Antibiotic-resistant oral streptococci in dental patients susceptible to infective endocarditis.

The aim of this study was to determine the incidence of amoxycillin and erythromycin resistance in oral streptococci in patients at risk from infective endocarditis. Samples of gingival crevicular flora were taken from 65 patients at the site of dental treatment, prior to the prophylactic administration of amoxycillin (54 patients) or erythromycin (11 patients). Samples were also taken from 65 dental patients who were not considered to be at risk from infective endocarditis. No isolate had a minimum inhibitory concentration (MIC) of amoxycillin greater than 24 mg/L. However, erythromycin-resistant oral streptococci with MIC values greater than 3.5 mg/L were isolated from 22% of patients receiving amoxycillin prophylaxis, 9% of patients receiving amoxycillin prophylaxis, 9% of patients given erythromycin prophylaxis and 9% of patients not at risk from infective endocarditis. The antibiotic-resistant streptococci comprised mainly Streptococcus sanguis biotype II, although S. sanguis biotype I, S. mitis and S. salivarius were also frequently recovered.

Endodontics in the adult patient: the role of antibiotics.

OBJECTIVES: The aim of this study was to review the published work on the indications and efficacy for antibiotics in endodontic therapy. DATA SOURCES: Published works in the medical and dental literature. STUDY SELECTION: Evaluation of published clinical trials in endodontic and other pertinent literature. CONCLUSIONS: Antibiotics are not routinely indicated in the practice of endodontics. Therapeutic antibiotics may be required as an adjunct to operative treatment when there is pyrexia and/or gross local swelling; they are only rarely indicated in the absence of operative intervention. Prophylactic antibiotics may be required for certain patients who are susceptible to serious infective sequaelae.

The use of antibiotics in the prevention of post-operative infection: a re-appraisal.

The use of antibiotics to prevent infection is a contentious issue in all surgical specialties. Ideally, antibiotic administration should reduce morbidity and mortality. In reality, they may cause drug interactions, allergic and other untoward reactions, and reduce colonisation resistance; this can result in infections with resistant microorganisms. Therefore, when used injudiciously, the patient may suffer more than if antibiotics had not been prescribed. The most effective use of prophylactic antibiotics has been shown to be in short term, high dosage regimens that are active against the common pathogens. To achieve any protective effect, antibiotics must be administered pre-operatively to provide adequate tissue concentrations at the time of surgery.

Infective endocarditis and the dental practitioner: a review of 53 cases involving litigation.

OBJECTIVE: To review episodes of infective endocarditis involving dental procedures that have resulted in litigation and to determine if any clinical recommendations can be obtained. DESIGN: 13-year retrospective study. INTERVENTION: Patient records were analysed to identify the probable cause of infective endocarditis. All were judged to be caused by dental manipulations on the basis of dental procedure, cardiac pathology, infecting micro-organism and time between onset of infection and dental manipulation. MAIN OUTCOME MEASURES: Cases were analysed to check if appropriate national guidelines on antibiotic prophylaxis were followed. Status of patient dental records was also evaluated. RESULTS: Dental procedures implicated in infective endocarditis were exodontia (23), scaling (21), root canal therapy with extra-canal instrumentation (7) and minor oral surgery (2). No medical history was recorded in 10 patients. In a further 31 medical history was inadequate or out of date. Dentists involved with these cases failed to give prophylactic antibiotics (48), prescribed incorrect antibiotics (2), or gave antibiotics at inappropriate times (2). There was one episode of prophylaxis with amoxycillin failing despite it being given correctly. CONCLUSIONS: If litigation is to be avoided dental practitioners must keep accurate dental records, take an appropriate medical history that is kept up to date and adhere to national guidelines on antibiotic prophylaxis.

Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy.

OBJECTIVE: To evaluate shortened courses of antibiotics in the management of dentoalveolar abscesses. DESIGN: Prospective clinical study over a 3-year period. SETTING: Examinations department of the Liverpool University Dental Hospital. SUBJECTS: 759 patients, with acute dentoalveolar abscesses associated with swelling, and an elevation of axillary temperature to above 38.5 degrees C, were included in the investigation. The minimum age of the patients was 16 years. INTERVENTIONS: The initial treatment was to drain the abscess by incision (124 patients), or extraction (635). The patients were prescribed amoxycillin (250 mg every 8 hours), clindamycin (150 mg every 6 hours) or erythromycin stearate (250 mg every 6 hours) and instructed to drink plenty of fluid. All the patients were seen 2 or 3 and 10 days later; only patients who were seen at these times were included in the trial. MAIN OUTCOME MEASURES: Resolution of the swelling and a normal axillary temperature. RESULTS: At first review 748 patients (98.6%) had normal temperatures, marked resolution of the swelling and the antibiotic was discontinued. None of these 748 patients required further antibiotic therapy. CONCLUSIONS: The duration of antibiotic therapy in most patients with acute dentoalveolar infections can safely be 2-3 days, provided that drainage has been established. It is not, therefore, necessary for the majority of patients to complete a 5-day course of antibiotics.

Cognitive-behavioural therapy for idiopathic burning mouth syndrome: a report of two cases.

Two cases of burning mouth syndrome (BMS) that were successfully managed with cognitive-behaviour therapy (CBT) are reported. The principles and application of CBT are described. The cases presented demonstrate the important role that this type of psychological approach can have in the management of patients with BMS.

The dental management of patients with natural rubber latex allergy.

Reports of allergic reactions to natural rubber latex have increased during the past two decades with both dental personnel and patients being affected. A dental management protocol is outlined for patients who have latex allergy. This includes: the identification of patients at high risk for developing latex allergy; the creation of a controlled, 'latex free' environment in the dental surgery; and the provision of emergency drugs and equipment that are free from natural rubber latex and may be required for the management of an allergic reaction.

The establishment of a xerostomia clinic: a prospective study.

The study investigated the aetiological factors and management of patients who have xerostomia. The subjects were 100 consecutive patients referred to the Oral Medicine Unit for investigation of oral dryness. A detailed case history was recorded and patients underwent a systematic examination together with sialometry, haematological, biochemical and immunological investigations. Suspected cases of Sjögren's syndrome (SS) were referred for assessment by a rheumatologist and ophthalmologist. Objective evidence of salivary gland hypofunction was found in 39 patients. A definite diagnosis of primary and secondary SS was made in 24 and 15 patients respectively, a further five cases had possible primary SS. Other causes of xerostomia were: undiagnosed diabetes (3); drug-induced (11); therapeutic radiation (3); alcohol-related (3); psychogenic (15) and idiopathic (21). Patients complaining of a dry mouth should be questioned about non-oral symptoms. In total, 40% of patients attending the dry mouth clinic had a diagnosis of SS.

Oral signs and symptoms as predictors of salivary gland hypofunction in general dental practice.

OBJECTIVE: To evaluate the signs and symptoms of oral dryness as predictors of salivary gland hypofunction (SGH) in general dental practice. DESIGN AND SETTING: Prospective study recruiting adult patients attending five general dental practices in Merseyside in 1999. MATERIALS AND METHOD: Patients were screened for subjective symptoms of oral dysfunction and clinical signs of oral dryness. Patients with oral symptoms or signs of SGH were invited to undergo sialometry. Results were analysed using multiple logistic regression. RESULTS: 1103 patients were screened for signs and symptoms of oral dryness, 115 reported continuous xerostomia, of these 65 were also clinically (subjectively) assessed as having a dry oral mucosa. One hundred and one patients attended for sialometry and 73% of these had objective evidence of SGH. Neither the patients' complaints of oral dryness or the assessment of dryness of the oral mucosa were significant predictors of SGH. CONCLUSIONS: Symptoms of oral dysfunction and clinical signs of oral dryness were not significant predictors of SGH in dental practice.

An immediate (type I) hypersensitivity reaction during placement of a dental rubber dam.

A dental student developed swelling of the lips and peri-oral urticaria, immediately after placement of a dental rubber dam during a chairside demonstration of clinical dentistry. A provisional diagnosis of a Type I hypersensitivity reaction to natural rubber latex was made and an appointment organised for specialist investigations. The student reported an atopic history and allergy to peanuts. A Radioallergosorbent Test (RAST), to measure Ig-E antibodies to latex, was positive. The dental student was given advice concerning the avoidance of natural rubber latex. Dental staff must be aware of potentially serious reactions to natural rubber latex in the dental surgery.

A practical guide to antibiotic prophylaxis in restorative dentistry.

The purpose of this paper is to review the principles and practicalities of antibiotic prophylaxis in medically compromised patients who require restorative dentistry. Guidelines for the management of patients who are susceptible to infection are given. The importance of oral health and the rational use of both local and systemic antimicrobial prophylaxis is described.

Dental management of the myasthenic patient.

Myasthenia gravis (MG) is an auto-immune disorder of neuromuscular transmission which results in weakness and fatigue of skeletal muscles. The defect in neuromuscular transmission is most commonly seen in the muscles of the eyes, face, neck and shoulders but, in some patients, the respiratory muscles are involved. Patients with this condition may present with problems that necessitate special consideration when managing their dental treatment. Patients who are only mildly affected by MG can be treated in general dental practice for routine care. There are no contra-indications to the use of local anaesthetic agents and the presence of a vasoconstrictor is desirable. More severely affected patients and those who are very anxious about dental treatment should be cared for within the hospital environment. In these patients, respiratory muscles may be affected and, as a result, a myasthenic crisis may arise which requires assisted ventilation and, in some cases, intubation. Those patients who are fearful of the dental environment are likely to be emotionally stressed during such times and this increases the risk of a myasthenic crisis; sedation techniques can be beneficial in this group of patients.

Murmurs, infective endocarditis and dentistry.

Patients with cardiac murmurs may have a predisposition to infective endocarditis, and the dental practitioner must be aware of this potential problem. This article reviews cardiac murmurs and how they are investigated by physicians to assess their significance. Practical advice is offered concerning the need to refer patients with a suspected heart murmur. The emergency and elective dental management of patients with heart murmurs is included, together with recommended regimens for antibiotic prophylaxis.

Intranasal/intravenous sedation for the dental care of adults with severe disabilities: a multicentre prospective audit.

OBJECTIVE: This study was designed to provide an evaluation of the combined intranasal/intravenous midazolam sedation technique. It involved adults with severe disabilities which prevented them from being able to co-operate with dental treatment and intravenous cannulation for sedation. METHOD: Following a previous retrospective audit, additional treatment centres were enrolled and a standardised form used to collect prospective data about the effectiveness of the technique in facilitating cannulation, dental examination and treatment. Data was also collected on safety and patient acceptability. RESULTS: In a total of 316 sedation episodes in primary and secondary care settings, cannulation was achieved in 96.2% (304). Dental examination and treatment was able to be carried out without major interference from the patient in 78.8% (241) episodes. Adverse sedation events occurred in 6.0% (19), the most frequent being desaturation which was easily managed. There were no incidents with serious sequelae. Favourable acceptability ratings were given by carers regarding advantages of ease of administration and speed of onset of the intranasal dose, plus reduction in the stress associated with cannulation and treatment. CONCLUSIONS: This study provides further evidence to support the effectiveness, safety and acceptability of this technique. The authors suggest this provides sufficient basis to justify its use by suitably trained dental practitioners in primary care as part of the spectrum of anxiety and behaviour management for this group.