Gingival crevicular fluid


Published on

Published in: Technology, Business
1 Comment
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Gingival crevicular fluid

  1. 1.  Introduction Transduate /Exudate Gingival vasculature and crevicular fluid Permeability of junctional and oral sulcular epithelium Methods of collectionSaturday, August 11, gingival crevicular fluid 12012
  2. 2.  GCF fluid flow Composition of GCF Biochemical markers of the progression of periodontitis Clinical significance ConclusionSaturday, August 11, gingival crevicular fluid 22012
  3. 3.  The gingival sulcusis the shallow crevice orspace around the tooth ,bounded by the surfaceof the tooth on one side andthe epithelial lining thefree margin of thegingiva on the other.Saturday, August 11, gingival crevicular fluid 32012
  4. 4. • It is V Shaped. The depth as determined with histological sections is 1.8mm.• The so-called probing depth of a clinically normal gingival sulcus is 2 to 3 mm• Sections show presence of three types of epithelium, 1. the oral or keratinized epithelium covering the gingival connective tissue in continuation with 2. the sulcular epithelium ,which is not keratinized. It forms the soft tissue wall of the gingival sulcus and the 3. junctional epithelium is in continuation with the oral and sulcular epithelium. It is formed by few strata of cells, with long flat basal layer and a very small desquamating surface that forms the base of the gingival sulcus. Saturday, August 11, gingival crevicular fluid 4 2012
  5. 5.  Studies on gingival crevice 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. ----- use of GCF as an indicator of periodontal diseases.Saturday, August 11, gingival crevicular fluid 52012
  6. 6.  Egelberg continued to analyze GCF and focused his studies on the dentogingival blood vessels and their permeability as they relate to GCF flow.  Attstrom R, Egelberg J. presence of leukocytes in gingival crevice during developing gingivitis in dogs. JPR 1971 : 6; 110 -114. The GCF studies boomed in the 1970s. The rationale for understanding dentogingival structure and physiology was created by the outstanding electron microscopic studies of Schroeder and Listgarten.Saturday, August 11, gingival crevicular fluid 62012
  7. 7.  Presence and functions of proteins – Sueda, Bang and Cimasoni. Collagenases and Elastase in GCF are derived from human cells - Ohlsson, Golub, Uitto. Flow rate of GCF may increase about 30 times in periodontitis patients than compared to healthy sites. Resting volume also increases with the formation of pockets. Goodson thoroughly studied major issues in GCF flow rate and its method of collection.Saturday, August 11, gingival crevicular fluid 72012
  8. 8.  In 1974 the first edition of the monograph The Crevicular Fluid by Cimasoni was published. This comprehensive review gave a big boost to GCF studies and towards the end of the first millennium the research on GCF increased dramatically.Saturday, August 11, gingival crevicular fluid 82012
  9. 9. Saturday, August gingival crevicular fluid 911, 2012
  10. 10. Is GCF a Transduate ofinterstitial fluid?  From the work of Alfano (1974) and from the hypothesis postulated by Pashley (1976) which 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 changed to become an inflammatory exudate Saturday, August 11, gingival crevicular fluid 10 2012
  11. 11.  The first studies by Alfano (1974) suggested that, at a clinically healthy gingival crevice, bacterial plaque would result in the accumulation of high molecular weight molecules. These would permeate the intercellular regions of the epithelium, but would then be limited by the basement membrane. This hypothesis was supported experimentally, by the application of phosphate-buffered saline containing 10 mg/ml of homologous serum albumin which resulted in a 100% increase in the volume of GCF produced. In contrast, the application of phosphate-buffered saline alone did not enhance the volume of GCF produced.Saturday, August 11, gingival crevicular fluid 112012
  12. 12.  The model proposed by Pashley (Fig. 1)predicted that GCF production is governedby the passage of fluid from capillaries intothe tissues (capillary filtrate) and the removalof this fluid by the lymphatic system(lymphatic uptake). When the rate ofcapillary filtrate exceeds that of lymphaticuptake, fluid will accumulate as edemaand/or leave the area as GCF Saturday, August 11, gingival crevicular fluid 12 2012
  13. 13.  Factors modulating:  Filtration coefficient of the lymphatic and capillary endothelium  Osmotic pressure within the different compartments. Therefore, even in health also, if the osmotic pressure of the sulcular fluid exceeds that of the tissue fluid, (possibly because of accumulation of plaque derived molecules) there will be net increase in the flow of GCF.Saturday, August 11, gingival crevicular fluid 132012
  14. 14.  Brill in 1959 demonstrated that increased vascular permeability plays an important role in the production of gingival fluid Egelberg in 1966, in a first experiment obtained an increased permeability of the blood vessels of healthy gingiva by the use of three different methods:  topical application of histamine,  gentle massage of the gingival by means of a ball-ended amalgam plugger  scraping of the gingiva crevice by means of a blunted dental explorerSaturday, August 11, gingival crevicular fluid 142012
  15. 15.  The capacity of the dentogingival vasculature to respond with increased permeability and phagocytosis following trauma was further investigated by Soderholm and Attstrom in 1977 Ranney and Montgomery in 1973 applied Endotoxins to the gingival margin in dogs and demonstrated an abnormal permeability of the dentogingival vessels. Hellden and Lindhe in 1973 and Kahnberg et al in 1977 applied a plaque extract to the marginal gingiva of dogs with healthy gingiva and also observed an abnormal permeability of the dentogingival vessels as well as increased flow of gingival fluid.Saturday, August 11, gingival crevicular fluid 152012
  16. 16.  A fluid occurring in minute amounts in the gingival crevice, believed by some authorities to be an inflammatory exudate and by others to cleanse material from the crevice, containing sticky plasma proteins which improve adhesions of the epithelial attachment, have antimicrobial properties, and exert antibody activity. (From Jablonski, Illustrated Dictionary of Dentistry, 1982Saturday, August 11, gingival crevicular fluid 162012
  17. 17.  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.Saturday, August 11, gingival crevicular fluid 172012
  18. 18.  Substances that have been shown to penetrate the sulcular epithelium include albumin, Endotoxins, thymidine, histamine, phenytoin, peroxidase. The main pathway for the transport of substances across the junctional and sulcular epithelia seems to be the intercellular spaces which according to Schroeder and Munzel – Pedrazzoli (1970) form 18% of the total volume of the junctional epithelium and 12% that of the oral sulcular epithelium.Saturday, August 11, gingival crevicular fluid 182012
  19. 19.  According to Squier (1973) the degree of permeability of the oral mucosa does not seem to depend upon its degree of Keratinization. The mechanisms of penetration through an intact epithelium were reviewed by Squier and Johnson. 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:Saturday, August 11, gingival crevicular fluid 192012
  20. 20.  In a series of experiments, Brill verified the assumption that Interstitial fluid entered the gingival sulcus through its epithelial wall ------ by showing that the tracer material, Sodium fluorescein administered parenterally or per orally, could be recovered form the gingival sulcus but not form other oral epithelia.Saturday, August 11, gingival crevicular fluid 202012
  21. 21.  Numerous investigations have studied the penetration of substances of varying molecular weight most frequently by introducing labeled molecules in the gingival sulcus of experimental animals and studying their presence in the gingival CT by auto radiography or in the general circulation by sampling of venous blood. The passage of substances from the gingival sulcus into the CT has been mostly studied in animals. Only few observations have been performed in man.Saturday, August 11, gingival crevicular fluid 212012
  22. 22. presence of plasma Brill was also first to show the proteins in the gingival fluid. The fundamental observations of Brill have been confirmed in other experiments, where it was shown that extraneous materials such as India Ink, labeled albumin or labeled fluorescein, tetracycline and saccharated iron oxide could be seen to pass from the gingival vessels into the gingival sulcus or pocket Saturday, August gingival crevicular fluid 22 11, 2012
  23. 23. Intra crevicular Extra crevicularSaturday, August 11, gingival crevicular fluid 232012
  25. 25. These strips are placed within thesulcus (Intrasulcular method) or at itsentrance (Extrasulcular method). Theplacement of filter paper strip inrelation to the sulcus or pocket isimportant. The Brill technique places itinto the pocket until resistance isencountered. DISADVANTAGE ---- This methodintroduces a degree of irritation of thesulcular epithelium than can, by itselftrigger the oozing of fluid. Saturday, August 11, gingival crevicular fluid 25 2012
  26. 26.  To minimize this irritation, Loe and Holm – Pedersen placed the filter paper strip just at the entrance of the pocket or over the pocket entrance. In this way, fluid seeping out is picked up by the strip, but the sulcular epithelium will not be in contact with the paper.Saturday, August 11, gingival crevicular fluid 262012
  27. 27. Saturday, August 11, gingival crevicular fluid 272012
  28. 28. Threads were placed in the gingival crevice around the tooth ,and the amount of fluid collected was estimated by weigh in the sample thread.Used by WEINSTEIN et alSaturday, August 11, gingival crevicular fluid 282012
  29. 29. KRASSE AND EGELBERG were first to utilize capillary tubing.This permits the collection of fluid by capillary action.After isolation and drying of collection site, capillary tubes of known diameter are inserted into the entrance of gingival crevice, GCF migrates into the tube by capillary action.As diameter is known, the amount of GCF can be calculated by measuring the distance which the GCF has migrated.And finally, their content is then centrifuged and analyzed.Saturday, August 11, gingival crevicular fluid 292012
  30. 30. Saturday, August gingival crevicular fluid 3011, 2012
  31. 31.  Disadvantages:  Long collection period  May cause trauma as excessive holding of pipette is required  The collection of the fluid is difficult because the viscosity of the fluid makes the aspiration difficultSaturday, August 11, gingival crevicular fluid 312012
  32. 32.  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.Saturday, August 11, gingival crevicular fluid 322012
  33. 33.  ADVANTAGES:  Useful for longitudinal studies  Permits collection without disturbing the integrity of the marginal tissues  Contamination is least DISADVANTAGES:  Complex procedure  Represents a dilution of crevicular fluidSaturday, August 11, gingival crevicular fluid 332012
  34. 34.  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 suctionSaturday, August 11, gingival crevicular fluid 342012
  35. 35.  ADVANTAGES  Useful for cases of clinically normal gingival  Useful for studying the number and state of cells and bacteria form the crevicular area DISADVANTAGES;  Does not permit absolute Quantitative assessment as the dilution factor cannot be determinedSaturday, August 11, gingival crevicular fluid 352012
  36. 36.  ContaminationThe major sources of contamination of GCF sample would be blood, saliva, or plaque. Sampling timeThe 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.Saturday, August 11, gingival crevicular fluid 362012
  37. 37.  Volume determination Recovery from strips Data reportingConstituents found within GCF samples have eitherbeen reported as absolute amount (mg), concentrations(mg/ml)Saturday, August 11, gingival crevicular fluid 372012
  38. 38.  Simple linear measurement:  Amount of GCF collected on strip was assessed by the distance the fluid had migrated up the strip. A more accurate value was achieved by  assessing the area of filter paper wetted by GCF sample.  Staining method: the strip is stained with ninhydrin to produce purple color in the area where GCF had accumulated.  Also 2g fluoroscein given systemically to each patient 3hrs prior to the collection following which the strips were examined under UV light.Saturday, August 11, gingival crevicular fluid 382012
  39. 39.  Disadvantages of staining method:  Cannot be used chair side.  Inevitable delay in measurement may result in increase variation due to evaporation of the fluid.  Staining of the strips for protein labeling prevents further lab investigations.Saturday, August 11, gingival crevicular fluid 392012
  40. 40.  Challacombe used an isotope dilution method to measure the amount of GCF present in a particular space at any given time.Saturday, August 11, gingival crevicular fluid 402012
  41. 41. An electronic method has been devised for measuring gingival fluid absorbed onpaper strips by Harco electronics called Periotron (Dental product divisionWinnipeg, Manitoba, Canada). Saturday, August 11, gingival crevicular fluid 41 2012
  42. 42.  An electronic measuring device which measures the affect on the electric 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 places  zero reading is obtained A wet paper strip will increase the capacitance in proportion to the volume of fluid and this can be measured as an increased value in the readout. Three models  600, 6000 and 8000. Limitations: inability to measure the volume of FCG greater than 1.0µl.Saturday, August 11, gingival crevicular fluid 422012
  43. 43. Saturday, August 11, gingival crevicular fluid 432012
  45. 45. Acid phosphatesAlkaline phosphataseAlpha 1 antitrypsinArylsulphatseAspartate aminotransfaraseChondroition sulphateCitric acidCystatinsB-glucuronidaseCathepsinMatrix metalloproteinsElastaseSaturday, August 11, gingival crevicular fluid 452012
  46. 46.  Acid phosphatase Alkaline phosphatase Collagenase Hyaluronidase Phospholipse-A Phospholipase-CSaturday, August gingival crevicular fluid 4611, 2012
  47. 47. Cellular elementsBacteriaDesquamated epithelial cellsLeucocytes ( PMN’S, monocytes/macrophages)ElectrolytesPotassiumCalciumSodiumOrganic compoundsCarbohydrates-GLUCOSEHEXOSAMINE -HEXURONIC ACIDProteinsSaturday, August 11, gingival crevicular fluid 472012
  48. 48.  Lactic acid Urea Hydroxyproline Endotoxins Cytotoxic substances Hydrogen sulphideSaturday, August 11, gingival crevicular fluid 482012
  49. 49.  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.Saturday, August 11, gingival crevicular fluid 492012
  50. 50. Saturday, August 11, gingival crevicular fluid 502012
  51. 51. 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.Saturday, August 11, gingival crevicular fluid 512012
  52. 52.  The first quantitative study on the absolute conc. of sodium and potassium in gingival fluid has been preformed by Matsue (1967). The mean conc. of sodium found in GCF was 174. and serum conc. of same point was found to be 136 (±7.9) significantly lower than that of GCF (Baug et al 1973) So sodium concentration is more in GCF than serum and it increases in cases of severe inflammationSaturday, August 11, gingival crevicular fluid 522012
  53. 53.  The potassium content of GCF is also generally more than that of serum. Values as high as 69 mEg/lit. have been reported by Nature (1967) from the inflamed areas. The potassium content of crevicular exudate tended to increase in cases showing more severe periodontitis. As suggested by Rasse & Egelberg (1962) the fluid passes through damaged tissues a decrease sodium : Potassium ratio would be found because of the accumulation of intracellular potassium from the disrupt cells.Saturday, August 11, gingival crevicular fluid 532012
  54. 54.  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.Saturday, August 11, gingival crevicular fluid 542012
  55. 55.  The total protein content of gingival fluid is much less than that of serum. No significant correlations have been found between the concentration of proteins in the gingival fluid and the severity of gingivitis, pocket depth and extent of bone loss. Proteins namely , , 2 and 1 globulins, transferrin, albumin, immunoglobulins such as IgG, IgM and IgA, complement components such as C1, C4, C3, C5, have been reported to be present in GCF. Proteins Include: - fibrinogen, ceruloplasmin, - lipoprotein, transferrin, 1 – antitrypsin and 2 – macroglobulin.Saturday, August 11, gingival crevicular fluid 552012
  56. 56. Metabolic and bacterial products identified in gingival fluid include lactic acid, urea, hydroxy proline, endotoxins, prostaglandins, c ytotoxic substances, hydrogen sulphide and antibacterial factors.Saturday, August 11, gingival crevicular fluid 562012
  57. 57. Various enzymes known to be present in gingival fluid include: - Acid phosphatase, Alkaline phosphatase, Pyrophosphatase, - Glucoronidase, Lysozyme, Hyaluronidase,Saturday, August 11, gingival crevicular fluid 572012
  58. 58. Proteolytic enzymes includes: Cathepsin D, Elastase, Cathepsin G, Plasminogen activators, Collagenase and Bacterial proteinases (i.e. endo and exopeptidases), and Lactic dehydrogenase serum proteinase inhibitors such as 2 – macroglobulin, 1 – antitrypsin, 1 – antichymotrypsin have also been known to be present in GCF. Saturday, August 11, gingival crevicular fluid 58 2012
  59. 59.  According to Armitage (2004), more than 65 GCF constituents have been evaluated as potential diagnostic markers of periodontal disease progression.
  60. 60.  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.
  61. 61.  Offenbacher et al (1986) showed that there were differences in the GCF concentration of PGE2 in patients with gingivitis compared with periodontitis. Subsequently, it was found that there was a correlation between increased PGE2 concentration and clinical attachment loss in patients who were diagnosed with moderate to severe periodontitis.Saturday, August 11, gingival crevicular fluid 612012
  62. 62.  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 - 1 , 1 ,  interleukin – 6,  interleukin – 8 and  tumor necrosis factor (TNF - ). Both IL - 1 and IL - 1 have pro-inflammatory effects and depending on a variety of factors can stimulate either bone resorption or formation.
  63. 63.  It has also been reported that in adult periodontitis patients, a higher percentage of sites are positive for IL - 1 (87%) and IL - 1 (56%) IL-6 has also been associated with bone resorption. GCF from sites with progressing periodontitis contains elevated amounts of IL-6. IL-8 was formerly called monocyte-derived neutrophil chemotactic factor. GCF from sites with periodontitis contains significantly more total IL-8 than GCF from healthy sites
  64. 64.  Proinflammatory cytokines in particular IL-1•, may play an integral role in the aetiology of periodontal disease. Lieu et al (1996) demonstrated that with an increase in gingival index and probing, there was a corresponding increase in IL-1 in both the gingival tissue and GCF. Engebretson et al through a longitudinal study suggested that GCF IL-1• expression is genetically influenced and not solely a result of local clinical parameters. Also, a GCF level of IL8 was found to be higher in periodontal diseases and was influenced by local IL-1 activities.Saturday, August 11, gingival crevicular fluid 642012
  65. 65.  Several reports suggest that, compared to periodontal healthy controls, GCF from sites with periodontitis has significantly elevated levels of total protein. Some study has reported that GCF from inflamed sites in patients with periodontitis have significantly lower protein concentrations than GCF from inflamed sites in patients with gingivitis alone
  66. 66. (a) Aspartate Aminotransferase: Aspartate aminotransferase enzyme (AST) is one of the components of GCF that is released and can be detected as a result of cell death. Significant associations between GCF levels of AST and clinical measurements have been determined, and a test system, the PeriogardTM periodontal tissue monitors (PTM), has been developed (Persson et al 1990.
  67. 67.  The commercial chair side test do not have the ability to reliably distinguish between progressing sites and those that are inflamed but not progressing.
  68. 68.  Alkaline phosphatase is a glycoprotein and membrane bound enzyme. It hydrolyzes monophosphate ester bonds at alkaline pH, increasing local concentrations of phosphate ions. In the periodontium, alkaline phosphatase is a very important enzyme as it is part of the normal turnover of periodontal ligament, root cement formation and maintenance, and bone homeostasis. It is produced by many cells, including fibroblasts, osteoblasts and osteoclasts, but the main source of alkaline phosphatase in gingival crevice fluid is neutrophils.Saturday, August 11, gingival crevicular fluid 682012
  69. 69.  Similar levels of alkaline phosphatase in GCF have been found in gingival health and experimental gingivitis, but a longitudinal study demonstrated that elevated alkaline phosphatase levels preceded clinical attachment loss and that the total amount of alkaline phosphatase in GCF was significantly higher in active sites (Nakashima 1996). The diagnostic value for alkaline phosphatase was limited; while the specificity for alkaline phosphatase as diagnostic marker was 86%, it appeared to have a 30% sensitivity.
  70. 70.  Beta-glucuronidase is a lysosomal enzyme that is active in the hydrolysis of glycosyl bonds of intercellular ground substance. It is highly conceivable, therefore, that periodontal disease activity is associated with increased levels of beta- glucuronidase in gingival crevice fluidSaturday, August 11, gingival crevicular fluid 702012
  71. 71.  ß glucuronidase is a glycoprotein of about 332,000 dalton. It is a homo tetramer comprised of four identical subunits. It has high sensitivity and specificity when related to occurrence of clinical attachment loss. This enzyme also proved to be a good predictor of the response to treatment and the risk for future periodontal breakdown (Lamster et al 1998). Subjects without active disease did not have elevated beta- glucuronidase in gingival crevice fluid. In relation to attachment loss, they observed beta-glucuronidase to have a sensitivity and specificity of 89% and 89%, respectively.
  72. 72.  Neutrophil elastase, sometimes referred to as granulocyte elastase, is an abundant proteinase released from the azurophilic granules of neutrophils, and as such is an indicator of neutrophil activity. Neutrophil elastase is a serine proteinase, active in the degradation of microbiological components in conjunction with, or without, phagocytosis. At the same time, when released extracellularly, this enzyme can degrade host intercellular matrix components, including elastin, fibronectin, and collagen.Saturday, August 11, gingival crevicular fluid 722012
  73. 73. Saturday, August 11, gingival crevicular fluid 732012
  74. 74.  Elastase levels in GCF increase with induction of experimental gingivitis, and decrease when plaque removal is reinstituted. In a longitudinal study, Eley and Cox (1996) demonstrated that increased elastase in GCF was predictive of periodontal attachment loss. Long-term observation of adult patients with periodontitis undergoing supportive periodontal therapy showed a positive correlation of elastase in GCF with clinical attachment loss. Smokers display higher levels of elastase than nonsmokers.  Soder B, Jin LJ, Wickholm S. Granulocyte elastase, matrix metalloproteinase-8 and prostaglandin E2 in gingival crevicular fluid in matched clinical sites in smokers and non-smokers with persistent periodontitis. J Clin Periodontol 2002: 29: 384–391
  75. 75.  Cathepsin B is an enzyme active in proteolysis; it belongs to the class of cysteine proteinases. The cellular source of cathepsin B in gingival crevice fluid seems to be mainly macrophages. Cathepsin B activity has been found in gingival crevice fluid in adult periodontitis. It seems to be increased in periodontitis but is not increased in gingivitis, even though the flow of gingival crevice fluid is more or less equal in these two periodontal conditions.Saturday, August 11, gingival crevicular fluid 752012
  76. 76.  Kunimatsu et al (1990) observed that levels of cathepsin B were increased in periodontitis when compared to gingivitis, despite similar GCF flow. Furthermore, GCF levels of cathepsin correlate significantly with clinical parameter before and after periodontal treatment suggesting a use for this enzyme in assessment of treatment outcomes. Cathepsin G may contribute to periodontal tissue destruction directly and indirectly, via proteolytic activation of latent neutrophil procollagenase (promatrix metalloproteinase-8). Eley & Cox have further investigated cathepsin B and evaluated its use as a predictor of attachment loss.
  77. 77. (g) Collagenases / Gelatinases / Neutral proteinases Stromelysins: GCF from sites with adult or juvenile forms of periodontitis exhibit significantly elevated collagenolytic activities compared to GCF from healthy or gingivitis sites. In ligature-induced periodontitis in the beagle dog, GCF collagenase activity increased to maximum values within weeks after ligature placement, active collagenase was elevated during active periodontitis and active collagenase was strongly correlated with attachment loss. Latent collagenase and collagenase inhibitors were prominent during gingivitis.
  78. 78. (a) Glycosaminoglycans (GAG’s): The GAG’s in GCF that have been most examined as possible diagnostic markers for periodontal diseases are:  Chondroitin – 4 – sulfate,  chondroitin – 6 – sulfate and  hyaluronic acid. The appearance of C-4-S in GCF has been suggested as a marker for bone resorption associated with periodontal disease or orthodontic tooth movement. But no studies have been conducted to determine its role in the progression of periodontitis.
  79. 79. (b) Hydroxyproline: It is a prominent aminoacid of collagen and its appearance in GCF has been preliminary investigated as a marker for the destruction of periodontal connective tissue. Data from one cross-sectional study in humans indicate that GCF hydroxy proline levels cannot distinguish between sites with gingivitis or periodontitis. Because of this it is not an attractive candidate as a potential marker for the progression of periodontitis.
  80. 80. (c) Fibronectin: These are a large group of heterogeneous glycoprotein present in blood and connective tissues. Data from most studies indicate that GCF fibronectin is not a promising diagnostic marker.
  81. 81. (d) Connective Tissue Proteins: Increased GCF levels of the amino terminal propertied of type I collagen have been reported at periodontitis sites. On a concentration basis, the amount of osteocalcin in GCF does not appear to be different at sites with gingivitis or periodontitis. Osteonectin another non-collagenous protein of bone and a variety of other tissues, has been reported to be elevated in GCF at sites with severe periodontitis. Neither Osteocalcin nor Osteonectin levels in GCF have been systematically evaluated as diagnostic markers for periodontitis.
  82. 82. It is evident that since periodontal disease isassociated mainly with the presence of certainbacteria which are recognized as the principaletiological agents, then factors derived from suchbacteria may be useful indicators of their presenceand metabolic activity.
  83. 83. Lipopolysaccharides (Endotoxins)These molecules are found in the outer membrane of the cell wall of Gram-negative bacteria. The presence of endotoxins has been positively correlated with gingival inflammation (Simonet al, 1971) when measured in GCF and in combination with clinical and histological studies. The level of endotoxin is related to the number of Gram-negative bacteria.Lipopolysaccharides (LPS) vary in their structure depending on bacterial source.
  84. 84. Bacterial Enzymes Perhaps the bulk of the work on bacterial enzymes has been carried out on proteolytic enzymes or proteinases. The most studied would be the trypsin-like proteinase of P.gingivalis.
  85. 85.  Similar trypsin-like enzymes are also associated with Treponema denticola (Makinin et al, 1987). Bacterial collagenases are also identified with Clostridium histolyticum and Streptococcus mutans. The presence of such enzymes in GCF correlates with the levels of these bacteria in the periodontal pocket and also with the severity of the attachment loss.
  86. 86. LactoferrinThis is an antimicrobial agent with a distribution in PMNs andsecretory fluids similar to that of Lysozyme. The antibacterialproperties of Lactoferrin are due to its high affinity for iron, thuslocking available sources required for bacterial growth.Lactoferrin showed better correlation with clinical indicesthan PMNs (Adonogianaki et al, 1993).
  87. 87. Friedman et al (1983) found that Lactoferrin increased twofold in GCF in sites showing gingivitis periodontitis, and localized juvenile periodontitis. It has also been reported that the ratio of Lactoferrin to Lysozyme may be more representative and a useful diagnostic assay of periodontal inflammation.
  88. 88. MyeloperoxidaseThis enzyme has also been shown to give good correlation with an inflammatory response where it is found in the primary granules of PMN (Smith et al, 1986).
  89. 89.  Several products show potential benefit, particularly those directly from specific regions of the periodontium which give a clue as to which tissue components are at risk. It is clear that no single marker will fulfill all the criteria necessary for assessment of the clinical state of the periodontium, and future research should be directed at the production of "marker packages". The development of a wide spectrum of marker factors will be a primary goal of periodontal research.
  90. 90.  COMMERCIALY AVAILABLE DIAGNOSTIC KIT  Periocheck - Neutral Proteinases - Approved by FDA  Periogard - AST  Prognostik- Elastase - Not Approved by FDA and ADA  Biolise - Elastase  Pocket watch - AST  TOPAS – Toxicity Pre-screening assay (bacterial toxins and proteases  MMP dipstick method - MMPs  Under development, for B - glucornidase and proteinasesSaturday, August 11, gingival crevicular fluid 902012
  91. 91. Saturday, August 11, gingival crevicular fluid 912012
  92. 92.  The components of gingival crevice fluid are analyzed with regard to their potential utility in fulfilling the following aims: (BRUNO G. LOOS & STANLEY TJOA) AIM 1 To detect a case of periodontitis, i.e., to distinguish periodontitis from health and gingivitis AIM 2 To classify a case of periodontitis, i.e., chronic periodontitis or aggressive periodontitis AIM 3 To plan treatment for the patient on the basis of the level of disease activity AIM 4 To monitor the treated patient based on the level of disease activitySaturday, August 11, gingival crevicular fluid 922012
  93. 93. Saturday, August 11, gingival crevicular fluid 932012
  94. 94.  Circadian Periodicity: There is a gradual increase in gingival fluid amount from 6:00AM to 10:00PM and a decrease afterward. On the other hand in the studies conducted by a group of investigators, there are no systematic differences between the flow of fluid measured at 9:00a.m and that of the fluid collected at 3p.mSaturday, August 11, gingival crevicular fluid 942012
  95. 95.  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. Pregnancy, ovulation and hormonal contraceptives all increase gingival fluid production.Saturday, August 11, gingival crevicular fluid 952012
  96. 96.  During menstrual cycle gingival fluid flow or exudate values are significantly higher on the day of ovulation as compared to those obtained during the menstrual days. ( Lindhe and Attstrom (1967). Lindhe and Brorn (1967) reported a 53% increase of GCF flow in the women using birth control pills as compared to the control subjects. Hugoson (1970) reported that the gingival exudate, reached maximum values during the last trimester and decreased to minimum 20 wks after delivery.Saturday, August 11, gingival crevicular fluid 962012
  97. 97.  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.Saturday, August 11, gingival crevicular fluid 972012
  98. 98.  Ciancio et al (1976) measured the concentration of tetracycline in blood and gingival fluid of 5 adult patients with advanced periodontitis, who were given 1g of tetracycline HCL daily for 2 weeks and 0.5g for 10 weeks. The concentration of the drug in gingival fluid was 1/10 of that found in serum. In a second study from the same laboratory the concentrations of the drug were found to be 5 times higher in samples of gingival fluid as compared to the concentrations in blood.Saturday, August 11, gingival crevicular fluid 982012
  99. 99.  Stephen et al (1980) measured the cone. of ampicillin, cephalexin, tetracycline erythemycin, clindamycin and rifampicin in serum, saliva and GCF after a single and dose administration Except on one occasion, 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).Saturday, August 11, gingival crevicular fluid 992012
  100. 100.  GCF in diabetic patients Ringelberg et al in 1977 described a higher flow rate of gingival fluid in a group of diabetic children, when compared to the flow rate measured in a group of children without diabetes. In healthy individuals Hara and Löe found exudate glucose values up to 6 times those of serum. Kjellman (1970) reported glucose values much lower in gingival fluid when compared to serum, this being true for both healthy and diabetic patients.Saturday, August 11, gingival crevicular fluid 1002012
  101. 101.  Periodontal therapy and GCF There is an increase in gingival fluid production during the healing period after 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 had been collected by deep intracrevicular technique. Suppipat et al in 1978 sampled gingival fluid 14, 21, 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 controlSaturday, August 11, gingival crevicular fluid 1012012
  102. 102.  Arnold et-al (1968) 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 the loss of an intact epithelial barrier. With the restoration of gingival integrity, a gradual drop in fluid flow occurred and the flow rate reached a minimal value 5 wks after gingivetomy.Saturday, August 11, gingival crevicular fluid 1022012
  103. 103.  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.Saturday, August 11, gingival crevicular fluid 1032012
  104. 104.  Smoking and GCF Smoking produces as immediate transient but marked increase in the gingival fluid flow. Mcluaghlin WS et al 1993Saturday, August 11, gingival crevicular fluid 1042012
  105. 105.  In conclusion one can say that the origin, the composition and the clinical significance of gingival fluid are now known with more precision and have significantly helped our understanding of the pathogenesis of periodontal disease. Up to now, for instance, none of the multiple components analyzed in the fluid has improved clinical judgment of the rate of progress of gingivitis and periodontitis or of the rate of repair of these conditions.
  106. 106.  CARANZZA Griffiths. Formation, collection and significance of GCF. Periodontal 2000 ; 2003 : volume 31, 32 – 42. Andrew J. Delina. Origin and function of the cellular components in GCF. Periodontal 2000; 2003: vol. 31, 55 – 76. J. Max Goodson. Gingival crevicular fluid. Periodontal 2000; 2003: vol.31, 43 – 54.Saturday, August 11, gingival crevicular fluid 1062012
  107. 107.  Ira B. Lamster. Evaluation of Components of Gingival Crevicular Fluid as Diagnostic Tests. Annals of periodontology. Vol. 2, No. 1, March 1997 BRUNO G. LOOS & STANLEY TJOA. Host-derived diagnostic markers for periodontitis: do they exist in gingival crevice fluid? Periodontology 2000, Vol. 39, 2005, 53–72Saturday, August 11, gingival crevicular fluid 1072012