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23 February 2021

Factors affecting incidence of bacteremia due to dental extractions

AUTHORS: Gabriele Villani, Giovanni Lodi, Andrea Sardella, Clementina Elvezia Cucuzza, Rosario Musumeci, Marianna Martinelli, Elena Maria Varoni

 Bacteremia of oral origin is defined as the presence of bacteria, coming from the supra and subgingival plaque, in the bloodstream. Usually, bacteremia is transient and asymptomatic, but in some cases, it can lead to clinical sequelae, such as septic shock and distant-site infections, including infective endocarditis. Many dental procedures and toothbrushing, can lead to the dissemination of these bacteria in the bloodstream, so, over time, antibiotic prophylaxis protocols have been set for patients at risk who are about to undergo to invasive dental procedures (e.g dental extractions, scaling and root planing). However, the role of patient’s clinical history and clinical picture in influencing the bacteremia associated with these dental procedures is still controversial. The aim of this review is to analyze all those factors that, according to the literature, could be related with the incidence of bacteremia after tooth extractions, in patients at high risk of infective endocarditis.

Materials and methods: we performed a research in Pubmed and Google Scholar, including all clinical randomized trials aimed at analyzing the incidence of bacteremia after extractions through the analysis of blood samples.

Results and conclusions: in patients at high risk of infective endocarditis, antibiotic prophylaxis using amoxicillin can produce a significant reduction on the incidence of bacteremia after tooth extractions. Second-choice antibiotics in prophylaxis, such as clindamycin or azitromycin, lead to lower reduction in bacteremia, as well as being associated with a greater number of adverse reactions. Also chlorhexidine mouthwash is less effective than amoxicillin, however, since it’s cheap and is characterized by a total absence of adverse reactions, routine use is recommended before dental extractions. No strong correlation between the incidence of bacteremia and the patient's age or sex, the number of teeth to extracted, the invasiveness of the procedure and the periodontal health indices could be found. However, further randomized clinical trials are required to show a conclusive dissertations; in particular, studies that analyze the prevalence of infective endocarditis as primary clinical outcome, and studies that identify the number of bacteria in the bloodstream are needed, since most of literature currently focuses only on the incidence of bacteremia (presence / absence of bacteria in the blood). The uses of antibiotic prophylaxis before tooth extractions in patients at risk has been largely debated, over the last few years. However, amoxicillin was found to significantly reduce the incidence of bacteremia due to dental extractions, in high risk patients.

Clinical significance: this review analyzes all those factors that could be related to the incidence of bacteremia after dental extractions, providing to the clinician useful information to assess the bacteremic risk incurred by any patient who is about to undergo that procedure.

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