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Microorganisms from pulpal chambers of intact teeth with necrotic pulps
JOURNAL OF ENDODONTICS I VOL 1, NO 5, MAY 1975
Microorganisms from pulpal chambers of intact teeth w i t h necrotic pulps Walter C. Wlttqow, Jr., Cdr (DC) USN, and Charles B. Sabiston, Jr., DDS, PhD, Iowa City
T h e p u l p a l c h a m b e r s of i n t a c t teeth w i t h n e c r o t i c p u l p s a s the r e s u l t of t r a u m a w e r e o p e n e d a n d sampled usinq climcal techniques t h a t m i n i m i z e d t h e p o s s i b i l i t y of c o n t a m i n a t o n b y o r a l flora. S a m p l e s w e r e p l a c e d in a n anaerobic environment at chairside and were cultured and identified with the techniques and c r i t e r i a d e v e l o p e d b y the V i r q i n i a P o l y t e c h n i c Institute A n a e r o b e L a b o r a t o r y . T h i r t y - t w o of the 40 teeth sampled had infected pulpal chambers. Three or more species of m i c r o o r q a n i s m s w e r e c u l t i v a t e d from 50% of t h e i n f e c t e d p u l p a l chambers. Pulpal necrosis of permanent anterior teeth as the result of a blow is a common problem in adolescents and young adults; it constitutes a significant part of the general and specialty practice of endodontics. When the pulpal chambers of these teeth remain intact, they provide convenient research materials since they are perhaps the only areas in the oral cavity that can be sampled without gross contamination by normal oral flora. The bacteriologic status of these teeth is of practical interest since the pathogenic potential and antibiotic resistance of bacteria
168
can influence treatment time and the patient's comfort as well as the overall prognosis. The answer to how a given bacterium reaches an intact pulpal chamber remains undecided. Whereas the vital pulps of healthy, intact teeth are nearly always free of microorganisms, '-s the injured dental pulp is subject to localization and fixation of blood-borne bacteria as demonstrated by Robinson and Boling/ Burke and Knighton, 5 and Gier and MitchellY Grossman 7 demonstrated the ability of bacteria to reach the pulpal tissue of traumatized teeth from the gingival suleus or the damaged marginal gingiva. Numerous investigations of the bacterial flora from intact, endodontically involved teeth have been made. 8-~3 Improvements in anaerobic technology since these studies justify a reassessment of our knowledge of intact teeth with pulpal necrosis as a result of trauma. Such a reassessment was recently initiated by Kantz and Henry. 14 Our study, while it uses somewhat different methods and includes patterns of antibiotic sensitivity, essentially parallels their study and confirms many of their findings as to species. The purpose of this study was to apply the techniques developed by the staff of the Anaerobe Laboratory,
Virginia Polytechnic Institute and State University, to the isolation and identification of bacteria from intact teeth that have necrotic pulps as a result of trauma. Methods F o r t y teeth from 33 patients were included in the study. The ages of the patients ranged from 15 to 36 years; the median age was 18 years. All teeth were incisors. They demonstrated no responses or questionable responses to the electric pulp tester. Ten of the patients selected had been receiving penicillin for periods ranging from three days to two weeks as prophylaxis against meningitis. The teeth were cleaned with pumice. A rubber dam was applied, and the area was chemically disinfected twice with 70% alcohol and 5% tincture of iodine. A field sterility control sample was taken by rubbing the butt end of a paper point that was held with sterile cotton pliers against the lingual surface of the tooth. The control point was cultured in fluid thioglycollate broth. Access to the pulpal chamber was gained with sterile burs using an aseptic technique. The teeth were sampled with sterile paper points that were dropped into a sterile tube containing oxygenfree
JOURNAL OF ENDODONTICS I VOL 1, NO 5, MAY 1975
carbon dioxide (CO2) and two drops of saline solution. When the tube was opened, oxygen was excluded by insertion of a cannula through which oxygenfree CO2 flowed. The laboratory procedures consisted of examinations of gramstained and phase-contrast preparations, and inoculations of prereduced brain-heart infusion agar roll tubes, blood agar plates poured from prereduced media and reduced in an anaerobe jar, and one each stock blood agar plates incubated aerobically and in a CO2 jar. All incubation was at 37 C. Representative colonies were selected from all media after three to five days. Strains were identified and classified using the procedures and criteria described in the manual published by the Virginia Polytechnic Institute Anaerobe Laboratory. 15 These procedures consisted of a battery of biochemical tests and gas chromatographic analysis of the fatty acids and alcohols produced in peptone-yeast-extract-glucose broth, in addition to analysis of morphology and gram-reaction. Antibiotic sensitivity testing of obligate anaerobes was by disk diffusion with high-potency disks,* as described by Wilkins and associates. 16 Testing for facultative organisms was by standard Kirby-Bauer procedures. 17 An addition of 0.2% glucose to the medium was made for lactic acid bacteria that required a fermentable carbohydrate for growth. Table 1 9 A total of 92 s p e c i e s identified in 40 t e e ~ .
No. of teeth sampled
No. of species Total species in each tooth characterized
8
0
0
7 9 10 4
1 2 3 4
7 18 30 16
1 1
5 6
5 6
Zone interpretations for Cephalothin, penicillin, and tetracycline were according to Wilkins and associates) e' Zone interpretations for other antibiotics were according to Blair and colleagues.' r
Anaerobic gram-positive rods in 10 teeth: 4 1 1 1
Eubacterium alactolyticum Lactobacillus species Arachnia propionica Propionibacterium aches
3 unidentified species Findings Thirty-two positive cultures were obtained from the 40 teeth sampled. Four of the eight negative cultures were from pulps that appeared vital on opening. Thirty-six of the teeth had necrotic pulp cavities; 30 of these had apical radiolucent areas. Thirty-one teeth yielded obligate anaerobes. Only one of the positive cultures failed to yield an obligate anaerobe. N o attempt was made to identify facultative isolants at the species level; accordingly, all facultative streptococcal strains were considered as a single species in each of the specimens in which they were present. Organisms are listed as unidentified if they were lost before identification, or if their characteristics did not closely fit those of recognized species. Thirty-nine of 40 field control samples were negative. Table 1 shows the number of teeth from which a given number of species were isolated. The total of 82 species isolated from the 40 teeth is an average of 2.05 species per tooth or 2.56 species per culturally positive tooth. The Illustration shows the organisms isolated, by species if possible, with the number of teeth from which each species was isolated. Table 2 lists the patterns of antibiotic sensitivity of some of the isolants. Strains are considered resistant ( R ) when the measured zone of inhibition was considered resistant or intermediate. Discussion
The results confirm the already well-established presence of bacteria
Anaerobic gram-negative rods in 27 teeth: 8 7 4 2
Bacteroides ruminicola ss brevis Bacteroides oralis Bacteroides species B melaninogenicus ss intermedius 3 Campylobacter sputorum 4 Fusobacterium nucleatum 4 Fusobacterium species
6 unidentified species Anaerobic gram-positive cocci in 9 teeth: 3 Peptostreptococcus micros 1 Peptostreptococcus intermedius 1 Peptostreptococcus anaerobius
4 unidentified species Anaerobic gram-negative cocci in 4 teeth: 4
Veillonella parvula
Facultative organisms in 15 teeth: 1 Lactobacillus species 1 A ctinomyces species 8 facultative streptococcus 1 Staphylococcus aureus
10 various unidentified cocci and rods O r g a n i s m s isolated ]rom 32 teeth with positive cultures.
in asymptomatic intact teeth with pulpal necrosis as a result of trauma. In our series, anaerobic gram-negative rods were evident in 67% of all teeth sampled, in 75% of all teeth with necrotic pulps, and in 84% of all teeth with positive cultures. F o r the most part, the species identified are known as part of the normal oral flora. Significantly, many of these species are known as opportunistic pathogens; they have been isolated from pyogenic oral infections. The
169
JOURNAL OF ENDODONTICS ] VOL 1, NO 5, MAY 1975
Table 2 9 Sensitivity patterns of 60 ~olants. No.
Isolant
Bacteroides oralis B ruminicola ss brevis B melaninogenicus Bacteroides species Campylobacter sputorum Fusobacterium nucleatum Fusobacterium species Unidentified Total anaerobic negative rods
Eubacterium alactolyticum Lactobacillus sp (anaerobic) Arachnia propionica Propionibacterium acnes Unidentified Total anaerobic positive rods
of stains 7 7 2 3 1 4 2 2 28
PEN * S~ R
MET S R
70 61 70 52 20 11 30 12 10 10 31 31 20 20 20 20 2 7 1 2 1 7
4 1 2 1 2 10100
ERY S R
TET S R
70 70 20 30 10 31 20 20 271
7 7 2 3 1 4 2 2 28
70 70 70 70 20 20 30 30 10 10 31 40 20 20 20 20 1 2 8 0 2 3 5
40 I0 20 10 20 10 0
40 10 20 10 20 10 0
40 10 20 10 20 10 0
30 10 40 80
30
2
10
1
40 80
4 7
1 0 0
21 10 40 71
30 10 40 80
30 10 40 80
30 l0 40 80
30 10 40 80
40 40 I0 10 10 10 10 10 10 10 I0 10 50 50 0 1 0 0
40 I0 10 10 10 10 41 91
40 10 10 I0 10 10 41 91
4
40
31
40
4
1
10
10
10
1
1
01 10
10 10
10 10
0
01
10
10
10 i0 41 50 7 3 1 0 0
10 41 91
56
4
4911
58
2
1
0 0 1 0
1 0 1
0
4 7
3
55
5
1 1
40 10 10 10 10 10 50 1 0 0 1 0 59
1
60
0
59
1
59
1
R
70 34 11 30 10 40 20 20
40 10 20 I0 20 10 0
Veillonella parvula .4 ctinomyces species Lactobicillus sp (facultative) Staphylococcus aureus
60
70 70 70 70 20 20 30 30 10 10 40 40 20 20 20 20 8 0 2 8 0 2 7
0 0 1 0 0 I
4 8
Totals
VAN S
R
4 1 1 1 2 9
Unidentified Total anaerobic positive cocci
5 10
CHL S
R
4o 10 20 10 20 100
30 I0 40 80
Unidentified positive rod Unidentified negative rod Facultative streptococcus Total facultative organisms
CEP S
R
31 Ol 20 10 11 73
3
1 1 1
L1N S
R
4o 10 20 10 20
Peptostreptococcus micros Peptostreptococcus anaerobius
1
0 0 0 0 0 0 0 0 0 2
CLI S
31 10 20 10 20 9 1
53
7
*PEN - penicillin G, 10 units; M E T - methacillin, 5/.tg; ERY - erythromycin, 15p~g; T E T - tetracycline, 30/zg; CLI - clindamycin, 2/u.g; LIN - lincomycin, 2ptg; CEP - Cephalothin, 30~g; C H L - chloramphenicol, 30~g; V A N - vancomycin HCL, 30 p.g. LS - sensitive; R - resistant or intermediate.
g r o u p w h i c h was f o u n d in eight teeth, d e s i g n a t e d Bacteroides ruminicola ss brevis, h a s b e e n f r e q u e n t l y isolated in o u r l a b o r a t o r y f r o m oral infections, is Strains of this species h a v e b e e n isolated t h a t are resistant to m u l t i p l e antibiotics, a9 T h i s species h a s t h e c h a r a c t e r i s t i c s d e s c r i b e d in the V i r ginia P o l y t e c h n i c I n s t i t u t e M a n u a l , b u t since it h a s n o t b e e n directly a n d 170
extensively c o m p a r e d with r e f e r e n c e strains, it m a y n o t b e identical to the r u m e n o r g a n i s m . T h e species Eubacterium alactolyticum, w h i c h was isolated f r o m f o u r t e e t h , was also n o t e d in the study b y K a n t z a n d H e n r y . 14 This o r g a n i s m was f o r m e r l y classified as Ramibacterium alactolyticum; acc o r d i n g to Bergey's manual of determinative bacteriology, it h a s b e e n
f o u n d in d e n t a l s u p p u r a t i o n s a n d in p u r u l e n t pleurisy. Its h a b i t a t is listed as t h e h u m a n m o u t h . T h e d a t a o n a n t i b i o t i c sensitivities d o n o t i n d i c a t e t h a t t h e r e is a n y subs t a n t i a l p r o b l e m in t h e selection of antibiotics f o r p r o p h y l a x i s o r c o n t r o l o f infections t h a t m a y b e p r o d u c e d by b a c t e r i a in t h e pulpal c a n a l s of i n t a c t t e e t h with pulpal necrosis as t h e result
JOURNAL OF ENDODONTICS j VOL 1, NO 5, MAY 1975
of trauma. Resistance would appear to be a problem in only a small percentage of the strains. A n adequate number of alternate drugs is available. Most species isolated were susceptible to antibiotics but many strains are identical to some that have been found in oral infections which are resistant to several antibiotics, including penicillin.1~ One must view many of these strains as potential pathogens that are capable of developing antibiotic resistance. On the basis of our sensitivity data and, more importantly, on the basis of years of favorable clinical experience, penicillin and erythromycin should control most infections; lincomycin and clindamycin are valuable alternate drugs.
This study substantiates others in that it was found that intact teeth that have necrotic pulps as a result of trauma were usually infected.
Conclusions
Dr. Wittgow was formerly a graduate student, division of endodontics, and Dr. Sabiston is an associate professor, department of periodontology, College of Dentistry, University of Iowa. Requests for reprints should be directed to Dr. C. B. Sabiston, Jr., Dept of Periodontology, College of Dentistry, University of Iowa, Iowa City, Iowa 52242.
The presence of opportunistic pathogens in such a large proportion of intact teeth with pulpal necrosis as a result of trauma should dictate caution when initiating endodontic therapy to prevent instrumentation beyond the apex. Such overinstrumentation would have the effect of injecting these microorganisms into the alveolar bone. Such manipulations may be a factor in acute flare-ups that occasionally occur when endodontic therapy is initiated on asymptomatic teeth. Summary A sampling of 40 intact teeth that had necrotic pulps as a result of trauma was accomplished with the use of clinical techniques that minimized the possibility of contamination of the sample by normal oral flora. Samples were placed in an anaerobic environment at chairside and were cultured and identified using techniques and criteria developed by the Virginia Polytechnic Institute Anaerobe Laboratory. The microorganisms isolated and their sensitivity to nine antibiotics were determined.
*Bacto-Sensitivity Disks, Difco, Detroit, Mich. The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or of the Department of Defense. This study was supported by a grant, D.E. 03662, from the Public Health Service, National Institute of Dental Research and by University of Iowa General Research Support Funds. The authors acknowledge the technical assistance of Ms. Nancy Segerstrom.
References
1. Henrici, A. T., and Hartzell, T. B. The bacteriology of the vital pulps. J Dent Res 1:419, 1919. 2. Gunter, J. H., and others. Bacteriology of dental pulp. J Dent Res (IADR Prog Abstr) 16:310 M.arch 1937. 3. Burket, L. W. Post-mortem bacteriological studies of different areas of human teeth and their supporting structures. J Dent Res 21:9 Feb 1942. 4. Robinson, H. B., and Boling, L. R. The anachoretic effect in pulpitis. Bacteriological studies. JADA 28:268 Feb 1941. 5. Burke, G. W., Jr., and Knighton, H. T. The localization of microorganisms in inflamed dental pulps of rats following bacteremia. J Dent Res 39:205 March-April t960. 6. Gier, R. E., and Mitchell, D. F. Anachoretic effect of pulpitis. J Dent Res 47:564 July -Aug 1968. 7. Gross.man, L. 1. Origin of microorganisms in traumatized pulpless, sound teeth. J Dent Res 46:551 May-June 1967.
8. MacDonald, J. B.; Hare, G. C.; and Wood, A. S. The bacteriologic status of the pulp chambers of intact teeth found to be non-vital following trauma. Oral Surg 10:318 March 1957. 9. Hobson, P. An investigation into the bacterioiogical control of infected root canals. Br Dent J 106:63 Jan 20, 1959. 10. Engstom, B., and Frostell, G. Bacteriological studies of the non-vital pulp in cases with intact pulp cavities. Acta Odontol Scand 19:23 May 1961. II. Crawford, J. J., and Shankle, R. J. Application of newer methods to study the importance of root canal and oral microbiota in endodonfics. Oral Surg 14:1109 Sept 1961. 12. Sulitzeanu, A.; Beuter, E. H.; and Epstein, L. I. Bacteriological studies of pulp-involved teeth by cultural and microscopic methods. JADA 69:300 Sept 1964. 13. Moiler, J. R. Microbiological examination of root canals and periapical tissues of human teeth, ed I. Gateborg, Akademiforlaget, 1966, pp 340-347. 14. Kantz, W. E., and Henry, C. A. Isolation and classification of anaerobic bacteria from intact pulp chambers of non-vital :teeth in man. Arch Oral Biol 19:91 Jan 1974. 15. Holdeman, L. V., and Moore, W. E. Anaerobe .laboratory manual. Blacksburg, Va, Virginia Polytechnic Institute Anaerobe Laboratory, 1972. 16. Wilkins, T. D., and others. Standardized single-disc method for antibiotic susceptibility testing of anaerobic bacteria. Antimicrob Agents Chemother 1: 451, 1972. 17. Blair, J. E.; Lennette, E. H.; and Truant, J. P. (eds.) Manual of clinical microbiology, ed 1. Bethesda, American Society for Microbiology, pp 299-310. 18. Sabiston, C. B., Jr., and Grigsby, W. R. Bacteroides from non-vital teeth and orat infections. J Dent Res (IADR Prog Abstr) 53:71 Feb 1974. 19. Sabiston, C. B., Jr., and Gold, W. A. Anaerobic bacteria in oral infections. Oral Surg 38:187 Aug 1974. 20. Breed, R. S.; Murray, E. G.; and Smith, N. R. Bergey's manual of determinative bacteriology, ed 7. Baltimore, Williams and Wilkins Co., pp 565-566.
171
Microorganisms from pulpal chambers of intact teeth w i t h necrotic pulps Walter C. Wlttqow, Jr., Cdr (DC) USN, and Charles B. Sabiston, Jr., DDS, PhD, Iowa City
T h e p u l p a l c h a m b e r s of i n t a c t teeth w i t h n e c r o t i c p u l p s a s the r e s u l t of t r a u m a w e r e o p e n e d a n d sampled usinq climcal techniques t h a t m i n i m i z e d t h e p o s s i b i l i t y of c o n t a m i n a t o n b y o r a l flora. S a m p l e s w e r e p l a c e d in a n anaerobic environment at chairside and were cultured and identified with the techniques and c r i t e r i a d e v e l o p e d b y the V i r q i n i a P o l y t e c h n i c Institute A n a e r o b e L a b o r a t o r y . T h i r t y - t w o of the 40 teeth sampled had infected pulpal chambers. Three or more species of m i c r o o r q a n i s m s w e r e c u l t i v a t e d from 50% of t h e i n f e c t e d p u l p a l chambers. Pulpal necrosis of permanent anterior teeth as the result of a blow is a common problem in adolescents and young adults; it constitutes a significant part of the general and specialty practice of endodontics. When the pulpal chambers of these teeth remain intact, they provide convenient research materials since they are perhaps the only areas in the oral cavity that can be sampled without gross contamination by normal oral flora. The bacteriologic status of these teeth is of practical interest since the pathogenic potential and antibiotic resistance of bacteria
168
can influence treatment time and the patient's comfort as well as the overall prognosis. The answer to how a given bacterium reaches an intact pulpal chamber remains undecided. Whereas the vital pulps of healthy, intact teeth are nearly always free of microorganisms, '-s the injured dental pulp is subject to localization and fixation of blood-borne bacteria as demonstrated by Robinson and Boling/ Burke and Knighton, 5 and Gier and MitchellY Grossman 7 demonstrated the ability of bacteria to reach the pulpal tissue of traumatized teeth from the gingival suleus or the damaged marginal gingiva. Numerous investigations of the bacterial flora from intact, endodontically involved teeth have been made. 8-~3 Improvements in anaerobic technology since these studies justify a reassessment of our knowledge of intact teeth with pulpal necrosis as a result of trauma. Such a reassessment was recently initiated by Kantz and Henry. 14 Our study, while it uses somewhat different methods and includes patterns of antibiotic sensitivity, essentially parallels their study and confirms many of their findings as to species. The purpose of this study was to apply the techniques developed by the staff of the Anaerobe Laboratory,
Virginia Polytechnic Institute and State University, to the isolation and identification of bacteria from intact teeth that have necrotic pulps as a result of trauma. Methods F o r t y teeth from 33 patients were included in the study. The ages of the patients ranged from 15 to 36 years; the median age was 18 years. All teeth were incisors. They demonstrated no responses or questionable responses to the electric pulp tester. Ten of the patients selected had been receiving penicillin for periods ranging from three days to two weeks as prophylaxis against meningitis. The teeth were cleaned with pumice. A rubber dam was applied, and the area was chemically disinfected twice with 70% alcohol and 5% tincture of iodine. A field sterility control sample was taken by rubbing the butt end of a paper point that was held with sterile cotton pliers against the lingual surface of the tooth. The control point was cultured in fluid thioglycollate broth. Access to the pulpal chamber was gained with sterile burs using an aseptic technique. The teeth were sampled with sterile paper points that were dropped into a sterile tube containing oxygenfree
JOURNAL OF ENDODONTICS I VOL 1, NO 5, MAY 1975
carbon dioxide (CO2) and two drops of saline solution. When the tube was opened, oxygen was excluded by insertion of a cannula through which oxygenfree CO2 flowed. The laboratory procedures consisted of examinations of gramstained and phase-contrast preparations, and inoculations of prereduced brain-heart infusion agar roll tubes, blood agar plates poured from prereduced media and reduced in an anaerobe jar, and one each stock blood agar plates incubated aerobically and in a CO2 jar. All incubation was at 37 C. Representative colonies were selected from all media after three to five days. Strains were identified and classified using the procedures and criteria described in the manual published by the Virginia Polytechnic Institute Anaerobe Laboratory. 15 These procedures consisted of a battery of biochemical tests and gas chromatographic analysis of the fatty acids and alcohols produced in peptone-yeast-extract-glucose broth, in addition to analysis of morphology and gram-reaction. Antibiotic sensitivity testing of obligate anaerobes was by disk diffusion with high-potency disks,* as described by Wilkins and associates. 16 Testing for facultative organisms was by standard Kirby-Bauer procedures. 17 An addition of 0.2% glucose to the medium was made for lactic acid bacteria that required a fermentable carbohydrate for growth. Table 1 9 A total of 92 s p e c i e s identified in 40 t e e ~ .
No. of teeth sampled
No. of species Total species in each tooth characterized
8
0
0
7 9 10 4
1 2 3 4
7 18 30 16
1 1
5 6
5 6
Zone interpretations for Cephalothin, penicillin, and tetracycline were according to Wilkins and associates) e' Zone interpretations for other antibiotics were according to Blair and colleagues.' r
Anaerobic gram-positive rods in 10 teeth: 4 1 1 1
Eubacterium alactolyticum Lactobacillus species Arachnia propionica Propionibacterium aches
3 unidentified species Findings Thirty-two positive cultures were obtained from the 40 teeth sampled. Four of the eight negative cultures were from pulps that appeared vital on opening. Thirty-six of the teeth had necrotic pulp cavities; 30 of these had apical radiolucent areas. Thirty-one teeth yielded obligate anaerobes. Only one of the positive cultures failed to yield an obligate anaerobe. N o attempt was made to identify facultative isolants at the species level; accordingly, all facultative streptococcal strains were considered as a single species in each of the specimens in which they were present. Organisms are listed as unidentified if they were lost before identification, or if their characteristics did not closely fit those of recognized species. Thirty-nine of 40 field control samples were negative. Table 1 shows the number of teeth from which a given number of species were isolated. The total of 82 species isolated from the 40 teeth is an average of 2.05 species per tooth or 2.56 species per culturally positive tooth. The Illustration shows the organisms isolated, by species if possible, with the number of teeth from which each species was isolated. Table 2 lists the patterns of antibiotic sensitivity of some of the isolants. Strains are considered resistant ( R ) when the measured zone of inhibition was considered resistant or intermediate. Discussion
The results confirm the already well-established presence of bacteria
Anaerobic gram-negative rods in 27 teeth: 8 7 4 2
Bacteroides ruminicola ss brevis Bacteroides oralis Bacteroides species B melaninogenicus ss intermedius 3 Campylobacter sputorum 4 Fusobacterium nucleatum 4 Fusobacterium species
6 unidentified species Anaerobic gram-positive cocci in 9 teeth: 3 Peptostreptococcus micros 1 Peptostreptococcus intermedius 1 Peptostreptococcus anaerobius
4 unidentified species Anaerobic gram-negative cocci in 4 teeth: 4
Veillonella parvula
Facultative organisms in 15 teeth: 1 Lactobacillus species 1 A ctinomyces species 8 facultative streptococcus 1 Staphylococcus aureus
10 various unidentified cocci and rods O r g a n i s m s isolated ]rom 32 teeth with positive cultures.
in asymptomatic intact teeth with pulpal necrosis as a result of trauma. In our series, anaerobic gram-negative rods were evident in 67% of all teeth sampled, in 75% of all teeth with necrotic pulps, and in 84% of all teeth with positive cultures. F o r the most part, the species identified are known as part of the normal oral flora. Significantly, many of these species are known as opportunistic pathogens; they have been isolated from pyogenic oral infections. The
169
JOURNAL OF ENDODONTICS ] VOL 1, NO 5, MAY 1975
Table 2 9 Sensitivity patterns of 60 ~olants. No.
Isolant
Bacteroides oralis B ruminicola ss brevis B melaninogenicus Bacteroides species Campylobacter sputorum Fusobacterium nucleatum Fusobacterium species Unidentified Total anaerobic negative rods
Eubacterium alactolyticum Lactobacillus sp (anaerobic) Arachnia propionica Propionibacterium acnes Unidentified Total anaerobic positive rods
of stains 7 7 2 3 1 4 2 2 28
PEN * S~ R
MET S R
70 61 70 52 20 11 30 12 10 10 31 31 20 20 20 20 2 7 1 2 1 7
4 1 2 1 2 10100
ERY S R
TET S R
70 70 20 30 10 31 20 20 271
7 7 2 3 1 4 2 2 28
70 70 70 70 20 20 30 30 10 10 31 40 20 20 20 20 1 2 8 0 2 3 5
40 I0 20 10 20 10 0
40 10 20 10 20 10 0
40 10 20 10 20 10 0
30 10 40 80
30
2
10
1
40 80
4 7
1 0 0
21 10 40 71
30 10 40 80
30 10 40 80
30 l0 40 80
30 10 40 80
40 40 I0 10 10 10 10 10 10 10 I0 10 50 50 0 1 0 0
40 I0 10 10 10 10 41 91
40 10 10 I0 10 10 41 91
4
40
31
40
4
1
10
10
10
1
1
01 10
10 10
10 10
0
01
10
10
10 i0 41 50 7 3 1 0 0
10 41 91
56
4
4911
58
2
1
0 0 1 0
1 0 1
0
4 7
3
55
5
1 1
40 10 10 10 10 10 50 1 0 0 1 0 59
1
60
0
59
1
59
1
R
70 34 11 30 10 40 20 20
40 10 20 I0 20 10 0
Veillonella parvula .4 ctinomyces species Lactobicillus sp (facultative) Staphylococcus aureus
60
70 70 70 70 20 20 30 30 10 10 40 40 20 20 20 20 8 0 2 8 0 2 7
0 0 1 0 0 I
4 8
Totals
VAN S
R
4 1 1 1 2 9
Unidentified Total anaerobic positive cocci
5 10
CHL S
R
4o 10 20 10 20 100
30 I0 40 80
Unidentified positive rod Unidentified negative rod Facultative streptococcus Total facultative organisms
CEP S
R
31 Ol 20 10 11 73
3
1 1 1
L1N S
R
4o 10 20 10 20
Peptostreptococcus micros Peptostreptococcus anaerobius
1
0 0 0 0 0 0 0 0 0 2
CLI S
31 10 20 10 20 9 1
53
7
*PEN - penicillin G, 10 units; M E T - methacillin, 5/.tg; ERY - erythromycin, 15p~g; T E T - tetracycline, 30/zg; CLI - clindamycin, 2/u.g; LIN - lincomycin, 2ptg; CEP - Cephalothin, 30~g; C H L - chloramphenicol, 30~g; V A N - vancomycin HCL, 30 p.g. LS - sensitive; R - resistant or intermediate.
g r o u p w h i c h was f o u n d in eight teeth, d e s i g n a t e d Bacteroides ruminicola ss brevis, h a s b e e n f r e q u e n t l y isolated in o u r l a b o r a t o r y f r o m oral infections, is Strains of this species h a v e b e e n isolated t h a t are resistant to m u l t i p l e antibiotics, a9 T h i s species h a s t h e c h a r a c t e r i s t i c s d e s c r i b e d in the V i r ginia P o l y t e c h n i c I n s t i t u t e M a n u a l , b u t since it h a s n o t b e e n directly a n d 170
extensively c o m p a r e d with r e f e r e n c e strains, it m a y n o t b e identical to the r u m e n o r g a n i s m . T h e species Eubacterium alactolyticum, w h i c h was isolated f r o m f o u r t e e t h , was also n o t e d in the study b y K a n t z a n d H e n r y . 14 This o r g a n i s m was f o r m e r l y classified as Ramibacterium alactolyticum; acc o r d i n g to Bergey's manual of determinative bacteriology, it h a s b e e n
f o u n d in d e n t a l s u p p u r a t i o n s a n d in p u r u l e n t pleurisy. Its h a b i t a t is listed as t h e h u m a n m o u t h . T h e d a t a o n a n t i b i o t i c sensitivities d o n o t i n d i c a t e t h a t t h e r e is a n y subs t a n t i a l p r o b l e m in t h e selection of antibiotics f o r p r o p h y l a x i s o r c o n t r o l o f infections t h a t m a y b e p r o d u c e d by b a c t e r i a in t h e pulpal c a n a l s of i n t a c t t e e t h with pulpal necrosis as t h e result
JOURNAL OF ENDODONTICS j VOL 1, NO 5, MAY 1975
of trauma. Resistance would appear to be a problem in only a small percentage of the strains. A n adequate number of alternate drugs is available. Most species isolated were susceptible to antibiotics but many strains are identical to some that have been found in oral infections which are resistant to several antibiotics, including penicillin.1~ One must view many of these strains as potential pathogens that are capable of developing antibiotic resistance. On the basis of our sensitivity data and, more importantly, on the basis of years of favorable clinical experience, penicillin and erythromycin should control most infections; lincomycin and clindamycin are valuable alternate drugs.
This study substantiates others in that it was found that intact teeth that have necrotic pulps as a result of trauma were usually infected.
Conclusions
Dr. Wittgow was formerly a graduate student, division of endodontics, and Dr. Sabiston is an associate professor, department of periodontology, College of Dentistry, University of Iowa. Requests for reprints should be directed to Dr. C. B. Sabiston, Jr., Dept of Periodontology, College of Dentistry, University of Iowa, Iowa City, Iowa 52242.
The presence of opportunistic pathogens in such a large proportion of intact teeth with pulpal necrosis as a result of trauma should dictate caution when initiating endodontic therapy to prevent instrumentation beyond the apex. Such overinstrumentation would have the effect of injecting these microorganisms into the alveolar bone. Such manipulations may be a factor in acute flare-ups that occasionally occur when endodontic therapy is initiated on asymptomatic teeth. Summary A sampling of 40 intact teeth that had necrotic pulps as a result of trauma was accomplished with the use of clinical techniques that minimized the possibility of contamination of the sample by normal oral flora. Samples were placed in an anaerobic environment at chairside and were cultured and identified using techniques and criteria developed by the Virginia Polytechnic Institute Anaerobe Laboratory. The microorganisms isolated and their sensitivity to nine antibiotics were determined.
*Bacto-Sensitivity Disks, Difco, Detroit, Mich. The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or of the Department of Defense. This study was supported by a grant, D.E. 03662, from the Public Health Service, National Institute of Dental Research and by University of Iowa General Research Support Funds. The authors acknowledge the technical assistance of Ms. Nancy Segerstrom.
References
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