Bacteremia associated with toothbrushing and dental extraction

Circulation. 2008 Jun 17;117(24):3118-25. doi: 10.1161/CIRCULATIONAHA.107.758524. Epub 2008 Jun 9.


Background: Antibiotic prophylaxis recommendations for the prevention of infective endocarditis are based in part on studies of bacteremia from dental procedures, but toothbrushing may pose a greater threat. The purpose of this study was to compare the incidence, duration, nature, and magnitude of endocarditis-related bacteremia from single-tooth extraction and toothbrushing and to determine the impact of amoxicillin prophylaxis on single-tooth extraction.

Methods and results: In this double-blind, placebo-controlled study, 290 subjects were randomized to (1) toothbrushing, (2) single-tooth extraction with amoxicillin prophylaxis, or (3) single-tooth extraction with identical placebo. Blood was drawn for bacterial culturing and identification at 6 time points before, during, and after these interventions. The focus of our analysis was on bacterial species reported to cause infective endocarditis. We identified 98 bacterial species, 32 of which are reported to cause endocarditis. Cumulative incidence of endocarditis-related bacteria from all 6 blood draws was 23%, 33%, and 60% for the toothbrushing, extraction-amoxicillin, and extraction-placebo groups, respectively (P<0.0001). Significant differences were identified among the 3 groups at draws 2, 3, 4, and 5 (all P<0.05). Amoxicillin resulted in a significant decrease in positive cultures (P<0.0001).

Conclusions: Although amoxicillin has a significant impact on bacteremia resulting from a single-tooth extraction, given the greater frequency for oral hygiene, toothbrushing may be a greater threat for individuals at risk for infective endocarditis.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Amoxicillin / therapeutic use
  • Anti-Bacterial Agents / therapeutic use
  • Bacteremia / blood
  • Bacteremia / epidemiology*
  • Bacteremia / prevention & control
  • Dental Plaque / epidemiology
  • Double-Blind Method
  • Ethnic Groups
  • Female
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Oral Hygiene / standards
  • Patient Selection
  • Placebos
  • Tooth Extraction / adverse effects*
  • Toothbrushing / adverse effects*


  • Anti-Bacterial Agents
  • Placebos
  • Amoxicillin