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Staphylococcus Species Bacteria in Oral Cavity: A Potential Risk for Prosthetic Hips and Knees
489
LETTERS TO THE EDITOR osteoporosis than the CTX has for bisphosphonate-induced osteonecrosis of the jaws. Dr Dodson is correct to demand more data, particularly concerning an indirect test such as the CTX. However, he seems to be less demanding of the data linking the DEXA scan and its BMD values to the occurrence of osteopenia and osteoporosis, particularly when recent independent studies, not sponsored by the bisphosphonate drug makers, have shown the very therapeutic value of oral bisphosphonates to be in serious question.3-5 Moreover, he seems to be unaware that additional correlative data are present in published medical studies. Actually, almost every osteoporosis study, even those conducted or sponsored by the bisphosphonate drug companies, used the CTX as a marker of bone turnover suppression and showed the same correlations to dosage, interval of exposure, and “drug holiday,” as was shown in the report by Kunchur et al and ours.1,2,6,7 Moreover, the findings in these 2 reports are remarkably the same and, therefore, represent a strong database, particularly considering that these studies were conducted on 2 different continents, with 2 different populations, with the CTX testing done at 2 separate and independent laboratories, all without collaboration between the 2 centers. One can become too dependent on statistical analysis. Most of us in research know that statistics can be made to support nearly any conclusion and opinion. They also can be recalculated to support a different conclusion, opinion, or bias. I see nothing wrong with the selection of the appropriate statistical method performed in the report by Kunchur et al.1 Although we academicians can debate the correlations of the BMD and CTX tests, the overview for the readers of the Journal is that both tests are imperfect but not invalid. My own studies have found the CTX test to not correlate well with bisphosphonate suppression of bone turnover in the presence of active cancer or concomitant or past methotrexate, raloxifene, or prednisone use. It also has a paradoxical lowering of its value at the beginning of a “drug holiday” in patients with 8 years or more of steady oral bisphosphonate use, particularly alendronate (Fosamax), which causes the vast majority of cases of oral bisphosphonate-induced osteonecrosis of the jaws because, among other factors, it is marketed at twice the dose of either ibandronate (Boniva) or residronate (Actonel). These data will be included in a future report. However, for the usual patient taking an oral bisphosphonate for osteopenia or osteoporosis, we have found the CTX test to be a good clinical guide to their state of bone turnover suppression, to the appropriateness of a drug holiday, and the needed length of the drug holiday (note, no oral bisphosphonate has been approved or even recommended by the Food and Drug Administration for osteopenia, yet many physicians have been encouraged to, and do, prescribe it for osteopenia). These data are consistent with the data from the sentinel study by Black et al,7 which also independently correlated increasing CTX values to a drug holiday and documented that the therapeutic value of alendronate (Fosamax) is limited to 5 years or less. Certainly, Dr Dodson is ultimately correct in demanding more data on the CTX test. I agree, but do not we also need more data on orthognathic surgery relapse, the causation of dry sockets, temporomandibular joint arthroscopy, the appropriateness of hyperbaric oxygen therapy for osteoradionecrosis, and just about everything we do? ROBERT E. MARX, DDS Miami, FL
References 1. Kunchur R, Need A, Hughes T, et al: Clinical investigation of C-terminal cross-linking telopeptide test in prevention and management of bisphosphonate-associated-osteonecrosis of the jaws. J Oral Maxillofac Surg 67:1167, 2009 2. Marx RE, Cillo JE Jr, Ulloa JJ: Oral bisphosphonate induced osteonecrosis: Risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg 65:2397, 2007 3. Alonso-Cuello P, Garcia-Franco AL, Guyatt C, et al: Drugs for pre-osteoporosis: Prevention or disease mongering. BMJ 336: 126, 2008 4. JaJanven TLN, Sievanen H, Khan KM, et al. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 336:124, 2008 5. Adani A, Isaia G, Luisetto S, et al: Osteoporosis treatment and fracture incidence: The ICARO longitudinal study. Osteoporos Int 19:1219, 2008 6. Cummings SR, Black DM, Thimpson DE, et al: Effects of alendronate on risk of fracture in women with low bone density but without vertebral fractures: Results from the Fracture Intervention Trial. JAMA 280:2077, 1998 7. Black DM, Schwartz AV, Ensrud KE, et al: Effect of continuing or stopping alendronate after 5 years of treatment. JAMA 296:2927, 2006
doi:10.1016/j.joms.2009.09.043
STAPHYLOCOCCUS SPECIES BACTERIA IN ORAL CAVITY: A POTENTIAL RISK FOR PROSTHETIC HIPS AND KNEES To the Editor:—A recent editorial in the Journal (J Oral Maxillofac Surg 67:1789-1790, 2009) about the need or lack thereof to provide antibiotic prophylaxis for patients with prosthetic hip and knee joints in place for more than 2 years and needing invasive dental treatment likely to cause a bacteremia with risk of infection and need of removal was intellectually stimulating. My specific concern was the clause “colonization at the time of (joint implant) surgery with Staphylococcus aureus and Staphylococcus epidermidis . . . remain(s) the primary source of infection (and that these) are gastrointestinal or cutaneous organisms.” The implication of this statement is that these bacteria are not found within the oral cavity, are not involved in dentofacial infections, and that the maxillofacial surgeon’s manipulation of tissues is without risk of causing a late hip or knee joint infection. As a surgeon who obtains cultures from all incision and drainage procedures, I frequently receive from the laboratory a report that identifies a mixed infection containing 1 or both of the these micro-organisms. To substantiate my clinical impression, I conducted a Medline search using the terms “oral cavity” and “staphylococcus” for the publication years 1999 through 2009. The first reference is consistent with the findings of numerous other researchers who have noted the ubiquitous nature of Staphylococcus species in the oral cavity, whereas all other citations are limited to those in which the patients were or might become in the future symptomatic with a dental infection and could require treatment by an oral and maxillofacial surgeon whose interventions might result in a bacteremia. Ohara-Nemoto et al1 demonstrated the abundant presence of Staphylococcus aureus and Staphylococcus epidermidis in the saliva and supragingival plaque specimens obtained from healthy dental students without evidence of periodontal disease or dental caries. Murdoch et al2 reported that more than half of young (aged 32-59 years, mean age 45) healthy individuals with periodontitis evi-
490
LETTERS TO THE EDITOR
dence both S. aureus and S. epidermidis in their subgingival sulci.2 These researchers also noted the ubiquitous presence of these same organisms from the patients’ palate and floor of mouth. The origin of these bacteria may be in question, but it is known that some are transiently resident in the oral cavity and that adherence mechanisms permit a portion of them to be retained in the periodontal pocket. Furthermore, because of microulceration of the sulcular and pocket lining epithelium and proximity to the bloodstream, bacteremias are likely to occur. Of significance, the epidermidis species is the predominant organism and is penicillin-resistant. Leonhardt et al3 noted that individuals with peri-implantitis, that is, failing implants defined as 3 or more exposed threads, bleeding on probing, or suppuration and radiographic evidence of bone loss on occasion (17%) demonstrate S. epidermidis in subgingival/peri-implant sulci. Acute endodontic infections are also an issue; in a letter to the British Medical Journal, a group of endodontists reported that staphylococci were isolated from aseptically opened root canals in 8 of 86 (9%) patients, and in 2 of these cases, staphylococci bacteria were the sole and major isolate from the canals.4 Smith et al5 reported that on culture, S. aureus was recovered from 6 patients with dentoalveolar abscesses and 1 patient with localized alveolar osteitis (dry socket). Similarly, in our own Journal, Storoe et al6 reported that individuals with odontogenic infections resulting in swelling of the face or neck and requiring extraoral drainage after rigorous preoperative antimicrobial skin preparation to avoid contamination of bacterial cultures many times evidence a polymicrobial milieu with significant presence of both S. aureus and coagulase-negative staphylococci (which was probably S. epidermidis but could not be stated with certainty because of changes in reporting protocol). Furthermore, many oral and maxillofacial surgical patients are treated in the operating room using general anesthesia. Of specific concern is the report of Valdes et al,7 which noted that of 60 patients provided nasoendotracheal intubation, almost 12% evidenced a bacteremia at 30 s and of these, 57% were Staphylococcus species. Similarly, of 50 patients provided oroendotracheal intubation, 12% developed a bacteremia at 30 s, and 50% of these were Staphylococcus species. Of concern, these isolates were often resistant to amoxicillin. Preoperative consultation between the surgeon and anesthesiologist should include choosing the most appropriate intravenous antibiotic agent and timing of administration so the patient is protected during both the intubation procedure and the surgical exercise. These results lead me to conclude that the constituents of oral microbial infections are more diverse than was suggested in the editorial. Thus, it logically follows that on occasion oral and maxillofacial surgical procedures may cause Staphylococcus bacteremias, which could be implicated in late joint prostheses infections. Furthermore, given staph’s occasional resistance to -lactam antibiotics including amoxicillin and some cephalosporins, I consider the German Society for Orthopaedics and Traumatology Prophylaxis recommendations8 with a suggested drug regimen of orally administering 2 g of amoxicillin-clavulanate or 600 mg of clindamycin by mouth shortly before and 4 hours after (this later dose is probably superfluous) dental treatment to be more appropriate than that recommended by the orthopedic societies (2 g of either cephalexin, cephradine or amoxicillin, 1 hour before procedure). ARTHUR H. FRIEDLANDER, DMD Los Angeles, CA
References 1. Ohara-Nemoto Y, Haraga H, Kimura S, et al: Occurrence of staphylococci in the oral cavities of healthy adults and nasal-oral trafficking of the bacteria. J Med Microbiol 57:95, 2008 2. Murdoch FE, Sammons RL, Chapple IL: Isolation and characterization of subgingival staphylococci from periodontitis patients and controls. Oral Dis 10:155, 2004 3. Leonhardt A, Renvert S, Dahlén G: Microbial findings at failing implants. Clin Oral Implants Res 10:339, 1999 4. Tsang PC, Chu FC, Samaranayake LP: Staphylococci may indeed cause acute dental infections. BMJ 325:599, 2002 5. Smith AJ, Robertson D, Tang MK, et al: Staphylococcus aureus in the oral cavity: A three-year retrospective analysis of clinical laboratory data. Br Dent J 195:701, 2003 6. Storoe W, Haug RH, Lillich TT: The changing face of odontogenic infections. J Oral Maxillofac Surg 59:739, 2001 7. Valdes C, Tomas I, Alvarez M, et al: The incidence of bacteraemia associated with tracheal intubation. J Anesth 63:588, 2008 8. Podbielski A, Pahncke D, Mittelmeier W: Antibiotic prophylaxis for patients with joint prosthesis undergoing dental treatment—A topic for discussion. Z Orthop Unfall 147:350, 2009
doi:10.1016/j.joms.2009.09.114
INTER-RADICULAR ADENOMATOID ODONTOGENIC TUMOR OF THE ANTERIOR MANDIBLE To the Editor:—Upon reading the recent report of adenomatoid odontogenic tumor (AOT) that was located between the roots of an erupted mandibular canine and first premolar by Gouvea et al,1 I would like to complement their case with one of my cases, which I have followed up for 14 years, to support the consistently benign behavior of this hamartomatous tumor and to re-emphasize the importance of smooth sclerotic margins and fine calcifications for radiographic diagnosis of this tumor type. The patient was a 22-year-old woman. During routine dental care, an asymptomatic, inter-radicular radiolucency was incidentally discovered in the mandibular right premolar region. There was no overlying bony expansion. Radiographs showed a small, unilocular radiolucent area with distinct radiopaque borders between slightly separated roots of the first and second premolars (Fig 1). Intralesional snowflake radiopacities were apparent. The clinical diagnosis of AOT was made. At surgery, a 1.0-cm diameter, rounded mass was attached to the root surface of the first
FIGURE 1. Round, inter-radicular radiolucency with smooth sclerotic margins. Note snowflake calcifications.
LETTERS TO THE EDITOR osteoporosis than the CTX has for bisphosphonate-induced osteonecrosis of the jaws. Dr Dodson is correct to demand more data, particularly concerning an indirect test such as the CTX. However, he seems to be less demanding of the data linking the DEXA scan and its BMD values to the occurrence of osteopenia and osteoporosis, particularly when recent independent studies, not sponsored by the bisphosphonate drug makers, have shown the very therapeutic value of oral bisphosphonates to be in serious question.3-5 Moreover, he seems to be unaware that additional correlative data are present in published medical studies. Actually, almost every osteoporosis study, even those conducted or sponsored by the bisphosphonate drug companies, used the CTX as a marker of bone turnover suppression and showed the same correlations to dosage, interval of exposure, and “drug holiday,” as was shown in the report by Kunchur et al and ours.1,2,6,7 Moreover, the findings in these 2 reports are remarkably the same and, therefore, represent a strong database, particularly considering that these studies were conducted on 2 different continents, with 2 different populations, with the CTX testing done at 2 separate and independent laboratories, all without collaboration between the 2 centers. One can become too dependent on statistical analysis. Most of us in research know that statistics can be made to support nearly any conclusion and opinion. They also can be recalculated to support a different conclusion, opinion, or bias. I see nothing wrong with the selection of the appropriate statistical method performed in the report by Kunchur et al.1 Although we academicians can debate the correlations of the BMD and CTX tests, the overview for the readers of the Journal is that both tests are imperfect but not invalid. My own studies have found the CTX test to not correlate well with bisphosphonate suppression of bone turnover in the presence of active cancer or concomitant or past methotrexate, raloxifene, or prednisone use. It also has a paradoxical lowering of its value at the beginning of a “drug holiday” in patients with 8 years or more of steady oral bisphosphonate use, particularly alendronate (Fosamax), which causes the vast majority of cases of oral bisphosphonate-induced osteonecrosis of the jaws because, among other factors, it is marketed at twice the dose of either ibandronate (Boniva) or residronate (Actonel). These data will be included in a future report. However, for the usual patient taking an oral bisphosphonate for osteopenia or osteoporosis, we have found the CTX test to be a good clinical guide to their state of bone turnover suppression, to the appropriateness of a drug holiday, and the needed length of the drug holiday (note, no oral bisphosphonate has been approved or even recommended by the Food and Drug Administration for osteopenia, yet many physicians have been encouraged to, and do, prescribe it for osteopenia). These data are consistent with the data from the sentinel study by Black et al,7 which also independently correlated increasing CTX values to a drug holiday and documented that the therapeutic value of alendronate (Fosamax) is limited to 5 years or less. Certainly, Dr Dodson is ultimately correct in demanding more data on the CTX test. I agree, but do not we also need more data on orthognathic surgery relapse, the causation of dry sockets, temporomandibular joint arthroscopy, the appropriateness of hyperbaric oxygen therapy for osteoradionecrosis, and just about everything we do? ROBERT E. MARX, DDS Miami, FL
References 1. Kunchur R, Need A, Hughes T, et al: Clinical investigation of C-terminal cross-linking telopeptide test in prevention and management of bisphosphonate-associated-osteonecrosis of the jaws. J Oral Maxillofac Surg 67:1167, 2009 2. Marx RE, Cillo JE Jr, Ulloa JJ: Oral bisphosphonate induced osteonecrosis: Risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg 65:2397, 2007 3. Alonso-Cuello P, Garcia-Franco AL, Guyatt C, et al: Drugs for pre-osteoporosis: Prevention or disease mongering. BMJ 336: 126, 2008 4. JaJanven TLN, Sievanen H, Khan KM, et al. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 336:124, 2008 5. Adani A, Isaia G, Luisetto S, et al: Osteoporosis treatment and fracture incidence: The ICARO longitudinal study. Osteoporos Int 19:1219, 2008 6. Cummings SR, Black DM, Thimpson DE, et al: Effects of alendronate on risk of fracture in women with low bone density but without vertebral fractures: Results from the Fracture Intervention Trial. JAMA 280:2077, 1998 7. Black DM, Schwartz AV, Ensrud KE, et al: Effect of continuing or stopping alendronate after 5 years of treatment. JAMA 296:2927, 2006
doi:10.1016/j.joms.2009.09.043
STAPHYLOCOCCUS SPECIES BACTERIA IN ORAL CAVITY: A POTENTIAL RISK FOR PROSTHETIC HIPS AND KNEES To the Editor:—A recent editorial in the Journal (J Oral Maxillofac Surg 67:1789-1790, 2009) about the need or lack thereof to provide antibiotic prophylaxis for patients with prosthetic hip and knee joints in place for more than 2 years and needing invasive dental treatment likely to cause a bacteremia with risk of infection and need of removal was intellectually stimulating. My specific concern was the clause “colonization at the time of (joint implant) surgery with Staphylococcus aureus and Staphylococcus epidermidis . . . remain(s) the primary source of infection (and that these) are gastrointestinal or cutaneous organisms.” The implication of this statement is that these bacteria are not found within the oral cavity, are not involved in dentofacial infections, and that the maxillofacial surgeon’s manipulation of tissues is without risk of causing a late hip or knee joint infection. As a surgeon who obtains cultures from all incision and drainage procedures, I frequently receive from the laboratory a report that identifies a mixed infection containing 1 or both of the these micro-organisms. To substantiate my clinical impression, I conducted a Medline search using the terms “oral cavity” and “staphylococcus” for the publication years 1999 through 2009. The first reference is consistent with the findings of numerous other researchers who have noted the ubiquitous nature of Staphylococcus species in the oral cavity, whereas all other citations are limited to those in which the patients were or might become in the future symptomatic with a dental infection and could require treatment by an oral and maxillofacial surgeon whose interventions might result in a bacteremia. Ohara-Nemoto et al1 demonstrated the abundant presence of Staphylococcus aureus and Staphylococcus epidermidis in the saliva and supragingival plaque specimens obtained from healthy dental students without evidence of periodontal disease or dental caries. Murdoch et al2 reported that more than half of young (aged 32-59 years, mean age 45) healthy individuals with periodontitis evi-
490
LETTERS TO THE EDITOR
dence both S. aureus and S. epidermidis in their subgingival sulci.2 These researchers also noted the ubiquitous presence of these same organisms from the patients’ palate and floor of mouth. The origin of these bacteria may be in question, but it is known that some are transiently resident in the oral cavity and that adherence mechanisms permit a portion of them to be retained in the periodontal pocket. Furthermore, because of microulceration of the sulcular and pocket lining epithelium and proximity to the bloodstream, bacteremias are likely to occur. Of significance, the epidermidis species is the predominant organism and is penicillin-resistant. Leonhardt et al3 noted that individuals with peri-implantitis, that is, failing implants defined as 3 or more exposed threads, bleeding on probing, or suppuration and radiographic evidence of bone loss on occasion (17%) demonstrate S. epidermidis in subgingival/peri-implant sulci. Acute endodontic infections are also an issue; in a letter to the British Medical Journal, a group of endodontists reported that staphylococci were isolated from aseptically opened root canals in 8 of 86 (9%) patients, and in 2 of these cases, staphylococci bacteria were the sole and major isolate from the canals.4 Smith et al5 reported that on culture, S. aureus was recovered from 6 patients with dentoalveolar abscesses and 1 patient with localized alveolar osteitis (dry socket). Similarly, in our own Journal, Storoe et al6 reported that individuals with odontogenic infections resulting in swelling of the face or neck and requiring extraoral drainage after rigorous preoperative antimicrobial skin preparation to avoid contamination of bacterial cultures many times evidence a polymicrobial milieu with significant presence of both S. aureus and coagulase-negative staphylococci (which was probably S. epidermidis but could not be stated with certainty because of changes in reporting protocol). Furthermore, many oral and maxillofacial surgical patients are treated in the operating room using general anesthesia. Of specific concern is the report of Valdes et al,7 which noted that of 60 patients provided nasoendotracheal intubation, almost 12% evidenced a bacteremia at 30 s and of these, 57% were Staphylococcus species. Similarly, of 50 patients provided oroendotracheal intubation, 12% developed a bacteremia at 30 s, and 50% of these were Staphylococcus species. Of concern, these isolates were often resistant to amoxicillin. Preoperative consultation between the surgeon and anesthesiologist should include choosing the most appropriate intravenous antibiotic agent and timing of administration so the patient is protected during both the intubation procedure and the surgical exercise. These results lead me to conclude that the constituents of oral microbial infections are more diverse than was suggested in the editorial. Thus, it logically follows that on occasion oral and maxillofacial surgical procedures may cause Staphylococcus bacteremias, which could be implicated in late joint prostheses infections. Furthermore, given staph’s occasional resistance to -lactam antibiotics including amoxicillin and some cephalosporins, I consider the German Society for Orthopaedics and Traumatology Prophylaxis recommendations8 with a suggested drug regimen of orally administering 2 g of amoxicillin-clavulanate or 600 mg of clindamycin by mouth shortly before and 4 hours after (this later dose is probably superfluous) dental treatment to be more appropriate than that recommended by the orthopedic societies (2 g of either cephalexin, cephradine or amoxicillin, 1 hour before procedure). ARTHUR H. FRIEDLANDER, DMD Los Angeles, CA
References 1. Ohara-Nemoto Y, Haraga H, Kimura S, et al: Occurrence of staphylococci in the oral cavities of healthy adults and nasal-oral trafficking of the bacteria. J Med Microbiol 57:95, 2008 2. Murdoch FE, Sammons RL, Chapple IL: Isolation and characterization of subgingival staphylococci from periodontitis patients and controls. Oral Dis 10:155, 2004 3. Leonhardt A, Renvert S, Dahlén G: Microbial findings at failing implants. Clin Oral Implants Res 10:339, 1999 4. Tsang PC, Chu FC, Samaranayake LP: Staphylococci may indeed cause acute dental infections. BMJ 325:599, 2002 5. Smith AJ, Robertson D, Tang MK, et al: Staphylococcus aureus in the oral cavity: A three-year retrospective analysis of clinical laboratory data. Br Dent J 195:701, 2003 6. Storoe W, Haug RH, Lillich TT: The changing face of odontogenic infections. J Oral Maxillofac Surg 59:739, 2001 7. Valdes C, Tomas I, Alvarez M, et al: The incidence of bacteraemia associated with tracheal intubation. J Anesth 63:588, 2008 8. Podbielski A, Pahncke D, Mittelmeier W: Antibiotic prophylaxis for patients with joint prosthesis undergoing dental treatment—A topic for discussion. Z Orthop Unfall 147:350, 2009
doi:10.1016/j.joms.2009.09.114
INTER-RADICULAR ADENOMATOID ODONTOGENIC TUMOR OF THE ANTERIOR MANDIBLE To the Editor:—Upon reading the recent report of adenomatoid odontogenic tumor (AOT) that was located between the roots of an erupted mandibular canine and first premolar by Gouvea et al,1 I would like to complement their case with one of my cases, which I have followed up for 14 years, to support the consistently benign behavior of this hamartomatous tumor and to re-emphasize the importance of smooth sclerotic margins and fine calcifications for radiographic diagnosis of this tumor type. The patient was a 22-year-old woman. During routine dental care, an asymptomatic, inter-radicular radiolucency was incidentally discovered in the mandibular right premolar region. There was no overlying bony expansion. Radiographs showed a small, unilocular radiolucent area with distinct radiopaque borders between slightly separated roots of the first and second premolars (Fig 1). Intralesional snowflake radiopacities were apparent. The clinical diagnosis of AOT was made. At surgery, a 1.0-cm diameter, rounded mass was attached to the root surface of the first
FIGURE 1. Round, inter-radicular radiolucency with smooth sclerotic margins. Note snowflake calcifications.