INTRODUCTION

The gingival tissue is constantly

subjected to mechanical & bacterial
aggressions.
Resistance to these action is provided
by:
1. Epithelium
2. gingival crevicular fluid
3. saliva
THE ROLE OF THE GINGIVAL
EPITHELIUM
The role of gingival epithelium in
defence by its degree of keratinization
& turn over rate.
Epithelium constitutes a continuous
lining of stratified squamous
epithelium.
Principle cells of this epithelium is
keratinocytes.
Other cells are non keratinocytes
which includes langerhan’s cells,merkel
cells & melanocytes.
The main function of the epithelium is
to protect the deep structure while
allowing selective intechange with oral
environment. This is achived by
proliferation & differtiation of the
keratinocytes.
Differentiation of keratinocytes by
keratinization process which leads to
production of an orthokeratinized
superficial horny layer which is made up
of mainly keratin protein.
This layer makes intact barrier between
the oral environment & deep layers.
 Other protein keratolinin & involucrin
forms a chemically resistant structure
(envelop) located below the cell
membrane.
The upper most cells of the stratum
spinosum contains dense granules known
as keratinosomes or odland bodies which
are modified lysosomes. They contain
large amount of acid phosphatase.
Acid phosphatase activity is related to
the degree of keratinization.
 Langerhans cells located among
keratinocytes at supra basal levels.
They belong to the mononuclear
phagocyte system as modified
monoctes.
They have an important role in immune
reaction as antigen presenting cells for
lymphocytes.
GINGIVAL CREVICULAR
FLUID
GCF is secreted by sulcular epithelium
in gingival sulcus.
The presence of crevicular fluid has
been known since the 19th century.
Its composition & possible role in oral
defence mechanism were elucidated by
WAERHANG,BRILL & KRASSE in 1950.
 Studies of BRILL considered that GCF
is a continuous transudate.
LOE,HOLM- PEDESEN, WEINSTEIN,
MANDEL ID & SALKIND demonstrated
that GCF is a inflammatory exudate.
METHODS OF
COLLECTION

o These includes:
1. Use of absorbing paper strips
2.Twisteel threads
3.Micropipettes
4.Intra crevicular washing
 1. Use of absorbing paper strips:
 Paper strips are placed into the sulcus
or pocket.
 This method causes the irritation of
the sulcular epithelium that can oozing
of fluid.

2. Extra sulcular method:

 Paper strips are placed at the entrance
or over the sulcus or pocket.
 The fluid seeping out is picked up by
the strip.
 3. Twisted threads:
 Preweighed twisted threads are placed
in the sulcus around the tooth & the
amount of fluid collected is estimated
by weighing the thread.

4. Micropipettes:
 Micropipettes (capillary tubes) of
standerized length & diameter are
placed in the pocket & their content is
centrifuged & analyzed.
 4. Intra crevicular washing:
 A acrylic plate appliance is used in this
method.
 Plate covering the maxilla with soft
border & groove following the gingival
margins.
 This appliance is connected by 4
collection tubes ,2 on palatal sides & 2
on buccal side.
 The washing is obtained by rinsing the
crevicular area from 1 side to the
other using a peristaltic pump.
 AMOUNT OF GCF

o The amount of fluid collected on paper

strip is evaluated by:
1. Staining
2. Electronic method
1. Staining:
o Wetted paper strips is stain by
ninhydrin.
o It is than measured planimetrically on
an enlarged photograph or a with help
of magnifing glass or a microscope.
 2.Electronic method:
o Fluid collected on a ‘blotter’
(periopaper) employing an electronic
transducer (periotron).
o Wettners of strip affects flow of
current & a digital read out.
o Measurement performed by CIMASONI
showed that a 1.5 mm wide strip paper
inserted 1mm within the sulcus of
inflammed gingiva absorbs about 0.1mg
of fluid.
o CHALLACOMBE used an isotope dilution
method to measure the amount of GCF
present in particular space at any given
time.
o His calculation in human with mean
gingival index of less than 1 showed
that mean GCF volume in proximal spce
of molar teeth ranged from 0.43 to
1.56 microlitre.
 COMPOSITION OF GCF
o It contains:
 Cellular elements
 Electrolytes
 Organic compounds
 Metabolic & bacterial products
 Enzymes & enzymes inhibitors
A. Cellular elements
1. Epithelial cells:
Oral sulcular epithelium & junctional
epithelium are constantly renewing & shed
cells will be found in GCF.
Krekelar & ochs showed that fluid originated
from area with more severe gingivitis contains
a much higher proportion of these cells thus
conferming the possible stimulating effect of
inflammation upon the renewal of sulcular or
junctional epithelium.
2. Leukocytes
The major site of entrance of leukocytes in oral
cavity is the gingival sulcus.
In sulcus the differential leukocytes count are
present in following relative proportion.
95-97% neutrophils
1-2% lymphocytes
2-2% monocytes
Among lymphocytes –
58% B lymphocytes
24% T lymphocytes
Number of leukocytes increase
with the intensity of
inflammatory process.
Their main function is phagocytic
& killing of bacteria therefore
they constitute a major
protective mechanism.
3.Bacteria
Bacteria cultured from GCF is similar
those grown from adjacent dental
plaque.
Eg. Strepto sanguis
Actinomyces viscosus
Porphyromonas gingivalis
Porphyromonas endodentalis
Camphylobacter rectus
Prevotella intermedia
B. Electrolytes
Na, k, Ca, F have been studied in
GCF.
1. Na concentration:
The investigation of GCF in
inflammed gingiva by matsue (1967)
show an average concentration of Na is
207- 222 meq Na \ litre.
While normal gingival fluid contains
158 meq Na/litre.
 2. K concentration:
Matsue reported that K
concentration is 69 meq K / litre
in inflammed area.
Normal GCF contains K conc. is
9.54 meq k / litre.
3.Na: k ratio:
Study of krasse & egelberg (1962)
showed that GCF of inflammed gingiva
contain Na:k ratio is 3:9.
While normal GCF shows Na:k ratio is
28:1.
4.concentration of other ions:
Ca, Mg, phosphate ion, chlorine ion have
also been determined in known amount in
GCF.
Krasse & egelburg (1962) reported Na:Ca
ratio average about 10 in normally healthy
gingiva.
In inflammed gingiva this ratio is 18.
Weinstein et al (1967) reported that ca:
protein ratio much higher in gingival fluid
than serum this ratio tended to decrease
in fluid from more inflammed areas.
 C. Organic compounds
Mainly 3 substances reported in crevicular
exudate.
1. Carbohydrates
Glucose
Hexasamine
Hexuronic acid
Exudate glucose content is higher in
inflammed gingiva than normal gingiva.
This is interpreted not only as a result of
metabolic activity of tissues but also as a
function of local microbial flora.
2.proteins
5 proteins alpha,beta,alpha 1,alpha 2
globulin & albumin were reported in
GCF.
Holmberg & killander confirmed that
IgG,IgA & IgM immunoglobulin are
present in GCF.
These immunoglobulins might
significantly contribute the oral
defence mechanism.
 3.Lipids:
• Gingival fluid contains many classes of
phospholipids as well as neutral lipids.
D. Metabolic & bacterial
products
1. Lactic acid:
Lactic acid present in gingival fluid
was reported positively correlation
to both the degree of
inflammation & intensity of gingival
fluid flow.
Its origin considered mainly tissue
origin.
2. Hydroxyproline:
Hydroxyproline is a major break
down products of collagen.
Its presence in gingival fluid is on
indicator of the rate of progression
of periodontal disease.
3.Prostaglandins:
It is a component of inflammatory
reaction.
Inflammed gingiva show more
concentration of prostaglandins.
It causes vasodilatation, bone
deposition & inhibition of collagen
synthesis.
4. Endotoxins:
Endotoxins released from gram
negative bacteria are highly toxic
to gingival tissue & pathogenic
factor in periodontal disease.
5.Cytotoxic substance:
Cytotoxic substance like
hydrogen sulphide which is toxic
metabolite of bacteria origin also
reported in gingival fluid &
causes gingival inflammation.
6. PH of gingival fluid:
Production of ammonia by
microorganism causes elevation of
PH.
Elevated PH increases the severity
of gingivitis & periodontitis.

7. Antibacterial factor:
Antibacterial factor like leukocytes
& flow of crevicular fluid is able to
remove various kinds of bacteria
from gingival pocket.
E. Enzyme & enzyme
inhibitor:
1. Acid phosphatase:
The main source of acid phosphatase in
crevicular area are probably the PMNs &
desqamating epithelial cells.
In PMNs the enzyme is confined with in
the azurophil granules.
Acid phosphatase is bacteriocidal.
It attacks teichoic acid which is 1 of
the components of the bacterial all wall.
 The enzyme is also found in bacteria
including those of the gingival sulcular
pocket.
Eg. Actinobacillus
Capnocytophaga
Veilloonella
 2. Alkaline phosphatase :
• The concentration of this enzyme is
significantly correlated with pocket
depth.
• This enzyme present in PMNs,
exclusively in specific or secondary
granules.
• Some gram negative subgingival plaque
bacteria also produces alkaline
phosphatase activity.
 3. Beta glucuronidase:
Beta glucuronidase is 1 of the
hydrolyses found in the azyrophilic or
primary granules of PMNs.
Beta glucuronidase is probably
responsible for the final degradation
of the oligosaccharides produced
initially by the action of hyaluronidase.
Beta glucuronidse also found in plaque
bacteria.
4. LYSOZYME:
Lysosome has bactericidal properties.
Its ability to hydrolyze B-1, 4-
glycosidic bond of peptidoglycans of
the bacterial cell wall.
It is found in PMNs.
The free enzyme may contribute to
pocket formation by its detrimental
effect upon epithelial cell stickness &
lytic activity of connective tissue.
It also accelerates the local release
of intracellulr bacterial enzyme.
5. Hyaluronodase:
Hyaluronidase splits B-1, 4-N-
acetyl glucasaminide link in
hyaluronic acid, condroitin 4 –
sulphate & condroitin 6- sulphate
which is components of bacterial
cell wall.
6. Proteolytic enzyme:
Proteinases might have major role in
the destruction of tissue component
during inflammation.
Mammalian proteinase:
(i) Cathepsin D:
It is a carboxy endopeptidase 1 of the
chief acid enzyme in lysosomes present
at high concentration in inflammed
tissues.
It is abundant in mononuclear
leukocytes.
(ii) Elastase:
Elastase found in azurophilic granules
of PMNs.
These are analogus to lysosomes.

(iii) Cathepsin G:
It is the serine endopeptidase
contained into the azurophilic granules
of PMNs.
It hydrolyze hemoglobin, fibrinogen,
casein, collagen & proteoglycan.
(iv) Plasminogen activators:
It is serine proteinase.
It activates the components of complement
which cause increased vascular permeability
& accumulation of PMNs & monocytes.
It also help in wound healing.

(v) Collagenase:
It is found in PMNs. (Specific granules)
It causes degradation of collagen.
Bacterial proteinase:
It includes serinr
endopeptidase,fibrinolytic enzyme,
bacterial collagenase etc.

Serum proteinase inhibitor:

These are mainly alpha-2
macroglobulin, alpha-1 anti tyypsin,
alpha -1 anti chymotrypsin.
These inhibits proteinase enzymes.
Its concentration increased during
inflammation.
Cellular & humoral activity
in GCF
Analysis of GCF has identified cellular &
humoral response in both healthy individuals &
these with periodontal disease.
The cellular immune response includes the
appearance of cytokines in GCF but there is
no clear evidence of a relationship between
them & disease.
Interleukin-1 alpha & -1 beta are known to
increase the binding of PMNs & monocytes to
endothelial cells, stimulate the production of
PGE2 & release of lysosomal enzyme &
stimulate bone resorption.
 There is also preliminary evidence of the
presence of y- interferon in GCF which may
have protective role in periodontal disease
because of its ability to inhibit the bone
resorption activity of interleukin -1B.
Presence of antibodies in GCF, its role in
gingival defence mechanism is Hard to
ascertain, there is a consensus indicating
that :
In a patient with periodontal disease a
reduction in antibody response is
deterimental.
Antibody response play a protective role in
periodontal disease.
Clinical significance of GCF:

Gingival fluid is an inflammatory

exudate.
Its presence in clinically normal sulcus
can be explained by the fact that
gingiva that appears clinically normal
exhibits inflammation when examined
microscopically.
 A. General health & gingival fluid:
(i) Circadian periodicity:
There is a gradual increase in gingival fluid amount
from 6.00 AM to 10.00 PM & decrease afterwards.

(ii) Sex hormones:

Female sex hormones increase the gingival fluid flow,
probably they enhance vascular permeability.
Clinical investigations have been shown an excerbation
of gingivitis during pregnancy, menstrual cycle & at
puberty.
B. Measurement of gingival inflammation:
Increased GCF is a sign of inflammation.

C. Influence of mechanical stimuli:

Chewing, vigrous gingival brushing,
intrasulcular placement of paper strips
increased the production of GCF.
D. Periodontal therapy:
There is a increased in gingival fluid
production during the healing period
after periodontal therapy.

E. Smoking:
Smoking causes marked increase in
gingival fluid.
 Drugs in GCF:

o Some antibiotics
o Eg. Tetracyclin, metronidazole, are
detected in GCF.
 Saliva
Salivary secretion are protective in
nature because they maintain the oral
tissue in a physiologic state.
Saliva exerts major influences:
o On plaque by mechanically cleansing the
expose oral surfaces.
o By buffering acids produced by
bacteria.
o By controlling bacterial activity.
• Saliva contains:
(i) Antibacterial factor:
Saliva contains lysozymes,
myeloperoxidase, lactoperoxidase,
glucoproteins, mucins & antibodies etc.
• (a) Lysosomes:
Lysosomes is a hydrolytic enzyme that
clevage linkage beta-1, 4- glycosidic
bond of peptidoglycans of bacterial cell
wall.
Eg. Veillnell species
Actinobacillus actinomycetemcomitans
(b) Lacto- peroxidase –thiocyanate:
Bactericidal is some strains of
lactobacillus & streptococcus by
preventing accumulation of lysine &
glutamia acids both of which are
essentials for bacterial growth.

(c) Myeloperoxidase:
It is bactericidal for actinobacillus.
(d) Glycoproteins & mucin:
It forms coating layer over tissue
structures & provides lubrication &
physical protection.

(e) Antibodies:
Saliva contains IgG,IgM & IgA
antibodies.
IgG preponderant immunoglobulin found
in saliva.
Antibodies causes opsonization of
bacteria.
(ii) Buffers & coagulation factor:
Salivary buffer bicarbonate – carbonic acid
system maintain the physiologic pH of oral
cavity.
Saliva contains coagulation factor- factor
viii, ix, x, PTA & hagman factor that
hasten blood coagulation & protect wound
from bacterial invasion.

(iii) Leukocytes:
Leukocytes reach the oral cavity migrating
through the gingival sulcus.
PMNs leukocytes chiefly found in saliva
that causes the phagocytosis.
 Summary:
o As we have seen that various component act in
defence of gingiva
o Eg. Sulcular fluid
Saliva
Gingival epithelium
Leukocytes etc.
o In which sulcular fluid is 1 of the most
important component of defence mechanism.
o These component through various mechanism
& enzymes resist against the mechanical &
bacterial aggressions & maintain the gingiva
normal healthy state.