Possible role of T cells in the establishment of IgG plasma cell-rich periodontal lesion--augmentation of IgG synthesis in the polyclonal B cell activation response by autoreactive T cells

Destructive periodontitis lesions are determined by the nature of the lymphocytic response

It is now 35 years since Brandtzaeg and Kraus (1965) published their seminal work entitled "Autoimmunity and periodontal disease". Initially, this work led to the concept that destructive periodontitis was a localized hypersensitivity reaction involving immune complex formation within the tissues. In 1970, Ivanyi and Lehner highlighted a possible role for cell-mediated immunity, which stimulated a flurry of activity centered on the role of lymphokines such as osteoclast-activating factor (OAF), macrophage-activating factor (MAF), macrophage migration inhibition factor (MIF), and myriad others. In the late 1970s and early 1980s, attention focused on the role of polymorphonuclear neutrophils, and it was thought that periodontal destruction occurred as a series of acute exacerbations. As well, at this stage doubt was being cast on the concept that there was a neutrophil chemotactic defect in periodontitis patients. Once it was realized that neutrophils were primarily protective and that severe periodontal destruction occurred in the absence of these cells, attention swung back to the role of lymphocytes and in particular the regulatory role of T-cells. By this time in the early 1990s, while the roles of interleukin (IL)-1, prostaglandin (PG) E(2), and metalloproteinases as the destructive mediators in periodontal disease were largely understood, the control and regulation of these cytokines remained controversial. With the widespread acceptance of the Th1/Th2 paradigm, the regulatory role of T-cells became the main focus of attention. Two apparently conflicting theories have emerged. One is based on direct observations of human lesions, while the other is based on animal model experiments and the inability to demonstrate IL-4 mRNA in gingival extracts. As part of the "Controversy" series, this review is intended to stimulate debate and hence may appear in some places provocative. In this context, this review will present the case that destructive periodontitis is due to the nature of the lymphocytic infiltrate and is not due to periodic acute exacerbations, nor is it due to the so-called virulence factors of putative periodontal pathogens.

Immune processes in periodontal disease: a review

The inflammatory and immune processes in periodontitis are complex and, although a great deal of information is available, many questions remain. Variation in human susceptibility to periodontitis has long been accepted, but the pathological basis of this is poorly understood. Similarly, we know little of the differences, if any, between the pathology of chronic and aggressive periodontitis. Genetics and environmental influences play a role in the susceptibility process, but if and how that translates through the immune and inflammatory processes to produce the plasma cell-dominated lesions seen in periodontitis remain to be elucidated. This review will focus on immunological aspects of the inflammatory changes seen in gingivitis and periodontitis, addressing both humoral and cellular responses to the microbial insult from dental plaque. A tendency for an individual or site to form an extensive plasma cell infiltrate may indicate an inability to defend against periodontopathogens and thus a predisposition to periodontitis. The issues to be considered include: 1) homing of immune and inflammatory cells to target tissues; 2) their local proliferation and synthetic activity; 3) the cytokine profile of the leukocytes; 4) the immunoglobulin subclasses of locally produced antibodies; 5) mucosal and systemic immune characteristics of the response; 6) the humoral immune response in periodontal health and disease states; and 7) the antigenic target of the immune response in periodontal lesions.

Role of cell-cell communication in inhibiting butyric acid-induced T-cell apoptosis

We have previously demonstrated that human gingival fibroblasts rescue butyric acid-induced T-cell apoptosis via proinflammatory cytokines such as interleukin 6 (IL-6) and IL-11, which are produced by fibroblasts stimulated with butyric acid. In this study, we determined if T-cell adhesion to human gingival fibroblasts influenced the susceptibility of T cells to butyric acid-induced apoptosis. We have shown that the number of Jurkat T cells adherent to gingival fibroblasts (Gin-1 cells) was significantly increased by the addition of butyric acid. All Jurkat cells that adhered to Gin-1 cells remained viable, while the nonadherent Jurkat cells dropped into apoptosis. The increase in T-cell adhesion to fibroblasts was also observed when Jurkat cells, but not Gin-1 cells, were pretreated with butyric acid. The expression levels of CD44, very late antigen 2 (VLA-2) and VLA-5 but not of leukocyte function-associated antigen 1 (LFA-1) and VLA-4 on Jurkat cells were increased following treatment with butyric acid. Furthermore, pretreatment of butyric acid-sensitized Jurkat cells with monoclonal antibodies against CD44, VLA-2, and VLA-5, but not LFA-1 and VLA-4, followed by coculture with Gin-1 cells inhibited T-cell adhesion to fibroblasts and increased apoptosis of nonadherent T cells after coculture of gingival fibroblasts and Jurkat cells. These results indicate that T-cell adherence to fibroblasts is enhanced by butyric acid and that butyric acid-induced T-cell apoptosis is down-regulated by T-cell adhesion to gingival fibroblasts through an interaction with the adhesion molecules CD44, VLA-2, and VLA-5 expressed on T cells stimulated with butyric acid.

Human gingival fibroblasts rescue butyric acid-induced T-cell apoptosis

We previously demonstrated that butyric acid, an extracellular metabolite from periodontopathic bacteria, induces cytotoxicity and apoptosis in murine thymocytes, splenic T cells, and human Jurkat T cells. In this study, we used a cell-to-cell interaction system to examine the contribution of gingival fibroblasts to the regulation of T-cell death induced by butyric acid. Butyric acid slightly suppressed fibroblast viability in a concentration-dependent fashion. However, DNA fragmentation assays indicated that butyric acid did not induce apoptosis for up to 21 h in human gingival fibroblasts (Gin 1, F41-G, and H. pulp cells). The culture supernatants were assayed for interleukin 1alpha (IL-1alpha), IL-1beta, IL-6, IL-8, IL-11, tumor necrosis factor alpha, and transforming growth factor beta, but only the IL-6, IL-8, and IL-11 levels were significantly increased by addition of butyric acid. Butyric acid- or Fas-induced Jurkat-cell apoptosis was attenuated when Jurkat cells were cocultured with either F41-G or Gin 1 cells that had been preincubated for 6 h with butyric acid. IL-8 slightly stimulated butyric acid- or Fas-induced Jurkat-cell apoptosis in a dose-dependent manner, although a low dose of IL-8 had a mildly inhibitory effect on apoptosis. In contrast, IL-6 and IL-11 significantly suppressed butyric acid- or Fas-induced apoptosis in a dose-dependent fashion. Furthermore, the addition of monoclonal antibodies against human IL-6 and IL-11 to cocultures of gingival fibroblasts and Jurkat cells partially eliminated T-cell recovery. These results suggest that the proinflammatory cytokines such as IL-6 and IL-11, produced in fibroblasts stimulated with butyric acid, are involved in the attenuation of T-cell apoptosis by gingival fibroblasts.

Anti-inflammatory cytokine IL-10 and T cell cytokine profile in periodontitis granulation tissue

Th2 cells are more abundant than Th1 cells in periodontitis lesions, but the relative importance of the Th1 and Th2 subsets in periodontal disease is not understood. In addition, the role of proinflammatory and anti-inflammatory cytokines in this disease process is unclear. Biopsies were obtained from 10 patients with early onset periodontitis (EOP) and 10 patients with adult periodontitis (AP). From all of the patients in the AP group we were able to obtain and section the gingival tissue to serve as controls. We used polyclonal monospecific antibodies to detect cells expressing IL-2, IL-4, IL-6, IL-10 and IL-15, tumour necrosis factor (TNF-alpha) and interferon-gamma (IFN-gamma) in formalin-fixed, paraffin-embedded sections of granulation tissue from periodontitis lesions. We also employed a series of oligonucleotide probes to detect cells expressing the cytokine transcripts in the same tissue biopsies. Cells that expressed IL-4 or IL-6 were more numerous than cells expressing either IL-2 or IFN-gamma. Th2 cells were more numerous in EOP and AP tissues. IL-15 substitutes for IL-2 in a number of biological activities related to the Th1 immune response, and interestingly, in periodontal lesions the IL-15-expressing cells outnumbered IL-2-expressing cells, suggesting that this is the pattern of immune regulation by T cells in the periodontium. The functional balance in the T cell subsets detected by their cytokine profiles underlies the importance of the anti-inflammatory mechanisms taking place in the diseased tissue. The numbers of inflammatory leucocytes that express the anti-inflammatory cytokine IL-10 are much more widely distributed than those that express the proinflammatory cytokines IL-6 and TNF-alpha. This study suggests that large numbers of infiltrating inflammatory cells as well as accessory cells are involved in the down-regulation of the inflammatory and immune response in periodontitis.

Interactions between non-immune host cells and the immune system during periodontal disease: role of the gingival keratinocyte

Periodontal disease and inflammatory dermatoses, such as psoriasis, are characterized by the accumulation of dense inflammatory infiltrates immediately beneath the epithelial cell layer of the gingiva and skin, respectively. Dermatologists are increasingly aware that the epidermal keratinocyte probably contributes to inflammatory disease progression by secreting a number of pro-inflammatory cytokines and expressing various adhesion molecules. In psoriatic lesions, it is now believed that epidermal keratinocytes may also act as antigen-presenting cells and participate directly in the superantigenic activation of T-cell clones, some of which may initiate, contribute to, or maintain the disease process. Although the role of the host response in periodontal disease has been extensively studied over the years, very little is known about the contribution of the gingival keratinocyte to the inflammatory response. The available published information is discussed in this review, and we suggest that, like its epidermal counterpart, the gingival keratinocyte may participate actively in the pathogenesis of periodontal disease.

Hen egg-white lysozyme inhibits biological activities of lipopolysaccharides from periodontopathic bacteria

Lysozyme has a bactericidal activity for some strains of Gram-positive bacteria, by enzymatic cleavage of peptidoglycans that constitute the cell wall. Hen egg-white lysozyme (HEL) was tested in vitro for effects on biological activities of lipopolysaccharides from periodontopathic Gram-negative bacteria. Actinobacillus actinomycetemcomitans, Prevotella intermedia and Porphyromonas gingivalis. HEL inhibited a wide range of activities of these lipopolysaccharides, including activation of Limulus amoebocyte lysate, stimulation of human leukocytes to secrete tumour necrosis factor-alpha, polyclonal activation of mouse B cells, and promotion of osteoclastic differentiation in mouse bone marrow cultures. The anti-endotoxic activity of HEL may be worthy of being intended for periodontal therapy.

In situ localization of cell synthesis and proliferation in periodontitis gingiva and tonsillar tissue

OBJECTIVE

Previous work indicates that large numbers of B and T cells accumulate in the periodontal soft tissues although we know little about cellular synthetic activity and proliferation in this site. The aim of this study was to examine lymphocytic cell synthetic activity and proliferation in periodontitis gingiva and compare this to a known site of leucocyte proliferation, namely the oropharyngeal tonsils.

MATERIALS AND METHODS

Messenger RNA (mRNA) and 28S ribosomal (28S rRNA) expressing cells in formalin-fixed/paraffin-embedded gingival and tonsillar tissue sections were detected by in situ hybridisation (ISH) using poly-deoxyribothymidine and 28S probes respectively. In addition S-phase proliferating and cycling cells were also detected by ISH with histone probes and by Ki-67 immunohistochemistry. Ten gingival biopsy samples were obtained from adult periodontitis patients and five tonsillar biopsies from tonsillectomy patients.

RESULTS

Both mRNA and 28S rRNA-expressing cells were detected in all the samples tested. Plasma cells showed the strongest signal for the two probes and slight to moderate staining could be seen in epithelium, fibroblasts and endothelial cells. In contrast, gingival lymphocytes were either weakly stained or were unstained for these probes of synthetic activity. In tonsils, most lymphocytes in germinal centres showed moderate staining and mantol zone cells were much more weakly stained. In gingival samples, histone mRNA-expressing and cycling (Ki-67) cells were detected in 4/10, 10/10 cases respectively. These positive cells were mainly basal and suprabasal epithelial cells and a few mononuclear cells, whereas most germinal centre lymphocytes (B cells) were positive for this probe. The number of Ki67 positive cells was greater than histone mRNA bearing cells both in gingiva and tonsillar tissue. In contrast, mantol zone cells (mainly T cells) were sparsely stained by probes of cell proliferation.

CONCLUSION

These results indicate that local proliferation of B cells does not occur in periodontitis gingiva in contrast with tonsillar tissue, although plasma cells showed strong synthetic activity in both tissues. T cells did not appear to proliferate greatly nor undergo active synthesis in either of these tissues. These findings substantiate previous hypotheses that specific leucocytes predominate in the gingival tissue through selective homing rather than by local proliferation.

CD44-hyaluronate interaction participates in the adherence of T-lymphocytes to gingival fibroblasts

It has already been clarified that peripheral blood T-lymphocytes which had been activated with phorbol 12-myristate 13-acetate (PMA) acquired the ability to bind to human gingival fibroblasts (HGF) and that the adherence was mediated by VLA integrins. However, these studies also raised the possibility that molecules other than VLA integrins should be involved in the adherence between T-lymphocytes and HGF. In this study, the possible involvement of CD44, a hyaluronate receptor, in heterotypic cell-cell interactions was investigated. It was confirmed that PMA-activated T-lymphocytes strongly adhered to plate-coated hyaluronate and that the hyaluronate binding was clearly inhibited by the addition of OS/37, a newly established mAb specific for the hyaluronate-binding epitope on CD44. Interestingly, OS/37 also blocked the HGF binding of the activated T-lymphocytes when the adherence to HGF was assessed at 4 degrees C, at which temperature the adhesion of integrin molecules diminished, while that of CD44 functioned normally. Immunofluorescence staining revealed that hyaluronate was anchored along the cell surface of HGF. Furthermore, the binding of activated T-lymphocytes to HGF was significantly inhibited by the treatment of HGF with hyaluronidase. These results clearly demonstrated that CD44-hyaluronate interactions participated at least in part in the adhesiveness of T-lymphocytes to HGF.

Antigen-presenting-cell function of interferon gamma-treated human gingival fibroblasts

The present study was carried out to examine the antigen-presenting cell (APC) functions of human gingival fibroblasts (HGF) elicited with IFN gamma. Stimulation of HGF with IFN gamma clearly induced HLA-DR expression and enhanced expression of intercellular adhesion molecule-1 (ICAM-1) on HGF. Despite the phenotypical resemblance of IFN gamma-treated HGF to so-called APC, HLA-DR positive HGF were unable to induce proliferation of allo-reactive peripheral blood T cells (PBT) isolated from different donors. The failure of IFN gamma-treated HGF to stimulate unprimed allo-reactive PBT was not due to the lack of production of IL-1 or the immunosuppressive effect of PGE2 from HGF. On the other hand, the fact that detectable expression of CD80, ligand for CD28, was not found on IFN gamma-treated HGF may at least in part explain the ineffective function of HGF as APC. Interestingly, IFN gamma-treated HGF induced proliferation of primed allo-reactive CD4+ T cells in a HLA-DR dependent manner, suggesting that IFN gamma-treated HGF may have the ability to stimulate pre-activated T cells. We then confirmed that high levels of IFN gamma mRNA were detectable in inflamed gingival tissue. Although it cannot be concluded from this study that HGF are incapable of effectively presenting antigenic peptides to autologous T cells bearing appropriate T cell receptors, present results suggest that HGF may be affected by locally-secreted IFN gamma and that the IFN gamma-stimulated HGF may play a role in regulating immune responsiveness in inflammatory periodontal lesions.

Diagnostic strategies of periodontitis based on the molecular mechanisms of periodontal tissue destruction

OBJECTIVE

Periodontitis is a disease showing differences in disease progression between patients and between sites within a patient. Routine clinical examinations today are not useful enough to distinguish susceptible patients and active lesions from resistant patients and chronic lesions. Diagnostic markers should be pathogenic and inflammatory factors participating in periodontal tissue destruction. These are both local and systemic factors.

MATERIALS AND METHODS

First of all, pathogenic factors and proinflammatory cytokines or mediators in gingival crevicular fluid (GCF) were examined and the difference was found between active and inactive periodontitis lesions distinguished by attachment loss. Active lesions were detected by discriminant-function analysis of these examinations, although the sensitivity of differential diagnosis was low. Then, we established a novel needle biopsy for understanding the pathophysiological conditions elicited in active and chronic inflammatory processes of periodontal tissue destruction. A variety of cytokines and mediators were detected in biopsied specimens by reversed transcription polymerase chain reactions (RT-PCR). Cytokine profiles were varied in inflammed periodontal biopsies. As IFN gamma mRNA expression was enhanced in inflamed gingiva, antigen-presenting-cell (APC) functions of human gingival fibroblasts (HGF) were examined.

RESULTS

Despite the phenotypical resemblance of IFN gamma-treated HGF to so-called APC, HLA-DR positive HGF could not induce proliferation but suppressed proliferation of alloreactive peripheral blood T cells (PBT). However, HLA-DR positive HGF stimulated the proliferative responses of PBT which had been primed with allo-APC. Regulatory immune responses by IFN gamma were different in T cell conditions.

CONCLUSIONS

Various kinds of cytokines participated in periodontal inflammation, and every cytokine is multi-functional. Complex and compound inflammatory processes can be clarified by examining cytokine networks and the precise effects of each cytokine on each of the cell types comprising periodontal tissue. It is, therefore, necessary for establishing diagnostic strategies to integrate pathogenic and inflammatory factors in periodontal tissue destruction.

Phenotypic analysis of B-cells extracted from human periodontal disease tissue

B-cells extracted from periodontal disease tissue were analyzed for the presence of activation markers using a range of monoclonal antibodies. In adult periodontitis (AP), 6% of B-cells expressed the IL-2 receptor (CD25) compared with 1-2% in peripheral blood and healthy or marginal gingivitis (H/MG) gingival B-cells. There was also an increase in the mean percentage of IgD-positive B-cells and a decrease in CD21 and CD22 expression. In both AP and H/MG lesions, 20-22% of the B-cells expressed CD23 compared with less than 5% in peripheral blood. As B-cells are activated by day 3 in culture and start differentiating into immunoglobulin-secreting cells by day 6, B-cell phenotypes were assayed at these times in this study. Following stimulation with the periodontopathic bacterium Porphyromonas gingivalis, the expression of CD23, CD21 and CD22 on B-cells extracted from AP lesions remained relatively constant over the 6-d culture period. However, with Fusobacterium nucleatum stimulation, there was a significant decrease in CD23, CD21 and CD22 expression after 3 d in culture, which corresponds to the activation time for B-cells. These results show that B-cells extracted from periodontal disease tissue display a range of activation markers and on stimulation, demonstrate differing responses to individual periodontopathic bacteria.

Immunologic mechanisms of pathogenesis in periodontal diseases: an assessment

Principal lines of evidence that immune reactions are central to the pathogenesis of periodontitis are reviewed. Necessary components of immunologic reactions are present in gingiva in the periodontal diseases. Differences between healthy and periodontitis patients with respect to some measures of immune function further indicate that immune reactions do occur in the gingiva during periodontitis. They are probably responsible for at least some of the destruction of connective tissue and bone that occurs. Classical antibody-mediated hypersensitivity reactions probably do not provide the reasons. Mechanisms are more likely to be found in the pro-inflammatory and tissue-degrading effects of cytokines released in host-protective, antigen-specific and polyclonal responses to oral bacterial constituents or products. Some evidence suggests that limitation of clinical destruction in localized early onset periodontitis (JP) may in part be a function of a protective antibody response which develops after an initial rapidly progressive infection. A relatively deficient immune responsiveness may allow progression to more severe and generalized disease (RPP). Suggestions are made for studies needed to confirm suspected pathogenetic mechanisms, approach resultant targeted therapies, and test hypotheses for contrasting roles of immune reactions in different clinical expressions of periodontitis.

Autoimmunity in periodontal disease

Periodontal disease in characterized by the loss of the normal supporting tissues of the teeth and a humoral and cellular immune response to bacterial antigen of dental plaque which accumulates at the dento-gingival junction. This review considers the evidence for the existence of an autoimmune component of the host immune response, the possible origin of such a response and the way in which such a host response may contribute to the changes observed in the periodontium in the disease.

The role of histopathology in the diagnosis and prognosis of periodontal diseases

The histological evaluation of surgical biopsies from affected tissues is a standard way of assessing pathological change and determining treatment in many diseases. In most forms of periodontal disease, however, this approach finds limited application. Here, we review what uses the histopathological approach has in the study and evaluation of the periodontal diseases. Current understanding of the changes in epithelial anatomy during pocket formation, the cellular composition and dynamics of the inflammatory infiltrate and the mechanisms of bone resorption and repair are reviewed from the perspective of the information available from microscopical investigation, including the uses and potential application of modern immunocytochemical methods to these questions. The usefulness of histological study of biopsy material is reassessed in the light of advances made in immunohistochemical techniques and their application to gingival inflammatory infiltrates and epithelia. Such techniques offer immediately valuable research opportunities with potential for diagnostic applications, noteably the recognition of phases of destructive activity and their differentiation from periods of effective host defence.

The function of gingival lymphocytes on the establishment of human periodontitis

Human periodontitis has been confirmed to be an IgG plasma cell-rich lesion. However, we also detected many T cells, both CD4-positive and CD8-positive cells, in periodontal lesions. Some of these T cells expressed HLA-DR (la-like) antigen on their surfaces, and the proportion of HLA-DR+ cells was approximately equal in both CD4+ and CD8+ cell populations (Okada et al., 1983, 1984). Consequently, both helper and suppressor T cells were believed to participate in the establishment of periodontal lesions.

On the other hand, B cells were thought to be activated polyclonally in periodontal lesions, because a variety of periodontal florae possessed polyclonal B-cell-activating activity. We demonstrated that Actinomyces viscosus T14V stimulated mouse spleen B cells polyclonally and induced many IgM-producing cells but few IgG-producing cells. Moreover, IgG-producing cells were differentiated from only surface IgG-positive B cells but not from surface IgG-negative B cells-namely, surface IgM- or IgA-positive B cells (Harada et al., 1988). These results suggested that memory B cells, which had already been primed with appropriate antigens, might migrate into periodontal lesions, and then be activated polyclonally and develop into IgG-producing cells.

The periodontal lesion could, therefore, be induced by the interactions of immunoregulatory mechanisms of T cells and polyclonal B cell activity of periodontal florae. In fact, L3T4-positive T cells (helper-inducer T cells) enhanced IgG synthesis of mouse spleen B cells which had been activated with T-independent B cell activators such as LPS and A. viscosus preparations (Okada et al., 1987; Ito et al., 1988). We hypothesized from the above results that autoreactive T cells recognized the increasing self-MHC class II(Ia) antigen on B cells which had been activated with polyclonal B cell activators, and then produced soluble factors, which could enhance IgG synthesis of these B cells. Autoreactive T cells as well as PBAs, thus, may play an important role in the establishment of the IgG plasma cell-rich periodontal lesion.