DEFENSE MECHANISM OF GINGIVA CONTENTS General Introduction Saliva - Introduction - Role of saliva in oral health - Composition and Function

on of each constituent - Salivary flow. - Salivary buffers - Salivary pH. - Conclusion Gingival crevicular fluid - Introduction - Composition rugs in GCF - Conclusion !issue Resistance - Introduction - !he anatomical barrier - "ucous #arrier - $pithelial #arrier - %eriodontal epithelium newly recogni&ed role in health' disease. - Conclusion Summary

 References. Introduction (ral cavity and periodontal tissues are e)posed to many factors that may cause disease' tissue destruction such as bacteria' viruses' masticatory forces' pH differences' temperature differences' physical irritation' trauma due to food particles. Several uni*ue environments for coloni&ation e)ist within the oral cavity. +ithin these environments' bacterial products are formed that can dissolve the tooth' stimulate bone resorption or cause tissue necrosis. !hese challenges to homeostasis are met with a variety of host immune responses often distinct immune mechanisms are encountered in different oral environments or different stages of disease. Defense Mechanisms !he mechanisms by which health is preserved in the face of potential disease' that is the defense mechanisms' can be roughly divided into innate defense mechanisms and ac*uired defense mechanisms. !he innate immunity acts as a first line of defense against infections' eliminating most potential pathogens before they establish an overt infection. !his defense mechanism is present since birth and is the resistance to infection' which an individual possesses by virtue of his genetic and constitutional ma,e up.

If the innate defense mechanism is unsuccessful' the adapti e immune system is activated and produces a specific reaction to each infectious agent. !he adaptive immune system also remembers the infectious agent and can prevent it from causing disease later. Defense mechanism of !in!i a !he gingival tissue is constantly sub-ected to mechanical and bacterial aggressions. !he saliva' epithelial surface and the gingival crevicular fluid provide resistance to these actions. SA"IVA Saliva has been defined as .the fluid secreted by the salivary glands that begins the digestion of foods/. - Contemporary #eriodontics$ Genco Saliva' however is hardly the simple body fluid' nor does it have the limited function' implied in this definition. Saliva bathes the oral tissues and is basic to the health status of the oral cavity. It plays a ma-or role' in the maintenance of health and in the production of disease by permitting or inhibiting the formation of pla*ue' calculus and the proliferation of selected micro-organisms saliva is thought to function in part by forming protective tenacious films or pellicles on the available oral surfaces. !he whole saliva that bathes the oral cavity is primarily a mi)ture of secretions form the paired ma-or 0parotid' submandibular and sublingual1 glands and the numerous minor 0labial' buccal and glossopalatine' palatine

and lingual1 glands. +hile salivary glands are normally not found in the gingival tissues' atopic salivary gland has been reported in the gingiva 0gingival salivary choristoma' Mos%o& and 'aden$ ()*+1. +hole saliva also contains bacteria 0about 234 5 236 7 ml1. !herefore' their products such as organic acids and en&ymes epithelial cells' food debris and components from GCF and is important to the hosts resistance to periodontal diseases. !herefore' their products such as organic acids and en&ymes epithelial cells' food debris and components from GCF and is important to the hosts resistance to periodontal diseases.

,O"E OF SA"IVA IN O,A" HEA"TH Function

8ubrication %hysical protection Cleansing #uffering !ooth integrity maintenance 9nti #acterial 9ction

Sa-i ary Components

Glycoproteins' "ucoids Glycoproteins' "ucoids %hysical Flow #icarbonate and %hosphate "inerals Ig9 8yso&yme 8acto %ero)idase.

#ro.a.-e Mechanism
Coating similar to gastric mucin Coating similar to gastric mucin Clearance of debris and bacteria 9ntacids "aturation' Remineralisation Control of bacterial coloni&ation #rea,s bacterial cell walls ()idation of susceptible bacteria

COM#OSITION OF SA"IVA
#roteins 9lbmin 9mylase #-glucuronidase Carbohydrates Cystatins $pidermal growth factor $sterases Fibronectin Gustin Histatins Immunoglobulin 9 Immunoglobulin G Immunoglobulin " <alli,rein 8actoferrin 8ipase 8actic acid dehydrogenase 8ysosyme "ucins :erve growth factor %arotid aggregins %eptidases %hosphatases %roline rich proteins Ribonucleases Salivary pero)ydases Secretory component Secretory Ig9 Serum protiens Sma-- Or!anic mo-ecu-es 9mino acids Creatinine Glucose 8ipids :itrogen Sialic acid ;rea ;ric acid E-ectro-ytes 9mmonia #icarbonate Calcium Chloride Fluoride Iodine "agnesium %hosphates %otassium Sodium Sulphates !hiocyanate

Mucins
!hese are high molecular weight glycoproteins that are more than =3> carbohydrate. ? chemically distinct mucins in submandibular and sublingual saliva' "G20"ucin glycoprotein-21 and "G?0"ucin glycoprotein-?1. In general' viscoelastic properties of mucins may aid in formation of bolus. MG( function a. b. c. 9t hard of soft tissue interface to provide a permeability barrier for protection against insult and dessication 9s a glycoprotein lubricant to minimi&e abrasion between occluding tooth surfaces. Comple)es with anti microbial factors in saliva to locali&e them at tissue environment interfaces. "G? has considerably lower molecular weight.

#ro-ine / rich proteins and !-yco proteins

!his comprises of acidic and basic phosphoproteins and basic glycoproteins that are characteri&ed by amino acid content containing @A43> proline' glutamine and glycine 0'ennic% ()*01.

Functions of pro-ine rich phosphoproteins a. !hey bind to calcium' have a high affinity for hydro)y apatite and ma,e up part of the ac*uired enamel pellicle. b. Can inhibit precipitation of calcium phosphate salts and thus protect the tooth surface from calculus formation. c. %rovide lubricating properties on the tooth surface' especially when comple)ed with serum albumin' a ma-or constituents of gingival crevicular fluid 0Hatton et a- ()*1$ "e ine et a- ()*012 d. #oth proline 5 rich phosphoproteins and glycoproteins play a role in modulating oral flora. !he peptide bac, bone provides attachment for actinomyces actinomycetum comitans and glycoprotein mediates attachment and 7 or clearance of streptococci 0'er!ey et a- ()*+' Gi..ons and Hay ()**1

Histatins and Statherin Histatins are a family of small basic peptides characteri&ed by a high content of histidine . Function3

a. Forms part of the ac*uired pellicle and inhibits precipitation of calcium phosphate salts. b. Shown to display bactericidal and fungicidal activities. c. Helps to maintain a relatively neutral pH in the oral cavity. Statherin is a tyrosine 5 rich phosphopeptide Function3 #inds calcium' has a high affinity for hydro)y apatite and plays a role in deminerali&ation by inhibiting the precipitation of calcium phosphate salts. Cystatins !hese molecules constitute a diverse group of thiol protease inhibitors. Function3 !hey comple) with mucins and target oral tissues where they cause deminerali&ation 7 remineralisation process and suppress the growth and thiol protease activity of oral pathogens. A-pha 3 amy-ases "ost abundant en&yme found in saliva. Function3 2. %reparation of digestion of starch by hydroly&ing B 2-= lin,ages in glucose containing polysaccharides to end-products glucose and maltose.

?.

Inhibits growth of nisseria gonorrhoeae' its presence in ac*uired pellicle and its capacity to bind streptococcus sangius suggests a role in oral microbial coloni&ation.

Sa-i ary #ero4ides Consists of pero)ide en&yme' the thiocyanate ion and hydrogen pero)ide. Function3 a. Forms o)idi&ed forms of thiocyanate which has direct to)icity on a variety of micro- organisms. b. Is effective in reducing acid production by glucose stimulated dental pla*ue. c. Can inhibit glucose upta,e of streptococcus mutans. C 9 system has been introduced for oral use to generate ideal levels of hydrogen pero)ide for endogenous sialopero)idase activity against streptococcus mutans and others pla*ue organisms. Car.onic Anhydrases !hese are &inc metalloen&ymes. !hey play a role in bicarbonate formation and thus contribute to the buffering capacity of saliva. "actoferrin !his is an iron 5 binding glycoprotein.

Functions in the oral cavity by its anti-microbial effect due to its ability to se*uester iron. 9lso' it has a direct' iron independent' bactericidal effect on streptococci mediated by an anionic target site for lactoferrin on surface of these micro-organisms 0"assiter et a-$ ()*01. "ysosyme 5Muramidase6 Functions3 a. Is a hydrolytic en&yme that can lyse the cell wall of gram positive bacteria by hydroly&ing muramic acid and :-acetyl glucosamine peptidoglycan constituents. b. !hose micro-organisms insensitive to its muramidase activity will be ,illed by lyso&ymes' by activating endogenous bacterial en&ymes 0#o--oc% et a- ()*01. c. "ay aggregate certain bacteria' thus affecting their clearance from the oral cavity. d. It probably repels certain transient bacterial invaders of the mouth. It wor,s on both gram positive and gram negative organisms'.Deillonella species and actinomycetem comitans are some of its targets. Secretory I!A !his glycoprotein is the predominant immunoglobulin found in all mucosal secretions.IgG and Ig" are also secreted in smaller amounts.

Functions3 a. %rovides a .first line of defense/ via immunological means. b. #inds to antigens' causing a local aggregation' which would inhibit their adherence to hard and soft tissue surfaces and thus hinder subsurface microbial invasion into deeper host tissues. It has been shown that Ig9 antibodies present in parotid saliva can inhibit attachment of oral Streptococcus species to epithelial cells 0Gi..ons et a- ()071. Gibbons and colleagues suggested that antibodies in secretions may impair the ability of bacteria to attach to mucosal or dental surfaces. c. %lay a role in viral neutrali&ation' attenuation of viral growth and replication on oral surfaces. d. :eutralisation and disposal of to)ins and food antigens. Fi.ronectin 9 high ".+. glycoprotein Functions3 a. (n epithelial surfaces' may preclude attachment of potential pathogens such as pseudomonas aeruginosa 08oods ()*01. b. Comple)ing of cell surface fibronectin with salivary molecules 0$)ampleE B - amylases1 can inhibit the epithelilal coloni&ation of gram-negative bacteria such as $. coli 0Hasty and Simpson ()*01.

Mye-opero4idase It is an en&yme similar to salivary pero)idase' is released by leu,ocytes and is bactericidal for actinobacillus 0Genco2 et2 a- ()*+1 but also has an added affect of inhibiting the attachment of actinomyces strains to hydro)yapeptite 0Miyasa%i et a- ()**1. Coa!u-ation factors Factors DIII' IF' F' FI 0%lasma thromboplastin antecedent1 and FII 0Hagemas factors1 faston blood coagulation and protect wounds from bacterial invasion 0"eon! et a- ()1*1. "eu%ocytes %rincipally %":Gs which vary from person to person and at different times of the day. Increasing during gingivitis' %":Gs reach the oral cavity by migrating through the lining of the gingival solcus. 8iving %":Gs in saliva and some times referred to as Oro!ranu-ocytes and their rate of migration into the oral cavity is termed as Oro!ranu-ocyte mi!ratory rate2 Some thin, this rate is related to gingival inflammation and hence a reliable inde) for assessing gingivitis 0S%ou!oard et a- ())91. Sa-i ary F-o& !otal salivary fluid produced during a ?= hours period is about H=3 5 2?33 ml 63> by parotid and submandibular salivary gland

A> by sublingual salivary gland A> by minor salivary gland. !he unstimulated flow rate of the ma-or salivary glands is less than 3.33A ml 7 min. 7 gland at rest and 3.A 0or greater1 ml 7 min7 gland with stimulation. Hence' it is apparent that 43 5 63> of the daily production of saliva is a result of stimulation. Sa-i ary .uffers !he maintenance of physiologic ion concentration at the mucosal epithelial cell surface and tooth surface is an important function of salivary buffers. Saliva provides a buffer that protects the oral cavity is ? waysFirst$ many bacteria re*uire a specific pH for ma)imal growth.

Hence' altering optimal environment conditions prevents coloni&ation. Second$ pla*ue organisms can produce acid from sugars which if not rapidly buffered and cleared by saliva can deminerali&e enamel. "uch of this buffering capacity resides in the bicarbonate and

phosphate ions. !he proteins have no role in buffering capacity. ;rea is a source of ammonia that serves as generated buffer as the result of bacterial action on the urea. Sa-i ary pH

:ormally mi)ed saliva has a pH of A.H 5 @.3' average H.@. !he pH increases with flow due to increased bicarbonate concentration. (ptimal pH for growth of bacteria is between H.A and @.A' lower range being =.A to A.3 and a upper range of 4 to 4.A. In the oral cavity' a low pH favours survival of lacto bacilli' yeasts and strepcocci and a high pH that of proteolytic bacteria. CONC":SION !he saliva' therefore' has a ma-or role to play in maintenance of oral tissue. It e)erts a ma-or influence on pla*ue initiation' maturation and metabolism. Salivary flow and composition also influence calculus' formation' periodontal disease and caries.

GINGIVA" C,EVIC:"A, F":ID !he formation of gingival fluid appears to be a highly speciali&ed function in the gingival' aiding in the defense of this region against the bacterial attac,' at the same time forming the possible basis for some pathologic changes. !he conditions prevailing in the gingival sulcus and along the cervical enamel depend greatly upon the composition of the fluid' its calcium or fluoride content for instance should be ,nown by students of cariology' while the presence of mammalian or bacterial proteases in the fluid be of interest to periodontists. is also ,nown. Composition A2 Ce--u-ar e-ements 3 #acteria es*uamated epithelial cells 8eu,ocytes 5 %":Gs 8ymphocytes "onocytes 7 "acrophages. Finally' the clinical significance of GCF as a possible carries of antibiotics from the general circulation into the oral cavity

Epithe-ia- ce--s !he oral sulcular epithelium and -unctional epithelium are constantly renewing and the shed cells will be found in the gingival crevice and gingival fluid samples. "eu%ocytes !he ma-or site of entrance of leu,ocytes into the oral cavity is the gingival sulcus 0"oe ()+(1. :eutrophilic granulocytes utili&e the intercellular spaces of the -unctional epithelium as a preferential pathway for emigration' since neither the oral sulcular epithelium nor the oral gingival epithelium serves that purpose. Gingival fluid as well as neutrophilic granulocytes originate form the vessels of the gingival ple)us. ;pon leaving the ple)us' they pass through the e)tra vascular connective tissue to enter the -unctional epithelium via the e)ternal basal lamina. In response to chemotactic gradients' they move by active locomotion through the intercellular spaces until they reach the sulcus bottom. In the rhesus mon,ey' the emigration time of %":Gs from blood vessels to the sulcus was reported to be about ?3-I3 min. 0Scu--y et a- ()0)$ ()*;1. In the sulcus' the differential leucocyte counts6A - 6@> :eutrophils 2 - ?> 8ymphocytes ? - I> "onocytes 0Attstrom ()0;$ S%ou!aard ())91

In the mononuclear leu,ocyte +ilton et. al 026@H1found the following > composition 5 !-lymphocytes 5 ?=> #-lymphocytes 5 A4>. "ononuclear phagocytes 5 24>. "ean ! cell to # cell ratio being 2 E I. Crevicular %":Gs 09bout 43>1 are vital and at least A3> of them nitro blue tetra&olium positive' indicating a high degree of en&yme activity. 'acteria Staining of gingival crevicular fluid with gram techni*ue have consistently shown presence of variety of micro-organisms. Counts of bacteria did not increase when more supra-gingival pla*ue was present on teeth. !he correlation was also poor between bacterial counts in gingival fluid and both the intensity of gingival inflammation and the depth of periodontal poc,ets 0<re%-er and Fric% $ ()001. '62 E-ectro-ytes 3 Sodium %otassium Calcium (thers Sodium concentrations

First *uantitative study on the absolute concentration of sodium and potasasium in gingival fluid was performed by Matsue 5()+06' who used filter paper for his collections. "ost studies seem to agree that the crevicular fluid contains a significantly higher amount of sodium than serum. Some of the reports also indicate that the sodium concentration tends to increase in cases of more severe inflammation. #otassium Concentrations It is generally agreed that the potassium content of crevicular e)udates greatly e)ceeds that of serum. <as-ic% et a- 5()0;6 could not show significant differences between the potassium concentrations in nearly normal and moderately inflamed' samples of gingival crevicular fluid. However' a positively and statistically significant correlation could be shown between conc. of potassium and the mean poc,et depth. Other ions3 F-uoride ions = It is now established that a possible source of fluoride to the cervical region is represented by gingival fluid. phosphate has been found in fluid. C6 Or!anic compounds Carbohydrates %roteins 8ipids Calcium'magnesium and

"etabolic and bacterial products 9nti bacterial substances

Car.ohydrates 9 *uantitative investigation on the glucose' he)osamine and he)uronic acid content in gingival fluid was performed by Hara and "oe 5()+)62 $)udate glucose content showed values I-H times higher than that of serum from the same patient and tended to decrease in cases of non-inflamed gingiva. :either he)osamine nor the he)uronic acid concentration showed any correlation with the variation in gingival inflammation. !hese I substances in gingival fluid have dual role. !hey can' on one hand' reflect the altered metabolic activity of the ad-acent tissues but might also be influenced by the immediacy of the local micro flora. #roteins 'an! and Cimasoni$ ()0( found no significant correlation between the conc. of proteins in gingival fluid and any of the I clinical parameters that were used to assess the gravity of gingivitis and periodontitis 0%"9 inde)' poc,et depth and bone loss1.

Histo chemically' it was determined that crevicular e)udates contain proteins similar to those found in serum.

(2 Immuno!-o.u-ins Gingival fluid probably represents an important source of immunoglobulins and antibiotics in the oral cavity. Ho-m.er! and <i--ander 5()0(6' by radial immunodiffusion showed presence of IgG' Ig9 and Ig" in concentrations compared to serum. Radial immunodiffusion was also used by Shi--itoe and "ehner 5()076 and by Schen%ein and Genco 5()006 in their *uantitative investigations and found IgG' Ig9 and Ig" are present in gingival fluid but at concentrations lower than those of serum. !he immunoglobulins of gingival fluid might significantly contributes to the oral defense particularly in the crevicular domain. 72 Comp-ement components !he demonstration of complement components in gingival fluid has helped classify the role that complement could play in the pathogenesis of tissue brea,down during periodontitis. !he activation of complement proteins may cause tissue damage through chemotactic attraction of %":Gs

and release of their lysoomal en&ymes and through complement mediated lysis of tissue cells and degranulation of mast cells. In their papers on the protein composition of gingival fluid' Schen%ein and Genco 5()006 confirmed that both the alternate and the classical pathway seem to be present in human gingival fluid. >2 Other proteins 9lbumin' fibrinogen' oromucoid 0an B2 5 globulin1' ceruloplasmin 0an B? 5 globulin1' J-lipoprotein 0a J2 5 globulin1 and transferrin 0a J2-globulin1. "ipids Gingival grecicular fluid contains many classes of phospholipids as well as neutral lipids. Serum seems to be the most probably source' although salivary' bacterial and tissue sources cannot be e)cluded. Meta.o-ic and .acteria- products (2 "actic acid %resent at concentrations which seem to be related to the gravity of the periodontal inflammation. 72Hydro4y pro-ine !his is a ma-or brea,down product of collagen' it is however difficult to differentiate between hydro)y proline arising from local tissue brea,

down and that derived from serum' hence difficult to use it as an indicator of the rate of progress of periodontal disease. >2 #rosta!-andins Synthesi&ed by most mammalian cells and have been implicated as components of the inflammatory reaction. Inflamed gingival was shown to contain more prostaglandin $? 0E- Attar$ ()0+1' at concentrations theoretical able to produce vasodilation' bone resorption and inhibition of collagen synthesis. 92 :rea Its concentration was shown to be several times higher than those of serum and saliva and inversely related to the severity of gingival inflammation. ;rea could be responsible for the elevated pH of supragingival pla*ue and gingival sulci through production of ammonia by microorganisms. 12 Endoto4in 8iposacharides of the cell wall of gram negative bacteria are released from autolysing bacterial cells and from live bacteria as well. !hey are highly to)ic for gingival tissue and has been considered as possible pathogenic factors in periodontal disease. +2 Cytoto4ic su.stances

!he nature of the cytoto)ic substances could not be determined. However' hydrogen sulphide is produced is measurable amounts from gingival fluid. So-is3Gaffar et a- 5()*;6 were able to *uantity the generation of from hydrogen sulphide samples of gingival crevicular fluid' they showed a strong positive correlation between hydrogen sulphide production and gingival inflammation.

02 Anti .acteria- factors Flow of crevicular fluid is able to remove various ,inds of particles' including bacteria from gingival poc,ets. 0Anttonen and Teno uo$ ()*(1. D2 En?yme and En?yme inhi.itors (2 Acid #hosphatase Has been widely investigated among the lysosomal en&ymes and has been used as a lysosomal mar,er. :ucleic acids can be attac,ed by acid phosphatase' teichoic acid' one of the components of bacterial cell wall can be attac,ed too. !he main sources are probably %":Gs and des*uamating epithelial cells. Investigations by Sueda and Cimason$ ()+* showed that H3> of the total en&yme originates from bacteria. 9 pero)idase 5 mediated antimicrobial system has also been show in human crevicular fluid

72 A-%a-ine phosphatase

!he conc. of al,. %hosphatase was found to be significantly correlated with poc,et depth. Sources include %":Gs and oral bacteria. >2 #yrophosphatase It is a ,nown inhibitor of calcification hence could play a ,ey role in controlling calculus formation.

92 @3!-ycoronidase J-glycoronidase is one of the hydrolases found in the a&urophilic or primary granules of %":Gs. J-glycoronidase has often been used as a lysosomal mar,ers to show the release of lysosomal hydrolases from phogocytosing cells in vitro. 12 "yso?yme 8yso&yme has bactericidal properties' lin,ed to it ability to hydrolyse J-2' =-glycosidic bonds of peptidoglycans of the bacterial cell wall. !he en&yme is found in a solouble and free in fluids li,e saliva' tears' nasal' gastric and intestinal secretions. !he free en&yme may contribute to the formation of the poc,et by its detrimental effect upon epithelial cells stic,iness and lytic activity upon the ground substance of connective tissue. 8yso&yme may also accelerate the local release of intra cellular bacterial en&ymes. +2 Hya-uronidase

Hyaluronidase splits J-2' =-:acetyl glucosaminide lin,s in hyaluronic acid' chondroitin-=-sulphate and chondroitin-H-sulphate. 8ysosomal and bacterial-crevicular hyaluronidases significantly increase in the presence of inflammation. 8ysosomal en&yme decreases when the number of crevicular leu,ocytes is lowered by antineutrophil serum 0Attstrom et a- ()0(1.

02 #roteo-ytic en?ymes %roteinases might have a ma-or role in the destruction of tissue components during inflammation. a2 Mamma-ian proteinases %ractically all the proteinases' which have been studied in the gingival sulcus' belong to the category of endopeptidases capable of splitting bonds within the polypeptide chain. Amon! these 2 carbo)yendopeptidase 5 Cathepsin I serine endopeptidase 5 :eutrophil elastase Cathepsin G %lasminogen activitor 2 metalloendopeptidase c2 Cathepsin D - Collagenase

(ne of the chief acid en&ymes in lyso&ymes present at high concentration in inflamed tissues. Its concentration was found to be 23 times higher in gingival crevicular fluid than in serum. increased in periodontitis and gingivitis. Seems to be

ii2 E-astase :eutrophil elastase is a serine proteinase confined to the a&urophilic granules of %":Gs. 'arret et a-2 ()0* showed that leu,ocyte elastase in able to attac, mature collagen fibres. 9lthough bacterial origin cannot be e)cluded' it is probable that most of this proteolytic activity is due to elastase originating from migratory %":Gs. iii2 Cathepsin G 9lso found in a&urophilic granules of human %":Gs. It has been shown to hydrolyse hemoglobin' fibrinogen' casein' collagen and proteoglycans. i 2 #-asmino!en acti ator #esides their role in fibrinolysis' plasminogen activators have a ma-or role in inflammation. %lasmin activates the third component of complement' which causes increased vascular permeability and accumulation of %":Gs and monocytes.

2 Co--a!enase Collagenolytic activity has been found in gingival fluid' where it increases with the severity of the disease.

.2 'acteria- proteinases $n&ymes produced by supragingival and subgingival bacteria' particularly proteinases could largely contribute to tissue damage in gingivitis and periodontitis. c2 Serum proteinase inhi.itors !he activity of proteases in the tissues is probably modulated by the presence of inhibitors either produced locally or circulating in plasma. "ain ones are B ? - macroglobulin and B 2 - antitrypsin 2-macroglobulin inhibits all proteinases of %":Gs by irreversible trapping of the en&yme molecules by the inhibitor. 1-antitrypsin inactivates serine proteinases' elastase and cathepsin G. *2 "actic dehydro!enase 5"DH6 8 H catalyses the reversible reduction of pyruvate to lactate. Gingival crevicular fluid was found to have 23-?3 times more 8 H than

blood. 9lthough' 8 H is found in bacteria' it is still probably that most of the en&ymes measured originates from periodontal tissues. D,:GS IN GINGIVA" F":ID Since gingival fluid seems to be a characteristics feature of gingival inflammation one could e)pect that suitable drugs could be given to a patient and carried from general circulation to the gingival sulcus or poc,et by the flow of gingival fluid. 'ader and Goldhaber 5()++6 were able to show that intravenously administered tetracycline drugs in dogs rapidly emerge within the sulcus. Stephan et a- 5()*;6 indicated that the concentration of antibiotics measured in mi)ed saliva was often found to be greater than those of parotid saliva' thus confirming the possible role of the gingival sulcus or poc,et as a pathway of entrance. Gingival crevicular fluid concentrations have been measured for only a few antibiotics. Tetracyclie - Gordon et al 1981. Minocyclie - Ciancio 1980. Metronidazole Brit and Pohlod 19862

CONC":SION

In conclusion' one can say that the origin' the composition and clinical significance of gingival fluid are now ,nown with more precision and have significantly helped our understanding of the pathogenesis of periodontal disease.

G,O8N ENVI,ONMENT
#otentia- patho!ens of compensa- popu-ation #ossi.-e iru-ent ariations of commensa- popu-ations Forei!n M2 Or!anisms "etabolic products

"OCA" TISS:E ENVI,ONMET

9natomical factors "ucus barrier $pithelial barrier

#E,IODONTI:M

!issue resistance

8ocal Inflammatory Responses

The host / parasitic re-ationship = A dynamic .io-o!ica- system2

TISS:E ,ESISTANCE !he resistance of periodontal tissues to irritation from the crown environment may be visuali&ed as a series of barriers' the breach of one or more of which is evidenced by disease.

Anatomica- factors !he health of individual tissues of the mouth is dependent on good functional anatomical relationships of the masticatory apparatus as a whole. 9 change in one component of the unit is reflected in other tissues. !he movement of the lips and chee,s during mastication and speech has a cleansing action by virtue of their functional contact against the teeth. !he teeth themselves have a shape' which deflects food from the -unction of soft tissue and tooth' and may thereby protect the gingival margins from damage during mastication. !he supra gingival fiber apparatus not only attached the gingiva to teeth and bone but also provides a dense frame wor, that accounts for the rigidity and biomechanical resistance of the gingiva. !hus' gingival pliability of the attached gingival as measured during micro compression is significantly smaller than that of the ad-acent alveolar mucosa. For this reason' the gingival is able to withstand frictional forces and pressures that result from mastication. !he fiber apparatus also controls the positioning of

teeth within the dental arch. In addition to contributing tooth positing and biostability of the gingival tissues' the supra gingival fiber apparatus also protects the very sophisticated cellular defenses located at the dentogingival interface. The mucus .arrier2 !he mucus membrane of the mouth is covered by a layer of saliva' which acts as a primary barrier to the spread of infection and constitutes the environment of the commensal population throughout the mouth. The epithe-ia- .arrier !he continuity of the epithelium is considered to be an important protective barrier to foreign agents' including bacteria' their to)ic products and antigenic substances. !he ability of an epithelial surface to resist penetration of bacterial to)ins is related to a. !hic,ness of the epithelium. b. egree of ,eratinisation c. Rate of turnover of the cell population Thic%ness of the epithe-ium !he oral mucosa has a well-developed capacity to respond to irritation by hyperplasia and downgrowth of basal layers and fre*uently to return to a normal histological appearance after the irritant has been removed. !he non-,eratinised' thin' sulcular epithelium is easily damaged and less

effective barrier to penetration of the connective tissue by bacterial products than is the oral mucosa in the other areas. De!ree of %eratinisation !he protection afforded by the epithelium is dependent to great e)tent on its ,eratinisation and its ability to des*uamate or shed epithelial cells. It has been shown that the epithelium of the chee, possesses a minimal ,eratinisation or lac,s it completely whereasK complete ,eratinisation is notable on the epithelium of the hard palate and gingiva. ,ate of turn o er of the ce-- popu-ation !here is a constant process of shedding and cell renewal in the oral epithelium. !he L.$. has a very high turn over rate and shedding rate' appro). A days in primates 0Shroeder H2E2 ()0062 !he following have been the reported turn over times time for different areas in the oral epithelium of e)perimental animals %alate' tongue' chee, Gingiva L.$. 2 5 H days. A - H days. 5S%ou!aard et a- ()+762 23 5 2? days

!he most important clinical considerations is the very high rate of shedding of L.$. cells' e)pressed as number of e)foliated cells 7 unit of surface area. !his rate has been calculated to be A3 to 233 times' faster than for oral gingival epithelium.

!his means that degenerated surface cells' covered and sometimes invaded by bacteria are e)pelled at a fast rate' and it also means that superficial epithelial tears are eliminated readily. !hus' the high turn over rate of epithelium as well as the connective tissue of the periodontium' are important aspects of the defense mechanism. In addition contributory factors to the defense of gingiva are 2. 8angerhans cells ?. (dland #ody. "an!erhans ce--s !hese are one of the clear cells or dendritic cells found in the upper layers of the s,in and the mucosal epithelium restricted to the &ones of ortho ,eratinisation. !he langerhans cells are of hematopoietic origin and are involved in the immune response. In the presence of antigenic challenge by bacterial pla*ue' langerhans cells migrate into the gingiva. !hey contain antigens' which they present to primed !-cells either locally or at lymph nodes. Od-and 'ody A <eratinosome A Mem.rane / coatin! !ranu-es !he upper most cells of the stratum spinosum contain numerous dense granules' keratinosomes' which are modified lysosomes. !hey contain a large amount of acid phosphatase' an en&yme involved in the destruction of

organelle membranes' which occurs suddenly between the granulosum and corneum strata and during the intercellular cementation of cornified cells. #E,IODONTA" E#ITHE"I:M = A NE8"B ,ECOGNISED ,O"E IN HEA"TH AND DISEASE !he epithelial compartment does provide a physical barrier to infectionK it also has an active role in innate host defense. !he epithelium participates actively in responding to infection and in signaling further host responses and integrating innate and ac*uired immune responses. $pithelial cells may also respond to bacteria cells may also respond to bacteria by increased proliferation' by alteration of cell signaling events' and by changes in differentiation and cell death' altering tissue homeostasis. Finally' via cyto,ines' langerhans cells and dendritic cells of bone marrow origin that is located within the epithelium is a connecting lin, with ac*uired immunity.

Common features of epithe-ium I critical features characteri&e every epithelial tissue. 2. ?. !he cells are closely opposed and attached via special cell 5 cell -unctions. $pithelial cells secrete a basal lamina on which the cells become organi&ed as a tissue and which separates the epithelium from the ad-acent connective tissue. I. $pithelial cells are characteri&ed by the presence of a cyto s,eleton composed by ,eratin intermediate filaments in addition to the typical actin filaments and microtubules.

Functions and features of epithe-ia Functions "echanical' chemical' water and microbial barrier signaling functions. rchitectural inte!rity Cell 5 cell attachments #asal lamina <eratin cytos,eleton

Ma"or cell ty#e <eratinocyte $ther cell ty#es 8ongerhans cells' melanocytes' mer,e- cells Constant rene%al Replacement of damaged cells. Cell cell attach&ents esmosomes 9dherens -unctions !ight -unctions Gap -unctions Cell Basal la&ina Synthesis of basal lamina components hemi-desmosome. Anti micro.ia- peptides and proteins and their ro-e in micro.ia- eco-o!y $pithelial tissues are e)posed to the environment and as such' must serve as a barrier to the barrage of microbial species that surround us several families of natural antibiotics peptides or proteins are e)pressed in epithelial as well as in neutrophils as part of this barrier.

ANTIMIC,O'IA" #E#TIDES AND #,OTEINS THAT MAB CONT,I':TE TO #E,IODONTA" HEA"TH

#eptide #rotein H:%2 5 = C-assification D / defensins E %eptides' cationic J-Sheet structure with I' s5 s bonds @3defensins %eptides' cationic J-Sheet structure with I ' s5 s bonds #resent In Epithe-ia #resent in #HNCs MM Function %resent in %": a&urophilic granules secreted in to L.$. and GCF ma-or non o)idatiaave bacterial ,illings mechanism h# -2 O h# -? are associated with antimicrobial barrier in stratified epithelia and can be secreted from cells. h# -? signals immature dendritic cells %resent in %": a&urophilic granules wound fluid' inflamed epithi. Cytoplasmic protein.

h# h# h# h# H$

52 5? 5I 5= - ?

M M M M M

88 5 I@ Calcoprotection

Cathe-icidin fami-y peptide' cationic' B-helical st. !wo-subunit protein composed of "R% 4= "R% 2=. 9nionic' binds calcium

M M

MM MM

!hese peptides have broad specificity with activity against gram positine and gram-negative bacteria' as well as against yeast and some viruses. #oth constitutive and inducible antimicrobial peptides are e)pressed in gingival epithelium' suggesting that they have normal surveillance function as well as a specific role in innate host defense in response to infection. !he individual variation in e)pression may contribute to disease susceptibility.

9ntimicrobial peptides are defined as proteins with less than 233 amino acids' with molecular weight ranging from appro)imately I'A33 to H'A33 a. !hey include the B and J defensins and a cathelicidin family !hese cationic peptides have a broad spectrum of member 088-I@1.

antimicrobial activity. !hey function by association with anionic microbial surface' then aggregate to form pores or disrupt microbial membranes. !he antimicrobial calcoprotein is also e)pressed in the cytoplasm of oral epithelia and neutrophils. 9lthough the anti microbial action has been poorly defined' the protein has been shown to inhibit the binding and infection of oral epithelial cells by %. gingivalis and other bacteria' suggesting its functional importance in the tissue. !he biological significance of 88-I@ is seen in animals lac,ing e)pression and this protein. !hey are highly susceptible to necrotic s,in infection caused by Group 9 streptococcus. J-defensins are induced by inflammation' by bacterial lipopolysaccharide 08%S1 and by pro-inflammatory cyto,ines. "OCA"IEED EF#,ESSION OF ANTI MIC,O'IA" #E#TIDES IN GINGIVA2 #oth B O J defensins and 88-I@ are locali&ed in different sites in the gingiva' suggesting that they are li,ely to serve different rolls in several ecological niches of the periodontium. J5defensins h# -2 and h# 5? are e)pressed in areas of differentiation and inflammation but are e)pressed poorly or not at all in the -unctional epithelium. $)pressed strongly at the gingival margin' where the

tissue can be e)pected to be in almost continuous contact with supra gingival pla*ue. B 5 defensins and 88-I@ are present in high amounts in neutrophils that migrate through the -unctional epithelium to the gingival sulcus. Some investigators believe that the primary role of J defensins may be to signal other innate and ac*uired immune responses' while B-defensins and 88 5 I@ may be most important for their anti microbial properties the gingival sulcus.

The ro-e of epithe-ia in inte!ratin! innate and acGuired immune responses2

$pithelial cells also respond to bacteria by altering cell-signaling events. Cell surface receptors are a ,ey to these cellular interactions as well as to signal transduction pathways. "ore recently' a family of pathogen pattern recognition receptors' the TOLL-like receptors' has been identified as critical in mediating responses to bacteria. !he study of e)pression and role of the !(88-li,e receptors in the epithelium is -ust beginning. !he epithelium responds to the presence of bacteria and subse*uent signaling amplifies the response. uring this process dendritic cells !-cells and macrophages are stimulated' providing a connection of the innate responses of epithelial cells with the ac*uired immune response for specific and long-term recognition of foreign antigens.

CONC":SION !he gingival tissues' with their speciali&ed relationship to the tooth surface' constitute the ma-or peripheral defense against microbial infections that may lead to periodontal disease. 9lthough the ,eratinised epithelium provides effective protection against both mechanical trauma and bacterial invasion' the non-,eratinised -unctional epithelium is only partly effective in its protective role' because its attachment function to the tooth is incompatible with good resistance to trauma. However' with the assistance of leu,ocytes residing in the Inter-cellular spaces and its high turn over rate' it provides a fairly effective barrier to bacterial penetration.

S:MMA,B !he mechanism of defense of the dento gingival unit involves tissues that provide for delivery of humoral and cellular responses to potentially destructive bacteria' their to)ins and antigenic substances. "echanisms of defense also include a high turn over rate of tissuesK this tissue when damaged is *uic,ly repaired. !he anatomical continuity provided by the -unctional epithelium and the functional characteristics of the -unctional epithelium that allow the passage of active neutrophils to the site of in-urious agents' involves a line of defense that are generally highly effective. In conditions where defenses are no longer effective' the onset of disease occurs.

,EFE,ENCES Contemporary %eriodontics 5 Robert L. Genco %eriodontics 5 Grants $ssentials of %eriodontology and %eriodontics 5 !or*oil "ac%hee %eriodontology and %eriodontics. "odern theory and practice Sigurd % Ramf-ord. (rbanGs oral histology and embryology Crevicular fluid updated 5 C.Cimasoni Carran&a 6th $dition LC% ?333K ?@. %eriodontology ?333' Dol. 2I' 266@. %eriodontology ?333' Dol. I3' ?33?.