GUIDED BY: PRESENTED BY:DR. AMIT GOEL DR .VIRSHALI GUPTA

PG 1 S T YEAR APPROVED

ON :11 /04 /16

GINGIVAL CREVICULAR FLUID

CONTENTS

IntroductionDefinitionFunctionHistoryFormationPermeability of junctional and oral sulcular epitheliumMethods of collectionProblems during collectionComposition of GCFClinical significanceConclusionReferences 1/34

INTRODUCTION

Complex mixture of substances

Serum

WBCs

Cells

Bacteria

2/34

FUNCTIONS

1) Cleanse material from the sulcus.

2) Contain plasma proteins that may improve adhesion of the epithelium to the tooth.

3) Possess antimicrobial properties.

4) Exert antibody activity in defense of the gingiva.

3/34

Waerhaug (1952)

Sulcus Gingival pocket

Periodontitis

Brill et al (1962)

Loe & Holm-Pederson (1965)

Indicator of periodontal diseases

Egelberg (1966)

Gingival vasculature and permeability

Schroeder (1969), Listgarten (1966)

Dentogingival structure

Cimasoni (1969)

Physiology and composition

Presence and functions of proteins in GCF

STUDIES ON GINGIVAL CREVICE FLUID (GCF) EXTEND OVER A PERIOD OF ABOUT 50 YEARS

4/34

FORMATION OF GCF

GCF is formed at the rate of 0.5- 2.4 ml/day. There are 2 theories that suggest the formation of GCF. Theory 1 (Brill and Egelberg)

Increase in the permeability of vessels seepage of fluids in sulcus

Formation of GCF

5/34

THEORY 2:

Alfano (1974) and Pashley (1976) suggested that the initial fluid produced could simply represent interstitial fluid which appears in the crevice as a result of an osmotic gradient.

This initial, pre-inflammatory fluid was considered to be a transduate and on stimulation, this changed to become an inflammatory exudate.

6/34

PASHLEY MODEL

GCF production is governed by passage of interstitial fluid from capillaries

tissues

lymphatic system

when capillary filtrate exceeds that of lymphatic uptake, fluid will accumulate as edema and/or leave the area as GCF

7/34

PERMEABILITY OF JUNCTIONAL AND ORAL SULCULAR EPITHELIA

Albumin,

Endotoxins,

Thymidine,

Histamine,

Phenytoin,

Peroxidase.

Intercellular Spaces

Schroeder and Munzel – Pedrazzoli (1970)

18% - junctional epithelium

12% - oral sulcular epithelium.

8/34

Squier (1973)

• Degree of permeability of the oral mucosa = its degree of Keratinization.

• Three routes have been described: • Passage Form CT Into The Sulcus

• Passage From The Sulcus Into The CT

• Passage of Substances through

pathological or experimentally modified gingival sulcus.

9/34

METHODS OF COLLECTION OF GCF

METHODS OF COLLECTION

Absorbing paper strips

Pre Weighed twisted threads

Micropipettes/

Capillary tubing

Intracrevicular washings

10/34

Absorbing paper strips

Brill and Krase (1958) Introduced filter paper into gingival sulcus of dogs previously injected im with fluorescein within 3 min the fluroscent material was recovered on the paper strip. This indicates the presence of fluid in gingival sulcus.

• Intracrevicular method

• Extracrevicular method

Loe & Holm Pederson (1965)

Rudin et al. 1970• Paper strips + notch at their tip

• Tip – sulcus entrance • Notch – safeguard against deeper

penetration

• it is quick and easy to use• can be applied to individual sites • Possibly, is the least traumatic when

correctly used.

11/34

Pre Weighed twisted threads

WEINSTEIN et al. (1967)

Thread is placed in the gingival crevice around the tooth and the amount of fluid collected is estimated by weighing the sample thread.

12/34

Intracrevicular washings

Gingival crevice + isotonic solution

dilution of crevicular fluid

cells + plasma proteins.

Oppenheim. 1970 - customized acrylic stent

• Useful for longitudinal studies• Permits collection without

disturbing the integrity of the marginal tissues

• Contamination is least

• Complex procedure• Represents a dilution of

crevicular fluid

13/34

Micropipettes/

Capillary tubing

KRASSE AND EGELBERG. 1962

• This technique appears to be ideal as it provides an undiluted sample of ‘native’ GCF whose volume can be accurately assessed.

• Time consumption – 30 min

• Difficulty in removing the complete sample

Principle- collection of fluid by capillary action.• After isolation and drying of collection site, capillary tubes of known diameter are inserted into the entrance of gingival crevice, GCF migrates into the tube by capillary action.•As diameter is known, the amount of GCF can be calculated by measuring the distance which the GCF has migrated.

14/34

METHODS OF ESTIMATING THE VOLUME COLLECTED:

1. Direct viewing and staining

2. Weighing of the strip

• The amount of GCF collected on a strip was assessed by the distance the fluid had migrated up the strip.

• Assessing the area of filter paper wetted by the GCF sample.

• Staining the strips with ninhydrin to produce a purple color in the area where GCF had accumulated

• 2g fluorescein given systemically to each patient 2hours prior to the collection of GCF, following which the strips were examined under ultraviolet light

Cimasoni et al. 1988

Weinstein E et al. 1967

• they are not easily applied at the chairside.

• The inevitable delay in measuring the strip may result in increased variation in the reported volume as a result of evaporation.

• the staining of the strips for protein labelling prevents further laboratory investigations of the components of GCF, effectively limiting the technique to that of volume determination

15/34

Periotron Harco electronics: “HAR 600 Gingival Crevice Fluid Meter”

Upper & Lower jaws

Electrical condenser

Machine in Operation

One jaw : +veOther jaw : -ve

Electricity does not flow Dry insulating paper strip

Wet strip Dielectric constant of the insulating material

600, 6000, 8000

16/34

• Subsequent chemical analysis• Evaporation is minimized

Inability to measure volumes of GCF greater than 0.1 µl

Periotron

17/34

PROBLEMS ASSOCIATEDWITH COLLECTION

Contamination Sampling time

Data reporting Volume

Determination

Recovery from strips

18/34

COMPOSITION

A. CELLULAR ELEMENTS C. ORGANIC COMPOUNDS1.EPITHELIAL CELLS 1.CARBOHYDRATES2. LEUKOCYTES 2.PROTEINS3. BACTERIA 3.LIPIDS

B. ELECTROLYTE D. METABOLIC ACID END PRODUCTS

1.SODIUM 1.LACTIC ACID2.POTASSIUM 2.HYDROXYPROLINE3.CALCIUM 3.PROSTAGLANDINS 4.UREA 5.ENDOTOXINS 6.CYTOTOXIC SUBSTANCES 7.ANTIBACTERIAL FACTORS

19/34

E. ENZYMES AND ENZYMES INHIBITORS:

1.ACID PHOSPHATASE2. ALKALINE PHOSPHATASE3. PYROPHOSPHATASE4.β – GLUCURONIDASE5. LYSOZYME6. HYALURONIDASE7. PROTEOLYTIC ENZYMES 8. LACTIC DEHYDROGENASE

20/34

GCF-AS A DIAGNOSTIC MARKER

An extensive search has been made for GCF components that might serve as potential diagnostic or prognostic markers for the progression of periodontitis.

Curtis et al. stated that "markers of disease" might encompass three separate categories:

1) indicators of current disease activity; 2) predictors of future disease progression; 3) predictors of future disease initiation at currently healthy sites.

21/34

CLASSIFICATION OF GCF BIOMARKERS (Gupta G 2012)

Host-derived enzymes and their inhibitors

Tissue breakdown products Inflammatory mediator and host response modifiers

• Aspartate aminotransferase• Alkaline phosphatase• Acid phosphatase• β-Glucuronidase• Elastase• Elastase inhibitors• α2 – Macroglobulin• α1 - Proteinase inhibitor• Cathepsins• Cysteine proteinases (B, H, L)• Serine proteinase (G)• Cathepsin D

• Glycosaminoglycans• Hyaluronic acid• Chondroitin-4-sulfate• Chondroitin-6-sulfate• Dermatan sulfate• Hydroxyproline• Fibronectin fragments• Connective tissue and bone

proteins• Osteonectin• Osteocalcin• Type I collagen peptides• Osteopontin

• Cytokines• IL- 1 alpha• IL- 1 beta• IL- 2• IL- 6• IL-8• TNF-alpha• Interferon alpha• Leukotriene B4• Prostaglandin E2• Transferrin• Lactoferrin• Ig-G1, G2, G3, G4, IgM

22/34

COMMERCIALY AVAILABLE DIAGNOSTIC KIT

23/34

ASSAY KIT FUNCTIONBacterial enzymes & host enzymes

BANA periodontal test

for bacterial trypsin like proteases

Periocheck Detects presence of neutal proteases i.e. Collagenase

PerioScan Detects enzymatic activity of A.a, T forsythus, P gingivalis

Immunological detection

Evalusite of antigens of A.a, P intermedia, P gingivalis using antibodies (ELISA)

Biochemical Identification

Periogard Detects the presence of ASTPocket watch Detects aspartate aminotransferase

through colorimetric detectionTOPAS Detects toxins derived from

anaerobic metabolism and measures GCF protein level

CLINICAL SIGNIFICANCE

Circadian periodicity: in GCF from 6:00AM to 10:00PM and a decrease afterward.

Average flow was greater in the evening and minimal early in the morning. (Bisada et al. 1967)

Did not find any systemic differences between the flow of fluid measured at 9 a.m. & that of the fluid collected at 3 p.m. (Suppipat et al. 1997)

24/34

Lindhe et al. 1969Lindhe & Lundgren, 1972

25/34

3 groups of females are studied:

1. During mensturation: inc in GCF because sex hormones cause inc in the gingival vascular permeability.

2. Females on birth control pills: significant inc in the amount of exudate recorded.

3. Females during pregnancy: gingival exudates reached max values during the last trimester and dec to min after delivery.

GCF AND SEX HORMONES:

PERIODONTAL THERAPY AND GCF

• One week after gingivectomy there was a striking increase in GCF flow (Arnold et al., 1966)

Gwinnette et al 1978…GCF flow decreases 1 week after oral prophylaxis and slowly returned to pretreatment values.

Suppipat et al 1978…inc in GCF flow during the first 2 weeks after surgery, followed by a gradual decrease….same when using mechanical or chemical plaque control

Tsuchida & Hara 1981..decrease in GCF flow 4 weeks following root planing & curettage

26/34

GCF IN DIABETIC PATIENTS

Ficara et al. 1975 similar conc. of glucose in GCF and serum in healthy and diabetic subjects

Ringelberg et al in 1977 described a higher flow rate of gingival fluid in a group of diabetic children, when compared to the flow rate measured in a group of children without diabetes.

With respect to glucose conc. In

GCF in the presence of diabetes,

they found that the exudate from

diabetic pts contained significantly

more glucose than exudate from

healthy subjects

(Hara et al. 1967)

27/34

Drugs that are excreted through the gingival fluid may be used advantageously in periodontal therapy.

DRUGS IN GCF:

Bader and Goldhaber demonstrated that intravenously administered tetracycline in dogs rapidly emerges within the sulcus.

Ciancio et al (1976) measured the concentration of tetracycline in blood and gingival fluid in 5 adult patients with advanced periodontitis, who were given 1g of tetracycline HCL daily for 2 weeks and 0.5g for 10 weeks. The concentration of the drug in gingival fluid was 1/10 of that found in serum.

In a second study from the same laboratory the concentrations of the drug were found to be 5 times higher in samples of gingival fluid as compared to the concentrations in blood.

28/34

Stephen et al (1980) measured the conc. of ampicillin, cephalexin, tetracycline, erythromycin, clindamycin and rifampicin in serum, saliva and GCF after a single dose administration. Except on one occasion, individual GCF antibiotic conc. were equal to or considerably greater than those found in saliva. But they were, however, always much lower than the concentration found in serum.

Metronidazole is another antibiotic that has been detected in human GCF. (Eiserbeng et-al 1991).

29/34

INFLUENCE OF MECHANICAL STIMULI

Brill 1959 investigated the effect of chewing and showed that it causes a significant increase in crevicular fluid flow

30/34

• Chewing and vigorous gingival brushing stimulate the oozing of gingival fluid.

• Even the minor stimuli represented by Intrasulcular placement of paper strips increase the production of fluid.

Smoking produces an immediate but transient increase in GCF flow. (Mcluaghlin WS et al 1993)

GCF production is not increased by trauma from occlusion.

SMOKING

31/34

RECENT FINDINGS IN GCF

OPG concentrations in GCF decreases proportionally with the progression of periodontal disease, that is gingival inflammation and clinical attatchment loss (CAL) (Bandari P et al. 2012).

GCF resistin level as a potential inflammatory marker for periodontitis with type 2 diabetes mellitus. (Gokhale NH et al.2013).

IL-23 level in GCF is directly proportional to the severity of periodontal affliction suggesting its possible role in periodontal inflammation. (Himani GS 2013).

Periodontal treatment down regulates protease-activated receptor 2. (VTE Alves 2013) 32/34

CONCLUSION

Monitoring periodontal disease – complicated task.

Analysis of GCF constituents in health and periodontal disease may be

extremely useful to monitor periodontal disease because GCF can be

easily obtained with non invasive methods.

Thorough knowledge- Better aid for diagnosis.

33/34

REFERENCES

CARRANZA,s Clinical Periodontology. 10th edition.

Griffiths. Formation, collection and significance of GCF. Periodontal 2000 2003; 31:32 – 42.

J. Max Goodson. Gingival crevicular fluid. Periodontal 2000 2003;31:43 – 54.

Catherine M.E. et al. Potential for gingival crevice fluid measures as predictors of risk for Periodontal disease. Periodontology 2000 2003;31:167-80.

Gupta G. GCF as a periodontal diagnostic indicator. J Med Life . 2012 Dec 15; 5(4): 390-7.

34/34