GINGIVAL CREVICULAR FLUID

1. GINGIVAL
CREVICULAR FLUID
Presenter – Dr. Rajat Singla

2. CONTENTS
• Introduction
• History
• GCF production
• Methods of collection
• Composition
• Clinical significance
• GCF as a biomarker
• Conclusion

3. INTRODUCTION
Gingival crevicular fluid (GCF) contains a rich array of
cellular and biochemical factors which have been shown to
indicate the metabolic status of the periodontium.
Such factors are
now finding value
as potential
diagnostic or
prognostic
markers of the
periodontium in
health and disease.

4. Studies on gingival crevicular fluid (GCF) extend over a
period of about 50 years.
The pioneer research of Waerhaug (1950) was focused
on the anatomy of the sulcus and its transformation into
a gingival pocket during the course of periodontitis.
Studies by Brill et al laid the foundation for
understanding the physiology of GCF formation and its
composition.
The studies of Löe et al helps to understand the use of
GCF as an indicator of periodontal disease.

5. DEFINITION
GCF is an exudate that
can be harvested from
the gingival crevice or
periodontal pocket using
either filter paper strips or
micropipettes.
Manson and Eley
GCF is a serum like
exudate that bathes the
gingival sulcus and
follows an osmotic
gradient within the local
tissues.
Per Axellson

6. In 1958, Niels Brill, a prosthodontist, and Bo Krasse, a
cardiologist, were examining the microflora of gingival
pockets in a dog.
Before the samples
were taken, gingiva
and teeth were
disinfected with an
iodine solution.
After intravenous
injection of a
fluorescein solution,
the occurrence of
fluorescein could be
recorded on filter
paper strips.
Thus, after stumbling
on the disappearance
of iodine from the
cervical areas of the
teeth, two non-
periodontologists
managed to
demonstrate why it
disappeared.
HISTORY

7. • The potential diagnostic importance of gingival fluid is
recognized for more than 60 years now.
• Serious investigation of the dynamics of GCF
production did not begin until the late 1950s with the
reports of Brill and co-workers.
• Egelberg (1966) continued to analyze GCF and focused
his studies on the dentogingival blood vessels and their
permeability as they relate to GCF flow.

8. HISTORICAL TIMELINE
REVIEWING THE STUDY OF GCF

9. • Presence and functions of
proteins and enzymes in GCF
were first explored by Sueda,
Bang and Cimasoni (1974, 1983).
• It was soon understood that
enzymes released from damaged
periodontal tissue possessed an
enormous potential for
periodontal diagnosis.
• In 1974, the first edition of the
monograph, The Crevicular Fluid
by Cimasoni was published which
was a shot in the arm for GCF
studies and research.

10. IS GCF A TRANSUDATE
OR AN INFLAMMATORY
EXUDATE?

11. MECHANISM OF
GINGIVAL FLUID
PRODUCTION
ALFANO
(1974)
PASHLEY
(1976)

12. Very early or pre-
inflammatory flow of gingival
fluid is osmotically mediated.
This osmotically modulated
fluid is a transudate.
Later, on stimulation, it may
progress to a secondary
inflammatory exudate.
Hypothesis of Alfano
(1974)

14. Thus, even in health, if
the osmotic pressure
of the sulcular
compartment exceeds
that of the tissue fluid,
possibly because of
accumulation of
plaque-derived
molecules, there will
be a net increase in
the flow of GCF.

15. Pashley’s Model (1976)
Based on STARLING HYPOTHESIS
governing fluid distribution across
capillaries.
The model proposed by Pashley, predicted
that GCF production is governed by-
CAPILLARY
FILTERATION
LYMPHATIC
UPTAKE

17. When the rate of
capillary filtrate
exceeds that of
lymphatic uptake,
fluid will accumulate
as edema and/or
leave the area as
GCF.
Both these are
goverened by the
following factors:-
Filteration coffiecient
of capillary and
lymphatic
endothelia.
Hydrostatic and
osmotic pressure of
the capillaries,
lymphatic and
interstitial fluid.

18. According to Alfano and Pashley, the initial fluid produced could
simply represent interstitial fluid which appears in the crevice as a
result of an osmotic gradient.
Whereas, the work of both Brill in 1962 and Egelberg in 1974
seemed to suggest that the production of GCF was primarily a
result of an inflammatory increase in the permeability of the
vessels underlying junctional and sulcular epithelium.
It was concluded that the initial, pre-inflammatory fluid was
considered to be a transudate, and, on stimulation and
inflammation, this changed to become an inflammatory exudate.
Bickel et al, 1985
TRANSUDATE OR EXUDATE?

19. Histamine
Mechanical
Stimuli & GCF
Factors affecting the Flow of GCF

20. According to Pashley 1976, GCF is
derived from plasma
and its rate of production depends on
regulation of gingival microcirculation.
GCF increases after administration of
histamine either intravenously (Brill 1959)
or topically (Egelberg 1966).
Effect of Histamine

21. GCF increases several days prior to detectable
clinical inflammation.
(Loe and Holm Pederson, 1965)
This supports that gingival fluid production
may initially be generated by an osmotic
gradient.
Pre-inflammatory Gingival
Fluid

22. Fluid collected from inflamed gingiva
contains same concentration of proteins as
that of serum.
(Bang and Cimasoni, 1971)
Concentration of proteins in fluid that is
collected in the absence of inflammation is
lower and similar to extracellular fluid.
Concentration of Proteins in
Gingival Fluid

23. Two independent phenomena
Fluid - Governed by
osmotic gradient
Kowashi, 1980
Cells - Chemotactic
factors
Golub, 1981
Passage of Fluid and PMNs in
the sulcus

24. Basal membrane is a major limiting barrier to
products diffusing from the connective tissue
into the sulcus or vice versa.
During inflammation, the membrane becomes
thinner - also disappears partially.
Takaraba 1974, Cergneux 1982
Inflammatory Changes of the
Basal Membrane

25. Loose organization of the junctional
epithelium,
Influences its coeffiecient of filteration
and
Explains the relative ease with which large
molecules and cells can permeate this
epithelial covering. (Pashley, 1976)
Morphology of the Junctional
Epithelium

26. Increased GCF
production
Mastication
Brill and Krasse,
1959
Tooth brushing
Brill, 1959
Mechanical Stimuli and
Gingival Fluid

27. METHODS OF GCF
COLLECTION

28. Several techniques
have been
employed for the
collection of GCF
and the technique
chosen will depend
upon the objectives
of the study as each
technique has
advantages and
disadvantages.
The techniques can
be divided into four
basic strategies,
subject to various
modifications in their
application by
different authors.

29. Absorbent
filter paper
strips
Capillary
tubing or
micropipettes
Gingival
washing
methods
Other
methods:-
Pre-weighed
twisted thread
Plastic
strips
Platinum
loops

30. Absorbent filter paper
strips

31. METHODS
INTRACREVICULAR
EXTRACREVICULAR

32. INTRASULCULAR METHOD
Brill in 1958

33. Modifications of Intracrevicular
Techniques:-
Strip is placed at the entrance of the crevice.
• Loe & Holm Pederson, 1965
Or just apical to the gingival margin.
• Stoller, 1990
It is inserted “until a frictional bind is felt.”
• Nowicki, 1981
Depth: 0.5 – 1mm in the sulcus.
• Egelberg & Attstrom, 1973

34. RUDIN (1970)
• Paper strips with a
notch at the tip.
• Tip of paper – at the
sulcus entrance
• Notch – used as a
safeguard against
deeper penetration
MANN (1963)
• Collection from a
limited area
• Assures that the
sample is
uncontaminated by
saliva.

35. EXTRASULCULAR METHOD
Loe and Holm-
Pedersen, 1965

36. Advantages:
Quick and
easy to
use.
It can be
applied to
individual
sites.
Possibly, it
is the least
traumatic
method
when
correctly
used.

37. Disadvantages:
The amount of fluid collected is extremely small.
Measurements performed have shown that a strip of
filter paper 1.5 mm wide, inserted 1mm within the
gingival crevice of slightly inflamed gingiva, absorbs
about 0.1 mg of fluid in 3 mins.
Rudin in 1970 and Mann in 1963
Contamination by saliva
Evaporation

38. Evaluation of the Amount of
Fluid Collected
1) Appreciation by Direct
Viewing/Staining:
- Strip can be directly viewed under a microscope.
OR
- Area of the wetted surface can be made visible
by staining with an alcoholic solution of ninhydrin.
GOLUB,1971; EGELBERG and ATTSTROM, 1973

39. The stained area can then be measured with:-
• An ordinary transparent ruler. (Egelberg in 1964)
• Sliding caliper. (Bjorn in 1965)
• Calibrated magnifying glass. (Oliver in 1969)
• Microscope with an eyepiece. (Wilson in 1971)
• A specially designed, inexpensive paper strip
viewer. (Wilson in 1978)

40. 2) Weighing the Strips
The time of collection was measured with a
chronometer & this enabled the investigator to
express the flow of fluid in mg/min.
Pre-weighed twisted
threads
• Weinstein, 1967
Weigh the sample (the
strips are weighed before
and immediately after
collection).
• Valazza, 1972

41. 3) Use of Periotron
The introduction of an electronic measuring device, the
Periotron by Harco Electronics, has allowed accurate
determination of the GCF volume.

42. Three models of Periotron have been produced:-
• 600
• 6000
• 8000
Each one is an
efficient means of
measuring the
volume of fluid
collected on filter
paper strips.

44. PerioPaper
Strips
Absorbs 0-1.2
microliters of fluid.
Box contains 24
sterilized packets.
Each packet contains
16 test strips.
Commercially
available:

45. PerioCol Paper
Strips
For collecting
larger volumes (0
- 2.0 micro-liters)
of GCF fluid.
Package contains
10 sterilized
strips.

46. Capillary tubing or
micropipettes

47. MICROPIPETTES
The use of micropipettes
allows the collection of
fluid by capillarity action.
Capillary tubes of
standardized length and
diameter are placed in the
pocket and their content is
later centrifuged and
analyzed.

48. Evaluation of the Amount of
Fluid Collected
Technique proposed by: Kaslick in 1968.
 Following the isolation and drying of a site, capillary tubes of
known internal diameter and length are inserted into the
entrance of the gingival crevice.
 GCF from the crevice migrates into the tube by capillary action.
 Since, the internal diameter of the capillary is known, the volume
of fluid collected can be determined accurately by measuring the
distance which the GCF has migrated.
Sueda T, Bang J, Cimasoni G. Collection of gingival fluid for quantitative
analysis. J Dent Res 1969: 48: 159

49. Technique by:
Sueda in 1969.
Micro-centrifugation
plastic tubes for its
recovery.
Their method
consisted of capillary
tubes – to collect
gingival fluid.
The glass tube capillaries have an internal diameter of 1.1 mm.
Contents are collected by centrifuging at 3000 rpm for 5 mins.
10 – 40 micro liters of fluid can be collected from upper anterior
teeth in 15 mins.

50. Advantages:
This technique appears
to be ideal as it
provides an undiluted
sample of ‘native’ GCF
whose volume can be
accurately assessed.
Larger volumes can be
collected.

51. Disadvantages:
Viscosity of the fluid makes aspiration through a
pipette very difficult.
Time consuming
Can be traumatic
Difficulty of removing the complete sample from the
tubing.

52. GINGIVAL WASHINGS
The gingival crevice is
washed with an
isotonic solution,
such as Hanks'
balanced salt solution
of fixed volume.
The fluid then
collected represents a
dilution of the
crevicular fluid.
It contains cells,
bacteria and plasma
proteins.

53. 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 Oppenheim (1970)

54. • 10 micro litres of Hanks’ balanced salt solution is ejected
and re-aspirated in the interdental gingival crevice area
12 times.
• This method uses two injection needles fitted one inside
the other.
• The inside (ejection) needle is at the bottom of the pocket
and the outside (collecting) one is at the gingival margin.
The method of Skapski and
Lehner (1976)

55. Advantages:
Qualitative assessment
Valuable for harvesting cells and bacteria
from the gingival crevice.

56. Disadvantages:
Complete fluid may not be recovered.
Thus accurate quantification of GCF volume
is not possible.

57. OTHER METHODS:
1) Use of plastic strips --- first proposed by Gins and Mattig in
1941.
• Transparent strips placed along the long axis of the tooth, either
over the gingival area or gently inserted into the gingival sulcus.
• Pressure is applied on the gingiva.
• After drying, the strips are stained, mounted in cedar oil and
observed under the microscope.
2) Use of platinum loops --- Crevicular fluid can also be
harvested by these loops, without provoking bleeding.

58. VOLUME OF
GINGIVAL FLUID
Molars = 0.43-
1.54 micro litres
Anteriors =
0.24-0.43 micro
litres
With crowns =
much higher
In humans with
mean gingival
index < 1

59. COMPOSITION OF GCF

61. Cellular
elements
Epithelial cells
Leukocytes
Bacteria
Erythrocytes

62. The oral sulcular epithelium and junctional
epithelium are constantly renewing and the shed
cells are found in the GCF.
Turnover rate -
* Oral sulcular epithelium: 10 –14 days
* Junctional epithelium: 4 – 6 days
Attström R. in 1975
Epithelial Cells

63. Exfoliated
cells of the
oral sulcular
epithelium
appear
extremely
flattened,
contains great
amount of
cytoplasmic
filaments,
shows
varying
stages of
disintegration.

64. At the sulcus bottom - cells are well
preserved, contains lysozome like bodies.
Coronal to the sulcus bottom - cells show
progressive necrosis.
• Lange and Schroeder in 1971
Two different types of cells originating from the
junctional epithelium can be seen depending on
their location:-

65. Inflammation of the marginal periodontium could
have an effect on both the rate of renewal and the
structural characteristics of the desquamating
epithelial cells.
A study by MARWAH et al (1960) showed marked
stimulation of cell division in the presence of
inflammation in the connective tissue.
Fluid originating from severe gingivitis cases ---
higher proportion of cells.
KREKELER G AND OCHS G. (1977)

66. In 1960, Sharry & Krasse determined that 47% of all cells
obtained from the gingival sulcus were leukocytes.
Leukocytes
Attström in 1970, was one of the first to
study the numbers of leukocytic cells
95–97%
neutrophils
1–2%
lymphocytes
2–3%
monocytes
differential
count

67. A subsequent study by Wilton et al. in 1976
established that of the 8.8% of total mononuclear
cells found,
24% were T
lymphocytes, and
58% were B
lymphocytes.
18% were
macrophages;
These authors also demonstrated that the mean
T-cell to B-cell ratio of 1: 2.7

68. Certain groups of bacteria, mostly gram-
negative bacteria, have been consistently
found in the destructive lesions of
periodontal disease.
Bacterial Cells:

69. Electrolytes
Sodium
concentration
Potassium
concentration
Sodium :
Potassium
Ratio
Fluorides in
gingival fluid
Concentration
of other ions

70. Variable results have been reported on the
concentration of ions in gingival fluid.
A partial explanation for these conflicting
results is the loss of water that occurs
through evaporation during collection.
HATTINGH & HO 1980, WHITFORD 1981
ELECTROLYTES

71. The first quantitative study has been performed by
Matsue in 1967.
Healthy gingiva: 158 mEq of sodium/L.
Inflamed gingiva: 207 - 222 mEq of sodium/L.
The crevicular fluid contains a significantly higher
amount of sodium than serum. Sodium
concentration tends to increase in cases of more
severe inflammation.
Sodium Concentration

72. Potassium Concentration
Matsue in 1967
Values as high as 69 mEq/L have been
reported.
Potassium concentration in gingival exudate is
higher than that in serum.

73. Kaslick in 1970 presented
that:-
Sodium and potassium
contents follow a circadian
periodicity,
Sodium concentration is
lower at noon than in the
morning, and
Potassium values are higher
towards the middle of the
day.

74. Sodium:Potassium Ratio
If the fluid passes through intact tissue, it should contain the
same proportion of sodium and potassium as plasma and
extracellular fluid.
If the fluid passes through damaged tissue, a decreased sodium
: potassium ratio would be found because of the accumulation
of intracellular potassium from the disrupted cells.
The results of Krasse and Egelberg in 1962 showed a sodium:
potassium ratio of 3.9:1 in gingival fluid, which is much lower
than the ratio of 28:1 normally found in extracellular fluid.

75. Flouride
• Source of flouride to cervical region of the teeth
- GINGIVAL SULCUS
(WEATHERELL 1977)
• Concentration of flouride in GCF similar to
plasma.
(WHITFORD 1981)

76. Other
ions:
CALCIUM
Normal - 10
mEq/L
Inflammed - 15.9
mEq/L
(Kaslick)
MAGNESIUM
0.8 mEq/L
ORGANIC
PHOSPHATE
4.2 mg/100ml

77. Organic
compounds
Carbohydrates
ProteinsLipids

78. Quantitative investigation on glucose, hexosamine and
hexuronic acid.
In inflammed gingiva - glucose is 3 - 6 times more than
serum.
Glucose decreased in non - inflammed gingiva.
No variation in hexosamine and hexuronic acid.
Carbohydrates
Hara K, Loe H. Carbohydrate component of gingival exudate.
J Periodont Res 1969:4;202-07

79. Sulfate glycosaminoglycans can be monitored in gcf at
healing sites.
Yan
2000

80. Proteins
In healthy gingiva, Brill and Bronnestam [1960] found a
concentration of proteins as low as 1:10 of that of serum.
Total protein concentration was determined in 20 samples of
gingival fluid from 20 individual patients showing varying degrees of
gingivitis and periodontitis.
The average fluid protein concentration was 6.83 g/100 ml.
[Bang and Cimasoni, 1971]

81. Identification of Proteins in
Gingival Fluid
Histochemically, it was determined that crevicular
exudate contains proteins similar to those found
in serum.
[Sueda et al, 1966]

82. Metabolic and
Bacterial Products:
Lactic acid
Hydroxyproline
Prostaglandins
Urea and pH
of Gingival
Fluid
Endotoxin

83. Lactic Acid
Its concentration in GCF was reported to
be positively correlated with
clinical degree of
gingival
inflammation
intensity of gingival
fluid flow.
(Hasegawa in 1967)

84. Since hydroxyproline is the major breakdown
product of collagen, Hara and Takahashi in
1975 compared its concentration in samples
of serum and GCF before and after various
types of periodontal surgery.
In both medium, the hydroxyproline
concentration increased for 1 month after
surgery and returned to baseline levels after
6 months.
Hydroxyproline

85. PGE-2 causes vasodilatation, bone resorption
and inhibition of collagen synthesis.
Used as a screening test for periodontal disease
activity.
Inflamed gingiva were shown to contain more
PGE-2 than healthy gingiva (El Attar in 1976).
Prostaglandins

86. A study conducted on Gingival cervicular fluid interleukin-1b,
prostaglandin E2 and periodontal status in a community population
RESULTS
Both GCF IL-1b and PGE2 were positively
related to MaxPD and BOP
Higher levels of GCF IL-1b and PG2 were
significantly associated with clinical signs
of periodontal disease
Zhong Y. Slade GD. Beck JD, Offenbacher S.J Clin Periodontol
2007; 34: 285- 293

87. Biswas in 1977 confirmed that urea concentration in
crevicular fluid seems to decrease when gingival
inflammation increases.
Urea could be responsible for the elevation of pH of gingival
sulcus, through the production of ammonia by
microorganisms.
(Klienberg and Hall in 1969)
Stephen in 1980 reported a pH range from 7.5 - 8.0 of
gingival fluid.
Urea and pH of Gingival Fluid

88. Lipopolysaccharides of gram negative bacteria
are released from autolyzing bacterial cells.
Gram negative flora
Endotoxin production
Parallels increase in
gingival inflammation
SIMON et al, 1971
Endotoxin

89. CYTOTOXIC SUBSTANCES
Present in GCF. COBB & BROWN ,1967
Hydrogen sulfide present in the sulcus
– a toxic metabolite of bacterial origin
RIZZO, 1967

90. Enzymes
Enzymes play an
important role in
pathogenesis of
gingivitis and
periodontitis.
Since the initial
observation of
Gustafsson and
Nilsson in 1961 on
the presence of
fibrinolytic activity
in gingival exudate,
several enzymes
have been studied.

91. Used as a lysosomal marker.
Associated with connective tissue catabolism.
Gingival fluid contains 10-20 times more acid
phosphatase than serum. (Sueda et al in 1967).
The main mammalian source of acid phosphatase in
crevicular area --- the PMNs and the desquamating
epithelial cells. (Sueda and Cimasoni in 1968)
Acid Phosphatase

92. It probably plays a role in calcification.
GCF contains twice as much as this enzyme in
serum.
The concentration of this enzyme in GCF was
found to be significantly correlated with pocket
depth.
(Ishikawa and Cimasoni in 1970)
Gibert in 2003 predicted alkaline phosphatase (ALP) as an
indicator for the future periodontal breakdown
Alkaline Phosphatase

93. • The decrease in GCF ALP activity at 15 days
corresponded to a decrease in clinical signs of
inflammation; in contrast, the increase in GCF ALP
activity at 60 days seemed to be related to subclinical
recurrent inflammation or further healing/remodeling of
the periodontal tissue. Therefore GCF ALP reflects the
short-term periodontal healing/recurrent inflammation
phases in chronic periodontitis patients. Perinetti etal
2008
• The presence of ALP in GCF is not simply a reflection of
the local inflammation state and that a patient’s estrogen
status may possibly influence local ALP levels in GCF.
Ozlem Daltaban etal 2006.

94. This enzyme could play a role in calculus
formation by controlling the concentration
of pyrophosphate, a known inhibitor of
calcification.
(Fleisch in 1964)
Pyrophosphatase

95. β- glucoronidase
This enzyme concentration is found to be positively
correlated with the mean percentage of bone loss.
Frequently used as a GCF marker of active periodontal lesion
Correlates significantly with attachment loss that may subsequently
occur in individuals with adult periodontitis.
Lamster IB, Oshrain RL, Celenti R, Levine K, Fine
JB. J
Clin Periodontol.1991
In gingival inflammation, its concentration in GCF is 10 times
higher than in serum.
Bang et al, 1970

96. • It contributes to the formation of pocket
by its detrimental effect upon epithelial
cells.
• No direct evidence that lysozyme is a
marker of disease activity.
Lysozyme

97. Two forms
Lysosomal Testicular
Hyaluronidase

98. Proteolytic Enzymes
Proteinases -- have a major
role in the destruction of
tissue components during
inflammation.
[Barrett, 1977; Havemann
and Janoff, 1978].

99. Cathepsin-D
It is one of the chief acid enzymes in
lysosomes, present at high concentration in
inflamed tissues.
Its concentration was found to be 10 times
higher in crevicular fluid than in serum and
this concentration was positively correlated
with periodontal destruction.
[Ishikawa and Cimasoni, 1977; Cimasoni et al,
1977]

100. Elastase
It is active upon elastin, hemoglobin, fibrinogen and collagen.
[Cimasoni and Kowashi, 1980]
Amounts of GCF elastase are greater in periodontitis patients than
healthy controls.
Ohlsson K, Olsson I, Tynelius- Bratthall G. Acta OdontolScand.1973
The concentration of free elastase rose significantly
during the no-brushing period and returned to baseline
levels after tooth brushing was resumed.
[Kowashi et al, 1979]

101. Cathepsin G
Cathepsin G is contained in the azurophil
granules of human PMNs.
[Barrett, 1977]
The enzyme has been shown to hydrolyze
hemoglobin, fibrinogen and collagen.
[Starkey, 1977]

102. Plasminogen Activators
Hidaka et al [1981] found that the
concentration of plasminogen activators in
human gingival fluid seems to increase as a
function of the severity of periodontitis.

103. Collagenase
It increases with the severity of the disease.
• Sueda et al., 1967, Robertson et al 1973;
Golub et al, 1979.
Higher concentration of collagenase from
crevicular fluid of chronically inflamed gingiva
was reported.
• Ohlsson et al 1973

104. Matrix metalloproteinases
collagenase-3 (MMP-13), rather than
collagenase-2 (MMP-8) secreted by
neutrophils, is a significant enzyme because it
appears to be released from fibroblasts and
pocket epithelial cells during tissue
destruction.
Golub LM, Lee HM, Greenwald RA, Ryan ME,
Sorsa T, Salo T, Giannobile WV. In 1997

105. Several other enzymes have been tested for
their potential to indicate periodontal disease
processes.
Amongst them, the best studied are neutrophil
elastase and beta-glucuronidase that are
neutrophil-specific granule enzymes involved
in tissue destruction during inflammation.
(Lamster IB. in
1997).

106. Lactate Dehydrogenase
• Catalyses the reversible reduction of pyruvate to
lactate.
• GCF contains 10-20 times more LDH than blood.
• No significant correlation is found between the
levels of LDH in gingival fluid and disease
severity.
Leng A. J Dent Med.1948;3(1):3-5

107. CLINICAL
SIGNIFICANCE

108. General health and gingival fluid
• Circadian Periodicity
• Gingival Fluid Flow and Sex Hormones
• Gingival Fluid in Diabetic Patients
• Drugs in Gingival Fluid
• Influence of Mechanical Stimuli
• Periodontal Therapy and Crevicular Fluid

109. Circadian Periodicity
Conflicting results have been reported
concerning the possibility of a circadian
pattern in the flow of crevicular fluid.

110. One group of investigators found that the
average flow was greater in the evening
and minimal early in the morning.
• (Bissada et al in 1967)
According to them there is gradual
increase in GCF amount from 6 AM to 10
PM and decrease afterword.

111. A second group did not find any systemic
differences between the flow of the fluid
measured at 9 a.m. and that of the fluid collected
at 3 p.m. .
• (Suppipat et al in 1977)
Daytime variations did not have significant
impact on GCF volume and the sampling
methodology had no apparent impact on the
circadian periodicity of GCF. Sevim
Gunday, J Periodontol 2014

112. Gingival Fluid flow and Sex
Hormones
During pregnancy (Loe in 1965), menstrual cycle
(Muhlemann in 1948) and at puberty (Sutcliffe in
1972), there is an exacerbation of gingivitis and
therefore, increased levels of GCF is seen.
According to Lindhe et al in 1969, female sex
hormones cause an increase in gingival vascular
permeability.

113. According to Ringelberg et al in 1977, higher flow
rate of gingival fluid in diabetic patients were
reported when compared to the flow rate of
healthy patients.
Investigators agree that the exudates collected
from diabetic patients contain significantly more
glucose than the exudates collected from healthy
individuals.
Gingival Fluid in Diabetic
Patients

114. Drugs in Gingival Fluid
Since gingival fluid seems to be a
characteristic feature of gingival
inflammation, one could reasonably expect
that suitable drugs could be given to a
patient and carried from the general
circulation to the gingival sulcus or pocket
by the flow of gingival fluid.

115. Stephen et al in 1980, measured the concentrations of
ampicillin, tetracycline, erythromycin and clindamycin in
serum, saliva and gingival fluid after a single oral dose
administration.
Gingival fluid antibiotic concentrations were equal to
those found in saliva.
They were, however, always much lower than the
concentrations found in serum.

116. Azithromycin concentrations in GCF were higher
and more sustained than those in serum. Based on
previous studies, the levels observed in GCF were
above the minimal inhibitory concentration for
Aggregatibacter actinomycetemcomitans ,
Porphyromonas gingivalis, and Prevotella
intermedia.
Pin-Chuang Lai, Weiting Ho, Nidhi Jain,John D.Walters
J Periodontol 2011;82:1582-1586
Azithromycin concentrations are similar in GCF from
gingivitis sites and healthy sites, suggesting that the
processes that regulate GCF azithromycin
concentration can compensate for local inflammatory
changes.
Nidhi Jain,Pin-Chuang Lai,John D. Walters
J Periodontol 2012;83:1122-1128.

117. The effect of chewing was
investigated by Brill in
1959 in a group showing
clinically healthy gingival
margins.
The amount of
gingival fluid was
shown to increase
significantly under
the influence of
chewing.
Fry in 1978, reported
that supervised
brushing for 40 days in
human volunteers had
an increased effect on
the production of
gingival fluid.
Influence of Mechanical
Stimuli

118. The effect of repeated prophylaxis on plaque
accumulation and gingival fluid flow were
studied by Gwinnett et al in 1978.
They found that the fluid flow decreased 1 week
after the first prophylaxis and then slowly
returned to pre-treatment values.
After a second prophylaxis the lower levels of
fluid were sustained for longer periods of time.
Periodontal Therapy and
Crevicular Fluid

119. Scaling and curettage caused
a decrease of gingival fluid
collection to a minimum at 14
days after treatment.
The values of gingival fluid
flow recorded at day 25
tended to increase but were
still much lower than those
recorded before treatment
(Suppipat et al in 1977)

120. GCF AS A BIOMARKER

121. Researchers created biomarkers
that indicated the presence or
absence of periodontal pathogens,
gingival and periodontal
inflammation, the host
inflammatory-immune response to
certain pathogenic species, and
host tissue destruction.

122. The rationale behind the use of GCF as a
biomarker is to:
1. Identify specific periodontal diseases,
2. Identify antibiotic susceptibility of infecting organisms colonizing
diseased sites.
3. Predict disease activity

123. There are 4 potential sources to obtain the biomarkers:-
• Blood or serum
• Saliva
• Subgingival plaque sample
• Gingival crevicular fluid (GCF)
Collecting GCF has its own advantages:
• GCF can be collected from individual desired sites.
• It gives information on local site activity.

124. 1. Host derived enzymes
• Aspartate aminotransferase
• Alkaline phosphatase
• B-glucoronidase
• Elastase
• Cathepsin
2. Tissue breakdown products
• Lactate dehydrogenase
• Fibronectin
• Hydroxyproline
3. Inflammatory mediators
• Prostaglandin E2
• Interleukin - 1ß
• Tumor necrosis factor
Biochemical Markers in GCF

126. CONCLUSION

127. The origin, the composition and the clinical
significance of GCF have significantly helped
our understanding of the pathogenesis of
periodontal diseases.
Through the biomarker discovery process,
new therapeutics have been designed linking
therapeutic and diagnostic approaches
together leading to more individualized and
targeted treatments for oral health.

128. REFERENCES
• Clinical periodontology , Carranza 10th edition
• Atlas of cosmetic & reconstructive periodontal surgery , Cohen
• Crevicular fluid, Cimasoni
• History of periodontology, Fermin Carranza, Gerald Shklar
• Ira B Lamster. Evaluation of components of Gingival Crevicular Fluid.
Annals of Periodontology. Vol 2, No 1, 1997
• Zia A, Khan S, Bey A, Gupta ND. Oral Biomarkers in the diagnosis and
progression of periodontal diseases.Biology and Medicine 2011Vol3 ,45-52
• Gary Armitage. Analysis of gingival crevicular fluid and risk of progression
of periodontitis. Periodontology 2000. Vol 34,109-119 2004
• Mario Taba, Janet Kinney, Amy s William V. Diagnostic biomarkers for oral
and periodontal diseases. Dent Clin North Am 2005;49(3):551