Louis G. DePaola

Microbiology of acute periodontal infection in myelosuppressed cancer patients.

This study characterized the subgingival microbial flora associated with 27 acute exacerbations of preexistent periodontal disease in 24 patients with chemotherapy-induced myelosuppression. All but two acute periodontal infections developed at low granulocyte levels (less than 1,000/microL). Suspected pathogens were detected in high concentrations in subgingival plaque specimens in 17 episodes of acute periodontal infection; a single pathogen was recovered in ten acute infections, and more than one pathogen was recovered in seven acute infections. Staphylococcus epidermidis, Candida albicans, S aureus, and Pseudomonas aeruginosa predominated, with combinations of these detected in some patients. Concomitant bacteremias developed in two of these patients. The subgingival microflora associated with ten acute periodontal infections was characterized by predominantly indigenous microorganisms, which in nine episodes were in abnormal proportions compared with microbial profiles in noncancer patients with similar degrees of periodontal disease. These data demonstrate that pathogens normally associated with infections in myelosuppressed cancer patients, as well as indigenous oral flora, are associated with acute periodontal infections during granulocytopenia. This finding is important, since this body site has not commonly been recognized as a source for acute infection in these patients.

Effect of an antimicrobial mouthrinse on recurrent aphthous ulcerations.

Recurrent aphthous ulceration (RAU) remains a clinical problem for many patients. Efforts in prevention and/or treatment with prescription and nonprescription formulations have to date resulted in minimal success at best. A 6-month double-blind clinical study of 96 adults compared a commercially available antimicrobial mouthrinse (Listerine Antiseptic [LA], Warner-Lambert Co., Morris Plains, N.J.) and a hydroalcoholic control to evaluate the effects of vigorous twice-daily rinsing on the incidence, duration, and severity of RAU in persons prone to this disorder. LA rinse and the hydroalcoholic rinse resulted in a statistically significant reduction in the incidence of RAU occurrences from baseline. The duration of lesions and the severity of pain in subjects with ulcers during the treatment period were also significantly reduced in the LA rinse group of patients when compared with baseline. The hydroalcoholic rinse did not show a significant effect versus baseline for either severity or duration of the lesions. Rinsing therefore can be of clinical value in reducing the occurrence of RAU in susceptible patients, and LA rinse can be of significant additional value in decreasing the duration and severity of RAU.

Effect of granulocytopenia on oral microbial relationships in patients with acute leukemia

Risk for acute infection increases as granulocyte levels decrease secondary to myelosuppressive chemotherapy in patients with acute nonlymphocytic leukemia (ANLL). Acute exacerbations of concomitant inflammatory periodontal diseases can result in systemic infections in these patients. However, host-oral bacterial relationships in the periodontium in patients with ANLL are not well understood. Twenty-one adult patients with ANLL with periodontal disease ranging from gingivitis to severe periodontitis were studied. Supragingival and subgingival plaque specimens were collected before chemotherapy (prechemotherapy), and at a defined midpoint of myelosuppression (midchemotherapy; day 14). All specimens were extensively cultured both aerobically and anaerobically. Data were submitted to a partial correlational analysis, controlling for covariation relation to oral hygiene intervention and antibiotic administration. Levels of total yeast exhibited a significant association with Staphylococcus sp. at supragingival sites midchemotherapy (r = 0.68, p less than or equal to 0.05). Levels of total yeast also correlated positively with Pseudomonas aeruginosa at subgingival sites both prechemotherapy (r = 0.70, p less than or equal to 0.01) and midchemotherapy (r = 0.61, p less than or equal to 0.05). Significant correlations of levels of Veillonella sp. with Neisseria sp. and gram-negative enteric bacilli were observed in both supragingival (r = 0.95, 0.77, p values less than or equal to 0.01) and subgingival (r = 0.69, 0.61, p values less than or equal to 0.05) plaque specimens midchemotherapy but not prechemotherapy. These data suggest that potentially pathogenic bacteria occur in plaque simultaneous with granulocytopenia in these patients. Multiple mechanisms, including intergeneric coaggregation and other symbiotic relationships, may influence infectivity of the mixed plaque flora and thus contribute to the oral ecology observed in these patients.

Evaluation of two novel immunoassays designed to detect HIV antibodies in oral fluids

The testing of oral fluid samples for the detection of HIV antibodies offers several advantages over the testing of blood. Our objective was to evaluate a new generation of rapid and simple assays designed specifically to detect HIV‐1 and HIV‐2 antibodies in oral fluids (saliva). Serum and oral fluid pairs were collected from 615 high‐ and low‐risk individuals in the United States, Peru, and the Ivory Coast. Two different oral fluid collection devices and rapid assay systems included: (1) the Orapette/SalivaCard HIV‐1/HIV‐2 and (2) the Omni‐Sal/ImmunoComb II HIV‐1 and HIV‐2. The corresponding serum pairs were analyzed by conventional ELISAs, and all reactive sera were confirmed with HIV‐1 and HIV‐2 Western blots. The results indicated a 100% sensitivity for both rapid oral fluid assays, including successful detection of HIV‐2 antibodies. Specificities ranged from 99.8% to 100%. One sample produced a reactive result by the SalivaCard while being nonreactive by the other assays including the Western blots. Both assays performed excellently, indicating that antibodies to HIV can be detected reliably in oral fluids by simple and rapid assays. This combination of rapid testing technology and the use of easily collected oral fluid samples offers an efficient and accurate alternative to conventional testing and can be appropriately applied to a variety of testing situations for the laboratory diagnosis of HIV infection. J. Clin. Lab. Anal. 11:63–68.

Isolation of pathogenic microorganisms from dentures and denture-soaking containers of myelosuppressed cancer patients.

I nfection is the leading cause of morbidity and mortality in patients undergoing myelosuppressive cancer chemotherapy. ‘9 2 Bone marrow supp ression and mucosal damage sustained during chemotherapy predispose these patients to infection.‘s4 Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, other gram-negative bacilli, Staphylococcus aureus, and yeasts are responsible for the majority of infections in this population. 5-* Many of these pathogens are thought to be acquired or to ascend to predominance after admission to the hospital. 6,7 At the Baltimore Cancer Research Center (BCRC) during 1971-1976, surveillance cultures of 135 patients with acute nonlymphocytic leukemia (ANLL) demonstrated that new organisms were acquired at a rate of 0.5 organism per patient per week. Many of these organisms were gram-negative bacilli and species of yeast.’ Severely myelosuppressed patients appear to be especially susceptible to infections from these organisms.2~3~5~7 Infection in these patients can be exogenously or endogenously derived.’ Defined exogenous sources include food, water, bathtubs, shower stalls, ice machines, respirators, humidifiers, intravenous catheters, urinary catheters, and members of the hospital staff.8~‘o The primary endogeneous source is the patient’s alimentary canal.8 Dental prostheses and denture-soaking containers might represent a significant microbial reservoir for infection and cross-contamination but have not been evaluated. Investigations have shown that complete dentures from immunocompetent patients are capable of supporting the growth of microorganisms and can, therefore, serve as inadvertent transport mediums for potentially infectious organ

Median palatine cyst

Median palatine cysts are rare, nonodontogenic lesion of the hard palate that do not involve the palatine papilla or incisive canal and that usually present as asymptomatic, fluctuant swellings. They may involve the floor the nasal cavity but are treated by simple enucleation, without recurrence. They are composed histologically of a fibrous collagenous tissue wall, with infiltration of chronic inflammatory cells, and lined by stratified squamous and/or respiratory epithelium. They are differentiated from the nasopalatine and other anterior maxillary cysts by the following diagnostic criteria: Appears grossly to be symmetrical along the midline of the hard palate. Located posterior to palatine papilla. Radiographically ovoid or circular in appearance. Not intimately associated with a nonvital tooth or found to have any communication with the incisive canal. Shows no histologic evidence of nerve trunks, large vascular spaces, hyaline cartilage, or accessory salivary gland tissue in the cyst wall.

Efficacy of Listerine® Antiseptic in reducing viral contamination of saliva

Abstract Aim: The anti‐viral efficacy of oral antimicrobial rinses has not been adequately studied in terms of potential clinical significance. As a follow‐up to an in vitro study on the effect of oral antiseptics on Herpes simplex virus, Type 1, this study was undertaken to evaluate the in vivo effect of an essential oil containing oral antiseptic on the reduction of viral titer in saliva during active viral infection. Method: Patients were recruited and evaluated in a single visit protocol at the onset of a perioral outbreak, consistent historically and clinically with recurrent Herpes labialis. Direct immunofluorescence of cytological smears of the lesions/oral fluids was used to confirm Herpes simplex virus types I or II. Patients were randomly assigned to one of two treatment groups: (1) active ingredient and (2) sterile water control. The viral lesion was evaluated as to clinical stage according to standard protocol. Salivary fluid samples were taken: (1) at baseline; (2) immediately following a 30 s rinse; (3) 30 min. after the 30 s rinse; and (4) on the repeat trial, also at 60 min. after the 30 s rinse. All samples were evaluated for viral titer and results compared. Results: In Trial 1, the sample population consisted of 19 males and 21 females with an average age of 29.2 and in Trial 2, 21 males, 19 females with an average age of 28. In both Trials 1 and 2, recoverable infectious virions were reduced to zero after a 30 s experimental rinse; whereas, the control rinse resulted in a non‐significant (p>0.05) reduction. The experimental group also demonstrated a continued significant (p<0.05) reduction 30 min. post rinse when compared with baseline while the control group returned to baseline levels. In Trial 2, the 60 min. post rinse follow‐up demonstrated a 1–2 log residual reduction from baseline in the experimental group; however, this was not significant. Conclusions: There is clinical efficacy in utilizing an oral rinse with the antimicrobial agent Listerine® Antiseptic in reducing the presence of viral contamination in oral fluids for at least 30 min. after oral rinse. The risk of viral cross contamination generated from these oral fluids in person to person contact or during dental treatment may be reduced.

Growth of potential pathogens in denture-soaking solution of myelosuppressed cancer patients

M yelosupprcssion that results in markedly decreased numbers of circulating granulocytes and mucosal damage sustained during antineoplastic chemotherapy may predispose cancer patients to infection.‘.’ The more profound the myelosuppression, the higher the risk of infection, with a significantly higher probability of infection when granulocyte levels fall to less than 1 OO/&‘~ * Most of the infections are caused by opportunistic gram-negative bacilli, especially Pseudomonas aeruginosa, and several species of fungi.“-” Many of the organisms, which are thought to be acquired nosocomially or succeed to predominance after admission to the hospital, effect a change in the patient’s normal flora.‘~‘~ I2 As the organisms are generally not present in the pharynx of a normal population, such factors as hospital treatment modalities, serious systemic disease, and debilitation are thought to select for these pathogens.‘3-‘S Most infections in this population result from microorganisms that have colonized the patient’s alimentary canal, including the oral cavity.‘0,‘P.20 Exogenous sources of infection include food, water, shower stalls, humidifiers, ice machines, respirators, intravenous catheters, and members of the hospital staff.” In one investigation, dentures and denture-soaking containers used by myelosuppressed hospital patients were found to be contaminated heavily with pathogens, especially gram-negative bacilli. 2’ Under these conditions dentures could serve as reservoirs for pathogens in the hospital environment and as a source of infection and cross-contamination. The objective of this investigation was to determine if denture-borne pathogens would

The use of an interim protective prosthesis during cancer chemotherapy

The use of an interim protective prosthesis during cancer chemotherapy allows immediate patient comfort and function by protecting ulcerated mucosa and providing a platform against which to masticate. Chemotherapeutically induced lesions can be exacerbated by trauma from the remaining natural dentition during mastication and parafunctional habits. The interim prosthesis protects ulcerated tissue from further injury, and healing is promoted. The greater the integrity of the oral tissues, the more resistant they become to microbial invasion, subsequent microbial colonization, and infection during periods of granulocytopenia. By the use of a conservative technique, the patientss quality of life is improved during cancer treatment, and definitive prosthodontic treatment is deferred until therapy can be better tolerated by the patient.