602

Bacteremia Following Subgingival Irrigation and Scaling and Root Planing John E. Lofthus, * Marc Y. Waki,f David L. Jolkovsky,* Joan Otomo-Corgel,s Michael G. Newman,11 Thomas Flemmig, * and Sushma Nachnanß

The

purpose of this study was to determine

the incidence of bacteremia after

a

single professional subgingival irrigation with a 0.12% Chlorhexidine gluconate mouthrinse (CHX) as well as after a subsequent scaling and root planing (S/RP) during the same visit. Thirty subjects each with at least 1 site that probed 4 mm or more and bled on probing were randomly assigned to the following groups: 1) irrigation with 0.12% CHX; 2) irrigation with sterile water; and 3) non-irrigated controls. To begin the study blood was drawn just before and 2 minutes after irrigation. Thirty minutes later, blood was drawn again just before and 2 minutes after S/RP at the same site. Specimens were cultured for anaerobic and aerobic microorganisms using standard cultural techniques. Eighteen blood cultures from 15 subjects yielded positive cultures resulting in 23 isolates. Gram-positive rods comprised 34.8% of the total isolates; Gram-positive cocci 34.8%, Gram-negative rods 21.7%, and Gram-negative cocci 8.7%. In the CHX group, bacteremia was detected in 5 subjects after irrigation and in 2 other subjects after S/RP. In the water group, bacteremia was detected in one subject after irrigation and in 4 subjects after S/RP. The control group had 3 bacteremias after S/RP. There was no significant difference between the incidence of bacteremia associated with irrigation by CHX or sterile water (P 0.141). There was also no significant difference in the incidence of bacteremia after S/RP between the CHX and sterile water irrigation groups and in patients who did not receive irrigation (control group) (P 0.88). Thus it appears that subginwith without effect or has no on the incidence of bacteremia medication, gival irrigation, Periodontol 62:602-607. a / 1991; following subsequent S/RP. =

=

Key Words: Bacterial endocarditis/etiology; bacterial endocarditis/prevention; chlorhex-

idine/therapeutic use.

Subgingival plaque removal and control is a fundamental objective of periodontal therapy. Conventional closed debridement of subgingival plaque from root surfaces can be effective, but is time consuming and technically demanding. It has been shown that the chance of failing to remove all of the subgingival plaque increases in pocket depths greater than 4 mm.1,2 Therefore, professional maintenance therapy may not always achieve complete or adequate de*Previously, Periodontal Section, Dental Service, Veterans Administration Medical Center, West Los Angeles, CA; currently, private practice, San Diego, CA. 'Previously, Periodontal Section, Veterans Administration Medical Center, West Los Angeles, CA; currently, private practice, Burbank, CA. Private practice, Sacramento, CA. 5Periodontal Section, Dental Service, Veterans Adminstration Medical Center, West Los Angeles CA and Section of Periodontics, University of California at Los Angeles, Los Angeles, CA. "Section of Periodontics, University of California at Los Angeles, Los Angeles, CA. 'Previously, UCLA; currently, Bayerische Julius Maximilians Universität, Würzburg, Germany.

bridement.1'2 In addition, many

patients

are

not

compliant

with the necessary frequency of professional maintenance visits.3 As subgingival plaque accumulates and matures, periodontal breakdown can occur. Adjunctive means of plaque control to enhance what is achievable through conventional mechanical therapy is an approach becoming increasingly popular today with the local application of

chemotherapeutic agents by subgingival irrigation.4 Simple rinsing and direct supragingival irrigation have not been proven to be efficacious in penetrating to the apical border of the subgingival plaque in pockets greater than 5 mm.5 Yet, if an irrigation cannula is placed within the pocket, penetration to the apical plaque border and the bottom of the periodontal pocket may be achieved.6 One of the potential risks of a subgingival irrigation is the production of a transient bacteremia. The occurrence of transient bacteremias after various manipulations in the oral cavity is well documented. Bacteremia has been associated with such factors as gingival massage,7 rocking of teeth,8 periodontal infections,9 mastication,10 tooth extraction,11

Volume 62 Number 10

LOFTHUS, WAKI, JOLKOVSKY, OTOMO-CORGEL, NEWMAN, FLEMMIG, NACHNANI

scaling, and periodontal surgery.12 Felix et al.13 found bacteremias in 15 of 30 subjects after 1 minute of direct supragingival pulsating water irrigation. O'Leary et al.14 found that pulsating supragingival irrigation may force carbon particles into periodontal pocket epithelium and connective tissue. They concluded, indirectly, that since bacteria are much smaller than the particles (2.5 µ), these microorgan-

Gingival Index Gingival Bleeding Probing Depth

3rd Blood Draw 1st Blood Draw

Irrigation 2nd Blood Draw

surveys have found that 20% to 50% of endocarditis patients have had 1 or more teeth extracted within 2 months before the onset of the disease.17"19 Patients at risk for bacterial endocarditis include those with cardiac valve abnormalities, a history of endocarditis, or a history of rheumatic fever. For patients at risk, antibiotic prophylaxis is routinely prescribed prior to any dental procedure that may cause gingival bleeding, including routine professional cleaning. Antibiotic prophylaxis has not been considered necessary for routine home care procedures. Patients at risk should also maintain optimal oral hygiene to reduce potential sources of bacteremias.20 Periodontal pocket irrigation and mouthrinsing with antiseptics have been evaluated in numerous studies for their potential to reduce or eliminate bacteremia during a subsequent dental procedure. Several authors have shown decreases in the incidence of bacteremia during extractions or scaling after both subgingival irrigation and mouthrinsing with various antiseptics.21 26 Madsen,27 however, showed that the use of Chlorhexidine (CHX) as a mouthrinse for 7 days did not significantly reduce the incidence of bacteremia caused by toothbrushing or the use of toothpicks in patients with gingivitis or Periodontitis. In the Periodontitis group, bacteremia was detected in 53.8% of the subjects initially and in 38.5% after the 1 week regime of CHX rinsing (P 0.69). Witzenberger et al.28 also found no reduction in bacteremia during scaling (55%) after subgingival irrigation with povidone-iodine when compared to nonirrigated controls (55%). They also stated that the subgingival irrigation itself does not seem to induce a bacteremia (0%). No other studies have commented on the question of whether subgingival irrigation itself can cause a transient bacteremia. Waki et al.29 found that the overall incidence of bacteremia after scaling and root planing in recall patients was low (18.5%). No effects on the incidence of bacteremia were noted in that study from daily home marginal irrigation for 3 months with CHX or tap water. The purpose of the present investigation was to determine whether subgingival irrigation with 0.12% CHX could cause a bacteremia and also whether such treatment could diminish the incidence of bacteremia during a subsequent scaling and root planing. =

Scaling/Root Planing

4th Blood Draw

30 Minutes later

could, therefore, be forced into the tissues. Tamimi et al.,15 however, found no evidence that a direct supragingival pulsated water irrigation caused bacteremia in 30 subisms

jects. Romans and App16 also found no statistically significant incidence of bacteremias after direct pulsating water irrigation. Bacteremia associated with dental manipulation has been implicated in causing bacterial endocarditis. Retrospective

603

Initial visit 1. Experimental Measurements

Figure

Experimental visit 4-7 days later Design Showing Time, Procedures,

and Clinical

MATERIALS AND METHODS Patient Selection

Thirty subjects were recruited from patients of record in the

Periodontal Section of the Dental Service at the Veterans Administration Medical Center in West Los Angeles. Subjects were selected according to the following criteria: Each patient: 1) must currently have been in periodontal maintenance; 2) must have had at least 1 pocket with a probing depth > 4 mm and which bled on probing; 3) had to demonstrate reasonable oral hygiene skills; 4) had to provide informed consent. Subjects were excluded if any of the following conditions were noted: 1) were pregnant or were likely to become pregnant during the course of the study; 2) had serious systemic diseases; 3) had taken systemic antibiotics within the last 3 months; 4) had clinical and/or radiographie evidence of pulpitis, periapical radiolucencies, impacted teeth, retained root fragments; 5) were taking medications that could alter the clinical presentation of the gingival tissues; 6) with prosthetic joint replacements or who were at risk for developing infective endocarditis. or

Pretreatment Procedures All subjects meeting the selection requirements were given a written and verbal explanation of the study and its risks. Their informed consent was obtained. Complete extraoral and intraoral soft tissue examinations were performed. Full mouth recording of the Gingival Index (GI)30 and probing depths, using an electronic pressure-sensitive probe1 set at 25g, were also made. A single periodontal pocket which probed > 4 mm and which bled on probing (GI 2 or 3) was selected in each subject as the experimental site. This initial exam took place 4 to 7 days prior to the experimental visit. (Fig. 1) Ten subjects were randomly assigned to each of 3 treatment groups: 1) irrigation with 0.12% Chlorhexidine (CHX); 2) irrigation with sterile water (W); or 3) no irrigation/ control (C). A professional, pulsating, low pressure irri=

'Valley Vine Research, Middlesex,

NY.

604

BACTEREMIA FOLLOWING

IRRIGATION, SCALING, AND ROOT

gation device** was used at a pressure setting of 2 (out of 10). It was equipped with a blunt 24 gauge cannulan designed for subgingival use. Clinical Procedures On the day of the experimental visit, the vein to be drawn was chosen and palpated prior to disinfection. The skin was disinfected with 70% isopropyl alcohol and 2% povidoneiodine.31 Blood specimens were drawn with an 18 gauge needle into a plain evacuated tube. Fresh venipuncture sites were chosen and similarly disinfected for each subsequent draw from the same subject. An initial 15 cc blood specimen was drawn prior to any oral manipulation as a baseline in each subject. The 20 experimental subjects were then irrigated subgingivally with either 0.12% CHX or sterile water for 20 seconds at the bottom of the preselected periodontal pocket. The second 15 cc blood sample was drawn 2 minutes after the initiation of irrigation. A period of 30 minutes was allowed to pass after irrigation and the third blood draw. The third 15 cc blood sample was then drawn to demonstrate clearance of any bacteremia prior to scaling and root planing. The subject was then scaled and root planed at the same periodontal pocket for 60 seconds. The fourth blood sample was drawn 2 minutes after the initiation of S/RP. The 10 non-irrigated subjects in the control group had only 2 blood samples drawn, before and after the S/RP.

Laboratory Procedures Blood specimens were cultured

and evaluated for the presof aerobic and anaerobic microorganisms using both standard cultural techniques and the Septi-Chek blood culture bottle.** Each Septi-Chek bottle contained 70 cc of tryptic soy broth with 0.05% polyanethol sulfonate and an atmosphere of C02- One bottle was used for aerobic culturing, and both a second Septi-Chek bottle and a 15 cc plain evacuated blood tube were used for the anaerobic ence

culturing.

From each 15

by syringe

to a

specimen, 10 cc was transferred Septi-Chek bottle for aerobic culturing.

cc

blood

From that bottle, 10 cc of the blood-culture broth mix was then transferred by syringe to a sterile, plain 15 cc evacuated blood tube for anaerobic culturing. The remaining 5 cc of the subject's blood was then transferred to the second Septi-Chek bottle used as a backup anaerobic culture. The bottles and tubes were then transported to the Periodontal Microbiology Laboratory at the UCLA School of Dentistry within 60 minutes for incubation at 37°C under the appropriate atmospheric conditions. After arrival to the laboratory, the aerobic bottle was vented to room air and a Septi-Chek slide was immediately "PerioPik, Model XP6-W, Teledyne Water Pik, "Maxi-I-Probe, MPL, Inc. Chicago, IL. **Roche Diagnostics Systems, Nutley, NJ.

Fort

Collins, CO.

PLANING

J Periodontol October 1991

placed onto it to enable aerobic subculturing. This "slide" is a plastic cylindrical sleeve which contains a plate with 3 different culture media: chocolate agar, MacConkey agar,

and malt agar. The sleeve screws onto the top of the culture bottle and subculturing is performed by inverting the bottle and flooding the media with the blood culture broth. The aerobic unit was subcultured at 3, 5, and 7 days. On day 9, the slide was read for positive cultures. The 15 cc blood tube used for anaerobic culturing was placed in an anaerobic glove box and vented with a 21 gauge needle placed through the rubber stopper to enable gas flow. The anaerobic blood tube was subcultured at 3, 5, and 7 days by plating 0.1 cc aliquots of cultured broth on three types of media: tryptic soy agar with 5% sheep blood (SB), tryptic soy agar with 5% rabbit blood (RB), and tryptic soy agar with bacitracin and vancomycin (TSBV). A variety of media were utilized to increase the sensitivity of bacteremia detection. The blood tubes were vented again with fresh 21 gauge needles. The anaerobic Septi-Chek bottle was not vented and did not receive the slide attachment. The anaerobic bottle was subcultured only at 7 days so that a closed anaerobic environment was maintained without the chance of exposure or contamination by previous subcultures. The same techniques and media mentioned above were used for subculture. The sheep and rabbit blood plates were used as a differential media for anaerobic growth.32 These plates were cultured in the anaerobic chamber. The TSBV plates were cultured at 37°C in an atmosphere of C02.32 All plates were incubated between 5 and 7 days. After this time all positive cultures were characterized by Gram's stains and morphology determinations.

Statistical Analysis The incidence of positive bacteremias was tabulated for each of the experimental groups and analyzed statistically using the Fisher exact test. RESULTS

Thirty one subjects from 32 to 81 years of age, with a mean age of 63.0 years, participated in the study. One subject declined further participation after the initial blood draw and those data are not included. The probing depths of the pockets selected for irrigation ranged from 4 mm to 6 mm

of 5.6 mm. All sites scored a GI 2. This was the minimum level of inflammation required for a site to be included in the study. At least 1 bacteremia was detected at some time point in 15 out of the 30 subjects (50%) who completed the study. In 3 of these subjects (#1, 7, and 23), bacteremias were detected at different time points (Table 1). Therefore, a total of 18 bacteremias were detected during the course of the with

a mean

study (Table 2).

=

Out of the 10 subjects in the CHX group, bacteremia was detected in 5 subjects (50%) after irrigation (#2, 7, 10, 16,

Volume 62 Number 10

LOFTHUS, WAKI, JOLKOVSKY, OTOMO-CORGEL, NEWMAN, FLEMMIG,

Table 1. Distribution of Bacteremia

Table 3.

Blood Draw Initial

Subject

(1st) CHX Irrigation 2 6 7 10

Microbiologie

After

Before

Irrigation (2nd)

Scaling (3rd)

Scaling (4th)

7 23

CHX CHX

No No

2

CHX CHX CHX CHX CHX Water

After No No No No No Yes Yes

CHX

No

8

Control

15 22 23

Control Control CHX

30

CHX

Yes Yes No No Yes Yes Yes Yes Yes Yes No No No

+ -

+

+ +

-

13

7 10 16 27

-

-

16 21 23 27 30

+ -

1

+ -

+

Water 1

Irrigation -

12 14 17 19 24 26 28

-

-

-

-

Water

-

-

Scaling/Root Planing Only

5

3 4 8 11 15 18 20 22 25 29

CHX

Irrigation (2nd)

Chlorhexidine

+ + -

+ +

+ +

Scaling (3rd) +

Scaling (4th)

+

+

+ +

Metabolism

Rods Cocci

Facultative Facultative

Rods Cocci Rods Rods Rods Cocci Rods

Facultative Facultative Anaerobic

Rods

Facultative

Cocci Rods Rods Cocci Cocci Rods Cocci Rods Cocci Rods Rods Cocci Cocci

Facultative Facultative Facultative Facultative Anaerobic Anaerobic Facultative Facultative Facultative Facultative Facultative Facultative Facultative

Facultative Facultative Facultative Facultative

gluconate (0.12%) irrigation group

experienced a bacteremia pre-scaling and did demonstrate another bacteremia either post-irrigation or post-scaling. This may represent either a contaminant or a CHX group not

background bacteremia from another source. In the sterile water irrigation group, bacteremia was detected in 1 subject out of 10 (10%) after irrigation (#1) and in 4 subjects (40%) after S/RP (#1, 5, 19, and 28). Subject #1 experienced 2 qualitatively similar bacteremias after both irrigation with sterile water and scaling. Both were true

= =

-

=

=

(0.12%).

Table 2. Incidence of Bacteremia

Type of Irrigation Blood Draw Initial After irrigation Before S/RP After S/RP Total

(1st) (2nd) (3rd) (4th)

CHX 2 5

Water 0 1

Total 2 6

1 2 10

0 4 5

1 9 18

Control 0

Value* 0.237 0.141 0.500 0.880

'Fisher exact test. CHX Chlorhexidine gluconate (0.12%). S/RP Scaling and root planing. =

=

27) and in 2 other subjects (20%) after S/RP (#23 and 30). Two subjects in the CHX group also presented with a "background" bacteremia (#7 and 23). Subject #7 had a subsequent qualitatively different bacteremia after irrigation, while subject #23 had a subsequent qualitatively different bacteremia after scaling. The latter was a polymicrobic bacteremia, i.e., demonstrating 2 or more organisms from a single blood culture. An additional subject (#6) in the and

=

+

Bacteremia detected. No bacteremia detected. * Polymicrobic bacteremia. CHX Chlorhexidine gluconate +

Water Water Water

19 28

Morphology

+

After

+*

5 9

Gram Stain Initial (1st)

Before

-

-

605

Characteristics of Bacteremias

Subject Group Polymicrobic After

NACHNANI

polymicrobic. The non-irrigated control group had 3 bacteremias (30%) after S/RP (#8, 15, and 22). One (#8) was polymicrobic. Overall, 6 out of 20 irrigated subjects (30%) and 9 out of 30 S/RP subjects (30%) experienced a bacteremia after manipulation. Three subjects also experienced "background" bacteremias giving a total of 18 bacteremias. Five specimens were polymicrobic yielding 2 isolates each, resulting in 23 total isolates. Gram-positive rods comprised

34.8% of these isolates. Gram-positive cocci, 34.8%; Gramnegative rods, 21.7%; and Gram-negative cocci, 8.7% (Table 3). Analysis of the data using the Fisher exact test revealed that there was no statistically significant difference between the incidence of bacteremia caused by irrigating with CHX versus sterile water (P 0.141). Similarly, there were no differences in the incidence of bacteremia after significant and between root the CHX, sterile water scaling planing and control groups (P 0.88) (Table 4). =

=

606

BACTEREMIA FOLLOWING

Table 4. Statistical

Analysis of the

Bacteremia After CHX No 5 Yes 5

Irrigation (n

Bacteremia After CHX No 8 Yes 2

Scaling and

Water

Incidence of Bacteremia*

Root Water 6 4

=

Planing (n

=

Control

0.141

30)

7 3

ROOT PLANING

=

0.88

gluconate (0.12%) irrigation group

DISCUSSION The results of this study suggest that a single subgingival irrigation of inflamed periodontal pockets with 0.12% CHX is not associated with a lower incidence of bacteremia when compared to sterile water irrigation. Additionally, when these same pockets were scaled and root planed 30 minutes later, no difference in the incidence of bacteremia was noted between the 2 irrigated groups or with the non-irrigated control group. Prior irrigation with sterile water or CHX did not appear to have an effect on bacteremia during S/RP. The observation of bacteremias in 6 of the 20 subgingival irrigation subjects (30%) and in 9 of the 30 subjects (30%) who were scaled and root planed demonstrates that both procedures can cause bacteremias in individuals with inflamed pockets (Table 2). This observed incidence is in agreement with a number of studies on bacteremia after dental manipulation, although the reported incidence varies greatly from 2% to 80%.22'33"41 A number of factors may play a role in the ability to detect a transient bacteremia. These include the degree of periodontal inflammation, the quantity and makeup of the resident flora, scaling and root planing technique, the timing of blood sampling, and methods of specimen collection and culturing. All blood draws were done 2 minutes after the initiation of either subgingival irrigation or scaling and root planing. A period of 1 to 2 minutes has been used as an appropriate interval in the majority of human bacteremia studies.22'3140 Note, however, that in this study the dental manipulation continues for 20 seconds in the case of subgingival irrigation and for 60 seconds with S/RP. This most likely continues to introduce bacteria into the bloodstream. The timing may be an important factor in determining the amount of bacteria recovered from the bloodstream and whether a bacteremia can be detected at all. In a healthy human, bacteria are cleared from the bloodstream rapidly. In a study on dogs the highest recovery rates were 30 seconds after the bacteremia was induced.42 The bacteria were usually cleared within 10 minutes and always within 20 minutes. Using an indwelling catheter to obtain serial specimens is impractical because once an individual experiences a bacteremia, the catheter must then be considered contaminated. For that reason, separate aseptic draws from fresh

J Periodontol October 1991

preferred. This method was used in the present investigation. In this study, the Septi-Chek blood culture system was used in conjunction with standard periodontal microbiological techniques. Together they provided comparable detection sensitivities to other published reports on bacteremia.22'31^0 The Septi-Chek blood culture system was shown to be an effective adjunct to conventional culturing techniques in detecting transient bacteremias after dental manipulation. The American Heart Association publishes guidelines periodically regarding antibiotic prophylaxis.20 Antibiotic prophylaxis is recommended in any patient with a cardiac condition that can increase their risk of developing bacterial endocarditis. Local disinfection of the gingival sulci by a variety of chemotherapeutic agents has shown promise in decreasing the incidence of bacteremia.2126 The present study found, however, that subgingival irrigation with CHX alone sites

20)

9 1

'Fisher Exact Test CHX Chlorhexidine =

=

IRRIGATION, SCALING, AND

are

of bacteremia relative to controls. Furthermore, the irrigation procedure itself was shown to cause a similar incidence of bacteremia as did scaling and root planing. In keeping with the current statement by the American Heart Association and the American Dental Association's Council on Dental Therapeutics, it is recommended that application of Chlorhexidine be used only as an adjunct to systemic antibiotic prophylaxis in patients at risk for endocarditis.20,43 Transient bacteremia is an acknowledged sequela to dental manipulation and is not known to pose any risk to healthy patients. Subgingival irrigation should be considered a safe procedure in healthy patients.

did not decrease the incidence water irrigation or non-irrigated

CONCLUSIONS 1. A single subgingival irrigation of an inflamed periodontal pocket with either 0.12% CHX or sterile water can result in a similar incidence of bacteremia as with other dental manipulations. 2. Irrigation of periodontal pockets with either 0.12% CHX or sterile water did not alter the incidence of bacteremia after scaling and root planing when compared to non-

irrigated periodontal pockets.

Acknowledgments

The authors would like to thank Robert Lijana, Procter and Gamble; Marsha Collins, Teledyne/Water Pik Co.; Roche Diagnostic Systems; and Jack Lee, D.D.S., Ph.D., statistical consultant. This study was supported in part by Procter & Gamble, Cincinnati, OH, USA and Roche Diagnostic Systems, Nutley, NJ. REFERENCES 1. Stambaugh RV, Dragoo M, 2.

Smith DM. The limits of subgingival scaling. Int J Periodontics Restorative Dent 1981; 1(5)30. Waerhaug J. Healing of the dento-epithelial junction following subgingival plaque control. II. As observed on extracted teeth. /

Periodontol 1978; 49:119.

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LOFTHUS, WAKI, JOLKOVSKY, OTOMO-CORGEL, NEWMAN, FLEMMIG,

3. Wilson TG, Jr., Glover ME, Schoen J, Baus C, Jacobs T. Compliance with maintenance therapy in a private periodontal practice. J Periodontol 1984; 55:468. 4. Greenstein G. Effects of subgingival irrigation on periodontal status. J Periodontol 1987; 58:827. 5. Pitcher GR, Newman , Strahan JD. Access to subgingival plaque by disclosing agents using mouthrinsing and direct irrigation. / Clin Periodontol 1980; 7:300. 6. Hardy JH, Newman HN, Strahan JD. Direct irrigation and subgingival plaque. / Clin Periodontol 1982; 9:57. 7. Richards JH. Bacteremia following irritation of foci of infection. / Am MedAssoc 1932; 99:1496. 8. Elliot SD. Bacteriaemia and oral sepsis. Proc R Soc Med 1939; 32:747. 9. Okell CC, Elliot SD. Bacteriaemia and oral sepsis with special reference to the aetiology of subacute bacterial endocarditis. Lancet 1935; 2:869. 10. Round H, Kirkpatrick HJ, Hails CG. Further investigations on bacteriological infections of the mouth. Proc R Soc Med 1936; 29:1552. 11. Bender IB, Selzer S, Tashman S, Meloff G. Dental procedures in patients with rheumatic heart disease. Oral Surg Oral Med Oral Patkol 1963; 16:466. 12. Korn NA, Schaffer EM. A comparison of the postoperative bacteremias induced following different periodontal procedures. / Periodontol 1962; 33:226. 13. Felix JE, Rosen S, App GR. Detection of bacteremia after the use of an oral irrigation device in subjects with Periodontitis. J Periodontol 1971; 42:785. 14. O'Leary TJ, Shafer WG, Swenson HM, Nesler DC, Van Dorn PR. Possible penetration of crevicular tissue from oral hygiene procedures: I. Use of oral irrigating devices. J Periodontol 1970; 41:158. 15. Tamimi HA, Thomassen PR, Moser EH. Bacteremia study using a water irrigation device. J Periodontol 1969; 40:424. 16. Romans AR, App GR. Bacteremia, a result from oral irrigation in subjects with gingivitis. J Periodontol 1971; 42:757. 17. Cates JE, Christie RV. Subacute bacterial endocarditis. A review of 442 patients treated in 14 centres appointed by the penicillin trials committee of the medical research council. Quart J Med 1951; 20:93. 18. Kelson SR, White PD. Notes on 250 cases of subacute bacterial (streptococcal) endocarditis studied and treated between 1927 and 1939. Ann Int Med 1945; 22:40. 19. Comroe BI, Collins LH, Crane MP. Internal Medicine in Practice. Philadelphia: Lea and Febiger, 1954:512. 20. Dajani AS, Bisno AL, Chung KJ, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. J Am Med Assoc 1990; 264:2919. 21. Winslow MB, Millstone SH. Bacteremia after prophylaxis. J Periodontol 1965 ; 36:371. 22. Rise E, Smith JF, Bell J. Reduction of bacteremia after oral manipulations. Arch Otolaryng 1969; 90:106. 23. Jones JC, Cutcher JL, Goldberg JR, Lilly GE. Control of bacteremia associated with extraction of teeth. Oral Surg Oral Med Oral Patkol 1970; 30:454. 24. Scopp IW, Orvieto LD. Gingival degerming by povidone-iodine irrigation: Bacteremia reduction in extraction procedures. / Am Dent Assoc 1971; 83:1294.

NACHNAN1

607

25. Francis LE, deVries J, Lang D. An oral antiseptic for the control of post-extraction bacteremia. / Can Dent Assoc 1973; 39:55. 26. MacFarlane TW, Ferguson MM, Mulgrew CI. Post-extraction bacteraemia: Role of antiseptics and antibiotics. Br Dent J 1984; 156:179. 27. Madsen KL. Effect of Chlorhexidine mouthrinse and periodontal treatment upon bacteremia produced by oral hygiene procedures. Scand J Dent Res 1974; 82:1. 28. Witzenberger T, O'Leary TJ, Gillette WB. Effect of a local germicide on the occurrence of bacteremia during subgingival scaling. / Periodontol 1982; 53:172. 29. Waki M, Jolkovsky D, Otomo-Corgel J, et al. Effects of subgingival irrigation on bacteremia following scaling and root planing. / Periodontol 1990; 61:405. 30. Löe H. The gingival index, the plaque index and the retention index systems. / Periodontol 1967; 38:610. 31. Lennette E. Collection, handling, and processing of specimens. In: Lennette E, ed. Manual of Clinical Microbiology. Washington, DC: American Society for Microbiology, 1985 ; 75. 32. Newman MG, Flemmig TF, Nachnani S, et al. Irrigation with 0.06% Chlorhexidine in naturally occurring gingivitis. II. 6 months microbiological observations. J Periodontol 1990; 61:427. 33. Hess J, Holloway Y, Dankert J. Incidence of postextraction bacteremia under penicillin cover in children with cardiac disease. Pediatrics 1983; 71:554. 34. Appleman MD, Sutter VL, Sims TN. Value of antibiotic prophylaxis in periodontal surgery. J Periodontol 1982; 53:319. 35. Loesche W. Indigenous human flora and bacteremia. In: Kaplan E, Taresky A, eds. Infective Endocarditis—An American Heart Association Symposium. Dallas: The American Heart Association, 1977: 40-43. 36. King RC, Crawford JJ, Small EW. Bacteremia following intraoral suture removal. Oral Surg Oral Med Oral Pathol 1988; 65:23. 37. Keosian J, Weinman I, Rafel S. The effect of aqueous diatomic iodine mouthwashes on the incidence of postextraction bacteremia. Oral Surg Oral Med Oral Pathol 1956; 9:1337. 38. Baltch AL, Schaffer C, Hammer MC, et al. Bacteremia following dental cleaning in patients with and without penicillin prophylaxis. Am Heart J 1982; 104:1335. 39. Rogosa M, Hampp EG, Nevin TA, Wagner HN, Driscoll EJ, Baer PN. Blood sampling and cultural studies in the detection of postoperative bacteremias. J Am Dent Assoc 1960; 60:171. 40. Hurwitz GA, Speck WT, Keller GB. Absence of bacteremia in children after prophylaxis. Oral Surg 1971; 32:891. 41. Conner HD, Haberman S, Collings CK, Winford TE. Bacteremias following periodontal scaling in patients with healthy appearing gingiva. J Periodontol 1967; 38:466. 42. Silver JG, Martin L, McBride BC. Recovery and clearance rates of oral microorganisms following experimental bacteremias in dogs. Archs Oral Biol 1975; 20:675. 43. Council on Dental Therapeutics; American Heart Association. Preventing bacterial endocarditis: A statement for the dental professional. J Am Dent Assoc 1991; 122:87. Send reprint requests to: Dr. John E. Lofthus, 4320 Genesee Suite 203, San Diego, CA 92117. Accepted for publication April 18, 1991.

Ave.,

Bacteremia following subgingival irrigation and scaling and root planing.

The purpose of this study was to determine the incidence of bacteremia after a single professional subgingival irrigation with a 0.12% chlorhexidine g...
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