecting the occurrence of bacteremia associated with tooth extraction. Int J Oral Maxillofac Surg 1995;24(3):239–42.[Medline]

  12. Roberts GJ, Watts R, Longhurst P, Gardner P. Bacteremia of dental origin and antimicrobial sensitivity following oral surgical procedures in children. Pediatr Dent 1998;20(1):28–36.[Medline]

  13. Daly CG, Mitchell DH, Highfield JE, Grossberg DE, Stewart D. Bacteremia due to periodontal probing: a clinical and microbiological investigation. J Periodontol 2001;72(2):210–4.[Medline]

  14. Lockhart PB, Brennan MT, Kent ML, Norton HJ, Weinrib DA. Impact of amoxicillin prophylaxis on the incidence, nature, and duration of bacteremia in children after intubation and dental procedures. Circulation 2004;109(23):2878–84.

  15. De Leo AA, Schoenknecht FD, Anderson MW, Peterson JC. The incidence of bacteremia following oral prophylaxis on pediatric patients. Oral Surg Oral Med Oral Pathol 1974;37(1):36–45.[Medline]

  16. Hess J, Holloway Y, Dankert J. Incidence of postextraction bacteremia under penicillin cover in children with cardiac disease. Pediatrics 1983;71(4):554–8.[Abstract/Free Full Text]

  17. Hurwitz GA, Speck WT, Keller GB. Absence of bacteremia in children after prophylaxis. Oral Surg Oral Med Oral Pathol 1971;32(6): 891–4.[Medline]

  18. Roberts GJ, Holzel HS, Sury MR, Simmons NA, Gardner P, Longhurst P. Dental bacteremia in children. Pediatr Cardiol 1997;18(1):24–7.[Medline]

  19. Löe H, Silness J. Periodontal disease in pregnancy, I: prevalence and severity. Acta Odontol Scand 1963;21:533–51.[Medline]

  20. Chokephaibulkit K, Wanprapa N, Srifuengfung S, et al. Comparison of BACTEC automated blood culture system and conventional system in hospitalized pediatric patients. J Med Assoc Thai 1999; 82(10):1011–6.[Medline]

  21. Baltch AL, Schaffer C, Hammer MC, et al. Bacteremia following dental cleaning in patients with and without penicillin prophylaxis. Am Heart J 1982;104(6):1335–9.[Medline]

  22. Baltch AL, Pressman HL, Schaffer C, et al. Bacteremia in patients undergoing oral procedures: study following parenteral antimicrobial prophylaxis as recommended by the American Heart Association, 1977. Arch Intern Med 1988;148(5):1084–8.[Abstract]

  23. Roberts GJ, Gardner P, Longhurst P, et al. Intensity of bacteraemia associated with conservative dental procedures in children. Br Dent J 2000;188(2):95–8.[Medline]

  24. Barco CT. Prevention of infective endocarditis: a review of the medical and dental literature. J Periodontol 1991;62(8):510–23.[Medline]

  25. Baumgartner JC, Heggers JP, Harrison JW. The incidence of bacteremias related to endodontic procedures, I: nonsurgical endodontics. J Endod 1976;2(5):135–40.[Medline]




This article has been cited by other articles:


Home page
 J Bone Joint Surg BrHome page
I. Uckay, D. Pittet, L. Bernard, D. Lew, A. Perrier, and R. Peter
Antibiotic prophylaxis before invasive dental procedures in patients with arthroplasties of the hip and knee
J Bone Joint Surg Br, July 1, 2008; 90-B(7): 833 - 838.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Brennan, M. T.
Right arrow Articles by Lockhart, P. B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Brennan, M. T.
Right arrow Articles by Lockhart, P. B.
Related Collections
Right arrow Infection Control

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS