SALIVA & GCF

SMRITI NARAYAN THAKUR DEPT. OF PROSTHODONTIC & MAXILLOFACIAL PROSTHETICS PEOPLES DENTAL COLLEGE DATE -1/06/2012

SALIVA

CONTENTS
SALIVA
Introduction Functions. Composition & Properties Anatomy & Histology of Salivary Glands Physiological considerations Clinical considerations. Saliva as a diagnostic tool.

GCF

Introduction Formation Composition GCF flow Methods of collection Clinical significance Conclusion References

Introduction
Saliva is a clear and slightly alkaline mucoserous exocrine secretion. It is a complex mixture of fluids, with contributions from major salivary glands ,parotid submandibular and sublingual, the minor or accessory glands and the gingival crevicular fluid.

Saliva refers to the mixture of fluids from the salivary glands, the gingival fold, oral mucosa transudate, mucous of the nasal cavity and pharynx, non-adherent oral bacterial, food remainders, desquamated epithelial and blood cells, as well as traces of medications or chemical products

 When referring to the fluid normally mouth present in the

the term whole

saliva is commonly used, as distinct from duct saliva which is that flowing from

the individual glands.

Functions

Chronology of defining salivary components and functions

Beginning in 1950s whole saliva evaluated (antimicrobial properties, role in microbial attachment, mineralization, taste, lubrication) Secretions of major glands (parotid and submandibular/sublingual) In 1970s individual components isolated and biochemically characterized In mid-1980s beginning to map functional domains (peptide synthesis and recombinant approaches)

COMPOSITION
water -99.5% solid substances- inorganic 0.2% organic 0.3%. Organic constituents: Protein: 200mg/100ml(only 3% of the protein concentration in plasma). Enzymes ,immunoglobulins, mucous glycoprotiens , traces of albumin , poly peptides etc.

Alpha amylase :
Major digestive enzyme. Parotid-60to120mg/100ml. Submandibular-25mg/100ml. Hydrolysis of alpha 1:4 glycoside bond- end product is maltose. Immunoglobulins:
Secretary IgA- predominant-20 mg /100ml
IgG-1.5mg/100ML IgM-0.2mg/100ml,arising from gingival crevice

Antibacterial Proteins
-Lysozyme-attacks components of the cell wall of certain bacteria leading to lysis. -Lactoferrin-iron binding protein- removes free iron from saliva depleting the supply of iron needed for bacterial growth. -Sialoperoxidase- oxidizes salivary thiocyanate ion to hypothiocyanate- potent antibacterial substance using hydrogen peroxide produced by oral bacteria as an oxidant.

-Glycoprotiens : MG1 and MG2- submandibular and sublingual saliva & a group of Proline rich glycoprotiens (PRPs)-parotid saliva. Other poly peptides: - Statherin- rich in tyrosine and proline- inhibits the hydroxyapatite crystal growth- inhibitor of calculus formation both in glands and on the teeth. - Sialin- helps to regulate the Ph of plaque.

Other Organic Compounds

Many free amino acids are present at low concentration. While

saliva can be used by some oral bacteria as a sole source

medium.

of

nutrient ,the amino acid content is too low to provide a rich growth

Urea - hydrolyzed by many bacteria with release of ammonia increase in pH.

Glucose- 0.5mg/100ml- are too low to support extensive growth, but

may be raised in diabetics.

Inorganic constituents of whole saliva(mg/100ml)

Saliva
Physical properties; - Volume ;daily secretion is about 800 -1500ml.

Appearance ; a clear colourless fluid.

pH = 6 7.4 (to suit the digestive action of the - amylase ) .

Specific gravity 1.002 1.008 .

Multifunctionality
Amylases, Cystatins, Histatins, Mucins, Peroxidases Carbonic anhydrases, Histatins AntiBacterial Buffering Amylases, Mucins, Lipase Digestion Salivary Families

Cystatins, Mucins

AntiViral

AntiFungal
Histatins Tissue Coating

Mineralization Lubrication &Viscoelasticity

Cystatins, Histatins, Prolinerich proteins, Statherins

Amylases, Cystatins, Mucins, Proline-rich proteins, Statherins

Mucins, Statherins

Amphifunctionality
A molecule may have both protective and detrimental properties - double-edged sword. May depend on molecules location or site of action
Amylases
In solution, they facilitate clearance of viridans streptococci Adsorbed to tooth surface, they can promote adherence of these bacteria and digest starch to dietary maltose and production of acid.

Statherin and acidic proline-rich proteins

At enamel surface, they play an important role in mineralization by inhibiting the formation of primary and secondary calcium phosphate salts. When adsorbed to the enamel surface, they promote attachment of cariogenic microorganisms.

 Functional relationships exist between different molecules in saliva. Two types of complexing (covalent and non-covalent)
homotypic (between similar molecules) heterotypic (between different molecules)

Complexing

Example: Mucins
homotypic complexes necessary for lubrication and viscoelastic properties. heterotypic complexes with sIgA, lysozyme and cystatins concentrate these anti-microbials at tissue interfaces

ANATOMY AND HISTOLOGY OF THE SALIVARY GLANDS

CLASSIFICATION OF SALIVARY GLANDS

According to the size: Major-3pairs Parotid Submandibular Sublingual Minor-400 TO 500 .- Glossopalatine, Buccal , Mucous glands of the cheek etc , spread in the oral cavity except at the gingiva and anterior part of the hard palate.

According to the location Glands whose duct open in the vestibule

Lip : superior labial and inferior labial Cheek: parotid and buccal.

Glands whose duct open in the oral cavity proper Floor of the mouth: submandibular, sublingual, glossopalatine. Tongue: Body: anterior lingual (of blandin & nuhn) Base: posterior lingual, von ebner. Palate- palatine.

According to the type of salivary secretion and duct opening:

a serous secretion (thin watery) containing the enzyme ptyalin

for the digestion of starchy foods.

a mucous secretion (viscid sticky or adhering) for lubrication.

serous- parotid , von ebner. mucous- palatine, posterior lingual mixed- predominantly serous - submandibular mixed- predominantly mucous-sublingual blandin & nuhn,

buccal &labial

PAROTID GLAND
60-65% of total salivary volume Pyramidal in shape

Parotid duct (Stensons duct) leaves the mesial angle of the gland and opens into the oral cavity close to the buccal surface of the maxillary first molar tooth. duct -5cm long and 3mm internal diameter

22

SUBMANDIBULAR(SUBMAXI LLARY) GLAND 20-30% of total salivary volume

Irregular, walnut in shape

Whartons duct - sublingual papilla at the side of the lingual frenum Tortuous duct-approximately 5cm long

23

SUBLINGUAL GLANDS 2-5% of total salivary contents

Lie beneath oral mucosa lining the floor of mouth. Series of small ducts (Bartholins ducts)sublingual folds on either side of the tongue.
24

Basic Histologic Structure

Secretory unit acinus myoepithelial cells intercalated duct striated duct excretory duct
.

25

Acinar cells- secretory granules serous glands - amylase mucous glands - mucin

26

Functions of ducts:
The main function of salivary gland ducts is to, convey the primary saliva secreted by the terminal secretory units to the oral cavity. They are not just passive conduits also they actively modify the primary saliva by secretion and reabsorption. Essentially all of the water enters saliva at the level of terminal secretory units, the striated and excretory ducts appear to be relatively impermeable to water

Saliva secretion
The secretion of saliva is a two stage operation : The first stage involves the production of the primary secretion which is an isotonic fluid that contains water, eletrolytes, mucus,and enzymes by the acini gland cells. In the second stage the fluid secreted by the acini cells will flow out to the collecting ducts , and within the ducts the composition of the primary secretion is altered by ; - the active reabsorbtion of Na+ . - the active secretion of K+ . -Cl- passive reabsorption. - HCO3 - secretion.

Small collecting ducts within salivary glands will carry the saliva to larger ducts, eventually forming a single large duct that empties into the oral cavity.

THE SECRETORY UNIT

The basic building block of all salivary glands ( Acini)

ACINI - water and ions derived from plasma

Saliva formed in acini flows down DUCTS to empty into the oral cavity.

Secretory Unit (salivon)

The basic unit salivon consists of: Acinus -initial secretory process Intercalated duct -initial portion of duct Striated duct -modification of secretory product Myoepithelial cells surround acinus and intercalated duct contraction moves saliva, prevents development of back pressure

TWO STAGE HYPOTHESIS OF SALIVA FORMATION

Most proteins

Na+ Cl- resorbed

Water & electrolytes

Some proteins

electrolytes

Hypotonic final saliva into mouth

Isotonic primary saliva

K+ secreted

Regulation salivary secretion

Innervation
Parasympathetic Abundant, watery saliva Amylase Sympathetic (superior CG) Scant, viscous saliva Amylase up
Parotid -parasympathetic fibers originate from CN IX -Lesser Superficial Petrosal nerve otic ganglion- auriculotemporal
Submandibular and Sublingual glands CN VII - Chorda Tympani - Submandibular ganglion

33

SALIVARY FLOW RATE

Flow rate= volume (milli litres) of saliva minute there is great variability in individual salivary flow rate. The accepted range of normal flow ml/min is as follows:

Methods of measurement of flow rate:

techniques for assessing salivation & salivary secretion
rate has been reviewed and evaluated by many authors.

Accurate measures of salivary flow rate are required for a variety of clinical and experimental situations.

Two methods- a.measurement of whole saliva

b.measurement of parotid saliva.. Techniques for measurement of whole saliva unstimulated (resting) Draining method Spitting method Suction method

Swab method

Techniques for collection stimulated whole saliva

Masticatory method (standardized piece of paraffin used) .

Gustatory method(1% to 6% citric acid used )

The spitting method for estimating resting flow and

masticatory method with paraffin chewing for stimulating

saliva for measuring flow rates are reliable.

SALIVARY FLOW AND AGEING

Flow rate of unstimulated (resting )whole saliva with age:

Since 70% of whole resting saliva comes from submandibular and sublingual glands , the decrease in its flow with age must largely be due to decrease in production. Histological findings demonstrate that there is 20 to 30% decrease in volume of salivary acini with age.
On the other hand numerous functional studies have failed to show any age related decrease in the flow of parotid saliva as the normal resting flow rates of parotid saliva are extremely small 0.04 to 0.06 ml/min .Therefore often no saliva can be obtained and the frequency of not obtaining it increases with age .

Effects of Aging
Total salivary flow independent of age Acinar cells degenerate with age Submandibular gland more sensitive to metabolic/physiologic change

40

Flow rate of stimulated whole saliva:

The relationship SFR and ageing- of whole saliva is mixed. Most studies show no change or only a modest decrease in flow rate even though the histological findings show a significant decline in the volume of salivary acini. The fact that this acinar reduction does not affect the stimulated flow rate of saliva should not be surprising- most organs when stimulated, compensate for the loss of parenchyma. Other factors influencing salivary flow rate: Diurnal variation, drugs, source of saliva, diet, duration and type of stimuli, hormones

Clinical considerations

XEROSTOMIA
It is a subjective sensation of a dry mouth, frequently but not

always associated with salivary gland hypofunction.

Dryness of mouth is one of the oldest symptoms recorded by

man.

Ancient records describe the use of rice tests to determine guilt or innocence: if innocent-ingestion of rice will stimulate the flow of saliva, if guilty mouth will be dry and swallowing difficult or even impossible.

CAUSES OF XEROSTOMIA

Diagnosis of xerostomia
Clinically Medical history, H/o radiation chemotherapy, oral infections, questionnaire. Dentists should provide the patients with a dry mouth questionnaire Do you sip liquids to aid the swallowing of foods? Does your mouth feel dry when eating? Do you have difficulties swallowing any foods? Does your mouth usually become dry when you speak? Lab tests: flow rate tests , sialometry ,etc.

MANAGEMENT
Reassurance, symptomatic and supportive care. Patient education- to compensate for the oral dryness patient may stop chewing & prefer a liquid or a semisolid diet rich in fermentable carbohydrates.

Because decreased mastication worsens the condition ,

patients should undergo nutritional counseling to limit the

harmful effects of reactionary diet modifications.

 Patient should be reminded to chew , as periodontal

mechanoreceptors & mechanical stimulation of the tongue & oral mucosa are vital stimuli for salivation. Sugar free candies & chewing gum are recommended .

Should sip cool water throughout the day and drink milk with their meals.

 Water is a poor mucosal wetting agent, lacks buffering capacity, lubricating mucins. Whole milk may serve as a better substitute. Citrus fruits, caffeine and alcohol, alcohol containing mouth washes cause dehydration & must be avoided.
Apply petrolatum based lubricants to lips during the day & bedtime. Cool air humidifier be placed in the room. Medication -capable of stimulating salivary glandspilocarpine -5 to 10 mg ,3 or 4 times daily, 30 min before meals administered.

ARTIFICIAL SALIVA SUBSTITUTES Commercially available products contain Carboxy methylcellulose lubrication

Animal mucins to increase viscosity

Parabens- inhibit bacterial growth Sugar free agents- xylitol, sorbitol- sweetners, mineral salts- simulate electrolyte content Flouride- reminaralisation Trade names: salivart(spray), oral balance (gel). mouthkote (spray),

The oral mucous and the intaglio surface of prosthesis can be sprayed throughout the day with artificial saliva .

Electrical stimulation- SALITRON.battery operated devices which deliver an electrical stimulus to the tongue and palate for saliva

production.
Acupuncture. Future aspects: gene therapy tissue engineering.

SIALORRHEA
Hypersalivation ,ptyalism and sialorrhea is excessive production of saliva.

It has also been defined as increased amount of saliva in the mouth, which may also be caused by decreased clearance of saliva

Etiology of Drooling
Acute vs. Chronic
acute - epiglottitis, neoplasm, abscess chronic - neurological (cerebral palsy) most common; usually related to head control

Direct vs. Indirect

direct - directly interferes with muscle tone or gland stimulation (anticholinesterase) indirect - macroglossia

Causes
Excessive production Decreased clearance

Excessive production
Conditions that can cause saliva overproduction include: Pregnancy Excessive starch intake Gastroesophageal reflux disease, in such cases specifically called a water brash, and is characterized by a sour fluid or almost tasteless saliva in the mouth. Pancreatitis Liver disease Serotonin syndrome Mouth ulcers Oral infections

Medications that can cause overproduction of saliva include: clozapine pilocarpine ketamine potassium chlorate Risperidone Toxins that can cause hypersalivation include: mercury copper organophosphates arsenic

Decreased clearance
Causes of decreased clearance of saliva include: Infections such as tonsillitis, retropharyngeal and peritonsillar abscesses, epiglottitis and mumps. Problems with the jaw, e.g. fracture or dislocation. Neurologic disorders such as myasthenia gravis, Parkinson's disease, rabies, bulbar paralysis, bilateral facial nerve palsy and hypoglossal nerve palsy.

Treatment
Hypersalivation is optimally treated by treating or avoiding the underlying cause.

SALIVA AS A DIAGNOSTIC TOOL

Saliva is not widely used as a indicator of health &. disease. However salivary testing is becoming more common as clinicians have begun to appreciate its advantages & investigators defined its worth. Salivary levels of drugs detected following therapeutic medications. Saliva drug testing kits are commercially available. Included in these are the tests for alcohol, cocaine HLA typing, HIV1 ,HIV2 ,DNA, etc. Salivary cortisol is an indicator of hypothalamic pituitary adrenal axis function- used to quantify the human stress & to determine the effect of treatment on it.

 To detect antibodies-hepatitis A, rubella virus, etc. To diagnose systemic disease after salivary gland dysfunction- sjogrens syndrome, alzheimers disease, cystic fibrosis,etc.

Forensic odontology.
Salivary pH assessment using telemetry:

Device called telemetry system is incorporated in the denture which has a radiosensitive diode, oscillator, ph sensor, and a computer analyzer.

Gingival crevicular (GCF)

Contents
Introduction Formation Composition GCF flow Methods of collection Clinical significance

Introduction
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.

Gingival Crevicular Fluid (GCF) Source: capillary network

Tooth surface under the junctional epithelium. Exits capillaries, passes through connective tissue, across basement membrane, & between the large intercellular spaces of the JE.

blood vessels in gingiva

Method of collection
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
The amount of fluid collected on paper strip is evaluated by: 1. Staining 2. Electronic method

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 inflammed gingiva absorbs about 0.1mg of fluid.

 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 spce of molar teeth ranged from 0.43 to 1.56 microlitre

COMPOSITION OF GCF
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.

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.

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 6sulphate 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 serinrendopeptidase,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:

Some antibiotics Eg. Tetracyclin, metronidazole, are detected in GCF.

Summary
The multi factorial role of salivary components continue to represent a focused area of dental research.

The knowledge of normal salivary composition, flow & function is extremely important on a daily basis when treating patients. Dental health professionals spend untold hours removing this precious natural resource to perform therapy, with little regard to its value until flow is significantly reduced.
Whether saliva occurs in quantities large or small , recognition should be given to the many contributions it makes to the preservation & maintenance of oral & systemic health.

Summary
As we have seen that various component act in defence of gingiva Eg. Sulcular fluid Saliva Gingival epithelium Leukocytes etc. In which sulcular fluid is 1 of the most important component of defence mechanism. These component through various mechanism & enzymes resist against the mechanical & bacterial aggressions & maintain the gingiva normal healthy state.

References
Richard Ten Cate. Oral Histology.5th edition. Mosby B.young, J. W. Heath.wheaters functional histology. 4th edition Carranzas cllinical periodontology. 10th edition. Eliasson L, Carlen A. An update on minor salivary gland secretions. Eur J Oral Sci 2010; 118: 435442. Gordon E. Green. Inherent Defense Mechanisms in Saliva. J DENT RES 1966 45: 624 Dawes C. Salivary flow patterns and the health of hard and soft oral tissues. J Am Dent Assoc. 2008 May;139 Suppl:18S-24S. Edger WM. Br Dent J. Saliva: its secretion, composition and functions. 1992 Apr 25;172(8):305-12 Harold Marcotte and Marc C. Lavoie . Oral Microbial Ecology and the Role of Salivary Immunoglobulin A . Universit Laval, Qubec, Canada GIK 7P4 L. saxen , J. Tenovoua, P. Vilja.Salivary defense mechanisms in juvenile periodontitis. Acta odontologica scandinavia..
107

References
Jeffrey L. Ebersole. Humoral immune responses in gingival crevice fluid: local and systemic implications Periodontology 2000, Vol. 31, 2003, 135166 Carranza's Clinical Periodontology. Tenth Edition Lindhes Clinical Periodontology and oral Implantology. 5th edijtion A. Refaie, O. Anuksaksathiem, G. Singh, J. Moran, A.E. Dolby.Antibody to Collagen Type I in Gingival Crevicular Fluid. J Periodontol 1990;60:289-292. Polson AM, Goodson JM. Periodontal diagnosis, current status and future needs. J Periodontol 1985: 56: 2534 Gary C. Armitage: periodontal disease:diagnosis Annals : 37-215 :section 1B
108