Intravenous amoxicillin/clavulanate for the prevention of bacteraemia following dental procedures: a randomized clinical trial.

OBJECTIVES: Although controversy exists regarding the efficacy of antibiotic prophylaxis for patients at risk of infective endocarditis, expert committees continue to publish recommendations for antibiotic prophylaxis regimens. This study aimed to evaluate the efficacy of four antimicrobial regimens for the prevention of bacteraemia following dental extractions. METHODS: The study population included 266 adults requiring dental extractions who were randomly assigned to the following five groups: control (no prophylaxis); 1000/200 mg of amoxicillin/clavulanate intravenously; 2 g of amoxicillin by mouth; 600 mg of clindamycin by mouth; and 600 mg of azithromycin by mouth. Venous blood samples were collected from each patient at baseline and at 30 s, 15 min and 1 h after dental extractions. Samples were inoculated into BACTEC Plus culture bottles and processed in the BACTEC 9240. Conventional microbiological techniques were used for subcultures and further identification of the isolated bacteria. The trial was registered at ClinicalTrials.gov with ID number NCT02115776. RESULTS: The incidence of bacteraemia in the control, amoxicillin/clavulanate, amoxicillin, clindamycin and azithromycin groups was: 96%, 0%, 50%, 87% and 81%, respectively, at 30 s; 65%, 0%, 10%, 65% and 49% at 15 min; and 18%, 0%, 4%, 19% and 18% at 1 h. Streptococci were the most frequently identified bacteria. The percentage of positive blood cultures at 30 s post-extraction was lower in the amoxicillin/clavulanate group than in the amoxicillin group (P < 0.001). The incidence of bacteraemia in the clindamycin group was similar to that in the control group. CONCLUSIONS: Bacteraemia following dental extractions was undetectable with amoxicillin/clavulanate prophylaxis. Alternative antimicrobial regimens should be sought for patients allergic to the ß-lactams.

Comparative efficacies of amoxicillin, clindamycin, and moxifloxacin in prevention of bacteremia following dental extractions.

We evaluated the efficacies of oral prophylactic treatment with amoxicillin (AMX), clindamycin (CLI), and moxifloxacin (MXF) in the prevention of bacteremia following dental extractions (BDE). Two hundred twenty-one adults who required dental extractions under general anesthesia were randomly assigned to a control group, an AMX group, a CLI group, and an MXF group (the individuals in the drug treatment groups received 2 g, 600 mg, and 400 mg, respectively, 1 to 2 h before anesthesia induction). Venous blood samples were collected from each patient at the baseline and 30 s, 15 min, and 1 h after the dental extractions. The samples were inoculated into BACTEC Plus aerobic and anaerobic blood culture bottles and were processed in a BACTEC 9240 instrument. Subculture and the further identification of the isolated bacteria were performed by conventional microbiological techniques. The prevalences of BDE in the control group, AMX group, CLI group, and MXF group were 96, 46, 85, and 57%, respectively, at 30 s; 64, 11, 70, and 24%, respectively, at 15 min; and 20, 4, 22, and 7%, respectively, at 1 h. Streptococcus spp. were the most frequently identified bacteria in all groups (44 to 68%), with the lowest percentage being detected in the AMX group (44%). AMX and MXF prophylaxis showed high efficacies in reducing the prevalence and duration of BDE, but CLI prophylaxis was noneffective. As a consequence, MXF prophylaxis is a promising antibiotic alternative for the prevention of BDE when beta-lactams are not indicated.

[Cerebral abscesses of oral origin]. / Abscesos cerebrales de origen oral.

INTRODUCTION: It has been suggested that between 3% and 13% of the cerebral abscesses (CA) are presumably associated to oral infections or dental procedures. AIM: Determine the prevalence of CA of oral origin, discussing their clinical and microbiological characteristics. PATIENTS AND METHODS: Retrospectively, 54 cases of CA diagnosed in 3 hospitals of Galicia between 2001 and 2002 were reviewed. RESULTS: A presumed oral portal of entry was recorded in 6 patients (11.1%); 4 cases were associated to oral infections and the remaining 2 had received dental treatment in the months prior to the onset of symptoms. Half of the patients showed irrelevant medical record, 2 had had previous extracranial abscesses and 1 presented a type A immunoglobulin deficiency. In 4 cases, the microbiological analysis was positive and typical oral bacteria (Streptococcus viridans and Peptostreptococcus spp.) were identified. CONCLUSIONS: The results of this study suggest that a significant number of CA are probably of oral origin. In consequence, to maintain a good oral health status is important and specific prophylactic measures before any dental procedure should be applied, especially in patients with risk recognized factors.

Abscesos cerebrales de origen oral / Cerebral abscesses of oral origin

Introducción. Se estima que entre el 3 y el 13 por ciento de los abscesos cerebrales (AC) pueden originarse como consecuencia de infecciones orales o manipulaciones odontológicas. Objetivo. Determinar la prevalencia de los AC de origen oral en nuestro entorno mediante el análisis de sus características clínicas y microbiológicas. Pacientes y métodos. Se estudiaron retrospectivamente las historias clínicas de 53 pacientes diagnosticados de AC en tres hospitales de Galicia en 2001 y 2002. Resultados. En seis casos (11,1 por ciento), los AC se consideraron de origen oral; cuatro se asociaron a la presencia de un proceso infeccioso, y los dos restantes a una manipulación odontológica que se realizó en los meses previos al inicio de los síntomas. En la mitad de los pacientes no existían antecedentes médicos de interés; dos tenían un historial previo de abscesos extracraneales y uno presentó un déficit de inmunoglobulina A. En cuatro casos, el estudio microbiológico del absceso fue positivo, y se identificaron bacterias típicas de la flora oral ( Streptococcus viridans y Peptostreptococcus spp.). Conclusiones. Los resultados del presente estudio demuestran que la prevalencia de los AC de origen oral es significativa; en consecuencia, es importante mantener un buen estado de salud oral y aplicar medidas de profilaxis específicas antes de cualquier manipulación odontológica, sobre todo en pacientes con factores de riesgo reconocidos (AU)

Introduction. It has been suggested that between 3% and 13% of the cerebral abscesses (CA) are presumably associated to oral infections or dental procedures. Aim. Determine the prevalence of CA of oral origin, discussing their clinical and microbiological characteristics. Patients and methods. Retrospectively, 54 cases of CA diagnosed in 3 hospitals of Galicia between 2001 and 2002 were reviewed. Results. A presumed oral portal of entry was recorded in 6 patients (11,1%); 4 cases were associated to oral infections and the remaining 2 had received dental treatment in the months prior to the onset of symptoms. Half of the patients showed unrelevant medical record, 2 had had previous extracraneal abscesses and 1 presented a type A immunoglobulin deficiency. In 4 cases, the microbiological analysis was positive and typical oral bacteria (Streptococcus viridans and Peptostreptococcus spp.) were identified. Conclusions. The results of this study suggest that a significant number of CA are probably of oral origin. In consequence, to maintain a good oral health status is important and specific prophylactic measures before any dental procedure should be applied, especially in patients with risk recognized factors (AU)

Quantitative and functional neutrophil deficiencies.

Neutrophil is a cell involved in the maintenance of homeostasis of the organism. It plays an important role in the elimination and control of certain pathogenic microorganisms. Deficiency in function and quantity of neutrophils, either due to congenital or secondary etiological extrinsic factors, lead to recurrent infectious processes of variable severity. The most frequent oral complications in these patients are ulcers, periodontal disease and candidiasis. Due to their high susceptibility to infections and the risk implied in undergoing surgical procedures, actions leading to a higher degree of prophylaxis must be carried out on these patients (oral hygiene habits, fluoridation, dietary advise, etc.). The use of granulocyte colony-stimulating factors (G-CSF) allows, in some cases, the fullfillment of some, until recently considered controversial dental procedures. Its administration demands an adequate selection of patients and a close collaboration between physician and dental practitioner. Despite G-CSF effectiveness, dental treatment in severe neutropenic patients must be carried out in a hospital and, in some cases, regardless of adequate care, the progress of periodontal disease cannot be avoided.

Extraoral etiology of halitosis.

Halitosis is a frequent complaint which is estimated to be found in around 50 to 60% of the general population and that carries serious personal and social repercussions. Although the majority of cases are due to oral problems, it is considered that 10-13% of halitosis cases are of extraoral etiology. In these cases the responsibility of the general dental practitioner, who is frequently the first person to examine and treat these patients, is to refer the patient for evaluation to an otorhinolaryngologist in order to rule out the presence of chronic tonsillitis or chronic sinusitis. If the otorhinolaryngologist does not detect alterations concerning his specialty, the digestive system should be explored in order to detect gastric pathology, obstructions or inflammatory gastrointestinal processes, the liver to rule out hepatic insufficiency or cirrhosis, the endocrine system to exclude diagnoses of diabetes or trimethylaminuria, the airways to rule out bronchiectasis or pulmonary abscesses, and the kidney to eliminate possible renal insufficiency. Finally, in the absence of any systemic organic pathology, the possibility of halitosis of psychiatric etiology, which requires the patient's psychological profile to be checked by the corresponding specialist, should be considered.

Etiología extraoral de la halitosis / Extraoral etiology of halitosis

La halitosis constituye una "queja" bastante frecuente, cuya prevalencia se estima en torno al 50-60 por ciento de la población general, que conlleva importantes repercusiones a nivel personal y social. Aunque en la mayoría de los pacientes responde a causas órales, se considera que en el 10-13 por ciento de los casos la halitosis es de etiología extraoral.En estos casos, la responsabilidad del odontólogo, que es con frecuencia el primero en examinar y tratar a estos pacientes, es derivar al paciente para ser evaluado inicialmente por un otorrinolaringólogo, que descarte la presencia de tonsilitis crónica o sinusitis crónica. Si éste no detecta alteraciones concernientes a su especialidad, deben explorarse: el aparato digestivo, con el fin de detectar patología gástrica, obstrucciones o procesos inflamatorios gastrointestinales; el hígado, para excluir una insuficiencia o cirrosis hepática; el sistema endocrino, para descartar el diagnóstico de diabetes o trimetilaminuria; la vía aérea, para excluir bronquiectasias o abscesos pulmonares, y finalmente el riñón, para eliminar una posible insuficiencia renal. Por último, en ausencia de patología orgánica sistémica, se debe considerar la posibilidad de una halitosis de etiología psiquiátrica, que requerirá una evaluación del perfil psicológico del paciente por el especialista correspondiente (AU)

Intra-alveolar granulocytic sarcoma developing after tooth extraction.

Granulocytic sarcoma (GS) is a malignant tumour composed of poorly differentiated myeloid cells forming in an extramedullary site. It is generally associated with acute leukaemia, particularly the myelocytic type. Its appearance in patients with chronic myeloid leukaemia is exceptional. GS can appear in multiple locations with the oral cavity being rarely involved. A mandibular GS detected in a patient with chronic myeloid leukaemia 10 days after a tooth extraction is reported. The pathogenesis (by metastatic cells or migration through the Haversian canals) of the tumour is discussed.

Tooth extraction in HIV sero-positive patients.

Tooth extraction is the dental treatment most commonly carried out among HIV positive patients. In this paper we propose a simple protocol for dental extractions in patients of this type, based on a review of the literature and on our own experience in this field. The factors to be considered when planning a dental extraction for HIV positive patients are: diagnosis of the lesion justifying the need for tooth extraction and medical assessment of the patient including the infection pathway, the stage of the disease, laboratory tests and drug therapy. The most frequent post extraction complications are a delay in the wound healing process, alveolitis and surgical wound infection. Fortunately, these complications tend to be rather uncommon and not too severe; they can be managed on an out-patient basis and their prevalence will probably tend to decrease with the introduction of the new anti-retroviral drugs for HIV-1.

Fluconazole response patterns in HIV-infected patients with oropharyngeal candidiasis.

A prospective study to assess the efficacy of fluconazole in oropharyngeal candidiasis in patients with HIV was conducted. A cohort of 30 HIV-positive persons with clinical and microbiologic confirmed oropharyngeal candidiasis (Candida albicans > 1000 CFU/ml) received fluconazole 100 mg daily for 7 days. In vitro antifungal susceptibility tests demonstrated a lack of fluconazole resistances. Cultures of mouth swabs were performed at the end of therapy and 2 weeks later. There was a clinical and microbiologic cure in 26 patients (87%). In 10 of these 26, cultures remained negative after 2 weeks; most of them had CD4 lymphocyte count > 400/ml. In the other 16 patients (53%), cultures showed a microbiologic relapse 2 weeks after treatment. In spite of clinical improvement, treatment failure was observed in four patients, all of them with CD4 lymphocyte count < 50 ml.

Functional consequences of partial glossectomy.

The postsurgical deglutition, oral suction, and speech capabilities of 11 patients who had undergone partial glossectomy for squamous cell carcinoma of the lateral aspect of the tongue were compared with that of 20 healthy control subjects. Volume swallowed per second and speech quality were significantly correlated with the area of tongue removed. Three patients subjected to a second operation to improve the mobility of the residual tongue regained almost normal speech intelligibility. In general, functional performance was better than expected, which justifies a radical surgical approach to this kind of tumor.

[A implant-supported auricular prosthesis]. / Prótesis auricular implantosoportada.

A case lf auricular reconstruction of a traumatically missing right ear in a 31-years-old woman is reported. Surgical and prosthetic procedures are described. This experience indicates that it is possible to retain an auricular prosthesis with osseointegrated implants and maintain a reaction-free skin penetration.