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Percentages of Bacteria Isolated in Root Canal Culture
644 • THE J O U R N A L O F T H E A M E R IC A N D EN T A L A S S O C IA T IO N
broth; finally the tooth was extracted as carefully as possible to prevent salivary contamination and the apex was cut off and cultured similarly. Growth occurred in only one of the dentin cultures, in none o f the pulp cultures, but in all o f the apical ones. “ Results do not confirm pre vious reports of the presence of bacteria in living, human dental pulps and cast doubt on the clinical significance of posi tive apical cultures from extracted teeth.” Similarly, TunniclifF and Hammond,31 in 1937, presented data which indicate that the value of reports based on the culture of extracted teeth is questionable. They summarize: Sixty-four intact teeth were treated with antiseptics and cultured eight days in glucosebrain broth to determine sterility. Thirty teeth showing no grow th were opened aseptically, and smears, sections and cultures o f the pulps were studied. Streptococcu s viridans, occa sionally associated with diphtheroids, was iso lated from ten o f the pulps o f externally sterile intact teeth. Since n o sign o f infection (n o leukocytic infiltration) was observed in smears or sections o f pulps containing strepto cocci, their presence is considered o f no sig nificance.
The information presented here indi cates that the organisms gained entrance to the pulps during extractions. Burket and Bum,58 in 1937, contami nating the gingival crevices of teeth to be extracted with cultures of the nonpathogenic Serratia marcescens, were able to recover these organisms, following the ex tractions, from the blood streams o f 37.8 per cent of a group o f 37 patients. Kanner,59 in 1938, using suspensions of Bacillus sporogenes in broth as the test organism, worked out an interesting labo ratory technic to examine the possibility that organisms gain entrance to pulps during the extraction o f teeth. He con cluded: “ It could be demonstrated that the bacteria enter the pulp by capillary attraction.” Conclusions regarding the importance of teeth as foci o f infection cannot be based on studies utilizing extracted teeth.
PERCENTAGES
OF
B A C T E R IA
IS O L A T E D IN R O O T C A N A L C U L T U R E
In 1941, Morse and Yates52 reported their bacterial findings in a follow up study of root filled teeth. In this study 265 cases were presented from which a total of 2,202 cultures were made during the period of treating the teeth (each case having two consecutive negative cultures before filling the root can al). O f the 265 teeth 77 cases (29 per cent) yielded no positive cultures at any time during treat ment. Disregarding those cases yielding no organisms and those yielding mixed cul tures, these two investigators summarize in a table their findings from the 388 cultures yielding “ single organism” cul tures : Str. anhemolyticus Str. viridans Str. hemolyticus Staph, albus Staph, aureus L . acidophilus B. subtilis Yeast
Number Per cent 158 41 46 12 3 1 86 22 30 8 16 4 7 27 5 22 388
100
In 1943, Hayes53 reported his bactério logie findings in 340 teeth selected for root canal therapy. On the first examina tion, 211 cases (62.2 per cent) were positive for microorganisms and 129 (37.8 per cent) were negative. His tabulated re sults for the 211 infected teeth are given here: Str. anhemolyticus Str. hemolyticus Str. viridans Staph, albus Staph, aureus L. acidophilus Combination of organisms
Number Per cent 41 19.4 1 0.5 53 25.1 56 26.6 2.4 5 8.5 18 37
17.5
211
100.0
D IA G N O S IS O F F O C A L IN F E C T IO N
In 1947, Gruchalla and Hamann60 re ported their bacteriologic findings for 263 infected teeth treated for root canal fillings. From 201 teeth, pure cultures were obtained, and from 62, mixed cul tures, with the following results :
Str. mitis Str. salivarius Str. faecalis Str. liquefaciens Anaerobic streptococci Staph, aureus Staph, albus Gram-positive rods Gram-negative rods Yeast
Number Per cent* 64 24.3 44.9 118 19.4 51 6.1 16 3.4 9 1.6 4 16.7 44 9.9 26 6.0 16 1.8 2 350
134.1
*The p e rce n ta g e s are ca lc u la te d on the num ber o f teeth cultured, som e o f which had m ore than one organism , and consequ ently to ta l m ore than 100 per cent.
In 1948, Ostrander and Crowley19 re-' ported their bacteriologic findings in 859 teeth cultured during routine root canal treatment. O f these teeth, 347 (40.4 per cent) were not infected and 512 (59.6 per cent) yielded organisms. Their data for the first cultures from the 512 infected teeth follow:
Various organisms Combination of organisms Str. anhemolyticus Str. viridans Str. hemolyticus Anaerobic streptococci L . acidophilus Actinomyces-like organisms Contaminations
Number Per cent 107 20.9 90 94 74 12 6 11
17.6 18.4 14.4 2.3 1.2 2.1
3 115
0.6 22.5
512
100.0
The striking finding, in these reports of cultures secured from teeth during root canal treatment, is the infreqeuncy of
V O L U M E 42, J U N E 1951 • 645
isolation of hemolytic streptococci organ isms which have been under suspicion as a possible etiologic factor in rheumatoid arthritis and particularly in rheumatic fever. On the other hand, the relatively high frequency of isolation is evident for Str. anhemolyticus and Str. viridans, or ganisms usually well tolerated by the human host.
T O X IN -F O R M IN G B A C T E R IA IS O L A T E D FR O M R O O T C A N A L S
In his 1944 textbook, Appleton61 pointed out: Bacteria act upon a variety o f organic com pounds— for example, carbohydrates, fats and proteins— and split these up into smaller, less com plicated molecules. Som e of these products of bacterial activities are more or less poison ous. . . . Ptomains, also known as “ animal alkaloids,” are com m on products o f the action of bacterial enzymes on proteins, lecithins, etc. M ost o f them are not very poisonous, while some o f the most toxic are the result o f nonpathogenic bacteria. A m ong the better known types are: putrescin, cadaverin, neurin, muscarin and sepsin. T h e three latter com pounds are highly poisonous.
He names the organisms which produce the true exotoxins (the ones that develop specific neutralizing substances— anti toxins— in the susceptible h o s t): bacilli of tetanus, diphtheria, symptomatic an thrax, and gas gangrene, Pseudomonas aeruginosa, Shiga’s dysentery bacillus, streptococcal strains associated with scar latina and erysipelas, and certain strains o f staphylococci. The exotoxin o f Clostri dium botulinum also can be ingested. The existence of the so-called endo toxins in the cell bodies of another small list of organisms, Appleton continues further, is being questioned. “ The ques tion is— did these toxic chemical entities exist as such within the living cell or are they postmortem derivatives?” Zinsser and Bayne-Jones62 confirm this list o f true toxins against which an anti toxin can be developed.
broth; finally the tooth was extracted as carefully as possible to prevent salivary contamination and the apex was cut off and cultured similarly. Growth occurred in only one of the dentin cultures, in none o f the pulp cultures, but in all o f the apical ones. “ Results do not confirm pre vious reports of the presence of bacteria in living, human dental pulps and cast doubt on the clinical significance of posi tive apical cultures from extracted teeth.” Similarly, TunniclifF and Hammond,31 in 1937, presented data which indicate that the value of reports based on the culture of extracted teeth is questionable. They summarize: Sixty-four intact teeth were treated with antiseptics and cultured eight days in glucosebrain broth to determine sterility. Thirty teeth showing no grow th were opened aseptically, and smears, sections and cultures o f the pulps were studied. Streptococcu s viridans, occa sionally associated with diphtheroids, was iso lated from ten o f the pulps o f externally sterile intact teeth. Since n o sign o f infection (n o leukocytic infiltration) was observed in smears or sections o f pulps containing strepto cocci, their presence is considered o f no sig nificance.
The information presented here indi cates that the organisms gained entrance to the pulps during extractions. Burket and Bum,58 in 1937, contami nating the gingival crevices of teeth to be extracted with cultures of the nonpathogenic Serratia marcescens, were able to recover these organisms, following the ex tractions, from the blood streams o f 37.8 per cent of a group o f 37 patients. Kanner,59 in 1938, using suspensions of Bacillus sporogenes in broth as the test organism, worked out an interesting labo ratory technic to examine the possibility that organisms gain entrance to pulps during the extraction o f teeth. He con cluded: “ It could be demonstrated that the bacteria enter the pulp by capillary attraction.” Conclusions regarding the importance of teeth as foci o f infection cannot be based on studies utilizing extracted teeth.
PERCENTAGES
OF
B A C T E R IA
IS O L A T E D IN R O O T C A N A L C U L T U R E
In 1941, Morse and Yates52 reported their bacterial findings in a follow up study of root filled teeth. In this study 265 cases were presented from which a total of 2,202 cultures were made during the period of treating the teeth (each case having two consecutive negative cultures before filling the root can al). O f the 265 teeth 77 cases (29 per cent) yielded no positive cultures at any time during treat ment. Disregarding those cases yielding no organisms and those yielding mixed cul tures, these two investigators summarize in a table their findings from the 388 cultures yielding “ single organism” cul tures : Str. anhemolyticus Str. viridans Str. hemolyticus Staph, albus Staph, aureus L . acidophilus B. subtilis Yeast
Number Per cent 158 41 46 12 3 1 86 22 30 8 16 4 7 27 5 22 388
100
In 1943, Hayes53 reported his bactério logie findings in 340 teeth selected for root canal therapy. On the first examina tion, 211 cases (62.2 per cent) were positive for microorganisms and 129 (37.8 per cent) were negative. His tabulated re sults for the 211 infected teeth are given here: Str. anhemolyticus Str. hemolyticus Str. viridans Staph, albus Staph, aureus L. acidophilus Combination of organisms
Number Per cent 41 19.4 1 0.5 53 25.1 56 26.6 2.4 5 8.5 18 37
17.5
211
100.0
D IA G N O S IS O F F O C A L IN F E C T IO N
In 1947, Gruchalla and Hamann60 re ported their bacteriologic findings for 263 infected teeth treated for root canal fillings. From 201 teeth, pure cultures were obtained, and from 62, mixed cul tures, with the following results :
Str. mitis Str. salivarius Str. faecalis Str. liquefaciens Anaerobic streptococci Staph, aureus Staph, albus Gram-positive rods Gram-negative rods Yeast
Number Per cent* 64 24.3 44.9 118 19.4 51 6.1 16 3.4 9 1.6 4 16.7 44 9.9 26 6.0 16 1.8 2 350
134.1
*The p e rce n ta g e s are ca lc u la te d on the num ber o f teeth cultured, som e o f which had m ore than one organism , and consequ ently to ta l m ore than 100 per cent.
In 1948, Ostrander and Crowley19 re-' ported their bacteriologic findings in 859 teeth cultured during routine root canal treatment. O f these teeth, 347 (40.4 per cent) were not infected and 512 (59.6 per cent) yielded organisms. Their data for the first cultures from the 512 infected teeth follow:
Various organisms Combination of organisms Str. anhemolyticus Str. viridans Str. hemolyticus Anaerobic streptococci L . acidophilus Actinomyces-like organisms Contaminations
Number Per cent 107 20.9 90 94 74 12 6 11
17.6 18.4 14.4 2.3 1.2 2.1
3 115
0.6 22.5
512
100.0
The striking finding, in these reports of cultures secured from teeth during root canal treatment, is the infreqeuncy of
V O L U M E 42, J U N E 1951 • 645
isolation of hemolytic streptococci organ isms which have been under suspicion as a possible etiologic factor in rheumatoid arthritis and particularly in rheumatic fever. On the other hand, the relatively high frequency of isolation is evident for Str. anhemolyticus and Str. viridans, or ganisms usually well tolerated by the human host.
T O X IN -F O R M IN G B A C T E R IA IS O L A T E D FR O M R O O T C A N A L S
In his 1944 textbook, Appleton61 pointed out: Bacteria act upon a variety o f organic com pounds— for example, carbohydrates, fats and proteins— and split these up into smaller, less com plicated molecules. Som e of these products of bacterial activities are more or less poison ous. . . . Ptomains, also known as “ animal alkaloids,” are com m on products o f the action of bacterial enzymes on proteins, lecithins, etc. M ost o f them are not very poisonous, while some o f the most toxic are the result o f nonpathogenic bacteria. A m ong the better known types are: putrescin, cadaverin, neurin, muscarin and sepsin. T h e three latter com pounds are highly poisonous.
He names the organisms which produce the true exotoxins (the ones that develop specific neutralizing substances— anti toxins— in the susceptible h o s t): bacilli of tetanus, diphtheria, symptomatic an thrax, and gas gangrene, Pseudomonas aeruginosa, Shiga’s dysentery bacillus, streptococcal strains associated with scar latina and erysipelas, and certain strains o f staphylococci. The exotoxin o f Clostri dium botulinum also can be ingested. The existence of the so-called endo toxins in the cell bodies of another small list of organisms, Appleton continues further, is being questioned. “ The ques tion is— did these toxic chemical entities exist as such within the living cell or are they postmortem derivatives?” Zinsser and Bayne-Jones62 confirm this list o f true toxins against which an anti toxin can be developed.