Neutrophils are the most abundant white blood cells and form the first line of defense against pathogens. They are formed in the bone marrow through a process called granulopoiesis regulated by G-CSF and migrate to sites of infection. Neutrophils phagocytose and kill microbes via oxidative and non-oxidative mechanisms. Disorders can cause quantitative or qualitative neutrophil defects, resulting in increased susceptibility to infection. Periodontal disease is more severe and widespread in patients with neutrophil disorders due to impaired host response and bacterial modulation of neutrophil functions.
3. ◦ The cellular components of blood contains :- RBC / Erythrocytes
WBC/ leucocytes
Platelet/ Thrombocytes.
◦ Neutrophils are the most abundant leucocytes, constituting 70% of WBCs .
◦ They are multilobed containing 2-5 lobes of nucleus hence the name polymorphonuclear (PMNs)
◦ They stain neutral with Wright stain hence the name neutrophils.
◦ The are the first line of defense in immunity.
INTRODUCTION
5. • Neutrophils formation in the bone marrow takes about 14days.
• Neutrophils are continuously generated in the bone marrow from myeloid precursors. Their daily production can reach up to
2 x 1011 cells.
• The process is controlled by granulocyte colony stimulating factor (G-CSF).
LEUKOPOIESIS
6.
7. Mature neutrophils retained in the
bone marrow:- interaction between
the CXCCR4 on the PMN &
CXCL12 produced by stromal cells
of bone marrow
IL-17 upregulates G-
CSF which promotes
release of neutrophils
from bone marrow.
At the inflammatory site the PMNs
release chemokines CCL2 & CCL20
which are ligands for chemokine
receptors on Th17.
This attracts the Th17 cell to the site
of inflammation.
Helper T cells release IL-17
which in turn recruits more
PMNs to the site of
inflammation .
Apoptotic PMNs are
phagocytosed by the
macrophages
IL-23 released
from the
macrophages
activate Th17
IL 11 production –
upregulation of G-CSF
in fibroblasts.
Initiation of anti-
inflammatory signal-
reduction in IL-23 from
macrophages.
Reduction in IL 17
production.
Reduced G-CSF
production
Reduced production of
neutrophils.
This mechanism of
feedback control
over neutrophil
production is called
NEUTROSTAT
TRAFFICKING
10. Neutrophil responses to infection can be divided into:
RECRUITMENT
RESPONSE
RESOLUTION
FUNCTIONS
11. 1. Changes in the formed elements of blood/ Margination
2. Rolling and adhesion
3. Transmigration
4. Chemotaxis
RECRUITMENT
12.
13.
14. Phagocytosis :- 1. Recognition and attachment
2. Engulfment
3. Killing and degradation
RESPONSE
15. RECOGNITION AND ATTACHMENT
• Receptors on macrophages which recognize microorganisms: mannose receptor and scavenger receptor.
• Microorganisms are coated with specific proteins, opsonins, from the serum and the process is called opsonization.
• Opsonins establish a bond between bacteria and the cell membrane of phagocytic cell.
• The main opsonins present in the serum and their corresponding receptors on the surface of phagocytic cells (PMNs or
macrophages) are as under:
i. IgG & C3b found in serum protein - opsonin.
ii. Receptors present on the surface of the phagocyte - Fc , CR1 &3 and C1q
iii. Lectins are carbohydrate-binding proteins in the plasma which bind to bacterial cell wall.
16. KILLING AND DEGRADATION
◦ In phagosomes, PMNs kill microorganisms
through two mechanisms:
1. Oxygen dependent mechanism (ROS,
generated by NADPH oxidase)
2. Oxygen independent mechanism (granular
proteases)
17. RESOLUTION
1. Nuclear & mitochondrial DNA is released into the
extracellular space.
2. Involves the activation of NADPH oxidase, histones &
decondensation of chromatin..
3. NETs are able to simultaneously trap and kill various
extracellular pathogens by providing a highly
concentrated supply of antimicrobial compounds.
4. This mechanism facilitates immobilization of a vast
number of microorganisms by neutrophils, that can
otherwise hinder the phagocytosis capacity.
Ref :- Benjamin E. Steinberg and Sergio Grinstein 2007
18. NEUTROPHIL CLEARANCE
• Apoptotic PMNs are phagocytosed
by the macrophages.
• The senescent PMNs return to the
bone marrow for clearance after they
have increased expression of
CXCCR4.
19. NEUTROPHIL DEFECTS
QUANTITATIVE
Decreased in
number of
neutrophils –
NEUTROPENIA
Increase in
number of
neutrophils-
NEUTROPHILI
A
QUALITATIVE
Defect in
ADHESION
Defect in
CHEMOTAXIS
Defect in
PHAGOCYTOSIS
&
INTRACELLULAR
KILLING
21. NEUTROPENIA
DISEASE PMN ABNORMAILTY CLINICAL FEATURES
CYCLIC NEUTROPENIA 1. Cause – mutation for gene neutrophil
elastase (ELA2).
2. Recurring episodes of neutropenia
occurring every 21days.
3. These episodes last for 3-6 days.
1. Malaise
2. Anorexia
3. Lymphadenopathy
4. Oral ulcers resembling aphthous
ulcers.
FELTY’S SYNDROME
(Augustus Felty in 1924)
1. Triad of – rheumatoid arthritis,
splenomegaly, neutropenia
1. Anemia, mucosal and skin ulcers,
2. respiratory tract infections,
3. thrombocytopenia, and
4. lymphadenopathy
KOSTMANN’S SYNDROME
(Rolf Kostmann in 1956 )
1. Impairment of myeloid differentiation
in the bone marrow with severe
absolute neutropenia.
2. less than 500 cells/L.
1. Frequent pyogenic infections since
birth, which included oral ulceration,
stomatitis and pharyngitis.
2. Cutaneous cellulitis, furunculosis,
pneumonia and septicaemia occurred
frequently, as did chronic
periodontitis.
22. 1. The attached gingiva surrounding all of the primary teeth exhibited
severe gingivitis with ulceration (Figure 1).
2. This gingivitis extended to the mesial of the first permanent molars. The
ulcerations were more evident in the interdental papilla.
3. An obvious loss of attachment surrounding the primary teeth
4. Probing of these teeth elicited hemorrhage and revealed pocket depths
ranging from 4-10 mm.
CYCLIC NEUTROPENIA : A CASE REPORT
Linwood M. Long, Jr., DDS, MS John R. Jacoway, DDS, PhD James W. Bawden, DDS, MS, PhD
23. Oral manifestations of
congenital neutropenia or
Kostmann syndrome
Periodontal disease was so rapidly destructive in this patient that the
permanent lower anterior teeth were almost exfoliated by the age of 14
years .
26. LEUCOCYTE ADHESION DEFICIENCY (Anderson &Spring,1986)
LAD 1
• Cell surface integrin (CD18) is affected.
• ADHSION affected
LAD 2
• Defect in Saily-lewis X glycoprotein CD15 which allows neutrophils to attach to selectins CD621 on the endothelial surface.
• ROLLING is affected
CLINICAL FEATURES
1. Both the primary and the permanent teeth are affected, often resulting in early tooth loss.
2. Profound defects in peripheral blood neutrophils and monocytes and an absence of neutrophils in the gingival tissues have
been noted in patients with LAD.
LAD 3
• Defective signaling of Beta 1, 2, 3 Integrins.
• INTEGRIN SIGNALLING, therefore ADHESION affected
28. DISEASE PMN ABNORMALITY CLINICAL FEATURES
HYPERIMMUNOGLOBULIN E /
JOB’S SYNDROME
1. Increased levels of serum IgE
2. Reduced chemotaxis
1. Skin ‘‘cold’’ abscesses,
2. pneumonia,
3. deep-set eyes,
4. oral ulcerations/gingivitis
HAIM-MUNK SYNDROME 1. Mutations of a gene (known as
cathepsin C [CTSC]) located on
the long arm of chromosome 11
1. Red, scaly thickened patches of skin on the
palms of the hands and soles of the feet .
2. Frequent pyogenic skin infections.
3. Overgrowth of the fingernails and toenails.
4. Degeneration of the periodontium
LAZY LEUKOCYTE SYNDROME 1. Affect both quality and quantity
of neutrophils.
2. Defective chemotaxis along with
neutropenia is seen.
1. Destruction of bone and early tooth loss.
2. Fever skin abscess, gingivitis, periodontitis
DOWNS SYNDROME 1. Endo - lack of lip seal, tongue
thrust, malocclusion, oral
hygiene
2. Exo - neutrophil, phagocytosis,
chemo intracellular killing
(Newman & Carranza 10th edition )
1. The high prevalence and increased severity of
periodontal destruction
29. Cathepsin is present in phagocytes and epithelium.
1.In phagocytes it activates lysosomal granules resulting in phagocytosis.
Mutations in the cathepsin C gene
Non – functional cathepsin C in epithelium - palmoplantar
hyperkeratosis
Defective barrier function of JE, phagocyte defect, reduced host
response – periodontal destruction.
Hallmark feature – palmoplantar keratosis + rapid periodontal
destruction of both dentitions.
PAPILLON–LEFÈVRE SYNDROME
Vol. 6, 1994, 88-1 00
THOMAS C. HART &
LIOR SHAPIRA
31. CHEDIAK HIGASHI SYNDROME
CHÉDIAK–HIGASHI SYNDROME
Mutation in LYST gene that aids in intracellular transport of
materials into lysosomes
Azurophilic granules and specific granules unite to form,
large granules called Megabodies.
Phagosome cannot fuse with the lysosome to form
phagolysosome
Phagocytosis and intercellular killing affected
Severe periodontitis, affecting both temporary and
permanent dentition
32. CHRONIC GRANULOMATOUS DISEASE (CGD)
◦ Seen in staphylococcus, proteus ,
pseudomonas species infections.
Congenitally defective NADPH oxidase
Reduced respiratory burst
Difficulty in killing pathogens
Over a period of time, cells gather around the
pathogen to stop it from spreading ( diag)
This leads to the formation
of granulomas in many organs
33. ◦ Nicotine alters the chemotaxis, phagocytosis and respiratory burst mechanism of
neutrophils.
◦ Elevated levels of TNF a and IL- 8, PGE2, neutrophil elastase, and matrix
metalloproteinase-8 are demonstrated in GCF.
◦ IgG2 has been seen to be reduced in smokers thus making them susceptible to
periodontal bacteria.
◦ Inhibition of fibroblast growth, attachment and collagen production.
◦ Altered cytokine production.
Smoking and periodontal disease
34. Diabetes Mellitus
◦ Diabetic patients demonstrate defects in PMN activity, including impaired chemotaxis,
phagocytosis and microbicidal functions .
◦ Diabetes prolongs the inflammatory response to Porphyromonas gingivalis, with increased
production of TNF-α
35. Treponema denticola
◦ Anaerobic, gram-negative motile spirochete.
◦ T . Denticola degrades IL-8 , which disables the neutrophil chemotactic gradient.
◦ Modulates neutrophil signaling pathways involved in cytoskeletal dynamics that are relevant in
chemotaxis and phagocytosis.
36. Porphyromonas gingivalis
◦ gingival epithelial cells (GECs) secrete the chemoattractant IL-8 to recruit neutrophils.
◦ P. gingivalis inhibits the secretion of IL-8 from GECs, resulting to reduced neutrophils in the area.
◦ trypsin-like protease (TLPase), plays a role in inhibition of phagocytosis.
◦ Endogenous lipoxin A4 (LXA4) appears to inhibit the oxidative burst response and overall
activation of human neutrophils when challenged by P. gingivalis.
◦ Gingipains are also involved in the breakdown of the neutrophils granule contents.
◦ Gingipains cause cleavage of complement protein C5a, also degrades C3
37. CONCLUSION
◦ Neutrophils make up the primary line of defense and their function is important to prevent and
eliminate infection from the body.
◦ Neutrophils constantly surveil the oral tissues, in order to guarantee oral health.
◦ It has been well understood that patients with defective neutrophils, demonstrate rapid periodontal
disease.
◦ Hence a through understanding of neutrophils is important to understand the etiopathogenesis of
periodontal disease.
38. REFERENCES
◦ Harsh Mohan 7th edition , text book of pathology.
◦ Newman and Carranza’s Clinical Periodontology 13thEDITION
◦ Joerg meyl, Leukocyte adhesion deficiency and prepubertal periodontitis , Periodontology 2000, Vol. 6, 1994.
◦ Pinkerton PH, Robinson JB, Senn JS. Lazy leucocyte syndrome--disorder of the granulocyte membrane? J Clin Pathol.
1978 Apr;31(4):300-8. doi: 10.1136/jcp.31.4.300. PMID: 641207; PMCID: PMC1145266.
◦ Dale, DAVID C., and K. Welte. "Neutropenia and neutrophilia." Williams hematology 8 (2001): 939-
50.
◦ C. Scully, E. MacFadyen, A. Campbell, Oral manifestation in cyclic neutropenia, British Journal of Oral Surgery,Volume 20,
Issue 2.
39. ◦ Condliffe AM, Kitchen E, Chilvers ER. Neutrophil priming: pathophysiological consequences and
underlying mechanisms. Clin Sci (Lond). 1998 May;94(5) 461-471. doi:10.1042/cs0940461. PMID:
9682667.
◦ Pejčić, Ana, et al. "Smoking and periodontal disease: A review." Med Biol 14.2 (2007): 53-9.
◦ Brian l. Mealey & gloria l. OCAMPO, Diabetes mellitus and periodontal disease, periodontology 2000, vol. 44, 2007, 127–15
◦ Yin C, Heit B. Armed for destruction: formation, function and trafficking of neutrophil granules. Cell
Tissue Res. 2018 Mar;371(3):455-471. doi: 10.1007/s00441-017-2731-8. Epub 2017 Nov 29. PMID:
29185068.
◦ Jack Goldberg, Robert S. Pinals, Felty syndrome, Seminars in Arthritis and Rheumatism ,Volume 10, Issue 1,1980,Pages 52-
65.
◦ Z.Y. Joazlina, M.L. Wastie, A. Kamarulzaman, Kostmann's syndrome, Clinical Imaging, Volume 29, Issue 5, 2005,Pages 364-
366.
Editor's Notes
Normal blood contains 4000-10,000 WBCs / ml
circulating lifespan of 6–8 h
azurophilic granules formed first, during the pro-myelocyte phase, followed by specific, gelatinase and secretory granules during the myelocyte/metamyelocyte, band cell and segmented cell stages
receptors recognize host proteins, called opsonins, that coat microbes and target them for phagocytosis (the process called opsonization).
IgG opsonin is the Fc fragment of immunoglobulin G; C3b opsonin is the fragment generated by activation of complement pathway, Lectins are carbohydrate-binding proteins in the plasma
The senescent pmns return to the bone marrow for clearane after they have increased expression of CXCCR4
Perio 2000- vol 6 JOERG MEYLE
The lazy leucocyte syndrome may be a consequence of altered membrane microfilamentous protein structure or function, and undue rigidity of the affected neutrophils may explain the clinicopathological features of the disease.
lysosomal trafficking regulator
also known as Bridges–Good syndrome, chronic granulomatous disorder, and Quie syndrome
caused by either x linked recessive disease or autosomal recessive disease.
Perio 2000- vol 32, fransico
The presence of calcium is fundamental during the actin filament modifications that lead to cell motility; thus, by reducing cytosolic calcium, the bacteria can disrupt neutrophil movement.
Gingipains have been called the principal virulence factor created by P. gingivalis and are involved in modulation of leukocyte responses.comprises a grup of cystine endopeptidase thataccountsfor 85% of proteolytic activity & 100% expression of trypsin like activity.
C5a- chemotactic factor for pmn infiltration , c3m derived opsonins this making the p, G resistant to phagocytosis