CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
AFRICA
343
(16.1% positive),
22
Kinane
et al.
(3%)
32
and Forner
et al.
(10%)
33
but not in the studies by Sconyers
et al.
,
23
Berger
et al.
34
and
Hartzell
et al.
35
Streptococci were the predominant organisms
isolated in these studies as well as in our study.
In our study, bacteraemia was unrelated to oral health status.
The frequency of bacteraemia in the study by Bhanji
et al.
was
46%.
36
They found no correlation between the plaque and gingival
scores and the occurrence of bacteraemia. However, using
molecular techniques, Lockhart
et al.
reported that the cumulative
incidence of infective endocarditis-related bacteraemia was
22.5% and that the incidence was significantly related to the state
of oral hygiene and gingival disease parameters.
28
Chewing did not produce bacteraemia in our study. Similar
results were obtained by Robinson
et al.
37
in patients chewing
wax, and by Cobe
21
in patients chewing gum. On the other hand,
bacteraemia was detected after chewing bubble gum in 22%
of patients by Diener
et al.
,
38
after chewing paraffin in 55% of
patients by Murray and Moosnick,
39
after chewing hard candy in
17.4% of patients by Cobe,
21
and after chewing bubble gum in
20% of patients by Forner
et al
.
33
One patient in our study had a bacteraemia prior to dental
extraction. His plaque and gingival index scores were rated as
poor.
Bacillus fragilis
was isolated. Reith and Squier obtained
positive blood cultures from 12% of 99 patients with no
demonstrable focus of infection.
40
Okell and Elliott found
that 10.9% of 110 patients with pyorrhoeal disease had a
streptococcal bacteraemia before any operative procedures.
7
Rogosa
et al.
41
and Roberts
et al.
2
found positive blood cultures
unrelated to dental procedures.
In a study of different antibiotic regimens in the prevention of
bacteraemia after dental extraction , Diz Dios
et al.
reported that
positive blood cultures were present prior to the dental extraction
in all four of their study groups (range: 5–12.5%).
42
On the other
hand Cobe,
21
Peterson and Peacock,
19
and Hall
et al.
43
found no
growth in pre-procedure blood cultures.
Our study confirmed that bacteraemia occurs after tooth
brushing. In the past, emphasis was placed on antibiotic
prophylaxis prior to dental procedures, especially dental
extraction.
Only 4% of the 1 322 patients with infective endocarditis
studied by Guntheroth had extractions in the previous two
months.
8
He noted that bacteraemia occurred in 40% of patients
after dental extraction, in 25% after tooth brushing or oral
irrigation, and in 38% with normal chewing. He concluded that
in a hypothetical month ending with a dental extraction, the
number of exposures to bacteraemia is almost 1 000 times more
for ‘physiological sources’ (e.g. tooth brushing and chewing) than
from a dental extraction. He stated that the physiological sources
of bacteraemia would explain the occurrence of endocarditis
due to viridans streptococci in patients who did not have dental
extractions.
Roberts also reported that the cumulative exposure to
bacteraemia from everyday procedures such as tooth brushing
was significantly greater than that following invasive procedures
such as dental extraction.
44
Conclusion
The emphasis in the prevention of infective endocarditis has now
shifted from the use of antibiotics prior to dental procedures
to the maintenance of good oral health in patients at risk of
developing infective endocarditis.
45,46
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