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Introduction Practitioners in our area tell children diagnosed with streptococcal pharyngitis to discard their toothbrushes. The literature for Group A Streptococcus (GAS) growth on toothbrushes is limited, targeting children with recurrent infections. Some literature suggests that GAS can live on toothbrushes for an extended period of time, dependent on oral habits, 3 days on a rinsed toothbrush and up to 15 days on a non-rinsed toothbrush.

Lauren Shepard, DO* Judith Rowen, MD** and Natalie Williams-Bouyer, PhD***UTMB Pediatric Residency Program, PGY-3*

UTMB Department of Pediatrics** and Pathology***

ResultsPre-Clinical Studies

Abstract

MethodsPre-clinical Studies

Conclusions

Our findings do not support the practice of discarding toothbrushes from GAS infected children, as that GAS was not isolated from brushes collected from children with documented infections. This preliminary study will need further investigation with a larger amount of subjects and used toothbrushes collected from the home.

References

Brook I, Gober AE. Persistence of Group A β-Hemolytic Streptococci in Toothbrushes and Removable Orthodontic Appliances Following Treatment of Pharyngotonsillitis. Arch Otolaryngol Head Neck Surg. 1998;124(9):993-995.

Falck G, Kjellander J, Schwan A. Recurrence Rate of Streptococcal Pharyngitis Related to Hygienic Measures. Scand J Prim Health Care. 1998;16:8–12.

 Komiyama EY, Back-Brito GN, Balducci I, Koga-Ito

CY. Evaluation of Alternative Methods for the Disinfection of Toothbrushes. Braz. oral res. [online]. 2010, vol.24, n.1, pp. 28-33.

 Petti S, Tarsitani G. Intra-individual Variations of

Salivary Microbial Levels in Young Adults. Eur J Oral Sci. 1998; 106: 616–622.

 Warren D, Goldschmidt MC, Thompson MB, Adler-

Storthz K, Keene HJ. The Effects of Toothpastes on the Residual Microbial Contamination of Toothbrushes. J Am Dent Assoc 2001;132;1241-1245.

Texas Pediatric Society Electronic Poster Contest

This project focused on the prevalence of GAS on toothbrushes of both the ill and well children in our clinics and urgent cares. Children ages two years to twenty years were approved for the study. Our hypothesis is that prevalence of GAS on toothbrushes is the same in healthy children and in children with recurrent GAS infections.

Participating children brushed their teeth for one minute in the clinic with a new toothbrush without toothpaste. Parents also filled out a small survey about oral habits, including the frequency of brushing, rinsing, and type of toothpaste used, the timeframe for last GAS infection including any current symptoms, and the timeframe of the last antibiotic administration.

Once the toothbrush was collected, it was placed in a sterile cover and transported to the lab where it was inoculated in broth and then swabbed onto Streptococcus selective blood agar plates to assess growth by 1+, 2+ and 3+ growth.

Preliminary studies in the lab have showed that this protocol isolated streptococcus on a toothbrush if it is present. It has also resulted in the finding that most “new” toothbrushes are not sterile and will grow different types of bacilli and staphylococcus.

Clinical studies had a total of 55 participants, 28 well children and 27 ill children with 15 diagnosed with GAS. Of those toothbrushes collected, only one toothbrush from a well child grew GAS.

Preclinical Plate Studies

Clinical Studies

1. Children ages 2 years to 20 years were asked to brush their teeth for 1 minute in the clinic with a new toothbrush without toothpaste.

2. Parents were given a small survey about oral habits, including the frequency of brushing, rinsing, and type of toothpaste used, the time frame of the last GAS infection (including any current symptoms), and the time frame of the last antibiotic administration.

3. The toothbrush was placed in a sterile cover and transported to the lab.

4. In the lab, the brushes were agitated in sterile thio broth.

5. The thio broth cultures were incubated overnight, then streaked onto strep selective blood agar plates in a quadrant streak fashion.

6. Plates were incubated for 48 hours before assessment of growth.

7. If GAS was suspected on a plate, a suspect bacterial colony (morphology and β-hemolysis consistent with GAS) was isolated and sub-cultured onto a second plate, left to incubate for 48 hours and then assessed.

8. If isolated colony was still suspicious for GAS, latex agglutination was used to identify the β-hemolytic colony.

1. Studies with un-inoculated toothbrushes and toothbrushes inoculated with 1:10 and 1:100 dilution of both 0.5 and 1.0 McFarland standard of a GAS quality control strain were conducted prior to clinical trials.

2. Both un-inoculated toothbrushes and inoculated toothbrushes were allowed to dry 24 to 48 hours after exposure to thioglycollate (thio) broth without bacteria and with the known concentrations of GAS, respectively.

3. The toothbrushes were agitated in sterile thio broth, then allowed to incubate overnight at 37° C. Overnight growth was plated on both streptococcus (strep) selective blood agar and colistin-nalidixic acid (CNA) plates.

4. Growth was measured after the plates were incubated for 24 hours and recorded quantitatively.

Two of the un-inoculated toothbrushes, one adult-sized and one child-sized, grew a type of bacilli and a type of Staphylococcus, respectively. It was proven that GAS grew from toothbrushes inoculated in 1:10 and 1:100 dilutions of both 0.5 and 1.0 McFarlend Standard of a GAS quality control strain. It was also proven that growth can be achieved with our methods 24-48 hours after the toothbrush was “left out” after inoculation.

Clinical Studies

In our clinical studies, toothbrushes were collected from 28 well children and 27 children with pharyngitis. Of those 27 with pharyngitis, 15 had documented GAS infection. While every toothbrush had some bactrerial growth, GAS was only isolated from one well patient. Growth varied on the other 54 toothbrushes, including α-hemolytic streptococcus and Staphylococcus species

Total number = 55