Klebsiella pneumoniae in endodontic therapy

endodontics Editor: MILTON SISKIN, D.D.S. College of Dentistry The University of Tennessee 847 Monroe Avenue Memphis, Tennessee 38163

Klebsiella pneumoniaein endodontic therapy Report of a case Jobs A. Little,

Major, DC, USA*

UNITED

ARMY

ARMY

STATES MEDICAL

CENTER,

INSTITUTE

OF DENTAL

WASHINGTON,

RESEARCH,

WALTER

REED

D. C.

A 4%year-old man underwent endodontic treatment of the lower left central incisor. In the course of treatment two acute exacerbations occurred. Penicillin therapy was initiated at the time of the first exacerbation. It was ineffective, and SL culture of the purulent exudate was taken at the time of the second acute response. The causative organism was Elebsiella pnezL?noniae, which was found to be sensitive to tetracyclines. After tetracycline therapy, endodontic therapy was completed. Healing has been uneventful.

K

lebsiella pneumoniae is a nonmotile, gram-negative rod. It possesses a polysaccharide capsule which contributes to its pathogenicity. Although capable of inhabiting the nasal and oral cavities and the intestinal tract, it is present in less than 5 per cent of all normal human respiratory tracts. When K. pneumonniae becomes pathogenic, it may cause pneumonia (3 per cent of all cases) and may be associated with a few inflammatory and suppurative infections. The pneumonia is often fata1.l The occurrence of K. pneumonicGe within root canals is uncommon. In their study of more than 4,000 root canal cultures, Winkler and van Amerongen2 found only twenty-eight instances in which gram-negative rods were isolated. That these were not differentiated into species indicates that probably fewer than twenty-eight were actually K. pneumonkze. Winkler and van Amerongen *Resident,

278

Endodontics

Program.

Klebsiella

Fig, 1. Radiograph Fi.g. d. Radiograph Fig. 3. Radiograph

pneumoniac

ill endodonfic

before endodontic treatment. Note outline at time of root filling. 4 months after endodontic treatment.

of periapical

therafJ,y

279

radiolucency.

were of the opinion that the gram-negative organisms were secondary invaders and would be unable to maintain themselves within the root canal. Likewise, Brown and Rudolph,3 Leavitt and his colleagues,* and Melville and Birch5 were able to isolate very few gram-negative rod bacteria. Learitt and associates* were able to plate one case of K. pneumoniae in a trypticase soy broth mixed with agar. In their studies of antibiotic resistance of microorganisms of root canals, Fox and Isenberg6 were able to identify eight cases involving K. pneumoniae. Root canal culturing has been the subject of much controversy.7-” When acute exacerbations occur during root canal therapy, however, culturing is very strongly urgedlo In the case to be described, a culture was taken. The causative was resistant to penicillin, and effective antiorganism, Klebsiella pneumoniae, biotic therapy was instituted after identification of the organism. CASE REPORT On Oct. 31, 1974, a 48.year-old male army sergeant reported for an endodontic evaluation. During a previous routine examination, a 1 cm. radiolucency had been noticed at the apex of the lower left central incisor. The tooth was asymptomatic, and the patient could recall no instance of trauma. Clinical examination revealed a noncarious tooth with a distal incisal line angle which appeared to have been fractured. The tooth was nonmobile, and there was no periodontal involvement. No sinus tract was evident. No response was elicited from thermal or electrical pulp tests; the adjacent teeth responded normally. Radiographic examination showed the large radiolucency (Fig. 1). The border of the lesion was smooth in its in&al portion but became ragged in its apical portion as it approached the right central incisor. Endodontie therapy was initiated at this time. The tooth was isolated with a rubber dam, opened, and irrigated with 3 per cent hydrogen peroxide and 5 per cent sodium hypochlorite. A small cotton pellet dampened with camphorated parachlorophenol (CMCP) was placed in the chamber of the partially instrumented canal and sealed with Cavit. The patient returned on November 2 to the emergency clinic, reporting severe pain in the lower anterior region. Swelling was evident in the mucogingival fold, and both the

280

Liftle

13~ Sovember 7, the Ixlticlnt was :lsyrlll)tonl:ltic~, and instrumcwtntion was complctcd at that time. The tooth WIS nwtlic~atc~d with CWM(‘P and again swlctl wit11 Cavit. On N~vemher 8, the patient returned in ~everc pain. Tlw toot11 was isolatc(1, and a culture was taken from the ciudate. Tlx drainagc~ c>ould not be stopped, ant1 the toot11 ,vas left open. ‘l’ll(? culture specimrn was sent to the Ia~~or:~tory for plating and itlw~tific~ation of tllc: causative organism. 12. The organism was itltntificd as The laboratory report was returned on Novrmbrx KlcbsieTln pneumonicw. It was resistant to IwnicGllin, crytllromycin, ampicillin, and carl)an:rcillin ant1 scnsitivr to tr4r:wycliw. ‘l’llo paticlnt was rwall~~tl tllnt cl:ly ant1 phw~l on trtrac~ycline lrydro~l~loride, 250 mg. four 1imes daily for 5 days. On November 21 the patient was xsylnptorll:ltic~, and tllv c~nral ~y.7~ se&t1 after irrigation and rcinstrumentntion. On lkwmber 5 c~ndo~lontic therapy was completc4, and the canal was scaled with laterally condensed guthpcrch (Fig. 2). At the 4.month postoperative evalu:~tion, the patient reportc(1 no addit ionnl symptoms crown rcstornt,ion was placrd. Rndioand the tooth was nonmol)ile. A l)or(:elain-fuseii-to-fold graphic examination revealed substantial healing of the periapical area (Fig. 3).

DISCUSSION In view of the rare occurrence of K. pteumoniae in the root canal, the diagnosis and treatment of this cast raise many questions. The possible routes of infection should be examined. There would seem to be three of these: (1) salivary contamination prior to treatment, (2) contamination during treatment, and (3) microbial ingress from the bloodstream.‘” Salivary contamination prior to treatment seems unlikelp. There was no carious lesion, and the feasibility of the organism’s gaining access through the incisal fracture site seems remote. During treatment an aseptic technique was used, thus minimizing the likelihood of contamination. Ilowever, WC cannot rule out the possibility of secondary invasion of the K. peumoGe after the initial acute exacerbation, at which time the canal was left open for drainage. Microorganisms have been shown to spread to inflamed tissue through the bloodstream.“, I” This process in known as anachoresis. Although the patient could not recall an,v trauma, the fractured incisal cdgc would indicate that trauma had occurred. Such trauma could cause the inflammatory response necessary for the anachoretic effect. If the pulp were unable to repair itself, it could act as a culture medium for the growth of the K. pweu?mcia.e.l” It would be unfair to question the USC of penicillin as the drug of choice when the initial acute exacerbation occurred. Goldman and Pearson’” studied the antibiotic sensitivity of bacterial organisms in 563 cultures. Penicillin and erythromycin were the drugs of choice in the vast majority. Dryden and his colleagues I4 have recentlv obtained very similar results. Once the organism ias identified, it was easily understood why the penicillin was ineffective. Our laboratory tests indicated the K. pneumolzine was sensitive

Volume Number

-co 2

Klebsiella

pneumoniae

in e?tdoclontic thercq,y

28 1

to tetracyclines, but it is interesting to note that resistance of K. pneumoniae to tctracyclines as well as chloramphcnicol has previously been reported.” SUMMARY

A 4%year-old man underwent endodontic treatment of a lower left central incisor. In the course of treatment two acute exacerbations occurred. Penicillin therapy was initiated at the time of the first exacerbation. It was ineffective, and a culture of the purulcnt exudate was taken at the time of the second acute response. The causative organism was Kl~ebsielln p~ezuno~~ke, and it was found to bc sensitive to tetracyclines. After tetracycline therapy, endodontic therapy was completed. Healing has been uneventful. REFERENCES 1. Burnet,

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

G. W., and Scherp, H. W.: Oral Microbiology and Infectious Disease, Baltimore, 1968, Williams & Wilkins Company, pp. 774-776. Winkler, R. C., and van Amerongen, J.: Bacteriologic Results From 4,000 Root Canal Cultures, 0~1, Sum. 12: 857, 1959. of Microorganisms Brown, L. R., Jr., and Rudolph, C. E., Jr. : Isolation and Ldcntification From Unexposed Canals of Pulp-Involved Teeth, ORAI, HtJMi. 10: 1094, 1957. Flora of Root Canals as Leavitt, J. M., Naidorf, I. J., and Shugaevsky, P.: The Bacterial Diwlosed by a Culture Medium for Endodontics, ORAL SURo. 11: 302, 1958. Floras of Infected Teeth, Melville, T. H., and Birch, R. H.: Root Canal and Periapical ORAT, SllRo. 23: 93, 1967. Fox, J., and lsenberg, H. D.: Antibiotic Resistance of Microorganisms Isolated From Root Canals, ORAI. SURF. 23: 230, 1967. Bender, 1. B., Seltzer, S., and Turkenkopf, 8.: To Culture or Not to Cululture? OR.AL SURG. 18: 527, 1964. Buehbindrr, M. : A Statistical Comparison of Cultured and Non-cultured Root Canal Cases, J. Dent. l&s. 20: 93, 1941. Zeldow. B. J.. and Jncrle. J. 1.: Correlation of the Positive Culture to the Proznosis of Endoddnticall; Treated Tketh: A Clinical Study, J. Am. Dent. Assoc. 66: 9, 1963. Weine, F. 8.: Endotlontic Therapy, Ht. Louis, 1972, The C. V. Mosby Company, p. 369. Burke, G. W., and Knighton, H. T.: The lneidrnce of Microorganisms in Inflamed Dental Pulps of R.ats Following Bncterrmia, J. Dent. Rrs. 39: 205, 1960. Smith, L., and Tappe, G. I).: Experimental Pulpitis in Rats, J. Dent. Res. 41: 17, 1962. Goldman, M., and Pearson, A. H.: Post-del)ridement B‘acterial Flora and Antibiotic Sensitivity, ORAL SI~RG. 28: 897, 1967. Dryden, J. A., Alnms, T. A., ant1 Brown, R. I,. : lncitl~~nce of Antibiotic Resistance in Microorganisms Isolated From Root Canals, J. Endo. 1: 116, 1975.

Eeprint requests to : Major John A. Little U.S. Army Tnstitute of Dental Research \V:rlter Reed Army Medical Crlntel Washington, D. (:. 20012