Spinal Epidural Abscess Following Minimally Invasive Dental Examination in a Rheumatoid Arthritis Patient Receiving Methotrexate, Glucocorticoids, and Anti–Tumor Necrosis Factor Therapy

Darley, Michael D; Saad, Dany; Haydoura, Souha; McGowan, David; Payne, Jeffrey B.; Cannon, Grant W.; Mikuls, Ted R.

doi:10.1097/rhu.0000000000000202

Cited by 6 publications

(4 citation statements)

References 7 publications

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“…1). The hazard period reflects the finding that PVO is more likely to occur within 4 weeks after a dental procedure [7,21,34]. We set 4-week washout periods between the hazard and control periods to avoid carryover effects and potential autocorrelation [18].…”

Section: Exposure Definitionmentioning

confidence: 99%

“…PVO is commonly caused by the hematogenous transfer of bacteria from different sites in the body [22]. Although the main source of infection is speculated to be urinary tract infection, skin wounds, intra-abdominal organ infection, or oral cavity, little evidence regarding this question has appeared because all previous studies were case series [7,11,14,21,25,34]. Dental procedures are reported to cause bacteremia [12], and a few case series and case reports of PVO after dental procedures have been reported [7,21,34].…”

Section: Introductionmentioning

confidence: 99%

“…Although the main source of infection is speculated to be urinary tract infection, skin wounds, intra-abdominal organ infection, or oral cavity, little evidence regarding this question has appeared because all previous studies were case series [7,11,14,21,25,34]. Dental procedures are reported to cause bacteremia [12], and a few case series and case reports of PVO after dental procedures have been reported [7,21,34]. However, these studies were limited by the absence of control patients, and recent studies have cast doubt on the infection risk after dental procedures and the necessity of routine antibiotic prophylaxis in unselected patients [26,30,32].…”

Section: Introductionmentioning

confidence: 99%

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Are Dental Procedures Associated With Pyogenic Vertebral Osteomyelitis?

Masuda,

Fukasawa,

Takeuchi

et al. 2023

Clin Orthop Relat Res

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Background Dental procedures can lead to bacteremia and have been considered a potential risk factor for pyogenic vertebral osteomyelitis (PVO). However, data on the association between dental procedures and PVO are limited. Questions/purposes (1) After controlling for relevant confounding variables, are dental procedures associated with an increased risk of PVO? (2) Does antibiotic prophylaxis before dental procedures effectively decrease the risk of PVO? Methods A case-crossover study was conducted to investigate the association between dental procedures and PVO using a Japanese claims database. The advantage of this study design is that confounding factors that do not vary over time are automatically adjusted for, because cases act as their own controls. From April 2014 to September 2021, the database included 8414 patients who were hospitalized for PVO. Of these, 50% (4182 of 8414) were excluded because they had not undergone any dental procedures before the index date, a further 0.1% (10 of 8414) were excluded because they were younger than 18 years at the index date, and a further 7% (623 of 8414) were excluded because they did not have at least 20 weeks of continuous enrollment before the index date, leaving 43% (3599 of 8414) eligible for analysis here. The mean age was 77 ± 11 years, and 55% (1985 of 3599) were men. Sixty-five percent (2356 of 3599) of patients had a diagnosis of diabetes mellitus, and 42% (1519 of 3599) of patients had a diagnosis of osteoporosis. We compared the frequency of dental procedures between a 4-week hazard period before the admission date for PVO and two control periods, 9 to 12 weeks and 17 to 20 weeks before the admission date for PVO, within individuals. We calculated odds ratios and 95% confidence intervals using conditional logistic regression analysis. Results Comparing the hazard and matched control periods within individuals demonstrated that dental procedures were not associated with an increased risk of PVO (OR 0.81 [95% CI 0.72 to 0.92]; p < 0.001). Additional analysis stratified by antibiotic prophylaxis use showed that antibiotic prophylaxis was not associated with a lower OR of developing PVO after dental procedures (with antibiotic prophylaxis: OR 1.11 [95% CI 0.93 to 1.32]; p < 0.26, without antibiotic prophylaxis: OR 0.72 [95% CI 0.63 to 0.83]; p < 0.001). Our sensitivity analyses, in which the exposure assessment interval was extended from 4 to 8 or 12 weeks and exposure was stratified by whether the dental procedure was invasive, demonstrated results that were consistent with our main analysis. Conclusion Dental procedures were not associated with an increased risk of subsequent PVO in this case-crossover study. The effectiveness of antibiotic prophylaxis was not demonstrated in the additional analysis that categorized exposure according to the use of antibiotic prophylaxis. Our results suggest that the association between dental procedures and PVO may have been overestimated. Maintaining good oral hygiene may be important in preventing the development of PVO. The indications for antibiotic prophylaxis before dental procedures should be reconsidered in view of the potential risk of adverse drug reactions to antibiotic prophylaxis and the emergence of drug-resistant pathogens. Larger randomized controlled trials are needed to confirm these findings and assess the role of antibiotic prophylaxis. Level of Evidence Level III, therapeutic study.

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Section: Exposure Definitionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Are Dental Procedures Associated With Pyogenic Vertebral Osteomyelitis?

Masuda,

Fukasawa,

Takeuchi

et al. 2023

Clin Orthop Relat Res

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“…abscess often occurs in immunodeficient patients, or in those with long-term immunodepressant drugs such as rituximab, infliximab, and methotrexate therapy, 3,4 previously healthy people are also reported to be infected with spinal epidural abscess. 5,6 In a rare case, cellulitis anterior to the cervical vertebra may spread and infect the vertebral body and disk, then penetrating into the epidural space, and finally causing acute epidural abscess.…”

mentioning

confidence: 99%