I am writing to you regarding the article by Cynthia Biron, RDH, titled, "Despite diligent staff, infective endocarditis surfaces during periodontal treatment" (March 1997). Infective endocarditis is extremely rare, as the article states. However, what the article failed to address was the relationship between infective endocarditis and periodontal disease, poor oral hygiene, and dental procedures.
The 1990 American Heart Association clearly addresses this issue in its paper published in the Dec. 12, 1990, issue of JAMA. The paper states:
- "Poor dental hygiene and periodontal or perapical infections may produce bacteremia even in the absence of dental procedure."
- "Individuals ... should establish and maintain the best possible oral health to reduce potential sources of bacterial seeding."
- "It is impossible to predict which patient (who is at risk) will develop this infection or which particular procedure will be responsible."
Ms. Biron does discuss antibiotics and some of the reasons that the prophylactic regime may fail. She goes on to discuss rinsing and irrigation as an additional precaution. However, while I agree with her recommendation to rinse prior to the procedure, I disagree with her about irrigating after the procedure has been completed.
Traditionally, when dental hygienists think of in-office irrigation, it is done after the completion of a procedure such as scaling and root planing. However, when irrigating is used as an adjunct to systemic antibiotics, the procedure should be done prior to beginning intraoral procedures, including probing.
The American Heart Association makes a recommendation in the 1990 paper advocating the use of pre-procedural irrigation with chlorhexidine on those patients who have poor oral hygiene or periodontitis. Most recently, in a study published in the May 1996 issue of JADA by Dr. Daniel Fine, pre-procedural irrigation and rinsing with Listerine was assessed. His findings show significant reduction in both aerobic and anaerobic bacteria. His feeling is that this provides experimental evidence to support the AHA recommendation of pre-procedural irrigation. It is also important to state that, according to the American Heart Association, pre-procedural irrigation is not intended as a substitute for systemic antibiotics.
For more information, I encourage everyone to get a copy of the AHA recommendation by calling your local heart association, and to gain access to a copy of the Fine study.
Carol A. Jahn, BSDH, RDH