GINGIVAL CREVICULAR

FLUID

E. Ramnath
Lecturer
Dept of Periodontology
INTRODUCTION
￮ Gingival Crevicular Fluid is classical defense mechanism of gingiva.

￮ Anatomy of Gingival Crevice :

￮ Shows three types of epithelium
￮ ORAL / KERATINIZED EPITHELIUM
￮ SULCULAR EPITHELIUM
￮ JUNCTIONAL EPITHELIUM

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HISTORY

￮ The presence of GCF has been known since 19 th Century.

￮ Its role in oral defense , composition and mechanisms in defense are elucidated

by WAERHAUG, BRILL and KRASSE – 1950.

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

Loe & Holm -

Waerhaug Brill et al
Pederson
(1952) (1962)
(1965)

Gingival sulcus  Physiology & Indicator of

Periodontitis  Pocket Compostion periodontal disease

Egelberg Schroeder
Cimasoni
(1966) (1969),
(1969)
Listgarten
(1966)

Gingival vasculature & Dentogingival Presence of

Permeability structure proteins
 Brill confirmed the presence of GCF

“ in humans and considered as

“TRANSUDATE”.

Other investigators demonstrated that

GCF is an inflammatory
“EXUDATE”, not a continuous
transudate

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 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.

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FORMATION OF GCF

￮ BRILL & EGELBERG THEORY

￮ ALFANO HYPOTHESIS
￮ PASHLEY MODEL

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BRILL & EGELBERG
THEORY

INCREASE IN
PERMEABILITY SEEPAGE OF
OF BLOOD FLUIDS INTO
VESSELS SULCUS

FORMATION OF
GINGIVAL
CREVICULAR
FLUID
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ALFANO HYPOTHESIS (1974)
￮ Alfano (1974) 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 changes to become an inflammatory exudate.

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 PASHLEY MODEL
(1976)

PASSAGE OF FLUID PASSES INTO when capillary filtrate

INTERSTITIAL TISSUES exceeds that of
FLUID FROM lymphatic uptake, fluid
CAPILLARIES will accumulate as
edema and/or leave the
area as GCF

LYMPHATIC SYSTEM

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PERMEABILITY OF JUNCTIONAL AND
SULCULAR EPITHELIUM
Studies by Brill and Krasse:
Fluorescein, India ink and Saccharated iron oxide.
Substances shown to penetrate sulcular epithelium:
￮ Albumin
￮ Endotoxin
￮ Thymidine
￮ Histamine
￮ Phenytoin 1000 kD Molecular
Weight
￮ Horseradish peroxidase

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SQUIER & JOHNSON (1973)

Reviewed the mechanism of penetration through an intact epithelium.

Intercellular movement of molecules and ions along intercellular

spaces appears to be possible mechanism.

Substances taking this route do not traverse the cell membranes.

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According to SQUIER the degree of permeability of the oral mucosa

does not seem to depend upon 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.

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METHODS OF COLLECTION

• ABSORBING PAPER STRIPS

• TWISTED THREADS

• MICROPIPETTES

• INTRACREVICULAR WASHINGS
ABSORBING PAPER STRIPS

INTRASULCULAR METHOD – Strips placed within sulcus.

EXTRASULCULAR METHOD – Strips placed at the entrance
of the sulcus.

BRILL TECHNIQUE induced irritation and by itself triggers the oozing of

fluid.

LOE and HOLM – PEDERSEN  placed filter paper at the entrance of the
pocket or over the pocket entrance.

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TWISTED THREADS
Preweighed twisted threads were used by WEINSTEIN et al.

Threads placed in the gingival crevice around the tooth.

The amount of fluid collected was estimated by weighing the sample

thread.

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MICROPIPETTES / CAPILLARY TUBE
Micropipettes are placed into the sulcus and it permits the absorption
of fluid by capillarity.

Capillary tubes of standardized length and diameter are placed in the

pocket and their content is later centrifuged and analyzed.

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CREVICULAR WASHINGS

The Method Of Oppenheim:

This method uses an appliance consisting of a hard
acrylic plate covering the maxilla with soft borders and
a groove following the gingival margins, connected to
four collection tubes.
The washings are obtained by rinsing the crevicular
areas from one side to the other, using a peristaltic
pump.
The Method Of Skapski And Lehner:

This method uses two injection needles fitted one within the other such that

during sampling the inside, or ejection, needle is at the bottom of the pocket

and the outside, or collecting, one is at the gingival margin. The collection

needle is drained into a sample tube by continuous suction

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PROBLEMS DURING GCF COLLECTION
 Contamination: The major sources of contamination of GCF sample
would be blood, saliva, or plaque.

 Sampling time: The problem with prolonged collection times is that the
nature of the GCF sample collected is likely to change with the protein
concentration of the initial GCF collected.

 Volume determination

 Recovery from strips

 Data reporting: Constituents found within GCF samples have either been
reported as absolute amount (mg), concentrations (mg/ml)
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METHODS OF ESTIMATING THE VOLUME
COLLECTED

WAYS OF EVALUATION:

STAINING
ELECTRONIC METHOD
STAINING:

The wetted area can be made more visible by staining with NINHYDRIN;

Then measured planimetrically on an enlarged photograph or magnifying glass

or a Microscope.

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ELECTRONIC METHOD

Fluid is collected on a “Blotter” (Periopaper), employing an electronic transducer

(PERIOTRON).

The wetness of the paper strip affects the flow of an electronic current and gives a
digital read-out.

￮Limitation: inability to measure the volume of

GCF greater than 1.0µl.

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AMOUNT
CIMASONI  Paper strip of 1.5 mm wide inserted 1mm within gingival
sulcus of gingiva absorbs about 0.1 mg in 3minutes.

CHALLACOMBE  used isotope dilution method to measure the amount of

gingival fluid.

His study in human volunteers with a mean gingival index of less than 1
showed that mean crevicular fluid volume in proximal spaces from molar teeth
ranged from 0.43 to 1.56 μl.

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COMPOSITION
GCF

ENZYMATIC COMPONENTS NON ENZYMATIC COMPONENTS

HOST DERIVED BACTERIA DERIVED

HOST
DERIVED
AND
ANDOTHER
OTHER CELLULAR ELECTROLYTES ORGANIC
PRODUCTS
PRODUCTS COMPONENT
COMPONENTS
• Alpha 1 antitrypsin
• Arylsulphatase
• Aspartate aminotransfarase
• Chondroition sulphate
• Cystatins
• B-glucuronidase
• Cathepsin
• Matrix metalloproteins
• Elastase
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• Alkaline phosphatase
• Acid phosphatase
• Collagenase
• Hyaluronidase
• Phospholipse-A
• Phospholipase-C

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The cellular elements found in the gingival fluid include:
Bacteria,
Desquamated epithelial cells and
Leukocytes (PMN’s, lymphocytes and monocytes) which
migrate through the sulcular epithelium.

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Potassium, Sodium, calcium, magnesium and fluoride
have been studied in gingival fluid. Most studies have
shown a positive correlation of calcium and sodium
concentrations and the sodium to potassium ratio
with inflammation.

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 Carbohydrates, proteins and lipids have been
investigated. Glucose hexosamine and hexuronic acid
are two of the compounds found in gingival fluid.
Glucose concentration in gingival fluid is 3-4 times
greater than that in serum.

 This is interpreted not only as a result of metabolic

activity of adjacent tissues, but also as a function of
the local microbial flora.
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 Proteins Include: - -

Fibrinogen,
Ceruloplasmin,
Lipoprotein,
Transferrin,
Antitrypsin,
Macroglobulin.
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METABOLIC AND BACTERIAL PRODUCTS

Metabolic and bacterial products identified in gingival fluid

include:
• Lactic acid,
• urea,
• hydroxyproline,
• endotoxins,
• prostaglandins,
• Cytotoxic substances,
• hydrogen sulphide.

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 PGE2 was first identified in GCF by Goodson et al. in
1974.

 PGE2 is a product of the cyclooxygenase pathway.

Elevated levels of PGE2 in GCF were found in patients
with periodontitis compared to patients with
gingivitis. PGE2 levels were three times higher in
patients with juvenile periodontitis compared to adult
periodontitis. 36
CYTOKINES

Cytokines are potent local mediators of inflammation that are produced by variety of
cells. Cytokines that are present in GCF and have been investigated as potential
diagnostic makers for periodontal disease include:

 interleukin - 1β, 1a

 interleukin – 6,

 interleukin – 8 and

 tumor necrosis factor (TNF -Alpha).

 Both IL – 1 alpha and IL - 1 beta have pro-inflammatory effects and

depending on a variety of factors can stimulate either bone resorption or
formation. 37
CELLULAR AND HUMORAL ACTIVITY IN GCF

￮ As inflammation of the gingiva increases, the transudate changes to an inflammatory exudate

containing higher levels of serum-derived molecules,vascular derived cellular components of
inflammation, and locally derived molecules from the gingival tissues.

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 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.

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 COMMERCIALY AVAILABLE DIAGNOSTIC KIT
ASSAY KIT FUNCTION
Bacterial BANA for bacterial trypsin like proteases
enzymes & host periodontal
enzymes test
Periocheck Detects presence of neutral proteases i.e.
Collagenase
PerioScan Detects enzymatic activity of A.A,
T. forsythus, P. gingivalis
Immunological Evalusite antigens of A.A, P. intermedia, P
detection gingivalis using antibodies (ELISA)

Biochemical Periogard Detects the presence of AST

Identification Pocket watch Detects aspartate aminotransferase
through colorimetric detection
TOPAS Detects toxins derived from anaerobic
metabolism and measures GCF protein
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Circadian Periodicity:

There is a gradual increase in gingival

fluid amount from 6:00AM to 10:00PM and a
decrease afterward.
GCF and sex hormones
Clinical investigations have shown an exacerbation of
gingivitis during pregnancy (loe 1965) during the
menstrual cycle (------Lemann 1948) and at puberty
(Sutcliffe 1972). Female sex hormones increase the
gingival fluid flow, probably because they enhance
vascular permeability.
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 GCF and drugs

Drugs that are excreted through the gingival fluid may be used
advantageously in periodontal therapy. Bader and Goldhaber
were able to show that intravenously administered tetracycline
in dogs rapidly emerges within the sulcus.

 Stephen et al (1980) measured the conc. of ampicillin, cephalexin,

tetracycline erythemycin, clindamycin and rifampicin in serum,
saliva and GCF after a single and dose administration, 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).

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Influence of mechanical stimulation

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.

Influence of Smoking:

Smoking produces as immediate transient but marked

increase in the gingival fluid flow.

Mcluaghlin WS et al 1993

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 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.

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REFERENCES

￮ Textbook of Clinical Periodontology – CARRANZA 8th & 10tH edition.

￮ Textbook of Clinical Periodontology and Implant Dentistry – LINDHE 5th Edition.

￮ Veli-Jukka Uitto; Gingival crevice fluid – an introduction; Periodontology 2000, Vol.

31, 2003, 9–11.

￮ Gareth S. Griffiths; Formation, collection and significance of gingival crevice fluid;

Periodontology 2000, Vol. 31, 2003, 32–42.

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REFERENCES

￮ JEFFREY J. EBERSOLE; Humoral immune responses in gingival crevice fluid: local and

systemic implications; Periodontology 2000, Vol. 31, 2003, 135–166.

￮ Andrew J. Delima, Thomas E. Van Dyke; Origin and function of the cellular components

in gingival crevice fluid; Periodontology 2000, Vol. 31, 2003, 55–76.

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THANK YOU

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