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Gingival Autografts as an Adjunct to Removable Partial Dentures
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CLINICAL
REPORTS
Gingival autografts as an adjunct to removable partial dentures Nicholas M. Dello Russo, DMD, MScD
Partial dentures often stress the tissues that support them. Two cases are described in which gingival autografts were used to restore the eroded tissue.
T he tw o cases illu strate th e ty p es of p roblem s th a t m ay occur.
R eport o f cases Case 1
M
o st c lin ic ia n s ag re e th a t th e h u m a n d e n titio n fu n ctio n s best w h en th e te eth are su rro u n d e d by a zone of a ttach ed k eratin ized g in g iv a.1 T he at tach ed g in g iv a h elp s pro tect th e u n d erly in g p e rio d o n ta l tissu es from the s tre s s e s o f m a s tic a tio n a n d to o th b ru sh in g a n d m ay retard the sp read of a m arg in al inflam m atory process. A l th o u g h d isa g re em en t exists as to how m u c h attac h ed gin g iv a is n ecessary,2 a zo ne of ap p ro x im ately 2 m m seem s c o n siste n t w ith p erio d o n tal h ealth in u n resto re d te e th .3 T he p la ce m en t of fixed or rem ovable p artial d en tu re s, how ever, subjects the te eth an d th e ir su p p o rtin g tissues to stresses of a differen t m agnitude; and th e s e te e th o fte n d e m a n d a m o re ro b u st p e rio d o n tiu m th a n u n resto re d teeth require. S uch a situ atio n occurs on th e lin g u a l asp ect of th e m a n d ib u lar an terio r te e th w h en a free-end sa d d le p artial d e n tu re is present. T he lin gual b ar of th ese partial d en tu res rests on th e soft tissu es lin g u a l to the in cisors an d ca n in e s a n d m ay place a great deal of p ressu re on th ese tissues, esp ecially if th e re is an y m ovem ent of th e p artial d e n tu re or if settling occurs.
A 54-year-old m an had severe pain in the m andibular anterior region w hen he tried to w ear his m andibular rem ovable partial d en tu re . T he clin ical exam ination d is closed that th e patient was edentulous, dis tal to both first prem olars in the low er arch, and had a free-end saddle type partial d en ture, w hich had not been relined in several years. The denture had settled and the lin gual bar was pressing heavily on the tissue lingual and apical to the m andibular in cisors. Figure 1 show s the area w hen the patient was first exam ined. There are two bony exostoses, clearly visible beneath the alveo lar mucosa. These are the m ental spines4 from w hich the genioglossus m uscle origi nates. Pressure of the lingual bar on these bony protruberances was causing the pain. The area could be treated w ith a free gingi val autograft, w hich w ould act as a buffer betw een the partial denture and the bone. W hile the patient was u n d er local anes thesia, the alveolar mucosa was carefully dissected away from the distal side of the right lateral incisor to the distal side of the left lateral incisor. A decision was m ade not to reduce the m ental spines for fear that the genioglossus m uscle w ould be damaged. A gingival autograft was obtained from the palate by the standard technique5 and was sutured to the recipient site w ith no. 4-0 interrupted silk sutures (Fig 2). Healing was uneventful. F ig u re 3 sh o w s th e site a fte r th re e m onths. At th a t time, a new partial denture was m ade, and the patient was able to wear it comfortably. At the one-year follow-up
visit, the patient reported that he w as able to w ear the partial denture comfortably.
Case 2 A 37-year-old woman was referred by a general dentist, w ho w as in the process of m aking a new m andibular rem ovable par tial denture. The patient w as w earing a free-end saddle partial denture, w hich was several years old. The retentive and bracing arm s and the occlusal rests had broken off from the partial denture, and the prosthesis had settled into the mucosa lingual to the m andibular left canine (Fig 4). W hen the partial denture was removed and the tissues examined (Fig 5), a large area of gingival erosion was observed on th e lingual sid e of the m an d ib u lar left canine. All of the lingual attached gingiva had been lost, and approxim ately 4 to 5mm of cem entum was exposed. Moreover, the mucosal tissues w ere grossly inflam ed and very painful to touch. To reconstruct the lost periodontal tissues, a free palatal gin gival autograft w as used. The epithelial and subm ucosal connective tissues w ere re moved with a no. 15 scalpel, w hich left the recipient site of alveolar bone covered with periosteum (Fig 6). After the exposed root surface was lightly planed, a free gingival autograft was obtained from the palate and was sutured firmly to the recipient site with no. 5-0 chrom ic gut suture (Fig 7). H ealing w as uneventful; Figure 8 shows the site 12 weeks after surgery. The graft is firmly bound, and approxim ately 3 mm of root coverage has been achieved. At that point the patient was ready to proceed with the prosthetic phase of therapy.
D iscu ssio n T he free-en d sa d d le (distal extension) rem ovable p a rtia l d e n tu re h as been describ ed as on e of th e m ost d ifficult JADA, Vol. 104, F ebruary 1982 « 1 7 9
Fig 3
Patient 1. Fig 1 ■ Before surgery. Lingual view of mandibular anterior teeth showing two prom inent mental spines beneath central incisors. Fig 2 ■ Free gingival graft is sutured to recipient site. Fig 3 ■ Three months later. Mental spines are covered with dense collagenous connective tissue.
Fig 4
Fig 6
Fig 8 Patient 2. Fig 4 ■ Mandibular free-end remov able partial denture has settled, pressing into mucosal tissues on lingual side of canine. Brac ing arm and occlusal re st are absent. Fig 5 ■ Damaged tissue on lingual side of mandibu lar left canine. Fig 6 ■ Damaged tissue has been removed and recipient site prepared to accept graft. Fig 7 ■ Graft is sutured into place up to cementoenamel junction. Fig 8 ■ Three months later. Patient is ready for prosthetic phase of treatment.
Fig 5
Fig 7
p ro s th e tic p ro b le m s.6 T h is ty p e of p ro sth esis is only partially su p p o rted by teeth an d m ust d ep e n d on th e ed e n tu lo u s ridges for a good deal of its su p p o rt an d stability. T hese ridges are in h eren tly labile and often resorb u n d er th e co n tin u in g stresses of m astication. As th e ridges resorb, th e partial d e n tu re w ill settle, a process w hich places large am ounts of torque on the ab u t m en t teeth and cause the lingual bar to press in to the un d erly in g soft tissues. T h ese occurrences m ay severely com p rom ise the abutm ent teeth an d lead to failure of the prosthesis.
Several s tu d ie s7 have sh o w n th a t th e u se of re m o v a b le p a r tia l d e n tu re s com prom ises th e p erio d o n tal h ea lth of th e s u p p o rtin g te e th alth o u g h , if a high level of p laq u e control is m a in tained and th e p atien t is frequently m onitored, th ese adverse effects can be k ept to a m in im u m .8 In p la n n in g a re m ovable p a rtia l d en tu re , esp ecially the free-end sad d le type, th e resto ra tive d en tist m u st carefully exam ine th e periodontal h ealth of th e rem ain in g te e th , in c lu d in g th e am o u n t of a t tached gingiva on th e lin g u al asp ect of th e low er anterio r teeth on w h ich the
180 ■ JADA, Vol. 104, February 1982
lin g u al bar w ill rest. If th is tissu e is insufficient, it sh o u ld be reco n stru cted before the m an u factu re of th e partial d en tu re .9-10
Sum m ary and recom m en dations T he lin g u al bar of a m an d ib u la r re m ovable p artial den tu re, esp ecially a free-end sa d d le type, m ay exert a great deal of p re ssu re on th e u n d e rly in g perio d o n tal tissues. It is best th a t th e lingual bar be p laced as far aw ay from th e m arginal tissues as possible b ut
CLINICAL
still on d ense, collagenous attached gingiva. If an in ad eq u ate am o u n t of attached gin g iv a is p rese n t on the lin g u al su r faces of th e m a n d ib u la r an terio r teeth, th is tissu e m ay be augm ented by a free, palatal g ingival autograft. T he p atien t w ith a p artial d en tu re m u st be con s t a n t l y m o n i t o r e d to d e t e r m i n e w h eth e r an y changes have occurred in th e ed e n tu lo u s sa d d le areas. R esorp tio n of th ese rid g es m ay allow th e p ar tia l d e n tu re to settle, th ereb y com p ro m isin g th e perio d o n tal h ealth of th e su p p o rtin g teeth. fT i& l
The author thanks Dr. Arnold Watkin and Miss Janice Bowen for their assistance. Dr. Dello Russo is in private practice and is the staff periodontist at the Beth Israel Hospital in Boston. Address requests for reprints to Dr. Dello Russo, 2 Center Plaza, Government Center, Bos ton, 02108. 1. Goldman, H.M., and Cohen, D.W. Periodon tal therapy, ed 5. St. Louis, C. V. Mosby Co, 1973, p 339. 2. Dorfman, H.S.; Kennedy, J.E.; and Bird, W.C. Longitudinal evaluation of free autogenous gin gival grafts. J Clin Periodontol 7(4) :316-324,1980. 3. Lang, N.P., and Loe, H. The relationship be tween the width of keratinized gingiva and gingi val health. J Periodont 43:623-627, 1972. 4. Goss, C.M. Gray’s anatomy, ed 28. Philadel phia, Lea & Febiger, 1966; p 164. 5. Sullivan, H.C., and Atkins, J.H. Free au
REPORTS
togenous gingival grafts. Principles of successful grafting. Periodontics 6:121-129, 1968. 6. Amsterdam, M. Periodontal prosthesis. Twenty-five years in retrospect. Alpha Omegan 67(3):8-52, 1974. 7. Carlsson, G.E.; Hedegard, B.; and Koivvmaa, K.K. Studies in partial denture prosthesis. Final results of a four year longitudinal investigation of dentogingivally supported partial dentures. Acta Odontol Scand 23:443, 1965. 8. Bergman, B.; Hugoson, A.; and Olsson, C.O, Caries and periodontal status in patient fitted with removable partial dentures. J Clin Perio dontol 4:134, 1977. 9. Schokking, C.C. Free grafts of palatal mu cosa on the lingual aspect of the mandible.J Clin Periodontol 3(4):251-255, 1976. 10. Langer, B., and Calagna, L. The alteration of lingual mucosa with free gingival grafts. J Periodontol 42(12):646-648, 1978.
Dental treatment and management of a patient with a prosthetic heart valve J. Craig Baumgartner, DDS William F. Plack III, DDS Dental treatment can produce transient bacteremias, which can be life-threatening to patients with prosthetic heart valves. Precautions can prevent serious complications.
T
J L h o u s a n d s o f p r o s th e t ic h e a r t valves are p laced in p atien ts each year in th e U n ited S tates.1 A lthough the p ro sth esis m ay increase th e p a tie n t’s life sp an a n d q u ality of life, th e p atien t requ ires close m edical atten tio n for the rest of h is or h e r life. O f p articu la r in terest to d en tists is th e su sc ep tib ility of p atien ts w ith pro sth etic h eart valves to infective endo card itis, or m ore specif ically, to p ro sth etic valv u lar endocar ditis. P ro sth etic valv u lar en docarditis m ay be caused by bacteria, fungi, rickettsia, an d possibly chlam ydiae or vi ru ses.2 W a ta n a k u n a k o rn 3,4 re p o rte d th a t th e in c id en c e of early pro sth etic v al v u la r en d o card itis, occurring w ith in
tw o m o n th s of th e o peration, is ap p ro x im a tely 1% a n d late p ro sth etic valv u lar endo card itis, occurring after th e first tw o m o n th s, is also 1%. At som e m ed ical centers, p atien ts w ith p ro sth e tic v a lv u la r en d o c a rd itis ac co u n t for a large p ercen tag e of infec tiv e en d o c ard itis,3 for exam ple, 33% of all cases of infective en d o card itis at th e R ush-P resbyterian-St. Lukes H os p ita l in Chicago. Early p ro sth etic val vular en d o c ard itis is th o u g h t to resu lt from c o n ta m in a tio n d u rin g surgery, an d late p ro sth etic v alv u lar end o car d itis is th o u g h t to be cau sed by tra n s ie n t b lo o d -b o rn e m ic ro o rg a n ism s. T he p resen ce of m icroorganism s is re cognized as a fu n d am en tal event in th e p a th o g e n e sis of in fec tiv e an d p ro s th etic v alv u lar en d o c ard itis.5-6 In 1930, R u sh to n 7 d em o n strated the presen ce of b acterem ia after to o th ex traction. W e n o w k n o w th a t th e p res ence of blood-bo rn e m icro o rg an ism s is a c o m m o n o c c u r r e n c e 8 a n d th a t nu m e ro u s d en tal p ro ced u res p ro d u ce tran sien t bacterem ias.9' 12 A n tib io tic th e ra p y to p rev en t p ro s th etic v alv u lar en d o c ard itis is u se d in
s u s c e p tib le p a tie n ts h a v in g d e n ta l tre a tm e n t th a t m ay p ro d u c e b lo o d b orne m icroorganism s. A stu d y 5 in an an im al m o d el su p p o rts th e effective n e s s o f c u r r e n t r e g im e n s r e c o m m e n d ed by a co m m ittee of th e A m eri can H eart A sso c iatio n .13 No clinical stu d ies h av e been d one to show that infective en d o c ard itis is p rev en ted by th e use of an tib io tics w ith suscep tib le p atien ts. A p p ro v al of su ch a stu d y by an y h u m a n subjects com m ittee is u n likely. D ental trea tm e n t has been rela ted to th e o n set of p ro sth etic v alv u lar e n d o card itis. In a rep o rt by K archm er an d asso ciates,14 n in e of 43 p atien ts w ith late p ro sth etic v alv u lar en d o car d itis h ad d en tal treatm en t before th e o n set of sym ptom s. Tw o oth er p atien ts in th a t gro u p h ad severe p eriodontal disease. O nly th ree of n in e p atien ts re c e iv in g d e n ta l tre a tm e n t h a d b ee n p la c e d o n p r o p h y la c tic a n tib io tic therapy. T h e m ortality rate w as 53%. In an o th er s tu d y rep o rted by D ism ukes an d asso ciates,15 of 19 cases of late p ro sth etic v alv u lar en d o card itis, four p atien ts h ad received d en tal treatm en t JADA, Vol. 104, February 1982 ■ 181
CLINICAL
REPORTS
Gingival autografts as an adjunct to removable partial dentures Nicholas M. Dello Russo, DMD, MScD
Partial dentures often stress the tissues that support them. Two cases are described in which gingival autografts were used to restore the eroded tissue.
T he tw o cases illu strate th e ty p es of p roblem s th a t m ay occur.
R eport o f cases Case 1
M
o st c lin ic ia n s ag re e th a t th e h u m a n d e n titio n fu n ctio n s best w h en th e te eth are su rro u n d e d by a zone of a ttach ed k eratin ized g in g iv a.1 T he at tach ed g in g iv a h elp s pro tect th e u n d erly in g p e rio d o n ta l tissu es from the s tre s s e s o f m a s tic a tio n a n d to o th b ru sh in g a n d m ay retard the sp read of a m arg in al inflam m atory process. A l th o u g h d isa g re em en t exists as to how m u c h attac h ed gin g iv a is n ecessary,2 a zo ne of ap p ro x im ately 2 m m seem s c o n siste n t w ith p erio d o n tal h ealth in u n resto re d te e th .3 T he p la ce m en t of fixed or rem ovable p artial d en tu re s, how ever, subjects the te eth an d th e ir su p p o rtin g tissues to stresses of a differen t m agnitude; and th e s e te e th o fte n d e m a n d a m o re ro b u st p e rio d o n tiu m th a n u n resto re d teeth require. S uch a situ atio n occurs on th e lin g u a l asp ect of th e m a n d ib u lar an terio r te e th w h en a free-end sa d d le p artial d e n tu re is present. T he lin gual b ar of th ese partial d en tu res rests on th e soft tissu es lin g u a l to the in cisors an d ca n in e s a n d m ay place a great deal of p ressu re on th ese tissues, esp ecially if th e re is an y m ovem ent of th e p artial d e n tu re or if settling occurs.
A 54-year-old m an had severe pain in the m andibular anterior region w hen he tried to w ear his m andibular rem ovable partial d en tu re . T he clin ical exam ination d is closed that th e patient was edentulous, dis tal to both first prem olars in the low er arch, and had a free-end saddle type partial d en ture, w hich had not been relined in several years. The denture had settled and the lin gual bar was pressing heavily on the tissue lingual and apical to the m andibular in cisors. Figure 1 show s the area w hen the patient was first exam ined. There are two bony exostoses, clearly visible beneath the alveo lar mucosa. These are the m ental spines4 from w hich the genioglossus m uscle origi nates. Pressure of the lingual bar on these bony protruberances was causing the pain. The area could be treated w ith a free gingi val autograft, w hich w ould act as a buffer betw een the partial denture and the bone. W hile the patient was u n d er local anes thesia, the alveolar mucosa was carefully dissected away from the distal side of the right lateral incisor to the distal side of the left lateral incisor. A decision was m ade not to reduce the m ental spines for fear that the genioglossus m uscle w ould be damaged. A gingival autograft was obtained from the palate by the standard technique5 and was sutured to the recipient site w ith no. 4-0 interrupted silk sutures (Fig 2). Healing was uneventful. F ig u re 3 sh o w s th e site a fte r th re e m onths. At th a t time, a new partial denture was m ade, and the patient was able to wear it comfortably. At the one-year follow-up
visit, the patient reported that he w as able to w ear the partial denture comfortably.
Case 2 A 37-year-old woman was referred by a general dentist, w ho w as in the process of m aking a new m andibular rem ovable par tial denture. The patient w as w earing a free-end saddle partial denture, w hich was several years old. The retentive and bracing arm s and the occlusal rests had broken off from the partial denture, and the prosthesis had settled into the mucosa lingual to the m andibular left canine (Fig 4). W hen the partial denture was removed and the tissues examined (Fig 5), a large area of gingival erosion was observed on th e lingual sid e of the m an d ib u lar left canine. All of the lingual attached gingiva had been lost, and approxim ately 4 to 5mm of cem entum was exposed. Moreover, the mucosal tissues w ere grossly inflam ed and very painful to touch. To reconstruct the lost periodontal tissues, a free palatal gin gival autograft w as used. The epithelial and subm ucosal connective tissues w ere re moved with a no. 15 scalpel, w hich left the recipient site of alveolar bone covered with periosteum (Fig 6). After the exposed root surface was lightly planed, a free gingival autograft was obtained from the palate and was sutured firmly to the recipient site with no. 5-0 chrom ic gut suture (Fig 7). H ealing w as uneventful; Figure 8 shows the site 12 weeks after surgery. The graft is firmly bound, and approxim ately 3 mm of root coverage has been achieved. At that point the patient was ready to proceed with the prosthetic phase of therapy.
D iscu ssio n T he free-en d sa d d le (distal extension) rem ovable p a rtia l d e n tu re h as been describ ed as on e of th e m ost d ifficult JADA, Vol. 104, F ebruary 1982 « 1 7 9
Fig 3
Patient 1. Fig 1 ■ Before surgery. Lingual view of mandibular anterior teeth showing two prom inent mental spines beneath central incisors. Fig 2 ■ Free gingival graft is sutured to recipient site. Fig 3 ■ Three months later. Mental spines are covered with dense collagenous connective tissue.
Fig 4
Fig 6
Fig 8 Patient 2. Fig 4 ■ Mandibular free-end remov able partial denture has settled, pressing into mucosal tissues on lingual side of canine. Brac ing arm and occlusal re st are absent. Fig 5 ■ Damaged tissue on lingual side of mandibu lar left canine. Fig 6 ■ Damaged tissue has been removed and recipient site prepared to accept graft. Fig 7 ■ Graft is sutured into place up to cementoenamel junction. Fig 8 ■ Three months later. Patient is ready for prosthetic phase of treatment.
Fig 5
Fig 7
p ro s th e tic p ro b le m s.6 T h is ty p e of p ro sth esis is only partially su p p o rted by teeth an d m ust d ep e n d on th e ed e n tu lo u s ridges for a good deal of its su p p o rt an d stability. T hese ridges are in h eren tly labile and often resorb u n d er th e co n tin u in g stresses of m astication. As th e ridges resorb, th e partial d e n tu re w ill settle, a process w hich places large am ounts of torque on the ab u t m en t teeth and cause the lingual bar to press in to the un d erly in g soft tissues. T h ese occurrences m ay severely com p rom ise the abutm ent teeth an d lead to failure of the prosthesis.
Several s tu d ie s7 have sh o w n th a t th e u se of re m o v a b le p a r tia l d e n tu re s com prom ises th e p erio d o n tal h ea lth of th e s u p p o rtin g te e th alth o u g h , if a high level of p laq u e control is m a in tained and th e p atien t is frequently m onitored, th ese adverse effects can be k ept to a m in im u m .8 In p la n n in g a re m ovable p a rtia l d en tu re , esp ecially the free-end sad d le type, th e resto ra tive d en tist m u st carefully exam ine th e periodontal h ealth of th e rem ain in g te e th , in c lu d in g th e am o u n t of a t tached gingiva on th e lin g u al asp ect of th e low er anterio r teeth on w h ich the
180 ■ JADA, Vol. 104, February 1982
lin g u al bar w ill rest. If th is tissu e is insufficient, it sh o u ld be reco n stru cted before the m an u factu re of th e partial d en tu re .9-10
Sum m ary and recom m en dations T he lin g u al bar of a m an d ib u la r re m ovable p artial den tu re, esp ecially a free-end sa d d le type, m ay exert a great deal of p re ssu re on th e u n d e rly in g perio d o n tal tissues. It is best th a t th e lingual bar be p laced as far aw ay from th e m arginal tissues as possible b ut
CLINICAL
still on d ense, collagenous attached gingiva. If an in ad eq u ate am o u n t of attached gin g iv a is p rese n t on the lin g u al su r faces of th e m a n d ib u la r an terio r teeth, th is tissu e m ay be augm ented by a free, palatal g ingival autograft. T he p atien t w ith a p artial d en tu re m u st be con s t a n t l y m o n i t o r e d to d e t e r m i n e w h eth e r an y changes have occurred in th e ed e n tu lo u s sa d d le areas. R esorp tio n of th ese rid g es m ay allow th e p ar tia l d e n tu re to settle, th ereb y com p ro m isin g th e perio d o n tal h ealth of th e su p p o rtin g teeth. fT i& l
The author thanks Dr. Arnold Watkin and Miss Janice Bowen for their assistance. Dr. Dello Russo is in private practice and is the staff periodontist at the Beth Israel Hospital in Boston. Address requests for reprints to Dr. Dello Russo, 2 Center Plaza, Government Center, Bos ton, 02108. 1. Goldman, H.M., and Cohen, D.W. Periodon tal therapy, ed 5. St. Louis, C. V. Mosby Co, 1973, p 339. 2. Dorfman, H.S.; Kennedy, J.E.; and Bird, W.C. Longitudinal evaluation of free autogenous gin gival grafts. J Clin Periodontol 7(4) :316-324,1980. 3. Lang, N.P., and Loe, H. The relationship be tween the width of keratinized gingiva and gingi val health. J Periodont 43:623-627, 1972. 4. Goss, C.M. Gray’s anatomy, ed 28. Philadel phia, Lea & Febiger, 1966; p 164. 5. Sullivan, H.C., and Atkins, J.H. Free au
REPORTS
togenous gingival grafts. Principles of successful grafting. Periodontics 6:121-129, 1968. 6. Amsterdam, M. Periodontal prosthesis. Twenty-five years in retrospect. Alpha Omegan 67(3):8-52, 1974. 7. Carlsson, G.E.; Hedegard, B.; and Koivvmaa, K.K. Studies in partial denture prosthesis. Final results of a four year longitudinal investigation of dentogingivally supported partial dentures. Acta Odontol Scand 23:443, 1965. 8. Bergman, B.; Hugoson, A.; and Olsson, C.O, Caries and periodontal status in patient fitted with removable partial dentures. J Clin Perio dontol 4:134, 1977. 9. Schokking, C.C. Free grafts of palatal mu cosa on the lingual aspect of the mandible.J Clin Periodontol 3(4):251-255, 1976. 10. Langer, B., and Calagna, L. The alteration of lingual mucosa with free gingival grafts. J Periodontol 42(12):646-648, 1978.
Dental treatment and management of a patient with a prosthetic heart valve J. Craig Baumgartner, DDS William F. Plack III, DDS Dental treatment can produce transient bacteremias, which can be life-threatening to patients with prosthetic heart valves. Precautions can prevent serious complications.
T
J L h o u s a n d s o f p r o s th e t ic h e a r t valves are p laced in p atien ts each year in th e U n ited S tates.1 A lthough the p ro sth esis m ay increase th e p a tie n t’s life sp an a n d q u ality of life, th e p atien t requ ires close m edical atten tio n for the rest of h is or h e r life. O f p articu la r in terest to d en tists is th e su sc ep tib ility of p atien ts w ith pro sth etic h eart valves to infective endo card itis, or m ore specif ically, to p ro sth etic valv u lar endocar ditis. P ro sth etic valv u lar en docarditis m ay be caused by bacteria, fungi, rickettsia, an d possibly chlam ydiae or vi ru ses.2 W a ta n a k u n a k o rn 3,4 re p o rte d th a t th e in c id en c e of early pro sth etic v al v u la r en d o card itis, occurring w ith in
tw o m o n th s of th e o peration, is ap p ro x im a tely 1% a n d late p ro sth etic valv u lar endo card itis, occurring after th e first tw o m o n th s, is also 1%. At som e m ed ical centers, p atien ts w ith p ro sth e tic v a lv u la r en d o c a rd itis ac co u n t for a large p ercen tag e of infec tiv e en d o c ard itis,3 for exam ple, 33% of all cases of infective en d o card itis at th e R ush-P resbyterian-St. Lukes H os p ita l in Chicago. Early p ro sth etic val vular en d o c ard itis is th o u g h t to resu lt from c o n ta m in a tio n d u rin g surgery, an d late p ro sth etic v alv u lar end o car d itis is th o u g h t to be cau sed by tra n s ie n t b lo o d -b o rn e m ic ro o rg a n ism s. T he p resen ce of m icroorganism s is re cognized as a fu n d am en tal event in th e p a th o g e n e sis of in fec tiv e an d p ro s th etic v alv u lar en d o c ard itis.5-6 In 1930, R u sh to n 7 d em o n strated the presen ce of b acterem ia after to o th ex traction. W e n o w k n o w th a t th e p res ence of blood-bo rn e m icro o rg an ism s is a c o m m o n o c c u r r e n c e 8 a n d th a t nu m e ro u s d en tal p ro ced u res p ro d u ce tran sien t bacterem ias.9' 12 A n tib io tic th e ra p y to p rev en t p ro s th etic v alv u lar en d o c ard itis is u se d in
s u s c e p tib le p a tie n ts h a v in g d e n ta l tre a tm e n t th a t m ay p ro d u c e b lo o d b orne m icroorganism s. A stu d y 5 in an an im al m o d el su p p o rts th e effective n e s s o f c u r r e n t r e g im e n s r e c o m m e n d ed by a co m m ittee of th e A m eri can H eart A sso c iatio n .13 No clinical stu d ies h av e been d one to show that infective en d o c ard itis is p rev en ted by th e use of an tib io tics w ith suscep tib le p atien ts. A p p ro v al of su ch a stu d y by an y h u m a n subjects com m ittee is u n likely. D ental trea tm e n t has been rela ted to th e o n set of p ro sth etic v alv u lar e n d o card itis. In a rep o rt by K archm er an d asso ciates,14 n in e of 43 p atien ts w ith late p ro sth etic v alv u lar en d o car d itis h ad d en tal treatm en t before th e o n set of sym ptom s. Tw o oth er p atien ts in th a t gro u p h ad severe p eriodontal disease. O nly th ree of n in e p atien ts re c e iv in g d e n ta l tre a tm e n t h a d b ee n p la c e d o n p r o p h y la c tic a n tib io tic therapy. T h e m ortality rate w as 53%. In an o th er s tu d y rep o rted by D ism ukes an d asso ciates,15 of 19 cases of late p ro sth etic v alv u lar en d o card itis, four p atien ts h ad received d en tal treatm en t JADA, Vol. 104, February 1982 ■ 181