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Tooth Extraction and Tooth Brushing Both Produce Bacteraemia of Endocarditis-Related Pathogens.
Tooth brushing may present a greater risk for infective endocarditis than tooth extraction, according to a study presented here at the 56th annual scientific session of the American College of Cardiology (ACC).

NEW ORLEANS, LA -- March 28, 2007 -- Tooth brushing may present a greater risk for infective endocarditis than tooth extraction, according to a study presented here at the 56th annual scientific session of the American College of Cardiology (ACC).


Although the incidence, nature and duration of bacteraemia from dental extractions -- considered the most invasive of dental procedures -- have been reported, there is little data on bacteraemia from common daily activities such as tooth brushing, said lead investigator Peter Lockhart, DDS, professor, department of oral medicine, Carolinas Medical Centre, Charlotte, North Carolina, United States.


The prospective, randomised, double-masked study was designed to compare the incidence, nature and duration of bacteraemia from endocarditis-related bacteria during and following a single tooth extraction and tooth brushing, and to determine the impact of the antibiotic amoxicillin on the incidence, nature and duration of bacteraemia from a single tooth extraction.


Dr. Lockhart and colleagues enrolled 167 male and 123 female subjects with a mean age of 40 years who needed a routine dental extraction. They were randomised into 3 equal groups -- extraction with amoxicillin, extraction with placebo, and tooth brushing alone. Patients in the extraction arms were given amoxicillin or placebo 1 hour before surgery began. For the brushing arm, subjects brushed with a new toothbrush for 2 minutes.


Baseline characteristics were similar for all groups.


For all 3 arms of the study, a large bore angiocatheter needle was placed in the antecubital fossa and there were six blood draws for aerobic and anaerobic BACTEC cultures at baseline, at 1.5 minutes and at 5 minutes after the initiation of surgery or brushing. Fourth, fifth and sixth samples of blood were drawn at 20, 40 and 60 minutes following the end of the procedure.


The overall incidence of bacteraemia from all 6 draws was 32%, 56% and 80% for the brushing, amoxicillin and placebo groups, respectively (P < .0001). There was a significant difference in the incidence of positive cultures between the 3 groups at all draws except at baseline (P < .01).


The highest incidence of positive cultures occurred at the 5-minute time point in the placebo group (73%). Positive cultures occurred during draws 2 and 3 in the placebo group (76%), followed by the amoxicillin (53%) and brushing (27%) groups.


The rate of positive cultures at 20 minutes was significantly greater in the placebo group (18%) than in the amoxicillin (4%) and tooth brushing (10%) groups (P < .0001).


The investigators identified 127 different bacterial species, the most common belonging to Viridans streptococci (49%), Prevotella (9%), and Actinomyces and Fusobacterium groups (each 5%). Overall, amoxicillin reduced the incidence of Viridans streptococci by 73%.


The brushing and amoxicillin groups, and the amoxicillin and placebo groups were similar to each other in the incidence of some bacterial pathogens reported to cause infective endocarditis.


In his presentation on March 27th, Dr. Lockhart said it is generally felt that "dental extractions are the most likely of dental procedures to cause bacteraemia," because of the invasiveness and duration of the procedures. However, tooth brushing may disrupt a larger surface area of gingival tissues. Therefore, it "may be as invasive as an extraction from the standpoint of the incidence, nature and duration of bacteraemia."


The study suggests that bacteraemia from tooth brushing is a common event and that the bacteraemia from brushing involves a similar spectrum of infective endocarditis-causing bacteria as tooth extraction.


Dr. Lockhart noted there was little difference between the amoxicillin and brushing groups in the spectrum of species known to cause infective endocarditis.


As well, given the bacteraemia incidence of 32% from tooth brushing, "there is a potential for bacteraemia to occur hundreds of times per year," while dental office-generated bacteraemia is far less frequent than that from home-based oral hygiene.


He concluded that tooth brushing may represent a greater risk for infective endocarditis than invasive dental office procedures and that, in the absence of a phase 3 trial, greater focus should be placed on avoidance of dental disease in patients at risk.


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Tooth Extraction and Tooth Brushing Both Produce Bacteraemia of Endocarditis-Related Pathogens.
Tooth brushing may present a greater risk for infective endocarditis than tooth extraction, according to a study presented here at the 56th annual scientific session of the American College of Cardiology (ACC).

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