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ARTICLE 3

BACTEREMIA AND INTRAORAL SUTURE REMOVAL:

CAN AN ANTIMICROBIAL RINSE HELP?
ALAN R. BROWN, D.D.S.; CHRISTOPHER J. PAPASIAN, PH.D., M.S.; PATTI SHULTZ, R.D.H., M.S.; FRANK C. THEISEN, D.D.S.; RUDANE E. SHULTZ, D.D.S.

Recent studies have shown that bacteremia can result from the removal of intraoral sutures. The authors found that preprocedural use of an antimicrobial oral rinse (0.12 percent chlorhexidine) did not significantly reduce the incidence of bacteremia when compared with no rinse at all. Similarly, a significant relationship between bleeding and bacteremia was not apparent. Most of the positive cultures yielded low colony counts. The results support the rationale for the American Heart Associations 1997 recommendations for use of antibiotic prophylaxis to prevent bacteremia, as well as the importance of good oral hygiene in prevention efforts.

otics, the incidence of bacterial endocarditis, or BE, has not decreased over the years.1 Furthermore, the condition still carries a 10 to 65 percent mortality rate,2 and so it must be taken seriously. Recognized as being at risk of developing bacteremia are patients with the following general conditions: dcongenital heart defects; dorganic valvular disease, most commonly related to a prior episode of rheumatic fever, but also seen in patients suffering from systemic lupus erythematosus; dplacement of prosthetic valvular replacements or systemic pulmonary shunts. People with the latter two entities, or a history of having had BE, constitute the high-risk group among whom the development of BE carries with it a mortality rate of up to 80 percent.2 Although it has never been scientifically verified, antibiotic prophylaxis for the prevention of BE in susceptible patients has long been practiced. The most recent American Heart Association, or AHA, recommendation for antibiotic prophylaxis was published in 1997.3 The AHA report states that any dental procedure capable of producing significant bleedingsignificant being a new, somewhat subjective qualifierhas the potential for introducing oral bacteria into the bloodstream and, as such, requires prophylaxis with an appropriate antibiotic. Interestingly, one of the many issues regarding the need for prophylaxis is the fact that bacteremia results less frequently from procedures performed by dental professionals than from routine daily activities performed by patients themselves: chewing4; brushing5; oral rinsing6; and the use of floss,7 toothpicks8 or mechanical irrigation devices,6,7 especially in the presence of chronic or acute periodontal infective states commonly seen with poor oral hygiene.3,9,10 It is certainly possible that such activities occurring in the absence of antibiotic coverage are the cause of more cases of BE than are believed to be related to procedures performed by dental professionals. Accordingly, both the American Dental Association and the American Heart Association have made strong recommendations that susceptible patients maintain impeccable oral hygiene.3 From the opposite perspective, it may be that routine
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Despite scientific advancements and the use of systemic antibi-

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CLINICAL PRACTICE
daily oral procedures are simply incapable of creating an inoculum of sufficient size to be capable of establishing infective seeding of existing endocardial vegetations. Studies of this possibility are lacking at present. As a response to initial theory, animal model studies, years of habit and the litigious nature of todays society, prophylaxis for any bleeding related to dental procedures remains either the accepted standard or dogma, depending on ones point of view. Researchers investigating the relationship of suture removal to the creation of bacteremia deduced that the incidence of bacteremia warranted bacterial endocarditis prophylaxis, or BEP, at least for high-risk patients.11,12 The 1997 AHA recommendations do not include BEP for suture removal procedures in any susceptible patient, including those at high risk of developing BE. When treating the aforementioned class of patients, some medical and dental practitioners might not concur with this all-inclusive position. In its recommendationswhich are not standardsthe AHA notes that the clinicians judgment may supersede a given recommendation. Various studies have shown that commercial antibacterial mouthrinse productschlorhexidine, iodophors and phenolicshave been effective in decreasing the overall oral quantity of bacteria and, as a result, their negative infective effects (such as periodontitis), as well as the incidence of bacteremia induced by various dental procedures.13-15 These mouthrinses also have been found to help reduce the incidence of bacteremia associated with third-molar extractions, as
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well as decrease the incidence of resultant localized alveolitis.16,17 However, as accurately noted by Lockhart and Schmidtke,10 the results are conflicting and difficult to compare; many studies show no significant drop in the incidence of positive cultures associated with either oral rinsing or sulcus irrigation.10,18,19 We designed a study to determine whether a relationship exists between the incidence of bacteremia and suture removal, especially in patients who experience bleeding at the surgical site, and to quantify the inoculum. More importantly, we aimed to determine whether a 0.12 percent chlorhexidine rinse, performed before the removal of sutures, could reduce or eliminate the bacteremia. If this was possible, an antibacterial rinse could prove to be an efficacious substitute for administration of systemic antibiotic prophylaxis before the simple suture removal procedure.
METHODS AND MATERIALS

Subjects. Seventy-one patients requiring the removal of third molars were included in the investigation. Ten patients failed to return for follow-up, leaving 61 participants (37 female, 24 male) aged 15 to 35 years. The sample size necessary for boosting the power of the nonparametric test we used for statistical analysis to 90 percent at P = .05 (n = 55) was determined by results obtained from an initial pilot study involving the first 16 patients, as well as bacteremia incidence rates previously reported in the literature.11,12 We gained approval of the study protocol from the investigational review board of the University of Missouri-

Kansas City schools of dentistry and medicine and obtained written consent from each participant. Inclusion criteria required healthy patients whose third-molar surgery would necessitate the placement of at least eight sutures. We evaluated each patients level of oral hygiene and classified it as good, fair or poor, depending on the amount of plaque, calculus, material alba and gingival inflammation present. Excluded from the study were patients who had systemic disease; were taking steroids or had used systemic antibiotics or oral rinses within the preceding four weeks; had moderate-to-severe periodontitis or residual pericoronitis; or required preoperative prophylactic antibiotics. Patients were dropped from the study if they required antibiotic therapy during the postoperative week. Extraction sites developing alveolar osteitis after surgery were selectively dropped from recovered data, but the patient and his or her remaining uninvolved sites were retained. Methods. The third molars were removed by one of three board-certified oral surgeons (A.R.B., F.C.T. and R.E.S.) using similar flap designs and 3-0 black silk suture placement. The surgeons used no medications in the sockets, nor did they use preoperative irrigations or rinses. Postoperatively, only warm salt-water rinses were allowed. The subjects returned for suture removal seven days after the extraction and were randomly assigned to one of two groups. Group 1, the test group, used a 0.12 percent chlorhexidine preprocedural rinse (Peridex, Zila Pharmaceuticals);

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CLINICAL PRACTICE
TABLE 1

STUDY RESULTS: POSITIVE CULTURES.

PATIENT NUMBER AND TYPE OF SPECIMEN* USED ORAL CHLORHYGIENE HEXIDINE RINSE ORGANISM(S) QUANTITY CONTAMINA- SUTURES TION BLEED SITES**

56A 5A 3B

No No No

Good Good Fair

Staphylococcus coagulase negative, or CN Propionibacterium Staphylococcus aureus Propionibacterium Staphylococcus CN Staphylococcus CN Staphylococcus CN Corynebacterium Streptococcus sanguis Bifidobacterium S. viridans Micrococcus S. mitis S. sanguis Prevotella species S. viridans Peptostreptococcus S. viridans

> 100 1 6 15 1 1 1 1 1 7 2 1 1 13 4 2 2

Definite Definite Probable Probable Probable Probable Probable Probable No No No No No No

11/11

None None 3/4

16B 37B 71B 12B 29B 49B 52B 59B 70B

No Yes Yes No Yes Yes Yes No Yes

Fair Good Good Good Fair Good Good Good Good

12/14 14/14 12/12 12/14 8/8 9/9 10/14 13/14 10/12

0/4 2/4 4/4 4/4 2/3 2/3 1/4 2/4 4/4

* **

A: preprocedural blood specimen; B: postprocedural blood specimen. Preoperative oral hygiene conditions simply classified as good, fair or poor, depending on the amount of plaque, calculus, material alba and gingival inflammation present. By colony count. Number present at suture removal appointment/original number of sutures placed. Number of extraction sites with bleeding from at least one suture removal/total number of extraction sites. As these patients had definite contaminants, the data relating to them were not used in any data computations.

Group 2 served as a no-treatment control. For both groups, the clinicians prepared the antecubital fossa with povidoneiodine surgical soap and inserted a 21-gauge intracatheter using aseptic technique. They then placed bacitracin ointment on the site and covered it with a taped sterile dressing to secure the site. The first 10 milliliters of blood withdrawn for the preand postprocedural specimens was discarded and a second syringe used to collect the specimen for culturing. A few patients preferred not to have the

intracatheter inserted; in their cases, the clinicians used regular syringes and drew the preprocedural blood specimen from one site and the postprocedural specimen from another site. The clinicians obtained a 10-mL blood sample for culturing, either when they inserted the needle or after establishing the intravenous catheter route. With the latter technique, the first 10 mL of blood obtained was discarded and a second syringe used to collect the specimen. Patients assigned to group 1 (the chlorhexidine rinse) used

a one-minute rinse with 30 cubic centimeters of 0.12 percent chlorhexidine. The doctor performing suture removal was unaware of whether or not the patient had used a rinse. Sutures were then removed as atraumatically as possible, and any bleeding from the sites, even if minimal, was noted. Ninety seconds were allowed to pass, and then a second 10-mL blood sample was obtained for culturing. All specimens were placed in an aerobic/anaerobic culture medium and immediately transported to the microbiolo1457

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CLINICAL PRACTICE
TABLE 2

BLOOD CULTURE RESULTS.

STUDY GROUP (N = 55) NO. OF SUBJECTS WITH BACTEREMIA

Group 1: Chlorhexidine Rinse (n = 31) Group 2: NoRinse Control (n = 24)

gy laboratory for culturing and identification. In the laboratory, specimens were promptly transferred to a lysis centrifugation collection tube (Isolator 10, Wampole Laboratories), delivered to the microbiology laboratory, and centrifuged at 3,000 gravity for 30 minutes. Supernatant fluid was discarded and the entire pellet was used to inoculate chocolate agar; trypticase soy agar with 5 percent sheep erythrocytes, also called blood agar plate, or BAP; CDC anaerobic blood agar, or CDC BAP; and laked kanamycin-vancomycin, or LKV agar (Remel). BAP and chocolate agars were incubated at 35 C in an atmosphere of 90 to 95 percent air and 5 to 10 percent carbon dioxide. The CDC BAP and LKV agars were incubated anaerobically at 35 C. All plates were examined daily for seven days before negative results were reported. Colony counts were performed on media showing growth, and organisms were identified using morphologic criteria and routine bacteriologic methods. Staphylococcus aureus was identified using Staphaurax Plus (Murex Diagnostics). Coagulase-negative staphylococci, facultatively anaerobic gram-negative bacilli, streptococci and obligate anaerobes
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were identified using the Pos Combo Panel 6 (Dade NO. OF Microscan), SUBJECTS WITH NO Neg Combo BACTEREMIA Panel 13 27 (Dade Microscan), Rapid STR 22 (Innovative Diagnostic Systems Inc.) and Rapid ANA II (Innovative Diagnostic Systems Inc.), respectively.
RESULTS

Ten of the initial randomly assigned 71 participants were lost to follow-up, two from the experimental group and eight from the control group. Six additional patients were eliminated because they had contaminated cultures: two who had positive cultures for both the pre- and postprocedure samples or a colony count greater than 100, and four who had positive cultures for coagulase-negative Staphylococcus, Propionibacterium or Corynebacterium). There were no postoperative infections and, hence, no patients lost because of a need to institute antibiotic coverage. Thus, we analyzed data from 55 subjects: 31 in the experimental group and 24 in the control group (Table 1). Pretreatment blood samples of these patients were all negative. Table 2 shows the post-treatment results of the blood cultures. Six blood cultures were positive and are deemed to represent valid procedure-related bacteremia, for a total incidence of 10.9 percent (six of 55). In all but one patient, colony counts of positive bacteremia were quite low. Facultative organisms, pre-

dominantly Streptococcus, were present in all specimens. Two samples yielded anaerobic growth of either Prevotella or Peptostreptococcus. Of the six patients with bacteremia, four were from the test group (12.9 percent) and two were from the control group (8.3 percent); only one of these six patients had less than good oral hygiene at the initial evaluation. Fishers Exact Test revealed no statistically significant difference in the proportion of bacteremia when we compared the experimental and control groups (P > .05). An analysis of the data that include the four patients deemed to have probable coagulase-negative Staphylococcus contaminants failed to change the statistical significance of the comparisons. The incidence of bacteremia only rose from 10.9 percent to 16.9 percent. Bacteremia rates for the chlorhexidine rinse group compared with those of the control group were 18.2 percent (six of 33) and 15.4 percent (four of 26), respectively. Table 3 compares data on bleeding with data on bacteremia. Bleeding on suture removal occurred in 47 of 55 patients. The proportion of patients exhibiting positive blood cultures after bleeding was 12.8 percent (six of 47); the remaining 87.2 percent did not develop bacteremia after bleeding. None of the eight subjects in whom bleeding did not occur developed bacteremia. Although 85.5 percent of the total patients (47 of 55) showed bleeding after suture removal at one or more sites, and all patients (100 percent, six of six) who had positive blood cultures bled after suture removal, data analysis failed to show a statistical-

JADA, Vol. 129, October 1998 Copyright 1998-2001 American Dental Association. All rights reserved.

CLINICAL PRACTICE
ly significant (P > .05) relationship between the presence of bleeding after suture removal and the incidence of bacteremia.
DISCUSSION

In this study, 10.9 percent of the patients developed bacteremia after the removal of sutures; the use of a preprocedural chlorhexidine rinse did not significantly reduce the incidence. The results (including the 16.9 percent rate of bacteremia if one wishes to consider the patients who had what we believed to be contaminants) are highly consistent with previous studies rates of 11 percent and 16 percent.11,12 One can certainly question our decision to exclude the culture results of the four patients whose specimens grew coagulase-negative Staphylococcus and/or diptheroids. All of these organisms may be recovered from the skin, the nasal cavity or the oral cavity, but they are not known as pathogens commonly found in the oral cavity. Microorganisms. The mouth is a well-known reservoir of more species of organisms than any other area of the body. However, based on existing knowledge of microbiological ecology, we suspect that the bacteria under question were most likely acquired during the phlebotomy procedure. Contamination during bloodculturing procedures can be a significant problem.20 When a standard bottle collection system is used, a contamination rate of 2 percent is the maximum allowable at the University of Missouri-Kansas City. We selected a different system for this study. Although it possessed greater accuracy regarding colony counts, the system

TABLE 3 was somewhat more susceptible to higher conNO. OF NO. OF SUBJECTS tamination SUBJECTS BLEEDING STATUS SUBJECTS WITH BACTEREMIA WITH NO during proBACTEREMIA cessing. It is Bleeding 6 41 important to (n = 47) remember No Bleeding 0 8 that both the (n = 8) analysis of the six valid cases of bacteremia and that of veloped later or an open postthe six valid plus the four quessurgical wound); tionable cases of bacteremia redthe patients age; sulted in little or no difference dother host defense considerain statistical significance or in tions such as an immunosupthe conclusions derived from pressed status (caused by diathe data. betes mellitus, advanced stages The flora grown from the of alcohol abuse, end-stage blood cultures in our study are renal disease or hematopoietic a fair representation of what deficiencies). should be expected. Although Intraoral sutures are not anaerobic organisms are known subjected to the anaerobic envifor constituting a significantly ronment of a deep gingival sullarger percentage of the oral micus or the infected, necrotic tiscrobiological population than sue of a fascial space abscess. are aerobes,21 this study recovThey are superficially located ered streptococcal species in all and thus are bathed in an envisix positive cases of bacteremia ronment sufficiently high in (100 percent) and anaerobes in oxygen to allow for the normal growth of aerobes or facultative only two (33 percent). This organisms such as the streptomight surprise clinicians who coccus we recovered. Counterfrequently treat periodontal or balancing this would be the surfascial space infections, in rounding inflammatory which anaerobic pathogens tend response from surgery, suture to predominate. wicking and the transient deGeneralized statements crease in the level of oral hyabout the oral bacterial milieu giene, all of which would likely are not as important in underhave a negativebut as yet unstanding condition-specific oral determinedeffect on the bacbacterial pathology as is knowlterial ecology of the area. edge of other key factors: dthe specific anatomic area afEffects of the mouthrinse. fected by a bacterial infection Surprisingly, our findings refut(in a carious lesion, the pulp, ed the hypothesis that an anthe periapical region, the periotibacterial rinse would decrease dontal sulcus, the mucosal surthe incidence of bacteremia. We face, the anterior or posterior did not observe a statistically regions of the mouth or fascial significant difference between spaces); group 1 (chlorhexidine rinse) dthe stage of the infection (an and group 2 (no rinse). With a early cellulitis, an abscess dereview of existing knowledge

BLEEDING VS. BACTEREMIA.

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and data from our study, we can readily offer satisfactory explanations for this finding. Daily use of a chlorhexidine rinse would be expected to lower the quantity of bacteria in the oral cavity and thereby assist in the treatment of periodontal inflammatory disease. It should be noted that use of this form of treatment is not recommended by the AHA,3 as it can result in the development of bacterial resistance.13 The use of forceful oral rinsing or mechanical irrigation of the gingival sulcus before procedures such as tooth extraction has been shown to be capable of creating bacteremia.22,23 For this reason, the present AHA statement also does not recommend the use of preprocedural antibacterial solutions in any manner other than as a gentle oral rinse.3 We believe that the forceful rinsing of inflamed tissues, possibly along with a very short period for antibacterial action by the chlorhexidine, provides several explanations for the higher incidence of bacteremia found in our test group. We did not have a control group that used a saline rinse; such a group would have assisted in clarifying questions in this regard. This lack does not, however, detract from the basic comparison between an antibacterial preprocedural rinse and no rinse at all. Also, regarding statistical considerations, we should note that had the patient sample size been larger, with randomization resulting in equal numbers for both groups, the findings conceivably could have been different. Even if this were the case, it is not likely that such a statistical change would have had any bearing on the clinical significance of the data analysis.
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Source of infection. Was the bacteremia found in this study of sufficient strength to provide an inoculum capable of infecting a cardiac valvular vegetation? Little, if any, evidence is available in the literature at this time to answer this all-important question. Interestingly, the early animal (rabbit) model studies substantiating the need for antibiotic prophylaxis to prevent BE following dental procedures21 used extremely high concentrations of inoculated or-

The use of forceful oral rinsing or mechanical irrigation of the gingival sulcus before procedures such as tooth extraction has been shown to be capable of creating bacteremia.
ganisms, a design fault often commented on by those who believe existing requirements for BEP are unfounded.22-24 Are these conclusions and recommendations applicable to low-level inocula? Indeed, the bacteremia that results from routine, daily procedures such as brushing and flossing creates a higher bacteremia rate and more likely inoculum load than those that occur after the postsurgical removal of intraoral sutures. Guntheroth24 determined that over a one-month period, physiologically stimulated bacteremia (such as that arising from chewing and brushing) would expose a patient to a bacteremia rate 1,000 times greater than that following a tooth extraction. If this is the

case, why do we not see cases of BE occurring in many more of the patients deemed to be susceptible to the deleterious effects of bacteremia? A more frequent, but much smaller, bacteremic load incapable of establishing BE offers a plausible answer. Why should the profession provide BEP for a procedure such as suture removal and not for daily home care procedures? When one considers the potential implications that poor oral hygiene or subacute bacterial periodontal conditions have for this issue, it becomes obvious that future therapeutic recommendations should address the role of inoculum load and other factors related to the effective pathogenic bacterial seeding of susceptible areas of endocardium. In our study, the largest colony count came from one patient in the nonrinse control group. The only other patient having a slightly elevated colony count was the one patient who had only a fair level of oral hygiene. Prophylaxis considerations. If the practitioners clinical judgment leads him or her to provide antibiotic prophylaxis for suture removal (such as in a high-risk patient who has considerable inflammation and a high likelihood of bleeding from probing for deeply embedded suture knots), which agent should he or she choose? Based on the AHA recommendations, a repeated dose of the same antibiotic administered four to seven days before the procedure is contraindicated, as resistant strains might have been generated by the original medication. If amoxicillin was first used preoperatively, should clindamycin or a cephalosporin be used for the suture removal ap-

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CLINICAL PRACTICE
pointment? Probably. Fortunately, there are simpler ways to deal with the question of prophylaxis for suture removal. dFirst, if possible, the clinician should avoid the use of sutures. dSecond, if sutures are deemed necessary, the clinician should use a resorbable suture that will be quickly and spontaneously lost, such as plain gut. dThird, if concerned about the inflammation that results from use of a gut suture, the clinician should use quick-resorbing polyglycolic acid sutures, as they have bacteriostatic properties. dFourth, the clinician should administer antibiotics only if significant bleeding occurs at the time of suture removal. As noted in the AHA recommendations, if administered within two hours of the bacteremic event, the antibiotic therapy should be effective.3
SUMMARY

does not significantly reduce the incidence of bacteremia. Further studies on bacteremia generated from the oral cavity, and the resultant clinical applications, should take into consideration the size of the bacterial inoculum load generated by a given procedure, and the effectiveness of the individual patients immune responses in dealing with low-level bacterial loads. s
Dr. Brown is an assistant professor, Department of Oral and Maxillofacial Surgery, University of Missouri-Kansas City, School of Dentistry, 650 E. 25th St., Kansas City, Mo. 64108. Address reprint requests to Dr. Brown. Dr. Papasian is an associate professor, Department of Pathology, University of Missouri-Kansas City, School of Medicine. Ms. Shultz is a dental hygienist, Department of Periodontics, University of Missouri-Kansas City, School of Dentistry. Dr. Theisen is an associate professor, Department of Oral and Maxillofacial Surgery, University of Missouri-Kansas City, School of Dentistry. Dr. Shultz is a professor and chairman, Department of Oral and Maxillofacial Surgery, University of Missouri-Kansas City, School of Dentistry. The authors wish to thank Chereyl Batliner, R.N., for her considerable and critical assistance in the clinical and data accumulation aspects of the study. 1. Bayliss R, Clarke C, Oakley C, Somerville W, Whitfield AGW. The teeth and infective endocarditis: a dilemma. Br Heart J 1983;50:506-12. 2. Duract DT. Infective endocarditis. In: Hoeprich PD, Jordan MC, eds. Infectious diseases: A modern treatise of infectious processes. 4th ed. Philadelphia: J.B. Lippincott; 1989:1237-53. 3. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277(22):1794-801. 4. Cobe HM. Transitory bacteremia. Oral Surg Oral Med Oral Pathol 1954;7:609-15. 5. Sconyers JR, Crawford JJ, Moriarity JD. Relationship of bacteremia to toothbrushing in patients with periodontitis. JADA 1973;87:616-22. 6. Felix C, Rosen S, App G. Detection of bacteremia after use of oral irrigation device in

Our study is consistent with previous reports on the incidence of bacteremia associated with the postoperative removal of intraoral sutures. However, we concur with the 1997 AHA recommendation that BEP is not required for the procedure in any susceptible patient. As the AHA notes, the recommendations are not to be construed as being standards; this leaves the door open for clinicians to use their clinical judgment about whether to use BEP in specific or atypical situations. Furthermore, this study has shown that use of a preprocedural antibiotic rinse unfortunately

subjects with periodontitis. J Periodontol 1971;42:785-7. 7. Faden HS. Dental procedures and bacteremia. Ann Intern Med 1974;81:274. 8. Bender IB, Naidorf IJ, Garvery GJ. Bacterial endocarditis: a consideration for physician and dentist. JADA 1984;109:41520. 9. Wahl MJ. Myths of dental-induced endocarditis. Compend Contin Educ Dent 1994;15(9):1100-20. 10. Lockhart PB, Schmidtke MA. Antibiotic considerations in medically compromised patients. Dent Clin North Am 1994;38(3):381402. 11. King RC, Crawford BA, Small EW. Bacteremia following intraoral suture removal. Oral Surg Oral Med Oral Pathol 1988;65:23-8. 12. Giglio JA, Rowland RW, Dalton HP, Laskin DM. Suture removal-induced bacteremia: a possible endocarditis risk. JADA 1992;123:65-70. 13. Pallasch TJ, Slots J. Antibiotic prophylaxis for medical risk patients. J Periodontol 1991;62:227-31. 14. Fine DH, Korik I, Furgang D, et al. Assessing pre-procedural subgingival irrigation and rinsing with an antiseptic mouthrinse to reduce bacteremia. JADA 1996;127:641-6. 15. Rahn R, Schneider S, Diehl O, Schafer V, Shah P. Preventing post-treatment bacteremia: comparing topical povidone-iodine and chlorhexidine. JADA 1995;126:1145-9. 16. Larsen PE. The effect of chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg 1991;49:932-7. 17. Ragno JR, Szkutnik AJ. Evaluation of 0.12 percent chlorhexidine rinse on the prevention of alveolar osteitis. Oral Surg Oral Med Oral Pathol 1991;72:524-6. 18. Epstein J, Vickars L, Spinelli J, Reece D. Efficacy of chlorhexidine and nystatin rinses in prevention of oral complications in leukemia and bone marrow transplantation. Oral Surg Oral Med Oral Pathol 1992;73:682-9. 19. Lofthus JE, Waki MY, Jolkovsky DL, et al. Bacteremia following subgingival irrigation and scaling and root planing. J Periodontol 1991;62:602-7. 20. Zaidi AK, Knaut AL, et al. Value of routine anaerobic blood cultures for pediatric patients. J Pediatr 1995;127:263-8. 21. Crawford JJ, Sconyers JR, Moriarty JD, King RC, West JF. Bacteremia after tooth extractions studied with the aid of prereduced anaerobically sterilized culture media. Appl Microbiol 1974;27:927-32. 22. Little JW, Falace DA. Infective endocarditis. In: Little JW, Falace DA, eds. Dental management of the medically compromised patient. 4th ed. St. Louis: Mosby; 1992:98-135. 23. Durack DT. Prevention of infective endocarditis. N Engl J Med 1995;332(1):38-44. 24. Guntheroth WG. How important are dental procedures as a cause of infective endocarditis? Am J Cardiol 1984;54:797-801.

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