Systemic Conenctions Flashcards by John Fixari

What was the major paradigm shift in microbiology?

Previous: “germs” - bacteria are pathogenic invaders
New: “Human-microbiome super-organism” - Microbes are essential and we are adapted to eachother

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How are microbes beneficial?

Resistance against pathogens
Metabolic functions
Immune activatoin

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How did the microbiology paradigm shift effect how we view bacteria?

Previously the goal was a sterile environment

Now, the goal is to manage and preserve native microbes (selectively rid of things)

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How did the microbiology paradigm shift change our understanding of disease?

Old: Koch’s postulates and single-species acute diseases
New: Chronic diseases are caused by microbial community disruption and loss of healthy species

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How did the microbiology paradigm shift change our direction for therapies?

Old: Therapies focused on broad eradication (antibiotics and antiseptics)
New: Therapies to encourage healthy communities (probiotics, prebiotics, targeted antimicrobials)

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What are prebiotics?

Encourage growth of good bacteria

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What are targeted antimicrobials?

Smart antibiotics that only target certain things

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Theory of Focal infection

Idea that oral “focus of infection” causes systemic disease dates back at least to Hippocrates who reported the cure of arthritis after removal of a tooth
People used to thing fillings form America were causing bad things

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New evidence is showing what?

Connections between oral infections and systemic diseases

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What are the direct mechanisms for oral connections?

Translocation of bacteria

Translocation of toxin

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Translocation of bacteria

Distant site infections are seeded by oral bacteria

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Translocation of toxin

Distant site effect from toxin produced by oral bacteria

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What is a major mechanism for immune system mediated oral-systemic condition connection?

Host hyper-inflammatory phenotype common pathway to disease

Example: IL-1 gene polumorphisms are associated with periodontitis and systemic diseases

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What do epidemiologic studies show?

They show association

Don’t establish causation

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What can Evidence of Causality entail?

Human trials showing oral diseases treatment prevents systemic disease or lowers systemic infections
Presence of oral bacteria at disease site
Demonstration of effect in animal model

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Infective Endocarditis

Platelets and fibrin adhere to exposed CT producing nonbacterial thrombotic endocarditis (NBTE)
Bacterial from the oral cavity enter the blood stream and adhere to NBTE causing a clotq
Bacteria multiply, infiltrate the heart, and cause cardiac and valvular injury
Discharged into the circulation produces emboli and stroke

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What are the major bacteria in Infective Endocarditis?

Oral streptococci 60+% (also A. actinomycetemocomitans and gemella)
Skin bacteria (25%)

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T/F - There is evidence that connects dental procedures with Infective Endocarditis

False

What is Antibiotic prohpylaxis? Can it prevent Infective Endocarditis?

Antibiotics are taken to (in theory) prevent spread of bacteria through bacteremia
In practice, it doesn’t really prevent bacteremia
It is unlikely to prevent many cases of IE

T/F - Random bacteremia form routine activities are more likely to cause IE than dental procedures

True

What is the most important factor in reducing the risk of Infective Endocarditis?

Optimize regular oral hygiene measures to keep bacterial load low
(Much more effective than antibiotic prophylaxis)

How did the paradigm shift effect the way we view antibiotic prophylaxis?

We shifted from using antibiotic prophylaxis to access to dental care and oral health
If a patient is high risk for Infective Endocarditis, and we are doing a very invasive procedure, we give a single high dose of amoxicillin right when we treat

What can cause “Aspiration Pneumonia”

Aspiration of oral secretions or oral bacteria
Aspiration pneumonia is common when airway protected reflexes are compromised (physically handicapped, elderly, very ill pts)

What can help prevent lung infections?

Oral hygiene measures
-reduce nosocomial pneumonia by 40%
-can prevent 10% of deaths in elderly nursing home
(strong evidence)

Preterm birth is connected with what? How?

Periodontitis Bacteria in amniotic fluid associated with preterm births have some oral species (not very strong evidence)

Why are immunosupressed patients high risk for disseminated strep or Candida of oral origin infection?

They don't have a good immune system, so they can't fight off normal oral microbiota if it gets somewhere it shouldn't be

What should we consider when treating an immunocompromised patient?

Focus on achieving/maintaining good oral hygiene Invasiveness of the procedure Bacterial load The degree of immunosuppression

Diabetes is connected with what oral disease? Why?

There is an increased prevalence of periodontitis in diabetics Treatment of periodontitis improves glycemic control (something about periodontitis makes glyvemia harder to control) -Evidence is strong, and the effect is moderate

What is the connection of Cardiovascular disease and oral bacteria?

Coronary heart disease, stroke, and peripheral vascular disease are all associated with periodontitis There is a link, but causative relationship hasn't been established Could be bacterial toxins or bacteria itself, or because people with that phenotype are hyper-inflammatory

What is the evidence for causality between CVD and periodontitis?

Perio Tx trials show favorable responses on labratory markers but do not show reduction of CVD P. gingivalis and other perio pathogens are found on atherosclerotic lesions P. gingivalis exacerbates CVD in animal models There are plausable biologic pathways

T/F - Studies show risk of pancreatic cancer in patients with periodontitis

True - we don't know it there's a common pathway, though

Cardiovascular Implantable Electronic Device (CIED) infections

Caused by bacteria from skin, hands of hospital workers, or environmental staph biofilms Not oral species Do not give antibiotic prophylaxis prior to dental treatment - hands are the issue

Patients with vascular grafts/stents

Most infections are caused by bacteria native to skin or bowels Oral organisms are rarely infecitous Do not give antibiotic prophylaxis prior to treatment

Patients with intravascular access devices

Wide variety of devices Infections are usually caused by staph or other skin environment bacteria Do not give antibiotic prophylaxis for any reason Good infection control practices are key

Joint prostheses

1-2% become infected (high morbidity) | Most infections occur in perioperative period from wound contamination

Primary prophylaxis for patients with joint prosthesis

Evidence is strong for primary antibiotic prophylaxis at the time of device placement

Secondary prophylaxis for patients with joint prosthesis

Evidence is lacking for secondary prophylaxis to reduce dental procedure-related bacteremia and distant site infection So prophylaxis for dental procedure is not generally recommended

Patients with bone pins, plates, and screws

Orthapedic hardware not within synovial joit is not at increased risk for hematogenous seeding by microorganisms Infections are caused by staph or other skin bacteria Not indicated for antibiotic prophylaxis prior to dental treatment

Patients with CSF shunts

Infections are caused by skin bacteria, not oral | Don't need AP

Direct transfer of oral bacteria can cause what issues?

Infective Endocarditis Pneumonia in compromised airway Immunosuppression Preterm birth?

What are the primary preventive strategies to prevent issues related to direct transfer of oral bacteria?

Improve oral health and reduce bacterial load | Antibiotic prophylaxis in specific high risk situaitons

Indirect transfer of oral bacteria or toxin, or common inflammatory pathways are related to what issues?

Type 2 diabetes Cardiovascular disease Pancreatic cancer

What is the primary preventive strategy to prevent issues related to oral bacteria or toxin transfer or common inflammatory pathways?

Treat periodontal disease to improve microbial profile | Improve overall health by addressing risk factors

T/F - Human microbiota is niche specific

True - and therefore they have limited range and limited ability to cause systemic disease