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    MC Hugh

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    of 11
    J. periodont res. 6: 227-236. 1971 The interdental gingivae W. D. McHucu Eastman Dental Center and University of Rochester, N.Y., U.S.A Material from 20 young rhesus monkeys was prepared for study of the interdental gingival epithelium. An additional four young monkeys were injected with tritiated thymidine and radio- autographs prepared for analysis of cell turnovel It was found that the interdental gingiva between recently erupted teeth in proximal contact has a col form. The appearance of the col can be simulated by vertical sections close to the roots of single teeth, Analysis of sections through the actual col showed that it is always lined by squamous epithelium, five or more cell-layers thick, without any recognizable ameloblasts. The radioautographs showed consistent evidence of thymidine uptake in all epithelia lining the col, It was concluded that the histological featui indicating cell-division, sand turnover-rate of epithelium in the interdental region are closely analogous to those of epithelium on other aspects of the teeth. Clinical studies of the presence and amount of plaque and gingivitis in 1,075 intact interdental areas in 48 young adults showed a high of plaque and the prevence and severity of gingivitis, ivitis starts interdentally bee: Introduction As periodontal disease is thought to start in the interdental region, the interdental gin- givae have long been the object of special attention, Until the studies of Cohen (1959a and b) were published, it was generally as- sumed that, in the bucco-lingual plane, the interdental gingivae were convex in outline. Cohen demonstrated, however, that between recently erupted teeth, the gingivae have a “col” form with buccal and lingual peaks and a depression between. This description of the form of the interdental gingivae was subsequently confirmed by Kohl and Zan- der (1961) and Holmes (1965). Cohen (1959b) reported that, in the pe- riod following tooth eruption, the part of the col between the peaks of the interdental of correlation between the presence and amount and lend support to the hypothesis that gingivae was lined by reduced enamel epi- thelium. Principally on the basis of this ob- servation, he put forward the hypothesis that the col is the area of greatest vulner- ability of the periodontium and that chronic breakdown of collagen fibres and the formation of an intra-bony pocket may occur before the reduced enamel epi- thelium is replaced by “oral” epithelium (Cohen 195 ulceration, concluded at the World Workshop in Periodontics (1966) that: “These suggestions warrant further consideration”. The present study was, therefore, planned to investigate the interdental gingivae, and particularly the development of its covering epithelium, in an attempt to confirm or Presidential Address delivered to British Society of Periodontology on 20.10.69. Fig. 1. A bu lingual section through the interdentai MCHUGH region between the lower second and ihird molars of a young adult monkey. Haematoxylin and eosin. Orig. Magn. x 12 refute the hypothesis that the interdental col is the area of greatest vulnerability be- cause it is lined by reduced enamel epi- thelium. The study consisted of three parts. with the and microscopic morphology of the inter- The first. was concerned macroscopic dental gingivae, the second with cell-turn- over in the interdental epithelium, and the part will third with clinical aspects. Each be described separately 1. MORPHOLOGY Material Twenty healthy young rhesus monkeys (Macaca mulatta) with ages estimated to range between three and ne + years were They were anesthetized, their vascular systems perfused with saline and ten per used. cent neutral buffered formalin, and blocks of two or more teeth and surrounding tis- sues carefully removed. After decalcifica- tion and embedding, some were cut in the mesio-distal and others in the bucco-lingual plane. In cut through the interdental r each case, serial sections were Results decalcified specimens confirmed previous descriptions of the morphology of the interdental gin- A col with a buccal and a lingual peak was present between all deciduous or permanent teeth in proximal contact with another tooth. Many ob- tained showing the histological appearance of the col with thick epithelium extending a short distance down the slopes and a layer of much thinner epithelium covering its base Macroscopic examination of givae. bucco-lingual sections were as described by previous workers (Fig. 1). When through the interdental region were exam- ined, however, it became apparent that this col appearance could be produced merely large numbers of serial sections THE Fig. 2. The upper picturo shows a black ball partly set into a block of plaster. Both block and ball wore sectioned through the plane shown by tho dotted line, and the lower picture shows the cut face with the appearance of a ‘col by the plane of section. This is illustrated by the model in Fig. 2 from which it will be seen that the appearance of a be produced by sectioning through any sphere partially enveloped by another ma- terial col” can Further, any vertical section close to but not passing through the root of a tooth could give this appearance, as illustrated by 3 which shows a “col” appearance in a section through the buccal aspect of a lower incisor The apparent distribution of different ty- pes of epithelium in the col is also depen- In Fig. 4, sections close to the dent upon the plane of section be seen that cemento-enamel junction will have larger areas of “thin” epithelium like that seen in Fig. 1. This “thin” epithelium can consist it can INTERDENTAL GINGIVAE 229 of reduced enamel epithelium (recognizable by the presence of ameloblasts), attached epithelial cuff epithelium, or partly of each Examination of serial bucco-lingual sec- tions through the interdental region showed that the morphology of the soft tissues was closely analogous to that on the buccal and lingual aspects of the teeth, as seen in mesio-distal sections. The appearance of the epithelium in the interdental region can be duplicated by fitting sections from the buc cal and lingual of a tooth together (Fig. 5). The similarity is even more obvious in in- terdental sections close enough to the neck of the tooth to include some cementum (Fig. 6). It was found that, as the proximal sur- face of the enamel of an erupting tooth ap- proached that of the neighboring erupted tooth, the reduced enamel epithelium cover- ing the erupting tooth underwent a consis- tent series of changes. The reduced amelo- blasts disappeared and the reduced enamel epithelium then consisted of an even layer of squamous-type epithelial cells, 5-6 cell- layers thick. This change had always taken place before the reduced enamel epithelium came into contact with the gingival cuff epithelium of the neighboring tooth The rate of replacement of ameloblasts appeared to vary considerably. Some un- erupted teeth found with reduced enamel epithelium consisting entirely of squamous cells extending right down to the cemento-enamel junction on one aspect of the tooth (e.g. the lingual) while shortened ameloblasts were present over the cervical the buccal) aspect of the same tooth. The replacement did not occur evenly and patches with recognizable ameloblasts were seen in the midst of areas of reduced enamel epithelium consisting en- were half of another (e. tirely of squamous-type cells. Serial sectioning showed that the epithe- lium lining the true col never contained recognizable ameloblasts and consisted only 230 MCHUGH Fig. 3. A mesio-distal section through the lower incisor teeth of a young adult monkey. The plane of section has passed buccal to the root of the incisor on the right. Where it has passed through the enamel at X, the epithelium has a ‘col Fig. 4. Diagrams showing now the plane of section will affect epithelium giving the appearance of a ‘col’. Plane 1 only passes through crovicular epithe- lium and the ‘col’ thus appears to have a thick lining with numerous rete pegs. In plane 2, the center of the section passes through the attached gingival cuff epithelium and the base of the ‘col’ then appears to consist of a thin even layer of epithelium, Note that these appearances can be produced by sections through a single standing tooth form. Haematoxylin and eosin. Orig. Magn. x 12. /\ (N Fig. 5. Diagrams illustrating how the appearance of the epithelium lining the interdental col (above) can be duplicated by fitting together sections through the middle of the buccal and lingual surfaces of the tooth (below) THE INTERDENTAL GINGIVAE 231 Fig. 6. A bucco-lingual section through the distal aspect of a lower second molar in a 3 /x-year-old monkey. A ‘col appearance has been produced by sectioning through enamel and some of the cementum (arrowed) fon the distal aspect of the crown of this tooth, This soction does not go through the true col. Haematoxylin and eosin, Orig. Magn. x 12 of squamous-type epithelial cells 5 or more cell-layers thick (Fig. 7). Bucco-lingual sec- tions mesial or distal to the middle of the col (and thus closer to the neck of a tooth) can, however, contain reduced enamel epi- thelium with recognizable ameloblasts. 2. CELL-TURNOVER Materi Four young rhesus monkeys (Macaca mu- latta) were used for this part of the study They were anesthetized with veterinary nembutal and given an intravenous injec- tion of tritiated thymidine at 1 ue per gram body weight. They were later sacrificed and blocks of one or two teeth and surrounding tissues carefully After fication and embedding, serial sections were cut bucco-lingually and every fifth section stained with routine histological stains. The remainder were de-paraffinized, coated with Kodak NTB 2 nuclear track liquid emulsion removed. decalci- by the dipping technic, exposed for six weeks at 4°C, developed, fixed, and lightly stained with hematoxylin. Sections were projected, tracings made and the epithelium divided into four zones as shown in Fig. 8. The radioautographs wi tritium-labelled cells identified by the pre- sence of eight or more silver grains in the emulsion overlying the nucleus. The length of the surface in each zone was measured e examined and with a planometer and the ratio of labelled cells per surface mm. calculated for each zone. While it is ea zones 1 and 2 (Fig. 8), there are difficulties in defining it in zones 3 and 4 where the epithelium is against the enamel. All the epithelium against the enamel zone 3 and zone 4) can be taken to constitute a “surface”, or it can be argued that some of the epithelium is “attached” to the enamel and does not, therefore, constitute a surface from which epithelial cells can be desqua- mated. In the latter case, all labelled cells y to define the surface in Fig. 7. A mesio-distal section through the middle of the interdental col between the lower first molar (on the left of the puctures) and the second premolar (on the right) which has recently erupted and is now in occlusion, In the higher magnification (b) which shows the tip of the interdental gingiva, the thin at- tached gingival cuff epithelium against the distal of the premolar can be seen. The gingival crevice is very shallow on this surface of the premolar in con- trast to the deeper crevice filled with leucocytes. etc. on the mesial of the molar. Note that this Interdental epithelium which lines the col consists entirely of squamous epithelium and contains no re- cognizable ameloblasts. Haematoxylin and eosin Orig. Magn. a) x 12. b) x 250. Fig. 8. A diagram showing the four zones into which epithelium was divided for analysis of the radioauto- graphs. Zones 1 and 2 are arbitrary divisions of tree and attached gingiva, zone 3 is crevicular epithelium and extends from the tip of the gingival crest to the base of the gingival crevice, and zone 4 is the at- tached gingival cuff epithelium apical to the base of the gingival crevice MCHUGH from zones 3 and 4 will be shed from the surface of the epithelium lining the gingival crevice and the appropriate ratio will be — all labelled cells in zones 3 and 4 to the surface of zone 3. Results Table I gives data analyzed on the basis of the four zones shown in Fig. 8, assuming that zone 4 constitutes a “surface’ Table | Zone 1 2 3 4 Labelled cells per surface mm 53 57 44 © 9 The results of the alternative method of analysis are shown in Table II. In this case, zones 1 and 2 are ed as before but zones 3 and 4 are treated as a single zone the “surface” of which is the surface of the crevicular epithelium only Table Il Labelled cells per surface mm Note that the type of analysis used for le 1 appears to indicate that the crev- icular epithelium (zone 3) has a lower in- cidence of labelled cells than the epithelium covering the oral aspect of the and 2), and that the epithelium (zone 4) has a The pro- gingivae (zones 1 ‘attached very low to the enamel incidence of labelled cells. method of analysis, duces results which are remarkably similar for the different zones (Table II). Examination of reduced enamel epithe- lium showed that it contained some labelled cells although these were few in number, In no case were any reduced ameloblasts other however, THE INTERDENTAL GINGIVAE seen to be labelled. The squamous-type epi- thelial cells lying next to the ameloblasts were occasionally labelled, and, when the ameloblasts had been replaced and the re- duced enamel epithelium consisted only of squamous-type cells, the number of labelled cells was slightly greater. As is apparent from Table I, however, the proportion of cells labelled in this epithelium (i.e. zone 4 in Fig. 8 and Table 1) was always con- siderably lower than in the other zones. 3. CLINICAL STUDIES Material Data from a clinical study where plaque and gingivitis were scored independently by two examiners was re-examined. The study and methods of examination have previ- ously been described in detail (Wilson and McHugh 1971). A total of 1,075 interdental spaces in 48 young adults were evaluated. Only spaces between teeth in proximal contact were in- cluded and interdental scores for plaque and gingivitis were compared with the corre- sponding buccal and lingual scores. Plaque was scored by the Plaque Index (PI 1) of Silness and Lée (1964) and gingivitis by both the Gingivitis Index (GI) of Lée and Silness (1963) and a Gingival Exudate In- dex (GEI) (Wilson and McHugh 1971). Results Of the 1,075 interdental spaces in these subjects, only five (i.e, 0.5 %) were scored as being free from plaque (PI I =0). In contrast, 808 (39%) of the 2,150 buccal and lingual surfaces of the same teeth were scored as being free from plaque. Since plaque scoring without the use of disclosing solutions is liable to greater error in the relatively inaccessible interproximal regions than on the buccal and lingual aspects of 233 the teeth, it is possible that the failure to detect plaque in the five interproximal re- gions was due to experimental error rather than the absence of plaque. Analysis of both clinical (GI) and exudate (GEI) indices of gingivitis showed that, in these subjects, gingivitis tended to be more common and more severe in the inter- proximal than on the buccal or lingual surfaces. As can be seen from Table II, proximal scores were more than twice as high as “free-surface” scores. Table Ill Mean gingival index (Gl) and gingival exudate (GEI) scores of different surfaces of 282 teeth Surfaces Gl Ge! Buccal and Lingual 0.62 10.82 Interproximal 1.38 247 Discussion This study has confirmed previous descrip- tions of the macroscopic morphology of the interdental region (Cohen 1959 and b, Kohl and Zander 1961, Holmes 1965). Where teeth are in proximal contact, the gingiva between is col-shaped with buccal and ling. ual peaks and a ridge between. Histologic sections giving the appearance of being through the col can, however, be artefacts resulting from the plane of section. Even mesio-distal sections through the buccal aspects of teeth can give this appearance (Fig. 3) Great care must, therefore, be taken to identify sections which are truly cut through the col before conclusions about its micro- scopic structure can be drawn. Careful analysis of serial sections cut both bucco-lingually and mesio-

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