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  • 1. GINGIVAL CREVICULAR FLUID DR. KHUSHBU MISHRA MDS 1ST YEAR

2. CONTENTS Introduction Definition Function History Formation Permeability of junctional and oral sulcularepithelium Methods of collection Problems during collection 3. Composition of GCF Brief review of pathogenesis of periodontitis Use of GCF inflammatory mediators as indicators of risk for Periodontal diseases Commercially available diagnostic kits Clinical significance Conclusion Recent findings in GCF References 4. Defence mechanism of oral cavity Defence mechanismSpecific 1. Humoral immunity 2. cell mediated immunityNon-specific 1.saliva 2.sulcular fluids 3.Higher tissue turnover 4.Intact epithelial barrier 5.Presence of normal flora 6.Local antibody production 7.Migrating leukocytes 5. Anatomy of the gingival creviceThe gingival 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.gingival crevicular fluidMonday, December 02, 20135 6. DefinitionA fluid occurring in minute amounts in gingival crevice, belived 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, 1982) 7. Functions :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.gingival crevicular fluidMonday, December 02, 20137 8. Studies on gingival crevice fluid (GCF) extend over a period of about 50 years The pioneer research of Waerhaug (1952) 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.(1962) laid the foundation for understanding the physiology of GCF formation and its composition. The studies of Le et al.(1965) ----- use of GCF as an indicator of periodontal diseases.gingival crevicular fluidMonday, December 02, 20138 9. Egelberg continued to analyze GCF and focused hisstudies 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.gingival crevicular fluidMonday, December 02, 20139 10. It was soon understood that enzymes released from damaged periodontal tissue possessed an enormous potential for periodontal diagnosis. Presence and functions of proteins Sueda, Bang and Cimasoni. Collagenases and Elastase in GCF are derived from human cells - Ohlsson, Golub, Uitto. Goodson thoroughly studied major issues in GCF flow rate and its method of collection. 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.gingival crevicular fluidMonday, December 02, 201310 11. In 1974 the first edition of the monograph The Crevicular Fluid by Cimasoni was published. Thiscomprehensive review gave a big boost to GCF studies and towards the end of the first millennium the research on GCF increased dramatically.gingival crevicular fluidMonday, December 02, 201311 12. Timelinegingival crevicular fluidMonday, December 02, 201312 13. Formation of GCF GCF is formed at the rate of 0.5- 2.4 ml/day. There are 2 theories that suggest the formation of GCF. Theory 1 (Brill and Egelberg)Increase in the permeability of vessels seepage of fluids in sulcus Formation of GCF 14. Theory 2 From the work of Alfano (1974) and from the hypothesispostulated 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. 15. The model proposed by Pashleypredicted that GCF production is governed by passage of interstial fluid from capillaries tissues lymphatic system). When the rate of when capillary filtrate exceeds that of lymphatic uptake, fluid will accumulate as edema and/or leave the area as GCF gingival crevicular fluidMonday, December 02, 201315 16. Factors modulating: Filtration coefficient of the lymphatic and capillaryendothelium 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.gingival crevicular fluidMonday, December 02, 201316 17. PERMEABILITY OF JUNCTIONAL AND ORAL SULCULAR EPITHELIA Substances that have been shown to penetrate the sulcularepithelium include albumin, Endotoxins, thymidine, histamine, phenytoin, per oxidase. The main pathway for the transport of substances acrossthe 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. gingival crevicular fluidMonday, December 02, 201317 18. According to Squier (1973) the degree of permeability of theoral 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 throughpathological or experimentally modified gingival sulcus.gingival crevicular fluidMonday, December 02, 201318 19. Brill was also first to show the presence of plasmaproteins 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 pocketgingival crevicular fluidMonday, December 02, 201319 20. Methods of collection 21. Absorbent filter paper stripsThese strips are placed for 3 mins and GCF sample is collected by 2 methods. a) Intrasulcular or Brill technique within the sulcus b) Extracellular or Loe & Holm pederson technique- at its entrance. 22. Evaluation of amount of fluid collected by paper strips 1. 2.Direct viewing and staining Weighing of the strip1. Direct viewing and staining: Alcoholic solution of ninhydrin (0.2%) -blue purple pink Measured with transparent scales, calipers, caliberated magnifying glassgingival crevicular fluidMonday, December 02, 201323 23. Disadvantages of staining method: Cannot be used chair side. Inevitable delay in measurement may result in increasevariation due to evaporation of the fluid. Staining of the strips for protein labeling prevents further lab investigations. 2. Weighing of strips Sealed micro centrifugation plastic tube. 24. PERIOTRONAn electronic method has been devised for measuring gingival fluid absorbed on paper strips by Harco electronics called Periotron (Dental product division Winnipeg, Manitoba, Canada). latest and standard method for measuring gingival fluid absorbed on paper strips. gingival crevicular fluidMonday, December 02, 201325 25. Developed by Harco electronics Principle:- The wetness of the paper strip affects the flow of an electronic current It has 2 metal jaws which acts as the plates of an electrical condenser. When a dry strip is placed 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.gingival crevicular fluidMonday, December 02, 201326 26. Advantages Simple procedures, can be viewed directly. Quantitative assessment of fluid can be obtained. Evaporation is kept minimum. Disadvantages Contamination can occur. In case of evaporation, has to be repeated many times. Care should be taken to insert paper strip in standardized position. inability to measure the volume of GCF greater than 1.0l. 27. Pre-weighed twisted threadsThread is placed in the gingival crevice around the tooth and the amount of fluid collected is estimated by weighing the sample thread. Used by WEINSTEIN et al.gingival crevicular fluidMonday, December 02, 201328 28. Micropipettes/ capillary tubing Krasse and Egelberg 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. And finally, their content is then centrifuged and analyzed. 29. Disadvantages Collection of fluid is difficult due to viscosity of the fluid. Recovery of sample is demanding. Long collection period. May cause trauma as prolonged holding of pipette is required. 30. Crevicular washings 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