Downloaded 138 times
![JensMartensson
18
Extracrevicular method Intracrevicular method ‘superficial’
[Loe & Holm-Pedersen]
Intracrevicular method
‘deep’ [Brill, 1958]](https://image.slidesharecdn.com/4gcf30919-191014184111/85/GINGIVAL-CREVICULAR-FLUID-18-320.jpg)
Uploaded byDr Antarleena Sengupta
GINGIVAL CREVICULAR FLUID
The document discusses gingival crevicular fluid (GCF), including its history of study over 50 years, mechanisms and factors affecting its production, methods of collection, composition, and clinical significance. GCF is a serum-like fluid found in the gingival sulcus that can be assessed to provide diagnostic information about periodontal health and disease. The document outlines the anatomy of the gingival crevice and epithelium, as well as various methods that have been used to collect and analyze GCF components.
More Related Content
Similar to GINGIVAL CREVICULAR FLUID
GINGIVAL CREVICULAR FLUID
- 1. Gingival Crevicular Fluid Dr. Antarleena Sengupta IYear PG, Deptt. Of Periodontology, MCODS Mangalore 2019-22
- 2. JensMartensson Contents• INTRODUCTION • HISTORY •GINGIVAL VASCULATURE AND PERMEABILITY • MECHANISMS OF GCF PRODUCTION • ASSESSMENT OF GCF • COMPOSITION • GCF as a diagnostic marker • ANALYSIS OF COMPONENTS • COMMERCIAL DIAGNOSTIC KITS • CLINICAL SIGNIFICANCE • CONCLUSION • REFERENCES 2
- 3. JensMartensson Introduction Anatomy of thegingival crevice • The gingival sulcus is the shallow crevice or space around the tooth, bound by surface of the tooth on one side and the epithelial lining the free gingival margin on the other. • V-shaped; depth as determined via histological sections is 2.1± 0.2 mm. 3
- 4. JensMartensson Sections show presenceof 3 types of epithelium, 1. The oral or keratinized epithelium covering the gingival 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. 4
- 5. JensMartensson 5 Definition • GCF isan exudate that can be harvested from the gingival crevice or periodontal pocket using either filter paper strips or micropipettes. (Manson & Eley, 2000) • GCF is a serum-like exudate that bathes the gingival sulcus and follows an osmotic gradient within the local tissues. (Per Axelsson, 2002)
- 6. JensMartensson 6 Definition Gingival crevicular fluid(GCF) is defined as a specific serum originating biologic fluid – found in periodontal microenvironment and can be harvested from the gingival sulcus of natural teeth Bulkacz J, Carranza FA. Defense mechanisms of the gingiva. In: Newman MG, Takei HH, Carranza FA, eds. Carranza’s Clinical Periodontology, 11th ed. Los Angeles: Saunders: 2012:66 – 70.
- 7. JensMartensson 7 History Studies on gingivalcrevicular fluid (GCF) extend over a period of more than 50 years Egelberg (1966) Gingival vasculature & permeability Waerhaug (1952) Sulcus periodontitis gingival pocket Cimasoni (1969) Presence and func. of proteins in GCF Brill et al (1962) Physiology and composition Loe & Holm-Pederson (1965) Indicator of periodontal diseases Schroeder (1969), Listgarten (1966) Dentogingival structure
- 8. JensMartensson 8 MECHANISMS OF GCFPRODUCTION • Existence of GCF – over 100 years (Black, GV. 1899) • BRILL & KRASSE, 1958 • BRILL & BJORN, 1959 • EGELBERG, 1966 Production of fluid is related to an inflammatory-related increased permeability of vessels underlying the sulcular & junctional epithelium
- 9. JensMartensson 9 MECHANISMS OF GCFPRODUCTION • Existence of GCF – over 100 years (Black, GV. 1899) EXUDATE TRANSUDATE
- 10. JensMartensson 10 GCF: EXUDATE v/s TRANSUDATE •Very early or pre-inflammatory flow of gingival fluid is osmotically mediated. • This osmostically mediated fluid is a TRANSUDATE. • Later, on stimulation, it may progress to a secondary inflammatory exudate. • Thus, even in health, if osmotic pressure >>tissue fluid due to accumulation of plaque → increased flow of GCF ALFANO (1974)
- 11. JensMartensson 11 GCF: EXUDATE v/s TRANSUDATEPASHLEY (1976) • Based on STARLING HYPOTHESIS governing fluid distribution across capillaries. • Model proposed by Pashley predicted that GCF production is governed by • CAPILLARY FILTRATION • LYMPHATIC UPTAKE • When the rate of capillary filtrate exceeds that of lymphatic uptake, fluid will accumulate as edema and/or leave the area as GCF.
- 12. JensMartensson 12 • According toAlfano 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. GCF: EXUDATE v/s TRANSUDATE 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
- 13. JensMartensson 13 Functions of GCF Cleansematerial from the sulcus Contain plasma proteins– may improve adhesion of epithelium to the tooth Possess antimicrobial properties Exert antibody activity in defense of the gingiva
- 14. JensMartensson 14 Histamine Pre- inflammator y GCF Conc. of protein Mechanic alstimuli Passage of fluid & PMNMorphology of JE Inflammator y changes of BM Factors affecting flow of GCF
- 15. JensMartensson 15 Gingival vasculature &Crevicular fluid • Increased vascular permeability plays an important role in the production of gingival fluid (Brill, 1959) • Increased permeability of the blood vessels of healthy gingiva by use of 3 different experimental methods (Egelberg, 1966): • Topical application of histamine • Gentle massage of the gingiva by means of a ball-ended amalgam plugger • Scraping of the gingival crevice by means of a blunted dental explorer. • 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. (Jablonski, Illustrated Dictionary of Dentistry, 1982)
- 16. JensMartensson 16 Permeability of Junctionaland Oral Sulcular Epithelia • Three routes have been described: • Passage from CT into the sulcus • Passage from the sulcus into the CT • Passage of substances through pathological or experimentally modified gingival sulcus (Squier, 1973)
- 17. JensMartensson 17 Absorbent paper strips Micropipettes Gingivalwashings Plastic strips Isotope dilution Pre- weighed twisted threads Methods of collectio n of GCF
- 18. JensMartensson 18 Extracrevicular method Intracrevicularmethod ‘superficial’ [Loe & Holm-Pedersen] Intracrevicular method ‘deep’ [Brill, 1958]
- 19. JensMartensson 19 • This techniqueappears to be ideal as it provides an undiluted sample of ‘native’ GCF whose volume can be accurately assessed ADVANTAGE • Time consumption – 30 min • Difficulty in removing the complete sample DISADVANTAGES KRASSE & EGELBERG, 1962 Principle- 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.
- 20. JensMartensson 20 WEINSTEIN et al,1967 thread is placed in the gingival crevice around the tooth and the amount of fluid collected is estimated by weighing the sample thread.
- 21. JensMartensson 21 Takamori & Oppenheimmethod (1970) - customized hard acrylic plate covering the maxilla with soft borders and a groove along the gingival margins which is connected to 4 plastic tubes; 4-6mL – 15 min – peristaltic pump Skapski & Lehner method (1976) ADVANTAGES • Useful for longitudinal studies • Permits collection without disturbing the integrity of the marginal tissues • Contamination is lowest DISADVANTAGES • Complex procedure • Represents a dilution of crevicular fluid 10 μL Hank’s Balanced Salt Solution (HBSS) are ejected and reaspirated 12 times by resting the point of a needle of a 50 μL microsyringe interdentally on the buccal surface of the teeth, just above the interdental papilla DISADVANTAGES • Does not permit absolute quantitative assessments • Dilution factor cannot be determined
- 22. JensMartensson 22 • GINS andMATTIG, 1941 • ATTSTROM, 1970 • RENGGLI and REGOLATI, 1972; LANGE, 1973 • Transparent strips are placed along long axis of the tooth • Pressure applied on the gingiva • Drying → staining → mounting in cedar oil →observed under microscope
- 23. JensMartensson 23 • CHALLACOMBE, 1980 •Isotope dilution method • Anteriors = 0.24 - 0.43 μL per tooth; Posteriors= 0.43 – 1.56 μL per tooth • Suggested that the total volume of GCF secreted in the human mouth per day = 0.5 – 2.4 mL of fluid
- 24. JensMartensson 24 METHODS OF ESTIMATINGGCF VOLUME COLLECTED • 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 & ATTSTROM, 1973 1. Direct viewing/ Staining: The stained area can then be measured with : • Ordinary transparent ruler (EGELBERG, 1964) • Sliding calliper (BJORN, 1965) • Calibrated magnifying glass (OLIVER, 1969) • Microscope with an eyepiece (WILSON, 1971) • Specially designed, inexpensive paper strip viewer (WILSON, 1978)
- 25. JensMartensson 25 • Pre- weighedtwisted threads (WEINSTEIN, 1967) • Weigh the sample – the strips are weighed before and immediately after collection (VALAZZA, 1972) The time of collection was measured with a chronometer and this enabled the investigator to express the flow of fluid in mg/min. 2. Weighing the strips
- 26. JensMartensson 26 3. Use ofPeriotron PERIOTRON 600 PERIOTRON 6000 PERIOTRON 8000 Considerably sensitive to qualitative differences in fluid Relatively unaffected by qualitative differences in fluids. Ability to quantitatively measure the gingival crevicular fluid without permanently altering it (Chapple et al, 1995) differences in calibration fluid composition (e.g. protein content) are reflected in the Periotron scores calibration of the Periotron 8000 seems to be consistent over a 1-wk interval. (Ciantar et al, 1998)
- 27. JensMartensson 27 Periotron reading Levelof gingival inflammation Gingival Index 0-20 Healthy 0 21-40 Mild 1 41-80 Moderate 2 81-200 Severe 3 Translation of Periotron values to clinical conditions and Gingival index with which they may be associated
- 28.
- 29.
- 30. JensMartensson 30 Epithelial cells –Lange & Schroeder, 1971 Cells of the sulcular epithelium • Flattened • Cytoplasmic filaments Cells originating from the junctional epithelium • Found at the bottom of the sulcus Role of inflammation • Rate of renewal • Structural characteristics of desquamating cells • Reduction in acid phosphatase activity (Cornaz et al., 1974) Epithelial cells, leukocytes and bacteria • CELLULAR ELEMENTS
- 31. JensMartensson 31 GCF Peripheral blood Neutrophil95- 97% 60% Monocyte 2- 3% 5- 10% Lymphocyte 1- 2% 20-30% T- cells 24% 50-75% B- cells 58% 15- 30% Mononuclear phagocyte 18% T : B 1 : 2.7 3 : 1 Differential leukocyte count in the sulcus Leukocytes Role of inflammation: ↑number (EGELBERG, 1963) Phagocytic function of PMNs: AgP < CP Poor correlation to severity of gingival inflammation and depth of pocket (KREKELER & FERCK, 1977) Bacteria
- 32. JensMartensson • ELECTROLYTES 32 SODIUM • NormalGCF – 158 mEq/L • Inflammation – 207 to 222 mEq/L • Follows circadian periodicity (KASLICK et al, 1970) • ↑pocket depth →↓Na concentration POTASSIUM • Mean conc. in GCF = 9.54 mEq/L • GCF >> serum • Increases towards the middle of the day • ↑severity of periodontitis • ↑pocket depth SODIUM-POTASSIUM RATIO • Diseased tissues-- ↓ratio • Accumulation of intracellular potassium • GCF < ECF (KRASSE & EGELBERG, 1962) 3.9 28.1
- 33. JensMartensson Other ions 33 • Fluoride: GCF = Plasma (WHITFORD et al, 1981) • Calcium: Normal gingiva – 10mEq/L Inflamed gingiva – 15.9mEq/L ↑ with inflammation GCF (30-50x) > Serum (BISWAS et al, 1977) • iPO4: 4.2 mg/100mL of GCF • Mg: 0.8 mEq/L • I: 40% of concentration in saliva
- 34. JensMartensson • ORGANIC COMPOUNDS 34 Carbohydrates Glucose,hexosamine and hexuronic acid (HARA & LOE, 1969) Glucose: GCF >>> serum Hexosamine & hexuronic acid – no correlation with variation in gingival inflammation Increased in: • Inflammation • Diabetes Lipids Serum, saliva, bacteria and host tissue Phospholipids and neutral lipids
- 35. JensMartensson 35 Proteins GCF <serum IgG, IgA - plasma cells Complements → tissue damage (SCHENKEIN & GENCO,1977) Chemotactic attraction of PMNs Release of lysosomal enzymes Degranulation of mast cells Albumin , fibrinogen, ceruloplasmin, ß-lipoproteins & transferrin (MANN & STOFFER, 1964) Bradykinin (RODIN et al,1973)
- 36. JensMartensson • Metabolic andbacterial products 36 Lactic acid – inflammation, flow Hydroxyproline Prostaglandins Urea and pH • Inversely related to severity of inflammation • GCF > saliva, serum • pH: 7.54 - 7.89 (BANG AND CIMASONI)
- 37. JensMartensson 37 Endotoxins • Lipopolysaccharides(LPS)of cell wall of Gram-ve bacteria released from autolysing bacteria cells • Highly toxic to gingival tissues & possible pathogenic factor in periodontal disease. • Positive correlation b/w LPS conc. & gingival inflammation (SHAPIRO, 1972) Cytotoxic substances - H2S
- 38. JensMartensson 38 Antibacterial factors •Crevicular fluid was found to be as potent as leukocyte extract in lysing S. aureus, S. faecalis & A.viscosus. S. mutans seemed more resistant. • Lysosomal enzymes present in GCF are lytic agents. (SELA et al, 1980) • A peroxidase mediated antimicrobial system has also been shown in human crevicular fluid • Growth stimulating factors – Lactobacilli ( TAKAMORI,1963)
- 39. JensMartensson 39 CLINICAL SIGNIFICANCE OF GCF CIRCADIAN PERIODICITY SEX HORMONES DRUGS DIABETES MECHANICAL STIMULATION PERIODONTAL THERAPY SMOKING gradual increasein gingival fluid amount from 6:00AM to 10:00PM and a decrease afterward. - Pregnancy - Menstrual cycle - Puberty - Metronidazole - Tetracycline I.V. - GCF antibiotic conc. equal to or considerably greater than those found in saliva. - Glucose values much lower in GCF in healthy & diabetics - Higher flow rate of gingival fluid - Chewing - Vigorous gingival brushing - Intrasulcular placement of paper strips - ↑GCF production during healing period after periodontal surgery - ↑gingival fluid flow during first 2 weeks after gingivectomy followed by a gradual decrease. - ↓GCF flow 4 weeks following root planing & curettage - Lower resting GCF flow rate - immediate transient but marked ↑GCF flow. - GCF volumes decreased further immediately after smoking - subsequently increased transiently after 10 minutes.
- 40. JensMartensson 40 PROBLEMS ASSOCIATED WITHGCF COLLECTION : CONTAMINATION SAMPLING TIME VOLUME DETERMINATION RECOVER FROM STRIPS DATA REPORTING
- 41. JensMartensson GCF v/s SALIVA:DIAGNOSTIC BIOMARKERS 41 SALIVA - Sample contamination with blood from oral mucosa and periodontal lesions due to inflammation - Collection methods are not completely standardized in terms of different physiological states and types of commercial kits - Most of the biomarker levels in saliva are lower than that found in the GCF. - Influenced by the method of collection and the degree of stimulation of salivary flow Pathiyil, Varsha & Udayasankar, Rahul. (2019). Salivary Diagnostics. 10.5772/intechopen.84722. GCF - >65 GCF constituents have been evaluated as potential diagnostic biomarkers of periodontal disease progression (Armitage et al, 2004) - can provide site-specific status of inflammation without necessitating histopathological evaluation - The calculated cut-off values for biomarkers from GCF gives higher sensitivity, specificity and predictive values than saliva samples (Hormdee et al, 2017) Gupta S, Chhina S, Arora SA. A systematic review of biomarkers of gingival crevicular fluid: Their predictive role in diagnosis of periodontal disease status. Journal of oral biology and craniofacial research. 2018 May 1;8(2):98-104.
- 42. JensMartensson CLASSIFICATION OF GCFBIOMARKERS (Gupta, G. 2012) 42 Host-derived enzymes and their inhibitors Tissue breakdown products Inflammatory mediators host response modifiers • Aspartate aminotransferase • Alkaline phosphatase • Acid phosphatase • β-glucoronidase • Elastase • Elastase inhibitors • α2 – macroglobulin • α1 – proteinase inhibitor • Cathepsins • Cysteine proteinases (B, H, L) • Serine proteinase (G) • Glycosaminoglycans • Hyaluronidase • Lactate dehydrogenase • Chondroitin-4-sulphate • Chondroitin-6-sulphate • Dermatan sulphate • Hydroxyproline • Fibronectic fragments • Connective tissue and bone proteins • Osteonectin • Osteocalcin • Type I collagen peptides • Osteopontin • Cytokines • IL-1 alpha • IL-1 beta • IL-2 • Il-6 • IL-8 • TNF alpha • Interferon alpha • Leukotriene B4 • Prostaglandin E2 • Transferrin • Lactoferrin • Ig- G1, G2, G3, G4, IgM
- 43. JensMartensson 43 • Enzymes andEnzyme Inhibitors Lysozyme Major source : PMNs Bactericidal - hydrolyzes β-1,4 glycosidic bonds of peptidoglycans of bacterial cell wall Activity : GCF, saliva > serum (BRANDTZAEG & MANN,1964) May contribute to the formation of pocket Accelerates release of bacterial enzymes (SELA ,1976)
- 44. JensMartensson 44 β glucoronidase • Lysozomalenzyme • Primary granules of PMNs • Sources : macrophages, fibroblasts, endothelial cells, bacteria • Plays a role in the catabolism of mucopolysaccharides Hyaluronidase Lysosomal enzyme Splits β-1,4–N– acetylglucosaminide links in hyaluronic acid and chondroitin sulphate pH : 3.5 – 4.1 Increases – Gram positive bacteria, inflammation (TYNELIUS- BRATHALL & ATTSTROM,1972)
- 45. JensMartensson 45 Acid phosphatase • Lysosomalenzyme • Present in azurophil granules • Sources : PMNs, desquamating epithelial cells • Associated with connective tissue catabolism • Can also attack teichoic acid • Acts at a pH of 4 to 5 Pyrophosphatase • Role in calculus formation • Concentration is positively correlated – amount of calculus Lactate dehydrogenase Pyruvate ↔ Lactate GCF > blood
- 46. JensMartensson 46 Proteolytic enzymes CathepsinD Elastase Cathepsin G Plasminogen activators Collagenase Bacterial proteinases (i.e. endo and exopeptidases) Lactic dehydrogenase serum proteinase inhibitors such as α2 – macroglobulin, α1 – antitrypsin, α1 – antichymotrypsin have also been known to be present in GCF.
- 47. JensMartensson • Host- derivedenzymes 47 (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). (b) Alkaline phosphatase: • part of the normal turnover of periodontal ligament, root cement formation and maintenance, and bone homeostasis. • main source of alkaline phosphatase in gingival crevice fluid is neutrophils. • 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).
- 48. JensMartensson 48 (c) Cathepsin B •active in proteolysis • cellular source of cathepsin B in gingival crevice fluid seems to be mainly macrophages. • KUNIMATSU et al (1990) observed that levels of cathepsin B were increased in periodontitis when compared to gingivitis, despite similar GCF flow. • ELEY & COX have further investigated cathepsin B and evaluated its use as a predictor of attachment loss. (d) Neutrophil elastase • 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
- 49. JensMartensson Prostaglandin E2 (PGE2) 49 •First identified in GCF by GOODSON ET AL. in 1974. • PGE2 is a product of the cyclooxygenase pathway. • ↑PGE2 in GCF are seen in patients with periodontitis compared to patients with gingivitis. • ↑PGE2 levels : patients with juvenile periodontitis >3x adult periodontitis. • OFFENBACHER ET AL (1986) • differences in the GCF concentration of PGE2 in patients with gingivitis compared with periodontitis. • correlation between ↑PGE2 concentration and clinical attachment loss in patients who were diagnosed with moderate to severe periodontitis.
- 50. JensMartensson Cytokines 50 Cytokines arepotent local mediators of inflammation that are produced by variety of cells. Cytokines that are present in GCF have potential diagnostic markers for periodontal disease including: • interleukin - 1α , 1β , • interleukin – 6, • interleukin – 8 and • tumor necrosis factor α (TNF -α ). 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. 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. ↑IL8 in periodontal diseases influenced by local IL-1 activities.
- 51. JensMartensson 51 DIAGNOSIS OF GCFBIOMARKERS
- 52. JensMartensson Analysis of components 52 TESTSCOMPONENTS ANALYSED Fluorometry MMPs ELISA Enzyme levels and IL-1β RIA COX derivatives and procollagen III HPLC Tinidazole Direct/Indirect immunodot tests Acute phase proteins
- 53.
- 54. JensMartensson RECENT FINDINGS INGCF 54 - IL-29: antiviral IL-29 level was highest in GCF of aggressive periodontitis patients while that of chronic periodontitis lying in between. After non-surgical therapy, IL-29 levels increased both in chronic and aggressive periodontitis patients as a potential therapeutic agent in treating periodontitis. (Shivaprasad BM, Pradeep AR 2013) - SYSTEMIC DISEASE-RELATED - PROGRANULIN – Chronic periodontitis & type 2 DM (Pradeep et al, 2013) - CAPSASE 3 – GCF and the serum concentration of capsase-3 proportionally increases with the progression of periodontal disease (Pradeep et al, 2014) - OBESITY RELATED - CHEMERIN – an adipokine; CP & DM - LEPTIN – the decreasing leptin level in GCF and gingival tissue was associated with a deteriorated periodontal status, and smokers also showed reduced GCF leptin levels in recent studies (Pradeep et al, 2015)
- 55.
- 56. CONCLUSION The origin, compositionand the clinical significance of gingival fluid are now known with more precision and have significantly helped our understanding of the pathogenesis of periodontal disease. On the other hand, none of the multiple components analysed in the fluid has improved clinical judgement of the rate of progress of gingivitis and periodontitis or of the rate of the repair of these conditions. 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. Several tests have been developed that are aimed at specifically and sensitively revealing the metabolic status of periodontal tissues. Some of them have shown good specificity and sensitivity values as well as potential for predicting disease progression. Unfortunately only a handful of GCF tests have made their way into clinical practice. Clinicians are still missing a practical test based on enzymes, tissue degradation products or cytokines that accurately indicates an initial periodontitis process, active disease periods or effective healing. This will eventually pave the way for the development of practical GCF indicators that will aid in the accurate diagnosis and appropriate treatment of periodontal diseases.
- 57. 1. CIMASONI G.I. Monographs in Oral Science. Crevicular fluid updated 1983 (Vol. 12, pp. 1-1). Karger Publishers. 2. NEWMAN MG, TAKEI H, KLOKKEVOLD PR, CARRANZA FA. Carranza's clinical periodontology. Elsevier health sciences; 2011. 3. KRASSE BO. Serendipity or luck: stumbling on gingival crevicular fluid. Journal of dental research. 1996 Sep;75(9):1627-30. 4. CARRANZA FA, SHKLAR G, WILLIAMS RC. History of periodontology. Quintessence Pub.; 2003 Jan. 5. ZIA A, KHAN S, BEY A, GUPTA ND. Oral Biomarkers in the diagnosis and progression of periodontal diseases. Biology and Medicine 2011Vol3. 6. GRIFFITHS. Formation, collection and significance of GCF. Periodontal 2000, 2003; 31:32 – 42. 7. J. MAX GOODSON. Gingival crevicular fluid. Periodontal 2000 2003;31:43 – 54. 8. GARY ARMITAGE. Analysis of gingival crevicular fluid and risk of progression of periodontitis. Periodontology 2000. Vol 34,109-119 2004 9. IRA B LAMSTER. Evaluation of components of Gingival Crevicular Fluid. Annals of Periodontology. Vol 2, No 1, 1997 10.Image credits: http://www.google.co.in/images REFERENCES
- 58.
Editor's Notes
- #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 1990s the research on GCF increased dramatically.
- #10 An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. It can be a pus-like or clear fluid. When an injury occurs, leaving skin exposed, it leaks out of the blood vessels and into nearby tissues. The fluid is composed of serum, fibrin, and white blood cells. Transudate is extravascular fluid with low protein content and a low specific gravity (< 1.012). It has low nucleated cell counts (less than 500 to 1000 /microlitre) and the primary cell types are mononuclear cells: macrophages, lymphocytes and mesothelial cells.
- #11 An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. It can be a pus-like or clear fluid. When an injury occurs, leaving skin exposed, it leaks out of the blood vessels and into nearby tissues. The fluid is composed of serum, fibrin, and white blood cells. Transudate is extravascular fluid with low protein content and a low specific gravity (< 1.012). It has low nucleated cell counts (less than 500 to 1000 /microlitre) and the primary cell types are mononuclear cells: macrophages, lymphocytes and mesothelial cells. STARLING’S the flow of fluids across capillary walls depends on the balance between the force of blood pressure on the walls which tends to force fluids out and the osmotic pressure across the walls which tends to force them in due to the greater concentration of dissolved substances in the blood
- #12 An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. It can be a pus-like or clear fluid. When an injury occurs, leaving skin exposed, it leaks out of the blood vessels and into nearby tissues. The fluid is composed of serum, fibrin, and white blood cells. Transudate is extravascular fluid with low protein content and a low specific gravity (< 1.012). It has low nucleated cell counts (less than 500 to 1000 /microlitre) and the primary cell types are mononuclear cells: macrophages, lymphocytes and mesothelial cells. STARLING’S the flow of fluids across capillary walls depends on the balance between the force of blood pressure on the walls which tends to force fluids out and the osmotic pressure across the walls which tends to force them in due to the greater concentration of dissolved substances in the blood
- #16 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 & Montgomery, 1973: applied endotoxins to the gingival margin in dogs and demonstrated an abnormal permeability of the dentogingival vessels. Hellden, Linde et al., 1973 and Kahnberg et al, 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 an increased flow of gingival fluid.
- #17 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 from 18% of the total volume of the junctional epithelium and 12% that of the oral sulcular epithelium (Schroeder & Munzel-Pedrazzoli, 1970) 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.
- #19 Extracrevicular method it is quick and easy to use; can be applied to individual sites; Possibly, is the least traumatic when correctly used. Intracrevicular method : SUPERFICIAL (Loe) strip is placed at the entrance of the crevice and fluid collected. Paper strips + notch at their tip; Tip – sulcus entrance; Notch – safeguard against deeper penetration Brill Introduced filter paper into gingival sulcus until resistance is felt. Method caused irritation of sulcu. Epi., hence fluid was exuded.
- #23 Either over the gingival area or gently inserted into the sulcus
- #24 Instilled 10 uL of Ig soln labelled with isotope iodine into approximal spaces and recovered as much fluid as he could– measured its volume and radioactivity
- #27 An electronic measuring device :Functions on the principle of capacitor i.e., it measures the electrical capacitance of wet filter paper strip placed between the jaws of the instrument. The instrument measures the effect on electrical current flow on the wetted paper strips. Dry strip→ ZERO READING is obtained Wet strip → increased capacitance in proportion to fluid volume Allowed accurate determination of the GCF volume and investigation of the sample composition Limitation of 8000: inability to measure volume of GCF >1.0 μL
- #28 Data supplied by manufacturer – adapted from research investigations
- #40 On the other hand in the studies conducted by another 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.m Female sex hormones increase the gingival fluid flow, probably because they enhance vascular permeability. Stephen et al (1980) measured the conc. of ampicillin, cephalexin, tetracycline erythromycin, clindamycin and rifampicin in serum, saliva and GCF after a single dose administration. Acc to Kjelman in 1970. Ringelberg et al in 1977 stimulate the oozing of gingival fluid. Even the minor stimuli represented by intrasulcular placement of paper strips increase the production of fluid. 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. TSUCHIDA & HARA, 1981. Persson et al, 1999. McLaughlin et al, 1993. luthra et al, 2012.
- #41 SAMPLING TIME: changes its nature. Initial sample- interstitial. Prolonged- serum CONTAMINATION: blood, saliva, plaque VOL DETERMN.: scarce material (0.5-1 ul). Might evaporate, high %of error. RECOVER FRM STRIPS: conflicting results DATA REPORTING: if early, conc. And total enzyme activity hampered If late, total amt of enzyme activity lowers
- #42 The diagnostic potential of GCF has been studied over 50 years. In 1960, it was first suggested that analysis of GCF might be a way to quantitatively evaluate the inflammatory status of gingival and periodontal tissues. GCF contains a rich array of cellular and biochemical factors which have been shown to indicate the metabolic status of various tissue components of the periodontium. Such factors are now finding value as potential diagnostic or prognostic markers of the periodontium in health and disease. Simultaneously, a contradictory school of thought existed until recently that favoured saliva as a potentially conclusive diagnostic tool to check for biomarkers of periodontitis due to its easy availability in diseased and non-diseased conditions.
- #51 Both IL - 1 and IL - 1 have pro-inflammatory effects and depending on a variety of factors can stimulate either bone resorption or formation. It was also 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.
- #52 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 activity
- #53 ELISA enzyme linked immune sorbet assay RIA radio immune assay HPLC High Performance Liquid Chromatography
- #54 BANA periodontal test utilises hydrolysis reacn- for bacterial trypsin-like protease Omnigene Parocheck DNA probe systems for subg bacteria Perioscan utilized BANA hydrolysis reacn to detect bact trypsin like proteases in plaque. Detects enzymatic activity of A.a, T. forsythia, P.gingivalis Evalusite uses novel membrane based enzyme immunoassay for the detection of 3 periodontopathogens: Aa, Pg, Pi Microdent probes, periotest for Pg, Aa, tf, Td and Pi PST only genetic test that analyses two interleukins IL 1 alpha and beta for variations Perio 2000 designed to display the sulphide levels digitally at various sites Periocheck measures neutral protease activity in GCF DIPSTICK MMP test looks for matrix metalloproteins TOPAS detects toxins derived from anaerobic metabolism and measures GCF protein level
- #56 OPG concentrations in GCF decreases proportionally with the progression of periodontal disease, that is gingival inflammation and CAL GCF resistin level as a potential inflammatory marker for periodontitis with type 2 DM IL-23 level in GCF is directly proportional to the severity of periodontal affliction suggesting its possible role in periodontal inflammation Periodontal tx downregulates protease-activated receptor 2 in GCF