Journal Kiki - Velda

CONTROVERSY
he article that follows is part of an ongoing "Controversy" series. This review presents the case that destructive periodontitis is due to the nature of the lymphocytic infiltrate. In presenting this case, the authors have highlighted several
controversial issues: (1) It is the inflammatory infiltrate that causes destruction and not the bacteriathat is, the lymphocytes and not the PMNs or macrophages are the primary source of destructive cytokines; (2) that susceptible subjects are
characterized by the production of non-protective antibodies; and (3) that Th1 cells are associated with the stable lesion,
while Th2 cells are associated with the progressive lesion. This review is intended to stimulate debate and further research,
and hence may occasionally appear to be selective rather than comprehensive.
Olav Alvares, Editor, CROBM
DESTRUCTIVE PERIODONTITIS LESIONS

ARE DETERMINED BY THE NATURE
OF THE LYMPHOCYTIC RESPONSE
E. Gemmell1*
K. Yamazaki2
G.J. Seymour1
1School of Dentistry, The University of Queensland, Brisbane 4072, Australia; and 2Faculty of Dentistry, Niigata University, Niigata 951-8514, Japan; *corresponding author, [email protected]
ABSTRACT: 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) E2, 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.
Key words. Destructive, periodontitis, lymphocytes, Th1/Th2, cytokines.
(I) Introduction
t is now generally accepted that periodontal disease results

from the inflammatory response to bacteria in dental plaque.
However, the innate susceptibility of the patient determines the
ultimate outcome of the disease process. In other words, it is the
nature of the inflammatory response which determines the
destructive character of the disease. With increased bacterial
challenge, bacterial products interact with the gingival epithelium to induce the expression of adhesion molecules and the production of pro-inflammatory cytokines and chemokines. Blood
vessels underlying the affected epithelium show increased per13(1):17-34 (2002)
meability and express adhesion molecules, and a gradient of

chemoattractant signals guides leukocytes into the gingival tissues. Neutrophils migrate through the junctional epithelium
and into the gingival sulcus. However, with the continued presence of bacteria, the formation of an inflammatory infiltrate in
the connective tissues consisting predominantly of lymphocytes
(T-cells) and macrophages takes place. Subsequently, in a susceptible person, this adaptive response still does not contain the
microbial challenge leading to a change in the nature of the
inflammatory response (B-cells/plasma cells) which results in
either protective antibody and subsequent control of the infection or non-protective antibodies and connective tissue destruc-
Crit Rev Oral Biol Med
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International and American Associations for Dental Research
17
tion and bone loss. Resident epithelial cells, endothelial cells,

and fibroblasts respond to agents such as bacterial lipopolysaccharide (LPS), IL-1, tumor necrosis factor-alpha (TNF-a), and
prostaglandins, particularly PGE2, and participate in the tissue
destruction. Fibroblasts normally produce several collagens;
however, in active periodontitis, the genes for collagens are
turned off, as are the genes for tissue inhibitors of metalloproteinases, and the genes for matrix metalloproteinases are turned
on, resulting in destruction of the extracellular matrix to make
way for the increasing inflammatory cell infiltrate (reviewed in
Page et al., 1997).
Page et al. (1997) have hypothesized that disease progression is due to a combination of several factors, including the
presence of periodontopathic bacteria, high levels of pro-inflammatory cytokines, matrix metalloproteinases, and PGE2, and low
levels of IL-10, TGF-b, and tissue inhibitors of metalloproteinase.
In this concept, it is clear that the balance of cytokines determines whether tissue destruction occurs or homeostasis is maintained (Page et al., 1997). In non-susceptible individuals, neutrophils and cell-mediated immunity will limit the extent of
attachment loss. However, in susceptible individuals and in the
presence of defined periodontopathic bacteria, such as
Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, or
Bacteroides forsythus, clearance by neutrophils will be averted and
disease progression will occur. The nature of the adaptive
immune response is under the control of T-cells which regulate
B-cell/plasma cell differentiation and antibody production.
Successful neutrophil clearance may depend upon the presence
of interferon-gamma (IFN-g) and may be further enhanced by
protective antibodies which in turn are controlled by the types of
cytokines produced by T-cells (reviewed in Page et al., 1997).
Therefore, it is clear that cytokines are fundamental in determining whether periodontal disease progresses or remains stable,
and the cytokines present in periodontal disease tissue are determined by the nature of the lymphocytic response.
(II) Innate Immunity

(A) NEUTROPHILS IN PERIODONTAL DISEASE
Phagocytic cells such as neutrophils and macrophages constitute the first line of defense against bacterial infection.
Neutrophils have been described as playing a major role in
periodontal disease (Dennison and Van Dyke, 1997), with both
protective and destructive influences being suggested. Much of
the evidence suggesting a protective function comes from the
observation that individuals who have neutrophil disorders
such as cyclic neutropenia (Cohen and Morris, 1961), ChdiakHigashi syndrome (Hamilton and Giansanti, 1974), and leukocyte adhesion deficiency syndrome (Springer et al., 1984;
Waldrop et al., 1987) have an increased susceptibility to periodontal destruction. Further, MacFarlane et al. (1992) reported
significantly impaired phagocytosis due to a decreased rate of
adhesion and opsonization by neutrophils from patients with
refractory periodontitis compared with healthy patients. In the
sulcus, neutrophils form a barrier between the epithelium and
plaque (Attstrm and Schroeder, 1979), which may prevent
bacterial invasion of the epithelium and underlying connective
tissue (Hemmerle and Frank, 1991).
Neutrophils therefore can minimize the destructive effects
of plaque bacteria (Dennison and Van Dyke, 1997). However,
bacteria such as P. gingivalis are able to evade host innate
immune responses (reviewed in Darveau et al., 1997). P. gingi-
18
valis, for example, does not stimulate the expression of the neutrophil binding adhesion molecule E-selectin on endothelial
cells, thus inhibiting their migration from the circulation into
the tissues. It also blocks the expression of this adhesion molecule by other Gram-negative bacteria and their LPS (Darveau
et al., 1995). Inhibition of neutrophil migration into P. gingivalisinduced lesions has been demonstrated in our mouse model
(Bird et al., 1995). Further, P. gingivalis-induced blocking of neutrophil transmigration through oral epithelium has been
reported to be due to inhibition of epithelial cell production of
the chemokine IL-8 (Madianos et al., 1997).
Bacteria including P. gingivalis produce proteases which
can cleave complement and immunoglobulins, thus preventing opsonization and subsequent neutrophil killing of invading bacteria. Gingipain-R, the major arginine-specific proteinase from Porphyromonas gingivalis, has been shown to
cleave a model peptide G-protein-coupled receptor found on
the surface of neutrophils (Lourbakos et al., 1998). Certain
strains of P. gingivalis produce enzymes which can cleave the Fc
regions of bacterial-bound IgG, preventing phagocytosis, and
can also cleave the C3b complement component, thereby causing evasion of neutrophil clearance (Sundqvist et al., 1984;
Schenkein, 1988; Schenkein et al., 1995). Additionally, since protective antibody production enhances neutrophil clearance
(Page et al., 1997), it is possible that P. gingivalis may induce
antibodies with poor antibacterial properties (Slots, 1999). If
the antibodies are not protective and neutrophils are inhibited,
bacteria will escape clearance. A. actinomycetemcomitans also
produces a protein which inhibits neutrophil chemotaxis and
H2O2 production (Ashkenazi et al., 1992a,b). In addition, it also
produces a cytolytic leukotoxin which lyses susceptible target
cells, including neutrophils, monocytes, and T-cells (Taichman
et al., 1980, 1991; Mangan et al., 1991). Despite this, however, the
bacteria per se do not cause tissue destruction in periodontal
disease. Rather, it is the nature of the inflammatory response to
these bacteria that results in tissue destruction.
A regulatory role for neutrophils in periodontitis has been
postulated (Seymour et al., 1993) based on the observation that
they secrete a range of cytokines including IL-1 and the IL-1
receptor antagonist (Lloyd and Oppenheim, 1992). This is supported by a study which showed that peripheral blood neutrophils stimulated with a range of periodontopathic bacteria
did not produce IL-1 but rather an IL-1 inhibitor, although the
nature of this inhibitor was not investigated at the time
(Yamazaki et al., 1989). The ability of the innate immune system
to regulate the adaptive immune response via the production of
cytokines such as the IL-1 receptor antagonist and IL-12 is being
recognized. A strong innate immune response may, on the one
hand, clear the periodontopathic bacteria and, on the other,
determine the nature of the lymphocytic response, which may
subsequently result in a stable or progressive form of the disease.
Controversy #1: Periodontopathic bacteria per se do not
cause tissue destruction. It is the inflammatory response which
leads to tissue destruction.
(B) MACROPHAGES IN PERIODONTAL DISEASE

Macrophages are important mediators of inflammation in the
connective tissue infiltrate, where they produce several
cytokines and also present antigens to T-cells (Dennison and
Van Dyke, 1997). Activated macrophages are essential for
innate resistance to intracellular infection. They produce proinflammatory cytokines which enhance phagocytosis and in
13(1):17-34 (2002)
most cases result in the successful elimination of the pathogen

(Trinchieri, 1997). Complete elimination of pathogens, however, involves antigen-specific T- and B-cells. The mechanisms of
innate and adaptive immune responses are hence seen to be
inter-dependent (Trinchieri, 1997). Cells of the innate response
influence T-cell differentiation by influencing the cytokine
milieu in the tissues or draining lymph nodes where antigenspecific T-cells expand in response to antigen presentation. A
high level of IL-12 during T-cell expansion will influence Th1
differentiation, while IL-4 is necessary for Th2 cells (Mosmann
and Coffman, 1989; Scott, 1993).
Few studies have been reported on macrophages in periodontal disease. However, while A. actinomycetemcomitans and P.
gingivalis have been shown to activate monocytes and
macrophages and stimulate the secretion of pro-inflammatory
and tissue-destructive mediators (Zadeh et al., 1999), a recent
report has shown that there is no increase in macrophage numbers and little evidence of macrophage activation in advanced
periodontitis compared with minimally inflamed tissues
(Chapple et al., 1998). This is supported by reports demonstrating negative effects by periodontal pathogens on monocytes/
macrophages. For example, P. gingivalis has been shown to affect
macrophage migration and activation by inhibiting the production of one of the major monocyte/macrophage chemokines,
monocyte chemoattractant protein-1 (MCP-1) (Gemmell et al.,
2000a). This suggests that macrophages may have protective
effects in the stable lesion which are abrogated in the advanced
destructive lesion. P. gingivalis, for example, has also been
demonstrated to induce the production of IL-1-b in B-cells,
rather than in monocytes, from periodontitis patients (Gemmell
and Seymour, 1998). This suggests that the major source of IL-1
in periodontal disease may be lymphocytic rather than macrophages, further supporting the concept that destructive periodontitis is determined by the nature of the lymphocytic response.
Controversy #2: Lymphocytes rather than macrophages are
the main source of destructive cytokines in periodontal disease.
(III) Susceptibility to Periodontal Disease

(A) ENVIRONMENTAL FACTORS
While periodontopathic bacteria and the inflammation they
provoke are essential for disease progression, environmental
risk factors such as tobacco smoking, psychosocial stress, and
systemic diseases such as diabetes modify the host response and
may be major determinants of the enormous variation in susceptibility (Page et al., 1997). These factors may modify the pathways by which bacteria cause inflammation and hence modify
disease progression, severity, and outcome (Page et al., 1997). It
is generally agreed that smoking is a risk factor for periodontal
disease (Grossi et al., 1994, 1995, 1996), exerting both local and
systemic effects. However, in a recent study, smoking has been
shown to have little effect on disease progression but rather to
have a highly significant effect on disease regression or healing,
such that the increased disease expression observed in smokers
is likely to be due to the inability to heal and the cumulative
effect of disease over time (Faddy et al., 2000).
(B) GENETIC FACTORS

Innate susceptibility to periodontal disease is influenced by host
genotype (Michalowicz, 1994). The relative contributions of
genetic factors to clinical measures of periodontal disease have
been studied in reared-together twins and monozygous twins
13(1):17-34 (2002)
reared apart (Michalowicz et al., 1991). This study suggested that

from 38 to 82% of the population variance for the periodontal
measures of disease could be attributed to genetic factors.
Genetic polymorphisms in Fc receptors on phagocytic cells
have been suggested to be significant in determining susceptibility to bacterial infections (Sanders et al., 1995). The Fc receptor for
IgG2 is FcgRIIa, and individuals with low-affinity receptors have
reduced IgG2-mediated phagocytosis of encapsulated bacteria
and are susceptible to a variety of bacteria, including meningococcal infections (Bredius et al., 1994; Sanders et al., 1994).
However, whether this is also true for individuals with chronic
periodontitis has not yet been demonstrated (Page et al., 1997).
Several studies have reported a predominance of serum
IgG2 antibodies in response to P. gingivalis (Lopatin and
Blackburn, 1992; Whitney et al., 1992; Polak et al., 1995; Wilton
et al., 1993). IgG2 antibodies are the primary immunoglobulin
subclass produced in response to bacterial carbohydrates and
LPS and lack strong complement fixation and opsonic properties. In periodontal disease subjects, a humoral response
involving IgG2 may be ineffective in clearing P. gingivalis,
depending upon the nature of the Fc receptor. One study of P.
gingivalis antibodies in groups of subjects with and without
periodontitis and with and without P. gingivalis infection
showed that IgG2 anti-P. gingivalis antibodies were significantly higher in the group of individuals who did not have P. gingivalis in their plaque samples and did not have periodontitis,
compared with individuals with P. gingivalis in their plaque
(Pietrzak et al., 1998). This suggests that IgG2 antibodies may
have resulted in clearance of the organism, although the Fc
receptor polymorphism status of these patients was unknown.
Cytokine polymorphisms are currently receiving a great deal
of attention, and there is increasing evidence that genetic variation within the TNF locus is an important factor in determining
susceptibility to several diseases, including malaria, leishmaniasis, and coeliac disease (McGuire et al., 1994; Wilson et al., 1995,
1997; Manus et al., 1996). Recently, TNF genotypes of 3 bi-allelic
polymorphisms were determined in adult periodontitis patients
and compared with those in healthy control subjects (Galbraith et
al., 1998). The level of TNF-a production by oral neutrophils correlated with the TNF-a 308 genotype in the periodontitis patients,
with increased production found in patients with the T1,2 genotype. This association was found only in patients with advanced
disease, suggesting that the TNF-a genotype may be a risk factor
for disease severity in periodontal disease.
Similarly, IL-1 polymorphisms have been claimed to be a
risk factor for severe periodontal disease, with genotype-positive individuals having a 20 times increased risk of developing
severe periodontitis after the age of 40 than those individuals
who are genotype-negative (Kornman et al., 1997). The polymorphism of the composite periodontitis-associated genotype
linked with expression of high levels of IL-1 has been examined
in a group of periodontitis patients, with 7/22 individuals
being positive for this genotype (Engebretson et al., 1999). The
positive and negative groups were comparable in terms of
existing periodontitis and age, and while IL-1-b levels in the
gingival crevicular fluid were higher in the positive group, a
reduction in IL-1-b levels after periodontal treatment occurred
only in the negative group. There was also a trend toward
higher IL-1-b levels in gingival biopsies of the positive group.
Recently, the frequency of IL-1-b genotypes including allele 2 of
the IL-1-b+3953 restriction fragment length bi-allelic polymorphism was shown to be significantly increased in patients with
19
adult periodontitis compared with individuals with early and

moderate disease (Gore et al., 1998). Further, allele 2 was associated with increased production of IL-1-b by activated peripheral blood neutrophils isolated from patients with advanced
disease. In a more recent study, it was shown that the IL-1 allele
2 composite phenotype was a contributing but non-essential
risk factor for periodontal disease progression over a five-year
period (Cullinan et al., 2001).
Controversy #3: There is no evidence that cytokine polymorphisms are essential factors in determining the progression
of periodontal disease.
(IV) Adaptive Immunity

In 1965, Brandtzaeg and Kraus demonstrated the presence of
immunoglobulin-producing plasma cells in the gingival tissues
of patients with periodontal disease. This was the first direct
evidence that adaptive immune mechanisms may play a role in
the pathogenesis of periodontal inflammation.
Ivanyi and Lehner (1970) used peripheral blood lymphocyte transformation assays to highlight a role for cell-mediated
immunity in periodontal disease. Subsequently, a great many
studies using a variety of lymphokine assays confirmed that
cell-mediated responses did play some part in pathogenesis,
but the exact role was unclear.
Direct immunohistologic investigation of the tissues
throughout the 1970s and 1980s (Mackler et al., 1977; Seymour
and Greenspan, 1979; Lindhe et al., 1980; Seymour et al., 1983,
1988; Reinhardt et al., 1988) seemed to confirm the hypothesis
that a change from gingivitis to periodontitis involved a shift
from a predominantly T-cell lesion to a B-cell/plasma cell
lesion (Seymour et al., 1979). This hypothesis was also supported by functional studies, albeit using peripheral blood cells,
which showed that suppressed cell-mediated immunity in
advanced periodontitis subjects (Ivanyi and Lehner, 1970;
Boyatzis and Seymour, 1986) could be reversed following treatment (Evans et al., 1989). Other studies also demonstrated lymphocyte suppression by periodontopathic bacteria. Low
responses to P. gingivalis, Treponema denticola, and
Capnocytophaga ochracea were found in both healthy and periodontitis peripheral blood lymphocytes compared with other
oral bacteria (Stashenko et al., 1983), and in another study, P.
gingivalis reduced the response of non-mitogen-stimulated
cells (Shenker and Slots, 1989; Gemmell and Seymour, 1992). A.
actinomycetemcomitans was also shown to suppress the peripheral blood lymphocyte response to mitogens (Shenker et al.,
1982a), and depletion of CD8 cells was found to abrogate this
response, suggesting the induction of a CD8 suppressor factor
(Shenker et al., 1982b).
In terms of the transition from gingivitis to periodontitis,
several studies have reported a decreased CD4/CD8 ratio
(Taubman et al., 1984a; Cole et al., 1987; Stoufi et al., 1987; Okada
et al., 1988; Wang et al., 1989) in periodontal lesions, while functional studies have reported a reduced autologous mixed-lymphocyte reaction (Cole et al., 1987). Taken together, these studies have suggested a local immunoregulatory imbalance. It is
now generally agreed that both T- and B-cells are present in
periodontal disease tissues (Zadeh et al., 1999). It is also clear
that the majority of T-cells are activated memory/primed cells
(Okada et al., 1988; Reinhardt et al., 1988; Takeuchi et al., 1991;
Gemmell et al., 1992; Yamazaki et al., 1993). Indeed, both T- and
B-cells extracted from gingival tissues have been reported to be
at a more advanced stage of the cell cycle than peripheral blood
20
T- and B-cells, indicative of activation within the tissues

(Gemmell and Seymour, 1992).
(A) B-CELLS IN PERIODONTAL DISEASE

Polyclonal B-cell activation has been cited as being significant
in the pathogenesis of periodontal disease. Sonic extracts of
periodontopathic bacteria were first shown to induce polyclonal B-cell activation of peripheral blood lymphocytes, as
assessed by the plaque-forming cell response to sheep red
blood cells (Bick et al., 1981; Donaldson et al., 1982) and by the
production of antibodies to several different organisms as well
as specific antibody to the stimulating organism (Mangan et al.,
1983; Carpenter et al., 1984). Several studies have shown that
this polyclonal B-cell response to oral organisms is dependent
on the presence of T-cells (Donaldson et al., 1984; Okada et al.,
1987; Ito et al., 1988). While most of these studies examined
peripheral blood responses, an in situ study recently reported
that local proliferation of B-cells does not occur in periodontitis tissues, although plasma cells showed strong synthetic
activity (Takahashi et al., 1996). However, Gemmell and
Seymour (1991) previously demonstrated that B-cells extracted
from periodontitis tissues do have a more activated phenotype
than cells from gingivitis tissues or peripheral blood. Murine
models have been used to demonstrate the induction of polyclonal B-cell activation by A. actinomycetemcomitans and P. gingivalis (Inada et al., 1994; Watanabe et al., 1996). However, when
T- and B-cells from mice immunized with a 40-kDa immunodominant outer membrane antigen of P. gingivalis were examined in vitro, the secondary antibody response required the
presence of B-cells, CD4+ T-cells, and H-2 restricted, Ia+ antigen-presenting cells (APC) (Oshikiri et al., 1994). The antibody
response to the 40-kDa P. gingivalis antigen, therefore, was generated in an antigen-specific manner and was not the result of
polyclonal B-cell activation.
The inability of specific antibodies to eliminate the
causative organisms of periodontal disease could be due to
several factors, including poor antigenicity of the virulence
determinants and elicitation of antibodies with poor antibacterial properties (Slots, 1999). High titers of specific antibody levels to P. gingivalis (Ling et al., 1993; Wilton et al., 1993; Meghji et
al., 1995) and A. actinomycetemcomitans (Saito et al., 1993; Meghji
et al., 1995; Engstrm et al., 1999) have been reported in serum
and gingival crevicular fluid, although many studies report
conflicting results. Positive correlations between elevated IgG
levels to P. gingivalis and A. actinomycetemcomitans have been
shown in gingivitis associated with both puberty and adult
periodontitis (Nakagawa et al., 1994), while a negative relationship between anti-A. actinomycetemcomitans antibodies in the
serum of periodontitis patients and the burden of A. actinomycetemcomitans in infected sites has also been reported
(Ebersole et al., 1994). Another study demonstrated no difference in the levels of anti-P. gingivalis antibodies in the gingival
crevicular fluid of periodontitis patients and healthy control
subjects, although there were moderate to strong correlations
with serum antibody levels (Baranowska et al., 1989).
Serum antibody changes have been suggested to reflect the
nature of the organism load (Taubman et al., 1992), and elevated levels of anti-P. gingivalis IgG antibodies have been linked to
the presence of marked periodontal lesions (Gmr et al., 1986),
while levels of antibodies in the gingival crevicular fluid have
been cited to be an inverse of the number of organisms at the
particular site of sampling (Kinane et al., 1993; Ebersole et al.,
13(1):17-34 (2002)
1995). Kinane et al. (1993) demonstrated a correlation of specific serum antibody titers to P. gingivalis and A. actinomycetemcomitans with mean gingival crevicular fluid titers, suggesting
protective humoral immune responses, although the IgG titers
to P. gingivalis in sites with higher probing depths were lower,
so that patients with greater inflammation had lower IgG levels. In another group of patients, Mooney and Kinane (1997)
found that anti-P. gingivalis IgG antibody levels in periodontitis
sites were lower than in gingivitis sites in the same subjects,
suggesting that a failure in local antibody production may contribute to the change from gingivitis to periodontitis lesions.
Reinhardt et al. (1989) measured IgG subclasses in the gingival
crevicular fluid of periodontally active and stable or healthy
sites. The mean IgG1 and IgG4 concentrations were higher in
the fluid from active periodontitis sites than in stable sites, suggesting that these antibodies were ineffective in eradicating the
bacteria. At the same time, the mean levels were generally
greater than in serum, especially for IgG4, further suggesting
that this subclass may be a useful indicator for immunological
changes which occur in active periodontal disease.
Humoral immune response studies have also focused on
the determination of immunodominant antigens and a study of
their functions. However, different patterns of immunoreactivity with periodontopathic bacteria have been demonstrated for
A. actinomycetemcomitans (Califano et al., 1991, 1992; Engstrm
et al., 1993; Ebersole et al., 1995) and for P. gingivalis (Curtis et al.,
1991; Kurihara et al., 1991; Polak et al., 1995). Since these
responses are regulated by immunoregulatory genes, it may be
that antibody responses are protective in one individual but not
in another (Offenbacher, 1996).
IgG subclasses and avidity have also been implicated in
periodontal disease progression; however, the functional characteristics which may help to define susceptibility to the disease are still to be ascertained (Ishikawa et al., 1997).
Underwood et al. (1993) suggested that high levels of anti-A.
actinomycetemcomitans antibodies with high avidity may confer
greater resistance to continued or repeated infection. Mooney et
al. (1993) showed that patients who did not experience attachment loss during a three-month monitoring period had anti-P.
gingivalis antibodies with higher avidity than those patients
who did experience attachment loss. Further, Lopatin and
Blackburn (1992) showed that anti-P. gingivalis and anti-P. gingivalis-LPS antibodies in periodontitis patients had significantly lower avidity than antibodies to streptokinase and tetanus
toxoid, and while antibodies of the IgG1 subclass were of relatively high avidity, those in the IgG2 subclass, which were the
predominant IgG subclass, were of significantly lower avidity.
The relationship between titers and avidities of serum antibodies to P. gingivalis and A. actinomycetemcomitans and to clinical
parameters of periodontal disease severity and the level of
infection with the homologous organism has been examined in
a group of periodontitis and gingivitis patients (Lamster et al.,
1998). There was a negative correlation between the mean probing depths and antibody titer and avidity to A. actinomycetemcomitans and to infection with A. actinomycetemcomitans, while
there was a positive correlation with respect to P. gingivalis. It
was concluded that the development of an antibody response
to A. actinomycetemcomitans appears to protect individuals from
infection, whereas the antibody response to P. gingivalis was not
able to eliminate the infection. Non-protective low-avidity antiP. gingivalis antibodies may be incapable of effectively mediating a variety of immune responses (Lopatin and Blackburn,
13(1):17-34 (2002)
1992; Whitney et al., 1992). The general inability to demonstrate

immune complexes in the gingival sulcus (Clagget and Page,
1978) supports the notion that there is a compromised ability to
eliminate or reduce the numbers of micro-organisms and their
products from the gingival sulcus (Lopatin and Blackburn,
1992). The production of anti-P. gingivalis antibodies with different avidities in various forms of periodontal disease has
been suggested to reflect the quality of the humoral response,
which may affect progression of the disease (Mooney and
Kinane, 1994). Wilton et al. (1993) reported that low titers to
organisms such as P. gingivalis in healthy individuals were of
low avidity.
The immune responses to self-antigens such as collagen
type I, a major component of the periodontium, have also been
suggested as a pathogenic pathway. High titers of anti-collagen
type I antibody are found in the sera (Hirsch et al., 1988) and
anti-collagen type I specific T-cell clones can be identified in the
inflamed gingival tissues of periodontitis patients (Wassenaar
et al., 1995). Sugawara et al. (1992) demonstrated that the autoreactive CD5+ B-cells increased in periodontitis lesions and the
CD5+ B-cells produced more IgM and IgG antibodies to collagen in vitro than did CD5- B-cells (Sugawara et al., 1992).
Although the mechanisms that induce an immune response to
self-components are not fully elucidated, molecular mimicry
has been cited to explain the linkage between infection with
bacteria and subsequent autoimmune mechanisms (Oldstone,
1987). Antibody responses to heat-shock protein 60 (hsp60) in
particular are thought to be important. It has been reported that
GroEL-like protein belonging to the hsp60 family is expressed
by periodontopathic bacteria such as P. gingivalis (Hotokezaka
et al., 1994; Maeda et al., 1994) and A. actinomycetemcomitans
(Nakano et al., 1995), while Tabeta et al. (2000) have demonstrated that serum antibodies to P. gingivalis GroEL and human
hsp60 are elevated in periodontitis patients compared with
healthy control subjects (Tabeta et al., 2000). They also demonstrated that these antibodies cross-reacted with one another
and concluded that the immune response to bacterial hsp60
may be an important pathogenic mechanism in periodontitis.
During the chronic phase of the disease, the antibody
response has been suggested to be generally protective, to facilitate bacterial clearance, and to arrest disease progression
(Offenbacher, 1996). Serum from patients with severe periodontitis containing high titers of anti-P. gingivalis antibodies
completely inhibited in vitro bone resorption, whereas serum
from patients with low titers failed to inhibit this bone resorption, confirming a possible protective role for specific antibodies in periodontitis (Meghji et al., 1993). Other studies suggesting a role for protective antibodies include the demonstration of
anti-P. gingivalis protease antibodies which occur late in periodontitis infections and which can block the anti-opsonizing
activity against C3 and IgG (Cutler et al., 1993). An increased
capacity of serum to opsonize P. gingivalis has been shown to be
a distinctive feature in patients with past destructive periodontal disease (Wilton et al., 1993). Opsonic IgG antibodies to A.
actinomycetemcomitans which may facilitate neutrophil-mediated phagocytosis and be protective against this periodontopathic organism have also been demonstrated (Baker and Wilson,
1989; Underwood et al., 1993). Repeated infection with A. actinomycetemcomitans has been shown to elicit an anti-leukotoxin
antibody which protects neutrophils from the leukocidal activity of the leukotoxin (Underwood et al., 1993). Tsai et al. (1981)
showed that the majority of sera from juvenile periodontitis
21
patients contain antibodies which neutralize A. actinomycetemcomitans leukotoxin, while sera from individuals without disease or those with other types of periodontal disease usually
amplified rather than inhibited the reaction to the A. actinomycetemcomitans leukotoxin. On the other hand, however,
Cutler et al. (1991) reported that only 3/17 serum samples from
several adult periodontitis patients with elevated IgG to P. gingivalis A7436 were opsonic for this particular strain. In another
study, antibody levels to subgingival plaque micro-organisms
were found to be a predictor of bone loss in an elderly group of
patients with anti-P. gingivalis antibodies to two strains of P.
gingivalis having significant correlations with loss of alveolar
bone (Wheeler et al., 1994).
Controversy #4: Specific antibodies produced in response
to periodontopathic bacteria are protective. However, susceptible subjects are characterized by the production of non-protective antibodies.
(B) T-CELLS IN PERIODONTAL DISEASE

It would appear, therefore, that locally produced specific antibodies may be able to clear the causative organism in some people, while in others polyclonal B-cell activation and the production of low-avidity specific antibodies may not clear the infection, and disease progresses. Offenbacher (1996) suggests that if
the antibody/neutrophil response does not result in clearance,
the outcome of the monocyte/lymphocyte challenge is the
secretion of catabolic cytokines and inflammatory mediators
such as IL-1, IL-6, TNF-a, and PGE2, which induce connective
tissue and bone loss. As the microbial challenge increases, and
with repeated challenge, the antibody response may become
protective and enable neutrophil clearance to occur, and the
infection reaches homeostasis. Such a concept, however, is not
in accord with the observation that the monocyte/lymphocyte
infiltrate occurs early in disease formation (Page and Schroeder,
1976; Seymour et al., 1988) followed by the B-cell/plasma cell
lesion which is characteristic of the advanced forms of the disease (Page and Schroeder, 1976). An alternative hypothesis,
therefore, would be that failure of the innate immune response
to clear the infection, even in the presence of stimulating
cytokines such as IFN-g, leads to the development of a Bcell/plasma cell lesion. If as a result specific antibodies with
high avidity are formed, the infection is cleared and the disease
does not progress. If on the other hand polyclonal B-cell activation and non-specific and/or low-avidity specific antibodies are
produced, the infection is not cleared. Continued B-cell activation leads to the production of high levels of IL-1, and as a
result, tissue destruction ensues. This hypothesis is consistent
with the normal functioning of the immune system in bacterial
infections, with the observation that B-cells are a potent source
of IL-1, that macrophages are not a dominant feature of the
advanced lesion, and that suppressed cell-mediated immunity
is associated with advanced periodontitis.
Clearly, whichever hypothesis is correct, T-cells must
play a fundamental role. T-cells are the dominant cell type in
the cell-mediated (macrophage/lymphocyte) response and
are necessary for both specific antibody production and polyclonal B-cell activation.
Immunohistological studies have clearly established that a
T-cell/macrophage lesion identical to a delayed hypersensitivity reaction (Poulter et al., 1982) occurs within 4 to 8 days of
plaque accumulation in an experimental gingivitis study
(Seymour et al., 1988). This is synonymous with the early lesion
22
of Page and Schroeder (1976) and with the putative stable

lesion (Seymour et al., 1979). The expression of HLA-DR and
DQ by these cells indicates that they are activated, but the lack
of CD25 expression would indicate that they are not proliferating locally within the tissues (Seymour et al., 1988). The striking similarities between this early/stable periodontal lesion
and delayed-type hypersensitivity prompted the suggestion
that cells with a Th1 cytokine profile are the major mediator.
Such a concept is consistent with the proposal that a strong
innate immune response leads to the production of IL-12,
which in turn leads to this Th1 response. The production of
IFN-g then enhances the phagocytic activity of both neutrophils and macrophages and hence containment of the infection. However, the stable lesion persists due to the continual
formation of the plaque biofilm (Gemmell and Seymour, 1994).
The dominance of B-cells/plasma cells in the advanced/
progressive lesion would suggest a role for Th2 cells. Clearly, if
the innate response is poor, low levels of IL-12 would be produced and a poor Th1 response may occur which may not then
contain the infection. Mast cell stimulation and the subsequent
production of IL-4 would encourage a Th2 response, B-cell activation, and antibody production. If as noted above these antibodies are protective and clear the infection, the disease will not
progress, but if on the other hand they are non-protective, the
lesion will persist, and continued B-cell activation would result
in large amounts of IL-1 and hence tissue destruction (Seymour
et al., 1993; Gemmell and Seymour, 1994, 1998).
To test this hypothesis, several investigators have attempted to delineate the Th1/Th2 profile in periodontal disease.
However, results are difficult to interpret due to differences in
material examined and methodologies used. Cytokines have
been studied in cells in situ, cells extracted from gingival tissues, peripheral blood mononuclear cells, T-cell lines, and
clones as well as purified cell populations. A variety of techniques has also been used, including flow cytometry, enzymelinked immunosorbent assay (ELISA), in situ hybridization,
and reverse-transcriptase/polymerase chain-reaction (RTPCR). Additionally, bacterial components including sonicates,
heat- and formalin-killed cells, outer membrane components,
and purified antigens have all been used to stimulate cells in
vitro, making comparisons of cytokine profiles difficult (Zadeh
et al., 1999). It is likely, as indicated above, that different T-cell
subsets predominate at different phases of disease, and the
inability to determine disease activity clinically is a major limitation in all these studies.
Several investigators have reported decreased Th1
responses in periodontal disease (Table). Pilon et al. (1991)
demonstrated lower levels of IL-2 in the gingival crevicular
fluid of periodontitis sites compared with healthy sites, and
Fujihashi et al. (1991) have shown that gingival mononuclear
cells from adult periodontitis patients produce IL-4 and IL-5
but not IL-2. Peripheral blood mononuclear cells from periodontitis patients stimulated with mitogens resulted in reduced
IFN-g secretion and mRNA expression of IFN-g and IL-2. At
the same time, significantly higher levels of IL-5 and GM-CSF
were observed (Sigusch et al., 1998). Significantly less IL-2
activity was also found in peripheral blood mononuclear cell
cultures stimulated with P. gingivalis and another oral Gramnegative anaerobe, Fusobacterium nucleatum, compared with
unstimulated cultures (Gemmell and Seymour, 1994). In this
study, IFN-g as measured by an ELISA could not be detected in
cultures containing both bacteria; furthermore, IFN-g was
13(1):17-34 (2002)
demonstrated in only 10/27 gingiTABLE

val mononuclear cell culture superTh1/Th2 Cytokine Profiles in Human Periodontal Disease
natants. A recent in vivo study has
confirmed these observations,
Observations
References
showing that priming of mice with
F. nucleatum prior to challenge with
Decreased Th1 (1) IL-2 in GCF in periodontitis compared with
P. gingivalis resulted in a polarized
responses
healthy sites.
Pilon et al., 1991
Th2 response, while P. gingivalis
(2) GMC from periodontitis patients produce IL-4 and IL-5
alone resulted in a Th1 response
but not IL-2.
Fujihashi et al., 1991
(Choi et al., 2000). This important
(3) IFN-g production, IFN-g and IL-2 mRNA in mitogenpaper highlights the complexities
stimulated PBMC from periodontitis patients.
Sigusch et al., 1998
involved in periodontal disease and
Gemmell and
(4) IL-2 activity by P. gingivalis- and F. nucleatumthe dangers of using single orgastimulated PBMC compared with unstimulated cultures. Seymour, 1994
nisms in highly artificial settings.
Increased Th2 responses in perioIncreased Th2 (1) IL-4 production by memory PB T-cells from periodontitis
dontitis have also been reported
responses
patients compared with T-cells from healthy subjects.
Aoyagi et al., 1995
(Table). Memory T-cells from the
(2) percent IL-4+ cells in the gingival tissues proportional
peripheral blood of adult periodontito increased B-cell/T-cell ratio.
Yamazaki et al., 1994a
tis patients with high anti-P. gingi(3) IgG4 concentrations (indicative of increased IL-4) in
valis titers stimulated in vitro with P.
GCF of active periodontitis sites compared with stable
gingivalis have been shown to prolesions.
Reinhardt et al., 1989
duce higher amounts of IL-4 than
(4) IL-4 and IL-5 mRNA in inflamed gingiva of periocells from healthy subjects (Aoyagi et
dontitis patients compared with gingivitis subjects.
Tokoro et al., 1997
al., 1995). In this study, no IL-4-pro(5) IL-4+ cells relative to IL-2+ cells in gingival tissues of
ducing memory T-cells were detectperiodontitis patients compared with gingivitis tissues. Manhart et al., 1994
Yamazaki et al.,
(6) IL-4+ cells in periodontitis lesions compared with
ed in healthy gingival tissues, and a
gingival tissues.
1994b
larger proportion of peripheral
blood memory T-cells from patients
Ebersole and
Th1 response (1) IFN-g mRNA prominently expressed by diseased
in whom high frequencies of IL-4
dominates over
gingival tissue cells.
Taubman, 1994
producing cells were identified in
Th2 response (2) IL-2 and IFN-g in GCF of periodontitis patients
the lesion produced IL-4 following
compared with IL-4 and IL-6.
Salvi et al., 1998
stimulation with antigen. Yamazaki
g
,
IL-6,
IL-13
mRNA
expressed
by
CD4+
cells
from
Th0
responses
(1)
IFNet al. (1994a) demonstrated an
periodontal disease lesions, but not IL-2, IL-4, or IL-5. Fujihashi et al., 1994
increased percentage of IL-4+ cells
(2) IFN-g but not IL-2 mRNA expressed in gingival
proportional to an increasing Btissue cells.
Takeichi et al., 1994
cell/T-cell ratio. IL-4 was the promi(3) expression of IL-6 and IFN-g mRNA in diseased
nent cytokine in periodontally affectcompared with healthy tissues.
Prabhu et al., 1996
ed tissues compared with IL-2, IFN- ,
(4) IFN-g, IL-6, and IL-13 mRNA expressed by CD4+
and IL-6. Another study suggested a
cells from inflamed gingivae. IL-10 mRNA not always
role for IL-4 and Th2 responses in
expressed.
Fujihashi et al., 1996
periodontitis lesions by the demon(5) IFN-g and IL-13 mRNA and IL-4 and IL-10 mRNA
stration of concentrations of IgG4
by PBMC stimulated with P. gingivalis.
Nakajima et al., 1999
many times higher in sites of active
(6) IFN-g mRNA and IL-10 mRNA in PB compared
periodontitis than in serum, as well
with gingival tissues with PB.
Yamazaki et al., 1997
as significantly elevated concentra(7) T-cell lines and clones specific for P. gingivalis,
Gemmell et al., 1995;
tions compared with stable lesions
predominantly Th0.
Karatzas et al., 1996
(8) Gingival CD4 clones (raised non-specifically)
(Reinhardt et al., 1989). A bias toward
predominantly Th2, while CD8 clones
Th2-type cytokines in periodontal
predominantly CD8.
Wassenaar et al., 1995
disease progression was also indicated when cytokine analysis of cells in
Increased.
inflamed gingiva by in situ
Decreased.
hybridization showed that the densiGCF
Gingival crevicular fluid.
ty of cells expressing IL-1- , IL-4, and
GMC
Gingival mononuclear cells.
IL-5 mRNA was higher in periodonPB
Peripheral blood.
titis than in gingivitis (Tokoro et al.,
PBMC
Peripheral blood mononuclear cells.
1997). Further, cell dot-blot analysis
of cytokine-producing gingival
strated a significantly higher level of IL-4-producing cells in
mononuclear cells showed that a higher percent of non-stimulatperiodontal lesions in comparison with gingivitis tissues, and
ed periodontal disease cells were IL-4+ (Manhart et al., 1994).
although this was also the case for IL-6-producing cells, the
Analysis of IL-2/IL-4 ratios revealed significantly lower ratios
results were not significant (Yamazaki et al., 1994b). In this study,
for cells derived from periodontitis tissues compared with cells
Th2-type cells were shown to accumulate in periodontitis. In a
from gingivitis tissues. An immunohistochemical study demon13(1):17-34 (2002)
23
recent study, peripheral blood mononuclear cells isolated from P.

gingivalis-positive gingivitis and periodontitis subjects were
stimulated with P. gingivalis outer membrane antigens. IL-4+ Tcells predominated over IFN-g+ and IL-10+ cells, although there
were no differences in the percentages of positive cells in comparison with cells stimulated in the absence of P. gingivalis antigens (Gemmell and Seymour, 1998), suggesting a non-specific
effect perhaps due to the very low numbers of P. gingivalis-specific precursor T-cells present in the peripheral circulation of
both healthy and diseased individuals (Mahanonda et al., 1991).
Taken together, however, these data seem to support the hypothesis that Th1 cells are associated with the stable lesion and a Th2
response with disease progression.
In contrast to these studies, Ebersole and Taubman (1994)
found that IFN-g message was prominently expressed by diseased gingival tissue cells (Table). Cytokine profiles of cells
extracted from six patients were consistent with Th1 cells in that
they were IL-2- and IFN-g-positive but negative for IL-4 and IL5. A further sample had message for IL-2 and IL-5, consistent
with Th0 cells. The investigators' inability to detect IL-4 mRNA
in these experiments could have been due to its very short halflife rather than to its absence from the tissues. As with other
studies, disease activity was not clearly defined, such that,
again, interpretation is difficult. Another study comparing the
local and systemic responses in periodontitis patients with socalled terminal dentition periodontitis demonstrated reduced
Th2 responses. Levels of PGE2, IL-1-b, and IL-2 in the gingival
crevicular fluid samples were highest, followed by lower levels
of TNF-a and IFN-g and even lower levels of IL-4 and IL-6
(Salvi et al., 1998) (Table). LPS-stimulated monocytes from these
patients resulted in significantly elevated levels of PGE2, IL-1-b,
and TNF-a compared with cultures of cells derived from control subjects with moderate to advanced disease. Cytokine
mRNA expression of Th1 and Th2 cytokines was present in isolated gingival mononuclear cells with low levels of IL-4 and IL12. While it was concluded that Th1 cytokine levels dominated
over the Th2 response in the gingival crevicular samples, and
that monocyte activation provided the major source of proinflammatory mediators, because different concentrations of
different cytokines result in different levels of biological activity, the comparison of different levels of cytokines in the same
patient is inappropriate. It would have been of greater value
had the levels of the same cytokines been compared in patients
from different disease groups. Equally, the ability of peripheral
blood monocytes to produce cytokines upon stimulation does
not imply that these are the major source of these cytokines in a
highly localized lesion as is seen in periodontal disease.
Interpretation of this study is therefore difficult.
Other studies have suggested the involvement of Th0 cells
in periodontal disease (Table). Fujihashi et al. (1994) extracted
mRNA for IFN-g, IL-6, and IL-13, but not for IL-2, IL-4, or IL-5
in CD4+ T-cells from periodontal disease lesions. Takeichi et al.
(1994) showed that IFN-g and IL-1-b mRNA was expressed by
some gingival cells on extraction, indicative of Type 1 cells, and
upon stimulation, IL-6 transcripts were also expressed but no IL2 or IL-2 receptor mRNA could be detected. Yet another study
found no skewing of cytokines toward a Th1 or Th2 profile in
diseased or healthy tissues, although there was a significantly
higher expression of IL-6 and IFN-a mRNA in diseased tissues
(Prabhu et al., 1996). Fujihashi et al. (1996) isolated CD4 cells from
inflamed gingival tissues and demonstrated two profiles, both of
which were positive for IFN-g, IL-6, and IL-13 mRNA, while one
24
group and not the other was also positive for IL-10. Nakajima et
al. (1999) demonstrated that stimulation of peripheral blood
mononuclear cells from individuals with periodontitis and gingivitis with P. gingivalis resulted in up-regulation of messenger
RNA for IFN-g and IL-13, while IL-4 and IL-10 were down-regulated, regardless of disease status or the presence of P. gingivalis
in plaque samples. Message for several cytokines has been compared in the gingival tissues and peripheral blood of periodontitis patients (Yamazaki et al., 1997). The mean expression of IFN-g
mRNA was higher in the peripheral circulation than in the gingival tissues, while that of IL-10 mRNA was higher in the gingival tissues. However, only 7/16 samples demonstrated a high
expression of IL-10, the other samples showing equivalent levels
in blood and tissues. IL-12 mRNA was similarly expressed to a
higher extent in 6/16 samples, the other samples showing no
differences between gingiva and peripheral blood. IL-4 mRNA
was weak but detectable in only 3 samples.
Studies on T-cell lines and clones have also demonstrated
conflicting results (Table). One such study reported that T-cell
lines and clones specific for P. gingivalis resembled Th0 cells,
although one CD4+ clone did produce IL-4 and IL-5 mRNA,
suggesting a Th2 profile (Karatzas et al., 1996). Flow cytometry
and RT-PCR have been used to show that CD4 and CD8 cells in
P. gingivalis-specific lines and clones derived from a P. gingivalispositive gingivitis subject and a P. gingivalis-positive periodontitis patient produced IL-4, IL-10, and IFN-g (Gemmell et
al., 1995). However, in a further study, several lines established
from P. gingivalis-positive gingivitis and periodontitis subjects
demonstrated highly variable profiles, although the mean
results showed that a high percentage of both CD4 and CD8
cells was positive for IFN-g, with lower percentages of IL-4+
and IFN-g+ cells. Lines established from the periodontitis subjects demonstrated more variation than lines from the gingivitis individuals, such that IL-4+ and/or IL-10+ T-cells predominated over IFN-g+ cells in a greater number of lines (Gemmell
et al., 1999). Wassenaar et al. (1995) established T-cell clones
from the gingival tissues of four patients with chronic periodontitis, although these were raised non-specifically with the
use of mitogen and IL-2. Eighty percent of the CD4 clones had
Th2 phenotypes producing high levels of IL-4 and low levels of
IFN-g, while the majority of CD8 clones demonstrated a Th0like pattern producing equal amounts of IL-4 and IFN-g. A further study demonstrated two subsets of CD8 clones expressing
the ab T-cell receptor, one of which produced high levels of
IFN-g but no IL-4 or IL-5 (Th1) and mediated cytolytic activity,
while the other subset produced high levels of IL-4 together
with IL-5 and displayed no cytotoxicity. The latter Th2 cells
suppressed the proliferative response of cytotoxic CD8 T-cell
clones, which could be abolished by the addition of anti-IL-4
antibodies, although IL-4 alone could not induce this suppression. Therefore, CD8 T-cells may participate in the local
response by suppressing IFN-g-producing cells and favoring
humoral immune responses (Wassenaar et al., 1996). While it is
difficult to interpret all these studies, the pattern seems to be
emerging that within the tissue, gingivitis seems to be associated with a Th1 response, while periodontitis is associated with
a Th2 response. This is consistent with the histology of these
two diseases. In peripheral blood, however, no clear pattern is
emerging. The reasons for this remain obscure.
Emanating from studies of cytokines in periodontal disease is the concept that IL-10 may be of fundamental importance in the control of periodontal disease progression. A sig-
13(1):17-34 (2002)
nificant decrease in the percent of IL-10+ CD8 cells in gingival

cells extracted from periodontitis tissues in comparison with
gingivitis samples has been demonstrated (Gemmell and
Seymour, 1998), although Stein and Hendrix (1996) found that
gingival mononuclear cells extracted from adult periodontitis
patients produced more IL-10 than cells derived from noninflamed tissue. As well, anti-IL-10 antibodies induced an 80%
decrease in the frequency of anti-collagen-secreting cells, and it
was suggested that IL-10 in inflamed gingival tissues potentiates a local autoimmune response characterized by an increase
in anti-collagen-secreting cell frequency. A role for IL-10 has
been suggested by another study which analyzed cytokine
expression in CD4+ gingival lymphocytes isolated from
inflamed periodontal tissues. As reported by Fujihashi et al.
(1996), two distinct profiles were noted. One pattern showed
the presence of IFN-g, IL-6, IL-10, and IL-13 mRNA, while the
other pattern was similar with the exception of a lack of IL-10
mRNA. In most cases, IL-2, IL-4, and IL-5 mRNA were not
detected (Yamamoto et al., 1997). IL-10 has been demonstrated
to inhibit LPS-induced B-cell proliferation in the mouse
(Marcelletti, 1996), and decreased IL-10 in periodontitis may
possibly allow for continued polyclonal B-cell activation.
Studies on cytokines have led to the formulation of several
hypotheses as to which T-cell subsets are associated with periodontitis. Seymour et al. (1993) proposed that due to the shift in
lymphocyte populations in the inflammatory infiltrate from
predominantly T-cells in gingivitis to an increased proportion
of B-cells in periodontitis, susceptibility to periodontal disease
progression may involve a predominantly Th2-like response in
which T-cells produce the cytokines required for B-cell proliferation and differentiation, leading to polyclonal B-cell activation, the production of elevated levels of non-protective antibodies, and the continued production of B-cell IL-1. Non-susceptibility to periodontal breakdown may involve a predominantly Th1-like response, resulting in T-cell activation, cellmediated immunity, IFN-g enhancement of innate immunity,
and, if necessary, the production of protective antibodies (Fig.,
A). On the other hand, Ebersole and Taubman (1994) have formulated their hypothesis (Fig., B) based on their adoptive
transfer experiments using the Th2 clone A3. They speculate
that Th2 cells abrogate periodontal disease symptoms and Th1
cells enhance disease. Th2 cells could be protective, providing
help for specific antibody production which they propose is a
key feature of protection against periodontal destruction, while
Th1 and CD8+ cells may be destructive via the production of
IFN-g and potential stimulation of macrophage IL-1, leading to
bone destruction. Th1 cells therefore exert pro-inflammatory
effects leading to tissue injury and immunopathology, while
Th2 cells produce cytokines leading to anti-inflammatory functions (IL-4 and IL-10 down-regulate IL-1 production [Essner et
al., 1989] and IL-10 increases IL-1 receptor antagonist secretion
[Schreiber et al., 1995]) and the down-regulation of Th1 cellmediated tissue-destroying effects (Del Prete et al., 1993).
Yet another hypothesis has been advanced by Dennison and
Van Dyke (1997), who suggest that alterations in the monocyte
response may lead to abnormal disease patterns (Fig., C). This is
based on studies showing that IL-4 inhibits the monocyte secretion of cytokines and PGE2 (Te Velde et al., 1990; Corcoran et al.,
1992). Macrophages play a central role in the immune response
to bacteria, by acting as APC to initiate responses, producing
pro-inflammatory cytokines and other mediators which induce
antibacterial responses by effector cells and by the killing of
13(1):17-34 (2002)
(A)
Gingivitis
Th1
Cell-mediated immunity
Strong innate immune response +

protective antibody production
Stable lesion
Periodontitis
Periodontopathic bacteria
Th2
B-cell expansion
Poor innate immune response +

non-protective antibody production
Lesion progression
(B)
Gingivitis
Th2
Specific antibody production +

anti-inflammatory cytokines (IL-4, IL-10)
IL-1, IL-1 receptor antagonist
Abrogation of periodontal
disease symptoms
Periodontitis
Th1
Pro-inflammatory effects
IFN-g
Macrophage activation
IL-1
Periodontal destruction
and immunopathology
(C)
Gingivitis
IL-4
Inhibition of macrophage production of

pro-inflammatory cytokines and PGE2 +
apoptosis of macrophages
Periodontitis
IL-4
Down-regulation of monocyte-induced
pro-inflammatory cytokines, including IL-1
Figure. Models for the roles of Th1 and Th2 cytokines in periodontal disease progression as proposed by (A) Seymour et al. (1993), (B) Ebersole
and Taubman (1994), and (C) Dennison and Van Dyke (1997).
micro-organisms (Ishikawa et al., 1997). LPS is a component of

Gram-negative bacteria, and while several LPS receptors have
been identified (Lynn and Golenbock, 1992), binding of CD14 on
monocytes, macrophages, and neutrophils mediates cytokine
secretion (Wright et al., 1990; Weinstein et al., 1993). CD14, one of
25
the major receptors for P. gingivalis LPS (Shapira et al., 1994), is

down-regulated by IL-4 (Lauener et al., 1990), and Ishikawa et al.
(1997) have suggested that IL-4 may play a major role in the antiinflammatory effects of LPS-stimulated monocytes by downregulating CD14 and cytokine secretion by IL-4. Due to reports
demonstrating an absence of IL-4-producing T-cells in periodontitis lesions, Shapira et al. (1992) suggest that a lack of down-regulation of monocytes by IL-4 leads to tissue destruction. In support of this hypothesis, gingival macrophages have been shown
to express high levels of IL-4 receptor mRNA compared with
peripheral blood monocytes, and when incubated with recombinant IL-4, cell viability was reduced as a result of apoptosis. IL4 may therefore inhibit the persistence of macrophages in periodontitis, which could lead to decreased tissue destruction
(Yamamoto et al., 1996). However, IL-13 has biological activities
similar to those of IL-4, and since IL-13 expression has been
demonstrated in periodontitis lesions (Fujihashi et al., 1996;
Yamazaki et al., 1997), it is possible that it may substitute for IL4 in periodontitis.
Overall, this hypothesis is not consistent with the observation that relatively few macrophages are present in those
advanced lesions showing the most tissue destruction (Chapple
et al., 1998). If this hypothesis was correct, one would reasonably expect to find the most numbers of macrophages where the
tissue destruction was greatest. The lack of macrophages in
these advanced lesions, however, is consistent with the presence of IL-4 (and/or IL-13) and hence of a Th2 response. The
source of IL-1 remains to be determined, but again, B-cells
would seem to be implicated (Gemmell and Seymour, 1998).
Controversy #5: Th1 cells are associated with the stable
lesion, while Th2 cells are associated with the progressive
lesion in humans.
(V) Animal Models

Investigators have used animal models to try to obtain a clearer picture of the pathogenesis of periodontal disease, which can
often be obscured in studies on humans because of the difficulty in diagnosing susceptible and non-susceptible individuals, of determining disease activity, and because of the different
bacterial complexes involved in different people. Animal
model studies have provided important information toward
building a picture of periodontopathic bacteria-mediated
response, particularly the responses to P. gingivalis and A. actinomycetemcomitans, but their extrapolation to human disease
always remains speculative.
Several investigators have reported on the effects of immunization of non-human primates with P. gingivalis. Anderson et
al. (1995) demonstrated the production of an antibody response
which enhanced neutrophil phagocytosis of P. gingivalis.
However, an enormous variability in the functional capacity of
the serum samples was noted, suggesting that antibody function may be a poor predictor of susceptibility to disease.
Another study using Macaca fascicularis demonstrated inhibition of the progression of periodontal tissue destruction
(Persson et al., 1994). Immunization with a purified P. gingivalis
cysteine protease induced a significantly elevated specific IgG
response and fewer alveolar bone density changes compared
with sham-immunized control animals (Moritz et al., 1998).
However, immunization of these animals with combined P.
gingivalis and Prevotella intermedia resulted in significantly
greater bone density loss in ligated teeth compared with control animals, so that mixed-bacterial immunization resulted in
26
increased disease (Ebersole et al., 1991). This model has also

shown that on the induction of experimental disease, the front
of inflammatory cells progresses toward alveolar bone, with
associated osteoclast formation (Graves et al., 1998). When IL-1
and TNF-a activity was blocked by local injection of soluble
receptors to these cytokines, the progression of the inflammatory cells was inhibited, suggesting that this activity was at
least partly dependent on IL-1 and/or TNF-a.
Rodent models have been used extensively to study the
immune responses to periodontopathic bacteria or their products, including LPS. Early studies demonstrated that LPS from P.
gingivalis strains induced marked mitogenic responses and polyclonal B-cell activation in spleen cells, activated both neutrophils
and macrophages, and enhanced IL-1 production by murine
peritoneal macrophages (Fujiwara et al., 1988; Isogai et al., 1988).
However, Kesavalu et al. (1992) found that immunization with
whole cells or LPS of P. gingivalis provided no protection against
the lethal effects after challenge with LPS. Additionally, Chen et
al. (1990) demonstrated that immunization of mice with P. gingivalis LPS did not result in readily detectable IgG or IgM levels to
LPS, nor did it reduce the severity of P. gingivalis infection. Taken
together, these results suggest that responses to LPS may not be
protective, and that a response to these antigens may not prevent
progression of disease.
Immunization with whole cells of P. gingivalis, on the other
hand, has been shown to elicit protection in the form of faster
healing of lesions and production of specific antibodies (Chen et
al., 1990; Genco et al., 1992; Kesavalu et al., 1992). Kesavalu et al.
(1992) demonstrated that this protection was primarily due to
opsonic antibodies, resulting in phagocytic destruction of virulence components. Using 4 strains of inbred mice, Gemmell et al.
(2000b) demonstrated that anti-P. gingivalis antibody levels correlated with lesion recovery after challenge with P. gingivalis.
Synthetic peptides of P. gingivalis fimbriae have been reported to induce both Th1 and Th2 cytokines in vitro with the use of
in vivo primed mouse T-cells (Deslauriers et al., 1996). Further,
mice immunized with recombinant fimbrillin and 2 synthetic
peptides induced specific antibodies to fimbrillin, and immunization with one of the peptides, PgF-P8, protected against a
lethal injection of P. gingivalis, although the degree of protection
depended on the time of immunization before challenge.
However, no correlation could be found between protection and
in vivo local cytokine production, specific antibody levels, or the
isotype of the anti-PgF-p8 antibodies produced (Deslauriers et al.,
1996).
Responses of mice to co-infection have been reported.
Mice infected with P. gingivalis together with F. nucleatum had
significantly greater skin lesions than those infected with P. gingivalis alone, while active immunization with P. gingivalis protected against challenge with both organisms (Ebersole et al.,
1997). Protection in this study correlated with levels of specific
serum antibodies. Chen et al. (1996) reported that immunization of A. actinomycetemcomitans together with P. gingivalis
resulted in first- and second-degree lesions compared with
first-degree lesions only, which followed immunization with A.
actinomycetemcomitans alone. The serum anti-P. gingivalis
response was higher in mice injected with both organisms than
in P. gingivalis-only-injected mice, although this was not
observed with the anti-A. actinomycetemcomitans antibody
response. As previously mentioned, Choi et al. (2000) have
shown that immunization with F. nucleatum followed by challenge with P. gingivalis leads to a polarized Th2 response,
13(1):17-34 (2002)
whereas immunization with P. gingivalis alone leads to a Th1

response. Gemmell et al. (1998) have previously shown a predominant splenic Th1 response with high percentages of IFNg-positive T-cells following immunization with a high dose of
P. gingivalis outer membrane antigens. These studies again
highlight the complex, often synergistic, responses (Ebersole et
al., 1991) with co-infection, which may have relevance to the
multibacterial infection of human periodontal disease.
The influence of T-cells on periodontal bone destruction
induced by endotoxin was reported in a study showing that
repeated injections of Escherichia coli endotoxin into the gingiva
of mice mandibles increased bone resorption in normal as well as
T-cell reconstituted nude mice compared with nude mice (Ukai
et al., 1996). The effects of P. gingivalis were demonstrated by
Baker et al. (1994, 1999), who infected the mouths of immunocompetent mice with P. gingivalis, resulting in increased levels of
specific antibody and significant bone loss. Infected severe combined immunodeficient (SCID) mice (lacking T- and B-cells) also
demonstrated bone loss, although not to the same extent as
immunocompetent mice. These studies support the contention
that tissue destruction and bone loss in periodontal disease are
determined by the lymphocytic infiltrate. In another study, Tcells derived from the spleen or Peyer's patches of normal
Fischer rats after oral inoculation with P. gingivalis were adoptively transferred into nude Fischer rats. After oral challenge
with live organisms, serum and salivary responses were noted in
treated nude rats compared with control rats which did not
receive T-cells, indicating a T-cell-dependent response to P. gingivalis. Splenic and Peyer's patch T-cells induced different responses with higher serum IgG, especially IgG2 induced by the former cells, although salivary IgA responses were similar. Less
horizontal bone loss was seen in rats adoptively transferred with
spleen T-cells. IgG2 responses indicate the involvement of Th1
cells with IgA, the involvement of Th2 cells suggesting that the
balance between these T-cell subsets may determine whether the
reponses are protective against experimental bone loss after oral
challenge to P. gingivalis (Katz and Michalek, 1998).
The role of the immune response to A. actinomycetemcomitans
has also been studied in rats. Taubman et al. (1984b) first showed
that immunization with A. actinomycetemcomitans induced a
delayed-type hypersensitivity reaction with elevated bone loss
compared with sham-immunized rats. Furthermore, athymic
nude rats demonstrated more bone loss than normal littermates,
although bone loss in nude rats reconstituted with thymus cells
was similar to that in control rats. It was concluded that T-cells
can exert protective and/or destructive effects on periodontal
destruction. When cells from an A. actinomycetemcomitans-specific T-cell clone (A3) were adoptively transferred into rats followed
by oral infection with A. actinomycetemcomitans, significantly elevated IgG and IgM antibodies to A. actinomycetemcomitans were
found, and bone loss was significantly lower than in rats which
did not receive the T-cells but were orally infected with the
organisms (Yamashita et al., 1991). In this study, T-cells appeared
to interfere with periodontal bone loss. Recently, gingival injection of A. actinomycetemcomitans was demonstrated to induce
local bone resorption in rats after the transfer of A. actinomycetemcomitans-specific Th1 clone cells but not after the transfer
of Th2 cells (Kawai et al., 2000). The clone cells were retained in
the gingival tissues for up to 3 days. A. actinomycetemcomitans
LPS was required for this bone resorption and for A. actinomycetemcomitans-specific IgG2 production. LPS also elicited the
expression of B7-1 and B7-2 molecules on gingival macrophages.
13(1):17-34 (2002)
The administration of CTLA4Ig, which is a functional antagonist

of CD28/B7 binding, abrogated the bone resorption induced by
Th1 clone cells after challenge with A. actinomycetemcomitans and
LPS. The results suggested that local antigen-specific activation
of Th1-type cells by B7 co-stimulation may trigger inflammatory
bone resorption. The relevance of these findings to human periodontal disease, however, remains to be determined.
(VI) Cell-based Therapy in Periodontal

DiseaseDendritic Cell Vaccines?
If the hypothesis that Th1 cells are associated with the stable
lesion and Th2 cells are associated with the progressive lesion is
true, it would follow that therapies aimed at enhancing a Th1
profile may have some role in the treatment of advanced or even
refractory periodontal disease. In this context, therefore, control
of the Th1/Th2 profile would be fundamental. APC differ in
their abilities to induce activation of different T-cell subsets and
hence the cytokine profiles induced (Sundstrom and Ansari,
1995). Dendritic cells are professional APC which have an extraordinary capacity for initiating primary and secondary T-cell
responses (Steinman, 1991). Immature dendritic cells originate
in the bone marrow and migrate to peripheral non-lymphoid
tissues. Dendritic cells process antigen and can also recruit
leukocytes to the site of inflammation by the production of
chemokines, inflammatory cytokines, and interferons. In the
presence of inflammatory signals such as LPS, IL-1, TNF-a, they
differentiate, and a switch in chemokine receptor expression
allows them to migrate from mucosal surfaces as veiled cells via
the afferent lymph to the draining lymph nodes. During this
process, dendritic cells down-regulate their ability to phagocytose and process antigen and up-regulate MHC class I and II
molecules and the co-stimulatory molecules CD80, CD86, and
CD40 and present antigen to T-cells in the T-cell areas (Pettit and
Thomas, 1999; Rescigno et al., 1999). Activated T-cells in the
lymph nodes may then activate B-cells. Follicular dendritic cells
in the germinal follicles can stimulate memory B-cells which in
turn stimulate further T-cell activity. Memory T-cells travel to
the site of inflammation and can be activated at the peripheral
sites. Memory T-cells can also travel via the afferent lymph back
to the lymph nodes, and B-cells can carry antigen into the nodes
from the circulation (Knight and Stagg, 1993).
T-cells in the gingival tissues are primed/memory cells
(Gemmell et al., 1992; Yamazaki et al., 1993), and in the development of periodontal disease, plaque bacterial antigens are most
likely initially presented to T-cells in the regional lymph nodes,
after which sensitized T-cells home back to the gingival tissues,
where they are further activated (Seymour et al., 1988). Higher
numbers of CD1+ Langerhans cells have been demonstrated in
the epithelium of marginal gingivitis and adult periodontitis
than in healthy tissues (Meng and Zheng, 1990), and increasing
numbers were shown in a 21-day experimental gingivitis study
(Seymour et al., 1988). In this study, adenosine triphosphatase+
cells with a morphology typical of interdigitating dendritic cells
were also demonstrated in the perivascular spaces in close contact with lymphocytes, although approximately four times as
many acid phosphatase+ phagocytic macrophages were present
within the lesions as well as in the subepithelial zones.
Increasing numbers of B-cells express an increasingly activated
phenotype in the progression from gingivitis to periodontitis
(Gemmell and Seymour, 1991), while macrophage numbers do
not increase in advanced periodontitis compared with minimally inflamed tissues (Chapple et al., 1998). The roles of dendritic
27
cells, B-cells, and macrophages as APC in periodontitis have not

yet been elucidated. However, unlike B-cells, macrophages and
dendritic cells both bind antigen by relatively non-specific
mechanisms. Macrophages and dendritic cells may therefore
provide signals that initially activate T-cells, while B-cell antigen presentation may allow for further activation and clonal
expansion of these already-activated cells.
Non-professional APC may initiate secondary immune
responses after the induction of MHC class II molecules by
cytokines such as IFN-g (Nickoloff and Turka, 1994). Gingival keratinocytes contribute to periodontal disease progression by the
secretion of several pro-inflammatory cytokines, including IL-1,
IL-6, and IL-8, and the expression of adhesion molecules, which
aid in the influx of leukocytes into the gingival sulcus. Epithelial
tissues act as physical barriers to the outside environment; however, unlike normal plaque flora, the periodontopathogens P. gingivalis and A. actinomycetemcomitans can disrupt the gingival
epithelial barrier by adhering to and invading epithelial cells and
even the connective tissues in diseased sites (Sandros et al., 1993;
Fives-Taylor et al., 1995), highlighting the possibility of antigen
presentation of P. gingivalis and A. actinomycetemcomitans antigens
by gingival keratinocytes (Saglie et al., 1988). Keratinocytes function as accessory cells by activating T-cells via the TCR/CD3 complex, and this involves signals by the adhesion molecules ICAM1 (CD54) on the keratinocyte and LFA-1 (CD11a) on the T-cell
(Nickoloff et al., 1993). Approximately 50% of cells in the infiltrates
of periodontal lesions have been shown to be LFA-1+ while keratinocytes in inflamed gingiva express HLA-DR, ICAM-1, and
LECAM-1 (CD62L) (Gemmell et al., 1994). As well as keratinocytes, other resident cells such as activated endothelial cells
and fibroblasts may also play a role in antigen presentation in
periodontitis lesions.
Suchett-Kaye et al. (1998) have suggested that T-cells in the
progressive lesion may respond to a wider range of APC,
including gingival keratinocytes, leading to dysregulation of
the T-cell response, particularly cell-mediated immunity, as
well as favoring non-protective polyclonal B-cell responses. In
the study alluded to earlier, peripheral blood mononuclear
cells were used as APC to present P. gingivalis antigens to P. gingivalis-specific T-cells, resulting in highly varied profiles, due
possibly to presentation by dendritic cells and/or monocytes
and/or B-cells (Gemmell et al., 1999). While these results were
inconclusive, we have recently been able to demonstrate that
when these same lines were presented with P. gingivalis antigens by autologous EBV-transformed B-cells (LCL), the
cytokine profiles were predominantly IL-4+, with lower numbers of IFN-g+ T-cells and very few IL-10+ T-cells, and these
profiles were constant for every T-cell line. These results
strongly suggest a central role for APC in periodontal disease.
While the function of different APC in periodontitis is
mostly purely speculative, Cutler et al. (1999) have recently put
forward a hypothesis on dendritic cells and P. gingivalis based
on their observations of in vivo and in vitro events. P. gingivalis
was identified in the epithelium and connective tissues of gingival sections from periodontitis subjects, and double immunofluorescence showed an association between P. gingivalis and
immature CD1a+ Langerhans cells in the epithelium. Immature
dendritic cells appeared to be limited to the epithelium, whereas mature dendritic cells were restricted to the connective tissue. It was hypothesized that immature dendritic cells could be
exposed to P. gingivalis, resulting in their activation/maturation
and movement into the connective tissue. In vitro evidence that
28
dendritic cells internalize P. gingivalis was demonstrated. As

well, maturation of the dendritic cells was shown by increased
expression of co-stimulatory molecules, CD83 and HLA-DR.
Sensitized dendritic cells were also able to stimulate T-cells to
proliferate in a dose-dependent manner. P. gingivalis sensitization of dendritic cells was further hypothesized to occur in
advanced gingivitis or early active periodontitis, followed by
the homing of P. gingivalis-specific effector T-cells with persistent P. gingivalis infection in severe periodontitis.
In the future, appropriate APC may be used to modulate
the immune response to induce protective responses in susceptible people. The use of dendritic cells as a powerful tool for
manipulating the immune system is currently being examined
in several areas. In particular, dendritic cells have been shown
to be potent immunotherapeutic agents when pulsed with
tumor-associated antigens, and trials based on their use as an
effective anti-cancer treatment (Hart, 1997) are currently being
conducted. Whether dendritic cells pulsed with protective antigens of periodontopathic bacteria will be an appropriate form
of treatment has yet to be determined.
(VII) Conclusion
This review, as part of the "Controversy" series, has highlighted several controversial issues related to our current knowledge of the pathogenesis of periodontal disease. The review is
intended to be provocative, to stimulate debate, and, importantly, to stimulate further research. In a true Popperian sense,
science advances by the formation of models or hypotheses
and by experiments being designed to disprove these hypotheses. In this context, if this review stimulates further research, it
will have achieved its aim.
REFERENCES
Anderson DM, Ebersole JL, Novak MJ (1995). Functional properties of nonhuman primate antibody to Porphyromonas gingivalis.
Infect Immun 63:3245-3252.
Aoyagi T, Sugawara-Aoyagi M, Yamazaki K, Hara K (1995).
Interleukin 4 (IL-4) and IL-6-producing memory T-cells in
peripheral blood and gingival tissues in periodontitis patients
with high serum antibody titers to Porphyromonas gingivalis.
Oral Microbiol Immunol 10:304-310.
Ashkenazi M, White RR, Dennison DK (1992a). Neutrophil modulation by Actinobacillus actinomycetemcomitans. I. Chemotaxis,
surface receptor expression and F-actin polymerization. J
Periodontal Res 27(4 Pt 1):264-273.
Ashkenazi M, White RR, Dennison DK (1992b). Neutrophil modulation by Actinobacillus actinomycetemcomitans. II. Phagocytosis and development of respiratory burst. J Periodontal Res
27:457-465.
Attstrm R, Schroeder HE (1979). Effect of experimental neutropenia on initial gingivitis in dogs. Scand J Dent Res 87:7-23.
Baker PJ, Wilson ME (1989). Opsonic IgG antibody against
Actinobacillus actinomycetemcomitans in localized juvenile periodontitis. Oral Microbiol Immunol 4:98-105.
Baker PJ, Evans RT, Roopenian DC (1994). Oral infection with
Porphyromonas gingivalis and induced alveolar bone loss in
immunocompetent and severe combined immunodeficient
mice. Arch Oral Biol 39:1035-1040.
Baker PJ, Dixon M, Evans RT, Dufour L, Johnson E, Roopenian DC
(1999). CD4(+) T cells and the proinflammatory cytokines
gamma interferon and interleukin-6 contribute to alveolar bone
loss in mice. Infect Immun 67:2804-2809.
13(1):17-34 (2002)
Baranowska HI, Palmer RM, Wilson RF (1989). A comparison of

antibody levels to Bacteroides gingivalis in serum and crevicular
fluid from patients with untreated periodontitis. Oral Microbiol
Immunol 4:173-175.
Bick PH, Carpenter AB, Holdeman LV, Miller GA, Ranney RR,
Palcanis KG, et al. (1981). Polyclonal B-cell activation induced
by extracts of Gram-negative bacteria isolated from periodontally diseased sites. Infect Immun 34:43-49.
Bird PS, Gemmell E, Polak B, Paton RG, Sosroseno W, Seymour GJ
(1995). Protective immunity to Porphyromonas gingivalis infection in a murine model. J Periodontol 66:351-362.
Boyatzis S, Seymour GJ (1986). Effect of age and periodontal disease status in man on the spontaneous proliferation of peripheral blood lymphocytes. Arch Oral Biol 31:749-755.
Brandtzaeg P, Kraus FW (1965). Autoimmunity and periodontal
disease. Odontology 73:285-393.
Bredius RG, Derkx BH, Fijen CA, de-Wit TP, de Haas M, Weening
RS, et al. (1994). Fc gamma receptor IIa (CD32) polymorphism
in fulminant meningococcal septic shock in children. J Infect Dis
170:848-853.
Califano JV, Schenkein HA, Tew JG (1991). Immunodominant antigens of Actinobacillus actinomycetemcomitans serotypes a and c in
high-responder patients. Oral Microbiol Immunol 6:228-235.
Califano JV, Schenkein HA, Tew JG (1992). Immunodominant antigens of Actinobacillus actinomycetemcomitans serotype b in earlyonset periodontitis patients. Oral Microbiol Immunol 7:65-70.
Carpenter AB, Sully EC, Ranney RR, Bick PH (1984). T-cell regulation of polyclonal B cell activation induced by extracts of oral
bacteria associated with periodontal diseases. Infect Immun
43:326-336.
Chapple CC, Srivastava M, Hunter N (1998). Failure of
macrophage activation in destructive periodontal disease. J
Pathol 186:281-286.
Chen PB, Davern LB, Schifferle R, Zambon JJ (1990). Protective
immunization against experimental Bacteroides (Porphyromonas)
gingivalis infection. Infect Immun 58:3394-3400.
Chen PB, Davern LB, Katz J, Eldridge JH, Michalek SM (1996). Host
responses induced by Porphyromonas gingivalis and
Actinobacillus actinomycetemcomitans in a murine model. Oral
Microbiol Immunol 11:274-281.
Choi JI, Borrello MA, Smith ES, Zauderer M (2000). Polarization of
Porphyromonas gingivalis-specific helper T-cell subsets by prior
immunization with Fusobacterium nucleatum. Oral Microbiol
Immunol 15:181-187.
Clagget JA, Page RC (1978). Insoluble immune complexes and
chronic periodontal diseases in man and the dog. Arch Oral Biol
23:153-165.
Cohen DW, Morris AL (1961). Periodontal manifestation of cyclic
neutropenia. J Periodontol 32:159-168.
Cole KC, Seymour GJ, Powell RN (1987). Phenotypic and functional analysis of T cells extracted from chronically inflamed human
periodontal tissues. J Periodontol 58:569-573.
Corcoran ML, Stetler-Stevenson WG, Brown PD, Wahl LM (1992).
Interleukin 4 inhibition of prostaglandin E2 synthesis blocks
interstitial collagenase and 92-kDa type IV collagenase/gelatinase production by human monocytes. J Biol Chem 267:515-519.
Cullinan MP, Westerman B, Hamlet SM, Palmer JE, Faddy MJ, Lang
NP, et al. (2001). A longitudinal study of interleukin-1 gene polymorphisms and periodontal disease in a general adult population. J Clin Periodontol 28:1137-1144.
Curtis MA, Slaney JM, Carman RJ, Johnson NW (1991). Identification
of the major surface protein antigens of Porphyromonas gingivalis
using IgG antibody reactivity of periodontal case-control serum.
Cutler CW, Kalmar JR, Arnold RR (1991). Phagocytosis of virulent
13(1):17-34 (2002)
Porphyromonas gingivalis by human polymorphonuclear leukocytes requires specific immunoglobulin G. Infect Immun
59:2097-2104.
Cutler CW, Arnold RR, Schenkein HA (1993). Inhibition of C3 and
IgG proteolysis enhances phagocytosis of Porphyromonas gingivalis. J Immunol 151:7016-7029.
Cutler CW, Jotwani R, Palucka KA, Davoust J, Bell D, Banchereau J
(1999). Evidence and a novel hypothesis for the role of dendritic cells and Porphyromonas gingivalis in adult periodontitis. J
Periodontal Res 34:406-412.
Darveau RP, Cunningham MD, Bailey T, Seachord C, Ratcliffe K,
Bainbridge B, et al. (1995). Ability of bacteria associated with
chronic inflammatory disease to stimulate E-selectin expression
and promote neutrophil adhesion. Infect Immun 63:1311-1317.
Darveau RP, Tanner A, Page RC (1997). The microbial challenge in
periodontitis. Periodontol 200014:12-32.
Del Prete G, De Carli M, Almerigogna F, Giudizi MG, Biagiotti R,
Romagnani S (1993). Human IL-10 is produced by both Type 1
helper (Th1) and Type 2 helper (Th2) T cell clones and inhibits
their antigen-specific proliferation and cytokine production. J
Immunol 150:353-360.
Dennison DK, Van Dyke TE (1997). The acute inflammatory
response and the role of phagocytic cells in periodontal health
and disease. Periodontol 2000 14:54-78.
Deslauriers M, Haque S, Flood PM (1996). Identification of murine
protective epitopes on the Porphyromonas gingivalis fimbrillin
molecule. Infect Immun 64:434-440.
Donaldson SL, Ranney RR, Burmeister JA, Tew JG (1982).
Blastogenic responses by lymphocytes from periodontally
healthy populations induced by periodontitis-associated bacteria. J Periodontol 53:743-751.
Donaldson SL, Ranney RR, Tew JG (1984). B-lymphocyte blastogenesis in response to periodontitis-associated bacteria. Kinetics
and proportion of total response. J Periodontol 55:359-363.
Ebersole JL, Taubman MA (1994). The protective nature of host
responses in periodontal diseases. Periodontol 2000 5:112-141.
Ebersole JL, Brunsvold M, Steffensen B, Wood R, Holt SC (1991).
Effects of immunization with Porphyromonas gingivalis and
Prevotella intermedia on progression of ligature-induced periodontitis in the nonhuman primate Macaca fascicularis. Infect
Immun 59:3351-3359.
Ebersole JL, Cappelli D, Sandoval MN (1994). Subgingival distribution of A. actinomycetemcomitans in periodontitis. J Clin
Periodontol 21:65-75.
Ebersole JL, Cappelli D, Sandoval MN, Steffen MJ (1995). Antigen
specificity of serum antibody in A. actinomycetemcomitansinfected periodontitis patients. J Dent Res 74:658-666.
Ebersole JL, Feuille F, Kesavalu L, Holt SC (1997). Host modulation
of tissue destruction caused by periodontopathogens: effects on
a mixed microbial infection composed of Porphyromonas gingivalis and Fusobacterium nucleatum. Microb Pathog 23:23-32.
Engebretson SP, Lamster IB, Herrera-Abreu M, Celenti RS, Timms
JM, Chaudhary AG, et al. (1999). The influence of interleukin
gene polymorphism on expression of interleukin-1beta and
tumor necrosis factor-alpha in periodontal tissue and gingival
crevicular fluid. J Periodontol 70:567-573.
Engstrm PE, Larsson A, Norhagen G, Smith CI, Sallberg M,
Helgeland K, et al. (1993). Specificity and levels of oral and systemic antibodies to Actinobacillus actinomycetemcomitans. J Clin
Engstrm PE, George M, Larsson P, Lally ET, Taichman NS,
Norhagen G (1999). Oral and systemic immunoglobulin G-subclass antibodies to Actinobacillus actinomycetemcomitans leukotoxin. Oral Microbiol Immunol 14:104-108.
Essner R, Rhoades K, McBride WH, Morton DL, Economou JS
29
(1989). IL-4 down-regulates IL-1 and TNF gene expression in

human monocytes. J Immunol 142:3857-3861.
Evans RI, Mikulecky M, Seymour GJ (1989). Effect of initial treatment of chronic inflammatory periodontal disease in adults on
spontaneous peripheral blood lymphocyte proliferation. J Clin
Faddy MJ, Cullinan MP, Palmer JE, Westerman B, Seymour GJ
(2000). Ante-dependence modeling in a longitudinal study of
periodontal disease: the effect of age, gender and smoking status. J Periodontol 71:454-459.
Fives-Taylor P, Meyer D, Mintz K (1995). Characteristics of
Actinobacillus actinomycetemcomitans invasion of and adhesion
to cultured epithelial cells. Adv Dent Res 9:55-62.
Fujihashi K, Kono Y, Yamamoto M, McGhee JR, Beagley K, Aicher
WK, et al. (1991). Interleukin production by gingival mononuclear cells isolated from adult periodontitis patients (abstract). J
Dent Res 70(Spec Iss):550.
Fujihashi K, Yamamoto M, McGhee JR, Kiyono H (1994). Type
1/Type 2 cytokine production by CD4+ T cells in adult periodontitis (abstract). J Dent Res 73(Spec Iss):204.
Fujihashi K, Yamamoto M, Hiroi T, Bamberg TV, McGhee JR,
Kiyono H (1996). Selected Th1 and Th2 cytokine mRNA expression by CD4(+) T cells isolated from inflamed human gingival
tissues. Clin Exp Immunol 103:422-428.
Fujiwara T, Nishihara T, Koga T, Hamada S (1988). Serological
properties and immunobiological activities of lipopolysaccharides from black-pigmented and related oral Bacteroides
species. J Gen Microbiol 134(Pt 11):2867-2876.
Galbraith GM, Steed RB, Sanders JJ, Pandey JP (1998). Tumor
necrosis factor alpha production by oral leukocytes: influence
of tumor necrosis factor genotype. J Periodontol 69:428-433.
Gemmell E, Seymour GJ (1991). Phenotypic analysis of B-cells
extracted from human periodontal disease tissue. Oral Microbiol
Immunol 6:356-362.
Gemmell E, Seymour GJ (1992). Different responses in B cells
induced by Porphyromonas gingivalis and Fusobacterium nucleatum. Arch Oral Biol 37:565-573.
Gemmell E, Seymour GJ (1994). Modulation of immune responses
to periodontal bacteria. Curr Opin Periodont 94:28-38.
Gemmell E, Seymour GJ (1998). Cytokine profiles of cells extracted
from humans with periodontal diseases. J Dent Res 77:16-26.
Gemmell E, Feldner B, Seymour GJ (1992). CD45RA and CD45RO
positive CD4 cells in human peripheral blood and periodontal
disease tissue before and after stimulation with periodontopathic bacteria. Oral Microbiol Immunol 7:84-88.
Gemmell E, Walsh LJ, Savage NW, Seymour GJ (1994). Adhesion
molecule expression in chronic inflammatory periodontal disease tissue. J Periodontal Res 29:46-53.
Gemmell E, Kjeldsen M, Yamazaki K, Nakajima T, Aldred MJ,
Seymour GJ (1995). Cytokine profiles of Porphyromonas gingivalis-reactive T lymphocyte line and clones derived from P. gingivalis-infected subjects. Oral Dis 1:139-146.
Gemmell E, Winning TA, Bird PS, Seymour GJ (1998). Cytokine
profiles of lesional and splenic T cells in Porphyromonas gingivalis infection in a murine model. J Periodontol 69:1131-1138.
Gemmell E, Grieco DA, Cullinan MP, Westerman B, Seymour GJ
(1999). The proportion of interleukin-4, interferon-10-positive
cells in Porphyromonas gingivalis-specific T-cell lines established
from P. gingivalis-positive subjects. Oral Microbiol Immunol
14:267-274.
Gemmell E, Grieco DA, Seymour GJ (2000a). Chemokine expression in Porphyromonas gingivalis-specific T-cell lines. Oral
Gemmell E, Winning TA, Grieco DA, Bird PS, Seymour GJ (2000b).
The influence of genetic variation on the splenic T cell cytokine
30
and specific serum antibody responses in Porphyromonas gingivalis in mice. J Periodontol 71:1130-1138
Genco CA, Cutler CW, Kapczynski D, Maloney K, Arnold RR
(1992). A novel mouse model to study the virulence of and host
response to Porphyromonas (Bacteroides) gingivalis. Infect Immun
59:1255-1263.
Gmr R, Hrodek K, Saxer UP, Guggenheim B (1986). Double-blind
analysis of the relation between adult periodontitis and systemic host response to suspected periodontal pathogens. Infect
Immun 52:768-776.
Gore EA, Sanders JJ, Pandey JP, Palesch Y, Galbraith GM (1998).
Interleukin-1beta+3953 allele 2: association with disease status
in adult periodontitis. J Clin Periodontol 25:781-785.
Graves DT, Delima AJ, Assuma R, Amar S, Oates T, Cochran D
(1998). Interleukin-1 and tumor necrosis factor antagonists
inhibit the progression of inflammatory cell infiltration toward
alveolar bone in experimental periodontitis. J Periodontol
69:1419-1425.
Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG, Machtei EE,
et al. (1994). Assessment of risk for periodontal disease. I. Risk
indicators for attachment loss. J Periodontol 65:260-267.
Grossi SG, Genco RJ, Machtei EE, Ho AW, Koch G, Dunford R, et al.
E (1995). Assessment of risk for periodontal disease. II. Risk
indicators for alveolar bone loss. J Periodontol 66:23-29.
Grossi SG, Skrepcinski FB, DeCaro T, Zambon JJ, Cummins D,
Genco RJ (1996). Response to periodontal therapy in diabetics
and smokers. J Periodontol 67(Suppl 10):1094-1102.
Hamilton RE Jr, Giansanti JS (1974). The Chediak-Higashi syndrome. Report of a case and review of the literature. Oral Surg
Oral Med Oral Pathol 37:754-761.
Hart DN (1997). Dendritic cells: unique leukocyte populations
which control the primary immune response. Blood 90:32453287.
Hemmerle J, Frank RM (1991). Bacterial invasion of periodontal
tissues after experimental immunosuppression in rats. J Biol
Buccale 19:271-282.
Hirsch HZ, Tarkowski A, Miller EJ, Gay S, Koopman WJ, Mestecky
J (1988). Autoimmunity to collagen in adult periodontal disease. J Oral Pathol 17:456-459.
Hotokezaka H, Hayashida H, Ohara N, Nomaguchi H, Kobayashi
K, Yamada T (1994). Cloning and sequencing of the groEL
homologue from Porphyromonas gingivalis. Biochim Biophys Acta
1219:175-178.
Inada K, Yoshida M, Sasaki O, Suzuki M, Yoshida H, Okuda K, et
al. (1994). Polyclonal B cell activation, endotoxin tolerance, and
limulus tests of endotoxin preparations of some periodontopathogens. Bull Tokyo Dent Coll 35:67-78.
Ishikawa I, Nakashima K, Koseki T, Nagasawa T, Watanabe H,
Arakawa S, et al. (1997). Induction of the immune response to
periodontopathic bacteria and its role in the pathogenesis of
periodontitis. Periodontol 2000 14:79-111.
Isogai H, Isogai E, Fujii N, Oguma K, Kagota W, Takano K (1988).
Histological changes and some in vitro biological activities
induced by lipopolysaccharide from Bacteroides gingivalis.
Zentralbl Bakteriol Mikrobiol Hyg A 269:64-77.
Ito H, Harada Y, Matsuo T, Ebisu S, Okada H (1988). 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. J Periodontal Res
23:39-45.
Ivanyi L, Lehner T (1970). Stimulation of lymphocyte transformation by bacterial antigens in patients with periodontal disease.
Arch Oral Biol 15:1089-1096.
Karatzas S, Novak MJ, Blieden TM (1996). Cytokine production by
Porphyromonas gingivalis-specific human T cells (abstract). J
13(1):17-34 (2002)

Katz J, Michalek SM (1998). Effect of immune T cells derived from
mucosal or systemic tissue on host responses to Porphyromonas
gingivalis. Oral Microbiol Immunol 13:73-80.
Kawai T, Eisen-Lev R, Seki M, Eastcott JW, Wilson ME, Taubman
MA (2000). Requirement of B7 costimulation for Th1-mediated
inflammatory bone resorption in experimental periodontal disease. J Immunol 164:2102-2109.
Kesavalu L, Ebersole JL, Machen RL, Holt SC (1992). Porphyromonas
gingivalis virulence in mice: induction of immunity to bacterial
components. Infect Immun 60:1455-1464.
Kinane DF, Mooney J, MacFarlane TW, McDonald M (1993). Local
and systemic antibody response to putative periodontopathogens in patients with chronic periodontitis: correlation
with clinical indices. Oral Microbiol Immunol 8:65-68.
Knight SC, Stagg AJ (1993). Antigen-presenting cell types. Curr
Opin Immunol 5:374-382.
Kornman KS, Crane A, Wang HY, di Giovine FS, Newman MG,
Pirk FW, et al. (1997). The interleukin-1 genotype as a severity
factor in adult periodontal disease. J Clin Periodontol 24:72-77.
Kurihara H, Nishimura F, Nakamura T, Nakagawa M, Tanimoto I,
Nomura Y, et al. (1991). Humoral immune response to an antigen from Porphyromonas gingivalis 381 in periodontal disease.
Lamster IB, Kaluszhner-Shapira I, Herrera-Abreu M, Sinha R, Grbic
JT (1998). Serum IgG antibody response to Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis: implications for
periodontal diagnosis. J Clin Periodontol 25:510-516.
Lauener RP, Goyert SM, Geha RS, Vercelli D (1990). Interleukin 4
down-regulates the expression of CD14 in normal human
monocytes. Eur J Immunol 20:2375-2381.
Lindhe J, Liljenberg B, Listgarten M (1980). Some microbiological
and histopathological features of periodontal disease in man. J
Ling TY, Sims TJ, Chen HA, Whitney CW, Moncla BJ, Engel LD, et
al. (1993). Titer and subclass distribution of serum IgG antibody
reactive with Actinobacillus actinomycetemcomitans in localized
juvenile periodontitis. J Clin Immunol 13:101-112.
Lloyd AR, Oppenheim JJ (1992). Poly's lament: the neglected role of
the polymorphonuclear neutrophil in the afferent limb of the
immune response. Immunol Today 13:169-172.
Lopatin DE, Blackburn E (1992). Avidity and titer of immunoglobulin G subclasses to Porphyromonas gingivalis in adult periodontitis patients. Oral Microbiol Immunol 7:332-337.
Lourbakos A, Chinni C, Thompson P, Potempa J, Travis J, Mackie
EJ, et al. (1998). Cleavage and activation of proteinase-activated
receptor-2 on human neutrophils by gingipain-R from
Porphyromonas gingivalis. FEBS Lett 435:45-48.
Lynn WA, Golenbock DT (1992). Lipopolysaccharide antagonists.
Immunol Today 13:271-276.
MacFarlane GD, Herzberg MC, Wolff LF, Hardie NA (1992).
Refractory periodontitis associated with abnormal polymorphonuclear leukocyte phagocytosis and cigarette smoking. J
Mackler BF, Frostad KB, Robertson PB, Levy BM (1977).
Immunoglobulin bearing lymphocytes and plasma cells in
human periodontal disease. J Periodontal Res 12:37-45.
Madianos PN, Papapanou PN, Sandros J (1997). Porphyromonas gingivalis infection of oral epithelium inhibits neutrophil transepithelial migration. Infect Immun 65:3983-3990.
Maeda H, Miyamoto M, Hongyo H, Nagai A, Kurihara H,
Murayama Y (1994). Heat shock protein 60 (GroEL) from
Porphyromonas gingivalis: molecular cloning and sequence
analysis of its gene and purification of the recombinant protein.
FEMS Microbiol Lett 119:129-136.
13(1):17-34 (2002)
Mahanonda R, Seymour GJ, Powell LW, Good MF, Halliday JW

(1991). Effect of initial treatment of chronic inflammatory periodontal disease on the frequency of peripheral blood T-lymphocytes specific to periodontopathic bacteria. Oral Microbiol
Immunol 6:221-227.
Mangan DF, Won T, Lopatin DE (1983). Nonspecific induction of
immunoglobulin M antibodies to periodontal disease-associated microorganisms after polyclonal human B-lymphocyte activation by Fusobacterium nucleatum. Infect Immun 41:1038-1045.
Mangan DF, Taichman NS, Lally ET, Wahl SM (1991). Lethal effects
of Actinobacillus actinomycetemcomitans leukotoxin on human T
lymphocytes. Infect Immun 59:3267-3272.
Manhart SS, Reinhardt RA, Payne JB, Seymour GJ, Gemmell E,
Dyer JK, et al. (1994). Gingival cell IL-2 and IL-4 in early-onset
periodontitis. J Periodontol 65:807-813.
Manus RM, Wilson AG, Mansfield J, Weir DG, Duff GW, Kelleher
D (1996). TNF2, a polymorphism of the tumour necrosis-alpha
gene promoter, is a component of the celiac disease major histocompatibility complex haplotype. Eur J Immunol 26:2113-2118.
Marcelletti JF (1996). IL-10 inhibits lipopolysaccharide-induced
murine B cell proliferation and cross-linking of surface antigen
receptors or ligation of CD40 restores the response. J Immunol
157:3323-3333.
McGuire W, Hill AV, Allsopp CE, Greenwood BM, Kwiatkowski D
(1994). Variation in the TNF-alpha promoter region associated
with susceptibility to cerebral malaria. Nature 371:508-510.
Meghji S, Henderson B, Wilson M (1993). Higher-titer antisera from
patients with periodontal disease inhibit bacterial capsuleinduced bone breakdown. J Periodontal Res 28:115-121.
Meghji S, Henderson B, Kirby A, Newman HN, Wilson M (1995).
Serum antibody response to surface-associated material from
periodontopathogenic bacteria. FEMS Immunol Med Microbiol
10:101-108.
Meng-HX, Zheng LF (1990). Langerhans cells in the gingival
epithelium. Chung Hua Kou Chiang Hsueh Tsa Chih 25:146-8,189.
Michalowicz BS (1994). Genetic and heritable risk factors in periodontal disease. J Periodontol 65(Suppl 5):479-488.
Michalowicz BS, Aeppli D, Virag JG, Klump DG, Hinrichs JE, Segal
NL, et al. (1991). Periodontal findings in adult twins. J
Mooney J, Kinane DF (1994). Humoral immune responses to
Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans in adult periodontitis and rapidly progressive periodontitis. Oral Microbiol Immunol 9:321-326.
Mooney J, Kinane DF (1997). Levels of specific immunoglobulin G
to Porphyromonas gingivalis in gingival crevicular fluid are related to site disease status. Oral Microbiol Immunol 12:112-116.
Mooney J, Adonogianaki E, Kinane DF (1993). Relative avidity of
serum antibodies to putative periodontopathogens in periodontal disease. J Periodontal Res 28(6 Pt 1):444-450.
Moritz AJ, Cappelli D, Lantz MS, Holt SC, Ebersole JL (1998).
Immunization with Porphyromonas gingivalis cysteine protease:
effects on experimental gingivitis and ligature-induced periodontitis in Macaca fascicularis. J Periodontol 69:686-697.
Mosmann TR, Coffman RL (1989). TH1 and TH2 cells: different patterns of lymphokine secretion lead to different functional properties. Ann Rev Immunol 7:145-173.
Nakagawa S, Machida Y, Nakagawa T, Fujii H, Yamada S, Takazoe
I, et al. (1994). Infection by Porphyromonas gingivalis and
Actinobacillus actinomycetemcomitans, and antibody responses at
different ages in humans. J Periodontal Res 29:9-16.
Nakajima T, Yamazaki K, Cullinan MP, Gemmell E, Seymour GJ
(1999). T-cell antigen specificity in humans following stimulation
with Porphyromonas gingivalis. Arch Oral Biol 44:1045-1053.
Nakano Y, Inai Y, Yamashita Y, Nagaoka S, Kusuzaki Nagira T,
31
Nishihara T, et al. (1995). Molecular and immunological characterization of a 64-kDa protein of Actinobacillus actinomycetemcomitans. Oral Microbiol Immunol 10:151-159.
Nickoloff BJ, Turka LA (1994). Immunological functions of nonprofessional antigen-presenting cells: new insights from studies of T-cell interactions with keratinocytes. Immunol Today
15:464-469.
Nickoloff BJ, Mitra RS, Green J, Zheng XG, Shimizu Y, Thompson
C, et al. (1993). Accessory cell function of keratinocytes for
superantigens. Dependence on lymphocyte function-associated antigen-1/intercellular adhesion molecule-1 interaction. J
Immunol 150:2148-2159.
Offenbacher S (1996). Periodontal diseases: pathogenesis. Ann
Okada H, Ito H, Harada Y (1987). T-cell requirement for establishment of the IgG-dominant B-cell lesion in periodontitis. J
Okada H, Shimabukuro Y, Kassai Y, Ito H, Matsuo T, Ebisu S, et al.
(1988). The function of gingival lymphocytes on the establishment of human periodontitis. Adv Dent Res 2:364-367.
Oldstone MBA (1987). Molecular mimicry and autoimmune disease. Cell 50:819-820.
Oshikiri K, Kawamura I, Hara K, Mitsuyama M (1994). Specific
immune response to the 40-kDa outer-membrane protein of
Porphyromonas gingivalis in mice. Arch Oral Biol 39:707-713.
Page RC, Schroeder HE (1976). Pathogenesis of inflammatory
periodontal disease. A summary of current work. Lab Invest
34:235-249.
Page RC, Offenbacher S, Schroeder HE, Seymour GJ, Kornman KS
(1997). Advances in the pathogenesis of periodontitis: summary of developments, clinical implication and future directions.
Periodontol 2000 14:216-248.
Persson GR, Engel D, Whitney C, Darveau R, Weinberg A,
Brunsvold M, et al. (1994). Immunization against Porphyromonas
gingivalis inhibits progression of experimental periodontitis in
nonhuman primates. Infect Immun 62:1026-1031.
Pettit AR, Thomas R (1999). Dendritic cells: the driving force
behind autoimmunity in rheumatoid arthritis. Immunol Cell Biol
77:420-427.
Pietrzak ER, Polak B, Walsh LJ, Savage NW, Seymour GJ (1998).
Characterization of serum antibodies to Porphyromonas gingivalis in individuals with and without periodontitis. Oral
Pilon M, Williams-Miller C, Cox DS (1991). Interleukin-2 levels in
gingival crevicular fluid in periodontitis (abstract). J Dent Res
70(Spec Iss):550.
Polak B, Vance JB, Dyer JK, Bird PS, Gemmell E, Reinhardt RA, et
al. (1995). IgG antibody subclass response to Porphyromonas gingivalis outer membrane antigens in gingivitis and adult periodontitis. J Periodontol 66:363-368.
Poulter LW, Seymour GJ, Duke O, Janossy G, Panayi G (1982).
Immunohistological analysis of delayed-type hypersensitivity
in man. Cell Immunol 74:358-369.
Prabhu A, Michalowicz BS, Mathur A (1996). Detection of local and
systemic cytokines in adult periodontitis. J Periodontol 67:515-522.
Reinhardt RA, Bolton RW, McDonald TL, DuBois LM, Kaldahl WB
(1988). In situ lymphocyte subpopulations from active versus
stable periodontal sites. J Periodontol 59:656-670.
Reinhardt RA, McDonald TL, Bolton RW, Dubois LM, Kaldahl WB
(1989). IgG subclasses in gingival crevicular fluid from active
versus stable periodontal sites. J Periodontol 60:44-50.
Rescigno M, Granucci F, Ricciardi-Castagnoli P (1999). Dendritic cells
at the end of the millennium. Immunol Cell Biol 77:404-410.
Saglie FR, Marfany A, Camargo P (1988). Intragingival occurrence
of Actinobacillus actinomycetemcomitans and Bacteroides gingi-
32
valis in active destructive periodontal lesions. J Periodontol

59:259-265.
Saito A, Hosaka Y, Nakagawa T, Seida K, Yamada S, Takazoe I, et al.
(1993). Significance of serum antibody against surface antigens
of Actinobacillus actinomycetemcomitans in patients with adult
periodontitis. Oral Microbiol Immunol 8:146-153.
Salvi GE, Brown CE, Fujihashi K, Kiyono H, Smith FW, Beck JD, et
al. (1998). Inflammatory mediators of the terminal dentition in
adult and early onset periodontitis. J Periodontal Res 33:212-225.
Sanders LA, van de Winkel JG, Rijkers GT, Voorhorst Ogink MM,
de Haas M, Capel PJ, et al. (1994). Fc gamma receptor IIa (CD32)
heterogeneity in patients with recurrent bacterial respiratory
tract infections. J Infect Dis 170:854-861.
Sanders LA, Feldman RG, Voorhorst Ogink MM, de Haas M,
Rijkers GT, Capel PJ, et al. (1995). Human immunoglobulin G
(IgG) Fc receptor IIA (CD32) polymorphism and IgG2-mediated bacterial phagocytosis by neutrophils. Infect Immun
63:73-81.
Sandros J, Papapanou P, Dahln G (1993). Porphyromonas gingivalis
invades oral epithelial cells in vitro. J Periodontal Res 28:219-226.
Schenkein HA (1988). The effect of periodontal proteolytic
Bacteroides species on proteins of the human complement system. J Periodontal Res 23:187-192.
Schenkein HA, Fletcher HM, Bodnar M, Macrina FL (1995).
Increased opsonization of a prtH-defective mutant of
Porphyromonas gingivalis W83 is caused by reduced degradation
of complement-derived opsonins. J Immunol 154:5331-5337.
Schreiber S, Heinig T, Thiele HG, Raedler A (1995).
Immunoregulatory role of interleukin 10 in patients with
inflammatory bowel disease. Gastroenterology 108:1434-1444.
Scott P (1993). Selective differentiation of CD4+ T helper cell subsets. Curr Opin Immunol 5:391-397.
Seymour GJ, Greenspan JS (1979). The phenotypic characterization
of lymphocyte subpopulations in established human periodontal disease. J Periodontal Res 14:39-46.
Seymour GJ, Powell RN, Davies WI (1979). Conversion of a stable
T-cell lesion to a progressive B-cell lesion in the pathogenesis of
chronic inflammatory periodontal disease: an hypothesis. J Clin
Seymour GJ, Powell RN, Aitken JF (1983). Experimental gingivitis
in humans. A clinical and histologic investigation. J Periodontol
54:522-528.
Seymour GJ, Gemmell E, Walsh LJ, Powell RN (1988).
Immunohistological analysis of experimental gingivitis in
humans. Clin Exp Immunol 71:132-137.
Seymour GJ, Gemmell E, Reinhardt RA, Eastcott J, Taubman MA
(1993). Immunopathogenesis of chronic inflammatory periodontal disease: cellular and molecular mechanisms. J
Shapira L, van Dyke TE, Hart TC (1992). A localized absence of
interleukin-4 triggers periodontal disease activity: a novel
hypothesis. Med Hypotheses 39:319-322.
Shapira L, Takashiba S, Amar S, Van Dyke TE (1994).
Porphyromonas gingivalis lipopolysaccharide stimulation of
human monocytes: dependence on serum and CD14 receptor.
Shenker BJ, Slots J (1989). Immunomodulatory effects of
Bacteroides products on in vitro human lymphocyte functions.
Shenker BJ, McArthur WP, Tsai CC (1982a). Immune suppression
induced by Actinobacillus actinomycetemcomitans. I. Effects on
human peripheral blood lymphocyte responses to mitogens
and antigens. J Immunol 128:148-154.
Shenker BJ, Tsai CC, Taichman NS (1982b). Suppression of lymphocyte responses by Actinobacillus actinomycetemcomitans. J
13(1):17-34 (2002)

Sigusch B, Klinger G, Glockmann E, Simon HU (1998). Early-onset
and adult periodontitis associated with abnormal cytokine production by activated T lymphocytes. J Periodontol 69:1098-1104.
Slots J (1999). Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis in periodontal disease: introduction. Periodontol
2000 20:7-13.
Springer TA, Thompson WS, Miller LJ, Schmalstieg FC, Anderson
DC (1984). Inherited deficiency of the Mac-1, LFA-1, p150,95 glycoprotein family and its molecular basis. J Exp Med 160:1901-1918.
Stashenko P, Resmini LM, Haffajee AD, Socransky SS (1983). T cell
responses of periodontal disease patients and healthy subjects
to oral microorganisms. J Periodontal Res 18:587-600.
Stein SH, Hendrix CL (1996). Interleukin-10 promotes anti-collagen
antibody production in gingival mononuclear cells (abstract). J
Steinman RM (1991). The dendritic cell system and its role in
immunogenicity. Annu Rev Immunol 9:271-296.
Stoufi ED, Taubman MA, Ebersole JL, Smith DJ, Stashenko PP
(1987). Phenotypic analyses of mononuclear cells recovered
from healthy and diseased human periodontal tissues. J Clin
Immunol 7:235-245.
Suchett-Kaye G, Morrier J-J, Barsotti O (1998). Interactions between
non-immune host cells and the immune system during periodontal disease: role of the gingival keratinocyte. Crit Rev Oral
Biol Med 9:292-305.
Sugawara M, Yamahita K, Yoshie H, Hara K (1992). Detection of,
and anti-collagen antibody produced by, CD5-positive B cells in
inflamed gingival tissues. J Periodontal Res 27:489-498.
Sundqvist GK, Carlsson J, Herrmann BF, Hofling JF, Vaatainen A
(1984). Degradation in vivo of the C3 protein of guinea-pig
complement by a pathogenic strain of Bacteroides gingivalis.
Scand J Dent Res 92:14-24.
Sundstrom JB, Ansari AA (1995). Comparative study of the role of
professional versus semiprofessional or nonprofessional antigen presenting cells in the rejection of vascularized organ allografts. Transpl Immunol 3:273-289.
Tabeta K, Yamazaki K, Hotokezaka H, Yoshie H, Hara K (2000).
Elevated humoral immune response to heat shock protein 60
family in periodontitis patients. Clin Exp Immunol 120:285-293.
Taichman NS, Dean RT, Sanderson CJ (1980). Biochemical and morphological characterization of the killing of human monocytes
by a leukotoxin derived from Actinobacillus actinomycetemcomitans. Infect Immun 28:258-268.
Taichman NS, Iwase M, Lally ET, Shattil SJ, Cunningham ME,
Korchak HM (1991). Early changes in cytosolic calcium and
membrane potential induced by Actinobacillus actinomycetemcomitans leukotoxin in susceptible and resistant target cells. J
Immunol 147:3587-3594.
Takahashi K, Lappin D, Kinane DF (1996). In situ localization of cell
synthesis and proliferation in periodontitis gingiva and tonsillar tissue. Oral Dis 2:210-216.
Takeichi O, Taubman MA, Haber J, Smith DJ, Moro I (1994).
Cytokine profiles of CD4 and CD8 T cells isolated from adult
periodontitis gingivae (abstract). J Dent Res 73(Spec Iss):205.
Takeuchi Y, Yoshie H, Hara K (1991). Expression of interleukin-2
receptor and HLA-DR on lymphocyte subsets of gingival
crevicular fluid in patients with periodontitis. J Periodontal Res
26:502-510.
Taubman MA, Stoufi ED, Ebersole JL, Smith DJ (1984a). Phenotypic
studies of cells from periodontal disease tissue. J Periodont Res
19:587-590.
Taubman MA, Yoshie H, Ebersole JL, Smith DJ, Olson CL (1984b).
Host response in experimental periodontal disease. J Dent Res
63:455-460.
13(1):17-34 (2002)
Taubman MA, Haffajee AD, Socransky SS, Smith DJ, Ebersole JL

(1992). Longitudinal monitoring of humoral antibody in subjects with destructive periodontal diseases. J Periodontal Res
27:511-521.
Te Velde AA, Huijbens RJ, Heije K, de Vries JE, Figdor CG (1990).
Interleukin-4 (IL-4) inhibits secretion of IL-1 beta, tumor necrosis factor alpha, and IL-6 by human monocytes. Blood 76:13921397.
Tokoro Y, Matsuki Y, Yamamoto T, Suzuki T, Hara K (1997).
Relevance of local Th2-type cytokine mRNA expression in
immunocompetent infiltrates in inflamed gingival tissue to
periodontal diseases. Clin Exp Immunol 107:166-174.
Trinchieri G (1997). Cytokines acting on or secreted by macrophages
during intracellular infection (IL-10, IL-12, IFN-g). Curr Opin
Immunol 9:17-23.
Tsai CC, McArthur WP, Baehni PC, Evian C, Genco RJ, Taichman
NS (1981). Serum neutralizing activity against Actinobacillus
actinomycetemcomitans leukotoxin in juvenile periodontitis. J
Clin Periodontol 8:338-348.
Ukai T, Hara Y, Kato I (1996). Effects of T cell adoptive transfer into
nude mice on alveolar bone resorption induced by endotoxin. J
Underwood K, Sjstrom K, Darveau R, Lamont R, Schenkein H,
Gunsolley J, et al. (1993). Serum antibody opsonic activity
against Actinobacillus actinomycetemcomitans in human periodontal diseases. J Infect Dis 168:1436-1443.
Waldrop TC, Anderson DC, Hallmon WW, Schmalstieg FC, Jacob
RL (1987). Periodontal manifestations of the heritable Mac-1,
LFA-1, deficiency syndrome. Clinical, histopathologic and molecular characteristics. J Periodontol 58:400-416.
Wang H, Taubman MA, Smith DJ (1989). Effect of depletion of
CD8+ T cells on immunoglobulin synthesis by gingival lymphocytes (abstract). J Dent Res 68(Spec Iss):221.
Wassenaar A, Reinhardus C, Thepen T, Abraham Inpijn L, Kievits
F (1995). Cloning, characterization, and antigen specificity of Tlymphocyte subsets extracted from gingival tissue of chronic
adult periodontitis patients. Infect Immun 63:2147-2153.
Wassenaar A, Reinhardus C, Abraham Inpijn L, Kievits F (1996).
Type-1 and type-2 CD8+ T-cell subsets isolated from chronic
adult periodontitis tissue differ in surface phenotype and biological functions. Immunology 87:113-118.
Watanabe K, Kumada H, Yoshimura F, Umemoto T (1996). The
induction of polyclonal B-cell activation and interleukin-1 production by the 75-kDa cell surface protein from Porphyromonas
gingivalis in mice. Arch Oral Biol 41:725-731.
Weinstein SL, June CH, DeFranco AL (1993). Lipopolysaccharideinduced protein tyrosine phosphorylation in human
macrophages is mediated by CD14. J Immunol 151:3829-3838.
Wheeler TT, McArthur WP, Magnusson I, Marks RG, Smith J,
Sarrett DC, et al. (1994). Modeling the relationship between
clinical, microbiologic, and immunologic parameters and
alveolar bone levels in an elderly population. J Periodontol
65:68-78.
Whitney C, Ant J, Moncla B, Johnson B, Page RC, Engel D (1992).
Serum immunoglobulin G antibody to Porphyromonas gingivalis
in rapidly progressive periodontitis: titer, avidity, and subclass
distribution. Infect Immun 60:2194-2200.
Wilson AG, di Giovine FS, Duff GW (1995). Genetics of tumour
necrosis factor-alpha in autoimmune, infectious, and neoplastic
diseases. J Inflamm 45:1-12.
Wilson AG, Symons JA, McDowell TL, McDevitt HO, Duff GW
(1997). Effects of a polymorphism in the human tumor necrosis
factor alpha promoter on transcriptional activation. Proc Natl
Acad Sci USA 94:3195-3199.
Wilton JM, Hurst TJ, Sterne JA (1993). Elevated opsonic activity for
33
Porphyromonas (Bacteroides) gingivalis in serum from patients

with a history of destructive periodontal disease. A case:control
study. J Clin Periodontol 20:563-569.
Wright SD, Ramos RA, Tobias PS, Ulevitch RJ, Mathison JC (1990).
CD14, a receptor for complexes of lipopolysaccharide (LPS)
and LPS binding protein. Science 249:1431-1433.
Yamamoto M, Kawabata K, Fujihashi K, McGhee JR, Van Dyke TE,
Bamberg TV, et al. (1996). Absence of exogenous interleukin-4induced apoptosis of gingival macrophages may contribute to
chronic inflammation in periodontal diseases. Am J Pathol
148:331-339.
Yamamoto M, Fujihashi K, Hiroi T, McGhee JR, Van Dyke TE,
Kiyono H (1997). Molecular and cellular mechanisms for periodontal diseases: role of Th1 and Th2 type cytokines in induction
of mucosal inflammation. J Periodontal Res 32:115-119.
Yamashita K, Eastcott JW, Taubman MA, Smith DJ, Cox DS (1991).
Effect of adoptive transfer of cloned Actinobacillus actinomycetemcomitans-specific T helper cells on periodontal disease.
Yamazaki K, Polak B, Bird PS, Gemmell E, Hara K, Seymour GJ
(1989). Effects of periodontopathic bacteria on IL-1 and IL-1
34
inhibitor production by human polymorphonuclear neutrophils. Oral Microbiol Immunol 4:193-198.

Yamazaki K, Nakajima T, Aoyagi T, Hara K (1993).
Immunohistological analysis of memory T lymphocytes and
activated B lymphocytes in tissues with periodontal disease. J
Yamazaki K, Nakajima T, Aoyagi T, Hara K (1994a).
Immunohistological analysis of memory T lymphocytes and
activated B lymphocytes in tissues with periodontal disease. J
Yamazaki K, Nakajima T, Gemmell E, Polak B, Seymour GJ, Hara
K (1994b). IL-4- and IL-6-producing cells in human periodontal
disease tissue. J Oral Pathol Med 23:347-353.
Yamazaki K, Nakajima T, Kubota Y, Gemmell E, Seymour GJ, Hara
K (1997). Cytokine messenger RNA expression in chronic
inflammatory periodontal disease. Oral Microbiol Immunol
12:281-287.
Zadeh HH, Nichols FC, Miyasaki KT (1999). The role of the cellmediated immune response to Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis in periodontitis.
Periodontol 2000 20:239-288.
13(1):17-34 (2002)

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CONTROVERSY

DESTRUCTIVE PERIODONTITIS LESIONS

t is now generally accepted that periodontal disease results

meability and express adhesion molecules, and a gradient of

Crit Rev Oral Biol Med

tion and bone loss. Resident epithelial cells, endothelial cells,

(II) Innate Immunity

(B) MACROPHAGES IN PERIODONTAL DISEASE

Crit Rev Oral Biol Med

most cases result in the successful elimination of the pathogen

(III) Susceptibility to Periodontal Disease

(B) GENETIC FACTORS

reared apart (Michalowicz et al., 1991). This study suggested that

Crit Rev Oral Biol Med

adult periodontitis compared with individuals with early and

(IV) Adaptive Immunity

T- and B-cells, indicative of activation within the tissues

(A) B-CELLS IN PERIODONTAL DISEASE

Crit Rev Oral Biol Med

1992; Whitney et al., 1992). The general inability to demonstrate

Crit Rev Oral Biol Med

(B) T-CELLS IN PERIODONTAL DISEASE

of Page and Schroeder (1976) and with the putative stable

Crit Rev Oral Biol Med

demonstrated in only 10/27 gingiTABLE

Crit Rev Oral Biol Med

recent study, peripheral blood mononuclear cells isolated from P.

Crit Rev Oral Biol Med

nificant decrease in the percent of IL-10+ CD8 cells in gingival

Strong innate immune response +

Poor innate immune response +

Specific antibody production +

IL-1, IL-1 receptor antagonist

Inhibition of macrophage production of

micro-organisms (Ishikawa et al., 1997). LPS is a component of

Crit Rev Oral Biol Med

the major receptors for P. gingivalis LPS (Shapira et al., 1994), is

(V) Animal Models

increased disease (Ebersole et al., 1991). This model has also

Crit Rev Oral Biol Med

whereas immunization with P. gingivalis alone leads to a Th1

The administration of CTLA4Ig, which is a functional antagonist

(VI) Cell-based Therapy in Periodontal

Crit Rev Oral Biol Med

cells, B-cells, and macrophages as APC in periodontitis have not

dendritic cells internalize P. gingivalis was demonstrated. As

Crit Rev Oral Biol Med

Baranowska HI, Palmer RM, Wilson RF (1989). A comparison of

Crit Rev Oral Biol Med

(1989). IL-4 down-regulates IL-1 and TNF gene expression in

Crit Rev Oral Biol Med

Dent Res 75(Spec Iss):322.

Mahanonda R, Seymour GJ, Powell LW, Good MF, Halliday JW

Crit Rev Oral Biol Med

valis in active destructive periodontal lesions. J Periodontol

Crit Rev Oral Biol Med

Periodontal Res 17:462-465.

Taubman MA, Haffajee AD, Socransky SS, Smith DJ, Ebersole JL

Crit Rev Oral Biol Med