(Mừng, Hồng) Gingival Crevicular Fluid: An Overview

Abstract
Gingival crevicular fluid is an inflammatory exudate derived from the periodontal tissues.
It is composed of serum and locally generated materials such as tissue breakdown
products, inflammatory mediators, and antibodies directed against dental plaque bacteria.
It plays a special part in maintaining the structure of junctional epithelium and the
antimicrobial defense of periodontium. Some of the suspected periodontal pathogens
such as Porphyromonas gingivalis and Treponema denticola produce broad-spectrum
neutral proteinases as part of their virulence arsenal. These proteinases may be detected
in plaque and gingival crevicular fluid samples of patients with periodontitis. The
potential diagnostic importance of gingival fluid was recognized more than six decades
ago. The fluid component of gingival crevicular fluid is derived primarily from
microvascular (postcapillary venule) leakage. There are number of distinct advantages
and challenges of using gingival crevicular fluid as a diagnostic test for periodontal
disease.
Keywords: Exudate, leukocytes, periodontium
Introduction
Gingival crevicular fluid (GCF) is an inflammatory exudate derived from the periodontal
tissues. It is composed of serum and locally generated materials such as tissue breakdown
products, inflammatory mediators, and antibodies directed against dental plaque bacteria.
Its constituents are derived from a number of sources, including serum, the connective
tissue, and epithelium through which GCF passes on its way to the crevice.[1] GCF plays
a special part in maintaining the structure of junctional epithelium and the antimicrobial
defense of periodontium.
Various investigators[2] have confirmed that GCF is a complex mixture of substances
derived from serum, leukocytes, and structural cells of the periodontium and oral
bacteria.
Junctional Epitheliumin the Antimicrobial Defense
The junctional epithelium is firmly attached to the tooth and thus forms an epithelial
barrier against the plaque bacteria and allows the access of GCF, inflammatory cells, and
components of the immunological host defense to the gingival margin. It also exhibits
rapid turnover, which contributes to the host–parasite equilibrium and rapid repair of
damaged tissues.
GCF is an exudate of varying composition found in the sulcus/periodontal pocket
between the tooth and marginal gingiva. It contains components of serum, inflammatory
cells, connective tissue, epithelium, and microbial flora inhabiting the gingival margin or
the sulcus/pocket. In the healthy sulcus, the amount of GCF is very less.
During inflammation, the GCF flow increases and its composition starts to resemble that
of an inflammatory exudate. The increased GCF flow contributes to host defense by
flushing bacterial colonies and their metabolites away from the sulcus. The main route for
GCF diffusion is through the basement membrane and then through the junctional
epithelium into the sulcus.
(Duyên, Kiên) Mechanism of Gingival Crevicular Fluid Production
Molecular sieving
Two events occurring in the inflammatory process are responsible for molecular sieving:
a rise of hydrostatic pressure within the microcirculation and unlocking of endothelial
cell junctions [Figure 1].
Egelberg[3] obtained an increased permeability of the blood vessels of healthy gingiva by
the use of three different methods, such as topical application of histamine, gentle
massage of gingiva by a ball-ended amalgam plugger, and scrapping of the gingival
crevice by a blunt dental explorer.
Gingival crevicular fluid flow
GCF flow is the process of fluid moving into and out of the gingival crevice or pocket. It
is a small stream, usually only a few microliters per hour. Fluid flow is a rate measure. It
is the volume that crosses a defined boundary over a given time, mathematically
symbolized as dV/dt, the first derivative of volume with respect to time.
Significance of gingival crevicular fluid
To assess the severity of gingival diseases, the effectiveness of periodontal therapy and
oral hygiene, the healing following gingival surgery, and the effectiveness of oral
hygiene.
To evaluate the rate of local destruction, to assess the permeability of junctional and
sulcular epithelium, and to assess the relationship between periodontal and systemic
diseases.
Factors stimulating gingival crevicular fluid flow
1. Gingival inflammation, mastication of coarse food, pocket depth, intracrevicular
scraping, scaling, and histamine topical application.
2. Enzymes and sex hormones: Female sex hormones increase the gingival fluid flow
because they enhance vascular permeability.
3. Circadian periodicity: There is gradual increase in gingival fluid amount from 6 am
to 10 pm and a decrease afterward.
4. Post-periodontal surgery, restorative procedure, strip placement, mobility,
increased body temperature, and salivary contamination.
5. Ovulation, hormonal contraceptives, and smoking.

Figure 1: Mechanism of gingival crevicular fluid production

 (Trung, Thái, Ngiu) Methods of Collection
Absorbing paper strips
Filter paper strips were used to collect GCF by inserting the strips into the crevice (apical
direction) until mild resistance was detected or by inserting the strips at or over the
entrance of the pocket to pick up the seeping fluid.
The fluid volume on the strips was quantified by a number of ways:
1. Originally, strips were stained with a protein disclosing dye such as ninhydrin at
concentration varying between 0.2% and 2%. The stained area can be measured by
using a magnifying device such as a graded microscope.
2. The strips were weighed before collection within a scaled microcentrifugation
plastic tube and the weighing was repeated immediately after collection in the
same microtubule.
3. An electronic method has been devised for measuring the fluid collected on a
blotter (PerioPaper) using an electronic transducer (Periotron). This electronic
device measures the changes in capacitance across the wetted strip. This change is
converted into a digital readout that can be correlated to the volume of GCF.
Preweighed twisted threads
The threads were placed in the gingival crevice around the tooth, and the amount of fluid
collected was estimated by weighing the sample threads.[4]
Micropipettes
The use of micropipettes permits the absorption of fluid by capillarity. Capillary tubes of
standardized length and diameter were placed in the pocket and their content was later
centrifuged and analyzed. The capillary tubes may contaminate native GCF by the influx
of serum following disruption of the gingival vasculature.
Crevicular washings
The appliance designed by Oppenheim permits collection of gingival fluid without
disturbing the integrity of the marginal gingiva and this is a modification of that
described by Takamori[5] and the acrylic splint. It consists of a hard acrylic plate
covering the maxilla with soft borders and a groove along the gingival margin, which is
connected to four plastic cubes. Gingival washings are obtained by rinsing the sulcular
area for a fixed period from one side to another through the palatine and buccal channels
with 4–6 mL of solution using a peristaltic pump.
 Composition of Gingival Crevicular Fluid
Cellular elements
Epithelial cells: Fluid originating from areas with more severe gingivitis contained a
much higher proportion of cells typical to the deepest epithelial layer.
Leukocytes: It has been established that 47% of somatic cells obtained from the gingival
sulcus were leukocytes, whereas the presence of inflammatory cells in the gingival
crevice showed 98% of polymorphonuclear cells. The absolute number of cells increased
proportionately with the intensity of inflammation, whereas the differential count was
95–97% neutrophils, 1–2% lymphocytes, and 2–3% mononuclear cells.
Bacteria: Bacteria cultured from GCF were similar to those found in the adjacent dental
plaque electrolyte.
Electrolytes
Na:K: Na:K ratio in GCF is 3:9 as opposed to its ratio of 28:1, which confirms that the
fluid passes through damaged tissue due to accumulation of intracellular potassium from
disrupted cells.[6]
Fluoride, calcium, iodine, and phosphorus: Minerals.
Organic compounds
Carbohydrates: Glucose hexosamine and hexuronic acid are two of the compounds
found in gingival fluid.
Proteins: The total protein content of gingival fluid is much less than that of serum.
Immunoglobulins: The total immunoglobulin in GCF does not correlate with disease
severity or progressions and indeed may be lower at progressive sites.
Complement: Complement proteins are present in GCF from sites with inflammation and
the split fragments C3 and factor B have been detected during experimental gingivitis.
Cytokines: Interleukin-1 (IL-1) and tumor necrosis factor alpha (TNF-α) are produced by
activated macrophages and other cells. IL-1α and IL-1β are present in inflamed gingiva.
Metabolic and bacterial products: Metabolic products, amino acids and harmones:
Metabolic products such as lactic acid found in gcf. Amino acid such as hydroxyproline
is found in gcf, and harmone such a sprostoglandin is found in gcf.
 (Phúc, Châu, Sang, Văn) Enzymes
Proteolytic and hydrolytic enzymes of inflammatory cell origin
Inflammatory process leads to the release of polymorphonuclear neutrophils or
leukocytes (PMN), macrophages, lymphocytes, and mast cells. The lysosomes of these
inflammatory cells contain destructive enzymes that degrade the bacterial and metabolic
by products during the process of phagocytosis. These enzymes are, however, capable of
degrading gingival tissue components if released.
Collagenases and Related Metalloproteinase
Collagenases are a part of matrix metalloproteinase family that degrades collagen. They
are synthesized by macrophages, neutrophils, and fibroblasts and keratinocytes are
secreted by these cells as latent enzymes when stimulated by some bacterial products and
cytokines. Total enzyme activity levels were significantly higher and enzyme inhibitor
levels were lower at diseased sites compared with healthy or treated sites.[7]
Cysteine proteinases
Cathepsins B, L, and H are a family of cellular cysteine proteinases, which can degrade
extracellular components including collagen. They act at acidic pH and are particularly
active during bone resorption. They are also produced principally by fibroblasts,
macrophages, and osteoclasts.[8] Levels of cathepsins B and C were significantly
reduced following periodontal treatment.[9]
Aspartate proteinases
Cathepsin D is found in gingival tissue, and GCF levels have been shown to correlate
significantly with increasing gingival inflammation, probing depth, probing attachment
level, and bone loss.[10]
Serine proteinases
Elastase: Active elastase can only occasionally be detected in gingival tissue and is
usually seen adjacent to junctional epithelium where PMNs are migrating into the crevice
or in granulation tissue at the advancing front of the lesion.[11]
Tryptase: Tryptase activity is present in large amounts in gingival tissue and in small
amounts in GCF and has been localized to gingival mast cells.[12] Tryptase stimulates
the release of collagenase from gingival fibroblasts and in inflamed gingival tissues.
 Dipeptidyl Peptidase
Dipeptidyl peptidase II (DPP II), which is active at acidic pH, and DPP IV, which is
active at alkaline pH, are present in gingival tissue and GCF.
Myeloperoxidase, lysosome, and lactoferrin
Myeloperoxidase is a potent bacterial enzyme produced by PMNs, which are higher at
periodontal disease sites than healthy sites, whereas lysosomes are found in body
secretions notably tears and saliva and in GCF. Lactoferrin is an antibacterial agent
produced by inflammatory cells, which are found in GCF.
Aspartate Aminotransferase and Lactate Dehydrogenase
Aspartate aminotransferase is confined to the cell cytoplasm that is released by dead or
dying cells, whereas lactate dehydrogenase is present in the cytoplasm of erythrocytes,
thrombocytes, and leukocytes.
Markers of Connective Tissue Degradation
The markers of connective tissue degradation present in gcf are namely types I, III, and
IV collagen, proteoglycans, hyaluronan, fibronectin, laminin, and bone-specific proteins.
Drugs in the Sulcular Fluid
Metronidazole and tetracycline can eliminate tissue bacteria, and in conjunction with
scaling and root planning, they suppress actinomycetemcomitans levels. Tetracycline in
low doses inhibits the activity of collagenase and other collagenolytic enzymes.
Gingival Crevicular Fluid and Implants
The levels of neutral proteases were higher at moderately to severely inflamed implant
sites compared to mildly inflamed sites. The levels of neutrophil elastase,
myeloperoxidase, and β-glucuronidase were significantly higher around sailing implants
compared to successful implants.
The levels of IL-1β were approximately three times higher than those of the healthy sites
in GCF around implants. Significantly low activity of elastase and collagenase was
detected in osseointegrated implants than in adult periodontitis.
Summary and Conclusion
The studies of GCF chemistry have suggested the importance of an exuberant PMN
response to subgingival plaque in the active phases of periodontal destructions.
Furthermore, the accumulated data regarding the functional status of PMN at sites of
infection and inflammation suggest that the tissue destruction associated with an influx of
PMN is a result of PMN hyperactivity. Further studies should focus on defining the
equilibrium and identifying shifts in the equilibrium that occur with different periodontal
diseases and the related changes in GCF chemistry.
The search for markers of periodontal disease activity and progression has accelerated
over the last decade and research is being aimed at establishing a more objective and
quantitative methodology, capable of rapid diagnosis prior to the appearance of clinical
signs of destructive disease. GCF has emerged in the last decade as a new domain for
improved periodontal diagnosis and therapy. However, further longitudinal and cross-
sectional studies are required to unequivocally establish their credence as potential
markers.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Lamster IB. Evaluation of components of gingival crevicular fluid as diagnostic
tests. Ann Periodontal. 1997;2:123–37. [PubMed] [Google Scholar]
2. Eley BM, Cox SW. Proteolytic and hydrolytic enzymes from putative periodontal
pathogens: Characterization, molecular genetics, effects on host defenses and tissues and
detection in gingival crevice fluid. Periodontol. 2000;2003(31):105–
24. [PubMed] [Google Scholar]
3. Egelberg J. Permeability of the dento-gingival blood vessels: I. Application of the
vascular labelling method and gingival fluid measurements. J Periodontal
Res. 1966;1:181–91. [PubMed] [Google Scholar]
4. Weinstein E, Khurana H, Madel ID. Lactate dehydrogenase isoenzymes in gingival
fluid. Arch Oral Biol. 1972;13:375–6. [PubMed] [Google Scholar]
5. Takamori K. The growth stimulating factors for lactobacillus appeared in tissue fluid
from gingival crevice. Bull Tokyo Med Dent Univ. 1963;10:533. [Google Scholar]
6. Krasse B, Egelberg J. The relative proportions of sodium, potassium and calcium in
gingival pocket fluid. Acta Odontol Scand. 1962;2:143–52. [PubMed] [Google Scholar]
7. Larivée J, Sodek J, Ferrior JM. Collagenase and collagenase inhibitor activity in
crevicular fluid of patients receiving treatment for localized juvenile periodontitis. J
Periodontal Res. 1986;21:702–15. [PubMed] [Google Scholar]
8. Kennet CN, Cox SW, Eley BM. Comparative histochemical, biochemical and immune-
cyto-chemical studies of cathepsin B in human gingiva. J Peridontal Res. 1994;29:203–
13. [PubMed] [Google Scholar]
9. Eley BM, Cox SW. Crevicular fluid dipeptidyl peptidase activities before and after
periodontal treatment. J Dent Res. 1992;71:622–32. [Google Scholar]
10. Ishikawa I, Cimasoni G. Possible role of lysosomal enzymes in the pathogens of
periodontitis: A study of cathepsin D in human gingival fluid. Arch Oral
Biol. 1972;17:111–7. [PubMed] [Google Scholar]
11. Golub LM, Siegel K, Ramamurthy NS, Mandel ID. Some characteristics of
collagenase activity in gingival crevicular fluid and its relationship in gingival disease in
humans. J Dent Res. 1976;55:1049–57. [PubMed] [Google Scholar]
12. Kennet CN, Cox SW, Eley BM. Localization of active and inactive elastase alpha 1
proteinase inhibitor and alpha-2 macroglobulin in human gingiva. J Dent
Res. 1995;74:667–74. [PubMed] [Google Scholar]