Pathogenesis of periodontal diseases

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PATHOGENESIS OF PERIODONTAL DISEASES By Patrick Bannerman- Agbesi

Transcript of Pathogenesis of periodontal diseases

Page 1: Pathogenesis of periodontal diseases

PATHOGENESIS OF PERIODONTAL

DISEASES

By Patrick Bannerman- Agbesi

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Outline • Introduction

•Clinically healthy gingiva

•Different lesions in Gingivitis/Periodontitis

•Host Parasite Interaction

•Host Defense process

•Summary and Conclusion

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INTRODUCTION•Definition –Origination and development of a disease

• -Mechanism by which an etiologic factor causes disease

•Greek “pathos”-suffering “genesis”-creation

• Unique clinical entity due to its anatomy and defensive processes

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INTRODUCTION•Referred to as a “mixed bacterial infection”–commensal and pathogenic interplay •Sub gingival biofilm and host-immune-inflammatory events leads to breakdown of periodontal fibers-----Clinical attachment loss and bone resorption.•The quality and quantity of the micro-organisms should be noted

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CLINICALLY HEALTHY GINGIVA

• Oral epithelium-keratinized

• Junctional epithelium (JE)—intrinsically “leaky”- reduced desmosome

• CT-collagen types I and III.

• Fiber arrangements-

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CLINICALLY HEALTHY GINGIVA• Pink in colour, scalloped margins,

knife edge volume, firm consistency,

• Page and Shroeder (1976)---polymorphonuclear neutrophils ( PMN) in the gingival crevice

• Gingival crevicular fluid (GCF)

• harbour of Chemo-attractant and chemotactic factors

• SUBCLINICAL GINGIVITIS ?

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CLINICALLY HEALTHY GINGIVA• Kept in check by the following-

• Intact barrier of JE• Regular shedding of cells into the oral cavity• Mechanical wash from the fluid into the crevice /dilution

and FLUSH• Antibodies, neutrophils, macrophages in sulcus • Complement action • When these responses are overwhelmed---periodontal

disease presents• NB---GINGIVITIS DOES NOT ALWAYS PROGRESS TO

PERIODONTITIS

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GINGIVAL INFLAMMATION

• CLINICAL FINDINGS• EDEMATOUS• ERYTHEMATOUS• BLEEDS EASILY ON

GENTLE PROBING• ROLLED• SOFT

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GINGIVAL INFLAMMATION

• HISTOPATHOLOGICAL FINDINGS •VASCULAR NETWORK CHANGES•DISRUPTION OF THE NORMAL ANATOMY OF THE CT •GCF EXUDATES AND PROTEIN CONCENTRATIONS INCREASE•CT INFILTRATES CHANGE TO LYMPHOCYTES AND MACROPHAGES•PLASMA CELLS AND ASSOCIATED COLLAGEN DEPLETION

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HISTOPATHOLOGY OF GINGIVITIS/PERIODONTITIS•Page and Shroeder -4 descriptions. • INITIAL LESION------CLINICALLY HEALTHY GINGIVA•EARLY LESION-------CLINICALLY HEALTHY GINGIVA•ESTABLISHED LESION-------CHRONIC GINGIVITIS•ADVANCED LESION-------PERIODONTITIS

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HISTOPATHOLOGY OF GINGIVITIS/PERIODONTITIS1.INITIAL LESION•Plaque in gingival third in 24 hours results in

vascular changes and intercellular gap formation and permeability-----leads to exudation in tissues and increased GCF .•PMN migration is influenced by adhesion molecules

( ICAM-1,ELAM-1) and a strong chemo attractant gradient.• The time frame for this is between 2-4 days

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HISTOPATHOLOGY OF GINGIVITIS/PERIODONTITIS2.EARLY LESION•More vascular changes occur ( redness as a clinical

symptom) • Fibroblast degenerate by apoptosis and must be

cleared hence more PMN infiltration (PAGE AND SHROEDER, TAKAHASHI)• Subsequent collagen fiber breakdown-----more

space for infiltrates• Time frame -1 WEEK

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HISTOPATHOLOGY OF GINGIVITIS/PERIODONTITIS

•3.ESTABLISHED LESION• Increased GCF flow and leukocyte infiltration.

PLASMA CELLS dominate according to PAGE AND SHROEDER. Brecx and Fransson propose lymphocytes in young people but plasma cells in older people.• JE +SE then changes to POCKET EPITHELIUM (PE)-

allowing for a more apical migration of the biofilm.•Pocket epithelium is more permeable and hence

bleeds easily

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HISTOPATHOLOGY OF GINGIVITIS/PERIODONTITIS4.ADVANCED LESION•New niche created by the apical migration of

biofilm is now an ANAEROBIC eco-niche.• The Established lesion progresses along with LOSS

OF CT ATTACHMENT AND LOSS OF ALVEOLAR BONE.•Pocket epithelium predominated with PLASMA

CELLS and CT infiltrates

NB-this progession of lesions is influenced greatly by the SUBJECT AND VARIABILITY.

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SCHEMATIC VIEW OF THE PROGRESSION

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HOST PARASITE INTERACTIONThe inflammatory responses in periodontium is influenced by •1. MICROBIAL VIRULENCE FACTORS•2.HOST- DERIVED INFLAMMATORY MEDIATORS

•1.MICROBIAL VIRULENCE FACTORS• These factors activate the immune inflammatory

response •A. LIPOPOLYSACCHARIDE (LPS)– ENDOTOXIN• The host has TOLL-LIKE RECEPTORS (TLR) which

recognize them and TRIGGERS a CASCADE of events for CYTOKINE PRODUCTION, BLOOD COAGULATION AND COMPLEMENT SYSTEM.

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HOST PARASITE INTERACTION

•B.ENZYMES AND NOXIOUS PRODUCTS•Metabolites such as ammonia, indole, hydrogen sulphide, butyric acid are known to induce T and B cell apoptosis and influence cytokine secretion.•Proteases such as Arg-1 protease by Porphyromonas gingivalis and Leukotoxin by Aggregatibacter actinomycetemcomitans

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HOST PARASITE INTERACTION

•C.MICROBIAL INVASION•P. gingivalis, A.a, Fusobacterium nucleatum•Translocation of from the biofilm

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HOST DEFENCE PROCESS• Two branches 1. NON-SPECIFIC/ INNATE

2.SPECIFIC/ ADAPTIVE

•1. INNATE IMMUNITY-

•Redness, swelling, heat, pain and loss of function.

• Saliva, GCF, epithelial keratinocytes, Normal flora. Concept of TOLL-LIKE RECPTORS.

a.SALIVA-antibodies, histatins, cystatins, lactoferrin, lysozyme, mucins, peroxidases

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HOST DEFENCE PROCESS

a.GCF- FLUSH /DILUTION effect and the medium for transporting blood components to the crevice

b. EPITHELIAL TISSUES- barrier function of oral mucosa. Junctional epithelium ( non-keratinized, high turnover )Host interaction with fimbriae of P.gingivalisc.PATHOGEN RECOGNITION AND ACTIVATION OF CELLULAR INNATE RESPONSE- Pattern Recognition Receptors (PRR) on macrophages and dendrites recognize MICROBE-ASSOCIATED MOLECULAR PATTERNS ( MAMPS) to signal an immune response

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HOST DEFENCE PROCESS2. SPECIFIC IMMUNITY

•Proteinases, Protease inhibitors, Matrix Metalloproteases (MMP), Cytokines ( Interleukins and Prostaglandins)• a. Proteinases- Endopeptidases and Exopeptidasesb. Protease inhibitors - Alpha-2- macroglobulin (A2-M) and Alpha-1 antitrypsin (A1-AT)C. MMP- responsible for tissue repair and remodeling. Neutrophil collagenase—pdl is the most metabolically active tissue and collagen metabolism represents most of its activity. Degrades ELASTIN,GELATIN, GAG.

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•d. CYTOKINES – soluble proteins serving as messenger molecules that initiate /maintain an immune response.•1.INTERLEUKIN 1 FAMILY CYTOKINES.• IL-1 BETA ---synergizes PGE2 to induce BONE

RESORPTION• TUMOUR NECROSIS FACTOR ALPHA------

osteoclast induction• IL-6-----monocyte differentiation to osteoclast•PGE2----induce MMPs •MMP-----Up regulates IL-1 beta

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LINKING PATHOGENESIS TO CLINICAL SIGNS OF DISEASE• FACT- bacteria in the pocket are never fully

ELIMINATED!!!

• END RESULT-----ALVEOLAR BONE

•RESORPTION

• This progression will be strongly

influenced by the concentration of the

mediators

• and the penetration of bacteria into alveolar bone

•BONE MODELLING SYSTEM---RANK/RANK-L/OPG.

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LINKING PATHOGENESIS TO CLINICAL SIGNS OF DISEASE

•RESOLUTION OF INFLAMMATION

• If the initial and early lesions do not progress to the established and advanced lesions, the gingivitis may resolve

•New agonists in this concept, LIPOXINS , RESOLVINS AND PROTECTINS function ACTIVELY as anti-inflammatory agents and inhibitors of neutrophil infiltration.

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LINKING PATHOGENESIS TO CLINICAL SIGNS OF DISEASE

•A. LIPOXINS (LXA4, LXB4) – inhibit PMN recruitment, chemotaxis and adhesion, signal macrophages to phagocytize .•B. RESOLVINS AND PROTECTINS—inhibit neutrophil

infiltration and transmigration, inhibit production of pro-inflammatory mediators, and REDUCE cytokine expression

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Summary and conclusion.

•Pathogenesis of periodontal disease is strongly influenced by the interplay of host-parasite interaction as well as the host response to the irritating factor.

•Gingivitis does not always progress to Periodontitis

• There is a wide variability in terms of progression in different subjects/individuals.

•Variations occur from tooth to tooth and from site to site.

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Summary and Conclusion

• These events are site specific and are not usually associated with pain and this makes them more sinister.

• These conditions are preventable with re-enforced oral hygiene instructions and client motivation.

•Visit your dentist twice a year for routine check-up and scaling and polishing prevent periodontal diseases.

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THANK YOU!!