Bacteremia Associated With Toothbrushing and Dental Extraction

TLDR

Infective endocarditis prophylaxis guidelines rely partly on dental procedure–induced bacteremia studies, yet toothbrushing may generate a greater bacterial load. This double‑blind, placebo‑controlled trial compared the incidence, duration, nature, and magnitude of endocarditis‑related bacteremia from single‑tooth extraction versus toothbrushing and assessed the effect of amoxicillin prophylaxis. Blood samples were collected at six time points before, during, and after the interventions, and bacterial cultures focused on species known to cause infective endocarditis. Among 290 participants, 32 of 98 identified species were endocarditis‑causing, with cumulative bacteremia incidence of 23 % for toothbrushing, 33 % for extraction with amoxicillin, and 60 % for extraction with placebo; amoxicillin significantly reduced positive cultures, but toothbrushing still posed a greater overall risk.

Abstract

Antibiotic prophylaxis recommendations for the prevention of infective endocarditis are based in part on studies of bacteremia from dental procedures, but toothbrushing may pose a greater threat. The purpose of this study was to compare the incidence, duration, nature, and magnitude of endocarditis-related bacteremia from single-tooth extraction and toothbrushing and to determine the impact of amoxicillin prophylaxis on single-tooth extraction.In this double-blind, placebo-controlled study, 290 subjects were randomized to (1) toothbrushing, (2) single-tooth extraction with amoxicillin prophylaxis, or (3) single-tooth extraction with identical placebo. Blood was drawn for bacterial culturing and identification at 6 time points before, during, and after these interventions. The focus of our analysis was on bacterial species reported to cause infective endocarditis. We identified 98 bacterial species, 32 of which are reported to cause endocarditis. Cumulative incidence of endocarditis-related bacteria from all 6 blood draws was 23%, 33%, and 60% for the toothbrushing, extraction-amoxicillin, and extraction-placebo groups, respectively (P<0.0001). Significant differences were identified among the 3 groups at draws 2, 3, 4, and 5 (all P<0.05). Amoxicillin resulted in a significant decrease in positive cultures (P<0.0001).Although amoxicillin has a significant impact on bacteremia resulting from a single-tooth extraction, given the greater frequency for oral hygiene, toothbrushing may be a greater threat for individuals at risk for infective endocarditis.