Blackwell Publishing IncMalden, USACHDCongenital Heart Disease(c) 2006 The Authors; Journal compilation (c) 2006 Blackwell Publishing, Inc.September/October 200615224228Original ArticleBacteremia Incidence in Pediatric Dental PatientsÖnça~ et al.
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Bacteremia Incidence in Pediatric Patients under Dental General Anesthesia ( Özant Önçag , DDS, PhD,* S¸öhret Aydemir, MDS, PhD,†‡ Nazan Ersin, DDS,* and Hüseyin Koca, DDS, PhD§ *Department of Pedodontics, Faculty of Dentistry, †Department of Microbiology, Faculty of Medicine, ‡Department of Clinical Microbiology, Faculty of Medicine, and §Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ege University, ˙Izmir, Turkey ABSTRACT
Background. The aim of this study was to assess the incidence of bacteremia from various procedures in children undergoing dental treatment under general anesthesia. Methods. Three blood samples for cultures were obtained from each patient; the first sample (10 ml basal) at the onset of the process and the second sample (10 ml) within 30 seconds following the nasotracheal intubation. The third blood sample (10 ml) was taken 30 seconds after the extraction of a deciduous tooth or a permanent tooth or slow drilling. Following incubation in an automated blood culture system, bacteria were identified by using conventional biochemical methods and commercial identification systems. Chi-square test was used to assess the findings statistically. Results. All blood cultures were negative before intubation (baseline) in every patient. However, the percentage of positive samples in deciduous tooth extraction and permanent tooth extraction groups were 18/26 (69.2%) and 18/ 25 (72%), respectively. These values were significantly greater than the results of baseline 0/74 (0%), slow drilling 3/23 (13%), and nasotracheal intubation 9/74 (12.3%) (P < .05). Conclusion. Consequently, the patients treated under dental general anesthesia have to be evaluated with detailed physical examination and antibiotic prophylaxis should be given if required in order to prevent further unexpected bacterial endocarditis. Key Words. Bacteremia; Dentistry; General Anesthesia; Children
espite the great advances in medical and surgical treatment, bacterial endocarditis (BE) is still a life-threatening disease with an estimated mortality of 10–40%.1,2 Although the importance of pre-existing cardiac abnormalities as principal risk factors in BE has been demonstrated,3 according to Carmona et al.’s results,4 between 34%5 and 57%6 of BE cases develop in patients who did not have previously known “at risk” cardiac conditions as defined by the American Heart Association (AHA).7 For risk group patients, the AHA7 and British Society for Antimicrobial Chemotherapy8 recommend chemoprophylaxis for tooth extraction, periodontal surgery, scaling, and prophylactic cleaning. However, some conservative dental procedures (rubberdam and matrix band with edge placement) may result in significant bacteremia,9
which could justify 1 case of BE in Carmona et al.’s4 series following filling. Besides during chewing of food and brushing of teeth, these microorganisms may reach the bloodstream and cause complications to the body.10 In healthy persons, the episodes of bacteremia are brief because of efficient clearance by the host’s immune system.11 However, in many patients whose resistance is defective owing to drug use, damaged organs, or diseases such as valvular heart disease, diabetes, and acquired immune deficiency syndrome, bacteremia is associated with an increased risk of serious and frequently lethal complications such as infectious endocarditis.11,12 Another cause of higher rate of bacteremia after dental treatment is a poor or no oral hygiene at all, as one can find in mentally ill patients, who do not cooperate with their dentist and who cannot be convinced to brush their teeth.11 Numerous studies have demonstrated that topical antiseptic application reduces
Congenit Heart Dis. 2006;1:224–228
© 2006, the Authors Journal compilation © 2006, Blackwell Publishing, Inc.
Introduction
D
225
Bacteremia Incidence in Pediatric Dental Patients the frequency and magnitude of bacteremia of oral origin.13–15 Streptococci are the most common cause of endocarditis, with the viridans group most often the pathogen.4,16 The aim of this study was to identify bacteremia risk in pediatric patients during dental treatment under general anesthesia procedures, and also to determine the circulating microorganisms in the blood. Methods
The project was approved by the Ethical Committee of the Faculty of Medicine, Ege University, Izmir, Turkey. Written consent was obtained from the parent or guardian to take blood samples while the pediatric patients were anesthetized. The patient exclusion criteria were: congenital heart disease, history of rheumatic fever; preexisting nasopharyngeal pathology; aortic stenosis, mitral stenosis, or both; prosthetic heart valves; history of subacute BE; hypertrophic cardiomyopathy; surgically constructed systemic pulmonary shunts; vascular and joint prostheses; immunosuppresion; diabetes; bleeding disorder; antibiotic usage within the past 1 month and regular use of antibiotic mouthwash. Before being operated on, all the patients underwent cardiac checkup (ecocardiography, electrocardiography, telecardiography, and physical examination) cardiogram, chest X-rays, general blood (creatine phosphokinase, lactate dehydrogenase, serum glutamate oxalsacate transaminase, serum glutamate pyruvate transaminase, hemogram) and urine tests. On the operation day, anesthesia was induced by the inhalation of 8% sevoflurane (Sevorane®) and 66% nitrous oxide and 33% oxygen, which had been orally premedicated with 0.5 mg/kg midazolam (Dormicum®) at the operation room of the Pediatric Surgery Department of Medical Faculty at Ege University, Izmir, Turkey. Blood for culturing was obtained from an antecubital veins in the arm opposite to that with the intravenous infusion. The region was disinfected with 70% isopropyl alcohol before infiltration. The area was wiped twice with povidone iodine using a circumferential outward motion, and then wiped with dry sterile gauze pad. The anesthesiologist wore sterile gloves to place the intravenous catheter. Three blood samples were taken from each patient: first 10 ml basal at the onset of process; second 10 ml within 30 seconds following the nasotracheal intubation. The third 10 ml blood sample was taken 30 seconds after the extraction of 1 deciduous
tooth or 1 permanent tooth extraction or slow drilling. Each blood sample taken for each procedure was immediately distributed and inoculated in 5 ml aerob and 5 ml anaerob BacT/ALERT (bioMérieux Inc, Durham, NC, USA) bottles. They were incubated in BacT/ALERT automatic blood culture system (bioMérieux Inc) at the Microbiology and the Clinical Microbiology Departments of Medical Faculty at Ege University. In case growth was detected during the incubation, the samples were subcultured on blood agar with 5% sheep blood and Mc Conkey agar. Following incubation, bacteria were identified using conventional and biochemical methods and commercial identification systems (api 20 Strep, api NH and ID 32 Staph, bioMérieux, Marcy, Etoile, France) that are universally used and accepted by clinical microbiologists. The statistical significance was assessed with chi-square test. The critical level for statistical significance was set as P < .05. Results
A total of 74 ASA (American Society of Anesthesiologists Classification) 1 or 2 patients were studied (25 girls, 49 boys). Those patients ranged in age from 3 to 15 years, with a mean age of 9.5 ± 4.3 years. Fifty-six of those children were intellectually disabled while the remaining patients (n = 18) were young, uncooperative anxious children who rejected dental treatment in the clinic. They were indicated by dental treatment under general anesthesia who applied to Pedodontics Department in Faculty of Dentistry at Ege University. They had rampant caries, necrotic and infectious primary and permanent teeth, and poor oral hygiene in their oral cavities. DMFS (D: decay, M: missing, F: filling, S: surface) = 5 ± 3.2, dfs (d: decay in deciduous dentition, f: filling in deciduous teeth, s: surface in deciduous teeth) = 18.0 ± 10.7, plaque indice = 2.4 ± 0.9, and periodontal indice = 2.3 ± 0.7 were detected. All blood cultures were negative before intubation (baseline) in every patient. However, other procedures were associated with bacteremia (Table 1). The procedures with the higher association were deciduous tooth extraction (69.2%) and permanent tooth extraction (72.0%), and that with the lowest association was the nasotracheal intubation (12.3%). The percentage of positive samples in deciduous tooth extraction 18/26 (69.2%) and permanent tooth extraction 18/25 (72%) groups were significantly greater than that in the baseline Congenit Heart Dis. 2006;1:224–228
( Önça g et al.
226 0/74 (0%), slow drilling 3/23 (13%), and nasotracheal intubation groups 9/74 (12.3%) (P < .05) (Table 1). The majority of organisms were viridans streptococci, followed by the coagulase negative staphylococci and the remainder was Leuconostoc spp., Neisseria polysaccharea, Staphylococcus aureus, Streptococcus pneumoniae, and the anaerobic cocci Peptostreptococcus spp. (Table 2). The majority (69.4%) of the organisms following tooth extraction were viridans streptococci. Discussion
Many studies have been performed in order to get a greater knowledge about the interaction between Table 1. Percentage of Positive Blood Cultures for Each Procedures
Blood Sample
Patient Number (N)
Number Positive/ Number in Group (n/N)
% Positive
Baseline Nasotracheal intubation Slow drilling Deciduous tooth extraction Permanent tooth extraction
74 74 23 26 25
0 9/74 3/23 18/26* 18/25*
0 12.3 13 69.2* 72*
*P < .05, statistically significantly high bacteremia (P < .05).
Table 2.
dental procedures and bacteremias. Especially infective endocarditis has been associated with bacteremias following dental treatment.4,11,17–23 In many previous investigations, various results were obtained in adults and children about the incidence of bacteremia following tooth extractions.11,13,22,24–26 Vergis et al.22 and Okabe et al.26 found bacteremia as 89% and 78.1%, respectively, in adult patients with inflammatory diseases such as apical periodontitis, pericoronitis, or marginal periodontitis. In pediatric patients, these incidences were ranged from 0 to 83%.24,27,28 In this study, the incidences of bacteremia were found as 69.2% and 72% following 1 single deciduous tooth extraction and permanent tooth extraction, respectively. While there are many studies claiming that the incidence of bacteremia following dental manipulation is lower in children than in adults,24,27 as Droz et al.,18 Messini et al.,11 and Coulter et al.17 mentioned, the high incidence of bacteremia following tooth extraction can be ascribed to the fact that the children in this study had multiple carious and necrotic infective teeth and poor oral hygiene. Moreover, besides tooth extraction some conservative dental procedures may also result in significant bacteremia. The incidence of bacteremia after slow drilling was found as 13% in the present study, which was in accordance with the results of
Organism Cultured from Blood Cultures at Onset, Post Intubation, and Following Various Dental Procedures
Blood Sample (N)
Species
Positive Cultures, N (%)
Baseline (74)
— Viridans streptococci (Streptococcus mutans, S. milleri, S. mitis) Coagulase-negative staphylococci (Staphylococcus epidermidis) Streptococcus pneumonia Staphylococcus aureus Viridans streptococci (Streptococcus sanguis, S. mitis) Coagulase negative staphylococci (Streptococcus capitis) Viridans streptococci (Streptococcus mutans, S. sanguis, S. salivarius, S. mitis, S. milleri) Coagulase negative staphylococci (Streptococcus hominis, S. epidermidis) Leuconostoc spp. Neisseria polysaccharea Streptococcus aureus Peptostreptococcus spp. Viridans streptococci (Streptococcus mutans, S. milleri, S. mitis, S. sanguis, S. salivarius) Streptococcus pneumoniae Coagulase-negative staphylococci (Streptococcus epidermidis) Neisseria polysaccharea
— 4 (5.4)
Intubation (74)
Slow drilling (23) Deciduous tooth extraction (26)
Permanent tooth extraction (25)
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3 (4.1) 1 (1.4) 1 (1.4) 2 (8.7) 1 (4.3) 11 (42.3) 2 (7.69) 1 2 1 1 14
(3.84) (7.69) (3.84) (3.84) (56)
1 (4) 2 (8) 1 (4)
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Bacteremia Incidence in Pediatric Dental Patients Roberts et al.21 who found the incidence as 12.2%. The same authors suggested that when no tooth extraction is performed and only multiple cavity preparation is in question, rubberdam, matrix band, and wedge applications are the chief causes of bacteremia and single-dose antibiotic prophylaxis was recommended in the risk group children given dental general anesthesia.21 However, the use of antibiotic prophylaxis for conservative dentistry is not recommended according to the AHA guidelines (1997).7 In this study in accordance with Dinner et al.29 and Okabe et al.26 no bacteremia was observed before treatment, in the basal blood samples. However, after nasotracheal intubation the incidence of bacteremia was found between 9.7% and 16%19,30,31 in children, which was similar to the rate of percentage 12.3 obtained in this study. Baltch et al.32 found bacteremia in 33% of the adult patients after nasotracheal intubation. They related this higher rate of bacteremia to the severe periodontitis or periapical abscess formation in 90% of the patients in their study. It could be suggested that bacteremia incidence was not large enough to warrant the routine use of prophylactic antibiotic for nasotracheal intubation. However, when patients were to receive a prophylactic antibiotic prior to surgery, it would be prudent to administer the antibiotic prior to intubation. Numerous epidemiologic studies in different countries have shown that in 14–20% of the cases BE were associated with a possible dental origin.6,18,33 Moreover, it was reported that BE is likely to occur at a proportion of 34%5 and 57%6 even in patients who do not have the cardiac risk conditions defined by AHA. Therefore, antibiotics were recommended during difficult surgical procedures even in patients without cardiopathy.18 However, there is a concern that widespread use of antibiotics for this purpose might contribute to antibiotic resistance, an important issue today, as well as needlessly expose patients to antibiotic side-effects such as allergic reactions.34 Moreover, although Lockhart et al.35 found that the use of amoxicillin on bacteremia is very effective, they recommended to be cautious about the routine use of amoxicillin because it does not prevent oral pathogens from entering the systemic circulation. In this study, as in many previous studies, the majority of organisms cultured in blood after dental extractions or other dental procedures were viridans streptococci.9,17,19,21,22 Also in the infective endocarditis, the most common group was reported as the viridans streptococci,17 which
accounted for approximately 40% of the cases.4,10,23 Unlike the findings above, Droz et al.’s18 results were not in accordance with the literature for blood cultures. They found staphylococcus as more frequent than streptococcus (24% vs. 20%). According to Okabe et al.,26 they encountered higher proportions of anaerobic bacteria, which they ascribed to the fact that their patients were adults with marginal periodontitis in whom the anaerobic bacteria colonization was greater. Consequently, the patients with poor oral hygiene and who had rampant caries and infected teeth treated with noninvasive and invasive dental procedures under day-stay general anesthesia have to be evaluated with cardiovascular examination and antibiotic prophylaxis which amoxicillin would be appropriate or clindamycin for those allergic to beta-lactams consistent with the AHA recommendations should be given if required in order to prevent further unexpected BE. Corresponding Author: Özant Önçag, DDS, PhD, Department of Pedodontics, Faculty of Dentistry, Ege University 35100, Bornova, Izmir, Turkey. Tel: (+90) 232-3886431; Fax: (+90) 232-3880325; E-mail:
[email protected] Accepted in final form: July 11, 2006. References
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