The association between dental health and procedures and developing shunt infections in pediatric patients

Clinical article

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Object

Cerebrospinal fluid–diverting shunts are often complicated by bacterial infections. Dental procedures are known to cause transient bacteremia that could potentially spread hematogenously to these implanted devices. No literature currently exists to inform practitioners as to the need for prophylactic antibiotics for patients who possess these implants. The authors performed a retrospective study to assess whether dental procedures and poor oral health were associated with a higher likelihood of developing CSF-diverting shunt infections.

Methods

Neurosurgical and pediatric dental records from January 2007 to December 2012 were reviewed for shunt surgeries and dental encounters. Indications for shunt surgery and infection rates were recorded. Dental records were reviewed for several markers of overall dental health, such as a DMFT (decayed, missing, and filled teeth) score and a gingival health/oral hygiene score. The association between these scores and the incidence of shunt infections were studied. Moreover, the relationship between the incidence of shunt infections and the timing and invasiveness of preceding dental encounters were analyzed.

Results

A total of 100 pediatric patients were included in our study, for a total of 204 shunt surgeries. Twenty-one shunt infections were noted during the 6-year study period. Five of these shunts infections occurred within 3 months of a dental procedure. The odds ratio (OR) of developing a shunt infection within 3 months of a dental procedure was 0.98 (95% confidence interval [CI] 0.27–3.01), and was not statistically significant. The OR of developing a shunt infection after a high-risk dental procedure compared with a low-risk dental procedure was 1.32 (95% CI 0.02–16.29), and was not statistically significant. There was no significant association between measures of dental health, such as DMFT and gingival health score, and the likelihood of developing a shunt infection. The ORs for these 2 scores were 0.51 (95% CI 0.04–4.96) and 1.58 (95% CI 0.03–20.06), respectively. The study was limited by sample size.

Conclusions

Dental health status and the number and type of dental procedures performed do not appear to confer a higher risk of developing a CSF-diverting shunt infection in this pediatric population.

Abbreviations used in this paper:CHLA = Children's Hospital of Los Angeles; CI = confidence interval; DMFT = decayed, missing, and filled teeth; OR = odds ratio.

Object

Cerebrospinal fluid–diverting shunts are often complicated by bacterial infections. Dental procedures are known to cause transient bacteremia that could potentially spread hematogenously to these implanted devices. No literature currently exists to inform practitioners as to the need for prophylactic antibiotics for patients who possess these implants. The authors performed a retrospective study to assess whether dental procedures and poor oral health were associated with a higher likelihood of developing CSF-diverting shunt infections.

Methods

Neurosurgical and pediatric dental records from January 2007 to December 2012 were reviewed for shunt surgeries and dental encounters. Indications for shunt surgery and infection rates were recorded. Dental records were reviewed for several markers of overall dental health, such as a DMFT (decayed, missing, and filled teeth) score and a gingival health/oral hygiene score. The association between these scores and the incidence of shunt infections were studied. Moreover, the relationship between the incidence of shunt infections and the timing and invasiveness of preceding dental encounters were analyzed.

Results

A total of 100 pediatric patients were included in our study, for a total of 204 shunt surgeries. Twenty-one shunt infections were noted during the 6-year study period. Five of these shunts infections occurred within 3 months of a dental procedure. The odds ratio (OR) of developing a shunt infection within 3 months of a dental procedure was 0.98 (95% confidence interval [CI] 0.27–3.01), and was not statistically significant. The OR of developing a shunt infection after a high-risk dental procedure compared with a low-risk dental procedure was 1.32 (95% CI 0.02–16.29), and was not statistically significant. There was no significant association between measures of dental health, such as DMFT and gingival health score, and the likelihood of developing a shunt infection. The ORs for these 2 scores were 0.51 (95% CI 0.04–4.96) and 1.58 (95% CI 0.03–20.06), respectively. The study was limited by sample size.

Conclusions

Dental health status and the number and type of dental procedures performed do not appear to confer a higher risk of developing a CSF-diverting shunt infection in this pediatric population.

Approximately 18,000 CSF-diverting shunts are placed in the US each year.7 In the pediatric population these shunts are predominantly placed for the indication of hydrocephalus, which serves as a final common outcome for a myriad of congenital and acquired conditions. Patients benefit from these shunts by allowing diversion of CSF to other compartments of the body, thus preventing the accumulation of CSF in the cranial vault and subsequent elevated intracranial pressures.

Long-term management of such shunts is not without complications, and one of the most common complications is infection. Infection rates have been variously reported to range between 5% and 20%.1,7 Shunt infections can be categorized into 2 groups (early and late). Early shunt infections usually occur within the first 3 months after shunt placement, when up to 90% of shunt infections can occur.10 These early shunt infections are believed to be related to perioperative factors such as colonization of the shunt lumen by skin or airborne bacteria during placement, or immediately after surgery during wound healing. Staphylococcus epidermidis account for the majority of these infections, but Staphylococcus aureus and gram-negative bacteria have also been reported.9 Late shunt infections, in contrast, occur in patients 6 months or more from their shunt placement. These infections are believed to be a result of bacterial seeding of shunt hardware by hematogenous spread.

Routine dental procedures such as dental extractions and periodontal procedures have been shown to cause transient bacteremia. Lockhart et al. have shown that patients with poor oral hygiene and plaque-induced gingivitis are at a higher risk of developing infective endocarditis, even with bacteremia caused by daily toothbrushing.6 The consequence of bacteremia in relation to various surgically implanted hardware, particularly prosthetic heart valves, has been well studied. Currently, the 2008 American College of Cardiology/American Heart Association guidelines on endocarditis cite Class IIb evidence in support of routine antibiotic prophylaxis for all patients with prosthetic heart valves undergoing dental procedures.8 Conversely, the 2012 consensus guidelines from the American Dental Association and the American Academy of Orthopedic Surgeons recommend against routine antibiotic prophylaxis for patients with hip or knee prosthetic joint implants.13 The only formal guidelines published specifically with regards to CSF-diverting shunts are from the UK Medicines Information network, whose recommendation to the National Health Service in the United Kingdom state that no prophylactic antibiotics are needed.12 However, these recommendations are based on minimal evidence-based data, and there currently exists a paucity of published data informing the use of prophylactic antibiotics for patients with CSF-diverting shunts.

Helpin et al. have performed the only prospective study to date investigating the incidence of shunt infections after dental procedures without antibiotic prophylaxis.5 They found no shunt infections in a 12-month follow-up period, but their study population included only 14 patients. Croll et al. published recommendations for dicloxacillin prophylaxis for such patients, but these recommendations were based solely on the incidence of postprocedure bacteremia and not specifically related to the incidence of shunt infection.2

We retrospectively analyzed the dental and neurosurgical records of pediatric patients who had CSF-diverting shunts at Children's Hospital of Los Angeles (CHLA) to study the relation of shunt infections and dental procedures.

Methods

Study Objectives

The primary objective of this study was to determine whether there is an increased risk of shunt infection due to dental procedures in pediatric patients. Additionally, we investigated the relation of overall dental health with the likelihood of developing a shunt infection. Approval for this retrospective analysis was obtained from all relevant human investigation committees at our institution.

Patient Selection

After obtaining institutional review board approval, we retrospectively reviewed all records of patients who underwent CSF-diverting shunt placement and revision surgeries at CHLA between January 2007 and December 2012. This population of patients was cross-referenced with dental records from the Division of Pediatric Dentistry at CHLA. Clinical data from these charts were reviewed to extract the following: patient age, sex, indication for shunt placement, microbiology of shunt infection when available, date of dental examination or procedure, use of antibiotics for dental prophylaxis or for any other indication at or near the time of dental intervention, as well as assessment of general oral health.

Clinical Data and Review

All shunt-related procedures during this period were investigated. The indication for shunt surgery was recorded, specifically looking for shunt infections requiring removal or revision. When available, microbiological data were obtained. Shunt infections were defined as cases with positive CSF cultures that were treated operatively. Data were also obtained from the CHLA Pediatric Dental Clinic charts. Dental encounters included dental examinations, prophylactic dental cleaning, removal or placement of orthodontic bands, fillings, stainless steel crown placement, pulpotomy, root canal therapy, scaling/root planning, tooth extractions, and oral surgeries. High-risk procedures for bacteremia were defined as any of these aforementioned encounters with the exception of dental examination and prophylactic dental cleaning. Both dental and medical records were reviewed to determine whether patients were given prophylactic antibiotics at the time of their dental procedures or if they were receiving antibiotics at that time for other indications. ADMFT (decayed, missing [tooth due to decay], and filled teeth) index score was given to each patient for each dental encounter. This score was determined by counting the total number of teeth with dental caries (decayed), teeth missing due to dental caries, and filled teeth that were present in the mouth on the day of the dental visit. Additionally, an assessment of gingival health and oral hygiene was made for each dental encounter based on available documentation. An author (E.N.) assigned a gingival health/oral hygiene score of 1 for patients recorded to have good to fair oral hygiene, with mild to moderate plaque and calculus; a score of 2 for poor oral hygiene, with heavy plaque and calculus; and a score of 3 for patients recorded to have periodontitis. This author was blinded to the neurosurgical data.

Statistical Analysis

Descriptive statistics and univariate analyses were generated and are presented in the results section. Unadjusted odds ratios (ORs), 95% confidence intervals (CIs), and p values from Fisher's exact tests were used to summarize the association between categorical predictors of interest and our bivariate dependent variable (development of shunt infection). Because no significant associations were found by univariate analyses, multivariate analyses were not performed. For continuous data, 2-sample Wilcoxon rank-sum (Mann-Whitney) tests were used. Additionally, univariate exact logistic regression analyses were performed for the continuous predictors. Two-tailed p values were calculated for all applicable tests and p values ≤ 0.05 was considered significant. All analyses were performed using the statistical software package Stata/IC (version 13.1, StataCorp LP).

Results

Between January 2007 and December 2012, a total of 727 patients underwent shunt procedures at CHLA. Of this total, 100 individual patients were found to have concurrent records available at the Divisions of Pediatric Neurosurgery and Pediatric Dentistry at our institution. Demographic data for this population is presented in Table 1.

TABLE 1:

Patient population demographics

VariablePercentage
sex
 male57
 female43
age at original shunt placement (yrs)
 <171
 1–1022
 >107
indication for original shunt placement
 congenital abnormalities37
 tumor17
 neural tube defects16
 intraventricular hemorrhage28
 other2

A total of 204 neurosurgical shunt procedures and 648 dental procedures performed during our study period matched the inclusion criteria. The frequency of neurosurgical shunt and dental procedures performed on each patient in the study are presented in Fig. 1A and B, respectively. There were 7 atrial shunts and 5 pleural shunts present within the study population; all other shunts were peritoneal. Of the dental procedures performed, 375 (57.9%) were classified as high-risk for bacteremia.

Fig. 1.
Fig. 1.

Graphs showing the number of shunt procedures performed on each patient (A), the number of dental procedures performed on each patient (B), and distribution of the frequency of shunt infections occurring per patient (C).

Of the 204 shunt procedures performed, 21 were due to shunt infections. These 21 shunt infection procedures occurred in 19 individual patients, and the distribution is summarized in Fig. 1C. Nine of these patients were boys and 10 were girls. The microbiological pathogens that were grown on culture for each of these infections are presented in Table 2. Eight of these shunt infections were classified as “late” shunt infections because they occurred more than 3 months after an antecedent neurosurgical procedure; conversely, 13 infections were classified as early (Table 3). Of the “late” shunt infections, 2 occurred within 3 months of an antecedent dental procedure, and 6 had no antecedent dental procedure. Of the early shunt infections, 3 occurred in the presence of an antecedent dental procedure, and 10 occurred with no antecedent dental procedure.

TABLE 2:

Summary of shunt infection microbes

Infection Microbe TypeValue (%)
Staphylococcus aureus8 (38)
Staphylococcus epidermidis5 (24)
coagulase-negative Staphylococcus2 (9)
Propionibacterium acnes1 (5)
Escherichia coli3 (14)
Enterococcus1 (5)
unknown1 (5)
total21 (100)
TABLE 3:

The frequency of early and late shunt infections with antecedent dental procedures

Shunt InfectionsAntecedent Dental Procedure Performed Within 3 Mos of InfectionTotal
YesNo
early31013
late268
total51621

All shunt procedure cases with antecedent dental procedures were analyzed to assess the effects that various factors played in the odds of developing a subsequent shunt infection. Of the 204 shunt procedures performed, 49 (24.0%) were within 3 months of an antecedent dental procedure. There was no effect on the odds of developing a shunt infection if a patient had received an antecedent dental procedure within the preceding 3 months compared with those who did not (OR = 0.98, 95% CI 0.27–3.01; Table 4). The OR changes to 1.11 (95% CI 0.072–12.93) when only considering “late” shunt infections. Neither OR is statistically significant.

TABLE 4:

The relationship between performance of dental procedures and likelihood of shunt infection*

VariableDental Procedure Performed Within 3 Mos of Shunt ProcedureTotal
YesNo
shunt infection51621
no shunt infection44139183
total49155204

Unadjusted OR = 0.98, 95% CI 0.27–3.01, χ2 = 0.00, p = 0.97.

Among these 49 shunt procedures, 5 shunt infections were reported. One shunt infection was noted among the 8 patients who had received a preceding high-risk dental procedure, and 4 shunt infections were among the 41 patients who received a preceding low-risk dental procedure. The odds of developing a shunt infection from a high-risk dental procedure versus a low-risk dental procedure was 1.32 (95% CI 0.02–16.29; Table 5), which was not statistically significant. Three of the 8 patients with preceding high-risk procedures received prophylactic antibiotics and none were receiving long-term antibiotics for other indications. The patient who developed a subsequent shunt infection did not receive prophylactic antibiotics.

TABLE 5:

Relationship between type of dental procedure and likelihood of shunt infection*

VariableType of Dental Procedure Performed Within 3 Mos of Shunt ProcedureTotal
High RiskLow Risk
shunt infection145
no shunt infection73744
total84149

Unadjusted OR = 1.32, 95% CI 0.02–16.29, χ2 = 0.06, p = 0.82.

The use of prophylactic antibiotics for dental procedures was rare in our patient population. Of the 49 procedures performed within 3 months of a dental procedure, only 5 cases were noted to have had received either prophylactic antibiotics or were receiving antibiotics for a separate indication. None of these 5 cases went on to develop subsequent shunt infections. Conversely, none of the 5 patients who developed shunt infections were given prophylactic antibiotics for their antecedent dental procedures.

The average DMFT score of all dental encounters that were followed by a shunt infection within 3 months was 2.4 ± 3.05 (n = 5). The average DMFT score of all dental encounters that were not followed by a shunt infection was 4.89 ± 5.40 (n = 4 4). T here was no statistically significant increased odds of developing a shunt infection with DMFT scores > 1 compared with scores ≤ 1 (Table 6).

TABLE 6:

The relationship between DMFT scores (categorized) and shunt infection*

VariableDMFT ScoreTotal
>1≤1
shunt infection235
no shunt infection251944
total272249

Unadjusted OR = 0.51, 95% CI 0.04–4.96, χ2 = 0.51, p = 0.47.

Finally, there was no significant association between the gingival health/oral hygiene score of a patient and the likelihood of developing a shunt infection. Of the 49 cases with preceding dental encounters, the comparison of those with and without shunt infections and gingival health scores above or below 1 did not reveal a statistically significant OR (Table 7).

TABLE 7:

The relationship between gingival health/oral (categorized) and likelihood of shunt infection*

VariableGingival ScoreTotal
>1≤1
shunt infection145
no shunt infection63844
total74249

Unadjusted OR = 1.58, 95% CI 0.03–20.06, χ2 = 0.15, p = 0.70.

Discussion

This study is the first to specifically investigate the influence of dental health and dental procedures on infection rates of implanted CSF-diverting shunts. The results suggest that poor dental health status is not a risk factor for developing shunt infections, and the performance of dental procedures does not confer a higher risk of shunt infections within the pediatric population. We found no correlation between several measures of overall dental health, such as the DMFT and the gingival health/oral hygiene score, and a higher rate of shunt infections. Our data do not show an increased risk of shunt infections in the subsequent 3 months following any dental encounter; this observation is unchanged when only taking into account high-risk invasive dental procedures. As further corroboration of these findings, we found that the distribution of pathogens causing shunt infections in our population do not reflect typical oral flora bacteria. It is worth noting that our data pertain only to the likelihood of developing shunt infections, and not due to shunt complications in general, such as mechanical complications.

Our results imply that transient bacteremia caused by invasive dental procedures does not induce infectious seeding of implanted intracranial hardware. This observation differs from the outcomes noted with prosthetic heart valves. This difference may exist because intracardiac devices are exposed to higher concentrations of inoculating bacteremia because they are in direct exposure to the bloodstream. Another factor is that intracranial devices have the benefit of being protected by the blood-brain barrier. Additionally, the extracranial components of the shunts are embedded within the subcutaneous soft tissue. The body mounts a reactive encapsulation response to this foreign object, which likely serves as a protective barrier to bloodstream inoculations.3

We caution readers not to misinterpret the proportion of infected shunts reported in our population as an incidence rate of shunt infections. The cohort studied consisted of many patients who were referred to our institution for treatment of infected shunts from regional community institutions. This introduces a selection bias that artificially increases the proportion of patients with active shunt infections relative to the general population. This bias accounts for the approximate 20% proportion of infected shunts, but this number should not be interpreted as a 20% incidence rate of shunt infections, which would be much higher than previously reported in the literature.11 The true incidence of shunt infections for shunts placed at our institution is, in fact, approximately 4% (unreported data).

Although we did not find a direct relation between dental health and an increased risk of shunt infection, there still may be confounding factors within this population that indirectly affect the chances of infection. Of note, the overall DMFT score of our population was higher than the national average for children in the US (1.05 for 2–5-year-olds, and 1.75 for 6–19-year-olds).4 Additionally, our data did not assess for baseline neurological function, which may play a role both in the incidence of shunt complications and the ability to maintain good dental health.

There are no other studies that have specifically investigated this clinical question to allow us to compare results. This is likely because few centers have access to such data. Most patients who receive specialized neurosurgical care at tertiary care centers still continue to receive dental care at private dental offices in the community. Obtaining dental records in this manner would be logistically forbidding. We were fortunate at our institution because many of the patients who were undergoing neurosurgical treatment also received pediatric dental treatment at our institution as well. This provided us access to both sets of clinical data to allow us to perform this study.

Our study has several limitations, primary of which is sample size. Although the proportion of shunt infections was relatively high, the absolute number of shunt infections was a small number (n = 21). This is subsequently reflected in the wide CIs calculated from the data. If there are subtle influences of dental procedures or health on the number of shunt infections, then the study may be underpowered to detect such correlations. These limitations are even more pronounced with regards to ventriculoatrial and ventriculopleural shunts, as the number of these types of shunts in our study population was very low. Although there were an adequate number of neurosurgical and dental procedures recorded during our time frame, only a fraction of neurosurgical procedures had antecedent dental data within the preceding 3 months. Therefore, for the majority of neurosurgical cases, it was unclear what the dental health status was for these patients. Extrapolating dental health data from dental encounters more than 3 months preceding a neurosurgical procedure would require the assumption that no significant changes had occurred to the patient's dental health status during this time; we did not make such assumptions. It is possible that patients were also undergoing examinations by private community dentists in addition to our own providers during the study period, allowing for dental encounters that are not captured in our data. Although our data cannot account for this possibility, our subjective experience has been that once patients establish care with our division of dentistry, they tend not to continue care with external providers. Finally, there may be some biases introduced into our patient population by selecting for only patients who are examined by our institution's pediatric dentists. This population may be of lower socioeconomic status than the general CHLA pediatric population, as many of these patients may have the means to access external providers for dental care. However, there are no specific dental or medical conditions that mandate hospital-based dental care at our institution.

Conclusions

This study suggests that dental health and dental procedures are not directly related to a higher risk of pediatric shunt infections. Although current patterns of practice by pediatric dentists are to not administer prophylactic antibiotics for implanted shunts, prior to this study no evidence-based data has been published to guide this practice. Our results suggest that the bacteremia caused by dental procedures does not induce a significant risk for shunt infections. This observation should reassure practitioners that prophylactic antibiotics are likely not needed for dental procedures, regardless of dental health status. Results from larger, prospectively designed studies could further corroborate these conclusions.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Moazzam, Polido, Habibian, Krieger. Acquisition of data: Moazzam, Nehrer, Da Silva, Arakelyan. Analysis and interpretation of data: Moazzam, Nehrer, Da Silva, Polido, Arakelyan, Habibian. Drafting the article: Moazzam, Da Silva, Polido, Arakelyan, Habibian. Critically revising the article: Moazzam, Da Silva, Polido, Arakelyan, Habibian, Krieger. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Moazzam. Statistical analysis: Moazzam, Da Silva, Arakelyan, Habibian. Administrative/technical/material support: Moazzam, Nehrer, Da Silva, Polido, Habibian, Krieger. Study supervision: Moazzam, Habibian, Krieger.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

References

  • 1

    Ammirati MRaimondi AJ: Cerebrospinal fluid shunt infections in children. A study on the relationship between the etiology of hydrocephalus, age at the time of shunt placement, and infection rate. Childs Nerv Syst 3:1061091987

    • Search Google Scholar
    • Export Citation
  • 2

    Croll TPGreiner DGSchut L: Antibiotic prophylaxis for the hydrocephalic dental patient with a shunt. Pediatr Dent 1:81851979

  • 3

    Del Bigio MR: Biological reactions to cerebrospinal fluid shunt devices: a review of the cellular pathology. Neurosurgery 42:3193261998

    • Search Google Scholar
    • Export Citation
  • 4

    Dental Oral and Craniofacial Data Resource Center National Institute of Dental and Craniofacial Research National Institutes of Health Division of Oral Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention: Oral Health U.S. 2002. Department of Health and Human Services2002. http://drc.hhs.gov/report/index.htm) [Accessed August 10 2014]

    • Search Google Scholar
    • Export Citation
  • 5

    Helpin MLRosenberg HMSayany ZSanford RA: Antibiotic prophylaxis in dental patients with ventriculo-peritoneal shunts: a pilot study. ASDC J Dent Child 65:2442471998

    • Search Google Scholar
    • Export Citation
  • 6

    Lockhart PBBrennan MTThornhill MMichalowicz BSNoll JBahrani-Mougeot FK: Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. J Am Dent Assoc 140:123812442009

    • Search Google Scholar
    • Export Citation
  • 7

    McGirt MJZaas AFuchs HEGeorge TMKaye KSexton DJ: Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 36:8588622003

    • Search Google Scholar
    • Export Citation
  • 8

    Nishimura RACarabello BAFaxon DPFreed MDLytle BWO'Gara PT: ACC/AHA 2008 Guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 52:6766852008

    • Search Google Scholar
    • Export Citation
  • 9

    Ohara-Nemoto YHaraga HKimura SNemoto TK: Occurrence of staphylococci in the oral cavities of healthy adults and nasal oral trafficking of the bacteria. J Med Microbiol 57:95992008

    • Search Google Scholar
    • Export Citation
  • 10

    Pople IK: Hydrocephalus and shunts: what the neurologist should know. J Neurol Neurosurg Psychiatry 73:Suppl 1i17i222002

  • 11

    Simon TDHall MRiva-Cambrin JAlbert JEJeffries HELafleur B: Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 4:1561652009

    • Search Google Scholar
    • Export Citation
  • 12

    UK Medicines Information: Medicines Q&A 76.5: Do patients with hydrocephalus shunts need antibiotic prophylaxis before undergoing dental procedures? (http://www.medicinesresources.nhs.uk/GetDocument.aspx?pageId=789080) [Accessed August 10 2014]

    • Search Google Scholar
    • Export Citation
  • 13

    Watters W IIIRethman MPHanson NBAbt EAnderson PACarroll KC: Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg 21:1801892013

    • Search Google Scholar
    • Export Citation

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Article Information

Address correspondence to: Alan A. Moazzam, M.D., 1500 San Pablo St., Los Angeles, CA 90033. email: alan.moazzam@usc.edu.

Please include this information when citing this paper: published online September 12, 2014; DOI: 10.3171/2014.8.PEDS1444.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graphs showing the number of shunt procedures performed on each patient (A), the number of dental procedures performed on each patient (B), and distribution of the frequency of shunt infections occurring per patient (C).

References

  • 1

    Ammirati MRaimondi AJ: Cerebrospinal fluid shunt infections in children. A study on the relationship between the etiology of hydrocephalus, age at the time of shunt placement, and infection rate. Childs Nerv Syst 3:1061091987

    • Search Google Scholar
    • Export Citation
  • 2

    Croll TPGreiner DGSchut L: Antibiotic prophylaxis for the hydrocephalic dental patient with a shunt. Pediatr Dent 1:81851979

  • 3

    Del Bigio MR: Biological reactions to cerebrospinal fluid shunt devices: a review of the cellular pathology. Neurosurgery 42:3193261998

    • Search Google Scholar
    • Export Citation
  • 4

    Dental Oral and Craniofacial Data Resource Center National Institute of Dental and Craniofacial Research National Institutes of Health Division of Oral Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention: Oral Health U.S. 2002. Department of Health and Human Services2002. http://drc.hhs.gov/report/index.htm) [Accessed August 10 2014]

    • Search Google Scholar
    • Export Citation
  • 5

    Helpin MLRosenberg HMSayany ZSanford RA: Antibiotic prophylaxis in dental patients with ventriculo-peritoneal shunts: a pilot study. ASDC J Dent Child 65:2442471998

    • Search Google Scholar
    • Export Citation
  • 6

    Lockhart PBBrennan MTThornhill MMichalowicz BSNoll JBahrani-Mougeot FK: Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. J Am Dent Assoc 140:123812442009

    • Search Google Scholar
    • Export Citation
  • 7

    McGirt MJZaas AFuchs HEGeorge TMKaye KSexton DJ: Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 36:8588622003

    • Search Google Scholar
    • Export Citation
  • 8

    Nishimura RACarabello BAFaxon DPFreed MDLytle BWO'Gara PT: ACC/AHA 2008 Guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 52:6766852008

    • Search Google Scholar
    • Export Citation
  • 9

    Ohara-Nemoto YHaraga HKimura SNemoto TK: Occurrence of staphylococci in the oral cavities of healthy adults and nasal oral trafficking of the bacteria. J Med Microbiol 57:95992008

    • Search Google Scholar
    • Export Citation
  • 10

    Pople IK: Hydrocephalus and shunts: what the neurologist should know. J Neurol Neurosurg Psychiatry 73:Suppl 1i17i222002

  • 11

    Simon TDHall MRiva-Cambrin JAlbert JEJeffries HELafleur B: Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 4:1561652009

    • Search Google Scholar
    • Export Citation
  • 12

    UK Medicines Information: Medicines Q&A 76.5: Do patients with hydrocephalus shunts need antibiotic prophylaxis before undergoing dental procedures? (http://www.medicinesresources.nhs.uk/GetDocument.aspx?pageId=789080) [Accessed August 10 2014]

    • Search Google Scholar
    • Export Citation
  • 13

    Watters W IIIRethman MPHanson NBAbt EAnderson PACarroll KC: Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg 21:1801892013

    • Search Google Scholar
    • Export Citation

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