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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 8  |  Issue : 4  |  Page : 205-207

Investigation of bacteremia after separator placement


1 Department of Orthodontics, BJS Dental College and Research Institute, Ludhiana, Punjab, India
2 Department of Orthodontics, Maharaja Ganga Singh Dental College, Ganganagar, Rajasthan, India
3 Department of Conservative Dentistry, Christian Dental College, Ludhiana, Punjab, India

Date of Web Publication27-Dec-2016

Correspondence Address:
Anjuman Preet Kaur Dua
78-C, BRS Nagar, Ludhiana - 141 012, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-4003.196804

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  Abstract 

Background: Simple orthodontic procedure such as separator placement can be associated with the occurrence of transient bacteraemia. Use of clorhexidine before separator placement has been recommended as a measure to decrease the bacteraemia. Aim: The purpose of this study was to detect the presence of transient bacteremia after separator placement following use of 0.2% chlorhexidine gluconate mouthwash. Methodology: The study group consisted of 27 adult patients who reported for orthodontic treatment (18 males and 9 females). The patients were asked to rinse their mouth for 60 sec with 15 mL of 0.2% chlorhexidine gluconate mouthwash before the separator placement. An aseptic technique was used to draw out 5 ml of blood was from either the left or right antecubital fossa immediately before orthodontic separator placement (as control group), and the second 5 ml sample was taken 1–2 min after the placement of separators mesial and distal to all the first molars. All the blood samples were inoculated into culture bottles containing Brain Heart Infusion and incubated aerobically for 7 days. Media used for bacterial growth is chocolate agar and MacConkey agar. Results: From a total of 27 patients and 54 samples, none of the sample was found positive for bacteremia. Conclusion: This study demonstrated that there is no bacteremia after the placement of separators following the use of chlorhexidine mouthwash.

Keywords: Chlorhexidine, separator placement, transient bacteremia


How to cite this article:
Dua AP, Jaiswal AK, Dua K. Investigation of bacteremia after separator placement. Indian J Dent Sci 2016;8:205-7

How to cite this URL:
Dua AP, Jaiswal AK, Dua K. Investigation of bacteremia after separator placement. Indian J Dent Sci [serial online] 2016 [cited 2017 Jun 29];8:205-7. Available from: http://www.ijds.in/text.asp?2016/8/4/205/196804


  Introduction Top


Bacteremia is the presence of viable bacteria in the circulating bloodstream.[1] Transient bacteremia can be produced not only as a result of dental manipulation but also with daily life activities such as eating, brushing the teeth, or using toothpicks.[2],[3],[4] Orthodontic procedures that have been investigated for their association with the occurrence of bacteremia include alginate impression taking, band cementation, orthodontic debanding, orthodontic removable appliance placement, archwire change, and orthodontic interdental stripping.[5],[6],[7] Studies have also suggested that the placing of orthodontic separators may also be a potential source of odontogenic bacteremia.[8],[9] In healthy individuals, bacteremia resulting from dental procedures is transient as the immune system is able to eliminate the bacteria within 10–30 min, so they pose no danger to the participant.[10],[11] However, patients with congenital and acquired heart defects, prosthetic heart valves, and rheumatic fever have been known to be at risk of developing infective endocarditis from bacteremia of dental origin.

Following the recommendations of the British Cardiac Society, which states that antibiotic prophylaxis should be given to high- and moderate-risk groups for all dental procedures in which the incidence of bacteremia is statistically significant when compared with baseline, antibiotic prophylaxis should be given before separator placement. However, the National Institute for Health and Clinical Excellence does not advocate the use of antibiotic prophylaxis for any dental procedure as it does not eliminate the occurrence of bacteremia and causes adverse drug reactions and the development of resistant bacterial strains.[12] Therefore, the benefits of antibiotic prophylaxis need to be weighed against these side effects. There is evidence in the literature that antiseptic mouthwashes applied before dental manipulations may reduce the incidence and severity of bacteremia.[13],[14] Initially used as an antiseptic cream for skin wounds, chlorhexidine gluconate was introduced as a mouthwash by Löe and Schiot in 1970.[15] For the past three decades, many studies have substantiated the beneficial effects of chlorhexidine in plaque control.[16],[17],[18] Chlorhexidine mouthwash is commercially available in 0.12% and 0.2% concentrations. Use of chlorhexidine before separator placement has been recommended as a measure to decrease the bacteremia.[19] Hence, the purpose of this work was to record the presence of bacteremia after placement of orthodontic separators following the use of chlorhexidine mouthwash.


  Materials and Methods Top


The study group consisted of 27 patients (9 females and 18 males) ranging from 18 to 27 years of age, with an average of 22 years. In accordance with the terms of the ethical approval for this investigation, the procedure was explained in detail to each participant and written consent obtained. High-risk patients with history of congenital heart disease, rheumatic fever, aortic stenosis, mitral stenosis, prosthetic heart valves, subacute bacterial endocarditis, vascular or joint prosthesis, immunosuppression, diabetes, bleeding disorders, and pregnancy were not included in the study.

Placement of elastic separator: Round cross-section elastic separators were placed mesial and distal to the upper first molars using separating pliers. The patients were asked to rinse their mouth for 60 s with 15 mL of 0.2% chlorhexidine gluconate mouthwash before the separator placement. The separators were then sprayed with local anesthetic spray to lessen the pain and add a lubricating effect for easy placement in tight contacts.

A blood sample was taken from each participant immediately before separator placement to act as a control and to ensure that any postprocedure bacteremia discovered could be attributed to the orthodontic procedure. For all the participants, the skin on either the left or right antecubital fossa was prepared with 10% povidone-iodine solution. A blood sample of 5 ml was obtained from an antecubital vein with a strict aseptic technique. The postprocedure blood samples were taken 2 min after the procedure. For optimal detection of bacteremia, it has been recommended that the blood should be collected no later than 2 min after trauma to the gingival margin or vigorous dentogingival manipulation. A total blood sample of 10 ml was taken from each patient (5 ml for each pre- and post-separator placement) and aseptically inoculated into Brain-Heart-Infusion culture bottles [Figure 1]. These were then incubated aerobically for 7 days and cultured into chocolate agar [Figure 2] and MacConkey agar [Figure 3].
Figure 1: Brain-Heart-Infusion culture bottle.

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Figure 2: Chocolate agar.

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Figure 3: MacConkey agar.

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  Results Top


The mean age of whole group was 22 years with range of 18–27 years. The mean plaque score was 0.673 (0.250–1.375), and the mean gingivitis score was 0.750 (0.125–1.375). Out of the total 27 patients, none of the samples before the placement of separators were positive for bacteremia. All the blood samples taken after separator placement were also found to be negative for bacteremia.


  Discussion Top


It is important to determine which procedures in the provision of orthodontic care are likely to cause bacteremia so that a decision can be made regarding antibiotic prophylaxis for individuals at risk. The intensity of bacteremia following dental procedures is controversial. Some studies have found that the bacteremia is minute and irrelevant compared with the intensity required to induce infective endocarditis. In the present study, transient bacteremia was not detected in blood samples postseparator placement following the use of chlorhexidine mouthwash.

No bacteremia of oral origin was detected in blood samples before the placement of separator procedures in an earlier study by Al-Khatieeb.[20] However, bacteremia was detected in 40% of the sample (4 out of 10 patients) after the placement of elastic separators in the same study. The mean total number of aerobic and anaerobic bacteria combined was significantly greater following placement of separators in a study by Lucas et al.[19] The prevalence of bacteremia following separator placement was also observed by Umeh et al.[21] This was attributed to the fact that separator placement is associated with trauma and bleeding in the interdental area, which further pushes plaque and food debris into the gingival crevice with resultant bacteremia. The absence of bacteremia in the present study could be due to the fact that placement of separators was done using LA spray which acted as a lubricant making the separator placement easy causing practically no insult to the gingival margin which was considered as a major factor for the bacteremia following separator placement. There is evidence in the literature that antiseptic mouthwashes applied before dental manipulations may reduce the incidence and severity of bacteremia.[15],[16] Use of chlorhexidine before separator placement has been recommended as a measure to decrease the bacteremia.[21] Erverdi et al. also detected that chlorhexidine mouthwash resulted in a decrease in bacteremia after banding and debanding, but the decrease was not statistically significant.[9] The effectiveness of chlorhexidine gluconate mouthwash in reducing bacteremia associated with separator placement was confirmed in the present study. The effectiveness of chlorhexidine gluconate mouthwash in reducing bacteremia associated with separator placement was confirmed in the present study. However, this can be reconfirmed by carrying out another study where the incidence of bacteremia on separator placement can be compared both with and without the prior use of chlorhexidine mouthwash. There is also scope for studies to evaluate the incidence of bacteremia for other simple orthodontic procedures such as band placement and debonding and the role of chlorhexidine in reducing the bacteremia.


  Conclusion Top


This study demonstrated that there occurs no transient bacteremia with separator placement following chlorhexidine mouthwash. The use of chlorhexidine may be justified when performing procedures with a low incidence and low grade of bacteremia. Use of local anesthetic spray on the separator is also suggested to lessen the trauma and gingival insult and the chance of bacteremia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Stedman TL. Stedman's Medical Dictionary Illustrated. 26th ed. Baltimore: Williams and Wilkins; 1995.  Back to cited text no. 1
    
2.
Coulter WA, Coffey A, Saunders ID, Emmerson AM. Bacteremia in children following dental extraction. J Dent Res 1990;69:1691-5.  Back to cited text no. 2
    
3.
Lucartorto FM, Franker CK, Maza J. Postscaling bacteremia in HIV-associated gingivitis and periodontitis. Oral Surg Oral Med Oral Pathol 1992;73:550-4.  Back to cited text no. 3
    
4.
Schlein RA, Kudlick EM, Reindorf CA, Gregory J, Royal GC. Toothbrushing and transient bacteremia in patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop 1991;99:466-72.  Back to cited text no. 4
    
5.
McLaughlin JO, Coulter WA, Coffey A, Burden DJ. The incidence of bacteremia after orthodontic banding. Am J Orthod Dentofacial Orthop 1996;109:639-44.  Back to cited text no. 5
    
6.
Erverdi N, Kadir T, Ozkan H, Acar A. Investigation of bacteremia after orthodontic banding. Am J Orthod Dentofacial Orthop 1999;116:687-90.  Back to cited text no. 6
    
7.
Yagci A, Uysal T, Demirsoy KK, Percin D. Relationship between odontogenic bacteremia and orthodontic stripping. Am J Orthod Dentofacial Orthop 2013;144:73-7.  Back to cited text no. 7
    
8.
Erverdi N, Biren S, Kadir T, Acar A. Investigation of bacteremia following orthodontic debanding. Angle Orthod 2000;70:11-4.  Back to cited text no. 8
    
9.
Erverdi N, Acar A, Isgüden B, Kadir T. Investigation of bacteremia after orthodontic banding and debanding following chlorhexidine mouth wash application. Angle Orthod 2001;71:190-4.  Back to cited text no. 9
    
10.
Shafer WG, Hine MK, Levy BM. Textbook of Oral Pathology. 4th ed. Philadelphia: WB Saunders; 1983. p. 522.  Back to cited text no. 10
    
11.
Heimdahl A, Hall G, Hedberg M, Sandberg H, Söder PO, Tunér K, et al. Detection and quantitation by lysis-filtration of bacteremia after different oral surgical procedures. J Clin Microbiol 1990;28:2205-9.  Back to cited text no. 11
    
12.
Delahaye F, Wong J, Mills PG. Infective endocarditis: A comparison of international guidelines. Heart 2007;93:524-7.  Back to cited text no. 12
    
13.
Macfarlane TW, Ferguson MM, Mulgrew CJ. Post-extraction bacteraemia: Role of antiseptics and antibiotics. Br Dent J 1984;156:179-81.  Back to cited text no. 13
    
14.
Tzukert AA, Leviner E, Sela M. Prevention of infective endocarditis: Not by antibiotics alone. A 7-year follow-up of 90 dental patients. Oral Surg Oral Med Oral Pathol 1986;62:385-8.  Back to cited text no. 14
    
15.
Löe H, Schiott CR. The effect of mouthrinses and topical application of chlorhexidine on the development of dental plaque and gingivitis in man. J Periodontal Res 1970;5:79-83.  Back to cited text no. 15
    
16.
Löe H, Schiött CR, Glavind L, Karring T. Two years oral use of chlorhexidine in man. I. General design and clinical effects. J Periodontal Res 1976;11:135-44.  Back to cited text no. 16
    
17.
Stirrups DR, Laws EA, Honigman JL. The effect of a chlorhexidine gluconate mouthrinse on oral health during fixed appliance orthodontic treatment. Br Dent J 1981;151:84-6.  Back to cited text no. 17
    
18.
Brightman LJ, Terezhalmy GT, Greenwell H, Jacobs M, Enlow DH. The effects of a 0.12% chlorhexidine gluconate mouthrinse on orthodontic patients aged 11 through 17 with established gingivitis. Am J Orthod Dentofacial Orthop 1991;100:324-9.  Back to cited text no. 18
    
19.
Lucas VS, Omar O, Vieira A, Roberts GJ. The relationship between odontogenic bacteraemia and orthodontic treatment procedures. Eur J Orthod 2002;24:293-301.  Back to cited text no. 19
    
20.
Al-Khatieeb MM. Bacteraemia following different orthodontic treatment procedure. J Fac Med Baghdad 2009;51:130-5.  Back to cited text no. 20
    
21.
Umeh OD, Sanu OO, Utomi IL, Nwaokorie FO. Prevalence and intensity of bacteraemia following orthodontic procedures. Int Orthod 2016;14:80-94.  Back to cited text no. 21
    


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