Bacteremia, a Result from
device. It has been reported that presence of periodon-
Oral Irrigation in
Subjects with Gingivitis
by
A L A N ROBERT R O M A N S , * D.D.S.., M.S.
GEORGE R . A P P , * * D.D.S., M.S.
TRANSIENT BACTEREMIA consisting of microorganisms
found in the oral cavity is potentially fatal to persons
with certain cardiovascular defects. Bacteremia from
1-11
an oral origin can be either self inflicted or iatro-
genic. -
12 17
There have been conflicting reports concerning
whether or not oral irrigation devices produce injury
to the crevicular epithelium. O'Leary, Swenson, Schafer,
and Nesler found carbon particles in the sulcular epi-
18
thelium and connective tissue following the use of a
pump-type irrigating device. The particles had been
placed in the water, and this solution forced onto the
gingival tissues by the pump. A r n i m has reported lat-
19
eral abscesses caused by pump-type irrigating devices.
The use of an oral irrigating device reportedly caused
a de-epithelialization of the gingival crevice and lateral
abscess formation in dogs. 20
Krajewski, Giblink, and Gargiulo found no tissue
21
injury when an oral irrigation device was used by pa-
tients treated surgically and nonsurgically for perio-
dontal disease. Krajewski, Rubach, and P o p e re- 22
ported that an oral irrigation device had no adverse
effect on clinically noninflamed crevicular epithelium
even at maximum pressures. There was slight con-
nective tissue hemorrhage apical to the base of the
crevicular epithelium. Hoover and Robinson found no
23
clinically observable tissue injury in a 90-day study of
39 patients who had periodontal disease. Crumley and
Sumner reported no clinical or histological tissue in-
24
jury in eight patients with deep pockets who used an
oral irrigation device for six weeks.
Felix ( 1 9 6 9 ) found that 50 percent of patients
17
with untreated generalized periodontitis developed
A thesis submitted by the senior author to the Graduate
School of The Ohio State University as partial fulfillment of
the requirements for a Master of Science Degree, 1970.
*Formerly a graduate student in the Department of Perio-
dontology, College of Dentistry, The Ohio State University,
Columbus, Ohio; presently in St. Petersburg, Florida.
** Professor Chairman and Graduate Director, Department of
Periodontology, College of Dentistry, The Ohio State Univer-
sity, Columbus, Ohio.
757
transient bacteremia after the use of an oral irrigation
titis in itself does not cause bacteremia. 25
The purpose of this study was to determine if transient
bacteremia would be induced in subjects with chronic,
generalized, mild, uncomplicated, papillary gingivitis 26
solely by the use of an oral irrigation device.*
MATERIALS AND M E T H O D S
Thirty subjects were selected for this study on the
following basis:
1. After the intended procedures and known risks
were explained, all subjects signed a research
form.
2. They had no more than a generalized, chronic,
mild, uncomplicated, papillary gingivitis. This 26
was determined by the following criteria:
a. There was slight hemorrhage from the papil-
lary area upon gentle probing. 27
b. There was no hemorrhage from the facial or
lingual crevicular areas.
c. Crevicular depth was no greater than 3 mm.
d. They had not used dental floss habitually to
remove plaque from proximal surfaces of the
teeth.
3. They had no known disease that was communica-
ble through the vascular system.
4. Their venous system was accessible from both the
right and left antecubital fossae.
5. They had no residual antibiotics in their system
from a previous administration.
6. They had not used an oral irrigation device pre-
viously.
7. They were free of cardiovascular problems.
The patients were required to remain quiet for at
least 15 minutes prior to the beginning of the proce-
dures. Both arms of each patient were selected as with-
drawal sites for blood specimens. The antecubital fossae
were cleansed with iodine and 70 percent ethanol as
described in previous s t u d i e s . '
8
The test blood
28-30
specimens were taken from one arm and the control
specimens were taken from the other.
Prior to using the oral irrigator, 10 cc of blood was
withdrawn from one arm. The syringe used was a
sterile, disposable, Becton-Dickinson # 8 1 0 L / S with a
sterile, disposable, 1½ inch, 21 gauge, T O M A C cart-
ridge P A K needle. This control specimen determined
the presence or absence of preoperative bacteremia.
* Water Pik: A registered trade mark name of Aqua Tec, A
Teledyne Company.
758 Romans and App
In order that the test sample might be withdrawn one
minute after the use of the oral irrigator, the arm to be
punctured was cleansed as described and wrapped in a
sterile towel before the oral irrigation. The towel com-
pletely encircled the arm at the elbow and was taped
in place.
A pilot study had shown that the use of the sterile
towel wrap was adequate to maintain the cleanliness of
the antecubital fossa.
Each subject was instructed individually in the cor-
rect use of the oral irrigation device. This included posi-
tioning the tip and adjusting the pressure dial. The
pressure dial is calibrated from 1 to 10. A l l subjects
used the oral irrigation device with the dial set on 5.
The subjects were told to direct the stream of water
into the gingival crevice. The tip of the irrigator was
not to touch the gingiva or teeth and was to remain 1/8
to 1/4 inch away from the marginal gingiva. The sub-
jects were instructed to irrigate the crevices of all teeth,
facial, lingual and proximal. Each subject used the oral
irrigator for one minute.
One minute elapsed after oral irrigation before the
10 cc of test blood were withdrawn. According to other
studies, '
1
one minute was adequate time to allow
8 , 2 5 , 3 0
microorganisms to reach the major veins of the ante-
cubital fossae.
The oral irrigation procedure was carried out with
the towel in position. A t the proper time the towel was
removed and the test blood withdrawn.
Identical culturing procedures were used for both the
control and test blood samples. Of the 10 cc of blood
withdrawn at each venipuncture site, 5 cc was injected
by sterile technique into each of the two culture bottles
in the closed blood culture system.
This closed blood culture system is the standard
technique used in the microbiology laboratory at the
Ohio State University Hospital, Columbus, O h i o . It31
consists of two closed McCartney Bottles, one for
aerobic growth and one for anaerobic growth. The aero-
bic bottle contains brain-heart infusion broth, para
amino-benzoic acid ( P A B A ) , 0.5 percent agar sup-
plement and trypticase soy agar in the form of a slant.
The anaerobic bottle contains thioglycollate media,
Brewer modified, without indicator.
The McCartney Bottles containing the blood were
agitated slightly to gently disperse the inoculum. This
blood-media mixture was incubated at 37°C and the
bottles were inspected daily for visible signs of bacterial
growth.
When visible signs of bacterial activity appeared, or
after 10 days of no visible activity, the cultures were
J. Periodont.
December, 1971
incubated at 37°C on blood agar plates. The inoculum
cultured with brain-heart infusion broth was subcul-
tured aerobically. The inoculum cultured with thio-
glycollate broth was subcultured anaerobically.
A #70304 Gas P A K Disposable Hydrogen and
Carbon Dioxide Generator was used to produce anaero-
bic conditions. A B B L anaerobic indicator was used
32
to determine the effectiveness of the anaerobic gen-
erator.
The agar plates were inspected daily for four days in
succession for growth. If no growth occurred by the
fourth day, the subculture was considered negative. If
growth occurred, the colony characteristics, morpho-
logic description, and gram staining of the microorga-
nisms isolated from the blood were recorded. Bacte-
riological tests as indicated in Bergey's M a n u a l were
33
used to aid in identifying microorganisms present in the
pure cultures.
A l l subjects in this study were sophomore dental stu-
dents at the Ohio State University College of Dentistry.
Analysis of the biographic data concerning their sex,
age, smoking habits and blood pressure, indicated that
there was no correlation between their blood pressure
and the presence or absence of bacteremia.
RESULTS
Microorganisms were detected in the postoperative
blood specimens of two subjects. None of the control
blood samples yielded any microorganisms when cul-
tured.
The two positive blood cultures yielded only one
type of microorganism each. One was a staphylococcus
and the other was a gram positive rod. The staphylo-
coccus grew aerobically in culture and the gram posi-
tive rod grew anaerobically.
A C h i square statistical analysis was done as follows:
( —) Bacteremia ( + ) Bacteremia
Preoperative 30 = A 0 = B
Postoperative 28 = C 2 = D
58 2
Total Number = N = 60
C h i square = N ( [ A D - B C ] - N / 2 )2
( A + B ) (C + D ) ( A + C ) (B + D )
C h i square = 60 ( [60 - 0] - 3 0 ) = 54000
2
(30) (30) (58) (2) 104400
C h i square = .51
p > 0.05
Volume 42
Number 12
DISCUSSION
In 2 of 30 patients with chronic papillary gingivitis,
the use of a pressurized stream of water from oral irri-
gation was followed by bacteremia. When treated statis-
tically, this occurrence of bacteremia was not significant
at the 0.05 level. However, the clinical significance is
important because of the relation between bacteremia
and bacterial endocarditis. Many of the same micro-
organisms that have been implicated in bacterial endo-
carditis '
5
are common inhabitants of the gingival
1 1
crevice in persons with gingivitis.
Antibiotics have decreased the role of streptococci
as an etiological agent in bacterial endocarditis. A t one
time streptococci were implicated in as much as 80
percent of all cases. N o w this figure is about 40 to 50
percent, and staphylococci and gram negative rods
have assumed an increasing role as etiologic agents.
In this study, a staphylococcus and a gram positive rod
were isolated.
Cardiovascular defects which predispose a person to
bacterial endocarditis are rheumatic heart disease, ar-
teriosclerotic heart disease, septal defects, injured
valves, prosthetic valves, and scarring from cardiac
surgery. ' 5
Healthy valves also may be affected by
1 1
bacterial endocarditis. 5, 3 6
Bender and Pressman have stated that 50 percent 6
of all cases of bacterial endocarditis can be traced to
gingival manipulation.
In a healthy periodontium the gingival crevicular
wall is characterized by an intact, unaltered epithelial
lining and corium. In gingivitis, changes involving the
37
crevicular wall are numerous: there is an increase in the
number of functioning capillaries and an increase in
the volume of blood in the capillary beds, epithelial
integrity is decreased through alteration of the inter-
cellular substance by enzymes, microscopic ulcera- 38, 3 9
tions occur in the epithelium, and the overall con- 38, 4 0
sistency of the gingiva is decreased due to the de-
struction of some of the fibrous elements in the
corium. 26, 37, 3 8
In order for bacteremia to have occurred there must
have been hemorrhage into the crevicular area. Injury
to the crevicular wall and capillaries was necessary to
initiate hemorrhage. The studies of O'Leary, Swenson,
Schafer, Nesler, and Krajewski, 18
are consistent with
the two following theories of tissue injury.
The gingival free margin does not adapt to the tooth
as tightly in gingivitis as in health. Because this mar-
ginal gingiva is less firm, it is more easily reflected from
the tooth. When a person with gingivitis uses an oral
irrigation device the stream of water may reflect this
more flaccid margin and strike the lateral crevicular
Bacteremia 759
wall. Engorged capillaries may be perforated or torn by
the water, allowing or forcing microorganisms from
the oral environment to enter the vascular system.
During oral irrigation, hemorrhage from the crevicu-
lar wall into the crevice could be initiated by the pul-
sating water striking the oral surface of the gingiva.
This intermittent compression of the gingivae may cause
engorged capillaries to rupture. Once there was hemor-
rhage into the crevice, the microorganisms in the crevic-
ular area could enter the blood vascular system.
34, 3 5
F e l i x found the incidence of bacteremia in 30 per-
17
sons with untreated, generalized, moderate periodon-
titis who used an oral irrigation device to be 50 per-
cent. In the present study the subjects had less severely
inflamed gingiva. The total area of ulcerated, weakened
5
crevicular wall was presumably less in the generalized
14
papillary gingivitis present in this study than in general-
ized moderate periodontitis present in the subjects of
Felix's study. The possibility of causing crevicular
hemorrhage with a pressurized stream of water is the-
oretically less in papillary gingivitis than in moderate
periodontitis considering both were generalized condi-
tions.
S U M M A R Y AND CONCLUSION
The incidence of transient bacteremia following the
use of an oral irrigation device was determined in 30
subjects with chronic, generalized, mild, uncomplicated,
papillary gingivitis.
Control blood samples of 10 cc each were withdrawn
from a vein in the antecubital fossa before oral irriga-
tion. A l l controls were cultured both aerobically and
anaerobically. N o microorganisms were recovered from
26, 2 7
the controls.
Test blood samples, also 10 cc each, were with-
drawn from the antecubital fossa of the opposite arm
after oral irrigation. The venipuncture was made one
minute after completion of the irrigation procedure to
allow adequate time for microorganisms to be carried
to the antecubital fossae from the oral cavity. Aerobic
and anaerobic culturing yielded two positive cultures
out of 30 subjects, or an incidence of 7 percent.
This investigation indicates that the use of a pump-
2 2 type oral irrigation device can be followed by transient
bacteremia in subjects with papillary gingivitis. Be-
cause of the relationship between transient bacteremia
and bacterial endocarditis we need to reevaluate the
use of oral irrigation devices by patients with gingi-
vitis who also have a history of cardiovascular defects.
It has been shown that in gingivitis the gingiva is weak-
ened, especially in the crevicular area. Persons in whom
bacteremia is potentially dangerous need to be meticu-
 760 Romans and App
lous in oral hygiene so that the periodontium remains
healthy.
Further investigation is needed into the use of oral
irrigation devices utilizing higher water pressures than
used in current studies and subjects with healthy perio-
dontium.
BIBLIOGRAPHY
1. Hopkins, J. A . : Streptococcus Viridans: Bacteremia
Following Extraction of Teeth. J. Amer. Dent. Assn., 26:
2002,1939.
2. Geiger, A . J.: Relation of Fatal Subacute Bacterial
Endocarditis to Tooth Extraction. J. Amer. Dent. Assn., 29:
1023, 1942.
3. Ruston, M . A . : Subacute Bacterial Endocarditis Fol-
lowing the Removal of Teeth and Tonsils. Guy's Hos. Rep.,
80:391,1930.
4. Morgan, W. L . and Bland, E. F.: Bacterial Endo-
carditis in A n Antibiotic Era. Circulation, 19:753, 1959.
5. Robbins, S. L . : Pathology, ed. 3 Philadelphia, W. B.
Saunders Co., 1967.
6. Bender, I. B. and Pressman, R. S.: Factors in Dental
Bacteremia. J. Amer. Dent. Assn., 32:836, 1945.
7. Friedman, M . , Katz, L . N . and Howell, K . : Experi-
mental Endocarditis Due to Streptococcus Viridans. Arch,
of Int. Med., 6:95, 1938.
8. Lanansky, J. P., Robinson, L . and Rodofsky, L.: Fac-
tors Influencing the Incidence of Bacteremias Following Sur-
gical Procedures in the Oral Cavity. J. Dent. Res., 28:533,
1959.
9. Muller, E . H . : Bacteremia after Tooth Extraction.
Dent. Abstr., 8:16, Jan., 1963.
10. Cooley, F. and Haberman, S.: The Use of Antibiotics
for the Prevention of Bacteremia Following Oral Surgery.
J. Dent. Res., 36:294, 1957.
11. Anderson, W. D . : Pathology, Vol. I, ed. 5 St. Louis,
C. V . Mosby Co., 1968.
12. Cobe, H . M . : Transitory Bacteremia. Oral Surg.,
7:609, 1954.
13. Murray, M . and Moosnick, F.: Incidence of Bacte-
remia in Patients with Dental Disease. J. Lab. and Clinical
Med., 26:801, Feb., 1941.
14. Conner, H . D., Haberman, S., Collings, C. K . and
Winford, T.: Bacteremias Following Periodontal Scaling in
Patients with Healthy Appearing Gingivae. J. Periodont.,
38:466,1967.
15. Winslow, M . B. and Millstone, S. H . : Bacteremia
after Prophylaxis II. J. Periodont, 36:371, 1965.
16. Wada, K . , Tomizawa, M . and Sasaki, I.: Study on
Bacteremia in Patients of Pyorrhea Alveolaris Caused by
Surgical Operations. J. Nihon University School of Den-
tisty, 10:52, June, 1968.
17. Felix, J. E.: Detection of Transient Bacteremia After
the Use of an Oral Irrigation Device, Master's Thesis, The
Ohio State University, 1969.
18. O'Leary, T. M . , Swenson, H . M . , Schafer, W. S.,
Nesler, D . M . : Penetration of Fluid from Oral Irrigating
Devices into the Gingival Crevice and Crevicular Tissue.
I A D R Abs., 47th General Meeting, p. 87, 1969.
J. Periodont.
December, 1971
19. Arnim, S. S.: Dental Irrigators for Oral Hygiene,
Periodontal Therapy and Prevention of Dental Disease. J.
Tenn. Dent. Assn., 47:65,1967.
20. Sumner, C : Paper presented at a meeting of the
American Academy of Periodontology, Las Vegas, Nov.,
1965.
21. Krajewski, J., Giblink, J. and Gargiulo, A . : Evalua-
tion of a Water Pressure Cleaning Device as an Adjunct to
Periodontal Treatment. J. Amer. Soc. of Periodont., 2:76,
1964.
22. Krajewski, J. L . , Rubach, W. C , and Pope, J. W.:
The Effect of Water Pressure Cleansing on the Clinically
Normal Gingival Crevice. J. Calif. Dent. Assn., 43:452,
Oct., 1967.
23. Hoover, D . R. and Robinson, H . B. G . : The Com-
parative Effectiveness of the Water Pik in a Non-instructed
Population. J. Periodont., 39:43,1968.
24. Crumley, P. J. and Sumner, C. F.: Effectiveness of a
Water Pressure Cleansing Device. J. Amer. Soc. of Perio-
dont, 3:193, 1965.
25. Khairat, O.: The Non-aerobis of Post Extraction
Bacteremia. J. Dent. Res., 45:1191, 1966.
26. Glickman, I.: Clinical Periodontology, ed. Phila-
delphia & London, W. B. Saunders Co., 1964.
27. Stallard, R.: National Consultant, U . S. A i r Force,
Wright Patterson A F B , Periodontal Postgraduate Seminar,
May, 1969.
28. Korn, N . A . and Schaffer, E . M . : A Comparison of
Post-operative Bacteremias Induced Following Different
Periodontal Procedures. J. of Periodont., 15:226, 1962.
29. Brandt, C. L., Korn, N . A . and Schaffer, E . M . : Bac-
teremia from Ultrasonics and Hand Instrumentation. J.
Periodont, 32:214, 1964.
30. Robinson, L . , Krause, F . W., Lazansky, J. P.,
Wheeler, R., Gordon, S. and Johnson, V . : Bacteremias of
Dental Origin. II. A Study of Factors Influencing Occur-
rence and Detections. Oral Surg., 3:923, July, 1950.
31. MacPherson, C. R. and Kimbleton, E . S.: A n Eco-
nomical Closed Blood Culture System. Amer. J. Med.
Tech., July-Aug., 1965.
32. Wilson, G . S. and Miles, A . A . : Topley and Wilson's
Principles of Bact. and Immunity, Vol. 1. Baltimore, Wil-
liams and Wilkins Co., 1964.
33. Bergey's Manual of Determinate Bacteriology, ed. 7
Baltimore, Williams and Wilkins Co., 1957.
34. Loe, H , Theilade, E . and Jensen, S.: Experimental
Gingivitis in Man. J. Periodont, 36:177, 1965.
35. Mandel, L : Dental Plaque: Nature, Formation, and
Effects. J. Periodont, 37:357,1966.
36. Angrist, A . A . and Masamichi, O.: Pathogenesis of
Bacterial Endocarditis. Dent. Abstr., 8:719, 1963.
37. Grant, D . , Stern, I. and Everett, F.: Orban's Perio-
dontics, ed. 3. St. Louis, C. V . Mosby Co., 1968.
38. Goldman, H . and Cohen, D . : Periodontal Therapy,
ed. 4 St. Louis, C. V . Mosby Co., 1968.
39. Bull. Eighth Dist. Dent. Soc., New York, 3:10, D e c ,
1969.
40. Diener, J.: Bacteremia and Oral Sepsis, with Particu-
lar Reference to the Possible Reduction of Systemic Disease
Originating from the Oral Cavity. J. Periodont., 35:236,
1964.