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Relation of the Orogranulocytic Migratory Rate to Periodontal Disease and Blood Leukocyte Count: A Clinical Study
D.A. Woolweaver, G.G. Koch, J.J. Crawford and R.L. Lundblad J DENT RES 1972 51: 929 DOI: 10.1177/00220345720510043401 The online version of this article can be found at: http://jdr.sagepub.com/content/51/4/929

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Relation of the Orogranulocytic Migratory Rate to Periodontal Disease and Blood Leukocyte Count: A Clinical Study
D. A. WOOLWEAVER, G. G. KOCH, J. J. CRAWFORD,* and R. L. LUNDBLAD Departments of Endodontics and Periodontics, Dental Research Center, School of Dentistry, and Department of Bio-statistics, School of Public Health, University of North Carolina, Chapel Hill, North Carolina 27514, USA Number and types of oral leukocytes counted in concatenated samples of saliva were related to the severity and extent of periodontal disease in 50 individuals between 19 and 65 years of age. The oral polymorphonuclear leukocyte level was independent of leukocyte levels in peripheral blood, and was correlated best with degrees of gingivitis.

The existence of leukocytes in the oral cavity has been known for some time.'-5 Their source, function, and significance have been the subject of a limited number of studies and much controversy. Some of the earliest investigators4'5 believed that the leukocytes actually were formed in the oral cavity by the transformation of lymphocytes and mucous cells. Now it is accepted generally that oral leukocytes are derived from systemic sources and enter the oral cavity by way of the gingival crevice.6-11 The number of leukocytes in the oral cavity has been related to various local and systemic factors: leukemia,'2 irradiation,11,13 drugs,'4 peripheral blood leukocyte count,11'14'15 dental caries,16"17 and gingival inflammation.18 For almost every positive correlation of oral leukocytes with these factors, a negative correlation has been re-

ported. A major factor contributing to these conBased on a MS thesis, University of North Carolina. This paper was presented at the International Symposium on Leukocytes, March 1970, University of Texas, Houston, Tex. This investigation was supported in part by USPHS Research Grant No. DE02668 and by USPHS Grant No. RR 05333. Statistical analysis was supported by USPHS Grant No. 1-K4-GM-70004. Received for publication April 23, 1971. * Request reprints from J. J. Crawford, Dental Research Center, University of North Carolina School of Dentistry, Chapel Hill, NC 27514.

flicting results has been lack of uniformity in techniques used to collect oral leukocytes. Pooled and paraffin-stimulated saliva used in many investigations is composed mainly of hypotonic parotid saliva, which disrupts leukocytes on contact. In 1963 Klinkhamer7 introduced a technique of saliva collection that preserves the leukocytes and permits the calculation of the number of leukocytes actively migrating into the oral cavity, which he termed the "orogranulocytic migratory rate" (OMR). In later articles Klinkhamer'9,20 has attempted to relate the OMR to general oral health and specifically the clinical health of the gingiva. The number of patients and the clinical evaluating criteria used in the studies reported have been limited. Recently, Skougaard, Bay, and Klinkhamer8 compared the OMR with the gingival health of 86 patients and found a significant correlation between the two. They concluded that the OMR is a reliable measure of oral health. In view of the controversies reported in the literature and with an improved collection technique available, validation of the OMR in another laboratory was considered to be important. The primary purpose of this study was to investigate further the number and types of oral leukocytes detectable in oral rinses, and to determine their relation to severity and extent of periodontal disease and to peripheral blood leukocyte counts in adult humans. Materials and Methods This investigation consisted of a convenience sample of 50 adult patients aged 19 to 65 years who were undergoing treatment in the periodontic clinic at the University 929

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930

WOOLWEAVER ET AL

J Dent Res

July-August

1972

of North Carolina School of Dentistry. No preference was given to either sex or race in selection of the patients. Each patient selected for the study was required to be in apparent good systemic health, to have no fewer than 24 teeth, and to have no pharyngeal inflammation. Patients were selected until predetermined quotas were reached in two group classifications. To ensure a distribution of patients with varying degrees of periodontal health, an effort was made to select 25 patients with relatively good periodontal health and 25 with relatively poor periodontal health. Patients chosen for the periodontally healthy group had uniform coral-pink gingiva. In a representative patient, the papillae were pointed and filled the interproximal spaces to the contact point. The marginal gingiva sloped coronally to a thin edge. The gingival margins were scalloped in contour. The gingiva was firm and resilient. Pocket depth measurements ranged from 1 to 3 mm throughout, and there was no evidence of plaque, debris, or calculus. Patients chosen for the periodontally diseased group had distinct regions of gingival inflammation. In a representative patient, several papillae were blunted and others were enlarged. There was considerable variation in marginal contour because of regions of enlargement and recession. There was a tendency for spontaneous hemorrhage and the patients complained of discomfort when brushing. Pocket depth measurements ranged from 3 to 5 mm. There were significant amounts of plaque, debris, and calculus visible on the tooth surfaces. ORAL EXAMINATION.-A no. 5 front-surfaced mouth mirror, and a University of Michigan no. 0 periodontal probe were used to score six selected teeth; clinical indexes describing gingivitis.2' plaque.2' debris,22 calculus,22 mobility, caries experience, and pocket depth were used. The six selected teeth were maxillary right first molar (tooth no. 3); maxillary left central incisor (tooth no. 9); maxillary left first premolar (tooth no. 12); mandibular left first molar (tooth no. 19); mandibular right central incisor (tooth no. 25); and mandibular right first premolar (tooth no. 28). With the exception of mobility and caries experience, each of the clinical indexes used has been described previously in detail.

The gingival status was scored by use of Ramfjord's Gingival Index.2' Plaque was scored by use of a modification of Ramfjord's Plaque Index.2' The modification, which was patterned after a method described by LUe23 in 1964, consisted of the substitution of a no. 17 explorer for the Bismarck brown solution in plaque assessment. The modification was instituted because of the possible deleterious effects of Bismarck brown solution on the migration rate of the oral leukocyte. Debris and calculus were scored using the Debris Index and Calculus Index of Greene and Vermillion.22 The mean debris and calculus scores were combined to obtain the Simplified Oral Hygiene Index (OHIS).22 The OHI-S values ranged from 0 to 6. Tooth mobility was scored based on movement in excess of physiologic limits. The following classification (used at the University of North Carolina School of Dentistry) was used to assess mobility: 0, physiologic mobility; 1, movement that is greater than physiologic mobility but no greater than 1 mm movement; 2, movement greater than 1 mm mobility, but in a mesiodistal or faciolingual direction; and 3, movement greater than 1 mm mobility and tooth can be rotated or intruded. Caries experience was recorded using the following classifications: A, no caries apparent, with no previous caries; B, no caries apparent, with no restorations within the past year; number of restored surfaces recorded; and C, caries present, with the number of surfaces recorded. Pocket depth was determined on six aspects of each of the six teeth. The distance from the free gingival crest to the depth of the pocket was recorded as the measurement for that particular tooth surface. In addition to the pocket measurement method just described, Ramfjord's2' system of pocket measurement was used on the buccal and mesial surfaces. Ramfjord's Gingival Index and Ramfjord's pocket measurements were combined to compute the Periodontal Disease Index (PDI).21
ORAL LEUKOCYTE EVALUATION.-On com-

pletion of the oral examination, a salivary sample and a peripheral blood sample were
taken. Concatenated salivary samples were collected and assayed with techniques described

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Vol 51 No. 4

OMR AND PERIODONTAL DISEASE

931

and evaluated by Klinkhamer.719,20 The method is given in detail to define concisely and completely Klinkhamer's techniques, which are applicable to the simple blood counting chamber available to any laboratory for routine investigations. Ten consecutively numbered 18 by 150 test tubes in a rack were filled with 5 ml of 1.2% (w/v) sodium chloride solution. The rack of tubes, along with a small polyethylene funnel, was placed before the patient. The patient was instructed to rinse his mouth with contents of the first tube by circulating the saline solution with a rhythmic chewing motion. At the end of 27 seconds the mouth rinse was expectorated through the funnel back into the first tube. Before or at the 30th second, the contents of the second tube were instilled immediately into the mouth. The sequential rinsings and expectorations were repeated until all ten samples were collected in separate tubes. Additional 1.2% (w/v) sodium chloride solution was added to each sample to bring the total volume to 8 ml. Samples 1, 2, 4, 5, 8, and 9 were centrifuged at 1,200 g for eight minutes. The supernatant fluid was removed from the samples to give a final volume of 6 ml. This was the total selected by Klinkhamer to ensure acceptable white cell distribution in the hemacytometer. Immediately after vibration on a mechanical vibrator for about one minute, a white blood cell counting pipette was inserted to the 3 ml level and filled to the 11 mark. The white blood cell pipette was placed in a pipette shaker for one minute. A hemacytometer* was charged. The preparation was allowed to stand in a moist covered Petri dish for two minutes. Leukocytes in five square millimeters were recorded. To obtain results that could be compared with those obtained by Klinkhamer, it was important that his methods be observed carefully and that proficiency in reproducing the oral leukocyte counts be reduced to a level of error approaching 20% or less. Counts of tubes 8, 9, and 10 from the first ten patients were consistent to + 2 cells per 25 cells counted in five squares of the counting chamber. Ten was a convenient number of concatenated samples to collect and provided enough samples to establish a base line.
*

Leukocytes in all ten tubes from the first ten patients were counted. Graphs of time vs leukocytes per sample corresponded in shape to those reported by Klinkhamer.7"19,20
For the remaining patients, only tubes 1, 2, 4, 5, 8, and 9 were counted since these provided adequate data for comparison. The total leukocyte count of sample number 9 was multiplied by 1.2 by 104 to give the total leukocytes in a 6 ml sample that was collected in a 30 second period. This value was recorded as the OMR.7 An OMR index was computed by: OMR x 32 D where D is the number of teeth present. The sediment of the first tube sample of five patients from the periodontally healthy group and in five patients from the periodontally diseased group was used to prepare smears for microscopic examination. Smears were air-dried and stained with Wright's stain.24 BLOOD LEUKOCYTE EVALUATION.-A peripheral blood sample was collected and a leukocyte count was made by standard methods.24 RECORDS AND DATA EVALUATION.-Data collected for each patient included the patient's name, age, sex, race, group number, present state of systemic health, status of the pharynx, number of teeth present, and all clinical and laboratory observations. Arithmetic means and standard deviations were computed for all the basic variables separately within the two groups of patients. For age and number of teeth, these descriptive statistics are reported in Table 1; for the oral evaluation criteria, in Table 2; for leukocyte counts in blood and oral rinses, in Table 3; and for clinical indexes, in Table 4. The statistical significance of differences between the two groups was evaluated in terms of the Wilcoxon statistic.2526 This method was chosen since the group of patients with good periodontal health tended to be considerably more homogeneous than the group of patients with poor periodontal health; the former group had much smaller standard deviations for most variables. In addition, the Wilcoxon statistic does not require any assumptions regarding the distribution of the data to which it is applied.

strument Co., Buffalo, NY.

AO Spencer Bright-Line hemacytometer, A.O. In-

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932

WOOLWEAVER ET AL TABLE
MEANS
AND
1

J Dent Res
OF

July-August 1972

STANDARD DEVIATIONS
Healthy Mean SD 20.72 28.24
a-0.01. a 0.05.

HEALTHY

AND

DISEASED PATIENT
x2

CHARACTERISTICS
Variable
Diseased Mean SD

(df = 1)
26.54*

Age No. of teeth

*

1.84 0.66

34.40 27.16

11.12 2.49

6.55t

Significant at

Significant at

TABLE 2
MEANS
AND

STANDARD DEVIATIONS OF ORAL EVALUATION CRITERIA HEALTHY AND DISEASED PATIENTS

Healthy Mean SD Diseased Mean SD

IN

X2

Variable

(df = 1

Gingivitis Facial pocket depth Lingual pocket depth Total pocket depth Calculus Plaque Debris Mobility
*

1.16 35.52 35.64 71.00 0.04 2.04 1.84 0.00

1.11

6.96 6.51 13.28 0.20 1.62 1.60 0.00

7.56 57.88 58.44 116.24 7.12 7.40 7.32 0.92

3.71 9.28 9.67

35.00*
...

18.66 5.64 3.40 3.51 1.61

-33.34* 35.62* 27.91 * 27.94* 12.08

Significant at

0.01.

MEANS

AND

TABLE 3 STANDARD DEVIATIONS OF LEUKOCYTE COUNTS IN BLOOD SALINE RINSES OF HEALTHY AND DISEASED PATIENTS
Healthy Mean
SD

AND

Variable

Diseased Mean

SD

X2 (df = 1)

WBC* 6,834.00 1,512.00 Direct hemacytometer counts Tube 1 121.32 25.93 13.39 Tube 2 83.92 13.17 58.04 Tube 4 11.85 Tube 5 52.28 12.60 43.16 Tube 8 Tube 9 42.16 12.48

6,924.00
516.20 348.00
185.04 154.44

1,519.7
277.39 186.75 72-97 56.21 48.85 47.89

0.14
...

... ...

123.08 120.80

32.23t

* Peripheral blood leukocyte count in cells per cubic millimeters. t Significant at a = 0.01.

MEANS

AND IN

TABLE 4 STANDARD DEVIATIONS OF CLINICAL INDEXES HEALTHY AND DISEASED PATIENTS

Healthy
Diseased
SD
2

Variable

Mean

Mean

SD

(df

1)

PD1 OHI-S

0.61
0.35

0.46
0.28

2.45
2.26

0.85
1.12

OMR indext
* Significant at t Index X 10g.

0.57
a

0.17

1.76

0.71

35.02* 30.44* 33.35*

= 0.01.

The computed values of a chi-square statistic with one degree of freedom derived from the Wilcoxon statistic are shown in the final column of Tables 1 to 4. A second aspect of statistical analysis was

concerned with the measurement of the association between various pairs of variables within each group. For this purpose, Kendall's rank correlation coefficient, tae and its standard error were computed as described

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Vol 51 No. 4
KENDALL'S ta CORRELATION
No. of Teeth
OF

OMR AND PERIODONTAL DISEASE

933

CLINICAL

AND

ILE 5 LABORATORY VARIABLES

Oral Leukocyte Count (Tube 9)

IN

HEALTHY PATIENTS
OMR

Age

Gingiva

Total Pocket Depth

WBC

PDI

OHI-S

Index

Age No. of teeth

-0.05 (0.06)

-0.02 (0.14) -0.04 (0.10)

Gingivitis
Pocket depth

0.29 (0.15) 0.01 (0.10) -0.23 (0.13)

0.12 (0.14) 0.02 (0.08) -0.11 (0.16) 0.24 (0.15)

WBC
Oral count (Tube 9) PDI
OHI-S

-0.12 (0.17) -0.07 (0.08) -0.01 (0.16) -0.17 (0.18) -0.39 (0.13)

0.22 0.30* (0.13) (0.14) 0.08 -0.04 (0.06) (0.07) 0.01 0.20 (0.13) (0.12) 0.32* 0.10 (0.14) (0.15) 0.06 0.03 (0.10) (0.14) -0.04 -0.01 (0.14) (0.15) 0.09 (0.17)

-0.11 (0.17) -0.08 (0.08) 0.01 (0.16) -0.17 (0.17) -0.36t (0.13) 0.96t (0.02)
-0.00 (0.14) -0.03 (0.15)

OMR index
Note: Upper numbers are ta and lower numbers in parentheses are estimated standard error. * Significant at a = 0.05. t Significant at a= 0.01.

by Davis and Quade.27 These values are shown in Tables 5 and 6. The index ta may be interpreted geometrically as measuring the tendency to which a scatterplot of the data for two variables exhibits a monotonically increasing pattern as opposed to a monotonically decreasing pattern. For sample sizes larger than 20, the statistic ta has approximately a normal distri-

bution. Hence, the association between two variables may be judged statistically significant at the a = 0.01 level if the corresponding value of ta exceeds 1.96 times its standard error, and may be judged statistically significant at the a = 0.01 level if the corresponding value of ta exceeds 2.58 times its standard error. In addition, the question of whether the relationship between two

TABLE 6
KENDALL'S te CORRELATION OF CLINICAL AND LABORATORY VARIABLES IN DISEASED PATIENTS
No. of Teeth Total Pocket Depth Oral Leukocyte
WBC

Age

Gingiva

Count (Tube 9)

OMR
PDI

OHI-S

Index

Age
No. of teeth

-0.35* (0.15)

-0.05 (0.18) 0.13 (0.15)

Gingivitis

0.24* (0.12) -0.09 (0.12) 0.29t (0.09)

Pocket depth WBC Oral count (Tube 9)

0.06 (0.17) 0.10 (0.14) 0.18 (0.16) -0.06 (0.14)

PDL

0.22 (0.14) (0.14) 0.05 -0.02 (0.12) (0.14) 0.57t 0.41t (0.09) (0.08) 0.30t 0.72t (0.10) (0.08) 0.04 0.08 (0.18) (0.13) 0.36t (0.09)

0.03

OHI-S
OMR index
Upper numbers are ta and lower numbers in parentheses are estimated standard error. * Significant at a = 0.05. t Significant at a = 0.01.

0.11 0.16 (0.13) (0.14) -0.13 -0.16 (0.13) (0.13) 0.40t 0.46t (0.14) (0.12) 0.27* 0.31t (0.12) (0.09) -0.01 0.09 (0.14) (0.18) 0.37t 0.71t (0.12) (0.08) 0.32* 0.34t (0.13) (0.10) 0.32t (0.12)

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934

WOOLWEAVER ET AL

J Dent Res July-August 1972

variables is significantly different in periodontally healthy patients than in periodontally diseased patients may be answered by comparing the observed difference between the two respective values of ta to its corresponding standard error (which is given by the square root of the sum of the squares of the standard errors of the two values of ta being compared). Such a difference is significant at the a = 0.05 level if it exceeds 1.96 times its standard error, and is significant at the a = 0.01 level if it exceeds 2.58 times its standard error. Finally, for descriptive purposes, regression lines were fitted for each group by least squares with PDI, OHI-S, and OMR index as the dependent variables and gingivitis and total pocket depth as the independent variables. The resulting estimated slopes are shown in Table 7. Corresponding scatterplots and fitted lines for OMR index versus gingivitis and OMR index vs pocket depth are shown in Figures 1 and 2. Results One clinical evaluation and one leukocyte determination were made for each of the 50 patients participating in the study. Cooperation of the patients was readily obtainable and facilitated collection of the sequential oral rinses. Table 8 indicates the distribution with regard to sex and race of the patients in the healthy and diseased groups. The healthy group was predominantly female, whereas the diseased group was predominantly male. The available population of patients did not permit matching of the healthy and diseased groups with respect to age; hence the age range of the healthy group was 19 to 25 years, whereas the age range for the diseased group was 23 to 65. The difference between the ages of the two groups (Table 1) was statistically significant (a = 0.01). Hence, age could be a factor related to the other observed differences between the groups with respect to the oral evaluation criteria and clinical indexes.

The two groups also differed significantly (a = 0.05) with respect to number of teeth (Table 1). However, this factor is not considered important since the corresponding means are comparable. The oral evaluation scores are summarized in Table 2. For gingivitis as well as total pocket depth, calculus, plaque, debris, and mobility, the means and standard deviations of the clinical indexes were noticeably larger in the diseased group. These differences between the two groups were statistically significant (a = 0.01). Otherwise, within each group the mean lingual pocket depth of both groups was slightly greater than the mean facial pocket depth. There was similarity between the intergroup plaque and debris means in both groups. There appeared to be a general decrease in gingivitis scores of the diseased group as the age of the patient increased. Three patients in the diseased group demonstrated frank gingivitis without the presence of visible plaque, debris, or calculus. This was attributed to patient's erratic attempts at oral hygiene, especially before a dental examination. According to the caries experience recorded on the patient record sheet, patients in this investigation fell into two categories: patients with no present or previous caries, and patients with restored surfaces, but no active caries. These data were not related to any of the clinical or laboratory variables and were not included in the statistical analysis.

The mean leukocyte count of peripheral blood was almost identical in both groups. Statistical analysis indicated no significant differences between the mean counts. Differential counts of leukocytes in the oral rinses of five patients from the healthy group and five patients from the diseased group indicated that almost 100% of the cells were polymorphonuclear leukocytes. Of 1,000 cells counted, only one monocyte and no lymphocytes were seen. The mean oral leukocyte counts of both

TABLE 7 ESTIMATED SLOPES OF REGRESSION LINES COMPARING INDEPENDENT WITH DEPENDENT VARIABLES IN Two PATIENT GROUPS
PDI

Healthy OHI-S

OMR

PDI

Diseased OHI-S

OMR

Gingivitis Total pocket depth

-0.056 0.018

0.047 0.003

-0.004 -0.001

0.100 0.040

0.184 0.017

0.119 0.009

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.0

2.0-

FIG L.-Scatterplot of corresponding values of gingivitis and OMR index for healthy and diseased patients and estimated regression lines.

30*

0~~~~~~~~~~~~~~~

0.5

2 ./ ~

X*~ ~ HEALTY
.
0 0

00

*-4 DISEASED COMBINED

11

4 5 6 7 8 GINGIVITIS SCORE

10

12

2.0

~ ~

;~ ~ ~ ~ ~ 0
v- --o DISEASED HEALTHY COMBINED

25

50 75 100 TOTAL POCKET DEPTH mm

125

150

FIG 2.-Scatterplot of corresponding values of total pocket depth obtained from six aspects of six teeth, and OMR injex for healthy and diseased patients and estimated regression lines.
935
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936

WOOLWEA VER ET AL

J Dent Res

hily-August 1972

TABLE 8 DISTRIBUTION OF HEALTHY AND DISEASED PATIENTS ACCORDING TO SEX AND RACE
Sex
Group
Male Female

Race Caucasian Negro

Healthy Diseased

6 16

19 9

25

0 19 6

groups decreased rapidly from tube 1 to tube 4. (Table 3). Counts in tubes 5, 8,and 9 were about the same. A plot of the mean oral leukocyte counts produces a hyperbolic curve that turns asymptotic after the fifth collection (Fig 3). Similarly shaped curves were produced by both groups. The oral leukocyte means and standard deviations of the diseased group were significantly (a = 0.01) greater than those in the healthy group for tube 9. Means and standard deviations for the clinical indexes are shown in Table 4. The PDI, OHI-S, and OMR were significantly (a = 0.01) larger in the diseased group than in the healthy group. No patient in the healthy group had an OMR index greater than 0.80 by 106. Two patients in the diseased group had an OMR index of less than 1.00 by 106. One patient in the diseased group had a gingivitis score of 12.0 with an OMR index of 1.10 by 106. Rank correlation matrixes for clinical and

500s

400

300
0x

i
z

200-

ito

HEALTHY

-2

01

I A 5 4 SALIVA SAMPLE NUMBER

FIG 3.-Means of oral leukocyte counts healthy and diseased patients,

Ir

laboratory variables within the two groups are given in Tables 5 and 6. For the healthy group the only significant (a - 0.05 or less) correlations were as follows: OMR index vs white blood cells (WBC) vs oral leukocyte count; OHI-S vs age; and PDI vs pocket depth. All of these associations are of only casual importance because they either are attributable to the way the sample was drawn or are consequences of already known functional relationships between the various indexes (eg, OMR is defined in terms of oral leukocyte count and blood leukocyte count). For the patients with poor periodontal health, the correlation matrix has a considerably different structure. In particular, the following relationships are significant (a = 0.05 or less): (1) gingivitis vs total pocket depth vs oral leukocyte count vs PDI vs OHI-S vs OMR Index; ie, every variable in this subset is significantly correlated with every other variable; and (2) age vs number of teeth. Of these conclusions, the first is the most important because it indicates the relationship between the clinical and laboratory values. Finally, the peripheral blood leukocyte count had little correlation with either oral leukocyte count or any of the other variables for patients in the diseased group. The reason for the different patterns of results for the two groups of patients can be seen by examining scatterplots of data points for the OMR index vs gingivitis (Fig 1) and the OMR index vs pocket depth (Fig 2). The healthy patients are highly clustered within a small area that only slightly overlaps a much larger area in which the diseased patients are clustered in a much more dispersed manner. Moreover, the scatterplot for the diseased patients tends to exhibit a monotonically increasing pattern whereas that for the healthy patients tends to exhibit no relationship. This difference between the two groups of patients is also evident from a comparison of the slopes of the fitted regression lines for PDI, OHI-S, and OMR as dependent variables with gingivitis and total pocket depth as independent variables (Table 7). For the OMR vs gingivitis and OMR vs pocket depth these fitted lines are shown in Figures 1 and 2, respectively. In addition, they each contain a fitted line for

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Vol 51 No. 4

OMR AND PERIODONTAL DISEASE

937

the combined sample of all patients which is of descriptive interest from the point of view that the healthy and diseased patients may be regarded as representing a continuum with respect to these variables; the healthy patients all have good oral health and low scores and the diseased patients have varying degrees of poor oral health and higher scores. Finally, the rank correlation of gingivitis with OMR is significantly greater (a = 0.05) in the diseased group than in the healthy group since the difference between the two values of ta is 0.46 -0.01 = 0.45 and the corresponding standard error is {(O.16)2 + (0.12)2}1/2 = 0.20. Discussion Mean leukocyte counts were significantly higher in the diseased group. The predominant cell type in the oral rinses of both groups was the polymorphonuclear (PMN) leukocyte. Differential oral leukocyte counts found in this study varied from some of those reported.28 Many PMN leukocytes probably were disrupted by saliva or other hypotonic solutions used in earlier research to collect oral leukocytes.9 The favorable comparison of differential counts in this study with counts of leukocytes migrating into the gingival crevice reported by Egelberg and Attstrom,29 indicated that the sampling technique used in this study was reliable in preserving the migrating leukocytes. Many of the oral leukocytes collected appeared viable and were probably capable of phagocytosis, although this phenomenon was not observed. Klinkhamer7 and others30 have suggested that oral leukocytes play an important role in host defense. The vital role of granulocytic leukocytes in destroying bacteria in deeper tissues as they participate in inflammation is well-established.31,32 The similar role that oral leukocytes play in the defense against invasion of the gingival tissues by dental plaque is wellillustrated by the tendency of leukopenic patients to develop stomatitis and severe ulcerative gingivitis.33 However, as reviewed by Tempel et al,34 and others,35 oral leukocytes also may contribute to the maintenance of gingival inflammation by the release of potent enzymes at the epithelial surface of the gingival sulcus. In health, a balance probably exists between protection and destruction. In disease, the gingival tis-

sues are insulted and the number of leukocytes migrating into the sulcus increases. The leukocytes phagocytize tissue debris and bacteria and autolyze and then release their enzymes, which results in tissue damage. This action may tend to perpetuate inflammation; it is doubtful, however, that the presence of leukocytes alone in the gingival crevice is the initiating factor in gin-

gival inflammation.34 The lack of specific correlation between oral leukocyte counts and peripheral blood leukocyte counts in otherwise healthy individuals in this study confirms previous investigations.14,15 The studies that reported good correlations of oral leukocyte counts with peripheral blood leukocyte counts used patients with systemic disorders or patients who had been irradiated and who tended to have decidedly abnormal blood leukocyte counts.'1',2 Leukopedesis controls the extravasation of leukocytes and is vital to host defense. The exact mechanism controlling leukopedesis is unknown. Among the factors under consideration are changes in blood vessel wall permeability and hydrostatic pressures.31'32 Also, chemotaxis appears to be involved.34 Klinkhamer36 has suggested that the autonomic nervous system also affects the migration of oral leukocytes. The collection of oral rinses for OMR determinations in this study was carried out in a uniform manner under generally uniform conditions. An effort was made to eliminate or to control as many interfering stimuli as possible that might nonspecifically affect leukopedesis. The clinical indexes of plaque, debris, and calculus can be affected by occasional efforts at oral physiotherapy. By contrast, gingivitis requires about seven days to develop and several days to resolve. The OMR is sensitive to the degree of gingivitis and not to the presence of plaque, debris, or calculus. This should increase its potential value for use in prophylactic studies and patient screening surveys that can even be performed by nondentally oriented technical personnel. The OMR seems to be related to the degree of gingivitis as defined by the Gingival Index of Ramfjord.21 Inflammation in gingivitis causes an enlargement in the marginal tissues, which prQyi4s ;, greater epi-

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938

WOOLWEAVER ET AL

J Dent Res

July-August

1972

thelial area for leukocyte migration. The flow of gingival crevice fluid is increased in inflammation33'37 and may carry migrating leukocytes out of the gingival crevice. It has been suggested8 that increased pocket depth would provide a greater surface area for migration of leukocytes and, therefore, the OMR would increase. Observations in the present investigation indicate that there is a general increase in the OMR of patients with increased pocket depth; however, the relationship between OMR and pocket depth may be only incidental, because patients with increased pocket depth usually have increased gingivitis scores.38 The clinical indexes21'22 used in this investigation were correlated significantly with clinical variables in the disease group. There were only limited correlations in the healthy group. It appears that clinical evaluation criteria are capable of defining disease, but not health. Unfortunately, the OMR index becomes effective only after a certain point is reached in the transition from health to disease. The definition of this phenomenon remains a challenge. Since the OMR index is determined in the laboratory, it is a nonsubjective measure of oral health and, as such, is independent of the investigator's clinical judgment. The OMR index can be duplicated by several investigators at distant locations with the same degree of accuracy. Use of the OMR Index in clinical surveys would materially improve the reliability of the observations and results.

References
1. KOLLIKER: cited in JASSINOWSKI, M.A.: Uber die Herkunft der Speichelkorperchen, Frankfurt Z Path 31:411, 1925. 2. MENDEL, J.: Manner of the Phagocytic Reaction in the Oral Cavity of Man, C R Soc Biol 70:925-928, 1916. 3. JASSINOWSKI, M.: Uber die Herkunit der Speichelkorperchen, Frankfur Z Path 31: 411, 1925. 4. RETTEREI, E., and LELIEVRE, A.: On the Nature and Origin of the Salivary Corpuscles, C R Soc Biol 74:667-670, 1913. 5. GoTT, H.: Die Speichelkorperchen, Int Mschr Anat Physiol 23:3-17, 1906. 6. SHARRY, J., and KRASSE, B.: Observations on the Origin of Salivary Leukocytes, Acta Odontol Scand 18:347-358, 1960. 7. KLINKHAMER, J.: Human Oral Leukocytes, Periodontics 1:109-117, 1963. 8. SKOUGAARD, M.; BAY, I.; and KLINKHAMER, J.: Correlation between Gingivitis and Orogranulocytic Migratory Rate, J Dent Res 48:716-718, 1969. 9. WRIGHT, D.E.: Leukocytes in the Saliva of Edentulous and Caries-Free Subjects, Arch Oral Biol 7:381-385, 1962. 10. WRIGHT, D.: Leukocytes in the Saliva of Infants, Br Dent J 110:50-53, 1961. 11. ISAACS, R., and DANIELIAN, E.: Maintenance of Leukocyte Level and Changes during Irradiation. A Study of the White Blood Corpuscles Appearing in the Saliva and Their Reaction to Those in the Blood. Am J Med Sci 174:70-87, 1927. 12. ALLEN, K., and DICKEY, L.: The Saliva Cell Counts in Myelogenous Leukemia, Am J Roentgenol 38:57-71, 1937. 13. WATANABE, Y.: The Effect of Roentgen Irradiation upon the Cellular Elements in the Human Saliva, Oral Surg 4:89-107, 1951. 14. COMROE, B.: Salivary Changes in Systemic Disease, Dent Cosmos 76:563-569, 1934. 15. STEPHENS, D., and JONES, E.: Leukocytes in the Saliva in Normal and Abnormal Subjects, Proc Soc Exp Biol Med 31:879880, 1934. 16. ORBAN, B., and WEINMANN, J.: Cellular Elements of Saliva and Their Possible Role in Caries, J Dent Res 18:258, 1939. 17. ORBAN, B., and WEINMANN, J.: Cellular Elements of Saliva and the Possible Role in Caries, JADA 26:2008-2097, 1939. 18. CALONIUS, P.: The Leukocyte Count in Saliva, Oral Surg 11:43-46, 1958. 19. KLINKHAMER, J.: Quantitative Evaluation of Gingivitis and Periodontal Disease. I. The Orogranulocytic Migratory Rate, Periodontics 6:207-211, 1968. 20, KLINKHAMER, J., and ZIMMERMAN, S.: The

Conclusions The following conclusions can be made from the data obtained in this investigation: The predominant leukocyte in oral saline rinses was the polymorphonuclear leukocyte. Many oral leukocytes were viable and appeared to be capable of phagocytosis. The OMR was not affected by normal ranges of peripheral blood leukocyte counts. As the severity of gingivitis increased, the OMR also increased. Pocket depth appeared to be correlated generally with the OMR. Under controlled conditions, the OMR can be a reliable indicator of the extent and severity of periodontal disease in a population; it has the advantage of being an objective laboratory test.

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Vol 51 No. 4 Function and Reliability of the Orogranulocytic Migratory Rate as a Measure of Oral Health, J Dent Res 48:709-715, 1969. RAMFJORD, S.: The Periodontal Disease Index (P.D.I.), J Periodontol 38:602-610, 1967. GREENE, J.: The Oral Hygiene IndexDevelopment and Uses, J Periodontol 38: 625-635, 1967. L6E, H., and SILVERS, J.: Periodontal Disease in Pregnancy. II. Correlation between Oral Hygiene and Periodontal Condition, Acta Odontol Scand 22:112-135, 1964. DAVIDSOHN, I., and HENRY, J.: Clinical Diagnosis by Laboratory Methods, 14th ed, Philadelphia: W. B. Saunders Co., 1969, pp 157-182. DIXON, W.J., and MASSEY, F.J.: Introduction to Statistical Analysis, New York: McGraw-Hill, 1969. KOCH, G.G.: The Use of Non-Parametric Methods in the Statistical Analysis of a Complex Split Plot Experiment, Biometrics 26:1, 1970. DAVIS, C.E., and QUADE, D.: On Comparing the Correlations Within Two Pairs of Variables, Biometrics 24:987-995, 1968. WRIGHT, D.: Differential Leukocyte Count of Human Saliva, Arch Oral Biol 13:11591161, 1968. EGELBERG, J., and ATTSTROM, R.: Presence of White Blood Cells within the Gingival Crevice, J Periodont Res 4:161, 1969.

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30. EICHEL, B., and LISANTI, V.: Leukocyte Metabolism in Human Saliva, Arch Oral Biol 9:299-314, 1964. 31. DUBOS, R., and HIRSCH, J.: Bacterial and Mycotic Infections of Man, 4th ed. Philadelphia: J. B. Lippincott Co., 1965, pp 217-230. 32. FLOREY, H.: General Pathology, 3d ed, Philadelphia: W. B. Saunders Co., 1962, pp 98-120. 33. GOLDMAN, H., and COHN, D.: Periodontal Therapy. St Louis: C. V. Mosby Co., 1968, pp 33, 126. 34. TEMPEL, T.R.; SNYDERMAN, R.; JORDAN, H.V.; and MERGENHAGEN, S.E.: Factors from Saliva and Oral Bacteria, Chemotactic for Polymorphonuclear Leukocytes: Their Possible Role in Gingival Inflammation, J Periodontol 41:71-80, 1970. 35. ATTSTROM, R., and EGELBERG, J.: Effect of Experimental Neutropenia on Gingival Inflammation in Dogs, J Periodont Res 4: 24, 1969. 36. KLINKHAMER, J.: Personal communication. 37. L6E, H., and HOLM-PEDERSON, P.: The Absence and Presence of Fluid from Normal and Inflamed Gingivae, Periodontics 3:171-177, 1965. 38. MANN, W.: The Correlation of Gingivitis, Pocket Depth and Exudate from the Gingival Crevice. J Periodontol 34:379-387, 1963.

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