Oral MecJicine

Dental infections and general health

Jukka H. Mctirniati, MD, PhD, Dr Odonl'-'

Abstract The detrimental effect of focal infections on general health has been known for decades. Chronic dental infections may worsen the condition of medically c

Clinical relevance There may be pathogens among these, too, Egyptian physicians knew in 1500 BC that infections ofthe teeth Demographic ehange in all industrialized countries must be appropriately treated to avoid life-threatening has brought more elderly and medically com- complications. Thus, the principal task ofthe dental promised patients to the dentist than ever before in profession is to treat and prevent infections ofthe oral history. Furthertnore, dental diseases have been cavity. shown to be statistical risk factors for many systemic diseases, such as atherosclerosis. Dentogenic bacteremia Dentogenic bacteremia follows dental extractions, periodontal treatment, and endodontic treatment in Introduction 17% to 100% of patients.- Bacteremia results after 55% of third molar surgeries bttt after 100% of normal The mouth is the habitat of hundreds of microbial extractions. The difference is probably due to the fact species. Just I mg of dental plaque may contain more that operative treattnent is perlbrmed as aseptically as than 10" microorganisms. Most oral tnicroorganisms possible, while no particular disinfection is applied in are harmless, but. if the patient's general condition is normal extraction. The oral bacteria cultivated from weakened for one reason or another, bacteria with the bloodstream of oral surgery patients may include normally low virulence may be detrimental. The corrunon periodontopathogens, such as Actinobacillus subgingival microfiora is mostly anaerobic, and most actlnomycetemcomitans. Pre vo tel la intermedia. Por- oral infections are caused by gram-negative bacilli. In phvromonas gingivalis. and Bacteroldesforsythus.^ The patients with periodontitis, anaerobes may account for niost well-known group, however, is the gratn-positive 90% ofthe tnicrofiora. of which 75% is gram negative,' viridatis streptococci. Cells ofthe endocardium and glomeruli are known * Prpfessor and Chair. I of Deniisiry. tjrtvcrsity of Helsinki, to cross-react with structural components of viridans Helsinki. Finland. streptococci, which makes the heart and kidney par- Reprint requcsls: Dr J. H Mcurman. Prufessor and Chain insliLute uf ticularly liable for infection by these ttticroorganisms in DenLisirs'. PO Box 41. FIN-00014. tjniversity of Helsinki. Heisinki, Finland. E-rraih Jjkka.Meurmiin^helsinki.fi certain disease conditions,''Antibiotic prophylaxis Is a

Quintessence International Volume 28, Number 12/1997 807 Meurman necessity in such patients before all denial procedures also been found to be affected by dental infections; likely to cause bleeding. Although endocarditis is those patients with exacerbations suflered more olten beyond the scope of this review, the following regimens from dental infections than did the patients whose are currently recommended for endocarditis prophy- disease was in remission,"* Clinical practice has laxis; amoxicillin. 3 g, I hour prior to treatment for the further shown that patients suliering from severe majority of patients: er>-thromycin. 800 mg. roxitro- arthritis may obtain relief from their symptoms after mycin. 300 mg, or clindamycin, 600 mg for patients eradication of dental infection foci. The pathogenic with penicillin allergy,^ mechanisms in these cases, however, are not fully There is a potential for hematogenic spread of oral understood, although respective pathogenic mechan- infections to the brain, heart, lungs, liver, kidney, hip isms have been suggested to play a role in arthritis joints, and knee joints, Dentogenic baeteremia is caused by intestinal bacteria," usually of short duration. Few bacteria can be culti- A more controversial issue is the dentogenic vated from the blood 10 minutes after invasive dental infection of joint prostheses and other artificial re- treatment, ln patients with chronic dental infections, placement parts of the human body. Lindqvist and however, frequent or continuous baeteremia may Slatis'- and Bartzokas and coworkers'-' have showti occur, and this can trigger both acute and chronic that hip and knee prostheses can become septically intlammations in other organs.*' infected from the mouth. These findings emphasize the need for accurate diagnosis and treatment of all potential foci of oral infection before joint operations. Dental ¡ufectious in medically compromised patieuts However, present recommendations concerning the use of antibiotics in dental treatment do not call for Patients are rendered medically compromised by the routine prophylaxis in these patients,'"' Nevertheless, following diseases, conditions, or attributes: when patients with joint prostheses are treated for 1. Cardiovaseular diseases dental infections, the possible presence of other 2. Chronic obstructive respiratory diseases underlying disease must always be taken into account. 3. Rheumatic diseases Antibiotic prophylaxis is recommended in connec- 4. Diabetes tion with periodontal or endodontic treatment, for 5. Psoriasis example, of patients who suffer from renal, rheumatic, 6. Severe arthritis or liver diseases, and/or who undergo immunosup- 7. Chronic infiammatory bowel diseases pressant therapy. The prophylaxis is particularly im- 8. Cancer portant to patients who have undergone surgery less 9. Immunosuppiessant medication than 6 months earlier. The artificial replacement parts 10, Organ transplants of the body become lined with endothelium within 11. Elderly with multiple diseases 6 months: during that period, baeteremia should be avoided and extensive dental treatment should be Dental infections are particularly harmful in patients postponed. The same holds true with all endopros- undergoing treatment for cancer. It has been estimated theses, ailificial blood vessels, and liquor shunts. In that septicemia during immunosuppression may orig- ail these patient groups, however, the daily main- inate from the oral cavity in 25% to 30% of cases, *" tenance of good oral hygiene and eradication of Lainc and coworkers^ found that septic episodes potential foci of infection in the mouth are more during anticancer chemotherapy were significantly important than antibiotic prophylaxis before dental more common in lymphoma patients who had had treatment. Patients with pacemakers do not need infection foci in the jaws before onset of treatment. antibiotic prophylaxis before dental treatment. The frequency of septic episodes could be reduced by application of antiseptic mouthwashes,'' Other immunosuppressed patients among whom The elderly—A potential risk group of increasing dental infections are known to be harmful include those with an organ transplant, severe rheumatic importance diseases, psoriasis, or diabetes. These patients all must The number ofthe elderly is increasing in all industri- maintain good oral health to prevent worsening of alized countries,'" Old age is unavoidably linked with their general disease. Patients suflering from Crohn's systemic diseases and with weakening ofthe physio- disease (a chronic inflammatory bowel disease) have logic defense mechanisms of the body. This may be

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manifested in the mouth as decreased salivary secre- Diagnosis of dentogenic infections and treatment tion, which, however, is most often caused by systemic strategies medication.'*' The prevalence of oral diseases is increased, increasing the need for preventive theiapy, The clinician must, above all. remember that the oral too. Dental prostheses fuaher complicate the oral cavity is a potential source of infections. The more environment, causing, for example, an increase in severe the patient's systemic disease, the more import- yeast growth, which may cause mucosal infeciions,"" am it is to avoid any infections. Such patients should All these aspecis indicate the need for focusing dental see the dentist on a more frequent basis than Ihe efforts toward treatment ol the elderly, who are in more healthy ones. Dental personnel should also examine need of treatment than children and the youngj* patients in hospital and geriatric wards and refer those in need for treatment. Chronic dental infections may be symptomlebs; therefore, it is the dentist's responsibility to diagnose Denlogenic infections and atherosclerotic diseases them properly. Panoramic radiography is a necessity In 1908. British doctors W Osier and T. McCrae for this. The most commonly encountered important suggested that infections may be detrimcntai to ihe dental infections include; heart. Mattila and coworkers'' found, in Finland, that patients with cardiac infarction have significantly more 1. Periapical abscesses (also, deep carious lesions) dental infection foci than their age- and sex-matched 2. Periodontal abscesses controls. This finding has been confirmed hy DeSte- 3. Deep vertical periodontal bone pockets (exceeding fano and coworkers,'^ in their case-control analysis 6 mm in probing depth I from the United States. Syrjänen and coworkers'" 4. Furcation lesions of multirooted teeth investigated stroke patients and showed that even 5. Pericoronitis of erupting or retained teeth (in brain infarction is associated with an increased number particular at third molars) 6. Cysts of the jaws of foci of dentogenic infection. Tooth Ioss resulting 7. Mucosal ulcers from periodontal disease may be associated with an increased risk of coronary heart disease.-'^ The dentist must thoroughly examine the patient's Thrombocjtic aggregation and adhesion are known oral mucosa and adjoining tissues, such as temporo- to increase in septic patients, causing a concomitant mandibular joints, salivary glands, etc. Deep carious deerease in antithrombin III. C-, and S-protein levels, lesions and severe gingivitis and/or periodontitis must which leads to impaired function of the fibrinol^lic be recorded, too. Mucosal ulcers or inflamed mucosal mechanisms. Intiammation disturbs the metaboiism of hypertrophy caused by ill-fitting dentures are other lipoproteins and sugar further affecting thrombocytes examples of problems to be recorded. Edentulous and blood coagulation.-' The presence of fihrinogen, patients are not immune to oral infections and must be an acute phase protein, increases in bacterial infec- examined accordingly. tions, and it has been shown to increase also in Because saliva is the principal defense system ofthe periodontal infections." StreptuciKcus sanguis has mouth, and many patients with systemic disease suffer been shown to aggregate thrombocytes,'-^ and this from dry mouth, salivary flow rates must be assessed. bacterium is known to play an important role in Both unstimulated and stimulated saliva must be dentogenic bacteremias. too.-* measured. The less saliva, the worse are the circum- The above-cited literature clearly indicates that oral stances in the mouth. The reader is referred to another bacteria indeed are potentially harmful when spread text for more information.-' The patients subjective into the bloodstream. Although the precise mechan- feeling of xerostomia is not necessarily corroborated isms by which these microbes cause their side effects by objective findings. (leading even to atherogenesis) are not known, caution Artificial saliva substitutes and saliva-stimulating should be taken in dental treatment planning for lozenges may be of help in relieving symptoms of dry patients with thromboembolic complications. There is mouth and controlling ovei^rowth of yeasts. In xero- evidence to show that even low-grade chronic dental stomic patients, the general degree of hydration is the Itifections are potential foci in this respect and should most important factor. Consequently, patients with be regarded as risk factors for coronary heart disease reduced saliva secretion must be advised to drink and other atherosclerotic complications,-'' enough fluids, preferably water. Severely ill patients

Quintessence International Volume 28, Number 12/1997 309 Meurman

are ölten Linwilling lo drink, and they become dehy- 5, Submandibular, submental, or parapharyngcal ab- drated. Sour and sugar-containing Juices and beverages scess should be avoided in patients with reduced saliva ilow Maintenance of good oral hygiene on a daily basis to avoid their detrimental ellecl on dental health,-'' is the most essential part in the oral health care of Strategy for the trealnient oforal infections depends medically compromised patients. Comprehensive pre- on the patient's general health and the severity of the ventive care, including fluorides, restriction of fre- underlying syslemic disease. For example, cancer quent intake of carbohydrates, eventual chemotherapy patients referred for radiotherapy to the head and neck of dental plaque with antiseptic preparations, and, must be treated with the greatest urgency and care so above all. the daily mechanical cleaning of the teeth, that no potential foci are left in the jaws. This prostheses. and mucosal membranes, must not be sometimes calls for total eradication of the teeth. Two forgotten. Properly advised home care of the patient is weeks are needed for wounds to epithelialize in the the cornerstone of therapy. mouth; this time must be taken into account when the treatment is planned. On the other hand, a patient with rheumatic disease, eg. may benefit from endodontic treatment ofa single gangrenous tooth that has been symptomless and has not been diagnosed before a References radiograph was taken. 1. Williams R. Pcriodonlal disease. NEnglJ Med l99O:.T22:373-382, Antibiotics are often prescribed as an adjunct to the 2. Heinidahl A, Hall G. Hedberg M. Sandberg H, Söder P. Tuner K. dental treatment in medically compromised patients. Nord C. Detection and quantitation by lysis filtration of bactereraia In many cases, the threshold for prescribing antibiotics after different oral surgical procedures J Clin Microbiol 1990; is. and must be. lower in patients sutfering from 2N:22O5-233(). ,1. Dehelian GJ, Olsen 1. Tronstód L, Systemic diseases caused by (irai systemic disease than in healthy patients. For example, micro-organisms, Endod Dent Traumatol 1994:IO:.')7-65 for endodontic treatment of a gangrenous tooth, a 4. Durack DT. Beeson PB, Pathogenesis of infective endocarditis. In: patient suffering from uncontrolled insulin-dependent Rahimtoola SH ¡ed). Infective Endocarditis, New York: Grune & diabetes is more in need of systemic antibiotics than an Stratton. 1978:1-17. elderly patient with stable angina pectoris and minor Durack DT. Prevention jf Enfectii carditis N Engl J Med 1995:332:38-44. anhritis of the knees. Cardiac bypass patients, do Peterson LJ. Principles of management and prevention of odonto- not need antibiotic prophylaxis, but if the patient's genic infections. !n: Peterson Li, Eliis E III, Hupp JR. Tucker MR systemic disease is not in balance, antibiotics may be (eds). Contemporaiy Orai atid Maxillofaciai Surgery. St Louis; Mosby-Year Book, 1993:409-435. prescribed as an adjunct to dental therapy. Penicillin is Bergmann O Oral infections and septicaemia in i mmunoco m pro- the drug of choice for all these patients. When the mised patients with hematoiogic maiignancies. 3 Clin Microbiul dentist is unsure, the patient's physician must he 1988:25 2105-2109, consulted. Laine P, Lindqvist C. Pyrhónen S, SI rand-Petti ne n I, Teerenhovi L, Meurman ¡H. Oral infections as a reason for febrile episodes in The main principle in treating dentogenic infec- lyniphoma patients receiving eytostatic drugs. Oral Oncol Eur J tions, however, remains that these infections do not Cancer 1992:286:103-107. Laine P. Oral Findings in Lymphonra Patients During Cyloitatic heal with antibiotics. The foci must be surgically Chemotherapy |thcsis|. University of Helsinki Printing House, 1993. eradicated by appropriate periodontal or endodontic Halme L. Meurman 3H. Lame P, von Smitten K. Syrjänen S. therapy, resection, extraction, or whatever is the Lindqvist C, Strand-Pettinen 1. Oral findings in patients with active treatment of choice in a particular case. In some or inactive Crohn's disease, Orai Surg Oral Med Oral Patliol 19^3: 76:175-181, emergency cases, patients must be referred to the AlbaniS, Ravelli A. Massa M. De BenottiF, Andrée G.RoudrerJ. et hospital for oral and maxillofaciai surgical treatment: al, I mmu no responses to the £'si-/;ef(V/(fafo/idna3 heat shock protein in juvenile rheumatoid arthritis and their correlation with disease 1, High septic fever that probably is caused by activity. 3 Pediatr ¡994:i24:5OI-5O5. oral/dental infection Lindqvist C, Slätis P, Dental bacteremia—A neglected cause uf anhroplastic infections. Acta Orthopcd Scand 1985;56:.S06-508, 2, Trismus caused by infection Bartioltas C, Johnson R, Jane M. Martin M. Pearce P. Saw Y 3, Breathing or swallowing difTiculties resulting from Relation between mouth and hematogenous infection in total joint infection replacement. Br Med J 1994:309:506-508. 4, Facial or submandibular edema that does not Cawson RA. Antibiotic prophylaxis for dental treatment. Eor heans subside in spite of adequate local treatment such as but not for prosthetic joint Br Med J i992;304:933-934. EtLinger RL, Aging-A global issue, J Dent Res 1995:74:724-726. tooth extraction, incision, or endodontic treat- Närhi TO. Ainamo A, Meurman 3H. Saiivary yeasts, saliva and oral ment mucosa in the elderly, J Dent Res i993;72:1009-1014,

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17. Mattila K., Nieminen M. Valionen V, Rasi V, Kesjniemi A, Syrjdta S. et al. Asaocialion belween dental health and acute myocardial How to order from infarction. Br Med J l98<);298;779-782. Quintessence IS. De Stefano M, Anda RF, Kalin FIS. Williamson D. Rüssel C. Dental disease and risk of eoronar> heart disease and nuiriality, Br Meil J I99.';3O6:688-69I. 19. Syrjänen J. Peltola J, Valtonen V. livanainen M, Kaste M, Huttunen 1-800-621-0387 tK. Dental infections in association with cerehral infaretions in (within USA & Canada) jBungand middle aged men. J Intern Med I989;225; 179-184. 2t). Joihipura KJ, Rinm EB, Douglas CW. Triehopoulos D, Ascherio A, 630-682-3223 Willett WC. Poor oral healih and coronar^' heart disease. J Denl Res t996J5:t63t-1636. 2t. Ernst E. Fibrinogen as a cardiovaseular risk factor—I me rre lal ion- ship wilh infections and inflammation. Eur Hearl J I993:l4(siippl K¡:82-88. 22. Lowe GD. Kweider M. Murray GD, Kinane D, MeGowan DA. Fibrinogen and dental disease—a coronary risk factor. In; Ernsi E, Koenig W. Lowe G. Meade T ledsl. Fibrinogen—A New Cardio- vascular Risk Factor. Vienna; BlackweM MZV Publications, 1992. 23. Her¿berg MC, tricksnn PR. Kane. Clawson D. Cla son C. HoffF. Píatele! interactive products of Slrvpimiictm tung if^ protoplasts. [email protected] Infecí Immun 199O;58;4117-4125. Web Site 24. Mattila KJ. Dental infeetions as a risk factor for acule rJial infarction. Eur Hearl J 1993;14lsuDpl KI:5l-53. http://www, quintpub.com 25. Edgar WM. O'Mullane DM. Saliva and Denial Heatih. Plymouth, England: Brilish Denial Association, 1990. 26. Meurman JH. Sorvari R, Pelttari A, Rylömaa I. Franssila S, Kroon L. Hospital mouth-cleaning aids may cause dental erosion. Spee Quintessence Publishing Co, Inc Care Dem I99fi;16:247-25O. Ö 551 North Kimberly Drive quinle//«ncc Carol Stream, IL60188-1881 booh/

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