DEFENSE MECHANISM OF ORAL

CAVITY

PRESENTED BY: Dr. Rucha K. Varu

DATE: 29/08/10

Introduction
Oral mucous membrane
Saliva
Gingival crevicular fluid
Teeth
Hypersensitivity reactions
Conclusion
Refrences

Introduction:
Oral cavity is the only area in the body in which hard
tissues break through the epithelial surface, implying
that periodontal tissue surrounding the tooth acquire a
specialization to form an effective attachment & seal
around each structure

ORAL MUCOUS MEMBRANE

Oral cavity is an ideal incubator for variety of organisms

Commensal organisms become pathogenic when host defense is
compromised
OMM acts as a mechanical barrier
The mucosa is in continuity with a number of anatomical structures
It is in direct continuity with the skin of the lips at the mucocutaneous junction and with the pharynx and larynx via the
oropharynx
Integrity of oral epithelium is an effective barrier for entry of
microorganisms

Infection occurs if epithelial integrity is broken or

epithelium becomes permeable to bacterial toxins

Number of adaptations of epithelium & CT --withstand the mechanical forces

Keratin:

Keratinized surface there is continuous outward

movement of desquamated epithelial cells --- protects
the underlying tissue

Membrane coating granules:

Cells in upper part of prickle
cell layer has membrane
coating granules which contain
glycolopid
As cell moves towards surface
it fuses with the superficial cell
membrane & discharge its
contents into intercellular
space.

Permeability barrier consist of lipids derived from

the membrane coating granules that become
aligned in precise pattern once they have entered
the intercellular spaces of upper cell layer

Cells of superficial part of granular layer develop

noticable thickning on inner aspect of cell
membrane --- resistance to chemical solvents

Squames:
At the junction of granular & keratinized layer sudden
change in their appearance occurs.
All organelles including nulceus & keratohyaline
granules disappears
Cells dehydrate & become packed with filaments
cross linked by disulfide bonds, which facilitate their
dense packing
Cells assume the form of hexagonal disks called
squames
Squames are lost --- desquamation --- programmed
enzymatic breakdown of lipids & proteins

This process occurs rapidly so that an individual

surface squame is shed

Rapid clearance of surface layer is important in limiting

the colonization & invasion of epithelial surfaces by
pathogenic microorganisms

Cohesiveness of epithelial cells --- function as barrier

to great extent
Cohesion between the cells --- viscous intercellular
material consisting of protein carbohydrate complex

Cell to cell --- desmosome

Cell to CT --- hemidesmosome
Tonofilament, hemidesmosome & basal lamina --mechanical linkage that distributes & dissipates
localized forces applied to epithelial surface over wide
area

Lymphocytes & PMNs are found in various levels of

epithelium

Keratinocytes produce interlukin1--- stimulate

lymphocyte

Stimulated lymphocyte produce gamma interferon --stimulate keratinocyte to express HLA-DR antigen

Basement membrane:

Lamina propria adjacent to basement membrane --lymphoid cells --- combat microorganisms that has
penetrated to this depth
These intraoral lymphoid aggregations function
together with extraoral lymph node

In several regions of oral cavity, there are nodules of

lymphoid tissue which consists of crypts formed by
invaginations of epithelium into lamina propria

Capillaries in CT carry adhession molecules like --endothelial cell leucocyte adhesion molecule,
intercellular adhesion molecule & vascular cell
adhesion molecule --- facilitate trafficking of leucocytes
from the blood

Infiltration of lymphocytes & plasma cells --- ability to

mount immunologic reaction --- important role in
combating infections in oral cavity

Largest accumulation of lymphoid tissue is seen in

posterior part of oral cavity --- lingual, pharyngeal &
palatine tonsils

Lingual tonsil:
Lie on either side of tongue,
distal to circumvallete papillae
Palatine tonsils:
Paired
Glossopalatine &
pharyngeopalatine arches
Lymphoid tissue contains
both B & T cells
Pharyngeal tonsil:
Mass of lymphoid tissue
under nasopharyngeal
mucosa

DENTIN
Dentinal sclerosis:
In cases of caries, attrision, abrasion, erosion or cavity preparation
--- stimuli is generated --- cause collagen fibers & apatite crystals
compactly arranged in dentinal tubules

Gradually entire dentinal tubule gets filled with such highly calcified
dentin & dentinal tubule gets obliterated

Reduces the permeability of the dentin & prolong the pulp vitality.

Fatty degeneration of Tomes dentinal fibers:

Fat contributes to the impermeability of dentinal
tubules

PULP

1.
2.

Pulp response to irritation by:

Producing reparative dentin
Mineralizing affected dentinal tubules

Reparative dentin or tertiary dentin:

Stimuli --- destruction of enamel --- exposure of

dentinal tubules & damage to odontoblastic processes
& odontoblasts

Damage is mild --- damaged odontoblasts themselves

deposit dentin --- subjacent to damaged dentinal
tubules --- reactive or responsive dentin.

Damage is severe --- odontoblast die & new

odontoblasts are differentiated from undifferentiated
mesenchymal cells situated in the pulp

These cells deposit dentin subjacent to damaged

dentinal tubules --- reparative dentin.

Oral fluids
Saliva
GCF

SALIVA

Saliva bathes the oral tissues and is responsible for the health status
of the oral cavity

Volume 1000 1500ml/day

Slightly acidic pH 6.7

Hypotonic to plasma

Functions of saliva is related both to its fluid character & specific

component

COMPOSITION OF SALIVA
Proteins Small Organic molecules Electrolytes

Albmin
Amylase
B-glucuronidase
Carbohydrates
Cystatins
Epidermal growth factor
Esterases
Fibronectin
Gustin
Histatins
Immunoglobulin A
Immunoglobulin G
Immunoglobulin M
Kallikrein
Lactoferrin
Lipase
Lactic acid dehydrogenase
Lysosyme
Mucins
Nerve growth factor
Parotid aggregins
Peptidases
Phosphatases
Proline rich proteins
Ribonucleases
Salivary peroxydases
Secretory component
Secretory IgA
Serum protiens

Amino acids
Creatinine
Glucose
Lipids
Nitrogen
Sialic acid
Urea
Uric acid

Ammonia
Bicarbonate
Calcium
Chloride
Fluoride
Iodine
Magnesium
Phosphates
Potassium
Sodium
Sulphates
Thiocyanate

Proteins:

Salivary proteins are the major organic component of

saliva

40 different types of proteins

Average total protein concentration is 2mg/ml of saliva

Some proteins protect the oral tissue against infections

while others coat & lubricate the oral tissue

Salivary mucins:

I.
II.
.
.

These are high molecular weight glycoproteins

Play a major role in the formation of protective coating covering
Two types --- based on macromolecular characteristics
High (> 1000 kDa) and
Low (200-300 kDa) molecular weight forms.
Differ with respect to bacterial clearance ability,
Identical carbohydrate chain make-up, ranging in size from 3 to 16
sugar units.

The mucins coating the oral mucosa, interact with the epithelial
surfaces through specific membrane receptors.

This interaction apparently involves the carbohydrate moiety of

mucin molecule, and may be rendered vulnerable to disruption by
opportunistic bacteria

Histatins:

Small antimicrobial peptide 3 to 4 kDa

Present in high concentration in parotid saliva

Lethal effect on oral fungi like candida albicans

Killing action on candida albicans depends on ionic strength of saliva

Becomes higher with low salt concentrations, in which histatin binds

with candida albicans

Bactericidal to streptococcus mutans

Alpha - amylases

Most abundant enzyme found in saliva

Digestion of starch by hydrolyzing 1-4 linkages in glucose

containing polysaccharides to end-products glucose and maltose.

Inhibits growth of nisseria gonorrhoeae

Presence in acquired pellicle and its capacity to bind streptococcus

sangius suggests a role in oral microbial colonization

Lysozyme / muramidsae:

Enzyme which has basic protein

Bactericidal --- splits the bond between N-acetyl glucosamine & Nacetyl muramic acid in mucopeptide component of bacterial cell wall

Those micro-organisms insensitive to its muramidase activity will be

killed by lysozymes

Keeps down the level of commensal organism in mouth by

interacting with other salivary component like IgA

Oral microbial flora appears to be reststant except s. mutans --- play

role in control of dental caries.

Lactoferrin:

This is an iron binding glycoprotein

Bind iron & thus it inhibits bacterial growth

Bacetriostatic --- Reduces the concentration of iron which is an

important co-factor for bacterial enzyme

It is reported that low level of lactoferrin there is high level of

potentially pathologic oral bacteria

Peroxidase:

Catalyses the oxygenation of thiocyanate to hypothiocyanate --reduces the bacterial growth by blocking essential metabolic process

It is also heat labile & kills lactobacillus acidophilus by inhibiting the

uptake of lysine

It also inactivates some streptococci by inhibiting their glycolytic

enzyme

Fibronectin:

Adhesive glycoprotein

Complexing of cell surface fibronectin, with salivary molecules like

amylase --- inhibit the epithelilal colonization of gram-negative
bacteria such as E. coli.

Salivary buffer:

Maintain the physiologic ion concentration at the mucosal epithelial

cell surface and tooth surface

Bicarbonate and phosphate ions

The proteins have no role in buffering capacity


1.
2.

Saliva provides a buffer that protects the oral cavity in 2

ways:
Alters the pH required by bacteria for their growth --prevents colonization
Plaque organisms produce acid from sugars which if not
rapidly buffered and cleared by saliva can demineralize
enamel.

Saliva pH:

Normal pH ---5.6 to 7.0 average --- 6.7

Optimum pH for growth of most of the bacteria is between 4.5 to 5.0

( growth diminishes in acidic pH)

pH exerts some degree of selective action on survival & growth of

certain species of microorganism

Low pH favours growth of lactobacilli, s.mutans, yeasts

High pH favours growth of proteolytic bacteria.

IgA:

Secretory IgA
90% --- total parotid IgA, 85% --- whole saliva IgA, 30-35% --- minor
salivary glands
Functions:
Inhibits bacterial colonization by agglutination
Binds to specific bacterial antigen involved with adherance
Affects specific enzymes which are essential for bacterial metabolism
IgA complex with protein covering the oral epithelium --- provide
protective immunoglobulin coating

Gingival crevicular fluid

Gingival fluid has a highly specialized function in the
gingiva, aiding in the defense of this region against the
bacterial attack.
Composition:
Bacteria
Desquamated epithelial cells
Leucocytes --- PMN
lymphocyte
monocyte / macrophage

Epithelium:

The oral sulcular epithelium

and junctional epithelium
are constantly renewing and
the shed cells will be found
in the gingival crevice and
gingival fluid samples.

ORIGIN AND FUNCTION OF CELLULAR COMPONENTS

Reported differential leukocyte counts from the gingival crevice fluid
Studies

Average percentage Average percentage mononuclear cells

of PMNs
lymphocytes
monocytes

Egelberg
Attstrm
Skapski & Lehner
Wilton et al.
Kowolik & Raeburn
Charon et al.
Sandholm
Saito et al.
Kennett et al.

98.6%
97.0%
91.5%
91.2%
98%
89.9%
9198%
89.7%
7080%

1.4%
1.0%
8.5%
8.8%
0.4%
10.2%
2-9%
1.7%
5.0%

2.0%
0.8%
2.3%
10-20%

Predominantly --- PMNs (91.5%)

Appear in small number extravascularly in CT adjacent
to bottom of the sulcus, from here they travel across
the epithelium to gingival sulcus
Mononuclear cells --- 8.5 to 8.8%
T and B lymphocytes --- ratio of 1:3 in GCF
Phagocytic and killing capacity --- major protective
mechanism against extension of plaque into gingival
sulcus

Immunoglobulins in GCF:

Gingival fluid probably represents an important source of

immunoglobulins in the oral cavity.

Most of IgG, small proportion of IgA & IgM.

The immunoglobulins of gingival fluid might significantly

contributes to the oral defense particularly in the crevicular
domain.

Dentogingival junction:

Junction formed between the gingiva

& the tooth surface
Relatively weak junction
Epithelium & CT attached to tooth --contribute to integrity of DGJ
Less resitstance to mechanical
forces & bacterial attack
Epithelium is injured --- replaced by
turnover of epithelial cells & by their
ability to migrate

CT is injured it is repaired by deposition of collagen

fibers
Defense against bacterial injury is by inflammatory
cells --- lymphocytes, plasma cells, neutrophils
Clusters of plasma cells are found adjacent to
junctional epithelium

DEFENSE CELLS:
Leucocytes
Langerhans cells
Mast cells

Leukocytes

Leukocytes are the mobile units of bodys protective

system

Formed partially in bone marrow (granulocytes,

monocytes & few lymphocytes) & partially in lymph
tissue (lymphocytes & plasma cells)

Transported to areas of infection & inflammation --rapid & potent defense

Two types:
Granulocytes
Neutrophils
Eosinophils
Basophils

Agranulocytes
Monocyte
Lymphocyte

Mononuclear Phagocytes:
Monocytes circulating in blood & macrophages in tissue
During hematopoiesis in bone marrow, G-M progenitor cell --promyocytes --- enter blood & differentiates into mature
monocytes.

Monocytes circulate in blood stream for around 8hrs & then

differentiate into tissue macrophage

Cell enlarge 5 to 10 fold

Intercellular organelle --- increased
Increased phagocytic ability
Produce high level of hydrolytic enzyme
Travel by amoeboid movement

Activated by variety of stimuli & activated

macrophages are more effective in eliminating
pathogens because
Greater phagocytic activity,
increased ability to kill ingested microbes,
increased secretion of inflammatory mediators &
increased ability to activate T cells

Secrete various cytotoxic proteins --- eliminate

virus infected cells, tumor cells & intracellular
bacteria

Phagocytosis:
Macrophages are capable of ingesting & digesting
exogenous antigens --- microbes & endogenous matter --injured/dead host cell, debris
Adherance of antigen to cell membrane initiates
phagocytosis
Complex antigens like bacterial cell, viral particles --- adhere
well & are readily phagocytosed
Encapsulated bacteria --- adhere poorly & less readily
phagocytosed

Adherence --- pseudopodia --- extend around attached

material & encloses material within phagosome --fuses with lysosome --- phagolysosome

Lysosome contains hydrolytic enzyme --- digest the

ingested material & digested contents are eleminated
by process of exocytosis.

Neutrophils:
Most common leucocyte --- 50 to 70%
multilobed nucleus
Cytoplasm --- granulated

Azurophilic granules / primary granules

First granules to appera
Contain myeloperoxidase & neutrophil defensins --- killing &
degrading engulfed microorganism

Secondary / specific granules:

Most numerous
Contain lysozyme, collagenase, lactoferrin
Tertiary / gelatinase granules:
Contain gelatinase --- breaks down the extracellular
matrix & insert adhesion molecule into cell membrane.

From circulation --- attracted by chemotactic factors

which are released either from tissue damage or due
to antigen antibody reaction

Chemotaxins --- stimulate neutrophils & also signals

secondary granules to fuse with cell surface

Cell adhesion proteins are expressed --- neutrophil to

stick to the endothelial cell & move into the tissue

Neutrophils & macrophages have bactericidal enzyme --- can

kill most of the bacteria

Several powerful oxidizing agents are formed by the enzymes

in membrane of phagosome or special organelle --peroxisome

These oxidizing agents includes --- superoxide, H2O2 &

hydroxyl ions --- lethal to most bacteria even in small quantity

Myeloperoxidase catalyzes reaction between H2O2 &

chloride --- hypochloride --- bactericidal

Lymphocyte:
20 to 50 % of leucocyte in circulation
Most circulating lymphocytes measure 6-9m --- small
lymphocyte
3% large lymphocyte --- 9-15m
Lymphocytes leave bone marrow, circulate in blood &
lymphatic system & reside in various lymphoid organs
Cell surface --- antigen binding receptors


1.
2.

Two population
B lymphocytes (B cells)
T lymphocytes (T cells)

B lymphocyte:
. Mature in bone marrow
. Stimulated B cells mature into plasma cell
. Plasma cells synthesize large amount of antibody (Ig)
. Unique antigen binding receptor on its membrane --- B cell receptor
. B cell receptor --- membrane bound antibody molecule

When B cell comes in contact with antigen for the first time
--- primary immune response
Binding of antigen to antibody cause cell to divide rapidly
Few cells mature to become memory B cells --- long lived
circulating lymphocytes which respond to quickly on
exposure to same antigen --- secondary immune response
Antibody production is more rapid & produce IgG & not IgM
Thus there is life time immunity

T lymphocytes:
Arise in bone marrow
Immature T cells migrate from marrow to thymus
where they develop into mature T cell
Mature T cells then populate secondary lymphoid
tissue & from here they circulate via bloodstream in
quest of antigen

Several functional subsets

T helper cells
Cytotoxic T cells
Supressor T cells
T helper cells:
Secrete interlukin
Help other cells like B cells, cytotoxic Tcells &
macrophages to perform their functions

Cytotoxic T cell:
Interaction with T helper cells, they become activated
& proliferate
Kill virus infected cells & some cancer cells
Supressor T cells:
Supress the immune responsiveness to self antigen
Switch off the response when antigen is removed.

Memory T cell:
Subsequent exposure to same antigen
Rapid reaction force

Eoisnophils

2-6% of leucocytes in circulating

blood

12-17 in diameter and is larger

than neutrophil

easily recognised by its large

specific granules in the cytoplasm,
which are coarse and stain red
with eosin

Nucleus is typically bilobed and

spectacle shaped
74

The specific granules of eosinophils contain a crystalloid

body

They contain four major proteins

i) An arginine rich protein called major basic protein (MBP)

ii) Eosinophil cation protein
iii)Eosinophil peroxidase
iv)Eosinophil derived neurotoxin

75

Specific granules also

contain histaminase

Smaller granules in the

mature eosinophils contain
aryl sulphatase and acid
phosphatase

Eosinophils are associated

with allergic reactions,
parasitic infections
76

Basophils

Are the least common leucocyte and

constitute less than 1% of leucocytes in
circulating blood

They are characterised by large intense

basophilic cytoplasmic granules and
share many structural and functional
similarities with mast cells

It is 14-16m in diameter, intermediate in

size between neutrophil and eosinophil

Nucleus is bilobed usually obscured by

large densely basophilic specific granules
80

Specific granules contain heparin, histamin ,heparan

sulphate

81

Langerhans cells:

Cell of hematopoietic origin

Penetrate epithelium from lamina propria
Cell has convoluted nucleus
Rod like granules in cytoplasm --- Birbeck granules
One end will distend into vesicle --- tennis racket

Vimentin type of intermediate filament

Migrate into gingiva
They also migrate into epithelium in response to
chemotactic factor released by keratinocytes to
surface receptors of langerhans cells

Dendritic cytoplasmic process --- they constantly

monitor the environment in epithelial surface & in
between the epithelial cells
They shuttle between epithelium & lymphoid system
They pick up the antigen & present it to lymphocyte
Play important role in contact hypersensitivity, anti
tumor immunity & graft rejection

Some chemical carcinogens, immunosupressive

agents & excessive ultraviolet light --- reduced the
number & effectiveness of Langerhans cells

In skin & oral mucosa they are responsible for

epithelial immunologic function by which skin &
mucosa communicate with the lymphoid system

Mast cells:

Precursors are formed in the bone marrow by

hematopoiesis & are released in the blood as
undifferentiated cells
Cytoplasmic granules --- proteoglycans consisting of
sulphated glycosaminoglycans --- metachromatic
staining property
Proteoglycans --- heparin, chondroitin sulphate,
histamine

Effector cells in allergic disorders mediated by IgE & T

cells
Membrane receptors specific for Fc segment of IgE
Exposure to allergen --- release of histamine (other
vasoactive amines) --- immediate hypersensitivity
reaction

Immunoglobulins:

Glycoproteins

Ig are synthesized by plasma cells

Present in serum & body fluids

Reactive & binds specifically to the antigen

Based on physiochemical and antigenic differences, 5 different

classes of Ig are recognized

IgG, IgA, IgM, IgD and IgE.

Structure of Ig:

Porter has studied the structure of Ig and the model of Ig is called as

Porters Model

Can be split into 3 parts by enzyme papain.

1Fc + 2 Fab

Fc fragment --- insoluble fraction crystallized in cold

Fab fragment --- antigen binding fragment.

Each molecule consists of 2 pairs of polypeptide chains of different

sizes

The smaller chains are called as Light chains (L) & longer chains as
Heavy chains (H)

Mol wt. of L chain is 25000

Mol wt. of H chain is 50000

L chain is attached to H chain

by disulphide bond

Two H chains are joined

together by 1-5 S-S bond
depending upon class of Ig.

L chain are similar in all Ig.

Occur in 2 varieties K chain (kappa) or chain (lamda)

Antigen combining site is at aminoterminal

Both L & H chains have 2 portions each of which one is constant

and other is variable region

Fab fragment has antigen combining capacity.

IgA

s
Second most abundant class

Major Ig in seromucous secretions like saliva, colostrum & tears

sIgA is dimeric form & composed of two basic four chain units (2
light & 2 heavy chains) & J chain --- secretory component

sIgA is resistant to digestive enzymes

Doesnot fix complement but can activate alternate complement

pathway

Provides a first line of defense via immunological means

Binds to antigens --- causing a local aggregation

Inhibit their adherence to hard and soft tissue surfaces
Thus hinder sub-surface microbial invasion into deeper host tissues
It has been shown that IgA antibodies present in parotid saliva

can inhibit attachment of oral Streptococcus species to

epithelial cells.
Gibbons and colleagues suggested that antibodies in
secretions may impair the ability of bacteria to attach to
mucosal or dental surfaces.

Play a role in viral neutralization, attenuation of viral growth and

replication on oral surfaces

Neutralisation and disposal of toxins and food antigens

Hypersensitivity reactions

1.
.
.
2.
.
.

The injurious consequences in sensitized host following

exposure of specific antigen is called hypersensitivity reaction
Immunity not always protects the body, sometimes it may cause
disease, tissue injury or death
Classification:
Immediate type
clinical response occurs within minutes
mediated by antibodies
Delayed type
Clinical response occurs within 24 to72 hours
Mediated by lymphocytes

Coomb & Gel classified hypersensitivity reactions into

four major types:
Type I --- anaphylactic
Type II --- cytotoxic
Type III --- immune complex
Type IV --- delayed or cell mediated

Conclusion:
Oral cavity is characterized by various functions,
which contribute to the protective purpose and favour
the establishment of regulated equilibrium between
health and disease.

Refrences:

GCF. Periodontology 2000, vol 31, 2003

In Defense of the Oral Cavity: The Protective Role of
the Salivary Secretions.
Pediatr Dent 2006;28:110-117
Text book of Oral Physiology --- Timothy S Miles
Applied Oral Physiology --- Lavelle
Clinical Periodontology --- Newman Carranza
Oral Histology & Embryology --- Orbans
Immunology --- Kuby