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.

1. ROLE OF NEUTROPHILS
IN HEALTH AND DISEASE
DR JASMINE RAO
DEPT. OF PERIODONTOLOGY & ORAL IMPLANTOLOGY

2. Contents
1. Introduction
2. Formation
3. Morphology
4. Functions
5. Neutrophil disorders
6. Conclusion

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

4. NEUTROPHIL HOMEOSTATSIS
◦ Neutrophil homeostatsis, consists of formation of neutrophils, their trafficking and their
clearance.

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

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

9. • Neutrophils contain – Azurophilic / primary granules,
Specific / secondary granules,
Gelatinase /tertiary granules
Secretory vesicles
NEUTROPHILIC GRANULES

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

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

20. QUANTITATIVE
NEUTROPENIA
1.1. Agranulocytosis
2.2. Chronic benign neutropenia
3.3. Cyclic neutropenia
4.4. Congenital neutropenia
5.(Kostmann syndrome)
6.5. Felty’s syndrome
NEUTROPHILIA

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 .

24. QUALITATIVE
Defect in
Adhesion
LAD 1
LAD 2
LAD 3
Defect in
Chemotaxis
1.1. Hyperimmunoglobulin E,
2. Papillon Le’Fevre syndrome,
3. Haim Munk syndrome,
4. Down’s syndrome,
5. Inflammatory bowel disease,
6. Lazy leukocyte syndrome
Defect in Phagocytosis
& Intracellular killing
1. Chronic granulomatous
disease.
2. Chediak Higashi syndrome
3. Specific granule deficiency,
4. Myeloperoxidase deficiency

25. DEFECT IN ADHESION

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

27. DEFECT IN CHEMOTAXIS

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

30. DEFECTS IN PHAGOCYTOSIS &
INTRACELLULAR KILLING

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.

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