TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

UCLA SCHOOL OF DENTISTRY

Presents
Dr. E. Barrie Kenney
Professor & Chairman
Section of Periodontics
 E. Barrie Kenney B.D.Sc., D.D.S., M.S., F.R.A.C.D.S.
Tarrson Family Endowed Chair in Periodontics.

Professor and Chairman Division of Associated Clinical Specialties UCLA

Pathogenesis of School of Dentistry

Periodontal Disease
 Gingivitis is widespread with 54 percent of the population
13 years or older having bleeding on probing.

The most common type of gingivitis is caused by Dental Plaque products

such as Exotoxins and Endotoxins initiating inflammation of gingival

GINGIVITIS tissues.
 Subgingival bacterial biofilm (plaque) initiates gingival
inflammation (Gingivitis).

This in some patients may extend apically to become periodontitis

ROLE OF
PLAQUE
The first bacteria that form a biofilm on cleaned tooth surfaces are
Streptococci species (Gram positive cocci)
Within two days Gram negative bacteria also appear in the subgingival
biofilm and gingival inflammation begins
Exotoxins are secreted by many Gram positive and Gram
negative bacteria.

Endotoxins are only seen with Gram negative bacteria

Examples of Exotoxins produced by sub gingival bacteria
Further examples of Exotoxins
Some Exotoxins directly inhibit the protective effects of
inflammatory cells and healing
 Bacterial Leukotoxin from some strains of Actinobaccilus
Actinomycetemcomitans (A.a) cause necrosis and apoptosis of
leukocytes
 Endotoxin is an important cause of gingival tissue damage by Gram
negative bacteria in the subgingival biofilm.
 Endotoxins directly destroy gingival cells. They enhance tissue
destruction due to stimulation of the immune response associated with
gingival inflammation
STIMULATION OF
IMMUNE
RESPONSE
Established Gingivitis present in lower incisor region.
Signs of acute inflammation, redness, and swelling
Subgingival bacteria initiate Gingivitis by their Exotoxins and Endotoxins
changing the epithelial cells lining the gingival crevice
 Scanning Electron Microscopic view of a healthy gingival sulcus.
The epithelial cells form an intact surface which acts as a barrier to
subgingival bacteria and their toxins.
Bacterial Exotoxins such as Hyaluronidase destroy the
intercellular connections between epithelial cells lining
the gingival sulcus.
This is one of the first stages of initiation of gingivitis
The barrier effect of epithelial cells is reduced by a widening
of intercellular spaces.
This allows penetration of other bacterial products
through the epithelium to the underlying gingival
connective tissue
Transmission Election Micrograph of epithelial cells from a healthy
gingival sulcus with narrow intercellular spaces.
 Transmission Election Micrograph of an epithelial cell from early
Gingivitis.

The intercellular spaces are widened and the epithelial barrier has
become more porous.
 Scanning Electron Micrograph of epithelial from Early Gingivitis. A
Cells of gingival sulcus showing normal areas of quiescence, other areas B
of widened intercellular spaces with leukocytes passing out from the
connective tissue.A area of normal quiescent epithelium.B bacteria.C
widened intercellular spaces.

C
B
C
High powered view with obvious widened intercellular spaces and holes
through the epithelium.
Other bacterial Exotoxins such as collagenase can This result in destruction of the basement membrane and
now penetrate through the epithelial cell barrier of the areas of loss of the epithelial cell layer with ulcer formation.
gingival sulcus.
E is area of normal intact epithelial cells, U is loss of epithelial cells and
ulceration.A area of ulceration.E normal epithelium.

Enlargements seen below show direct exposure of gingival connective

tissue collagen to subgingival bacteria at the base of the A E
ulcerated epithelium. C collagen fibers of connective tissue.

C C
 Transmission Election Micrograph of Gingivitis. E
Bacteria have penetrated into the connective tissue.E epithelial cell BM
cytoplasm BM basement membrane .C connective tissue.B bacteria.

Bacteria first contact with immune system occurs in epithelium with Langerhams C
cells which process antigens.

B
Epithelial ulceration provides a portal for subgingival
bacteria and their products to the gingival connective
tissue.
Bacteria may now enter blood vessels and cause a
bacteremia.
Most subgingival bacteria that penetrate into connective
tissue in gingivitis do not proliferate in the tissue.
This is because they are anaerobic and the tissues are
aerobic.
Bacterial products that contact gingival connective Gingivitis is seen clinically as acute inflammation with
tissue initiates an acute inflammatory response with redness and edema of tissues and exudates of inflammatory
vasodilatation, edema and polymorphonuclear fluid from the gingival sulcus.
leukocyte (P.M.N) activation.
Early Gingivitis.
There is bleeding from the gingival sulcus with probing, brushing or
mastication.

This is a result of epithelial ulceration in the gingival sulcus and acute

inflammation of the connective tissue.
Gingival bleeding on probing is seen as early as the
second day of initiation of Gingivitis.
It may persist through to the later stages of
Periodontitis
Bleeding on probing is a sign of active tissue destruction.
If Gingivitis is treated, the epithelium can heal and bleeding
can disappear after seven to ten days.
One of the first effects of bacterial contact with Mast cells are inflammatory cells of the Basophil series of
gingival tissue is activation of Mast cells granular leukocytes
Mast cells have Toll like receptors which initiate prodution of vasoactive
substances such as Histamine which induce vascular permeability and
vasodilatation.
This vasodilatation and increased permeability of capillaries is
associated with edema and diapedesis of leukocytes from the blood
vessels into the connective tissue of the gingiva.

Mast cells produce other inflammatory mediators such as Slow- Reacting

Substance of Anaphylaxis, Leukotriene C4, Tumor Necrosis factor alpha
(TNF).and IL6. These activate the acute inflammatory response.
Light Micrograph of connective tissue in Gingivitis vasodilatation, edema,
and migration of Leukocytes.
 Vascular tree of normal gingival tissue.
Peripheral vessels allow rapid movement of blood from the arterioles
through the capillaries to the venulus.
Gingiva color in health is pale pink
With vasodilatation in Gingivitis terminal circulation is more convoluted
so gingiva appears red and often has a purplish color
 Vasodilatation results in more complex pathways of blood flow so that
circulation is slowed through gingival tissues.

This results in redness as well as increased reduced Hemoglobin giving a

purplish color to the gingiva.
Polymorphonuclear leukocytes (P.M.N.s) are the characteristic dominant
inflammatory cells of acute inflammation of the gingiva
In Gingivitis PMNs and edema fluid appear in the connective tissue and
pass through the damaged epithelial cells into the gingival sulcus and
then into the mouth. PMNS move to the IL8 chemoattractant seen in
junctional epithelium and are attached by ICAM 1-INTERCELLULAR
ADHESION MOLECULE from Langerhams cells.

One to two percent of PMNS pass through

junctional epithelium each day.

GIngival fluid is an indicator of gingival inflammation and it carries

PMNSand antibodies into the pocket
Scanning Electron Micrograph of PMN (L) passing from connective tissue
(CT) through epithelium (E).
CT

L
LL
l

E

PMNs are able to migrate through tissue towards
chemotaxic substances such as peptides from
bacteria, saliva, Endotoxin,IL8 and activated
complement.
This chemotaxis brings PMNs out of blood vessels
and they accumulate in connective tissue and
epithelium and eventually pass into the pocket to be
moved by gingival fluid into the mouth.
PMNs are able to engulf bacteria by a process of
phagocytosis.
Engulfed bacteria are destroyed by oxidative production of
toxic reduced oxygen metabolites such as superoxide
anion. Non oxidative lysosomal enzymes such as defensins
and proteases found in lysosomal granules,
also kill bacteria .In the increasing anaerobiosis of the
pocket oxidative killing is impaired.
 PMNs lysosomal granules can destroy bacteria intracellularly.
They can be released and cause connective tissue and bacterial
destruction extracellularly.
 Light microscopic view of Gingivitis.
PMNs seen in connective tissue and migrating through epithelium into
gingival sulcus.
High power view of PMNs in gingival fluid of gingival crevice
Scanning Electron Micrograph of PMNs passing through epithelium.

Note bacteria attached to PMNs in process of being phagocytosed

High power view of PMN and bacteria attached undergoing phagocytosis.
B bacteria

B
Light Microscopic view of PMNs from gingival fluid showing evidence of
phagocytosis.
White spheres inside PMNs have been engulfed.
PMN’s form a protective layer in regions where epithelium of the gingival
sulcus has been disrupted in Gingivitis
Clinical example of established Gingivitis with emphasis on the acute
inflammatory reaction
 The Basophil series are seen in Gingivitis as Mast cells, Neutrophils as
PMNs.

Eosinophils are not significant contributors to plaque induced Gingivitis

Inflammatory cells of the Agranular series of Leukocytes are also seen in
gingivitis
 Monocytes become Macrophages in inflamed gingival tissue.

They exhibit chemotaxis, phagocytosis, enzyme production and bacterial

killing similar to PMNs. They are activated by bacterial products like
LIPOPOLYSACCHARIDE LPS.

They also produce cytokines such as IL1 and TUMOR NECROSIS

FACTOR TNF which have a wide inflammatory influence as well as
stimulating osteoclast proliferation,differentiation and activation.
PROSTAGLANDIN E PGE another inflammatory and osteoclast activator
is also secreted in response to IL1,TNF And LPS.
Macrophages interact with Lymphocytes by assisting in Bacterial Antigen
presentation to Lymphocytes which then produce specific antibodies (B
cells)or cytokines (T cells). Macrophages then clean up the destroyed
bacterial remnants by phagocytosis.
As Gingivitis develops the initial acute inflammatory response continues
and a chronic inflammatory response is added.

Lymphocytes and capillary proliferation characterize this chronic

inflammation.
B cells are Lymphocytes derived from Bone Marrow and produce
antibodies to bacterial antigens.

T cells are lymphocytes derived from the Thymus and initiate cell
mediated immunity by producing lymphokines
 B cells interact with macrophages in gingival tissue and become plasma
cells which produce antibodies.

There are also B cells series that carry the memory of a particular antigen
and can quickly produce antibodies, this memory is dependant on
interactions with T cells.
Plasma cells (B cells) produce immunoglobulins within gingival tissue
which bind to and inactivate bacterial antigens including Exotoxins.
Antibody – Antigen complexes also activate Complement
Plasma cells produce a variety of immunoglobulins with each one being
specific for a particular bacterial antigen and have memory to become
quickly activated.

Patients with periodontal disease have high serum levels of IgG specific
for plaque bacteria.
Activation of complement is another part of the immune response seen in
Gingivitis
Activation of complement produces molecules such as
C2a C5b that are cytotoxic, increase vascular
permeability and are chemotactic for PMNs and
Macrophages. Activation of complement can occur directly due to antibody
antigen complexes.
Indirectly complement is activated by Endotoxin,
Bacterial inactivation by antibodies is also enhanced polysaccharides and other bacterial products.
by C3b an opsonin from complement which coats
bacteria and enhances phagocytosis.

Mast cells are activated by C3a and C5a.

 T Lymphocytes are very common in gingivitis. They interact with
bacterial Antigens processed by Macrophages.
T cells then undergo proliferation and differentiation into the different
types of T cells.
In Early gingivitis, T cells are the dominant Lymphocytes, but eventually
B cells dominate.T cells have dense round nuclei with very little
cytoplasm.B cells (plasma cells) are larger than T lymphocytes and have
an eccentric lighter staining nucleus with an almost equal sized
cytoplasm
Electron Micrograph of plasma cell (B cell) with eccentric nucleus and
prominent endoplasmic reticulum for protein antibody production
 Activated T Lymphocytes produce cytokines. These are bioactive
molecules that enhance inflammation and also can cause damage to
gingival and periodontal cells.

Two important cytokines are Interleukin-1 (IL-1) and Tumor Necrosis

Factor (TNF).
With chronic inflammation gingival blood vessels and inflammatory cells
proliferate into the areas of destroyed connective tissue.
 Established Gingivitis around lower incisors.
Acute inflammatory changes are superimposed on chronic inflammation
charges.
The combined acute and chronic inflammation seen in Gingivitis and
periodontitis is destructive of bacteria.

It also causes damage to the connective tissue of gingiva and the

periodontal tissues
Another mechanism of breakdown of connective tissue in Periodontal Gingival Metalloproteins can be reduced by systemic administration
disease involves Matrix Metalloproteinases (M.M.P).
of low dose Doxycycline--20mg.every 12 hours .This is the basis for
the use of Periostat to treat Periodontal disease,

These are produced by PMNs, Macrophages ,Fibroblasts and Epithelial

cells. MMP8comes from PMNS MMP1 comes from resident cells.
Examples of MMP
The bacterial induced inflammation of Gingivitis can
spread apically and involves the destruction of
connective tissue of the Periodontium including bone.
This is Periodontitis
The damaged epithelium of the gingival sulcus proliferates
apically.
As loss of attachment of connective tissue fibers to
cementum occurs the pocket epithelium migrates to line the
root surface.
 Light microscope view of lower incisor with Periodontitis.
Gingival Inflammation has spread apically and bone destruction has
occurred.
There is apical migration of epithelium causing attachment loss and
increase of pocket depth.
High power view with epithelium E migrated apical to bone crest B, and
inflammation causing bone loss

E
OSTEOBLAST - Bone Loss Due to
Inhibition of Osteoblasts,
OSTEOCLAST Stimulation of
INTERACTION Osteoclasts.
High power view of osteoclast causing bone loss in periodontitis
Macrophages produce prostaglandin E (PGE) and (IL-1) and lymphocytes
produce Interleukin-1 (IL-1) which activate osteoclasts by interacting with
osteoblasts.
The mechanisms causing bone loss in Periodontitis
are not well documented.
Bone destruction is a result of osteoblasts or
inflammatory cells signaling osteoclasts activation via
cytokines such as IL-1 and TNF and Prostaglandins
(PGE).
Activated osteoclasts destroy the inorganic bone
components by release of acid hydrolases.
MMPs from osteoblasts destroy the organic collagenous
components.
Possible mechanisms of bone loss in Periodontitis Other mechanisms of bone loss:
include:
Up regulation of cytokine and PGE secretion by
 Suppression of osteoblasts by inflammation with inflammatory cells and
lowered bone production osteoblasts
 Loss of collagen attachment with reduction of Up regulation of MMPs from inflammatory and connective
tensile forces on bone tissue cells.
Direct bacterial toxicity on osteoblasts and collagen
Clinical example of Periodontists with emphasis on chronic inflammatory
changes.

There were 7mm pockets after initial therapy.

Same case being treated with flap surgery. Note bone loss.
Radiograph of advance Periodontitis with evidence of interproximal bone
loss
Same case with flap surgery. Extensive bone loss due to plaque induced
Periodontitis.
For further information use the text Carranza’s Clinical Chapter 9
Periodontology Molecular Biology of the host-microbe interaction in
Periodontal Diseases.
9th Edition
W B Saunders 10. 2002 Chapter 16
Gingival Inflammation
Chapter 7
Immunity and Inflammation Chapter 17
Clinical features of Gingivitis
Chapter 8
Microbial Interactions with the host in Periodontal Chapter 22
Diseases The Periodontal Pocket