The role of lactobacilli and probiotics in maintaining vaginal health

Stress Physiology of Lactic Acid Bacteria

Lactic acid bacteria (LAB) are important starter, commensal, or pathogenic microorganisms. The stress physiology of LAB has been studied in depth for over 2 decades, fueled mostly by the technological implications of LAB robustness in the food industry. Survival of probiotic LAB in the host and the potential relatedness of LAB virulence to their stress resilience have intensified interest in the field. Thus, a wealth of information concerning stress responses exists today for strains as diverse as starter (e.g., Lactococcus lactis), probiotic (e.g., several Lactobacillus spp.), and pathogenic (e.g., Enterococcus and Streptococcus spp.) LAB. Here we present the state of the art for LAB stress behavior. We describe the multitude of stresses that LAB are confronted with, and we present the experimental context used to study the stress responses of LAB, focusing on adaptation, habituation, and cross-protection as well as on self-induced multistress resistance in stationary phase, biofilms, and dormancy. We also consider stress responses at the population and single-cell levels. Subsequently, we concentrate on the stress defense mechanisms that have been reported to date, grouping them according to their direct participation in preserving cell energy, defending macromolecules, and protecting the cell envelope. Stress-induced responses of probiotic LAB and commensal/pathogenic LAB are highlighted separately due to the complexity of the peculiar multistress conditions to which these bacteria are subjected in their hosts. Induction of prophages under environmental stresses is then discussed. Finally, we present systems-based strategies to characterize the "stressome" of LAB and to engineer new food-related and probiotic LAB with improved stress tolerance.

Is it possible to prevent recurrent vulvovaginitis? The role of Lactobacillus plantarum I1001 (CECT7504)

The purpose of this study was to prospectively evaluate the impact of the use of L. plantarum I1001 applied vaginally on Vulvovaginal Candidiasis (VVC) time-until-recurrence after treatment with single-dose vaginal clotrimazole. This was a clinical open-label, prospective study of two non-randomized parallel cohorts with symptomatic acute VVC: (1) 33 sexually active women 18–50 years old, prescribed a standard single-dose 500 mg vaginal tablet of clotrimazole followed by vaginal tablets with L. plantarum I1001 as adjuvant therapy, and (2) 22 women of similar characteristics but prescribed single-dose clotrimazole only. Use of the probiotic and factors that might influence recurrence risk (age, recurrent VVC within previous year, antibiotic prior to study enrolment, diaphragm or IUD contraception, among others) were included in a multivariate Cox regression model to adjust for potential between-cohort differences. Probiotic use was associated with a three-fold reduction in the adjusted risk of recurrence (HR [95 %CI]: 0.30 [0.10–0.91]; P = 0.033). Adjusted free-survival recurrence was 72.83 % and 34.88 % for the probiotic and control groups, respectively. A higher cumulative recurrence was also observed in cases with use of antibiotics prior to enrolment (HR [95 %CI]: 10.46 [2.18–50.12]; P = 0.003). Similar findings were found at six months after azole treatment in women with RVVC. Overall, good compliance with the probiotic was reported for 91.3 % of women. The study suggests that follow-up therapy with vaginal tablets with L. plantarum I1001 could increase the effectiveness of single-dose 500 mg clotrimazole at preventing recurrence of VVC, an effect that was also observed in women with recurrent vulvovaginal candidiasis (RVVC) after six months of azole treatment.

Characterization of cytological changes, IgA, IgG and IL-8 levels and pH value in the vagina of prepubertal and sexually mature Ellegaard Göttingen minipigs during an estrous cycle

The pig is increasingly used as an advanced animal model of the genital tract in women and knowledge on the genital immune system is therefore needed. In this study, evaluation of vaginal smears revealed that almost no neutrophils or other leukocytes were present in the vaginal mucosa of prepubertal minipigs (n = 10). In sexually mature minipigs (n = 10), evaluated through an estrous cycle, there was an increase in number of mucosal neutrophils and other leukocytes during estrus. The level of total IgA on the vaginal mucosa increased during diestrus. The level of total IgG showed no significant changes through the cycle. The vaginal IgA level in the prepubertal minipigs was similar to the low estrus level in sexually mature minipigs, and the IgG level in prepubertal was similar to the stable level in the sexually mature minipigs.

Lactobacillus crispatus strain SJ-3C-US induces human dendritic cells (DCs) maturation and confers an anti-inflammatory phenotype to DCs

Lactobacillus crispatus is one of the most predominant species in the healthy vagina microbiota. Nevertheless, the interactions between this commensal bacterium and the immune system are largely unknown. Given the importance of the dendritic cells (DCs) in the regulation of the immunity, this study was performed to elucidate the influence of vaginal isolated L. crispatus SJ-3C-US from healthy Iranian women on DCs, either directly by exposure of DCs to ultraviolet-inactivated (UVI) and heat-killed (HK) L. crispatus SJ-3C-US or indirectly to its cell-free supernatant (CFS), and the outcomes of immune response. In this work we showed that L. crispatus SJ-3C-US induced strong dose-dependent activation of dendritic cells and production of high levels of IL-10, whereas IL-12p70 production was induced at low level in an inverse dose-dependent manner. This stimulation skewed T cells polarization toward CD4(+) CD25(+) FOXP3(+) Treg cells and production of IL-10 in a dose-dependent manner in mixed leukocyte reaction (MLR) test. The mode of bacterial inactivation did not affect the DCs activation pattern, upon encounter with L. crispatus SJ-3C-US. Moreover, while DCs stimulated with CFS showed moderate phenotypic maturation and IL-10 production, it failed to skew T cells polarization toward CD4(+) CD25(+) FOXP3(+) regulatory T cells (Treg) and production of IL-10. This study showed that L. crispatus SJ-3C-US confers an anti-inflammatory phenotype to DCs through up-regulation of anti-inflammatory/regulatory IL-10 cytokine production and induction of CD4(+) CD25(+) FOXP3(+) T cells at optimal dosage. Our findings suggest that L. crispatus SJ-3C-US could be a potent candidate as protective probiotic against human immune-mediated pathologies, such as chronic inflammation, vaginitis or pelvic inflammatory disease (PID).

Selection of Lactobacillus strains as potential probiotics for vaginitis treatment

Lactobacilli are the dominant bacteria of the vaginal tract of healthy women, and imbalance of the local microbiota can predispose women to acquire infections, such as bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC). Although antimicrobial therapy is generally effective, there is still a high incidence of recurrence and increase of microbial resistance due to the repetitive use of antimicrobials. Thus, it has been suggested that administration of probiotics incorporating selected Lactobacillus strains may be an effective strategy for preventing vaginal infections. Accordingly, the in vitro probiotic potential of 23 lactobacilli isolated from the vaginal ecosystem of healthy women from Cuba was evaluated for use in BV and VVC treatments. Eight strains were selected based on their antagonist potential against Gardnerella vaginalis, Candida albicansor both. In vitro assays revealed that all these strains reduced the pathogen counts in co-incubation, showed excellent adhesive properties (biofilm formation and auto-aggregation), were able to co-aggregate with G. vaginalis and C. albicans, yielded high amounts of hydrogen peroxide and lactic acid and demonstrated high adhesion rates to epithelial HeLa cells. Interference tests within HeLa cells showed that all strains were able to reduce the adherence of pathogens by exclusion or displacement. Lactobacilli were able to inhibit HeLa cell apoptosis caused by pathogens when the cells were incubated with the probiotics prior to challenge. These results suggest that these strains have a promising probiotic potential and can be used for prevention or treatment of BV and VVC.

Bioengineered probiotics as a new hope for health and diseases: an overview of potential and prospects

Despite the use of microorganisms as therapeutics for over a century, the scientific and clinical admiration of their potential is a recent phenomenon. Genome sequencing and genetic engineering has enabled researchers to develop novel strategies, such as bioengineered probiotics or pharmabiotics, which may become a therapeutic strategy. Bioengineered probiotics with multiple immunogenic or antagonistic properties could be a viable option to improve human health. The bacteria are tailored to deliver drugs, therapeutic proteins or gene therapy vectors with precision and a higher degree of site specificity than conventional drug administration regimes. This article provides an overview of methodological concepts, thereby encouraging research and interest in this topic, with the ultimate goal of using designer probiotics as therapeutics in clinical practice.

A review of food-grade vectors in lactic acid bacteria: from the laboratory to their application

Lactic acid bacteria (LAB) have a long history of use in fermented foods and as probiotics. Genetic manipulation of these microorganisms has great potential for new applications in food safety, as well as in the development of improved food products and in health. While genetic engineering of LAB could have a major positive impact on the food and pharmaceutical industries, progress could be prevented by legal issues related to the controversy surrounding this technology. The safe use of genetically modified LAB requires the development of food-grade cloning systems containing only the DNA from homologous hosts or generally considered as safe organisms, and not dependent antibiotic markers. The rationale for the development of cloning vectors derived from cryptic LAB plasmids is the need for new genetic engineering tools, therefore a vision from cryptic plasmids to applications in food-grade vectors for LAB plasmids is shown in this review. Replicative and integrative vectors for the construction of food-grade vectors, and the relationship between resistance mechanism and expression systems, will be treated in depth in this paper. Finally, we will discuss the limited use of these vectors, and the problems arising from their use.

Biological modeling of mucus to modulate mucus barriers

A recent study using a transgenic mouse, whose intestinal mucus contains a molecule made of 12 copies of a domain found in many gelling mucins, demonstrates that it is possible to strengthen mucus properties in situ, leading to promising new treatment strategies in diseases in which the mucosal barrier is impaired.

Bacterial Vaginosis Biofilms: Challenges to Current Therapies and Emerging Solutions

Bacterial vaginosis (BV) is the most common genital tract infection in women during their reproductive years and it has been associated with serious health complications, such as preterm delivery and acquisition or transmission of several sexually transmitted agents. BV is characterized by a reduction of beneficial lactobacilli and a significant increase in number of anaerobic bacteria, including Gardnerella vaginalis, Atopobium vaginae, Mobiluncus spp., Bacteroides spp. and Prevotella spp.. Being polymicrobial in nature, BV etiology remains unclear. However, it is certain that BV involves the presence of a thick vaginal multi-species biofilm, where G. vaginalis is the predominant species. Similar to what happens in many other biofilm-related infections, standard antibiotics, like metronidazole, are unable to fully eradicate the vaginal biofilm, which can explain the high recurrence rates of BV. Furthermore, antibiotic therapy can also cause a negative impact on the healthy vaginal microflora. These issues sparked the interest in developing alternative therapeutic strategies. This review provides a quick synopsis of the currently approved and available antibiotics for BV treatment while presenting an overview of novel strategies that are being explored for the treatment of this disorder, with special focus on natural compounds that are able to overcome biofilm-associated antibiotic resistance.

Vaginitis Caused by Corynebacterium amycolatum in a Prepubescent Girl

BACKGROUND

Vaginal discharge is the most common gynecological symptom in prepubescent girls.

CASE

We report a case of vaginitis caused by Corynebacterium amycolatum in a prepubescent girl and successful treatment with targeted antibiotics.

SUMMARY AND CONCLUSION

Vaginal discharge is most commonly attributed to poor hygiene or nonspecific irritants; however, some patients have recurrent vulvovaginitis that is primarily caused by a variety of bacteria. For these patients, identifying the associated pathogens is critical for treatment.

The vaginal microbiome is stable in prepubertal and sexually mature Ellegaard Göttingen Minipigs throughout an estrous cycle

Although the pig has been introduced as an advanced animal model of genital tract infections in women, almost no knowledge exists on the porcine vaginal microbiota, especially in barrier-raised Göttingen Minipigs. In women, the vaginal microbiota plays a crucial role for a healthy vaginal environment and the fate of sexually transmitted infections such as Chlamydia trachomatis infections. Therefore, knowledge on the vaginal microbiota is urgently needed for the minipig model. The aim of this study was to characterize the microbiota of the anterior vagina by 16 s rRNA gene sequencing in prepubertal and sexually mature Göttingen Minipigs during an estrous cycle. The dominating phyla in the vaginal microbiota consisted of Firmicutes, Proteobacteria, Actinobacteria, Bacteriodetes and Tenericutes. The most abundant bacterial families were Enterobacteriaceae, unclassified families from Gammaproteobacteria, Clostridiales Family XI Incertae Sedis, Paenibacillaceae, Lactobacillaceae, Ruminococcaceae and Syntrophaceae. We found a higher abundance of Lactobacillaceae in the prepubertal Göttingen Minipigs compared to sexually mature non-pregnant Göttingen Minipigs. However, correlation tests and diversity parameters revealed a very stable vaginal microbiota in the Göttingen Minipigs, both before and after sexual maturity and on different days throughout an estrous cycle. The vaginal microbiota in Göttingen Minipigs was not dominated by lactobacilli, as it is in women and according to our results the minipig vaginal microbiota is very stable, in opposite to women. These differences should be considered when using the minipig as a model of the genital tract in women.

In vitro evaluation on HeLa cells of protective mechanisms of probiotic lactobacilli against Candida clinical isolates

AIMS

To characterize in vitro the ability of human Lactobacillus strains to inhibit the adhesion, to displace and to compete with clinically isolated Candida strains.

METHODS AND RESULTS

Three types of assays were performed to determine the inhibitory effect of Lactobacillus plantarum 319, Lactobacillus rhamnosus IMC 501, Lactobacillus paracasei IMC 502 and a specific probiotic combination (SYNBIO) on adhesion of Candida pathogens to HeLa cells: blockage by exclusion (lactobacilli and HeLa followed by pathogens), competition (lactobacilli, HeLa and pathogens together) and displacement (pathogens and HeLa followed by the addition of lactobacilli). Bacterial adhesion to HeLa was quantified by microscopy after May-Grünwald/Giemsa stain. The inhibition results highlight a significant (P < 0·05) competition of the considered probiotics against all the Candida strains. The results suggest that the probiotic strains used in this study could prevent colonization of the urogenital tract by relevant pathogens such as Candida strains through barrier and interference mechanisms (mainly displacement and competition), but the degree of inhibition of adhesion was bacterial strain-dependent.

CONCLUSIONS

The results support the potential of these Lactobacillus probiotic strains as anti-infective agents in the vagina and encourage further studies about their capacity to prevent and manage urogenital tract infections in females.

SIGNIFICANCE AND IMPACT OF THE STUDY

To optimize the defensive properties of the vaginal microbiota, improving the health of many women by probiotic intervention.

Profiles and technological requirements of urogenital probiotics

Probiotics, defined as live microorganisms that, when administered in adequate amounts, confer a health benefit on the host, are considered a valid and novel alternative for the prevention and treatment of female urogenital tract infections. Lactobacilli, the predominant microorganisms of the healthy human vaginal microbiome, can be included as active pharmaceutical ingredients in probiotics products. Several requirements must be considered or criteria fulfilled during the development of a probiotic product or formula for the female urogenital tract. This review deals with the main selection criteria for urogenital probiotic microorganisms: host specificity, potential beneficial properties, functional specifications, technological characteristics and clinical trials used to test their effect on certain physiological and pathological conditions. Further studies are required to complement the current knowledge and support the clinical applications of probiotics in the urogenital tract. This therapy will allow the restoration of the ecological equilibrium of the urogenital tract microbiome as well as the recovery of the sexual and reproductive health of women.

The vaginal isolate Lactobacillus paracasei LPC-S01 (DSM 26760) is suitable for oral administration

Bacterial vaginosis is one of the most common urogenital diseases affecting women in reproductive age. The administration of probiotics as vaginal suppository has been proposed as a strategy to cure this condition and reduce its recurrence. Nonetheless, also oral consumption of probiotics, which is a more practical route of administration, proved to be an efficient strategy. In this perspective, we studied Lactobacillus paracasei LPC-S01 (DSM 26760), a human vaginal isolate included in commercial probiotic preparations for topical use, in order to assess if this bacterium can also perform as gastrointestinal probiotic. Comparative genomics revealed the presence of several accessory genes suggesting that LPC-S01 is a niche-generalist member of its species. According to a procedure conventionally used to predict the probiotic potential, we demonstrated that the probiotic properties of strain LPC-S01, with respect to those of the well-known probiotic references L. paracasei Shirota and DG, are equal for the bile tolerance and the reduction of NF-κB activation in Caco-2 cells, or superior for the tolerance to gastric juice and the adhesion to Caco-2 epithelial cells. We then demonstrated that LPC-S01 is susceptible to antibiotics indicated by EFSA and does not produce biogenic amines. Finally, a double-blind cross-over pilot intervention trial on healthy human volunteers showed that, after a 7-days oral consumption of capsules containing about 24 billion live cells, the fecal cell concentrations of strains LPC-S01 and DG (evaluated by qPCR) were not dissimilar. Specifically, both probiotics' cell concentrations were above the detection limit for an average of 5 days from the end of the treatment, corresponding to a mean number of evacuations of 7 ± 2. Taken together, these data demonstrate that the vaginal isolate L. paracasei LPC-S01 possesses safety and functional properties that may support its use as probiotic to be administered per os for potential intestinal as well as vaginal applications.

Biopolymers from lactic acid bacteria. Novel applications in foods and beverages

Lactic acid bacteria (LAB) are microorganisms widely used in the fermented food industry worldwide. Certain LAB are able to produce exopolysaccharides (EPS) either attached to the cell wall (capsular EPS) or released to the extracellular environment (EPS). According to their composition, LAB may synthesize heteropolysaccharides or homopolysaccharides. A wide diversity of EPS are produced by LAB concerning their monomer composition, molecular mass, and structure. Although EPS-producing LAB strains have been traditionally applied in the manufacture of dairy products such as fermented milks and yogurts, their use in the elaboration of low-fat cheeses, diverse type of sourdough breads, and certain beverages are some of the novel applications of these polymers. This work aims to collect the most relevant issues of the former reviews concerning the monomer composition, structure, and yields and biosynthetic enzymes of EPS from LAB; to describe the recently characterized EPS and to present the application of both EPS-producing strains and their polymers in the fermented (specifically beverages and cereal-based) food industry.

Isolation of Vaginal Lactobacilli and Characterization of Anti-Candida Activity

Healthy vaginal microbiota is dominated by Lactobacillus spp., which form a critical line of defence against pathogens, including Candida spp. The present study aims to identify vaginal lactobacilli exerting in vitro activity against Candida spp. and to characterize their antifungal mechanisms of action. Lactobacillus strains were isolated from vaginal swabs of healthy premenopausal women. The isolates were taxonomically identified to species level (L. crispatus B1-BC8, L. gasseri BC9-BC14 and L. vaginalis BC15-BC17) by sequencing the 16S rRNA genes. All strains produced hydrogen peroxide and lactate. Fungistatic and fungicidal activities against C. albicans, C. glabrata, C. krusei, C. tropicalis, C. parapsilosis and C. lusitaniae were evaluated by broth micro-dilution method. The broadest spectrum of activity was observed for L. crispatus BC1, BC4, BC5 and L. vaginalis BC15, demonstrating fungicidal activity against all isolates of C. albicans and C. lusitaniae. Metabolic profiles of lactobacilli supernatants were studied by 1H-NMR analysis. Metabolome was found to be correlated with both taxonomy and activity score. Exclusion, competition and displacement experiments were carried out to investigate the interference exerted by lactobacilli toward the yeast adhesion to HeLa cells. Most Lactobacillus strains significantly reduced C. albicans adhesion through all mechanisms. In particular, L. crispatus BC2, L. gasseri BC10 and L. gasseri BC11 appeared to be the most active strains in reducing pathogen adhesion, as their effects were mediated by both cells and supernatants. Inhibition of histone deacetylases was hypothesised to support the antifungal activity of vaginal lactobacilli. Our results are prerequisites for the development of new therapeutic agents based on probiotics for prophylaxis and adjuvant therapy of Candida infection.

Pediococcus pentosaceus SB83 as a potential probiotic incorporated in a liquid system for vaginal delivery

Pediococcus pentosaceus SB83 is a bacteriocinogenic culture having potential use as a vaginal probiotic. The objective of this study was to evaluate the behaviour of P. pentosaceus SB83 incorporated in a liquid system for eventually formulating a gel for vaginal delivery. The vaginal probiotic incorporated into glycerol was able to survive in simulated vaginal fluid at normal vaginal pH (4.2) and at pH of vaginal infections (5.5 and 6.5). The probiotic can be stored at 4 °C for a longer period of time than at room temperature, however, after 13 weeks of storage at low temperature, there was a total loss of viable cells. The probiotic strain incorporated into glycerol showed bacteriocinogenic activity in simulated vaginal fluid, although the antimicrobial activity against Listeria monocytogenes declined during storage. This study showed the behaviour of P. pentosaceus SB83 in glycerol and in simulated vaginal fluid. However, it is necessary to optimise the formulation to produce an actively probiotic vaginal gel.

Lactobacilli vaginal colonisation after oral consumption of Respecta(®) complex: a randomised controlled pilot study

PURPOSE

The aim of the current pilot study was to determine if oral consumption of a combination of two probiotics; L. acidophilus La-14, L. rhamnosus HN001, and bovine lactoferrin (Respecta(®) complex), would lead to the detection with molecular techniques of the consumed probiotic strains in the vagina.

METHODS

Healthy volunteers (40) consumed the study product twice daily for 2 weeks. Vaginal swabs were collected at 0, 1, 2 and 3 weeks and analysed for the consumed organisms by qPCR.

RESULTS

Vaginal L. rhamnosus and L. acidophilus levels were significantly increased on days 14 and 21. On days 14 and 21 a significant number of women had increased levels of vaginal L. acidophilus and on days 7 and 21 a significant number of women had increased levels of vaginal L. rhamnosus.

CONCLUSIONS

Consumption of L. acidophilus La-14, L. rhamnosus HN001 in combination with bovine lactoferrin leads to vaginal detection; even 1 week after consumption was stopped. This provides a basis for future studies on urogenital tract health.

Microbiotica in women

The perception that certain body cavities and spaces that are heavily inhabited by micro-organisms should be regarded as 'external' to the body function is no longer valid. Extensive research during recent years has demonstrated the importance of those microbes to normal physiology, which means that the human body and those tiny organisms are actually symbiotic. The major point of interaction between the human body and the microbiome is the gut. There are also gender-specific aspects for this symbiosis: bacterial vaginosis has serious implications for female morbidity, including reports of pelvic inflammatory disease, adverse pregnancy outcomes, increased susceptibility to sexually transmitted infections and infertility. Re-establishing a normal flora might be beneficial and therefore the use of probiotics and re-colonization by 'healthy' bacteria have become very popular. Probiotics may serve as an adjunct for treating recurrences of urogenital infections and vaginal atrophy. Some animal studies have pointed at potential beneficial effects of Lactobacilli species on bone health.

Is there a role for probiotics in the prevention of preterm birth?

Preterm birth (PTB) continues to be a global health challenge. An over-production of inflammatory cytokines and chemokines, as well as an altered maternal vaginal microbiome has been implicated in the pathogenesis of inflammation/infection-associated PTB. Lactobacillus represents the dominant species in the vagina of most healthy pregnant women. The depletion of Lactobacillus in women with bacterial vaginosis (BV) has been associated with an increased risk of PTB. It remains unknown at what point an aberrant vaginal microbiome composition specifically induces the cascade leading to PTB. The ability of oral or vaginal lactobacilli probiotics to reduce BV occurrence and/or dampen inflammation is being considered as a means to prevent PTB. Certain anti-inflammatory properties of lactobacilli suggest potential mechanisms. To date, clinical studies have not been powered with sufficiently high rates of PTB, but overall, there is merit in examining this promising area of clinical science.

Dynamic interactions of neutrophils and biofilms

BACKGROUND

The majority of microbial infections in humans are biofilm-associated and difficult to treat, as biofilms are highly resistant to antimicrobial agents and protect themselves from external threats in various ways. Biofilms are tenaciously attached to surfaces and impede the ability of host defense molecules and cells to penetrate them. On the other hand, some biofilms are beneficial for the host and contain protective microorganisms. Microbes in biofilms express pathogen-associated molecular patterns and epitopes that can be recognized by innate immune cells and opsonins, leading to activation of neutrophils and other leukocytes. Neutrophils are part of the first line of defense and have multiple antimicrobial strategies allowing them to attack pathogenic biofilms.

OBJECTIVE/DESIGN

In this paper, interaction modes of neutrophils with biofilms are reviewed. Antimicrobial strategies of neutrophils and the counteractions of the biofilm communities, with special attention to oral biofilms, are presented. Moreover, possible adverse effects of neutrophil activity and their biofilm-promoting side effects are discussed.

RESULTS/CONCLUSION

Biofilms are partially, but not entirely, protected against neutrophil assault, which include the processes of phagocytosis, degranulation, and formation of neutrophil extracellular traps. However, virulence factors of microorganisms, microbial composition, and properties of the extracellular matrix determine whether a biofilm and subsequent microbial spread can be controlled by neutrophils and other host defense factors. Besides, neutrophils may inadvertently contribute to the physical and ecological stability of biofilms by promoting selection of more resistant strains. Moreover, neutrophil enzymes can degrade collagen and other proteins and, as a result, cause harm to the host tissues. These parameters could be crucial factors in the onset of periodontal inflammation and the subsequent tissue breakdown.