Gingival crevicular fluid

2. GINGIVAL
CREVICULAR FLUID
Presented By:
Roopanshi Mehrotra
(PG II)

3. CONTENTS
• Introduction
• Historical Background
• GCF as transudate and exudate
• Formation of GCF
• Factors affecting flow of GCF
• Permeability of Junctional and sulcular epithelia
• Methods of collection.
• Methods of estimating the GCF volume collected
• Amount

4. • Problems with GCF collection and data interpretation
• Composition
• Methodology used to analyze GCF components
• Functions of GCF
• Clinical significance
• Drugs in Gingival Crevicular Fluid
• GCF as biomarker
• Conclusion
• References

5. INTRODUCTION

6. • The gingival sulcus is the shallow
crevice or space around the tooth
bounded by the surface of the tooth on
one side and the epithelium lining the
free margin of the gingiva on the
other side.
• Sulcular fluid, or gingival crevicular
fluid (GCF), contains an array of
biologic mediators, cells, and bacteria

7. Historical
Background

9. GCF- Transudate or
Exudate?

10. Transudate Exudate

11. • 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.
• This initial, pre-inflammatory fluid was considered to be a transudate,
and, on stimulation, this changed to become an inflammatory exudate

13. Formation of GCF

14. Alfano Model (1974)
Bacterial plaque
Accumulation of high molecular
weight molecules
Permeate the intercellular regions
of the epithelium
Osmotic gradient
Flow of interstitial fluid from the
connective tissue to the gingival
sulcus.

15. Pashley Model (1976)
When the rate of capillary filtrate exceeds that of
lymphatic uptake, fluid will accumulate as edema
and/or leave the area as GCF.
Capillaries Tissues
Lymphatic
system

16. Factors affecting flow of GCF:
Osmotic pressure
within the
different
compartments.
Filtration
coefficients of the
lymphatic and
capillary
endothelium

17. Permeability of
Junctional and
Sulcular Epithelia

18. • The initial studies by Brill and Krasse (1958) involving the use of
fluorescein were later conirmed with substances such as India ink and
saccharated iron oxide.
• Substances that have been shown to penetrate the sulcular epithelium
include:
Albumin
Endotoxin
Thymidine
Histamine
Phenytoin
Horseradish peroxidase.

19. • Squier and Johnson (1975) reviewed the mechanisms of penetration
through an intact epithelium. The intercellular movement of molecules
and ions along intercellular spaces appears to be a possible
mechanism.
• Substances that take this route do not traverse the cell membranes.

20. Methods of Collection

21. Absorbing paper strips
• Intra sulcular method:
The Brill (1958) technique involves
inserting it into the pocket until resistance
is encountered.
This method introduces a degree of
irritation of the sulcular epithelium that
can, by itself, trigger the flow of fluid

22. • Extrasulcular method:
Löe and Holm-Pedersen (1965) placed the
filter paper strip just at or over the pocket
entrance .
In this way, fluid that seeps out is picked up
by the strip, but the sulcular epithelium is not
in contact with the paper

23. Advantages
Quick and easy to use.
It can be applied to individual
sites.
Possibly, it is the least traumatic
method when correctly used
Disadvantages
The procedure delivers a level of
aggravation of the crevicular
epithelium that expands the
creation of gingival crevicular
liquid
GCF tests are typically debased
by blood, spit, or dental plaque
and their essence influences the
precision in volume assurance
and organization of GCF.

24. Preweighed twisted threads
(Weinstein and colleagues(1967) )
• Threads were set in the gingival hole
around the tooth
• The strings were weighed before
assortment inside a fixed micro
centrifugation plastic cylinder and
the weighing was rehashed following
the collection.

25. Micropipettes or capillary tubing method
(Krasse and Egelberg (1962) )
• Capillary tubes of standardized length and
diameter are placed in the pocket.
• Their contents are later centrifuged and
analyzed.

26. Advantages
Larger volume can be collected
It provides an undiluted sample
of native GCF whose volume can
be accurately assessed.
Disadvantages
Time consuming
It would also require more effort
from the clinician
Difficulty of removing complete
sample from the tubing

27. Gingival crevicular washings methods:
Oppenheim (1970)
Suggested the use of an appliance that consists of a hard acrylic plate
that covers the maxilla, with soft borders and a groove that follows the
gingival margins.
It is connected to four collection tubes.
Washings are obtained by rinsing the crevicular areas from one side to
the other with the use of a peristaltic pump

28. Skapski and Lehner (1976):
Suggested the use of two injection needles
that have been fitted one within the other.
During sampling, the inside (ejection) needle
is at the bottom of the pocket and the outside
(collecting) needle is at the gingival margin.
The collection needle is drained into a
sample tube via continuous suction.

29. 10μl of Hank's reasonable salt arrangement shot out into interdental
papilla from a miniaturized scale syringe and the arrangement is re-
suctioned once more.
Advantages
Qualitative appraisal
Valuable for gathering cells and microscopic organisms from the
gingival hole.
Disadvantages
GCF from singular destinations can't be examined.
High pace of blood sullying because of the expanded chance of
gingival aggravation.
Production of altered acrylic stents is confused and in fact requesting.

30. Curette collection method

31. Advantages
• Quick and simple to utilize
Disadvantages
• The measure of gathered liquid is
incredibly little. GCF tests are
generally defiled by blood, spit,
or dental plaque and their
essence influences the exactness
in volume assurance a structure
of GCF.

32. Methods of estimating
the GCF volume
collected

33. Staining of strips
• The wetted area can be made
more visible by staining with
Ninhydrin.
• It is then measured
planimetrically on an enlarged
photograph or with a magnifying
glass or a microscope.

34. Electronic method
• An electronic method has been devised
for measuring the fluid collected on a
“blotter” (Periopaper) with the use of
an electronic transducer (Periotron,
Harco Electronics, Winnipeg,
Manitoba, Canada).
• The wetness of the paper strip affects
the flow of an electric current and
provides a digital readout.

35. Three models of Periotron have been produced:-
600
6000
8000
Advantages
Rapid technique
Has no discernable effect on GCF sample

37. Weighting the strip
Pre-weighted strip is inserted into the gingival crevice & then
determined the amount of fluid collected by weighting the sample
Isotope dilution method
To measure extremely small amount of GCF present in a particular
space at any given time (Challacombe 1980)

38. Amount of GCF
collected

39. • The amount of GCF collected is extremely small.
• Measurements performed by Cimasoni (1983) showed that a strip of
paper 1.5-mm wide and inserted 1 mm within the gingival sulcus of a
slightly inflamed gingiva absorbs about 0.1 mg of GCF in 3 minutes
• Challacombe’s calculations for human volunteers with mean gingival
indices of less than 1 showed that the mean GCF volume in the
proximal spaces from the molar teeth ranged from 0.43 to 1.56 µL.

40. Problems with GCF
collection and data
interpretation:

42. Composition

43. Cellular elements
• Epithelial cells
• Leukocytes
• Bacteria
Electrolytes
• Potassium
• Sodium
• Calcium
Organic
compounds
• Carbohydrates
• Proteins
• Lipids
Metabolic and Bacterial
products
• Lactic acid
• Urea
• Hydroxyproline
• Endotoxins
• Cytotoxic substances
• Antibacterial factors

44. Enzymes
• Acid phosphatase
• Alkaline phosphatase
• α1-Antitrypsin
• Arylsulfatase
• Aspartate aminotransferase
• Chondroitin sulfatase
• Citric acid
• Cystatins
• Cytokines (interleukins)
• Endopeptidases
• Exopeptidases
• Fibrin
• Fibronectin
• β-Glucuronidase
• Glycosidases
• Hyaluronidase
• Immunoglobulins

45. Compounds and Enzymes (Products) of Possible Bacterial Origin
• Acid phosphatase
• Alkaline phosphatase
• Aminopeptidases
• Chondroitin sulfatase
• Chymotrypsin-like product
• Collagenase
• Deoxyribonuclease (DNase)
• Dipeptidylaminopeptidase IV–
like enzyme
• Phospholipase C
• Prostaglandin-like product
• Fibrinolysin
• Glucosidases
• Hemolysin
• Hyaluronidase
• Iminopeptidases
• Immunoglobulinases
• βLactamase
• Lysophospholipase
• Phospholipase A
• Trypsinlike enzyme

46. Bacteria Associated with GCF
Diagnostic tests based on the use of
GCF sample can also indicate the
presence of bacteria such as:
Porphyromonas gingivalis,
Actinobacillus
actinomycetemcomitans
Prevotella intermedia
Treponema denticola
Tannarella forsythensisi
Capnocytophaga spp

47. Methodology used to
analyze GCF
components

48. • metalloproteinases
Fluorometry
• enzyme levels and interleukin-1β (IL-1β)
Enzyme-Linked
Immunosorbent Assays
• cyclooxygenase derivatives and
procollagen III
Radioimmunoassays
• timidazole
High-pressure liquid
chromatography
• acute-phase proteins
Direct and indirect
immunodot tests

49. Functions of GCF

51. Clinical Significance

52. Circadian Periodicity
Gradual increase in the
amount of GCF from 6
a.m. to 10 p.m. and a
decrease thereafter.
(Bissada et al in 1967)
Daytime variations did not
have significant impact on
GCF volume (Suppipat et
al 1997, Denizer et al 2000)

53. Sex Hormones
Increase
GCF
production
Pregnancy (Loe
1965)
Menstrual cycle
(Lindhe and
Attstrom 1967)
Ovulation
(Liew V et al
1991)
Hormonal
contraceptives
(Lindhe et al in
1969)

54. Mechanical Stimulation
i) Chewing
ii) Vigorous gingival brushing
iii) Minor stimuli represented by
intrasulcular placement of paper strips
(Brill in 1959)
Increases
GCF
flow

55. Smoking
(McLaughlin WS 1993)
Immediate transient
but marked increase
in GCF flow
In the long term, a
decrease of salivary
and GCF flow

56. Periodontal Therapy
During the healing period after
periodontal surgery (Amold R et al
1966)

57. In diabetic patients
Ringelberg et al (1977)
Diabetic patients
Normal individuals

58. Drugs in Gingival Crevicular Fluid
• Drugs that are excreted through the GCF may be used advantageously
in periodontal therapy.
• Bader and Goldhaber (1966) demonstrated in dogs that tetracyclines
are excreted through the GCF.
• Azithromycin concentrations in GCF were higher and more sustained
than those in serum. (Pin-Chuang Lai et al (2011))

59. • Stephen et al (1980) measured the concentrations of ampicillin,
tetracycline, erythromycin and clindamycin in serum, saliva and
gingival fluid after a single oral dose administration.
• Eisenberg et al. (1991) detected metronidazole in GCF
• Gingival fluid antibiotic concentrations were equal to those found in
saliva
• They were, however, always much lower than the concentrations
found in serum

60. GCF as a biomarker

61. Biomarker???
A biomarker is defined as a “Parameter that is objectively measured and
evaluated as an indicator of normal biological or pathological processes, or
pharmacological responses to a therapeutic intervention” (NIH 1998).

62. The rationale behind the use of GCF as a
biomarker
Identify specific
periodontal diseases
Identify antibiotic
susceptibility of
infecting organisms
colonizing diseased
sites.
Predict disease activity

63. According to Armitage (2004), more than 65 GCF constituents have
been evaluated as potential diagnostic markers of periodontal diseases.
These components fall into 3 general categories:
Biomarkers
Host derived enzymes
and their inhibitors
Inflammatory mediators
and host response
modifiers
Byproduct of tissue
breakdown

64. • Aspartate
aminotransferase
• Alkaline phosphatase
• β-glucoronidase
• Elastase
• Cathepsin
• Trypsin like enzymes
• Glycosidase
• Collagenase
• MMP- 1,2,3,8,9,13
• TIMP 1
• Lactate dehydrogenase
• Creatinine Kinase
Host derived
enzymes and their
inhibitors
• Prostaglandin E2
• Interleukin – 1β,
1α,2,6,8
• Tumor necrosis
factor
• Acute phase
proteins
• Auto antibodies
• IgG, IgM, IgA
• Plaminogen
Activator
• CD14
Inflammatory
mediators and
host-response
modifiers
• Fibronectin
• Hydroxyproline
• Glycosaaminoglyc
ans
• Osteonectin
• Osteocalcin
• Pyridinoline cross
links
• Laminin
Byproducts of
tissue
breakdown

65. GCF Composition in Relation with
Systemic Diseases
Systemic conditions are associated with changes in the levels of certain
biomarkers that could be detected in GCF.
• Increase glucose in diabetic patient.
• Increase urea, alteration of protein in kidney disease.
• Increase lactic acid in liver disease.
• Increase calcium in hyperparathyroidism.
• Increase alkaline phosphatase in bone disease (Ricket's, Paget's
disease)

66. Advantages of collecting GCF as a
biomarker
noninvasive
site-specific about
teeth
comparatively easy
to perform
offers one of the most
accessible entrees of any
tissue in the body

67. Conclusion
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

68. References
• Newman Takei, Klokkevold, Carranza, Carranza’s clinical periodontology,
Elsevier publication 13th edition
• Newman Takei, Klokkevold, Carranza, Carranza’s clinical periodontology,
Elsevier publication 10th edition
• Griffiths. Formation, collection and significance of GCF.Periodontol2000; 2003:
volume 31,32-42.
• Gingival Crevicular Fluid Lecture: 12 Dr. Ali A Abdulkareem
• A comprehensive updated review on gingival crevicular fluid: characteristics,
collection and estimation Gajbhiye Pranali, Gholse Yogesh, Kasliwal Rahul,
Thakre Anup Priyadarshini Journal of Medical Pharmaceutical and Allied
Sciences, V 9-I 1, 901. March-April 2020, 2405-2411.

69. • Evaluation of Components of Gingival Crevicular Fluid as Diagnostic
Tests Ira B. Lamster: Annals of Periodontology; Vol. 2, No. 1, March
1997; 123-137.
• The Origin of Gingival Fluid Michael C. Alfano J. Theor. Biol. (1974)
47, 127-136.
• Pin-Chuang Lai, Weiting Ho, Nidhi Jain, John D.Walters J Periodontol
2011;82:1582-1586.
• Analysis of gingival crevice fluid and risk of progression of
periodontitis. Gary C Armitage. Periodontol2000; 2004: volume 34,
109-119.
• Analysis of Daytime Variations in Gingival Crevicular Fluid: A
Circadian Periodicity. Sevim Gunday, Ali Orkun Topcu, Esra Ercan,
and Nermin Yamalik. J Periodontol 2014; 85:47-56.