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Characterization of Streptococcus constellatus strains recovered from a brain abscess and periodontal pockets in an immunocompromised patient.

BACKGROUND: There have been a number of reports of brain abscesses suggesting an odontogenic etiology. However, no efforts have been made to compare brain abscess isolates with isolates from the oral cavity using highly discriminative methods. We report a brain abscess caused by Streptococcus constellatus in an immunocompromised patient where oral infection (periodontitis) was suspected to be implicated. METHODS: The brain abscess and oral isolates were compared by means of one phenotypic and three genetic (restriction fragment length polymorphism [RFLP], ribotyping, and random amplified polymorphic DNA [RAPD]) fingerprinting techniques. RESULTS: The phenotypic method and RFLP showed identical profiles between brain and periodontal isolates, while ribotyping and RAPD showed very close similarity, with only one band difference in one of the three ribotypes and in one of the three polymorphic RAPD. CONCLUSIONS: Gene transfer by genetic recombinational events in the periodontal pocket might have been responsible for the emergence of a strain variant of S. constellatus that had the potential to cause an abscess at a distant site (brain). The importance of odontogenic sources as potential foci of infection for brain abscesses is discussed.

Brain Abscess↗

Direct detection of Prevotella intermedia and P. nigrescens in suppurative oral infection by amplification of 16S rRNA gene.

A specific 16S rDNA PCR and subsequent hybridisation reaction was designed to discriminate between strains of Prevotella intermedia (n = 15) and P. nigrescens (n = 15). This technique was then used to detect the presence of these two bacterial species in acute suppurative oral infection. A total of 36 pus samples aspirated from 26 peri-apical abscesses, three root canals, three periodontal abscesses, two cases of refractory periodontitis, one cyst and one haematoma was examined. A portion of the pus sample was processed by PCR and the remainder of the specimen was subjected to routine culture. The PCR-based technique gave an identical pattern of detection of P. intermedia or P. nigrescens to that obtained by culture for 30 of the 36 specimens. Either P. intermedia or P. nigrescens was present in 14 samples and neither species was detected in 16 samples. In the remaining six samples the PCR method indicated the presence of one (n = 3) or both (n = 3) of the Prevotella species but neither or only one species was isolated by culture. It is concluded that the presence of P. intermedia and P. nigrescens in pus can be detected rapidly and specifically by direct PCR amplification of 16S rDNA. P. nigrescens was detected more frequently than P. intermedia in suppurative peri-apical infection both by culture and PCR.

Bacteroidaceae Infections↗

Dental screening of pediatric cardiac surgical patients.

Dental screenings were completed on 209 pediatric patients six months and older that were scheduled for cardiac surgery from two different geographical locations. The screening involved an educational session on bacterial endocarditis and preventive dentistry followed by a dental examination. We found that sixty-two (30 percent) patients had seen a dentist regularly, ninety-three (44 percent) practiced daily oral hygiene and thirty-seven (18 percent) knew about bacterial endocarditis. Local dentists performed invasive procedures on seventy-one (34 percent) patients and thirty-four (48 percent) received antibiotic prophylaxis. Only twenty-three (68 percent) of the thirty-four patients received the then current American Heart Association antibiotic regimen. Dental disease was diagnosed in 175 (84 percent) of the 209 patients: 164 (78 percent) gingivitis; sixty (29 percent) caries; six (7 percent) dental abscess; three (1 percent) periodontal abscess; five (2 percent) periocornitis. Cardiac surgery was postponed in twenty-four (12 percent) patients. We conclude that parents lacked knowledge about bacterial endocarditis even after being informed during their routine cardiology visit, there appears to be a deficiency of knowledge among dentists regarding the indications and antibiotic regimen required to prevent bacterial endocarditis, and all cardiac surgical patients should have a dental exam and preventive dental program implemented prior to six months of age and dental screening prior to their cardiac surgery.

Abscess↗

Maxillary sinusitis and periapical abscess following periodontal therapy: a case report using three-dimensional evaluation.

BACKGROUND: Maxillary sinusitis may develop from the extension of periodontal disease. In this case, reconstructed three-dimensional images from multidetector spiral computed tomographs were helpful in evaluating periodontal bony defects and their relationship with the maxillary sinus. METHODS: A 42-year-old woman in good general health presented with a chronic deep periodontal pocket on the palatal and interproximal aspects of tooth #14. Probing depths of the tooth ranged from 2 to 9 mm, and it exhibited a Class 1 mobility. Radiographs revealed a close relationship between the root apex and the maxillary sinus. The patient's periodontal diagnosis was localized severe chronic periodontitis. Treatment of the tooth consisted of cause-related therapy, surgical exploration, and bone grafting. A very deep circumferential bony defect at the palatal root of tooth #14 was noted during surgery. After the operation, the wound healed without incidence, but 10 days later, a maxillary sinusitis and periapical abscess developed. To control the infection, an evaluation of sinus and alveolus using computed tomographs was performed, systemic antibiotics were prescribed, and endodontic treatment was initiated. RESULTS: Two weeks after surgical treatment, the infection was relieved with the help of antibiotics and endodontic treatment. Bilateral bony communications between the maxillary sinus and periodontal bony defect of maxillary first molars were shown on three-dimensional computed tomographs. The digitally reconstructed images added valuable information for evaluating the periodontal defects. CONCLUSION: Three-dimensional images from spiral computed tomographs (CT) aided in evaluating and treating the close relationship between maxillary sinus disease and adjacent periodontal defects.

Adult↗

Changes in the prevalence of subgingival enteric rods, staphylococci and yeasts after treatment with penicillin and erythromycin.

The changes in the balance of microbial flora in the periodontium after antibiotic treatment were investigated in a blind study. The prevalence of gram-negative enteric rods, staphylococci and yeasts was followed before and during penicillin or erythromycin treatment of 72 periodontitis patients without periodontal cleaning. The prevalence of subgingival coagulase-positive staphylococci increased significantly following systemic penicillin therapy. After systemic erythromycin therapy, the prevalence of subgingival gram-negative enteric rods increased. Ten of 24 (42%) patients receiving systemic penicillin therapy developed clinical evidence of periodontal abscesses. In the absence of conventional mechanical cleaning, systemic administration of penicillin and erythromycin antibiotic to patients with pre-existing periodontitis may lead to periodontal superinfection with opportunistic organisms.

Adult↗

Repeated metronidazole and amoxicillin treatment of periodontitis. A follow-up study.

BACKGROUND: The prevailing concept is that little or no clear benefit is derived from antibiotic therapy in chronic periodontitis. Studies to determine the effect of metronidazole plus amoxicillin (M+A) on adult periodontitis are questionable because standard design for clinical trials was usually not used. In addition, there is no information about the effect of M+A as the sole therapy for periodontitis. METHODS: A randomized, triple-blind, controlled clinical trial was used to determine the effect of systemic administration of M+A, as the sole therapy, in progressive adult periodontitis. Forty-six subjects with moderate to advanced adult periodontitis who showed > or =2 mm attachment loss in at least 2 sites in the previous 2 months were entered in the study. Subjects were randomly distributed to a group who received 21 tablets of metronidazole 250 mg plus amoxicillin 500 mg, or to a group receiving a placebo (1 tablet every 8 hours for 1 week). Patients were examined every 2 months for 12 months. The M+A or placebo regimen was repeated at 4 and 8 months. No effort was made to change the oral habits of patients and they received no additional therapy. Differences between groups were assessed using the Mann-Whitney U test. The differences at every 2-month interval within each group were assessed using the ANOVA test. RESULTS: Seven subjects abandoned the study; at 12 months the M+A group had 20 subjects and the placebo group 19. There were no significant differences in the clinical parameters at baseline between the 2 groups. After 2 months and thereafter, the M+A group showed significant clinical improvement while the placebo group showed a progressive deterioration of periodontal status. At 12 months compared to baseline, subjects of the M+A group showed: 1) a significant overall mean attachment gain of 0.43 mm (P = 0.005); 2) a significant decrease of active sites (P< or =0.03); 3) a significant increase of sites gaining attachment level (P< or =0.01); 4) a significant reduction of pocket depth (P< or =0.00006); and 5) a significant decrease in percentage of bleeding on probing sites (BOP) (P< or =0.0005). Significant differences between both groups at all 2-month evaluations were found in overall mean attachment level (P < or =0.000004), in percent of active sites (P< or =0.03), and in percent of BOP sites (P< or =0.02). Sites exhibiting > or =2 mm of attachment loss in 2 successive or alternate evaluations, and periodontal abscess were noticed only in the placebo group. CONCLUSIONS: A 1-week course of systemic M+A every 4 months, as the only therapy, arrests the progression of adult periodontitis and significantly improves the clinical parameters of the disease.

Adult↗

Serial doxycycline and metronidazole in prevention of recurrent periodontitis in high-risk patients.

The efficacy of metronidazole and doxycycline in preventing recurrent periodontitis was studied in 23 patients. After treatment in the previous 7 months with either bimonthly scaling and 3 weeks of systemic doxycycline (11 subjects) or scaling and placebo (12 subjects), patients were monitored for recurrent periodontitis and were scaled every 2 months. When either a periodontal abscess or greater than 2 mm loss of gingival attachment was observed, metronidazole was administered (250 mg every 8 hours) for 10 days. In the placebo plus metronidazole group, 5 patients (42%) exhibited recurrent periodontitis after the metronidazole regimen compared with only one (9%) in the doxycycline plus metronidazole group (P less than 0.096). Subgingival plaque samples at study and healthy control sites were screened for the presence of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Eikenella corrodens, and Fusobacterium nucleatum by immunofluorescence and for spirochetes using Ryu's stain. Presence/absence analysis of the sum of scores of the 6 individual pathogens demonstrated large reductions (P less than 0.005) in the frequency of detection of pathogens in the former doxycycline compared with the placebo plus metronidazole group at both study and control sites before and one month after metronidazole. By 7 months after metronidazole, there was no detectable difference between groups. These results indicate that prevention of recurrent periodontitis with metronidazole may be enhanced by previous treatment with doxycycline.

Bacteria↗

Detection of anaerobic odontogenic infections by fluorine-18 fluoromisonidazole.

Odontogenic infections are a potential risk for patients who receive cervicofacial radiotherapy and should be treated before irradiation. Anaerobic microbial infections are the most common causes. This study assessed the value of the hypoxic imaging agent fluorine-18 fluoromisonidazole (FMISO) in detecting anaerobic odontogenic infections. Positron emission tomography (PET) imaging was performed at 2 h after injection of 370 MBq (10 mCi) of FMISO in 26 nasopharyngeal carcinoma patients and six controls with healthy teeth. Tomograms were interpreted visually to identify hypoxic foci in the jaw. All patients received thorough dental examinations as a pre-radiotherapy work-up. Fifty-one sites of periodontitis, 15 periodontal abscesses, 14 sites of dental caries with root canal infection, 23 sites of dental caries without root canal infection, and seven necrotic pulps were found by dental examination. Anaerobic pathogens were isolated from 12 patients. Increased uptake of FMISO was found at 45 out of 51 sites of periodontitis, all 15 sites of periodontal abscess, all 14 sites of dental caries with root canal infection, all seven sites of necrotic pulp and 15 sites of dental caries without obvious evidence of active root canal infection. No abnormal uptake was seen in the healthy teeth of patients or in the six controls. The diagnostic sensitivity, specificity, positive and negative predictive values, and accuracy of FMISO PET scan in detecting odontogenic infections were 93%, 97%, 84%, 99% and 96%, respectively. 18F-fluoride ion bone scan done in three patients showed that 18F-fluoride ion plays no role in the demonstration of anaerobic odontogenic infection. FMISO PET scan is a sensitive method for the detection of anaerobic odontogenic infections, and may play a complementary role in the evaluation of the dental condition of patients with head and neck tumours prior to radiation therapy.

Bacteria, Anaerobic↗

Gingival sequela from a retained piece of dental floss.

A case was reported where a piece of dental floss broke and was retained in an interproximal area. The patient came to the clinic a few days later with a periodontal abscess. After the retained fragment of dental floss was removed, the abscess resolved. Therefore, a retained portion of dental floss should be immediately removed to prevent gingival irritation and tissue injury.

Adult↗

Osteomyelitis associated with chronic periodontitis: a report of three cases.

Correctly differentiating between periodontal abscess (localized, acute suppurative infection of the periodontium) and osteomyelitis (the extension of an infection into the bone medullary cavity) is crucial since the former may not require antibiotics for resolution, while the latter will. Initial assessment and treatment of osteomyelitis should be based on clinical examination, radiographic interpretation, and experience. Three case histories of osteomyelitis are presented, ranging from a periodontally well-localized case to one involving a hemimandible and crossing the midline. Successful early diagnosis and case management may benefit from scintigraphic interpretation and culture-and-sensitivity studies.

Adult↗

The radicular lingual groove: an overlooked differential diagnosis.

A periodontal abscess with symptoms simulating an endodontic problem is discussed. The diffculty of diagnosis, compounded by the apparent failure of endodontic treatment on an adjacent tooth, is described. This case history illustrates the importance of awareness of developmental defects in teeth and the potential problems that they pose.

Diagnosis, Differential↗

Microbial identification and antibiotic sensitivity testing, an aid for patients refractory to periodontal therapy. A report of 3 cases.

The importance of microbial surveillance is illustrated in 3 clinical cases. Each case demonstrated a continued lack of response to conventional periodontal treatment. Repeated bouts of periodontal abscess formation and bone loss occurred over a 3- to 4-year period, despite numerous surgeries supplemented with antibiotics. As a result, patients were termed refractory to treatment and extensive microbiological analysis and sensitivity testing was performed. Following institution of the appropriate antibiotic and conservative therapy consisting of several sessions of scaling and root planning, each of these cases demonstrated a dramatic remission of disease progression. No further breakdown has been seen for a minimum of 2 1/2 years. While anecdotal in nature, these cases support the usefulness of microbial identification coupled with antibiotic sensitivity as an adjunct to conventional conservative periodontal therapy.

Adult↗

Deep neck infection complicated by diabetes mellitus. Report of a case.

A poorly controlled diabetic patient who developed a life-threatening deep neck infection from a periodontal abscess is presented. Despite treatment reflecting the current surgical and medical approach to management of this infection, he failed to show the consistent improvement that would be expected in a nondiabetic patient. The physiologic differences in the defense systems of the diabetic versus the nondiabetic host are discussed, and general guidelines for identification of the diabetic patient are offered.

Diabetes Mellitus↗

Barodontalgia at 12,000 feet.

Persons susceptible to barodontalgia include those with peridontal abscesses, carious teeth, maxillary sinus congestion, or those who have had recent extractions or restorations. A 38-year-old man had acute pain while he was in a depressurized chamber. Treatment of a periodontal abscess alleviated the problem.

Aerospace Medicine↗

Dental dysplasia in rats and mice.

Malformations of the maxillary incisors, diagnosed as dental dysplasia, were observed as a spontaneous background lesion in 3% (females) to 9% (males) of CD-1 mice and 14.5% (females) to 10.5% (males) of CD (Sprague-Dawley) rats in a chronic inhalation study. Lesions were reported grossly as overgrown, maloccluded, or malformed incisors. Microscopic findings included tooth pulp and periodontal abscesses, fractured and necrotic teeth, periodontal cysts, malformations of the incisor roots, and expansile masses, including odontomas, of the incisor roots. Development of lesions followed a pattern of tooth pulp necrosis and/or traumatic disruption of the epithelial root sheath at the base of the tooth. Feeding a powdered ration, which reduced the normal wearing of the incisors, and repeated clipping of overgrown incisors were believed to contribute to the incidence of disease.

Animals↗