United States Public Health Service

DENTAL NEWSLETTERA publication of the Dental Professional Advisory Committee

Volume IV, Issue #1 (Issue #12 overall) April 15, 2004

In this issue of the USPHS Dental Newsletter:

Click on the titles below to go directly to the articles.

COVER STORYPHS dentists deploy in support of war

REGULAR SECTIONSChief Dental Officer’s column – Pg. 2DePAC Chair’s column – Pg. 2DePAC Vice Chair’s column – Pg. 3Agency Updates – Pg. 4Organizational Updates – Pg. 6

FEATURESJunior Officer Profile – Pg. 8Senior Officer Profile – Pg. 8Question of the Month – Pg. 9Clinical Perspectives – Pg. 10 Selection and Use of Antibiotics – Pg. 10 Antibiotic prophylaxis – Pg. 12Deployment pictures – Pg. 15

The USPHS Dental Newsletter is now published 6-8 times annually, and is distributed electronically through the USPHS Dental Bulletin Board, agency distribution lists, and the USPHS Dental Directory.

The next issue of the newsletter will be published in early June 2004. The deadline for submitting articles is May 15, 2004.

If you have suggestions or comments about this newsletter, or would like to submit an article, please contact the Editor. If you would like to comment on organizational or agency reports, contact the Section Co-Editor. If you have comments or suggestions regarding clinical articles, contact the Clinical Perspectives Co-Editor.

The Dental Professional Advisory Committee is pleased to announce that the USPHS Dental Category Home Page is now available to all USPHS dentists.

After months of tedious work by both CDR Jim Webb and CDR Arlan Andrews, the new and improved web page features more basic information, more links, more career development information, and improved graphics from the previous web page.

All dentists are encouraged to view this webpage (click this link to go directly to it, or go to: http://www.phs-dental.org/depac/newfile.html). If you have comments about the web page, contact the webmaster.

In support of the war effort, USPHS dentists have been deployed over the past few months to 29 Palms, the Marine Corps Air Ground Combat Center (MCAGCC), and to the US Marine Camp at Camp LeJeune, North Carolina.

The following officers were deployed to Camp LeJeune during the time period of 29 October 2003 – 28 February 2004: CDR Dean Coppola, LCDR Charles Webber, LCDR Scott Trapp, CDR Lawrence Gaskin, CDR Hiro Nakatsuchi, LCDR Robin Scheper, CAPT Thomas Bermel, CDR Pedro Perez, CDR Lisa Cayous, LCDR Aaron Means, CAPT Shawneequa Harris, CDR Renee Joskow, CDR Jose Rodriguez, LT Kathryn Bagg, LCDR Robert Lloyd, and LCDR Laura Lund.

The following officers were deployed to 29 Palms during the time period of 4 January – 27 March 2004: CDR Luis Garabis, CDR Randall Mayberry, CDR Mark, McDowell, CAPT Lee Shackelford, CDR David Crain, LT Bleuel, CDR Elmer Guerrero, LCDR Jeffrey Roth, CDR Dan Huber, CDR Edward Arnold, LCDR Kelly, CAPT Gary Pannabecker, CDR Steve Torna, LT Kaci Solt, CDR Steven Florer, LT Morazan, LCDR Dickert, CDR Tania Macias, CAPT Samuel Bundrant, CAPT Jeff Carolla, and CDR Paul Krispinsky

►See deployment pictures, page 15

Page 2 USPHS Dental Newsletter April 2004

Dushanka V. Kleinman, D.D.S., M.Sc.D.Assistant Surgeon General

The early stages of the Transformation of the Corps are in full swing and it is timely to provide active and constructive input into the process. While organizational functions and delegations of authority for the management of Corps operations and policies have been documented (Federal Register, Vol. 68, No. 243, 12/13/03 and on the DCP website), there is still much work to do before the new structure and functions are fully implemented.

The Assistant Secretary for Health, the Surgeon General, RADM Knouss, RADM Williams, agency liaisons and agency heads have been holding agency-specific all hands meetings to listen to concerns, answer questions and gain input from officers. In addition there is a contract with The Lewin Group, a consulting firm that is conducting a variety of activities for additional input for the transformation. I am serving on their billets and missions “policy panel”. They also are conducting a policy panel on hard to fill and hardship billets, a “technical panel” on billet standards and a number of focus groups. These focus groups will address such topics as input from junior officers on careers and assignments, online website users, user agencies and input from potential recruits. The latter will reach out to professional associations relevant to each category. I encourage your input and welcome your questions. Your DePAC is working hard to keep you informed, and I will forward documents and materials as they become available.

Ronald E. Bajuscak, D.M.D., M.S.CAPT, USPHS

This is a time of change that we are seeing as we go through the transformation of the Com-missioned Corps. These changes will be continuing to develop and will occur over thenext few years. As with any company or corporation, changes create both excitement and panic at the same time. But before we panic too much, I think it is most important that we remember who we are and what we do. We are a group of extremely conscientious healthcare members that provide a service to a part of the nation that truly needs our care and that the average healthcare provider would not and could not handle. It is a skill far beyond clinical hands-on and requires dedication, commitment and compassion. We provide so much both clinically, administratively and scientifically that in many ways we are not truly replaceable.

Keeping this in mind, we should embrace the changes that our Surgeon General is establishing. Certainly there is full intent to make us a better organization that can utilize the many facets of abilities we have and demonstrate daily. I am reminded daily by the many communications I receive, that we are an extremely talented group of dentists, health leaders, researchers and diplomats whose skills far exceed clinical dentistry only. I look forward with excitement at what new things we will accomplish and know we are the true leaders of oral health care in this wonderful nation.

Page 3 USPHS Dental Newsletter April 2004

Gary L. Pannabecker, D.D.S.CAPT, USPHS

One of the common themes identified by PHS dentists from the recent DePAC Dental Category Survey was a lack of awareness of the duties, purpose, and objectives of the Dental Professional Advisory Committee (DePAC). Well, believe it or not, new DePAC members have often expressed that same ambiguity. The ongoing transformation and restructuring of DCP has contributed to a need to clarify the role and vision of DePAC. To meet this need, RADM Dushanka Kleinman, along with the DePAC leadership, supported and organized a retreat January 14-16, 2004 held at the Bolger Center for Leadership Development in Potomac, Maryland. The retreat facilitator, Preston Littleton, D.D.S., M.S., PhD., RADM USPHS (ret), interviewed DePAC members prior to the retreat to help clarify its goals and objectives, which were:

1. To develop a common understanding of the Dental Category problems, issues, and opportunities as identified by DePAC members,

2. To develop a common understanding of problems, issues, and opportunities as identified by the Secretary, Surgeon General, the Chief Professional Officer’s Board, and the Chief Dental Officer,

3. Increase the effectiveness and efficiency of the DePAC and ability of its members to work as a team, 4. Ensure the orientation of new members and a common understanding by all members of their

responsibilities and accountability for service on the DePAC, and 5. To develop a Category-specific strategic plan with a clearly identified one year agenda.

In addition, RADM Kleinman stressed the need to concentrate on addressing how we can reach out to all members of the PHS Dental Category, including civil service, Commisioned Corps, tribal-hire, and contract dentists.

The action plan for DePAC 2004 that resulted from the effort at the retreat includes the following:1. Provide advice, assistance to the Chief Dental Officer. The rapid transformation has increased the demand

for such input.2. Improve communications with all PHS dentists (i.e., the entire dental category). DePAC believes that

accurate and focused communications with the dental category will also prompt improved input from the dental category, so DePAC can be as informed as possible about PHS dentists’ concerns.

3. Develop a guide, booklet to provide recent hire and mid-career PHS dentists answers to common questions and information regarding career options, advancement.

4. Expand the existing mentoring program to include civil service, tribal-hire, contract dentists to provide assistance, support to new dentists.

5. Develop orientation program for new DePAC members. DePAC membership is for a 3-year term. An orientation program is needed to shorten the learning curve so 1st year members can immediately become involved and contribute.

DePAC encourages input from all PHS dentists regarding concerns, issues, and ideas for additional services and support that DePAC may provide the dental category.

The earnest participation by all DePAC members, expert facilitation by Dr. Littleton, and outstanding leadership by the current DePAC Chair, CAPT Ron Bajuscak, and Past- DePAC Chair, CDR Dan Hickey resulted in a very productive, worthwhile retreat.

Links of Interest (click on link)Links of Interest (click on link)

USPHS Dental Category Home PageUSPHS Dental Category Home Page Division of Commissioned PersonnelDivision of Commissioned Personnel2004 Dental Professional Advisory Committee Roster2004 Dental Professional Advisory Committee Roster USPHS Dental Listserv HomeUSPHS Dental Listserv HomeLinks to USPHS and Dental OrganizationsLinks to USPHS and Dental Organizations Links to previous newslettersLinks to previous newsletters

Page 4 USPHS Dental Newsletter April 2004

New NIH Initiative:“Roadmap for Medical Research”

James Lipton, D.D.S., Ph.D.CAPT, USPHS

Senior Advisor to the Chief Dental Officer

On September 30, 2003, Dr. Elias Zerhouni, Director, NIH, and the directors of the individual NIH Institutes and Centers announced a series of initiatives known collectively as the NIH Roadmap for Medical Research. These initiatives are designed to transform the nation's medical research capabilities and speed the movement of research discoveries from the bench and into practice for the benefit of the public.

Developed with input from more than 300 nationally recognized leaders in academia, industry, government, and the public, the NIH Roadmap provides a framework for the avenues of exploration that the NIH needs to address to optimize its entire research portfolio. In setting forth a vision for a more efficient and productive system of medical research, the NIH Roadmap focuses on the most compelling opportunities in three main areas: new pathways to scientific discovery, research teams of the future and re-engineering the clinical research enterprise. To learn more, click this link: the NIH Roadmap.

In the Fall and Winter of 2003, Dr. Zerhouni began to assemble a team to coordinate the implementation of related activities for the NIH Roadmap. As part of this effort, Dr. Zerhouni asked RADM Dushanka V. Kleinman, Deputy Director for the National Institute of Dental and Craniofacial Research (NIDCR), to serve in the new Office of NIH Director position of Assistant Director for Roadmap Coordination, beginning December 15, 2003. During this initial six-month detail, Dr. Kleinman will work closely with the NIH Roadmap Implementation Coordination Committee, designated Roadmap liaisons from the NIH Institutes and Centers, the to—be-named Senior Advisor for Clinical Research Re-engineering Activities, and NIH Office of Director Senior Staff to facilitate policy development and key decisions related to Roadmap implementation. In addition, a team of advisors will be formed to address key aspects such as monitoring, communication, and evaluation. During this detail, Dr.

Kleinman will continue in her role as Chief Dental Officer, USPHS.

CAPT James Lipton, NIDCR, serves full-time as the Senior Advisor to the Chief Dental Officer, USPHS. This is in response to the increased activities associated with Secretary Tommy Thompson's transformation of the Corps. Dr. Lipton is a senior commissioned officer and has experience with both the regional and central offices of the Public Health Service. Additionally, he has served as Chair for the Dental Professional Advisory Committee.

CAPT Kevin Hardwick has assumed responsibility for the NIDCR dental school research infrastructure and curriculum development program. This is in addition to his responsibilities in the NIDCR Office of International Health. Dr. Hardwick has worked with dental schools both nationally and internationally at the Health Resources and Services Administration and at the National Institutes of Health.

CAPT Isabel Garcia is the acting director of the Office of Science Policy and Analysis (OSPA) at NIDCR. She was formerly the Special Assistant for Science Transfer, directing activities to promote science-based practice and coordinating the implementation of the NIDCR health disparities plan. Dr. Garcia also is the co-director of the NIDCR Dental Public Health Residency. She recently led the update of the NIDCR Strategic Plan and will be overseeing its implementation as part of her role as the acting director of OSPA.

The NIDCR recently announced several exciting new oral health research initiatives in clinical, behavioral and basic sciences. These include the development of a general dental practice-based research network to conduct multiple clinical trials and prospective observational studies that will answer questions facing general dental practitioners in the routine care of their patients. Other programs focus on oral complications of HIV infection including oral malignancies and tumors, new uses of fluoride to improve oral health and prospective studies on craniofacial pain and dysfunction. Additional programs include reducing pre-term and low birth weight in minority families, training in clinical research, oral health of special needs and older populations, social and cultural dimensions of health, quality of life in long-term care recipients, and the development of research-oriented curricula in dental schools.

Page 5 USPHS Dental Newsletter April 2004

What do CDC dentists do?

Monica Klevens, D.D.S., M.P.H.CDR, USPHS

Although there are relatively few dentists at CDC (~0.2% of CDC staff are dentists), many opportunities exist. Most dentists at CDC have a degree in public health. About half of these dentists apply their training and experience in dental public health, and the other half apply epidemiology to diverse scientific content areas.

In the area of oral health, dental officers provide technical assistance to state and local health departments to build and maintain oral health programs infrastructure. Currently, the Division of Oral Health provides funding for 12 states and one territory to build core capacity for the improvement of oral health. Officers provide the scientific support for programs to integrate and coordinate their oral health program activities with school health programs, strengthen the scientific evidence of the benefits of oral disease prevention programs and support interventions in communities, and provide leadership in modifying oral health practice and policy by developing and distributing guidelines based on scientific research. Additional information about the activities of the Division of Oral Health is available by clicking here: CDC DOH.  Dental officers assigned to other areas of CDC serve as project officers for epidemiological studies including one that monitors high-risk behaviors among HIV-infected individuals and one that measures and describes drug resistant invasive infections. There are dental officers coordinating HIV epidemiological studies, supporting state surveillance activities in the National Notifiable Diseases Surveillance System, and characterizing the toxicological profile of fluoride.

There are several training opportunities at CDC for dental officers who have a masters degree in public health, including a 1-year residency in Dental Public Health and a training opportunity with the Epidemic Intelligence Service, on-the-job training in applied epidemiological skills – skills vital to maintenance of public health. Currently one dental officer in that program works in HIV/AIDS surveillance. For more information about training opportunities, click here: training opportunities at CDC. For questions about CDC experiences for dental officers, please contact CDR Ruth Monica Klevens (click on name).

FEDERAL BUREAU OF PRISONSBOP Dentists Texas-bound

Daniel J. Hickey, D.M.D.CDR, USPHS

A foundation of the delivery of dental health care in the Federal correctional setting involves fostering continued proficiency of general dentists through quality continuing professional education in order to better serve patients and the U.S. Public Health Service. In that light, CAPT Nick Makrides, Chief Dental Officer, Federal Bureau of Prisons, has been working diligently in preparing the Bureau of Prisons biannual Continuing Professional Education Dental Conference. Scheduled for the week of July 12 - 16, 2004 in San Antonio, TX, the meeting of Chief Dental Officers promises a blend of clinical issues, administrative updates, and policy changes.

For those BOP dental officers who attended the last gathering in Phoenix, AZ (2002), you may recall a survey was taken at the conclusion of that conference. Based on the needs assessment from that survey, several clinical disciplines were identified for CDE presentation and elaboration. Input was also received from the Regional Dental Consultants in the field. Working closely with our uniformed services partners in the Army and Navy, CAPT Makrides has crafted an impressive conference agenda. Dr. Dennis Hannon, an oral and maxillofacial surgeon at Wilford Hall Medical Center, Lackland Air Force Base, will present on oral surgery and oral pathology. Proper diagnosis and management of odontogenic infections will be discussed. Periodontist Dr. Stephen Abel will feature a lecture on identification and management of the HIV patient; cardinal oral manifestations of the disease, along with systemic signs, laboratory testing and values, and guidelines to therapy will be highlighted. Dr. Abel’s name may ring a bell; he is one of the co-editors of “Principles of Oral Health Management for the HIV/AIDS Patient,” a guideline manual that was distributed to BOP dentists. Dr. Sharon Stancliff, an M.D. and infectious disease specialist, will give a 21st century update on this priority area within the BOP healthcare system.

The conference will convene at a hotel (as of yet undetermined; several bids are pending) on San Antonio’s famed Riverwalk in the downtown district. Within minutes of the Alamo, superb shopping, exquisite artistic venues, and fine and casual dining - combined with the relaxed ambience of the Riverwalk - this meeting promises to be an exciting, enlightening, and entertaining affair.

Page 6 USPHS Dental Newsletter April 2004

Lights, Camera, Call to Action:Spotlight on Oral Health

Jane Weintraub, D.D.S., M.P.H.AAPHD President-Elect

Coming attractions: Excitement is building around the upcoming National Oral Health Conference to be held May 3-5, 2004 at the Los Angeles Airport Marriott Hotel. We received a record breaking 90 abstracts for our contributed sessions and additional abstracts for the student award competition. Online registration and conference information is available on the American Association of Public Health Dentistry website, http://www.aaphd.org.

The following features are new to the conference this year:

Meeting dedication to Herschel Horowitz, and the “Herschel Horowitz Memorial Symposium: Recent advances in the Fluoride Legacy. “

Topics not previously featured including health literacy, genomics, role of physicians in improving children’s oral health, and sessions that spotlight oral health needs of children with special needs, dental care utilization for Hispanic populations, and legal scope of practice for dental hygienists.

An opening American Board of Dental Public Health plenary session featuring speakers from the American Dental Association, the Henry Schein Company, and the Public Health Director from New Hampshire, all addressing the national Call to Action.

A celebrity speaker, Rob Reiner, for our closing session.

An AAPHD foundation fundraiser evening dessert and entertainment event featuring “Cher” (impersonator).

A Tuesday evening social event at the Redondo Beach Seaside Lagoon.

Three contributed sessions in poster-discussion format. Posters in the general poster session organized by topic. Continuing Education credit for participation at poster

and roundtable sessions. Optional Sunday site-seeing tours of Los Angeles or the

Getty Museum.

Pre-conference sessions include special programs for the American Association for Community Dental Programs, Medicaid/SCHIP dental program representatives, the

American Board of Dental Public Health specialty examination, ASTDD and AAPHD Executive Council and business meetings.

All of these activities are in addition to our very full three-day scientific program, exhibitor booths, AAPHD and ASTDD award and recognition luncheons, late-breaking hot picks session, networking opportunities and AAPHD town hall business meeting where our organization’s strategic planning, proposed resolutions and culmination of year-long committee work will be presented, discussed, and acted upon.

We encourage everyone to register for the meeting at aaphd.org and make your hotel reservations early. Camera-shy or not, come join the action and share the spotlight!

Destination: Anaheim 2004 Annual Meeting

R. Doug Shepherd, D.D.SCDR, USPHS

AGD PHS President

Now is the time to make arrangements for the 2004 Annual Academy of General Dentistry meeting. The meeting is slated for July 8-11, 2004 in Anaheim, CA at the Anaheim Convention Center. The Anaheim Convention Center and hotels are within minutes of Disneyland and Downtown Disney. Also, nearby sporting events, beaches, and a vast amount of various dining and shopping spots makes a great and fun environment for you and your family. With your registration fee you get a choice of 30 hands-on courses and several lectures and capsule clinics. Also if you come early, you can kickoff the meeting by playing in the 4th Annual AGD Golf Outing at the Tustin Golf Club. For more information on this meeting, including registration information, visit the AGD web page. Hope to see you there!

Membership Drive

This year, the PHS Constituency of the Academy of General Dentistry is sponsoring a membership drive for new members. Here's how it works. If you are a current member of the AGD, and you recruit a new member, your name will be entered into a raffle. For each new member you recruit, you will be entered into the raffle (so, if you recruit 3 new members, your name will be in the raffle 3 times).

▼ Continued on the next pagePage 7 USPHS Dental Newsletter April 2004

AGD Article – continued from previous pageThe Grand Prize for the raffle will be a 5 0% deduction in your 2005 AGD dues, a $125-145 value depending on your current membership dues. The PHS Constituency will directly pay this amount toward your 2005 AGD dues. The

raffle will be held at the AGD annual meeting in Anaheim. There may be additional raffle items as well.

To be eligible for this raffle, membership applications can be obtained through any AGD member or through myself, CDR Doug Shepherd {W- (812) 238-1531 ext 429, fax (812) 238-3308}, or Membership Chair, LCDR Tim Ricks{W- (775) 574-1018 ext 224, fax (775) 574-1028 ext. 224}. You can also obtain an application by calling the AGD at 1-888-AGD-DENT or visit the AGD web page click on “Join the Academy”. It should list the sponsor name on the form (bottom of the application). The sponsor is the current AGD member that recruited the dentist to join AGD. If you want to make sure your name is entered in the raffle, you can send a copy of the membership application to either LCDR Ricks or me.

Interested candidates can join the Academy without having a sponsor. Also, candidates from other dental specialties can join. Again, to be eligible for the raffle prize(s), all you have to do is to get another PHS dentist to join the AGD (and have them list you on the application), so go ahead and talk to your colleagues today.

Spread the word about the opportunities and rewards that you get with the AGD!

Call for Nominations: Elected USPHS Delegate

Carolyn A. Tylenda, D.M.D., Ph.D.Chairperson, Selection Committee

The Public Health Service (PHS) Delegate Selection Committee for the American Dental Association (ADA) House of Delegates is accepting nominations for the position of elected delegate to the ADA House of Delegates for the term July 2004 to June 2007. This is a unique opportunity to represent U.S. Public Health Service dentists, to gain insight into the deliberations of organized dentistry, and to have impact on issues in public health dentistry.

Background: The USPHS is authorized by the ADA to have two voting delegates to the American Dental Association House of Delegates. One is the Chief Dental Officer of the USPHS. The other is elected by all USPHS dentists,

including PHS officers and civil service dentists within the Department of Health and Human Services.

Every two years an election is held to select an ADA-member USPHS dentist who will serve a four-year term. During the first two years the dentist serves as an alternate delegate to the elected voting delegate and substitutes for the elected voting delegate as needed. During the next two years, the dentist is a voting delegate to the ADA House of Delegates.

For more information, including responsibilities of the elected delegate, qualifications, nomination procedure, election procedure, and where to get more information, see the entire announcement on the USPHS Dental Bulletin Board (click the link, go to browse, type in DentalBulletinBoard, click on April 2004 archives) for the USPHS ADA Delegate.

ADA Foundation Proposals for Children’s Oral Health Programs

(Reprinted from web site)

The ADA Foundation, the charitable arm of the American Dental Association, has established a permanent endowment fund dedicated to the  prevention of childhood caries and oral health  maintenance for children. The Harris Fund will award competitive grants to applicants whose oral health promotion programs are designed to improve and maintain children's oral health through community education programs.

The grant program's main objective is to help children whose socioeconomic status impacts their access to professional oral care and adversely affects their oral health habits at home.

Proposals of up to $5,000 for community-based, non-profit, oral health promotion programs in the United States and its territories will be considered.

Examples of qualified oral health promotions include: dental health education conducted at schools, health fairs, and social agencies, via mobile dental clinics or outreach programs; dental health education programs held in conjunction with preventive programs such as fluoride and dental sealant application programs; oral health and nutrition education materials designed for parents and/or dental professionals; instruction in the proper use of oral care products; development of public service announcements (PSAs) to increase awareness and  appreciation for effective proper childhood oral care. Click on this RFP link for more info:

Page 8 USPHS Dental Newsletter April 2004

Junior Officer Spotlight:LCDR Phillip Woods

Wilnetta Sweeting, D.D.S.CDR, USPHS

The son of a Baptist preacher and one of six children, LCDR Phillip Woods was born and raised in Burlington, North Carolina. He attended primary school in Burlington and upon graduating from High School in 1976, attended the University of North Carolina at Chapel Hill where he received an AB in chemistry and a DDS degree in dentistry. LCDR Woods then pursued a periodontal certificate from Tufts Dental School and most recently, a master’s degree in public health from Harvard University in 2002.

LCDR Woods joined the United States Public Health Services in March 2003. He is Staff Dental Specialist at FCI Phoenix, Arizona and serves as the only PHS periodontist for the Federal Bureau of Prisons. Involved in numerous professional affiliations, he has received various awards and honors. One may remember LCDR Woods from his Category Day presentation at the USPHS COA 2003 annual conference in Scottsdale, Arizona where he delivered an abstract entitled "The Impact of Dental School Admissions on Workforce Development".

In 1997, LCDR Woods began a series of paintings based on family photos. Soon he ran out of photos he felt captured his African American Southern rural roots. In September 2000, while searching through online Library of Congress WPA prints and photographs (circa 1939), LCDR Woods was both shocked and thrilled to find several “youthful” photos of his now deceased grandparents, as well as other elderly cousins, family and friends. Specific names were not listed but Woods’ parents, and other relatives helped him confirm their identities. The familiar settings and subjects of these photographs touched him on many levels. Thus his project then began, a project which would become an artistic, spiritual and emotional as well as a genealogical journey. Nearly four years from it’s inception, his work has culminated with his first solo show of oil paintings entitled, "My People". Through his art, he gives tribute to his parents, grandparents, cousins, and elders who first taught him the importance of courage and faith, as well as

the value of hard work and living a life devoted to service. In his paintings, he has attempts to capture everyday people in such familiar settings as at work and Church. Should you ever be given an opportunity to view his work, you may be reminded of an aunt, someone from Church or perhaps an event from childhood past.

Though LCDR Woods has only been in the USPHS for approximately a year, his professionalism, commitment, and energy as a dental officer are already evident. His is a bright future with the PHS. Should you get a chance to view his paintings in the future, his talent as an artist will be evident as well.

Senior Officer Spotlight:CAPT Frank Mendoza

Robin Scheper, D.D.S.LCDR, USPHS

CAPT Frank Mendoza began his career with the USPHS in 1982 as a National Health Service Corps Scholarship recipient. His first assignment was on the Navajo Reservation, at the Chinle Service Unit in Arizona. CAPT Mendoza practiced both at the Lukachukai and Chinle clinics during his two-year tour of duty. He then transferred to the Cherokee Service Unit in North Carolina, where he spent five years as a staff dentist. His next assignment was as Chief Dental Officer of the Winslow Service Unit Dental Program back in Arizona. CAPT Mendoza then took advantage of a long-term training opportunity in Pediatric Dentistry. He received his Certificate in Pediatric Dentistry from the University of Minnesota College of Dentistry in 1993. After completing his residency, he returned to the Chinle Service Unit and served as the Navajo Area Regional Pediatric Dental Consultant until 1998. He then transferred to the Portland Area, specifically to the Warm Springs Service Unit, in Warm Springs, Oregon, where he currently serves as the Area/Regional Clinical Specialty Consultant.

As the Area/Regional Clinical Specialty Consultant for the Portland Area Indian Health Service, CAPT Mendoza is responsible for area, state, and national dental staff training in pediatric and interceptive dental procedures.

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Senior Officer Spotlight – continued

He is also responsible for treatment and consultation of pediatric dental referrals from dental and non-dental health care providers from the area and state of Oregon. He also serves as a consultant for pediatric dental preventive dental procedures and techniques. CAPT Mendoza is a member of both the Indian Health Service Early Childhood Caries Prevention Committee and the Oregon Early Childhood Caries Prevention Coalition. What is unique about the pediatric dental program at Warm Springs Health and Wellness Center is that the facility is an ambulatory clinic, and not a hospital, which has an operating room to treat young children with significant dental disease. Prior to his tenure at Warm Springs CAPT Mendoza coordinated with a hospital in Bend, Oregon, to be able to treat the patients in an operating room setting. He didn’t let the fact that OR facilities weren’t immediately available prevent him researching the options of being be able to provide non-traumatic full mouth dental rehabilitative care to the young children of the Confederated Tribes of Warm Springs in a extramural setting.

During his tour of duty at Warm Springs, CAPT Mendoza became involved in a Food and Drug Administration clinical trial, which began in February of 2003. The clinical trial is studying the effects of chlorhexidine varnish on the reduction of Streptococcus mutans. The purpose of the study is to determine if chlorhexidine reduces the level of Streptococcus mutans in mothers, thereby preventing the transmission of the caries causing bacteria to the child when the child’s teeth are first erupting. The clinical trial is will evaluate 600 pairs of mothers and their children. First, the mothers have to be caries free, and her child must be at least five months of age. The chlorhexidine varnish is applied in two stages. The first stage entails coating the mother’s teeth with an active chlorhexidine layer, and the second stage is a thin sealant coating on the mother’s teeth. The coating allows the chlorhexidine to be more effective than a rinse or a gel because it keeps the active ingredient in contact with the tooth for a longer period of time. Evaluation of the effectiveness of the chlorhexidine varnish in this double blind placebo controlled study involves CAPT Mendoza, and the other staff working on the study, evaluating caries progression in the mother and child every six months until the child reaches age two. In February 2003 Warm Springs was the first I.H.S. site to actively treat mothers in this study. The Yakama Service Unit began their clinical trial last summer, and Tuba City Service Unit initiates their clinical trail this year. It is anticipated that the trial will go until 2006.

In the past 20 years that CAPT Mendoza has served in the USPHS, he noted that the I.H.S. has become much less centralized. With this decentralization has come the loss of the opportunity for close interaction with fellow dental colleagues that existed in the early 1980’s. He stated that the addition of dental hygienist providers into many the I.H.S. areas began during this period. He also noted that the option to hire Civil Service dentists has increased the Indian Health Service’s ability to hire more dentists.

Regarding the future of the category, relative to I.H.S., CAPT Mendoza believes that the need to treat Native Americans will never go away. Even though he has just begun his 22nd year of active duty, he has no plans on retiring any time soon. He thoroughly enjoys the experiences he has had with the Indian Health Service over the years. He can think of no other job that offers such diversity, opportunity, and fulfillment, not even private practice.

How do I become part of the PHS Ensemble if I don’t live in the D.C. Area?

Suzanne K. Saville, D.D.S.CDR, USPHS

CAPT John Bartko (Ret) answered this question for me. I began a search for the PHS march when our local community band director stated that he would like to play all of the marches of the military branches. Through electronic mail forwarded several times I was directed to CAPT John Bartko (Ret). He was able to send me an electronic version of the PHS march and he told me how I could participate as a field ensemble member by forming a group and playing for an official function. Finding the group was easy; members of the community band volunteered to play. The official function was a retirement ceremony for a USPHS Coast Guard dentist. We played the PHS march, National Anthem and Semper Paratus. Many compliments were made about the band’s performance and there is talk of our group playing for a change of command ceremony in the distant future. The retiree felt honored by the band’s performance and thought it brought the retirement ceremony to a new level. If you would like more information about the ensemble, please contact CDR Randall Mayberry or CAPT John Bartko (Ret) for information.

Page 10 USPHS Dental Newsletter April 2004

Selection and Use of Antibiotics

Jerry Holbrook, D.D.S.Oral & Maxillofacial Surgery Consultant

So, you have decided your patient needs antibiotics. This decision was based on the patient’s clinical presentation; you know, color, dolor, tumor, rubor, and functio laseo! The cardinal signs of inflammation. The patient also has the signs of systemic involvement; fever, malaise, elevated white blood cell count, and a toxic sick appearance. Two major decisions go into selecting an antibiotic, which one to use and how long to use it. Now, which antibiotic are you going to select? Penicillin is always a good choice, but is it the right choice? Here is a better question; why is penicillin a good choice? Do you know? What kind of information did you use to select penicillin? How long should you keep your patient on their antibiotics? Did you answer: seven days? Why seven days? Is the answer always seven days? Will the questions in this introduction ever stop?

Let’s begin by evaluating how we select an antibiotic. As clinicians we typically make an empiric choice (practice based solely on experience) to select the antibiotic we use for our patients. If an empiric decision for an antibiotic is made, it is known as initial antibiotic therapy. If the organism(s) is clearly identified by culture and antibiotic sensitivity testing results are known, definitive therapy can be initiated and we have made a scientific antibiotic choice. We can make an empiric choice of an antibiotic in dentistry because the microbiologic patterns of odontogenic infections have been clearly defined in the dental literature.1

The most common mild to moderate odontogenic infection is composed of a mixed flora of aerobic and anaerobic organisms. In early cellulitis type infections aerobic organisms predominate. In well-circumscribed abscess type infections anaerobic organisms predominate. The most common aerobe organisms are the Streptococcus Viridans type, which are usually sensitive to penicillins and similar antimicrobials. The most common anaerobic organisms are Prevotella Spp., Fusobacterium Spp., and Streptococcus Spp. These anaerobes have varying sensitivities to the penicillins with Prevotella likely to be resistant and Fusobacterium & Streptococcus likely to be sensitive.2 Understanding the microbial nature of an oral infection is an important basis for the empiric selection of antibiotics.

The other important factors in antibiotic selection besides organism sensitivity are: 1. Utilizing narrow spectrum antibiotics 2. Bactericidal antibiotic 3. Toxicity of antibiotic 4. Antibiotic cost 5. Patient history of allergies, sensitivities and drug interactions 6. Patient compliance 7. Host defense mechanisms 8. Severity or magnitude of the infection. Each plays an important role in our choice of drug for an odontogenic infection. Oral infections have a long history of effective treatment with penicillin, which in turn is still one of the best fits of the listed criteria.

Now let’s discuss the duration of antibiotic therapy. If we place the patient on antibiotics for seven days and never check the patient for signs of recovery, we have made an empiric decision about the duration of antibiotic treatment. We cannot make empiric decisions about duration for antibiotic therapy. There is no scientific evidence that odontogenic infections last seven days (or ten days). If we re-evaluate our patient after seven days of antibiotics and find that the signs and symptoms of infection have abated for at least three days, we can then make a clinical decision to stop antibiotics. The duration of antibiotic therapy should be 3 days after the signs and symptoms of infection have abated. You must continue to follow your patient during antibiotic therapy to assess the effectiveness of your prescribed treatment. Your first follow-up exam should be in 48 hours to assess the impact your dental treatment and the antibiotics have had on the patient’s symptoms. You can then continue your prescribed treatment, change or add antibiotics if indicated, or perform additional surgical treatment if indicated.

Let us review the main antimicrobial classes utilized in dentistry. This will not include the dosing and pharmacology since this information is readily accessed in the many texts and pharmacology resources. Instead I will try to give you some practical information as to which antibiotic to prescribe in clinical situations and the side effects to be aware of with each antibiotic. There are 7 antimicrobial classes to consider: 1. Penicillins & Cephalosporins. 2. Metronidazole 3. Clindamycin 4. Sulfonamides 5. Macrolides 6. Quinolones 7. Tetracyclines. Only the first three should be used on an empiric basis. It is unusual to use any other antibiotics on an outpatient basis or without appropriate laboratory studies.

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Penicillins & CephalosporinsThe beta-lactams are bacteriocidal and are the dental workhorse in mild to moderate dental infections. Some are paired with clavulanate to neutralize the effect of beta lactamase. Penicillin V is my drug of choice for minor infections and is very effective coupled with a correct diagnosis and dental surgical treatment (root canal debridment, extraction, etc) of an infection. Penicillin G given IM or IV is an excellent choice for more severe infections and for children who may be unable or unwilling to take oral medicine. Penicillin G is also good to use as a loading dose prior to surgical treatment for tissue prophylaxis. Amoxicillin is an alternative to penicillin, essentially providing the same microbial coverage as penicillin, but at a higher cost. The GI tract better absorbs it, but as a broad spectrum antimicrobial may have more side effects during treatment. Amoxicillin is known to cause skin eruptions and psuedomembranous colitis as side effects. When paired with clavulanate it has improved microbial spectrum coverage for beta lactamase producing organisms. Clavulnate increases the cost of therapy about ten-fold. Other penicillinase resistant antibiotics include cloxacillin, nafcillin, and dicloxacillin. These can also be used when a beta lactamase producing organism such as staph aureus is suspected. The extended spectrum penicillins such as ticarcillin, mezlocillin, and piperacillin have limited usefulness in most oral infections. Ten percent of patients will have some type of sensitivity or allergy to this class of medications. Of this ten percent – ten percent will have cross reactivity between penicillins and cephalosporins. The first generation cephlasporins also have similar microbial coverage as penicillin. They have a significantly broader spectrum and similar side effects as the penicillins. Depending on the generation, costs are two to ten times that of penicillin. Cephalosporins have better coverage of staph aureus and I will use a first generation cephalosporin like Keflex for my trauma patients with skin lacerations.

MetronidazoleOk, so Flagyl and Clindamycin are not a class, but they are very valuable antibiotics. Metronidazole is bactericidal and has very good anaerobic coverage. Ninety percent of obligate anaerobes are sensitive to this antibiotic,3 but is not used as a single agent in oral and facial infections since it will not cover aerobic organisms. It is a great adjunct when used with penicillin in odontogenic infections. I will add it to a patient’s antibiotic therapy when there is no improvement in symptoms after 48 hours. Flagyl works well for patient compliance because you can use it on the same dosing schedule as penicillin. The cost is double the cost of penicillin. Common side effects include GI upset and a

metallic–tasting glossitis. Drug-drug interactions include Coumadin, alcohol and phenobarbital.

ClindamycinIn high doses, clindamycin is a bactericidal with excellent aerobic and anaerobic coverage. This makes it an excellent choice for the polymicrobial nature of oral infections.4 I use clindamycin for moderate to severe infections. With the increasing resistance of bacteria found with the penicillins, clindamycin is becoming a valuable chemotherapeutic agent for my severe odontogenic infections. Some texts now state this is the first line drug of choice for oro-facial infections. It is important that we try to reserve this drug for our major infections or infections that have a definitive culture and sensitivity. In addition, this antimicrobial has very good bone penetration which makes it my initial drug of choice for an osteomyelitis. It has replaced erythromycin as the second drug of choice for endocarditis prophylaxis. Clindamycin, like most broad-spectrum antibiotics, can cause drug-induced colitis. Clindamycin is triple the cost of penicillin.

The selection and use of antibiotics is part of the art of and science of treating infections. Antibiotics are never a stand-alone treatment for infections. Infections must be treated with an appropriate surgical intervention to allow the patient’s host defense mechanisms the best opportunity to overcome the microbial invasion. Treatment should be initiated as soon as possible to allow the host and the antibiotic the best chance to be effective. It is important to educate your patient about dose, timing, and duration of therapy. Keep your patient motivated and informed about the care you are providing. Vigilance and timely intervention help to prevent treatment failures and determine if a patient requires a higher level of care. We are fortunate that most odontogenic infections respond to dental treatment and the use of antibiotic therapy.

1. Peterson LJ: Microbiology of head and neck infections, Oral Maxillofac Surg Clin North Am 3:255, 1991.

2. Topazian RG, Goldberg MH, Hupp JR: Oral and Maxillofacial Infections, Philadelphia, 4th Ed. 2002, W.B.Saunders.

3. Goldberg M: Antibiotics-Old Friends and New Acquaintances, Oral Maxillofac Surg Clin North Am 13:15, Feb 2001.

4. Flynn TR, Halpern LR: Antibiotic Selection in Head and Neck Infections, Oral Maxillofac Surg Clin North Am, 15:19, Feb 2003.

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Antibiotic Prophylaxis for Patients with Artificial Joints

Stephen P. Torna, D.D.S.Clinical Perspectives Editor

Artificial joint failure is associated with crippling morbidity and mortality. Infected joints may require extensive revision and result in permanent deformity, shortening of limbs, and death. “The devastating morbidity and unusually high rate of mortality (18%) associated with infected prosthetic joints would seem to far overshadow the risks and academically debatable benefits of antibiotic prophylaxis.” 1 The seriousness of potential sequelae requires a thoughtful approach to the management of artificial joint patients.

The American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS) recognize the potential for hematogenous spread of infection from the oral cavity to an artificial joint. The ADA and AAOS have developed recommendations and guidelines for antibiotic prophylaxis prior to providing invasive dental treatment for the arthroplasty patient.3 All patients within their first two years of joint replacement, immune compromised patients, and those with type 1 diabetes are among the highest risk for joint infection. Cephalexin and clindimycin have been identified as the preferred prophylactic antibiotics.

Evidence for a dental origin of metastatic artificial joint infection is largely circumstantial. The literature indicates that joint infections following arthroplasty may originate from distant sites and many cases have convincing evidence that hematogenous joint infection has occurred (identical bacterial isolates from infected joint and distant infection). Urinary, gastrointestinal and upper respiratory tracts, dental, and skin infections are among those implicated in causing some artificial joint infections.1,2,8,9,15

There are two theories for the pathogenesis of artificial joint infection. Metastatic or hematogenous spread of infection may result from a chronic or transient bacteremia originating from a number of different anatomical sites. Additionally artificial joint infection may be the result of bacteria introduced during the

arthroplasty procedure. Bacterial contamination at the time of surgery is thought to be the predominate cause for these infections.4 The dental community is concerned with the possibility of a hematogenous route to infection.

Joint infections are classified as early and late. Most authors agree that an early infection occurs up to 3 to 6 months following arthroplasty. Early infections account for as many as 50% of joint infection cases. The origin of the early infection is most often considered to be wound contamination during the procedure and the bacterial culprits are predominately Staphylococcal organisms.

Evidence for hematogenous joint infection of dental origin has been reported.1,2,12The literature shows that streptococcus and other common oral bacteria have been isolated from infected joints. In some cases an invasive dental procedure was documented just prior to the joint infection. These cases suggest a dental oral origin for the infection.

Bartzokas et al reported four late total joint infections in males ages 58-83 in which the common oral microbe Streptococcus sanguis was isolated from the infected joints. All four men were diagnosed with advanced periodontal disease. Although it cannot be proven that these streptococcal joint infections were a result of hematogenous spread originating from the oral cavity, the circumstantial evidence is compelling. Any other possible route or cause for these infections is unlikely. Interestingly, these infections were not the theoretical result of invasive dental treatment but rather the result of poor hygiene and dental neglect. The inference is that a chronic bacteremia from untreated disease and not a treatment induced transient bacteremia was the source of the joint infection. 18

Jacobsen and Murray reviewed 1855 hip replacement patients in which thirty-three patients (1.7%) developed infections. Bacterial isolates from each of the thirty-three infected hips included fifteen Staphylococcus aureus, six Staphylococcus epidermidis, six Psuedomonas auriginosa, four Streptococci, two Enterobacteria, one Peptostreptococcus, and one Candida tropicalis. One of these cases was considered to be suspicious of dental origin and the authors concluded that a correlation between dental treatment and the infected joint could not be positively demonstrated.7

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Rubin reported three cases of joint infection proximate to dental treatment that he describes as having a worrisome

relation with the total hip replacement (THR) failures. In the first case, a 68 year-old female 5-½ years post THR

Page 13 USPHS Dental Newsletter April 2004

received several months of dental care including restorative, endodontic, and periodontal treatment. The dentist and orthopedic surgeon agreed that antibiotic prophylaxis was not necessary. Four weeks following dental care, the patient was diagnosed with an infected joint. Proteus mirabilis was cultured from the hip and the joint was removed. In the second case a 58-year-old female underwent periodontal surgery 17 days post THR. The patient was given prophylactic antibiotics. Dental abscesses were cultured and grew Steptococcus and Neisseria. Five years later, the patient required tooth extraction and 3 weeks post extraction her hip prosthesis was removed. The bacterial isolate from the hip was Staphylococcus aureus. Although present in small numbers in the oral cavity, it is possible that dental care was the cause. It is also plausible that this late joint infection resulted from a latent bacterial contamination introduced at the time of the initial orthopedic surgery. The third case involved a 62-year-old male THR patient that developed a joint infection 2 years after arthroplasty and 8 months following root canal therapy for an abscessed tooth. The dental abscess was not cultured but the infected hip yielded beta-hemolytic streptococci. The prosthesis was removed.2 Each patient survived the infection with a significantly impaired ability to ambulate. One of the patients became septic and experienced a long and complicated hospitalization.

Ahlberg et al conducted a retrospective study of 7 THR infection cases that were considered to be the result of hematogenous spread. An infected rheumatoid nodule on an elbow, gangrene of the hand, an infected toe and an infected finger wound were among distant Staphylococcal infections that were attributed as the cause of the joint infection. Cases of Salmonella and beta-hemolytic Streptococci cultured from infected joints with gastrointestinal and unknown primary foci respectively were also mentioned. This study cited additional cases that identified pneumonia, urinary tract infection, dental abscess, kidney infection and parototitis as likely foci of the primary infection.9

In another retrospective study, Jacobsen and Millard, looked at 2693 total joint replacement patients and found that thirty (1.7%) of these joints became infected. Of the thirty late infections, seven occurred in patients with type

1 diabetes mellitus and two people were immune suppressed. Eight of the thirty had a history of early infection and five patients had proximate urinary tract infections. Staphylococcus aureus and epidermidis were isolated in 54% of these cases while 15% of joint aspirates cultured Psuedomonas auriginosa. The

remaining 31% yielded Beta Steptococci, Enterobacteria cloacae, Peptosterptococcus, Streptococcus faecalis, Proteus mirabilis, Esherechia coli, Klebsiella pneumonia, Diptheroids, Streptococcus viridans and Lactobacillus.15

In a 1998 study Berbari et al retrospectively examined 468 total joint infection cases that occurred out of 26,505 arthroplasty procedures performed at a Minnesota institution. Many post arthroplasty risk factors for infection were identified in this study. The major risk factors include rheumatoid arthritis, steroid therapy, malignancy, diabetes, malnutrition, prior arthroplasty, and prior joint infection. Staphylococcal organisms were identified in more then 50% of the infections and Streptococci, gram-negative bacilli, and various anaerobes were also isolated.16 The authors stress risk assessment and risk management in preventing total joint infections.

A 2003 joint statement by the ADA in conjunction with the American Academy of Orthopedic Surgeons (AAOS) has identified arthroplasty patients that may be at increased risk for hematogenous joint infections. According to this statement all patients within 2 years post arthroplasty require antibiotic prophylaxis prior to invasive dental treatment. Immune compromise, malnutrition, type 1 diabetes, blood dyscrasias, cancer and a history of previous joint infection are among conditions that may increase the risk for metastatic joint infection following dental treatment.3 The suggested antibiotic prophylaxis regimen is Cephalexin (keflex) 2 grams 1hour prior to dental treatment for those not allergic to penicillin. For patients allergic to penicillin, the recommendation is clindimycin 600 mg 1 hour prior to dental care.3 Cephalexin is acid stable, quickly absorbed, has a high degree of bone penetration, and it is effective against penicillinase producing Staphylococci (aureus and epidermidis). Beta-hemolytic Streptococci, Proteus mirabilis, Neisseria and other bacteria implicated

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in joint infection are susceptible to Cephalexin.1,6 This advisory statement also specifies that dental extractions, periodontal procedures, implantology, endodontics, orthodontic band placement, and intraligamentary anesthesia have the greatest incidence of causing a transient bacteremia.

In summary, artificial joint infection may result in devastating and disabling morbidity with a mortality that may reach as high as 18%. Studies have shown that more than 50 % of early and late joint infections result from

Page 14 USPHS Dental Newsletter April 2004

1

Staphylococcus epidermis and Staphyloccocus aureus. The remaining cases are caused by alpha and beta Streptococci, Pneumococcus, Peptostreptococci, Proteous, Escherichia, Proprionibacterium and other organisms. 1,2,8,9 Among the non-Staphylococcal infections, Streptococci are the most commonly isolated microbes. Reasons for joint replacement include rheumatoid arthritis, osteoarthritis, degenerative joint disease, hip dysplasia, and trauma. The literature identifies rheumatoid arthritis, type 1 diabetes mellitus, malignancy, history of artificial joint dislocation, and immune compromise as major risk factors for the development of these infections. It is possible that metastatically spread late prosthetic joint infections of dental origin have occurred. Invasive dental procedures that cause a transient bacteremia as well as chronic bacteremia resulting from untreated dental disease have been implicated as a primary source for hematogenous joint infection.

References

1.Cioffe GA, Terezhalmy GT, Taybos GM. Total joint replacement: consideration for antimicrobial prophylaxis. Oral Surg Oral Med Oral Pathol 1988:66:124-9.

2.Rubin R, Salvati EA, Lewis R. Infected total hip replacement after dental procedures. Oral Surg Oral Med Oral Pathol 1986;41:18-23.

3.Advisory Statement American Dental Association and American Academy of Orthopedic Surgeons Advisory Statement. Antibiotic prophylaxis for dental patients with total joint replacement. JADA 2003;134:895-99.

4.Little JW. The need for antibiotic coverage for dental treatment of patients with joint replacements. Oral Surg Oral Med Oral Pathol 1983;55:20-3.

5.Advisory Statement American Dental Association and American Academy of Orthopedic Surgeons. JADA 1997;128:1004-08.

6.Little JW. Managing dental patients with joint prosthesis. JADA;125:1374-78.

7.Jacobsen PL, Murray W. Prophylactic coverage of dental patients with artificial joints: A retrospective analysis of thirty-three infections in hip prosthesis. Oral Surg Oral Med Oral Pathol 1980;50:130-3.

8.AndrewsHJ, Arden GP, Hart GM, Owen JW. Deep infection after total hip replacement. J Bone Joint Surg Br 1981 Feb;63-B(1):53-7.

9.Ahlberg A, Carlsson AS, Lindberg L. Prophylactic antibiotics against early and late deep infections after total hip replacement. Clin Orthop 1978;137:69-75.

10. Jacobsen JJ, Millard HD, Plieza R, Blankenship JR. Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 1986;61:413-7.

11.Thyne GM, Ferguson JW. Antibiotic prophylaxis during dental treatment in patients with prosthetic joints. J Bone Joint Surg Br 1991;73-B:191-4.

12.Downes EM. Late infection after total hip replacement. J Bone Joint Surg Br 1977;59-B:42-4.

13.Council on Dental Therapeutics. Management of dental patients with prosthetic joints. JADA 190;121:537-8.

14.Ince A, Tiemer B, Gille J, Boos C, Russlies M. Total knee arthroplasty infection due to Abiotrophia defectiva. J Med Microbiol 2002;51:899-902.

15. Jacobsen JJ, Millard HD, Plieza R, Blankenship JR. Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 1986;61:413-7.

16.Berbari EF, Hanssen AD, Duffy MC, Ilstrup DM, Harmsen WS, Osmon DR. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998;27:1247-54.

17.Jacobsen JJ, Patel B, Asher G, Wooliscroft JO, Schaberg D. Oral Staphylococcus in elderly subjects with rheumatic arthritis. J Am Geriatr Soc 1997;45:1-5.

18. Bartzokas CA, Johnson R, Jane M, Martin MV, Pearce PK, Saw Y. Relation between mouth and hemaetogenous infection in total joint replacement. Br Med J 1994;309:506-8.

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Pictures courtesy of LCDR Aaron Means, CDR DavidCrain, LCDR Scott Trapp, and CDR Randall Mayberry.

Thanks to all of those USPHS Dental Officers that have served on these recent deployments!