Plaque Borders Research Articles

Limitations to the use of virtual histology-intravascular ultrasound to detect vulnerable plaque

Surmely et al. 1 used virtual histology-intravascular ultrasound (VH-IVUS) to characterize coronary plaque in patients with acute coronary syndrome (ACS) and stable angina. Although VH-IVUS is a promising plaque-imaging platform, we believe that significant methodological issues must be resolved before VH-IVUS is used to detect vulnerable plaque, let alone direct therapy. First, in thrombus-laden arteries, VH-IVUS does not enhance the imprecise detection of plaque borders by grey-scale IVUS. Unfortunately, the authors do not describe their method of thrombus border …

Comparative evaluation of despeckle filtering in ultrasound imaging of the carotid artery

It is well-known that speckle is a multiplicative noise that degrades the visual evaluation in ultrasound imaging. The recent advancements in ultrasound instrumentation and portable ultrasound devices necessitate the need of more robust despeckling techniques for enhanced ultrasound medical imaging for both routine clinical practice and teleconsultation. The objective of this work was to carry out a comparative evaluation of despeckle filtering based on texture analysis, image quality evaluation metrics, and visual evaluation by medical experts in the assessment of 440 (220 asymptomatic and 220 symptomatic) ultrasound images of the carotid artery bifurcation. In this paper a total of 10 despeckle filters were evaluated based on local statistics, median filtering, pixel homogeneity, geometric filtering, homomorphic filtering, anisotropic diffusion, nonlinear coherence diffusion, and wavelet filtering. The results of this study suggest that the first order statistics filter lsmv, gave the best performance, followed by the geometric filter gf4d, and the homogeneous mask area filter lsminsc. These filters improved the class separation between the asymptomatic and the symptomatic classes based on the statistics of the extracted texture features, gave only a marginal improvement in the classification success rate, and improved the visual assessment carried out by the two experts. More specifically, filters lsmv or gf4d can be used for despeckling asymptomatic images in which the expert is interested mainly in the plaque composition and texture analysis; and filters lsmv, gf4d, or lsminsc can be used for the despeckling of symptomatic images in which the expert is interested in identifying the degree of stenosis and the plaque borders. The proper selection of a despeckle filter is very important in the enhancement of ultrasonic imaging of the carotid artery. Further work is needed to evaluate at a larger scale and in clinical practice the performance of the proposed despeckle filters in the automated segmentation, texture analysis, and classification of carotid ultrasound imaging.

In vivo multiphoton imaging of a transgenic mouse model of Alzheimer disease reveals marked thioflavine-S-associated alterations in neurite trajectories.

Postmortem analyses of senile plaques reveal numerous dystrophic processes in their vicinity. We used in vivo multiphoton microscopy of a transgenic model of Alzheimer disease (AD) to simultaneously image senile plaques and nearby neuronal processes. Plaques were labeled by immunofluorescent staining or thioflavine-S and neuronal processes were labeled with a fluorescent dextran conjugate. Imaging of 3-dimensional volumes in the vicinity of plaques revealed subtle changes in neurite geometry in or near diffuse plaques. By contrast, disruptions in neurite morphology, including dystrophic neurites immediately surrounding plaques as well as major alterations in neurite trajectories, were seen in association with thioflavine-S-positive plaques. Nearly half of all labeled processes that came within 50 microm of a thioflavine-S-positive plaque were altered, suggesting a fairly large "halo" of neuropil alterations that extend beyond the discrete border of a thioflavine-S plaque. These results support the hypothesis that compact thioflavine-S-positive plaques disrupt the neuropil in AD.

Risk factors for acute and subacute stent thrombosis after high-pressure stent implantation: A study by intracoronary ultrasound

Background In the era of coronary stenting with high-pressure expansion, stent thrombosis remains a major life-threatening risk. Because of its superior imaging mode, intracoronary ultrasound could provide insight into potential risk factors for stent thrombosis. Patients and Methods In 215 patients with stent implantations controlled by intracoronary ultrasound, four occurrences of subacute stent thrombosis, two complete acute thrombotic occlusions, and four occurrences of incomplete acute thrombosis were observed. All stents were expanded with inflation pressures of at least 14 atm (17 ± 3 atm). The clinical data and the qualitative and quantitative ultrasound information were compared between stents with thrombosis and stents without thrombosis. The luminal area and the plaque border of the reference segments, and of the smallest and largest site of the stented segment after the initial and final expansion, were measured. Results Stents in the left anterior descending artery were more often involved in stent thrombosis than other vessels, but the vessel dimensions in this target vessel were smaller than in the right coronary artery. The plaque burden was considerably larger after stent implantation with subsequent thrombosis compared with no thrombosis (74.1 ± 8.8% vs 63.6 ± 8.0%; p < 0.001), and the stent area was smaller (4.80% ± 1.33 mm 2 vs 6.86 ± 2.08 mm 2; p < 0.01). In stents with thrombosis the plaque burden of the stent site with the smallest and largest lumen differed by 15.2%, whereas the difference in plaque burden in stents without thrombosis was 2.7%. Intracoronary ultrasound showed that the best risk predictor of thrombosis was the residual plaque burden of the stented segment (odds ratio 15.7 [confidence interval 2.4 to 104.7]), and a small stent area after implantation (odds ratio 6.8 [confidence interval 1.9 to 24.3]). Conclusion In a multivariate risk analysis plaque burden was the strongest independent risk factor for stent thrombosis. The amount of residual plaque mass around the stent might be a potential trigger for thrombus formation. (Am Heart J 1998;135:300-9.)

Inflammatory central nervous system demyelination: correlation of magnetic resonance imaging findings with lesion pathology.

Magnetic resonance imaging (MRI) is widely used to evaluate and monitor disease activity in inflammatory demyelinating central nervous system (CNS) diseases such as multiple sclerosis. The present study aimed at correlating MRI findings with histological parameters in 6 cases of biopsy-proven inflammatory demyelination of the CNS. The earliest stages of demyelinating activity manifested as almost isointense lesions with a massive gadolinium-DTPA (Gd-DTPA) enhancement in T1-weighted scans. In T2-weighted scans, early active lesions formed a border of decreased intensity compared with the lesion center and the perifocal edema. The morphological correlate of this pattern in our patients was activated macrophages in the zone of myelin destruction at the plaque border. Late active lesions were hypointense in T1 and hyperintense in T2 scans. Inactive demyelinated and remyelinating lesions were hyperintense in T2 scans and enhanced inhomogenously after Gd-DTPA application. T1 scans revealed major differences in the degree of hypointensity that correlated with the extent of axonal damage, extracellular edema, and the degree of demyelination or remyelination.

Regional Capture of Fibrillating Ventricular Myocardium

Previous investigations have suggested that during ventricular fibrillation (VF) pacing stimuli are incapable of evoking propagated ventricular activations. To determine whether regional myocardial capture could be achieved during rapid pacing in VF, extracellular unipolar potentials were sampled (2 kHz) and recorded from 506 Ag-AgCl electrodes arranged in a rectangular grid (22 x 23, 1.12-mm spacing) embedded in a plaque overlying two pacing electrodes in the epicardium of the anterobasal right ventricle in pentobarbital-anesthetized pigs (25 to 30 kg, n = 6). During separate episodes of electrically induced VF, two bursts of 40 monophasic stimuli (10 mA, 2-millisecond duration) were asynchronously applied to the stimulating electrodes in either a bipolar, unipolar anodal, or unipolar cathodal mode. Evidence of regional capture was provided by (1) animating the first temporal derivative of the extracellular potentials, (2) analyzing inter-beat interval patterns, and (3) employing the Karhunen-Loeve decomposition method to quantify the repetitiveness of spatio-temporal patterns of activation. Regional capture of ventricular myocardium during VF was observed when pacing stimuli fell late in the local myocardial activation interval and when the pacing cycle length was 80% to 115% of the mean subplaque activation cycle length. When myocardial activations became phase locked to the pacing stimuli, repeatable spatiotemporal patterns of activation followed each stimulus. Poincaré sections at the plaque border revealed that during VF prior to pacing, interbeat intervals were irregular but were driven by pacing to stable fixed values at times corresponding to our qualitative declaration of regional capture. A similar correspondence was demonstrated between the time of capture, defined by direct observation of the activation patterns, and a rise in the power contained in the first two spatial modes of a Karhunen-Loeve decomposition. These data demonstrate that appropriately timed stimuli produce regional capture of fibrillating right ventricular myocardium in the pig and support the existence of an excitable gap during VF in this model.

The apical border plaque in severe periodontitis. An ultrastructural study.

This study concerns the apical border (AB) plaque in relation to severe forms of periodontitis (SP), including juvenile, post-juvenile, and rapidly progressing periodontitis. Twenty-four (24) teeth from 16 patients with SP were examined by transmission electron microscopy (TEM). The AB was not discrete, with islands of bacteria in the so-called plaque-free zone (PFZ). Coronal to the AB the established plaque consisted of a layer of Gram-positive cocci and ghost cells and a superficial layer mainly of Gram-negative morphotypes, including cocci, rods, filaments, fusiforms, and spirochetes. The most apical apparently intact organisms in the PFZ were in bacterial islands or in isolation and were predominantly Gram-negative cocci and rods, with ghost cells in abundance. Ruthenium red, alcian blue-lanthanum nitrate, and safranin O were used to label matrix polyanionic macromolecules, and periodic acid (thiosemicarbazide) silver proteinate for intracellular polysaccharide (IPS). The matrix components were mainly fibrillar. Many intact bacteria exhibited extracellular polysaccharides or glycocalyces associated with their cell wall, and cytoplasmic IPS granules. The latter varied in distribution and were evident even in the most apically advanced intact microorganisms. The results indicate that IPS and some matrix features of the apical border plaque in severe periodontitis in certain aspects resemble those of sub-contact area plaque on children's teeth, in health or associated with early chronic gingivitis, and with those in chronic adult periodontitis. They also suggest the establishment of acidic regions in the microniche at the bottom of the periodontal pocket in the various forms of periodontitis differing in rate of progression. It was concluded that there was a limited range of intact bacterial morphotypes in the apical border plaque in severe periodontitis, similar to those in chronic adult periodontitis.

Segmentation of intravascular ultrasound images: a knowledge-based approach

Intravascular ultrasound imaging of coronary arteries provides important information about coronary lumen, wall, and plaque characteristics. Quantitative studies of coronary atherosclerosis using intravascular ultrasound and manual identification of wall and plaque borders are limited by the need for observers with substantial experience and the tedious nature of manual border detection. We have developed a method for segmentation of intravascular ultrasound images that identifies the internal and external elastic laminae and the plaque-lumen interface. The border detection algorithm was evaluated in a set of 38 intravascular ultrasound images acquired from fresh cadaveric hearts using a 30 MHz imaging catheter. To assess the performance of our border detection method we compared five quantitative measures of arterial anatomy derived from computer-detected borders with measures derived from borders manually defined by expert observers. Computer-detected and observer-defined lumen areas correlated very well (r=0.96, y=1.02x+0.52), as did plaque areas (r=0.95, y=1.07x-0.48), and percent area stenosis (r=0.93, y=0.99x-1.34.) Computer-derived segmental plaque thickness measurements were highly accurate. Our knowledge-based intravascular ultrasound segmentation method shows substantial promise for the quantitative analysis of in vivo intravascular ultrasound image data.

Proliferative potential of the attached cells of human junctional epithelium

Samples of the attached cells of junctional epithelium (DAT cells) were obtained during extractions of eight erupted bicuspids from young healthy subjects. Each extracted tooth, with its layer of living DAT cells, was incubated for three hours in minimum essential medium (MEM) containing 5 microCi/ml of 3H-thymidine, and prepared for autoradiography. An average of 3 labeled cells per 1 mm of the epithelial attachment was found along the vertical dimension of the tooth. The attachment of an individual cell to the tooth surface was found to be a prerequisite for the cell's DNA synthesis suggesting that the tooth has a nonspecific epigenetic role in defining the functional phenotype of the DAT cells. Even the most coronal DAT cells located about 200 microns apical from the plaque border, were found to synthesize DNA. The finding suggests that mechanisms which regulate the multiplication of DAT cells are involved in the preservation of the integrity of the dentogingival junction.

Local calcification as a determinant of the outcome of excimer laser coronary angioplasty

Calcification influences the outcome of various angioplasty techniques in the treatment of coronary artery disease. During angioscopic in vitro studies, we observed that dissections and perforations not caused by vessel bending frequently occurred at the boundary areas of plaque and adjacent vessel wall. This study investigated whether this is related to the distribution of calcific deposits. Postmortem excimer laser coronary angioplasty (308-nm XeCl) was performed in 51 stenotic coronary arteries. Twenty-three segments were further examined; these consisted of 11 perforations, six dissections, three segments with no ablative effect after the application of 20,000 laser impulses, and three successfully passed stenoses without complications. X-ray diffraction analysis and scanning electron microscopy were performed to detect calcium deposits and their spatial relationship to perforations and dissections. X-ray diffractions analysis detected calcifications in 21 of 23 specimens. Postmortem angiography revealed calcifications only on 11 of 23 segments. Three of 11 perforations were located at the plaque border, as were three of six dissections. In all six complications at the plaque border, x-ray diffraction analysis revealed that the plaque border was identical with a border of calcium deposits. Eight of 11 perforations and three of six dissections could be explained by axis divergence between the laser catheter and the vessel orientation. Contributing factors for perforations and dissections during excimer laser coronary angioplasty are axis divergence and the distribution of plaque calcification. More sensitive methods are needed to detect local vessel wall calcium in vivo.

α2-macroglobulin expression in neuritic-type plaques in patients with Alzheimer's disease

Because it has been suggested that α2M could be involved in the generation of amyloid peptide, attention was given to a possible association of α2M expression and amyloid accumulation in the brain. Therefore, we investigated the presence of the proteinase inhibitor α2-macroglobulin (α2M) in the cerebra of 4 patients with Alzheimer's Disease (AD). One case of a patient with Down's syndrome, 2 cases of patients with Dementia of the Lewy Body type (DLB), 1 case of an aged, clinically nondemented person who displayed many amyloid plaques, and 3 normal aged control brains were also studied. The results obtained by immunocytochemistry with monoclonal antibodies directed against two different epitopes of human α2M showed an association of α2M, only with neuritic-type plaques in patients with AD. No α2M immunoreactivity was found in either preamyloid-type plaques or burned out-type plaques in AD, DLB, or aged nondemented controls. The results do not support a direct role of this proteinase inhibitor in the formation of amyloid. Because α2M is observed to be associated with reactive microglia in the outer border of the neuritic plaques, the data suggest that α2M could be a marker for an inflammatory cellular process in these neuritic plaques.

The "plaque-free zone" in health and disease: a scanning electron microscope study.

A "plaque-free" zone has been described on the enamel surface of healthy extracted teeth. This study examined this zone on chronic adult periodontitis-affected teeth (CAPT). Ten healthy controls and 16 CAPT were collected immediately after extraction, fixed, dehydrated, critical point dried, coated, and viewed by scanning electron microscopy (SEM). The "plaque-free" zone was observed in both groups as an area with few bacteria between the apical plaque border and the coronal limit of an epithelial layer on the root surface, extending to the residual periodontal ligament. On the healthy specimens, the apical plaque border consisted mainly of cocci and short rods, while on the CAPT specimens spirochetes predominated. Isolated or small groups of microorganisms were always present in the "plaque-free" zone and at its apical limit, close to or in contact with junctional epithelial cells. This zone is therefore not completely free of plaque, as suggested. It was concluded that a tissue complex, analogous to that in health on enamel, persists on the root surfaces of CAPT throughout the disease process. It comprises a discrete plaque border, a dental cuticle with sparse organisms, and an epithelium analogous to junctional epithelium. Its main function would appear to be to prevent bulk access of plaque to the surrounding tissues, including direct contact of bacteria with underlying ligament.

The apical border plaque in chronic adult periodontitis. An ultrastructural study. I. Morphology, structure, and cell content.

THIS STUDY CONCERNS THE APICAL BORDER (AB) plaque in relation to chronic adult periodontitis (AP). Fifty-six teeth from 24 patients with AP were examined by transmission electron microscopy (TEM). The AB was not discrete with islands of bacteria in the so-called plaque-free zone (PFZ). Coronal to the AB, the established plaque commonly consisted of three to four layers of Gram-positive and Gram-negative cocci, rods, filaments, and spirochetes and a superficial layer, mainly of spirochetes, but including filaments, "test tube brush," and "corn-cob" formations. The most apical apparently intact organisms in the PFZ were in bacterial islands or in isolation and were predominantly Gram-negative cocci and rods, with occasional other morphotypes. The most apical microorganisms were invariably ghost cells. A cuticle of varying thickness and structure was present at the plaque/tooth interface. It was concluded that there was a limited range of intact bacterial morphotypes in the apical border plaque in chronic periodontitis.

The apical border plaque in chronic adult periodontitis. An ultrastructural study. II. Adhesion, matrix, and carbohydrate metabolism.

THE AIM OF THIS STUDY was to characterize the plaque matrix and relevant aspects of metabolism of the apical border plaque in relation to teeth affected by chronic adult periodontitis. The material comprised 56 teeth from 24 patients. Ruthenium red, alcian blue, lanthanum nitrate, and safranin 0 were used to label matrix polyanionic macromolecules and periodic acid-thiosemicarbazide-silver proteinate for intracellular polysaccharide (IPS). The matrix components were amorphous, fibrillar, or globular. Many intact bacteria exhibited extracellular polysaccharides or glycocalyces associated with their cell wall and cytoplasmic IPS granules. The latter varied in size and distribution and were evident even in the most apically-advanced intact microorganisms. The results indicate that the matrix and IPS features of the apical border plaque in chronic periodontitis in certain respects resemble those of subcontact area plaque on children's teeth, associated with chronic gingivitis and approximal caries. They also suggest the establishment of acidic regions in the microniches of the periodontal pocket.

Associations between subgingival plaque bacterial morphotypes and clinical indices?

The aim of the present study was to evaluate possible associations between subgingival plaque bacterial morphotypes, as assessed by darkground microscopy, and clinical indices of routine adult chronic periodontitis. Clinical indices were plaque index (PlI), gingival index (GI), sulcus bleeding index (SBI), papilla bleeding index (PBI), attachment loss (AL), pocket depth (PD) and probeable pocket depth (PPD). Apical border plaque was sampled in vivo and after extraction to test whether direct or indirect sampling affected any such associations. Similarly, pocket depth and attachment loss were also assessed directly and indirectly on the same teeth, in vivo or after extraction. The influence of the type of index used to record inflammation (GI, SBI, PBI) was also assessed, as were the effects of the numbers of sampled subjects and the method of analysis, which comprised the use of transformed and untransformed data and of parametric and non-parametric tests. Data were collected in relation to the approximal surfaces of 44 teeth extracted from 22 adults (2 teeth each) and from 1 pair of contralateral upper anterior or premolar teeth in each of 100 adults, all which untreated routine chronic periodontitis. Selected subjects had greater than or equal to 4 mm probeable pocket depth and/or attachment loss, and radiographic evidence of bone loss in relation to 1 approximal surface on each of 1 pair of contralateral anterior or premolar teeth, or to 2 teeth scheduled for extraction. Plaque preparation and darkground microscopy were as described previously. Insignificant associations (p greater than 0.05) were demonstrated between supragingival plaque (PlI) and periodontal inflammation (GI, SBI, PBI) or destruction (PPD and AL), as well as between inflammation and attachment level. In contrast, significant moderate associations (r = 0.5-0.77) were demonstrated between each of the 3 morphotype groups; spirochaetes, other motiles and cocci. Spirochaetes showed a significant moderate (r = 0.5) positive association with pocket depth with a 2.43% mean increase of spirochaetes for each 1 mm increase of PPD. Although highly significant associations (r = 0.9) were demonstrable between the 3 inflammation indices (GI, SBI, PBI) themselves, only PBI showed significant positive associations (r = 0.3) with spirochaetes and other motiles. Also, PlI showed significant associations with each of the 4 morphotypes (r = 0.3-0.5). The heterogeneity of spirochaetes and other motiles as well as the multiplicity of possible aetiological microbial agents in plaque may have resulted in underestimated associations between subjects as well as undetectable association within a given mouth using only 4 morphotype groups.(ABSTRACT TRUNCATED AT 400 WORDS)

Identification ofPorphyromonas gingivalisandActinobacillus actinomycetemcomitansin Apical Border Plaque

This study concerns the identification of Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans in subgingival plaque close to the bottom of the pocket using the combination of ultrastructural criteria and postembedding immunogold labelling. Specimens of plaque from deep periodontal pockets were fixed in 0.5 per cent glutaraldehyde in 0.1 M sodium cacodylate buffer, dehydrated, and embedded in LR White acrylic resin. Pure cultures of P. gingivalis and A. actinomycetemcomitans were processed in the same way. Ultrastructural differences in the structure of the cell wall envelope and cytoplasm were noted between the two organisms. Similar differences were observed in certain Gram-negative organisms within the apical border plaque samples. Following immunogold labelling, cells with the same ultrastructural features as P. gingivalis or A. actinomycetemcomitans showed positive labelling. None of the other organisms in the plaque was labelled. We therefore suggest that the combination of morphological criteria and a specific marking system such as colloidal gold provides a method by which organisms in apical border plaque can be identified in situ , although differentiation between strains may as yet be more difficult. Keywords: Porphyromonas gingivalis ; Actinobacillus actinomycetemcomitans ; Periodontitis; Plaque; Ultrastructure; Immunogold.

Morphological characterization of carotid artery stenoses by ultrasound duplex scanning

Ulcerations and intraplaque hemorrhages are thought to play an important role in the development of neurological deficits in carotid artery stenoses. To assess the ability of duplex scanning to predict plaque morphology we compared different sonographic criteria (plaque border, plaque density, plaque structure) with the morphological findings in 169 consecutive carotid endarterectomies (144 cases with diameter reduction > 50%). Two percent of the sonograms were inadequate, and 20% showed poor image quality. Regular plaque borders revealed a smooth or at most minimally ulcerated surface in 92%. Grossly ulcerated stenoses, however, were only found in 27% of the irregular plaques. Moreover, the plaque border was nonvisible in 35% of all cases. Simple, fibro-atheromatous plaques were found to be echogenic in 72% and echolucency was present in 80% of the stenoses with relevant intraplaque hemorrhage. In conclusion, duplex scanning proved to be capable of detecting smooth, fibro-atheromatous stenoses with high accuracy. Ulcerations, however, cannot be predicted reliably, and intraplaque hemorrhage cannot be differentiated from atheromatous debris.

Immunocytochemical characterisation of the immune reaction in the central nervous system in multiple sclerosis: Possible role for microglia in lesion growth

As there is evidence that in multiple sclerosis T-cell activation occurs in the central nervous system rather than outside, the inflammatory lesion may be extended through antigen presentation by cells at the edge of the plaque. In this study we present an immunocytochemical report on CNS tissue from an active case of MS, with an analysis of the distribution of CD4 and CD8 binding T cells and the expression of class I and II MHC determinants in plaques and white matter. Perivascular cuffs of early lesions, as judged by hypercellularity and minimal demyelination, contained activated T (Tac +) cells, which reacted with an anti-IL-2 monoclonal antibody. Thus sufficient T-cell growth factor would appear to be present to fuel the immune reaction in a growing lesion. The preponderance of T cells of the cytotoxic/suppressor (CD8) phenotype in the CNS parenchyma was found in conjunction with widespread staining of class I MHC antigen, a prerequisite for activity of cytotoxic T cells. Potential antigen presenting cells were demonstrated in MS plaques with a monoclonal antibody against the cytoplasmic, invariant chain of class II MHC. Macrophages and astrocytes, contributed to the staining in the hypercellular plaque border while the distribution of class II + microglia in white matter suggest they may also be of importance in local antigen presentation.

Middle zone of the root surface integument of human teeth affected by chronic periodontitis.

This study has confirmed the presence on the root surface of teeth affected by chronic periodontitis of a zoned organic integument analogous to that on enamel. Measurements showed a highly significant correlation between the levels of the bounding structures of this zone, that is, the apical plaque border and the coronal border of residual periodontal ligament, for both shallow and deep pockets. The middle zone between these two was on average 1 mm wide.

Neutrophils and IgG at the host-plaque interface on children's teeth.

This study is part of an investigation aimed at discovering how subcontact area plaque, unlike corresponding embrasure plaque, survives the host response and enters the gingival crevice. Approximal gingival margin plaques incorporating these two sites were obtained from children's teeth and subjected to transmission electron and immunoelectron microscopy. The specimens were examined for the main components of the initial host response at the plaque-host interface, namely polymorphonuclear leukocytes and IgG. Both were found preferentially at the actual apical border of plaque, especially in embrasures. Some polymorphs showed evidence of phagocytosis. Most of those in contact with plaque showed lysosome and glycogen loss and occasional phagocytosis. It was concluded that at least one important mechanism by which chronic gingivitis and approximal caries are initiated, involves lack of polymorph activity apical to the contact area. Possible explanations include the stagnation of gingival fluid so that neutrophils do not reach the plaque, failure of neutrophils to adhere to tapering border plaque, lysis of polymorphonuclear leukocytes (PMN) or elaboration of antichemotactic or other factors inhibiting PMN function by the colonizers of the gingival crevice.