Contents

•Introduction •Role of phagocytic cells in host defense •Role of neutrophils in host defense •Neutrophils & periodontal tissue •Periodontal disease associated with neutrophil

abnormalities •Neutrophil defects •Neutrophil disorders associated with periodontal disease •Possible implications for therapy •Conclusion

Introduction
•Neutrophils are granulocytes which contain neutrophilic granules. •Also known as polymorphonuclear leukocytes, or PMNs •They account for approximately 50-70% of all white blood cells
(leukocytes) •Size - 10μm diameter •Normal Count- 3000- 6000 cells/mm3 •Average half-life of neutrophils – 6hrs •Possess many lysosomes within their cytoplasm •The granules contains- proteases -antimicrobial proteins called defensins •Show rapid response - primary immune response

Role of phagocytic cells in host defense

Role of neutrophil in host defense
Acute inflammatory cells (neutrophil), protects the local tissues by controlling the periodontal microbiota within gingival crevice and junctional epithelium. It’s the 1st leukocyte to arrive at the site of inflammation. And are the dominant cell types within the junctional epithelium and gingival crevices. For neutrophil to control infection their function includes: 1. Transendothelial migration 2. Chemotaxis 3. Phagocytosis

TRANSENDOTHELIAL MIGRATION
It is a selective interaction between leukocytes and endothelium that results in the leukocyte pushing its way between endothelial cells to exit the blood and enter the tissues. It can be divided into the following steps:
1) 2) 3) 4) 5) 6) 7) 8) 9) Margination and pavementing Rolling Complement activation Signalling endothelium Increased rolling Chemokine signal Rolling arrest CD31 zipper Basement membrane degradation

leukocyte function associated antigen VLA 4-very late antigen VCAM – vascular cell adhesion molecule .intercellular cell adhesion molecule LFA.TRANSENDOTHELIAL MIGRATION ICAM.

Chemotaxis It is the leukocyte's ability to sense a chemical gradient across its cell body and migrate in the direction of increasing concentration. . The phagocyte senses only a limited number of chemicals chemotaxins for which it has receptors. The receptors for chemotaxis belong to a family called the G-protein coupled family. The only class of chemotaxins derived directly from bacteria are formyl-methionyl peptides. or chemotaxin receptors.

Two types: Exogenous .Directly derived from bacteria e. IL-8. N-formyl methionyl peptide (FMLP) Endogenous – Those produced within the body e. Leukotrines B4. neutrophil chemotactic factor & platelet activating factor .g TNF.The agents acting as potent chemotactic substances for different leukocytes are called chemokines/chemotaxins.g. C5a.

.Chemotaxins for neutrophils .

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3. 4. Recognition and attachment ( Opsonisation) Engulfment stage Secretion stage Digestion or degradation .PHAGOCYTOSIS Phagocytosis is the process by which cells ingest particles of a size visible to light microscope. Phagocytic cells: Neutrophils and monocytes / macrophages The process of phagocytosis can be divided into the following steps: 1. 2.

This is referred to as opsonization . which enable the phagocyte to bind and ingest the pathogen.Opsonisation The immune system has evolved mechanisms of coating the pathogen with a few recognizable ligands or opsonin.

Engulfment stage Opsonized particle bound to the surface of phagocyte Formation of cytoplasmic pseudopodes around it due to activation of actin filament beneath cell wall Phagocytic vacuole + lysosome of cell cytoplasm Phagolysosome .

Eg: lactoferrin. Specific or secondary granules: Both extracellulur and intra cellular secretion. Eg: myeloperoxidase. Neutrophils contain three types of granules: 1. Tertiary granules: gelatinase . cathepsin . collagenase and proteinase 3. Azurophil granules: Intra phagolysosomal secretion. alkaline phosphatase and collagenase 2. lysozyme.Degranulation stage Preformed granules / stored products of PMNs are discharged or secreted into phagosome ( or extracellular environment). acid hydrolases and neutral proteases such as elastase.

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. Requires: 1) presence of oxygen 2) an oxidation-reduction potential (Eh at or above -160mV) Neutrophil produces toxic reduced oxygen metabolites such as superoxide anion using NADPH oxidase.Killing and degradation stage Once microbe is ingested. it is killed by two broad categories of killing mechanism: a) Oxidative mechanism b) Non-oxidative mechanism OXIDATIVE KILLING Based on reduction of oxygen.

A phase of increased oxygen consumption(respiratory burst) by activated neutrophil requires the essential presence of NADPH oxidase. Oxygen molecule NADPH oxidase Superoxide ion NADPH NADP + hydrogen ion Bactericidal properties carried out by: 1) Myeloperoxidase(MPO) dependent pathway 2) Myeloperoxidase independent pathway .

1) MPO Dependent killing Hypochlorous acid 2) MPO Independent killing Hydroxyl radical Hydroxyl radical NADPH oxidase deficiency Chronic granulomatous disease Inconsistently associated with aggressive periodontal (AP) disease Oxidative microbicidal mechanisms are of some importance in PDL infection .

) 1 min after secretion of specific granule it secrete azurophil granule. lactoferrin. HNP-3 & HNP-4) serprocidins ( elastase. Other antimicrobial compounds: α-defensins( eg. proteinase 3.OXIDATIVE KILLING Don’t require oxygen phagosome + lysosome phagolysosome Insertion of lysosomal component into phagosome In less than 30 seconds neutrophil secretes specific granules( lysosomes. HNP-1..NON. etc. azurocidin) cathepsin G . HNP-2.

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Once a pathogenic microorganism is ingested. Because of the highly anaerobic conditions in the periodontal environment. non-oxidative mechanisms of killing are of particular importance. . phagocytosis is of primary importance in the ability of a host to resist or combat infection.In summary. several mechanisms of killing are possible.

-PMN’s form a layer on the surface of plaque. . neutrophils must leave the tissues & enter gingival crevice or periodontal pocket. so in order to kill them. They secrete their enzymes & kill bacteria externally without phagocytosis.Neutrophil and periodontal tissues -Plaque microorganisms do not normally enter the tissues. but cannot phagocytose the adherent bacteria which are embedded in plaque matrix.

The low oxygen concentration & redox potential in deep pockets also inhibits neutrophil function.Unattached bacteria could be killed in traditional manner. . but this is unusual because: Neutrophil function is inhibited by microbial factors such as endotoxins. complement & protease inhibitors in crevicular fluid which inhibits phagocytosis by blocking surface receptors. formyl peptides & by host factors like degraded antibody.

NUG . can cause -For some aggressive periodontal diseases. -Neutrophil mediated tissue injury in periodontium destruction of attachment apparatus & bone loss. 1.Periodontal Diseases Associated with Neutrophil Disorders -A healthy individual with severe periodontal disease may have subtle defect in neutrophil function. Aggressive Periodontitis 2. a strong association between altered PMN function & disease has been reported. Chronic Periodontitis 3.

Altered phagocyte function & Aggressive Periodontitis Bacterial infection Induction of cytokines Altered function of PMN Chemotaxis & chemotactic receptors adherence Superoxide anions & degranulation Reduced migration of PMN to site of infection .

Neutrophils in gingival crevice Expression of CD11/CD18 Increased adhesion Vascular adhesion GP-110 Chemotaxis Receptor for C5a & LB4 Phagocytosis phagocytosis? superoxide CYTOKINES chemotaxis Receptor expression Locomotion & migration CYTOKINES Microbial killing killing .

(Sudha Agarwal et.An overaggressive immune response can provide a basis for unified explanation for observed altered neutrophil functions. severe tissue damage & bone loss in periodontium.al J.P-1996) . familial nature & other immunological findings associated with pathogenesis of this disease.

Altered neutrophil function & Chronic Periodontitis A) PMN mediated Tissue injury B)Bacteria & its products modulate PMN function C)Delayed neutrophil Apoptosis .

A) PMN mediated tissue injury Neutrophil mediated tissue injury was first demonstrated by Deguchi.al ACTIVATED NEUTROPHIL & PMN degranulation releases proteolytic enzymes Releases pro-inflammatory mediators: LTB4 & PAF Magnify inflammation Host tissue damage . et.

B. Bacteria & its products modulate PMN function BACTERIA LPS Indirectly acts on cellular component of gingival tissue. Activate cellular factors Destruction of connective tissue and bone Modulates complement (Pg degrades C3 & C5 -Scheinkein) Activate neutrophils Adhere to periodontal fibroblast Damage PDL fibroblast (Deguchi) Prevents opsonization and phagocytosis .

C)Delayed neutrophil Apoptosis Circulating neutrophils Short half life Onset of apoptosis Loss of several important functions such as adhesion & phagocytosis (Dransifield 1998) Apoptotic PMN cleared by macrophage Resolution of inflammation (Simon) This constitutive tendency to undergo apoptosis prevents neutrophils from lingering at the infection site & limits their proinflammatory potential (Haslett) .

reducing caspase activity & downregulating gene expression (Tsiyjmoto & Shimizir 2000) •Recent studies have shown that bacterial products isolated from different strains of P.•However cytokines such as TNF-alpha & GM-CSF may delay neutrophil apoptosis by increasing their mitochondrial stability. gingivalis also delay neutrophil apoptosis in dose dependent manner ( Preshaw et al 1999) .

.Role of Neutrophils in NUG Cogen et al. particularly in PMN chemotaxis and phagocytosis in NUG patients. 1983 described a depression in host defense mechanism. . Furthermore NUG is not found in well nourished individual with fully functional immune system.

Neutrophil defects Neutrophil defects Quantitative Neutropenia Qualitative Defects in adhesionLAD1 & LAD2 Defects in chemotaxis Defects in phagocytosis Defects in microbicidal activity .

Neutrophil Disorders Associated with Periodontal Diseases Severe periodontitis is associated in individual with primary neutrophil disorder: 1) Neutropenia 2) Agranulocytosis 3) Chediak.Higashi syndrome 4) Lazy leukocyte syndrome 5) Leukocyte Adhesion Deficiency Periodontitis associated with secondary neutrophil disorder: 1) Down Syndrome 2) Papillon Lefevre Syndrome .

1) Neutropenia NEUTROPHIL ABNORMALITY: .in number of neutrophils -ANC < 1500 cells/ microliter < 1000cells/μl moderate < 500 cells/μl severe < 150 cells/μl very severe ( inability to mount an inflammatory response) CAUSES: -genetic -drug induced (zidovudine. and gancyclovir) -viral infection PERIODONTAL MANIFESTATION: -severe aggressive periodontitis . trimethoprim-sulfamethoxazole.

5-year-old boy with neutropenia. . A 7-year-old boy with neutropenia demonstrating acute and extensive gingival inflammation and advanced attachment loss with recession evident.Clinical appearance of patients with neutropenia A. B. Note the aggressive and extensive inflammation in the gingival tissues.

Etiology: Drug idiosyncracy (aminopyrine. and throat . general weakness. malaise. benzene ring derivatives. and sore throat. Ulceration in the oral cavity. or arsenical agents) Sometimes unknown SYMPTOMS: fever. barbiturates and their derivatives.2) Agranulocytosis number of circulating granulocytes severe infection Less severe form of disease – neutropenia and granulocytopenia. sulfonamides. gold salts. oropharynx.

Gingival hemorrhage. and fetid odor. Generalized aggressive periodontitis .ORAL MANIFESTATION: The mucosa exhibits isolated necrotic patches that are black and gray and are sharply demarcated from the adjacent uninvolved areas. . The absence of a notable inflammatory reaction caused by lack of granulocytes is a striking feature. increased salivation. necrosis.

Higashi syndrome Rare disease that affects the production of organelles found in almost every cell. giant lysosomes (Megabodies) that can fuse with the phagosome.neutrophil chemotaxis and secretion . . It affects mostly the: melanocytes partial albinism platelets mild bleeding disorder phagocytes recurrent bacterial infection NEUTROPHIL ABNORMAILTY: -Neutrophils contain abnormal. but their ability to release their contents is impaired.3) Chediak.

Patient with partial albinism and greyish discolorization of hair Aggressive periodontitis as oral manifestation of Chediak Higashi Syndrome .PERIODONTAL MANIFESTATION: Aggressive periodontitis and oral ulceration. LYST. The syndrome is caused by a mutation in the vesicle trafficking regulator gene.

.4)Lazy leukocyte syndrome CHARACTERIZED BY : Susceptibility to severe microbial infections NEUTROPHIL DEFECT: Defect in neutrophil chemotaxis Neutropenia Abnormal inflammatory response PERIODONTAL MANIFESTATION: Susceptible to aggressive periodontitis with destruction of bone and early tooth loss.

Neutrophils fail to express the ligand (CD15) for P.5) Leukocyte Adhesion Deficiency NEUTROPHIL ABNORMAILTY Defects in leukocyte function due to lack of integrin ß2 subunit (CD18). resulting in impaired transendothelial migration in response to inflammation PERIODONTAL MANIFESTATION Aggressive periodontitis. Type I Type II Aggressive periodontitis at a young age .and E-selectins. Neutrophil defects include impaired migration and phagocytosis. at an early age and affecting primary and permanent dentition. Histologically. almost no extravascular neutrophils are evident in periodontal lesions. in individuals who are homozygous for the defective gene.

C and D. Persistent ulceration is seen on the left lower labial mucosa. This disorder involves defects in neutrophil transendothelial migration. loss seen in these patients blunting of the papillae. and loss of (D) attachment. Note the tissue inflammation evident clinically (C) and the extensive bone periodontal condition. . Clinical and radiographic appearances of patients with leukocyte adhesion deficiency (LAD type 1). with inflamed gingiva. resulting in a lack illustrates Initial clinical presentationof extravascular neutrophils in periodontal lesions.

60:238-242. phagocytosis. et al: Defective neutrophil chemotaxis in Down's syndrome patients and its relationship to periodontal destruction. . trisomy 21 Congenital disease caused by a chromosomal abnormality. and intracellular killing*. J Periodontol 1989. Characterized by mental deficiency and growth retardation. *Izumi Y.6)Down Syndrome Mongolism. Shinozuka O. Sugiyama S. PERIODONTAL MANIFESTATION: Formation of deep periodontal pockets associated with substantial plaque accumulation and moderate gingivitis. NEUTROPHIL ABNORMALITY: Most likely explained by poor PMN chemotaxis.

Note the extensive loss of periodontal support around the mandibular incisors as evidenced by severe gingival recession . .Severe periodontal destruction in 14year-old patient with Down syndrome.

Very rare inherited condition. soles. The skin lesions consist of hyperkeratosis and ichthyosis of localized areas on palms. Autosomal recessive pattern. and elbows . severe destruction of the periodontium. Recently associated in affected individuals with a mutation in the cathepsin-C gene. calcification of the dura. SYSTEMIC SYMPTOMS The syndrome is characterized by hyperkeratotic skin lesions. knees.7) Papillon Lefevre Syndrome First described by French physicians Papillon and Lefèvre. and in some cases.

scaly lesions NEUTROPHIL DEFECTS: Multiple functional neutrophil defects. . Clinical view of knees with hyperkeratotic. B. including myeloperoxidase deficiency as well as defective chemotaxis and phagocytosis. Clinical view of palms demonstrating hyperkeratosis of skin. A.Papillon-Lefèvre syndrome in a 17-year-old male.

The missing teeth were exfoliated .PERIODONTAL MANIFESTATION: Early inflammatory changes that lead to bone loss and exfoliation of teeth. Intraoral clinical view of 17-year-old boy with Papillon-Lefèvre syndrome showing early tooth loss and severe bone loss around remaining teeth as evidenced by gingival recession. which may involve the primary and permanent dentition. Severe aggressive periodontal destruction at an early age.

adhesion. and did not affect bactericidal activity (Han et al. or bactericidal activity. One approach is to block specific neutrophil pathways that do not appear essential for clearance of periodontal pathogens but do appear to contribute to tissue damage. Resolvins. It was suggested that some natural lipid agonists.Possible implications for therapy: The essential question for therapy is how to control neutrophilmediated damage without mimicking neutrophil deficiency states due to lack of migration. 2006). which blocked the TNF-α induced rise in intracellular calcium but did not block neutrophil degranulation following phagocytosis of bacteria. Han et al. 2005. neucalcin. have a potential to actively induce resolution of persistent inflammation followed by clinical resolution of the disease (Van Dyke 2011). .  A new molecule.

•Thus it may be proposed that either hypofunction or altered function or hyperfunction of PMN may result in increased susceptibility to periodontal disease. •Also. these phagocytic cells can cause some damage to healthy tissues.Conclusion • Neutrophils are important in periodontal disease because they control the periodontal microecology prior to involvement of chronic inflammatory cells. though they are essential for host defense. .bystander effect.