GINGIVAL CREVICULAR

FLUID

S.LAKSHMI AJITHAN
3RD BDS
ROLL NO:44
CONTENTS
Introduction
Functions of Gingival Crevicular Fluid
Composition of Gingival Crevicular Fluid
Permeability of junctional and sulcular
epithelia
Methods of collection of Gingival
Crevicular Fluid
Amount of sulcular fluid
Cellular and Humoral activity in Gingival
Crevicular Fluid
Clinical significance
Periodontal therapy and Gingival Crevicular
Fluid
 GCF and preterm low birth weight infant
Drugs in Gingival Crevicular Fluid
Conclusion
Reference
INTRODUCTION
SYNONYM:
GINGIVAL SULCULAR FLUID

• DEFINITION:
GCF is a serum exudate that appears
in the gingival sulcus and that contains
molecular and cellular elements of
immune response.
GCF originates from the post capillary
venules of gingival plexus.
If can be represented as either a
transudate or an exudate.
In healthy sulcus the amount of the
gingival fluid is very small.
During inflammation however the
gingival fluid flow increases.
FUNCTIONS OF GCF
i)Cleanse material from the sulcus.

ii)Contain plasma proteins that may improve

adhesion of the epithelium to the tooth.

iii)Posses antimicrobial properties.

iv)Exert antibody activity to defend the

gingiva.
 COMPOSITION OF GCF

GCF

ENZYMATIC NON-ENZYMATIC COMPONENTS

COMPONENTS CELLULAR
ELEMENTS
HOST DERIVED BACTERIA ELCTROLYTE
AND DERIVED S
OTHER ORGANIC
PRODUCTS COMPOUNDS
CELLULAR ELEMENTS
Bacteria
Desquamated epithelial cells
Leukocytes
ELECTROLYTES
Sodium
Potassium
Calcium
ORGANIC COMPOUNDS
• Glucose hexosamine and hexuronic acid are
two of the compounds found in GCF.

• The total protein content of GCF is much less

than that of serum.

• Metabolic and bacterial products identified in

GCF include lactic acid, urea, hydroxyproline,
endotoxins, cytotoxic substances, hydrogen
sulfide and antibacterial factors
 HOST DERIVED ENZYMES AND
OTHER COMPOUNDS
Acid phosphatase
Alkaline phosphatase
Chondrotin Sulfatase
Citric acid
Cytokines
Endopeptidases
Fibrin
Fibronectin
Lactic acid
Lysozyme
 BACTERIA DERIVED ENZYMES
Acid phosphatase
Alkaline phosphatase
Amino peptidases
Chontroitin sulfate
Collagenase
Deoxyribonuclease
Fibrinolysin
Hemolysin
Beta-Lactamase
Phospholipase A,C
 PERMEABILITY OF JUNCTIONAL AND
SULCULAR EPITHELIA
The main route of gingival fluid diffusion is
through the basement membrane.

Substances shown to penetrate the sulcular

epithelium include albumin, endotoxin,
thymidine, histamine, phenytoin and horseradish
peroxidase.

Squier and Johnson reviewed the mechanisms of

penetration through an intact epithelium.
METHODS OF COLLECTION OF GCF

Absorbing paper strips

Twisted threads
Micropipettes
Intracrevicular washings
ABSORBING PAPER STRIPS
 ABSORBING PAPER STRIPS
The absorbing paper strips within the sulcus
(intrasulcular method) or at its entrance
(extrasulcular method)

The placement of the filter paper strip in

relation to sulcus or pocket is important.
The Brill technique inserts it into the pocket until
resistance is encountered.
Disadvantage:
This method produces some degree of irritation of
sulcular epithelium that by itself can trigger the flow
of fluid.
To minimize this irritation, Loe and HolmPedersen
placed the filter paper strip just at the entrance of
the pocket or ever the pocket entrance. In this way,
fluid seeping out is picked up by the strip just at the
entrance, but the sulcular epithelium is not in
contact with the paper.
PREWEIGHTED TWISTED THREADS
PREWEIGHTED TWISTED THREADS

It was used by Weinstein et al.

 The threads were placed in the gingival
crevice around the tooth and the amount
of fluid collected was estimated by
weighting the sample thread.
MICROPIPETTES
MICROPIPETTES
The use of micropipettes permits the
collection of fluid by capillarity.
 Capillary tubes of standardized length
and diameter are placed in the pocket, and
their content is later centrifuged and
analyzed.
CREVICULAR WASHINGS
Crevicular washings can be used to study
GCF from clinically normal gingiva.
 One method uses an appliance consisting of
hard acrylic plate covering the maxilla with
soft borders and a groove following the
gingival margins, it is connected to four
collection tubes.
The washings are obtained by rinsing the
crevicular areas from one side to the other,
using a peristaltic pump.
Advantages:-

Useful for longitudinal studies.

Permits collection without disturbing the inte
of marginal tissues.
Contamination is least.
Disadvantages:-

Complex procedure
Represents a dilution of crevicular fluid.

Problems during GCF collection:-

Contamination – Major sources of

contamination are blood, saliva or plaque.
Sampling time – Prolonged collection
time is likely to change the protein
concentration of initial GCF collected.
 AMOUNT OF SULCULAR FLIUD
The amount of GCF collected on a paper stripcan be evaluated in a
variety of ways.

The wetted area can be made more visible by staining with

ninhydrin; it is then measured plainimetrically on an enlarged
photograph or with a magnifying glass or a microscope.
An electronic method has been devised for measuring the fluid
collected on a “blottee” (periopaper) employing an electronic
transducer.
The wetness of paper strips affects the flow of an electronic
transducer.

The wetness of paper strips affects the flow of an electronic

current and gives a digital readout.
 PERIOTRON
An electronic method that has been devised
for measuring gingival fluid absorbed on paper
strips by Harco electronics called periotron.
(Dental product division Winnipeg, Manitoba,
Canada).
An electronic measuring device which
measures the affect on the electronic current
flow of wetted paper strip.
It has 2 metal jaws which acts as the plates of
an electrical condenser.
When a dry strip is placed zero reading is
obtained.
A wet paper strip will increase the capacitare in
proportion to the volume of fluid and this can be
measured as an increased value in the read out.
3 models: 600,6000 and 8000
Limitations:-
Inability to measure the volume of FCG greater
than 1.0 µl.
Translation of periotron values to clinical conditions
and Gingival Index with which they may be
associated.
Periotron Level of gingival
Gingival Index
reading inflammation

0-20 HEALTHY 0

21-40 MILD 1

41-80 MODERATE 2

81-200 SEVERE 3
 The components of GCF are analyzed with regard to
their potential utility in fulfilling the following aims.

AIM1: -
To detect a case of periodontitis ie. to distinguish
periodontitis from health and gingivitis.

AIM2: -
To classify a case of periodontitis ie chronic or
aggressive periodontitis.
AIM3 :-
To plan treatment for the patient on the basis of the
level of disease activity.

AIM 4: -
To monitor the treated patient based on level of
disease activity.

The amount of GCF collected is extremely small.

Measurements performed by Cimasone showed that a
strip of paper 1.5 mm wide and inserted mm within
the gingival sulcus of a slightly inflamed gingiva
absorbs about 0.1mg of GCF in 3 minutes.
 COMMERCIALLY AVAILABLE
DIAGNOSTIC KITS
Periocheck – Neutral Proteinases – Approved by
FDA
Periogard – AST
Prognostik Elastase – Not approved by FDA and
ADA
Biolise- Elatase –Not approved by FDA and ADA
Biolise – Elastase
Pocket Watch – AST
TOPAS Toxicity – Pre Screening Assay
MMP dipstick method.
 CELLULAR AND HUMORAL
ACTIVITY IN GCF
 Monitoring periodontal disease is a complicated task because very
few non invasive procedures can follow the initiation and progress
of the disease. Analysis of GCF constituents in health and disease
may be extremely useful because of GCF’s simplicity and because
GCF can be obtained with non invasive methods.
 Analysis of GCF has identified cell and humoral responses in both
healthy individuals and those with periodontal disease. The
cellular immune response includes the appearance of cytokines in
GCF.
 However,interleukin –alpha and IL- are known to increase the
binding to PMNs and monocytes/macrophages to endothelial cells
stimulate the production of PGE2and release of lysosomal enzymes
and stimulate bone resorption
 Preliminary evidence also indicates the presence of interferon -
in GCF which may have a protection role in periodontal disease .
Because the amount of fluid recoverable from
gingival crevices small, only the use of very
sensitive immunoassays permits the analysis of the
specificity of antibodies.
Role of antibodies in a patient with periodontal
disease.
1. A reduction in antibody response is detrimental.
2. An antibody response plays a protective role.
CLINICAL SIGNIFICANCE
GCF is an inflammatory exudate.
The amount of GCF is increased when
inflammation is present.
GCF production is not increased by trauma
from occlusion but is increased by mastication
of coarse foods, tooth brushing and gingival
massage, ovulation, hormonal contraceptives,
and smoking. Other factors that influence
amount of GCF are circadian periodicity and
periodontal therapy.
CICARDIAN PERIODICITY :-
There is a gradual increase in GCF amount
from 6AM to 10 PM and a decrease afterward.

SEX HORMONES: -
Female sex hormones increase GCF flow,
probably because they enhance vascular
permeability. Pregnancy, ovulation and
hormonal contraceptives all increase gingival
fluid production.
MECHANICAL STIMULATION: -
Chewing and vigorous gingival brushing stimulate
the flow of GCF. Even the minor stimuli
represented by intrasulcular placement of paper
strips increases the production of fluid.
SMOKING : -
Smoking produces an immediate transient but
marked increase in GCF flow.
PERIODONTAL THERAPY: -
There is an increase in GCF production during the
healing period after periodical surgery.
EFFECT ON GCF DURING GINGIVITIS: -

Exudation of GCF and proteins from the dentogingival plexus will increase
and this will make the tissue edematous and swollen. The presence in GCF
of antibodies to microbial products prevent progressing to clinical gingivitis.

In the initial lesion of gingivitis the flow of GCF

increases. Noxious substances released from the biofilm are diluted both
inside the gingival tissue and in the crevice. Furthermore, bacteria and there
products may be flushed away from the crevice regions and end up in the
saliva.

Plasma proteins are part of GCF and include defensive proteins such as
antibodies, complement and protease inhibitors, and other macromolecules
with numerous functions.

In the established lesion also the flow of GCF is increased.

ROLE OF GCF IN INNATE DEFENSE
SYSTEMS: -

Molecules present in the GCF include

complement which can kill bacteria
directly or together with antibodies and
can bring PMNs to the region and hereby
initiate and facilitate the process of
phagocytosis.
 PERIODONTAL THERAPY ANDGCF

There is an increase in gingival fluid production during

the healing period after the periodontal surgery.
According to Arnold et al 1966 this increase was
probably the result of the inflammatory reaction from
gingival trauma and the loss of an intact epithelial
barrier, especially considering the fact that fluid has been
collected by deep intracrevicular technique.

Suppipat et al in 1978 sampled gingival fluid 4, 2, 28
and 35 days after gingivectomy and found an increase in
gingival fluid flow during the first 2 weeks after surgery
followed by a gradual decrease. This decrease was same
when using mechanical or chemical plaque control.
GCF AND PRETERM LOW BIRTH
WEIGHT INFANT
Several systematic reviews indicate periodontal
disease may adversely effect pregnancy
outcomes.
The current opinion is that the correlation of
periodontal disease of PLBW births may occur
as a result of infection and is mediated indirectly,
principally by the translocation of bacterial
products such as endotoxin (lipopolysaccharide)
and the action of maternally produced
inflammatory mediators. Biologically active
molecules such as PGE2 and TNF – x which are
Raised to artificially high levels by the
infection process, which may foster
premature labor.
Gingival crevicular fluid (GCF) levels of
PGE2 were positively associated with intra
amniotic PGE2 levels suggesting that gram
negative periodontal infection may present a
systemic challenge sufficient to initiate the
onset of premature labor as a source of LPS
or through stimulation of secondary
inflammatory mediators such as PGE2 and
interleukin-1 beta.
Often bacher et al suggested a dose –
response relationship for increasing GCF
PGE2 as a marker of current periodontal
disease activity and decreasing birth weight
Four organisms associated with mature
plaque and progressing periodontitis.
T.forsythia, P.gingivalis denticola were
detected at higher levels in PLBW mothers
compared with normal birth weight controls.
HOST DEFENCE
Gingiva when exposed to oral environment
develops signs of inflammation. Histologic
studies have shown that the vascular
network in the gingiva is located very
superficially in relation to sulcular and
junctional epithelium and slightest irritation
to gingivial margin and cause increase in the
marginal capillary permeability. Mean GCF
volume in individuals with gingival index <
1 in proximal spaces of
Molars ranges from 0.3 to 1.56µ l and in
interior teeth, the volume ranges from 0.24
to 0.3 µl. It has been reported that the rate
of GCF is about 20 µl/hr. replacing the mean
pocket volume of 0.5 µl/hr replacing the
mean pocket volume of 0.5 µl 40 times/hr.
Waerhaug and Steen demonstrate that
introduction of pathogenic bacteria in
bacteria free gingival sulcus caused
epithelial necrosis
 and inflammation of connective tissue with
formation of exudate. However after 48 hours,
the inflammation subsided and gingival sulcus
returned to sterile condition. Thus it was
demonstrated that flow of GCF by itself is
capable of removing bacteria and small foreign
particles from gingival sulcus. Many of plaque
bacteria trigger the immune response and as a
result the GCF contains complement factors and
specific antibodies like IgG and IgM react with
bacteria and complement activation take place
by action of bacterial products such as
endotoxin bring about lysis of bacteria.
In addition to complement activation IgG
antibodies bind to bacterial cell wall and
initiative phagocytosis. Antibodies such as
IgA, IgM, IgM neutralize exotoxins of
plaque bacteria and thus prevent tissue
damage to some extent. IgA present in GCF
prevent bacterial adherence to oral tissue and
also prevent antigen penetration.

All these host defense mechanisms are in

action normally and periodontal health is
maintained.
 DRUGS IN GCF
Drugs that are excreted through the GCF may be used
advantageously in periodontal therapy. Bader and Goldhaber
demonstrated in dogs that tetracyclines and excreted through the
GCF, this finding triggered extensive research that showed a
concentration of tetracyclines in GCF compared with serum.
Metronidazole is another antibiotic that has been detected in
human GCF.
 Tetracyclines are effective in treating periodontal in the gingival
crevice is 2 to 10 times that in serum.
 This allows a high drug concentration to be delivered into
periodontal pockets. In addition, several studies have
demonstrated that tetracyclines at a low GCF concentration (2 to
4 g/ml) are very effective against many periodontal pathogens.
A single dose of metronidazole (250 mg orally)
appears in both serum and GCF in sufficient
quantities to inhibit a wide range of suspected
periodontal pathogens.
Erythromycin does not concentrate in GCF and it
is not effective against most putative periodontal
pathogens.
Stephen et al (980) measured the concentration
of ampicillin, cephalexin, tetracycline,
erythemycin, clindamycin and rifampicin in GCF
after a single dose administration. But the
concentration is always much lower than the
concentration found in the serum.
Arnold et al observed that 1 week after
gingivectomy there was a striking increase
in gingival fluid flow. This was probably
the result of the inflammatory reaction from
gingival trauma and of loss of an intact
epithelial barrier. With the restoration of
gingival integrity, a gradual drop influid
flow occurred and the flow rate reached a
minimal value 3 weeks after gingivectomy.
CONCLUSION
GCF is an inflammatory exudate present in
gingival sulcus.
The gingival fluid contain components of
connective tissue, epithelium, inflammatory cells,
serum and microbial flora in habiting the gingival
margin or the sulcus.
The gingival fluid contains a vast array of
biochemical factors, offering potential use as a
diagnostic or prognostic biomarker of the biologic
state of the periodontium in health and disease.
 REFERENCE
i) Carranza’s Clinical Periodontology 11th
edition.
ii)Clinical Perodontology and implant
Dentistry 5th edition – Jan Lindhe.