the periodontal pocket at the mesial facial line angle and
A Quantitative Measurement of
Bacteremia and Its Relationship
to Plaque Control
by
HARVEY A. WANK, D.M.D.*
M A T T H E W E. LEVISON, M.D.†
LOUIS F. ROSE, D.D.S., M.D.‡
D. WALTER COHEN, D.D.S.§
TRAUMA TO THE mucosal surfaces of the oral cavity,
1,10
caused by a variety of procedures, may induce
transient bacteremia in as high as 100% of patients. For
example, bacteremia has been found in approximately
3,7,11,12
0% to 26% of people following tooth b r u s h i n g .
Daily debridement of microbial plaque with floss and
"deplaquing" with a perio-aid, in addition to tooth
brushing, is thought to be the best means of prevention of
the inflammatory forms of periodontal disease. However,
the frequency of bacteremia following these recom­
mended procedures in comparison to tooth brushing
alone is unknown. The purpose of the present study is to
determine the frequency of bacteremia using rigorous
anaerobic bacteriologic techniques following brushing,
flossing, and "deplaquing" with a perio-aid in patients
with varying degrees of severity of periodontal disease.
This was evaluated before and after institution of perio­
dontal therapy and a plaque control program.
M E T H O D S AND MATERIALS
Patients. Twenty-one healthy subjects (11 males and
10 females) consented to participate in this study at the
Hospital of the Medical College of Pennsylvania. They
were between 31 and 49 years of age and were not
previously in an oral disease control program. They had
eighteen or more remaining natural teeth, were without
dentures, and had not taken antimicrobial agents for at
least 1 month prior to the study. None of the patients
had periapical pathology present upon examination by
oral radiography. The severity of periodontal disease
was graded on a scale of 0 to 6 by measuring the depth of
* Resident, Department of Oral Surgery, University of Pennsylvania
at the Philadelphia General Hospital, 34th and Civic Center Blvd.,
Philadelphia, Pa. 19104.
† Associate Professor, Department of Medicine, Chief, Division of
Infectious Diseases, The Medical College of Pennsylvania.
‡ Assistant Professor of Periodontics, University of Pennsylvania,
School of Dental Medicine, Chief of Dental Medicine and Surgery,
The Medical College of Pennsylvania.
§ Professor, Department of Periodontics, Dean, University of
Pennsylvania, School of Dental Medicine, Professor, Dental Medicine
and Surgery, Medical College of Pennsylvania.
683
the degree of gingival inflammation, i.e., "Gingival-
13
Periodontal Index" (GPI). The extent of calculus for­
mation, plaque deposits, and defective restorations was
13
graded 0 to 3, i.e., "Irritant Index" (II).
Patients were instructed on the proper performance of
tooth brushing, flossing and deplaquing with a perio-aid.
On day 1, patients brushed for 5 minutes utilizing
toothbrush (Butler 411) and toothpaste (Colgate). One
week later they flossed all the interproximal areas of their
teeth with unwaxed floss (Johnson & Johnson). After a
second 1-week interval, patients used the "perio-aid"
deplaquer|| and toothpick around the teeth at 'the
gingival margin.
Ten ml of blood were drawn aseptically from the
antecubital fossa into a heparin-treated syringe immedi­
ately before each procedure and within 90 seconds
following the procedure. The needle was then changed,
and 5 of the 10 ml were placed in 45 ml of broth for
aerobic incubation in trypticase soy broth with C 0 and
2
SPS (BBL). The other 5 ml were placed in 45 ml of pre-
reduced broth for anaerobic incubation (brain-heart in­
fusion broth W/SPS, supplemented with cysteine,
hemin, and vitamin K.** Both media were incubated at
37°C and subcultured weekly for 3 weeks, aerobically,
microaerophically (5% C 0 incubator), and anerobically
2
(GasPak jar, BBL).
The anaerobes were identified according to the criteria
of the Anaerobe Laboratory, Virginia Polytechnic Insti­
14
tute. The aerobes were identified by generally recog­
15
nized methods.
The patients then underwent initial periodontal prepa­
ration which consisted of scaling, root planing, ultrasonic
debridement, gingival curettage, and polishing of the
teeth with an abrasive powder. A 5 to 6 week program of
plaque control was instituted which consisted of daily
brushing, flossing, and deplaquing with a perio-aid
utilizing disclosing tablets.††
The patients were reevaluated weekly during the
plaque-control program, and the proper performance of
each procedure was reinforced. Blood cultures were
repeated after brushing, flossing and deplaquing as was
done prior to the plaque-control program.
RESULTS
The results of blood cultures in 21 patients who
underwent a total of 126 procedures (63 procedures
before and 63 after the plaque-control program) are
given in Table 1. Of the 126 blood cultures taken prior to
brushing, flossing, or deplaquing, 122 were sterile and
four grew Propionibacterium denes (one blood culture
prior to the plaque-control program and the three
following the plaque-control program) (Table 2). Of the
|| Marquis Dental Mfg. Co., Denver, Colo.
Worlds Fair, Forster Mfg. Co., Wilton, Maine.
** Scott Laboratories, Fiskeville, R.I.
† J. O. Butler & Co., Chicago, 111.
 J. Periodontol.
684 Wank, Levison, Rose, Cohen December, 1976

TABLE 1. Results of Blood Cultures

Before plaque control program After plaque control program

Patient
No.
Brush Floss "Deplaquing" Brush Floss "Deplaquing"

GROUP I*

1 Aerobic Lactobacillus sp. Viridans Moraxella sp.,

streptococci. TM-1.

2 Viridans Fusobacterium nucleatum,

streptococci. Microaerophilic
Gram (-) rod.

3 Propioni- Bacteroides ochraceus. Anaerobic

bacterium unspeciated
acnes. Gram ( + ) coccus.

4 Aerobic
diphtheroid.

GROUP lI†

5 Bifidobacterium sp., Aerobic P. acnes.§ P. acnes.§

Lactobacillus.

6 Peptococcus constellatus, P. acnes.§

Viridans streptococcus,
Aerobic Lactobacillus sp.

7 Eubacterium sp.

8 Aerobic diphtheroid,
Staphylococcus
epidermidis, Aerobic
Lactobacillus sp.

9 Bacteroides sp.

10 Anaerobic
unspeciated
Gram ( + )
coccus,
Anaerobic
unspeciated
Gram ( + )
bacillus.

11 Arachnia Arachnia
prop ionic a. propionica.

GROUP 111‡

12 P. granulosum,
Veillonella
parvula.

13 P. acnes.§ P. acnes.

* Patients with positive blood cultures following a procedure before and after initial periodontal therapy.
† Patients with positive blood cultures following a procedure only before initial periodontal therapy and plaque control program.
X Patients with positive blood cultures following a procedure only after initial periodontal therapy and plaque control program.
§ Bacteremia immediately before procedure, no bacteremia noted after procedure.

126 blood cultures (63 taken before and 63 after the plaque-control program (P < 0.01, t test, paired observa­
plaque-control program), following brushing, flossing, or tion). Eight patients had sterile blood cultures following
deplaquing, 19 (15%) grew microorganisms. brushing, flossing, and deplaquing, both before and after
The GPI, and II declined significantly following the the plaque-control program. There were 12 episodes of
Volume 47
Number 12 Bacteremia and Plaque Control6 8 5

bacteremia after 63 procedures (19%) in 10 patients prior
to plaque control as compared to seven bacteremic
episodes after 63 procedures (11%) in five patients
following the program (Table 3). Two patients had
bacteremia following brushing, flossing or deplaquing
prior to and after the plaque-control program. Before the
plaque-control program only eight patients demonstrated
bacteremia, and only three patients demonstrated bacte­
remia after the program. Although the frequency of
bacteremia after plaque control was almost half that
found prior to the plaque control, the difference was not
significant (P > 0.05 by sign test).
Forty-two trials of brushing were followed by four
bacteremic episodes (10%). Two occurred before and two
after plaque control was initiated (Table 4). Forty-two
bacteremia following each of the procedures (P > 0.05,
chi square test).
In the 19 episodes of bacteremia following brushing,
flossing, or deplaquing, one microorganism was isolated
in 12 blood cultures, two microorganisms were isolated in
five blood cultures, and three microorganisms were
isolated from two blood cultures. The frequency of
polymicrobial bacteremia was not reduced by the initial
periodontal preparation and the plaque-control program
(four episodes prior to and three episodes after the
plaque-control program). Twenty-eight microorganisms
were recovered from blood cultures; 15 were obligate
anaerobes, and 13 were facultative anaerobes (Table 7).
DISCUSSION

trials of flossing were followed by nine bacteremic Many studies have demonstrated that the oral cavity is
episodes (22%). Six occurred prior to and three after a source of bacteremia, and they have implicated specific
plaque control (Table 5). Forty-two trials of deplaquing microflora of the oral cavity as the etiology for subacute
were followed by six bacteremic episodes (14%). Four bacterial endocarditis in susceptible patients. The fre­
occurred before and two after the control program (Table quency of bacteremia observed in the present investiga­
6). There was no significant difference in the frequency of tion is consistent with previous studies. These showed
that the incidence of bacteremia following manual brush-
T A B L E 2. Blood Cultures Prior to Brushing, Flossing and "Deplaquing"
TABLE 6. "Deplaquing"
Blood cultures
Plaque control program Blood cultures
Positive Total Plaque control program
Positive Total
Before 1 63
After 3 63 Before 4 21 (19%)
Total 4* 126 After 2 21 (10%)
Total 6 42(14%)
* Propionibacterium acnes.

T A B L E 3. Blood Cultures afterBrushing, Flossing and "Deplaquing" T A B L E 7. 28 Microorganisms Cultivated from Blood Cultures following
Oral Manipulative Procedure
Blood cultures
Plaque control program Frequency of
Positive Total isolates
Microorganisms
from blood
Before 12 63(19%) cultures
After 7 63(11%)
Total 19 126(15%) OBLIGATE ANAEROBES
Fusobacterium nucleatum 1
Bacteroides ochraceus 1
T A B L E 4. Brushing Anaerobic unspeciated Gram ( + ) cocci 2
Propionibacterium acnes 2
Blood cultures Propionibacterium granulosum 1
Plaque control program Unspeciated Gram (+) bacillus 1
Positive Total Eubacterium sp. 1
Bifidobacterium species 1
Before 2 21 (10%) Peptococcus constellatus 1
After 2 21 (10%) Bacteroides species 1
Total 4 42 (10%) A rachnia propionica 2
Veillonella parvula 1
AEROBES
T A B L E 5. Flossing
Aerobic Lactobacillus sp. 4
Viridans streptococci 3
Blood cultures
Moraxella species 1
Plaque control program TM-1
Positive Total
Microaerophillic Gram (-) rod 1
Aerobic diphtheroid 2
Before 6 21 (29%)
Staphlococcus epidermidis 1
After 3 21 (14%)
Total 9 42(22%) 28

686 Wank, Levison, Rose, Cohen
ing in subjects with apparently minimal periodontal dis­
7 1 2
ease ranged from 0 to 26% in subjects with various
degrees of periodontal disease, the incidence was 24.2%. 3
9
Lineberger and DeMarco have shown that the use of
dental floss in patients with periodontal disease caused
bacteremia in two of 10 patients, and the use of stimu-
dents in patients with periodontitis caused bacteremia in
four of 10 patients. In patients pretreated with scaling
and prophylaxis, bacteremia occurred in two of 10 after
10
the use of stimudents. Richards found a 17.6% occur­
rence of bacteremia in patients with "infected gums"
who received a 10 minute gingival massage. Sconyers et
al. found five of 30 patients developed bacteremia fol­
lowing use of an electric tooth brush.
More sophisticated culturing techniques recently have
lead to the recovery of greater numbers of anaerobic
bacteria in addition to viridans streptococcus from blood
cultures following gingival trauma. Some of these bacte­
ria which are normal inhabitants of the gingival crevice
16
rarely have been implicated in bacterial endocarditis.
The relatively high incidence of anaerobic bacteria which
we recovered, i.e., 54% obligate anaerobes, can be
accounted for by these newer techniques.
Only four of 126 blood cultures obtained prior to the
gingival trauma were positive. The four occurrences of P.
acnes in our preoperative cultures may be due to
contamination since this organism is a normal inhabitant
of the skin.17
The only preventive measure to reduce the risk, during
oral manipulative procedures, of bacteremia and subse­
quent endocarditis in susceptible patients has been the
use of prophylactic antibiotics. Many studies have cor­
related an increased incidence of bacteremia with an
increase in the severity of periodontal disease. 1,18,19
Therefore, based on such findings it was hoped that an
appropriate regimen could be found to decrease the
incidence of bacteremia. However, this study demon­
strated that despite a significant improvement in both the
GPI, which is a measure of periodontal status, and II,
which is a measure of oral hygiene, the frequency of
bacteremia was not significantly different before and
after initial periodontal preparation and plaque control.
This lack of significance may be due to the small number
of subjects studied and the low incidence of bacteremia
encountered.
SUMMARY
Despite the improvement in the patients' oral hygiene,
there was no significant decrease in the frequency of
bacteremia. There was no significant difference in bacte­
remia between brushing, flossing, or deplaquing either
before or after initial periodontal preparation and plaque
control in 21 healthy subjects. Utilizing more sophisti­
J. Periodontol.
December, 1976
cated bacteriologic techniques for the cultivation of obli­
gate anaerobes, a relatively high frequency of anaerobic
bacteremia was found.
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