Gingival crevice fluid (GCF) is a complex mixture derived from serum, leukocytes, and oral bacteria that has the potential to serve as an indicator of periodontal disease and healing. This document discusses the history and methods of GCF collection and analysis. It describes the composition of GCF and how components like enzymes, cytokines, antibodies, and complement can indicate periodontal inflammation and tissue destruction. Understanding GCF provides insights into periodontal defense mechanisms and diagnosis.

1. DEFENSE
MECHANISM:
ROLE OF GCF
D R . L B K A M A I T
D E P T O F P E R I O D O N TO L O G Y A N D O R A L
I M P L A N TO L O G Y 1

2. CONTENTS
• Introduction
• History
• Methods of collection
• Composition
• Function
• Conclusion
• References
2

3. INTRODUCTION
• Gingival crevice fluid (GCF) is a complex
mixture of substances derived from serum,
leukocytes, structural cells of periodontium
and oral bacteria
• These substances possess a great potential
for serving as indicators of periodontal
disease and healing after therapy
3

4. HISTORY
• In the late 1950s and early 1960s a series of
studies by Brill et al - understanding the
physiology of GCF formation and its
composition
• The studies of Loe et al contributed to this
understanding and started to explore the use
of GCF as indicator of periodontal diseases
4

5. • Egelberg continued to analyze GCF and focused his studies on
the dentogingival blood vessels and their permeability as they
relate to GCF flow
• 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
5

6. • Presence and functions of proteins, especially
enzymes in GCF were first explored by -
Sueda, Bang and Cimasoni
• It was soon understood that enzymes
released from damaged periodontal tissue
possessed an enormous potential for
periodontal diagnosis.
6

7. GINGIVAL SULCUS
• Sulcus is the shallow crevice or space around the
tooth ,bounded by the surface of the tooth on one
side and the epithelial lining the free margin of the
gingiva on the other.
• 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
7

8. PERMEABILITY OF JUNCTIONAL
AND ORAL EPITHELIA
• Substances that have been
shown to penetrate the
sulcular epithelium include
albumin, Endotoxins,
thymidine, histamine,
phenytoin, horseradish
peroxidase
• These findings indicate
permeability to substances
with a molecular weight of up
to 1000 kD
8

9. • The main pathway for the transport of substances across the
junctional and sulcular epithelia seems to be the intercellular
spaces
• Squier and johnson reviewed the mechanisms of penetration
through an intact epithelium
• Intercellular movement of molecules and ions along intercellular
spaces appears to be a possible mechanism
• Substances taking this route do not traverse the cell membranes
9

10. • Three routes have been described:
a) Passage Form CT Into The Sulcus
b) Passage From The Sulcus Into The CT
c) Passage Of Substances through Pathological Or Experimentally
Modified Gingival Sulcus
10

11. GCF FLOW
• GCF flow (or flow rate) is the process of fluid
moving into and out of the gingival crevice or
pocket
• It is a small stream, usually only a few µl/hr.
– Shallow pockets – 3 to 8 µl/hr
– Intermediate PD- 20 µl/hr
– Advanced PD – 137 µl/hr
11

12. AMOUNT
• Is extremely small
• Cimasoni showed that a strip of paper 1.5 mm wide and
inserted 1mm within the gingival sulcus of a slightly inflamed
gingiva absorbs about 0.1 mg of GCF in 3 minutes
• Challacombe used isotope dilution method
– showed that mean GCF volume in proximal spaces from molar
teeth ranged from 0.43 to 1.56 µl
12

13. FUNCTION
• Cleanse material from the sulcus
• Contain plasma proteins that may improve adhesion of the
epithelium to the tooth.
• Possess antimicrobial properties.
• Exert antibody activity in defense of the gingiva.
13

14. METHODS OF COLLECTION
1. Use of absorbing paper strips
2. Twisted threads placed around and into the sulcus
3. Micropipettes
4. Intracrevicular washings
14

15. USE OF ABSORBING PAPER
STRIPS :
a) Placed within the sulcus
(intrasulcular method) or
at its entrance
(extrasulcular method).
b) The Brill technique places it
into the pocket until
resistance is encountered.
15

16. b) This method introduces a degree
of irritation of the sulcular
epithelium
c) Loe and Holm- Pedersen placed
the filter strip at the entrance of
the pocket or over the pocket
entrance
• minimize irritation of sulcular
epithelium
d) The fluid seeping out is picked up
by the strip, but the sulcular
epithelium is not in contact with
the paper. 16

17. TWISTED THREADS :
a) Preweighed twisted threads were used by Weinstein et al.
b) The threads were placed in the gingival crevice around the
tooth, and the amount of fluid collected was estimated by
weighing the sample thread.
17

18. MICROPIPETTES :
a) The use of micropipettes
permits the collection of
fluid by capillarity.
b) Capillary tubes of
standardized length and
diameter are placed in the
pocket, and their content
is later centrifuged and
analyzed.
18

19. CREVICULAR WASHINGS :
• Used to study GCF from clinically
normal gingiva
• 2 methods
1. uses an appliance consisting
of a hard acrylic plate
covering the maxilla with soft
borders and a groove
following the gingival
margins.
1. It is connected to four
collection tubes
2. The washings are obtained
by rinsing the crevicular
areas from one side to the
other, using a peristaltic
pump. 19

20. CREVICULAR WASHINGS :
2. A modification of the method
uses two injection needles fitted one
within the other.
1. 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
2. The collection needle
is drained into a
sample tube by
continuous suction.
20

21. METHODS OF ESTIMATING
THE VOLUME COLLECTION
• The amount of GCF collected on a strip was
assessed by the distance the fluid had migrated
up the strip
• This was often taken as a simple linear
measurement, but a more accurate value was
achieved by assessing the area of filter paper
wetted by the GCF sample.
21

22. • Further accuracy was achieved by staining the
strips with ninhydrin to produce a purple
color in the area where GCF had accumulated
accumulated
22

23. • Disadvantages of staining techniques
– They are not easily applied at the chairside.
– The inevitable delay in measuring the strip may result
in increased variation in the reported volume d/to
evaporation
– The staining of the strips for protein labeling
prevents further laboratory investigations of the
components of GCF
23

24. THE PERIOTRON
• An electronic
measuring device
• allowed accurate
determination of the
GCF volume and
investigation of the
sample composition.
• The instrument
measures the affect on
the electrical current
flow of the wetted
paper strips
24

25. • It has two metal ‘jaws’ which act as the plates
of an electrical condenser
• If a dry strip is placed between the ‘jaws’, the
capacitance is translated via the electrical
circuitry and registers ‘zero’ on the digital
readout
25

26. LIMITATIONS
• inability to measure volumes of GCF greater
than 1.0ml, although when using filter strips
such as Whatman 3MM strips, the strips
themselves are capable of absorbing much larger
volumes
• Volumes greater than 1.0ml may be recovered
from severely inflamed sites which may be the
samples of most interest in any study of volume,
flow rate, or composition of GCF.
26

27. 27

28. CREVICULAR FLUID AND
MATRIX DESTRUCTION
• More than 40 components in the GCF
• Classified by Cimasoni (1983) into
1. Cellular elements
2. Electrocytes
3. Organic compounds
4. Bacterial products
5. Metabolic products
6. Enzymes , and enzyme inhibitors
28

29. Composition
of GCF
Enzymatic
Components
Host derived & other
products
Bacteria derived
Nonenzymatic
Components
Cellular
components
Electrolytes
Organic
components
29

30. COMPONENTS OF GCF
A. Cells
• Bacteria, Epithelial cells , leukocytes
B. Electrocytes
• calcium , sodium , fluoride , magnesium , phosphate ,
potassium
C. Microbial plaque products
• Bacterial enzymes, cytotoxic substances , metabolic
end products , lipopolysaccharide
30

31. D. Inflammatory end products
– acute –phase proteins ,cytokines,
immunoglobulins,enzymes(matrix
degrading)lysosomal enzymes, prostaglandins
E. Host derived
– complement , fibrin ,fibronectin, collagens ,
osteocalcin, osteonectin , proteoglycans
31

32. RATIONALE FOR THE USE OF
GCF AS A DIAGNOSTIC TEST
• Easily and noninvasively collected
• GCF contains many of the reaction products
associated with periodontal inflammation and
provides a rich source of potential markers
32

33. LIMITATION OF GCF AS A
DIAGNOSTIC MEDIUM
• Is the lack of a gold standard against which the
test can be evaluated (Listgarten 1986; Beck
1995)
– Any comparisons to an inadequate standard can lead
to false impressions and inaccurate conclusions
• Unknown dynamics of the complex gingival
environment
• Limited knowledge regarding what happens to
the binding, metabolism, and redistribution of
fluid components
33

34. IS GCF A TRANSUDATE OF
INTERSTITIAL FLUID
• The hypothesis of Alfano
– state that the initial fluid accumulation represents
a transudate of interstitial fluid produced by an
osmotic gradient
– later fluid represents a true exudate
34

35. BIOCHEMICAL MEDIATORS AND
PRODUCTS OF INFLAMMATION
• Antibodies to periodontopathic bacteria are
found in both serum and GCF of patients with
a history of periodontal infection
• Elevated levels of IgG were found at sites of
PD activity and demonstrated a positive
correlation with BOP and disease progression
35

36. CYTOKINES
• Specifically IL- 1α ,IL-1β,IL-6, IL-8 and TNF-α, have
been found in GCF
• IL-1 is released by activated macrophages PML ,
lymphocytes, and fibroblast is involved in
proinflammatory process, matrix destruction and
wound healing
– Due to its strong relationship with bone resorption
considered as potential marker for active tissue
destruction
36

37. • IL-1β concentration increase
significantly during episodes of
periodontal inflammation
–Cross- sectional studies have indicated
that the levels of IL-1β are increased at
periodontitis sites compared to
gingivitis and healthy sites
37

38. COMPLEMENT
• Activated forms of the complement system have
been found in the GCF (Niekrash and Patters 1986)
and are important in defense against foreign
substances
• An increase in C3 cleavage has been noted to
correlate positively with plaque accumulation and
subsequent development of gingivitis (patters et al
1989)
38

39. PROSTAGLANDINS
• Found abundance at sites of inflammation
• These potent molecules are associated with tissue
destruction , changes in fibroblast metabolism, and
bone resorption (Keuhl and Egan 1980)
• The levels of PgE2 in GCF have been reported to
correlate positively with periodontal inflammation
and impending tissue destruction (Offenbacher et al
1991)
39

40. • PGE2 levels have been noted to be elevated in
the GCF from pts with juvenile periodontitis
compared to pt with adult periodontitis and
gingivitis (Offenbacher et al 1984)
40

41. ΑLPHA 2 – MACROGLOBULIN
AND ΑLPHA 1 -ANTITRYPSIN
• Are acute-phase proteins found at all sites
where there is active acute inflammation
occuring with concomitant tissue destruction
• Under condition of experimental gingivitis ,
both of these proteins have been found in
elevated amounts
41

42. C-REACTIVE PROTEIN
• Acute –phase protein derived from serum
• It is found in most inflammatory exudate
• This protein coats bacteria and aids
complement binding
• Found in increased levels at sites of
inflammation
• does not show any differences in gingivitis or
periodontitis (Sibraa et al 1991)
42

43. LYSOZYME
• Is found in the azurophil granules of PMNs
• Is released at sites of acute inflammation
• This enzyme acts as a bactericidal agent by
cleaving the peptidoglycan component of
bacterial cell walls
• Levels of this enzyme in GCF do not
distinguish between adult periodontitis and
gingivitis
43

44. LACTOFERRIN
• Found within PMNL
• has antibacterial properties
• lactoferrin in normal crevicular fluid is 2 to 10
fold greater than that of lysozyme
• changes in the ratio of lysozyme to lactoferrin
may be of diagnostic value in distinguishing
gingivitis and periodontitis sites
44

45. TRANSFERRIN
• Antibacterial serum protein found at
inflammatory sites
• It acts in a manner similar to lactoferrin by
binding iron required for bacterial growth
• the level of transferrin in GCF has been noted
to increase with the development of gingivitis
45

46. ACID PHOSPHATASE
• Is an intracellular enzyme commonly used to
determine lysosomal activity
• its presence in gingival crevicular fluid does
not correlate well with the presence of
disease
46

47. HOST –DERIVED ENZYMES
• Levels of proteolytic and hydrolytic
enzymes in GCF be of potential value as
diagnostic marker
• These enzymes includes collagenase,
elastase, cathepsins , alkaline phosphatase
, arysulfatase and β-glucuronidase,
aspartate aminotransferase
47

48. COLLAGENASE
• GCF from sites with chronic or aggressive forms
of periodontitis exhibit significantly elevated
collagenolytic activities compared to GCF from
healthy or gingivitis sites
• May derived from host cells, including PMN
leukocytes, macrophages, fibroblast
,keratinocytes, osteoclasts bacteria
48

49. ELASTASE
• Neutrophil elastase, also referred as
granulocyte elastase, is an abundant
proteinase released from the azurophilic
granules of neutrophils
• An indicator of neutrophil activity
• Increased elastase in GCF was predictive of
periodontal attachment loss
49

50. • Neutrophil elastase is a serine
proteinase
• This enzyme can degrade host
intercellular matrix components,
including elastin, fibronectin, and
collagen.
50

51. ΒETA- GLUCURONIDASE
• is a lysosomal enzyme that is active in the
hydrolysis of glycosyl bonds of intercellular
ground substance
• Periodontal disease activity is associated with
increased levels of beta- glucuronidase in
gingival crevice fluid
51

52. EXTRACELLULAR MATRIX
COMPONENTS
• Both catabolic and anabolic products from the
extracellular matrix may be present in the GCF
• These are potentially important markers of disease
and tissue turnover (Embery et al 1991)
• These are collagen, proteoglycans and
glycosaminoglycans, osteonectin, fibronectin ,
osteocalsin
52

53. CLINICAL SIGNIFICANCE
• Circadian Periodicity:
– There is a gradual increase in gingival fluid
amount from 6:00AM to 10:00PM and a
decrease afterward
53

54. CLINICAL SIGNIFICANCE
• Sex hormones
– Female sex hormones increase the gingival
fluid flow, probably because they enhance
vascular permeability
– Pregnancy, ovulation and hormonal
contraceptives all increase gingival fluid
production
54

55. CLINICAL SIGNIFICANCE
• Periodontal therapy and GCF
–There is an increase in gingival fluid
production during the healing period after
periodontal surgery.
55

56. CLINICAL SIGNIFICANCE
• 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 GCF
56

57. CLINICAL SIGNIFICANCE
• Smoking and GCF
–Smoking produces as immediate
transient but marked increase in the
gingival fluid flow
57

58. DRUG IN GCF
• 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
• Metronidazole is another antibiotic that has been
detected in human GCF. (Eiserbeng et-al 1991)
58