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DEFENCE MECHANISM FOR GINGIVA

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Dr. Tapan Vanwani College of Dental Sciences & Hospital, Indore Gingiva is part of the soft tissue lining of the mouth. They surround the teeth and provide a seal around them. Most of the Gingiva is tightly bound to the underlying bone which helps resist the friction of food passing over them. The gingiva is a very important part of the oral anatomy, and caring for them is critical to maintaining oral health. The gingiva also creates a seal which prevents bacteria, plaque, and other foreign material from entering the roots of the teeth, where it could cause trauma or infection. The gingival cavity micro ecosystem, fueled by food residues and saliva, can support the growth of many microorganisms. Improper or insufficient oral hygiene can thus lead to many gingival and periodontal disorders, including gingivitis or pyorrhea, which is major causes for tooth failure. The gingival tissue is constantly subjected to mechanical & bacterial aggressions. A number of mechanisms operate to protect the body from attack by foreign bodies & toxins including infections by bacteria.

Non Specific Mechanisms

a) Bacterial balance:There exists a balance between different species of Microorganisms which maintains a Crevicular domain in mouth. b) Junctional Epithelium: The Junctional Epithelium has structural and functional features which contribute to prevent pathogenic bacterial flora from harboring sub gingival tooth surface. It acts in following ways:

1) Firm attachment to Tooth and thus forms an Epithelial Barrier. 2) Allows access of Gingival Crevicular Fluid (GCF), Inflammatory cells to Gingival Margin. 3) Exhibits Rapid Turnover, which contributes to host- parasite equilibrium. 4) It consists of Active cells having Anti Microbial Function, which together form First line of defenceagainst Microbial Invasion. Diagram showing Location of Junctional

Epithelium adjacent to tooth Diagram showing Antimicrobial substances produced by Junctional epithelium cells are Defensins, Lysosoma l enzymes, Interleukins (IL-1, IL-6, IL-8) and TNF- which prevent Microbial Invasion, form first line of defence. c) Sur face Fluids : All Vital surfaces are washed by fluids, which are capable of attacking foreign materials, e.g. Gastric acid, Lysozyme. These constitute mainly: 1) Saliva 2) GCF (Gingival Crevicular Fluid) Role of SALIVA in Defence of Gingiva: Saliva exerts a major influence on plaque initiation, maturation and metabolism. It also influences Calculus information, periodontal disease and caries. Salivary secretions are protective in nature, because they maintain the tissue in normal Physiologic state. Saliva exerts major influences: a) On Plaque by mechanically cleansing the exposed Oral Surfaces. b) By buffering acids produced by Bacteria. c) By Controlling Bacterial Activity. Saliva Contains : (i) Antibacterial factor: Saliva contains lysozymes, myeloperoxidase, lactoperoxidase, glucoproteins, mucins & antibodies etc. (a) Lysozyme: Lysozyme is a hydrolytic enzyme that cleavage linkage beta-1, 4- glycosidic bond of peptidoglycans of bacterial cell wall. Eg. Veilnell species Actinobacillus actinomycetemcomitans.

(b) Lacto- peroxidase thiocyanate: Bactericidal is some strains of lactobacillus & streptococcus by preventing accumulation of lysine & glutamic 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 & provide lubrication & physical protection. (e) Antibodies: 1) Saliva IgG, IgM and IgA antibodies. 2) IgG preponderant Immunoglobulin found in Saliva. 3) Antibodies prevents Opsonization of Bacteria. (ii) Buffers & coagulation factor: Salivary buffer bicarbonate carbonic acid system maintains 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. Poly Morpho Nuclear Leukocytes chiefly found in Saliva mainly causes the Phagocytosis of Bacteria. Role of Gingival Crevicular Fluid (GCF) in Defence of Gingiva: It is an Exudate found in Sulcus or Periodontal Pocket between the tooth and marginal gingiva. GCF is a complex mixture of Serum, Inflammatory cells, connective tissue, Epithelium, and microbial flora inhabiting the Gingival margin of Sulcus/pocket. GCF is secreted by Sulcular Epithelium in Gingival Sulcus. Its composition & possible role in oral defence mechanism were elucidated by WAERHANG,BRILL & KRASSE in 1950. LOE,HOLM- PEDESEN, WEINSTEIN, MANDEL ID & SALKIND demonstrated that GCF is a inflammatory exudate.

GCF provides a unique window for analysis of periodontal condition.

METHODS OF COLLECTION of GCF: These include: 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 cause oozing of fluid. Diag. showing collection of GCF

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 standardized length & diameter are placed in the pocket & their content is centrifuged & analyzed. Diagram showing collection of GCF through pipettes.

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 The amount of fluid collected on paper strip is evaluated by: 1. Staining

2. Electronic method 1. Staining: Wetted paper strips is stain by ninhydrin. It is than measured plan metrically on an enlarged photograph or a with help of magnifying glass or a microscope. 2.Electronic method: Fluid collected on a blotter (periopaper) employing an electronic transducer (periotron). Wettners of strip affects flow of current & a digital read out. Measurement performed by CIMASONI showed that a 1.5 mm wide strip paper inserted 1mm within the sulcus of inflamed gingiva absorbs about 0.1mg of fluid.

Periopaper

Periotron

CHALLACOMBE used an Isotope dilution method to measure the amount of GCF present in particular space at any given time. His calculation in human with Mean gingival index of less than 1 showed that mean GCF volume in proximal space of molar teeth ranged from: 0.43 to 1.56 microlitre. Periotron Reading Level of Gingival Inflammation 0-20 Healthy 21-40 Mild 41-80 Moderate 81-100 Severe Measures showing Periotron Indices in respect to Gingival Diseases COMPOSITION OF GCF It contains: a) Cellular elements. b) Electrolytes. c) Organic compounds. d) Metabolic & bacterial products. e) 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 confirming the possible stimulating effect of inflammation upon the renewal of sulcular or junctional epithelium.

Gingival Index 0 1 2 3

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. a) 95-97% Neutrophils b) 1-2% lymphocytes c) 2-2% monocytes Among lymphocytes a) 58% B lymphocytes b) 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

B. ELECTROLYTES: It contains mainly: a) Sodium b) Potassium c) Calcium C. ORGANIC COMPOUNDS: It contains mainly: a) Carbohydrates b) Proteins: Two types Immunoglobulin, Complement system. c) Lipids D. METABOLIC AND BACTERIAL PRODUCTS: It contains: a) Lactic Acid b) Hydroxyproline c) Prostaglandins d) Urea e) Endotoxins f) Cytotoxic Substances E. ENZYME AND ENZYME INHIBITORS : It contains : a) Acid Phosphatase b) Alkaline Phosphatase c) Pyrophosphatase d) Glucornidase e) Lysozyme f) Hyaluronidase g) Proteolytic enzymes ( e.g. Mammalian proteinases, Bacterial proteinase) h) Lactic dehydrogenase.

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. Therefore, Antibody response plays a protective role in periodontal disease.

Clinical significance of GCF: a) Gingival fluid is an inflammatory exudate. b) 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 exacerbation 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, vigorous gingival brushing, intrasulcular placement of paper strips increases 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 Gingival Crevicular Fluid: (GCF) When suitable drugs are given to patient, it can be carried from general circulation to Gingival Sulcus. The concentration of drug seems to be five times higher in Gingival Fluid as compared to the Blood Serum. The drugs which are detected in Gingival Crevicular fluid are: a) Minocycline b) Eryhthromycin c) Clindamycin d) Metronidazole Functions of GCF: a) It washes the Sulcus, carries out shed Epithelial cells. b) It contains many Anti Microbial Agents. c) It contains Neutrophils and Macrophages for Phagocytosing Bacteria. d) It transports Immunoglobulins and other immune factors to destroy Microorganisms. e) The monitoring of GCF and its contents is used diagnostically to access the severity of Gingival Inflammation, effectiveness of Oral Hygiene, response of tissue to Oral Hygiene. Summary: As we have seen that various component act in defence of Gingiva. Example: a) Sulcular Fluid b) Gingival Epithelium c) Saliva d) Leukocytes etc. The Sulcular fluid is one of the most important component of defence mechanism. These component acts through various mechanisms and enzymes resist against the mechanical and bacterial aggressions and maintain the Gingival health.