Download Manifestation of ulcerative lichen planus and

Study of the expression of CD68+
macrophages and CD8+ T cells in
human granulomas and periapical
cysts.
Rodini CO, Lara VS.
Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2001 Aug;92(2):221-7
Commentary
Evolution from granuloma to cyst:
possible mechanisms involved in
epithelial proliferation of Malassez
rests.
Antonio Schütz, Ph.D.
Dentist, Pharmacist, Master in Oral Pathology
at the Federal University of Rio de Janeiro
(UFRJ), Doctor in Oral Pathology for the
Bauru School of Dentistry, University of Sao
Paulo (FOB/USP), Brazil.
Address reprint
request to Dr. Antonio Beltrao Schütz, José
Bonifácio 2598/103, telephone: (5555) 3221 6763, CEP: 97015-450, Santa Maria, RS,
Brazil. Email: [email protected]
Las t r e v is i on : M ai 21 , 20 0 7.
With relation to Professor Lara, we first meeting was in
the memorable reunion of the Brazilian Society of
Stomatology, in Curitiba, 1988. In that time, was student
of the first year of post-graduation in Oral Pathology at the
Federal University of Rio de Janeiro (FOUFRJ), at the
staff of the professor José Carlos Borges Teles, exstudent at the Indiana University, and Professor Lara,
student of the last year of graduation at FOB/USP,
presented a clinic case organized by Professor
Consolaro. As disagree of an aspect of the presentation,
asked her; responding me, “I do not know”. Moment in
that thought, “She will certainly be a Brazilian professor”.
My prevision confirmed itself. After some years, again,
meet us at the Department of Pathology at Bauru School
of Dentistry at Sao Paulo University (FOB/USP). Coursed
the first year of my doctoral study (Ph.D.) in Oral
Pathology, and Professor Lara finished her mastered
study.
As in our first meet, disagree of the conclusion of
Rodini; Lara (2001),1 affirming that in the advanced stage
of periapical granulomatous lesions, among the
population of leukocytes, would predominate OKT8+ cells
with suppressor phenotype, implicating in a state of
immune suppression associated with the formation of
periapical cyst (p. 226). Contrarily, this state of immune
suppression would explicate the concept of “dormancy”,
where the differential expression of key cell surface
antigens on oral epithelial cells may keep to recruit
immune effectors cells in a state of unresponsiveness;
thus, contributing to the long quiescent period observed in
many periodontal and endodontic lesions (Han; Huang;
Lin ; Warner et al., 2003).2 Other data contrasting with the
CD8+ suppressor phenotype was the identification of
periapical lesions of chemokines RANTES, IP-10, and
MCP-1 (Silva; Garlet; Lara; Martins et al., 2005),3 since
IP-10, preferentially, attracts activated CD4+ Th1 cells;
activated Th1 cells stimulate natural killer cells or
macrophages to kill tumor cells or to stimulate dendritic
cells to prime cytotoxic T cells. Thus IP-10 contributes to
killing tumor cells via activated Th1 cells (Kanda;
Watanabe, 2002),4 as well as, in periapical lesions,
presents anti-proliferative effect to epithelial cells,
explicating also, at least in part, the long period of
“dormancy” of Malassez epithelial rest, which is
possivebly, partially, disturbed for the increase of the local
concentration of nitirc oxide causing dowregulation of the
production of IP-10.
In development and progression from granuloma to
cyst were detected high levels of IFN-gamma in all
samples, after cell stimulation with phorbol myristate
acetate and Ca(2+) ionophore, which were not statistically
different from the levels of IFN-gamma in PB-MNC
cultures. IL-4 was detected in 76% samples, but its
concentrations were much lower than in PB-MNC
samples. The levels of IFN-gamma were higher in
cultures of PL-MNC isolated from periapical lesions with
predominance of T cells (T-type lesions) and correlated
positively with the proportion of antigen-presenting cells
(macrophages and dendritic cells), CD4(+) T cells and
IgG2(+) B cells/plasma cells. The levels of IL-4 correlated
negatively with the proportion of macrophages, but
positively with the number of mast cells and IgG4(+) cells.
IL-18Ralpha, a stable marker of Th1 cells, was detected
on a relatively small proportion of CD3(+) T cells and its
expression correlated with the levels of IFN-gamma.
However, the expression of ST2L, a stable Th2 cell
marker, was not detected. The levels of Th1 and Th2
cytokines did not correlate with clinical characteristics of
the lesions, defined for the presence of symptoms,
concluding that the results suggested the predominance
of Th1 immune response in periapical lesions (Colic;
Lukic; Vucevic; Milosavljevic et al., 2006)5.
Similar results there was been yet verified by Liapatas;
Nakou; Rontogianni, 2003.6 No statistically significant
differences were detected in the inflammatory infiltrate
between periradicular granulomas and cysts. The T4/T8
ratio ranged approximately from 1 to 3 and greater, being
consistent with inflammation of periradicular tissues. The
final differentiation of B lymphocytes to plasma cells was
also detected, whilst natural killer (NK) cells were found in
only 10 cases (22%). Moreover, antigen presenting cells
and T suppressor/cytotoxic cells were found to be
associated with both pre-existing and newly formed
epithelium. These results suggested that periradicular
granulomas and cysts represent two different stages in
the development of chronic periradicular pathosis as a
normal result of the process of immune reactions in which
B-lymphocyte and T-lymphocyte-mediated immunologic
reactions have been implicated and that can not be
inhibited;4 in spite of the endodontic treatment not only to
stop the invasion of injurious factors but also proliferation
of epithelium (Yanagisawa, 1980).7
In a study about the identification of the various
subpopulations of T-lymphocytes identified in periapical
lesions was verified the presence of T-cells, indicating
the participation of cell-mediated reactions in their
pathogenesis, considering that 14 of 15 periapical lesions
stained themselves positively for pan T-lymphocytes
(T11), T helper cells (T4), and T cytotoxic cells (T8)
(Barkhordar; Desouza, 1988)8.
Other data that support the activation of the immune
response in the final stage of the evolution from
granuloma to cyst, and not its suppression, is the
accentuated presence of Langerhans Cells in
subepithelial localization of epithelial granulomas
suggesting that LCs appeared to be associated with T
lymphocyte infiltration (relation CD4/CD8 positive) and
with the proliferative potential of the epithelial tissue in
periapical lesions (Suzuki; Kumamoto; Ooya; Motegi,
2001)9.
In addition, monocytes/macrophages were associated
with the majority of periapical granulomata, dental
developmental cysts being present in all periapical cysts.
Langerhans cells, intraepithelial lymphocytes, and
monocytes/macrophages were found in some epithelia
within periapical granulomata and in the majority of the
epithelial linings of odontogenic cysts. Increased numbers
of immune cells were seen around proliferative epithelia
and adjacent to the epithelial linings of cysts suggesting
that cell-mediated and humoral immunoreactions occur in
these lesions and may be associated with the epithelial
proliferation within the periapical lesions (Gao;
Mackenzie; Rittman; Korszun et al., 1988).10
Of course, there are some articles publishing the
greater presence of cells OKT8+ (CD8) than OKT4
(CD4)4,11 Similar conclusion to Rodini; Lara (2001)2 was
made by Levine; Witherspoon; Gutmann; Nunn; et al.,
(2001),12 in a study about the effect of feline
immunodeficiency virus (FIV) on CD4+ and CD8+ counts
in periradicular lesions using immunohistochemical
staining for CD4+ and CD8+ receptors, having been
verified a significantly lower CD4+ counts and CD4+/
CD8+ ratios, observed at all time periods in the
periradicular region of the FIV group (P = 0.0006).
In spite of the presence of IgE producing cells, the
morphological picture of mast cells would not suggest the
presence of anaphylactic reaction in periapical
granulomatous lesions. Moreover, the diffuse distribution
of T lymphocytes with the prevalence of Tsuppressor/cytotoxic over T-helper lymphocytes, and not
numerous macrophages in the inflammatory infiltrates
would not also suggest the participation of a typical cellmediated immunity reaction in the development of
periapical granulomas. Numerous T-suppressor/cytotoxic
lymphocytes and low numbers of macrophages could be
important factors of chronicity of the periapical
inflammatory diseases (Babal; Brozman; Jakubovsky;
Basset et al. (1989).13 However, in this work, was studied
a greater number of dental abscesses or granulomas
secondary infected in evolution to abscesses; explicating,
at least in part, the decreased number of macrophages,
as well as the prevalence of T suppressor cells over T
helper cells. Possibly, the same may have occurred in the
study of Rodini; Lara (2001).2
In the big majority of the published articles, the cellular
population predominant, in periapical granulomas, was
monocytes/macrophages, particularly, in lesions that
showed a positive reaction to percussion or were tender
on palpation than in lesions without these symptoms.
(Matsuo; Ebisu; Shimabukuro; Ohtake et al., 1992)
Macrophages, lymphocytes, and endothelial cells
expressed RAGE; and these cellular types, in addition to
plasma cells, also exhibited anti-iNOS immunoreactivity,
suggesting that in periapical lesions there is an interaction
between the presence of the receptor for advanced
glycation end products (RAGE) and inducible nitric oxide
synthase (iNOS), with relation to production of nitric oxide
(NO) (Hama; Takeichi; Saito; Ito, 2007).14 This mediator
influences the processes of proliferation and
differentiation of epithelial cells; thus, resembling effects
mediated by protein-type factors EGF and KGF (Krischel
et al. 1998).15 In addition, was suggested that NO might
promote the progression of periapical lesion by inducing
apoptosis of macrophages and osteoblasts (Lin; Kok; Lin;
Wang et al., 2007).16
Epithelial cell proliferation is often observed in
periapical lesions of endodontic origin. However, the
mechanisms that stimulate the epithelial cell rests of
Malassez to proliferate are not understood fully. In
periapical lesions without epithelial cell proliferation has
been identified a weak immunoperoxidase staining or low
specific binding of 125I-EGF, whereas in periapical
lesions with epithelial cell proliferation and cyst formation
has been identified a strong immunoperoxidase staining
in the epithelial cells or high specific binding of 125I-EGF
(Lin LM, Wang SL, Wu-Wang C, Chang KM, Leung C,
1996).17
Keratinocyte growth factor (KGF) was recently identified
as a growth factor that is produced by stromal fibroblasts
that acts specifically stimulating the epithelial growth and
differentiation. KGF-expressing cells were found in the
connective tissue stroma closed to dense foci of
inflammatory cells, of proliferating epithelial elements and
of cystic epithelial linings, suggesting that the induction of
KGF expression in the stromal cells of periapical lesions
might play an important role in the stimulation of the
epithelial proliferation associated with cyst formation
(Gao; Flaitz; Mackenzie, 1996)18.
Fibroblast growth factor is of a class of heparin-binding
growth factors that has been implicated in the stimulation
of the endothelial cell proliferation, migration in vitro and
angiogenesis in vivo. An immunopositive, cytoplasmic,
and nuclear reaction for basic fibroblast growth factor with
varying degrees of upregulation has been identified in
periapical lesions indicating that a local rise in the tissue
level of basic fibroblast growth factor might play an
important role in the pathogenesis of chronic apical
periodontitis and periapical cysts (Moldauer; Velez;
Kuttler, 2006),19 resultant of the link of FGF in receptors
on ME (epithelial cells) dominantly bind to FGF-1 and
FGF-7/KGF, which transduce their signals via FGFR2-IIIb
(Yamanaka; Sakamoto; Tanaka; Zhanget al., 2000 ).20
Therefore, proliferation of the epithelial rests of
Malassez to form the lining of inflammatory dental cysts
induced by these growth factor appears to be associated
with a change from an unusual epithelial phenotype to
that of a stratified non-cornifying epithelium in which some
epithelial keratins are coexpressed, considering that the
immunocytochemistry and a panel of monoclonal
antibodies directed against various keratin polypeptides
indicated that (a) keratin 19 was expressed by all
epithelia; (b) rests of Malassez also expressed keratin 5
but not large amounts of other keratins; and (c) epithelial
proliferation in periapical lesions was associated with
increased expression of keratin 14, a marker of stratifying
epithelia, new expression of keratins 4 and 13,
differentiation markers for non-cornifying epithelia and
variable, low levels of keratins 8 and 18, markers of
simple epithelia (Gao; Mackenzie; Williams; Cruchley et
al., 1988).21
The epithelial rests of Malassez (ERM) verified inside
granulomatous tissue are derived from the disintegrating
epithelial root sheath of Hertwig that guides root formation
during tooth development. Low concentrations of nitric
oxide (NO) produced by NO-synthase I (NOS I) and NOS
III activate intracellular soluble guanylate cyclase (sGC) to
produce
intracellular
cyclic
guanosine
3':5'monophosphate (cGMP), which triggers rapid cellular
responses such as cell proliferation, cell differentiation,
and apoptosis under physiological conditions (Korkmaz;
Bloch; Behrends; Schroder et al., 2004).22 The basal
production of NO by eNOS, in Mallassez epithelial rests,
is modulated by phosphorylation of eNOS at Ser1177 and
Ser116 residues, while the basal activity of eNOS is not
influenced by phosphorylation of eNOS at Thr495 residue,
proving evidence that phosphorylation plays a key role for
regulation of the catalytic activity of eNOS (Korkmaz;
Bloch; Addicks; Schneider; Baumann et al., 2005).23
Samples of radicular cyst-lining epithelium, which is
considered to be identical to the cell rests of Malassez,
might play a role in the apical cyst formation for the
interaction with surrounding connective tissue or
hematopoietic cells through the expression of various
cytokines, growth factors and epithelial cell growth-related
receptors by RT-PCR. All samples studied expressed IL1alpha, -1beta, IL-6, IL-8, IL-11, TGF-beta1, PDGF-A and
aFGF, and receptors for EGF (c-erbB), KGF, HGF (c-met)
and IL-6. Some of the specimens expressed MIP-1alpha,
RANTES, GM-CSF, M-CSF, TNF-alpha, PDGF-B and
bFGF, but no expression of IL-2, IL-4, IFN-gamma, IGF-I,
EGF and KGF was detected (Ohshima; Nishiyama;
Tokunaga; Sato et al., 2000).24
Heat shock protein (HSP) is a small HSP family that
plays part in the regulation of epithelial cell growth and
differentiation, wound healing, apoptosis and cell
protection against inflammatory cytotoxicity mediators.
The expression of HSP27 was investigated
immunohistochemically in periapical granulomas with
epithelial rests of Malassez and in radicular cysts. AntiHSP27 mouse monoclonal antibody and peroxidaselabeled streptavidin-biotin standard technique were used
to study the expression of HSP27. Proliferating epithelial
cell rests, and islands of epithelium and epithelial lining of
microcysts strongly reacted in all layers, whereas
radicular cysts epithelial lining presented mainly a
moderate suprabasal staining pattern. However both the
proliferating epithelial cell rests and radicular cysts shared
an over-expression of HSP27 immunostaining intensity in
coincidence with the presence of local infiltration of
immune cells (Leonardi; Villari; Caltabiano; Travali,
2001).25
HSP60 was detected in some lymphocytes of
granulation tissue and in lining epithelium of periapical
inflammatory lesions, whereas Malassez epithelial rests
showed no staining for HSP60. Epithelial HSP60 reactivity
was more intense in RCs than in RRCs. HSP70 was
expressed in lymphocytes, endothelial cells and lining
epithelium of periapical inflammatory lesions and in
Malassez epithelial rests. The staining intensity of HSP70
in Malassez epithelial rests was slightly lower than that in
lining epithelium of RCs and RRCs.7
Bacterial heat shock protein 60 (hsp60) induces
cultured epithelial cell proliferation within 24 h. The
number of viable cells in hsp60-treated culture was 37%
higher than the number in the control at 24 h but 27%
lower at 144 h. A kinetics study of the effect of hsp60 on
the phosphorylation of mitogen-activated protein kinases
(MAPKs) involving Western blotting with phospho-specific
antibodies showed that in addition to a transient early
increase in p38 levels, a second peak appeared in
keratinocytes 24 h after the addition of hsp60. In contrast,
prolonged incubation with hsp60 caused a decrease in
the level of phosphorylated extracellular signal-regulated
kinase 1/2 (ERK1/2) compared with that in the controls,
possibly as a result of protein phosphatase activity
(Zhang, Pelech; Uitto, 2004).26
In a study for detecting the presence of
periopathogenic bacteria in persistent periapical lesions
and to compare the reliability of two different methods:
anaerobic culture and the DNA hybridization technique
was verified that in at least one periodontal pathogenic
bacterium was found in seven of 24 cases. Bacterial
species present were Treponema denticola (three cases),
Porphyromonas gingivalis (three cases), Tannerella
forsythensis (four cases), Prevotella intermedia (one
case), and Actinobacillus actinomycetemcomitans (three
cases) (Lin; Sela; Sprecher, 2007).27 Against these
bacteria are also express gene-encoded molecules
named of antimicrobial peptides, firstly discovered for
their microbicidal properties, but that recently shown to
have pro- or anti-inflammatory functions. Their role as
immune regulators is being expanded with evidence that
some antimicrobial peptides stimulate epithelial migration,
proliferation and cytokine or chemokine production.
Schauber J, Gallo RL, 2007).28 hBD-2, -3, and -4 but not
hBD-1 stimulated human keratinocytes to increase their
gene expression and protein production of IL-6, IL-10, IP10, monocyte chemoattractant protein-1, macrophage
inflammatory protein-3alpha, and RANTES. This
stimulatory effect was markedly suppressed by pertussis
toxin and U-73122, inhibitors for G protein and
phospholipase C, respectively. Was also demonstrated
that hBDs elicited intracellular Ca2+ mobilization, and
increased keratinocyte migration, and proliferation. In
addition, these peptides induced phosphorylation of
EGFR, signal transducer and activator of transcription
(STAT)1, and STAT3, which are intracellular signaling
molecules involved in keratinocyte migration and
proliferation (Niyonsaba; Ushio; Nakano; Sayama; et al.,
2007).29
In the epithelial rests of Malassez, in vitro, was detected
the mRNA expression of interleukin (IL)-1 alpha, IL-6, IL8, and granulocyte macrophage colony-stimulating factor
(GM-CSF), and beta defensin 1 (BD-1) - an antimicrobial
peptide - having been also studied the effect of
lipopolysaccharide (LPS) on the mRNA expression by
quantitative RT-PCR assay with a LightCycler, using the
double-stranded DNA dye SYBR Green I. The mRNA
expressions of IL-1 alpha, IL-6, IL-8, and GM-CSF were
upregulated by stimulation with LPS in a dose- and timedependent manner. Epithelial cells incubated with 1000
ng/ml of LPS for 6 h showed the most significant
upregulation of the cytokine mRNAs. On the other hand,
no obvious alteration of BD-1 expression by LPS
stimulation was observed (Liu F, Abiko Y, Nishimura M,
Kusano K, Shi S, Kaku T, 2001).30
Histological investigations have demonstrated that root
canal sealers can induce from mild to severe
inflammatory alternations, causing deregulated cytokine
productions at local disease sites. Of these, Interleukin
(IL)-6 and IL-8 released have been reported to play an
important role in the pathogenesis of inflammation,
considering that the exposure of quiescent U2OS cells to
N2 and AH Plus resulted in the induction of IL-6 and IL-8
mRNA gene expression (p < 0.05). The intensity of IL-8
mRNA gene was found to be significant higher than IL-6
mRNA gene (p < 0.05) suggesting that this expression
might be one of the pathogenesis of zinc oxide-eugenol
based and epoxy resin based root canal sealers-induced
periapical inflammation (Huang FM, Tsai CH, Yang SF,
Chang YC 2005),31 stimulating the proliferation of
epithelial rest of Malassez.
Using immunohistochemistry, confocal and light
microscopy, Malassez epithelium and gingival epithelium
from mature cats (n = 5) were examined for cells
containing the neuropeptides calcitonin gene-related
peptide (CGRP), substance P (SP), and vasoactive
intestinal peptide (VIP) having been verified that Malassez
epithelium regularly displayed cells immunoreactive to
CGRP, SP, and VIP, most frequently present in the
epithelial cell clusters and inside strands of Malassez
located in the cervical half of thc periodontal ligament,
suggesting that the presence of neuroendocrine cells in
Malassez epithelium strongly would imply in biological
functions of this tissue, and the neuropeptide content
might, thus, to indicate endocrine functions of the cells
(Kvinnsland; Tadokoro; Heyeraas; Kozawa et al.,
2000),32 modulating their cellular proliferation via RANKL,
considering that epithelial rests of Malassez present
immunoreactivity of TrkA, which is an high-affinity
receptor of nerve growth factor (NGF), in the periodontal
ligament of rats (Yamashiro; Fujiyama; Fukunaga; Wang
et al., 2000).33
Hedgehog family (Hh) of intercellular signaling proteins
have come to be recognized as key mediators of many
fundamental processes in embryonic development. In
some contexts, Hedgehog signals act as morphogens in
the dose-dependent induction of distinct cell fates within a
target field, in others as mitogens regulating cell
proliferation or as inducing factors controlling the form of a
developing organ (Ingham PW, McMahon AP, 2001).34 In
most mouse keratocysts arised from quiescent rests of
Malassez, was demonstrated that epithelium-specific Hh
signaling might reprogram these cells to proliferate,
stratify, and terminally differentiate. Moreover, analysis of
early keratocysts in K5-Gli2 mice reveals that these
lesions originate by reactivation of quiescent epithelial
rests of Malassez, triggering proliferation, stratification,
and terminal differentiation of these normally quiescent
cells, resultant of the combined function of Hh-regulated
Gli transcription factors (Gli1, Gli2, and Gli3) controls Hhmediated alterations in gene expression in responsive
types cellular (Grachtchouk; Liu; Wang; Wei et al.,
2006).35
So, we hypnotize that in the evolution from periapical
granuloma to cyst implicates in a state of continue
hypersensibility immune, culminating with the proliferation
epithelial rest of Malassez partially induced by activation
of nitric oxide synthase (NOS) via activation of guanylate
cyclase (sGC) by NO, resulting in the production
intracellular of cGMPc, able to activate Hedgehog family
of intercellular signaling proteins, inducing the Gli2mediated reactivation of quiescent epithelial rests and
their differentiation into cystic lining cell as well as their
proliferation epithelial, also via PGE2 effects resultant of
the selective stimulation of the EP2 receptor subtype
mediated by ERK1/2 activation, leading to epidermal
growth factor receptor (EGFR) transactivation via protein
kinase A (PKA) and c-Src activation. In addition, decrease
in cyclin D1 levels induced by NO arrests epithelial cells
in the G1 phase. However, noxin, identified as a nitric
oxide (NO)-inducible gene, p53/p21(cip1/waf1) and p53
independent cyclin D1 pathways might be also involved,
causing induction of apoptosis of the central cells in
proliferates epithelial rests of Malassez and formation of
cystic cavity, contributes too, at least in part, to their long
period of ‘dormancy” or “quiescence” while the proliferate
stimuli is not preponderant. In these process, salient
themselves the decreased number of macrophages and
CD8+ (citotoxic cells) with localization intra-epithelial
attracted to this local by bacterial antigen.
Cytokines and growth factors pro-inflammatory
(VEGF/VPF, FGF, IGF, EGF, IL-6, TGF-b1) synthesized
and secreted in the periapical region also present
proprieties modulators of the immune response and
participate of control of the process of proliferation of
epithelial rests of Malassez, whose mechanisms, at least
in part, cause alteration in the normal expression of
keratins , via activation of AP-1 target genes (k5, k8, k14
k18 and k19) involved in the control of the cell
proliferation including cyclin D1 and PCNA.
In the process of hypersensibility immune, especially
cellular and mediated for antibodies, salient itself the
participation of lymphocytes and macrophages, as well as
mast cells able to product metalloproteinases and other
proteinases inductors of the synthesis and secretion of
chemistries mediators, such as nitric oxide (NO),
promoter of the inhibition of the synthesis and secretion of
cytokines and chemokines (IP-10) inhibitors of the
epithelial proliferation; or as urokinase plasminogen
activator (uPA), also directly involved in the epithelial
cellular proliferation.
Of these metalloproteinases, protrude itself the
participation of MMP-13, expressed in fibroblast, epithelial
cell and endothelial cells, as resultant of their interaction
with immune cells, which conjunctly with VIP, is able to
interact with ON, especially synthesized and secreted by
macrophages. Eosinophils have also participation in the
process of epithelial proliferation by to synthesize and to
secrete TGF-beta 1, altering the kinetic of the cellular
cycle, as result of the production of cellular and nuclear
factors, including the absence or disruption of cyclindependent kinase inhibitors; therefore, actuating as
epithelial growth-promoting factor.
Bacterial antigens of the intracanal microbiota, and that
eventually may be identified in the interior of the
granulomatous tissue, among other, from Actinobacillus
actinomycetemcomitans,
Treponema
denticola
Porphyromonas gingivalis and Prevotella intermedia,
such as of the family of Heat shock protein 27, 60, 70
(hsp27, 60, 70) have also participation in the final phase
of evolution from granuloma to cyst, because are able to
promote the epithelial proliferation and to contribute to
formation of the cavity cystic, via biphasic activation of
MAPKs ERK1/2 and P38, involving a short-term activator
effect for ERK1/2 resulting in increased cell proliferation,
as well as a long-term effect, however, resulting in a
sustained phosphorylation of p38 and an increased rate of
cell death, contributing to formation of the cavity cystic in
the proliferant rest.
In addition, is possible that antimicrobial peptides
human or beta-defensins (hBD) and LL-37 expresses in
epithelial rest of Malassez activate different immune and
inflammatory cells, against these bacterias, inducing
phosphorylation of EGFR, signal transducer and activator
of transcription (STAT)1, and STAT3, which are
intracellular signaling molecules involved in epithelial
proliferation.
In epithelial periapical lesions and resistant to the
endodontic treatment, these antigens together with
antigens promoted by root canal sellers are able to induce
to synthesis and secretion of several cytokines, such as
IL-6, which induces the cell cycle to arrest at G1/S phase,
also inducing cellular proliferation in Malassez rests. This
cytokine, conjunctly with other cytokines and chemokines
(IL8, MCP-1, RANTES, SP) are also able to promote the
proliferation of these rests for activating RANKL receptors
express in epithelial cells, possibly via a linear signaling
cascade: RANKL → RANK → IKKα → IκBα → NF-κB
→ cyclin D1. In addition, other cytokines and growth
involved in the attempt of repair of the periapical region of
the endodontic treated tooth also induces epithelial
proliferation of these lesions.
Therefore, we postulate that in epithelial granulomas
resistant to the endodontic treatment, the epithelial
proliferation is caused for the production of cytokines and
growth factors involved in the attempt of bone repair. In
lesions without treatment, the evolution from granuloma to
cyst is caused for the hyperactivation of the immune
response resulting in the augment of the production of
nitric oxide, principally, for macrophages and CD8+
(citotoxic) cells, with diminution of the production of some
cytokines and growth factors pro-inflammatory to a level a
little superior the physiologic, without
to cause
suppression of immune response via CD8+ (suppressor)
cells, such as affirmed Rondini and Lara (2001), as well
as inducing the activation of genes activators of the
cellular proliferation as via these mediators as directly by
nitric oxide,.
1
Rodini CO, Lara VS. Study of the expression of CD68+
macrophages and CD8+ T cells in human granulomas and
periapical cysts. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2001 Aug;92(2):221-7
2
Han DC, Huang GT, Lin LM, Warner NA, Gim JS, Jewett A
Expression of MHC Class II, CD70, CD80, CD86 and
pro-inflammatory cytokines is differentially regulated in
oral epithelial cells following bacterial challenge. Oral
Microbiol Immunol. 2003 Dec;18(6):350-8
3
Silva TA, Garlet GP, Lara VS, Martins W Jr, Silva JS, Cunha
FQ. Differential expression of chemokines and chemokine
receptors in inflammatory periapical diseases. Oral
Microbiol Immunol. 2005 Oct;20(5):310-6
4
Kanda N, Watanabe S. Histamine inhibits the production of
interferon-induced protein of 10 kDa in human squamous
cell carcinoma and melanoma. J Invest Dermatol.
2002 Dec;119(6):1411-9.
5
Colic M, Lukic A, Vucevic D, Milosavljevic P, Majstorovic I,
Marjanovic M, Dimitrijevic J. Correlation between
phenotypic characteristics of mononuclear cells isolated
from human periapical lesions and their in vitro
production of Th1 and Th2 cytokines. Arch Oral Biol.
2006 Dec;51(12):1120-30.
6
Liapatas S, Nakou M, Rontogianni D. Inflammatory infiltrate
of chronic periradicular lesions: an immunohistochemical
study. Int Endod J. 2003 Jul;36(7):464-71.
7
Yanagisawa S. Pathologic study of periapical lesions 1.
Periapical granulomas: clinical, histopathologic and
immunohistopathologic studies. J Oral Pathol. 1980
Sep;9(5):288-300.
8
Barkhordar RA, Desouza YG. Human T-lymphocyte
subpopulations in periapical lesions. Oral Surg Oral
Med Oral Pathol. 1988 Jun;65(6):763-6
9
Suzuki T, Kumamoto H, Ooya K, Motegi K.
Immunohistochemical
analysis
of
CD1a-labeled
Langerhans cells in human dental periapical inflammatory
lesions--correlation with inflammatory cells and epithelial
cells. Oral Dis. 2001 Nov;7(6):336-43
10
Gao Z, Mackenzie IC, Rittman BR, Korszun AK, Williams
DM, Cruchley AT. Immunocytochemical examination of
immune cells in periapical granulomata and odontogenic
cysts. J Oral Pathol. 1988 Feb;17(2):84-90.
11
Kontiainen S, Ranta H, Lautenschlager I. Cells infiltrating
human periapical inflammatory lesions. J Oral Pathol.
1986 Nov;15(10):544-6.
12
Levine DF, Witherspoon DE, Gutmann JL, Nunn ME,
Newman JT, Iacopino AM. The effect of FIV infection on
CD4+ and CD8+ counts in periradicular lesions. Int
Endod J. 2001 Dec;34(8):586-93.
13
Babal P, Brozman M, Jakubovsky J, Basset F, Jany Z.
Cellular composition of periapical granulomas and its
function.
Histological,
immunohistochemical
and
electronmicroscopic
study.
Czech
Med.
1989;12(4):193-215.
14
Hama S, Takeichi O, Saito I, Ito K. Involvement of inducible
nitric oxide synthase and receptor for advanced glycation
end products in periapical granulomas. J Endod. 2007
Feb;33(2):137-41.
15
Krischel V, Bruch-Gerharz D, Suschek C, Kroncke KD,
Ruzicka T, Kolb-Bachofen V. Biphasic effect of
exogenous nitric oxide on proliferation and differentiation
in skin derived keratinocytes but not fibroblasts. J Invest
Dermatol. 1998 Aug;111(2):286-91.
16
Lin SK, Kok SH, Lin LD, Wang CC, Kuo MY, Lin CT,
Hsiao M, Hong CY. Nitric oxide promotes the progression
of periapical lesion via inducing macrophage and
osteoblast apoptosis. Oral Microbiol Immunol. 2007
Feb;22(1):24-9.
17
Lin LM, Wang SL, Wu-Wang C, Chang KM, Leung C.
Detection of epidermal growth factor receptor in
inflammatory periapical lesions. Int Endod J. 1996
May;29(3):179-84
18
Gao Z, Flaitz CM, Mackenzie IC. Expression of keratinocyte
growth factor in periapical lesions. J Dent Res. 1996
Sep;75(9):1658-63.
19
Moldauer I, Velez I, Kuttler S. Upregulation of basic
fibroblast growth factor in human periapical lesions J
Endod. 2006 May;32(5):408-11.
20
Yamanaka T, Sakamoto A, Tanaka Y, Zhang Y, Hayashido
Y, Toratani S, Akagawa Y, Okamoto T. Isolation and
serum-free culture of epithelial cells derived from
epithelial rests of Malassez in human periodontal
ligament. In Vitro Cell Dev Biol Anim. 2000
Sep;36(8):548-53.
21
Gao Z, Mackenzie IC, Williams DM, Cruchley AT, Leigh I,
Lane EB. Patterns of keratin-expression in rests of
Malassez and periapical lesions. J Oral Pathol. 1988
Apr;17(4):178-85.
22
Korkmaz Y, Bloch W, Behrends S, Schroder H, Addicks K,
Baumann MA. NO-cGMP signaling molecules in the rat
epithelial rests of Malassez. Eur J Oral Sci. 2004
Feb;112(1):55-60.
23
Korkmaz Y, Bloch W, Addicks K, Schneider K, Baumann
MA, Raab WH The Basal phosphorylation sites of
endothelial nitric oxide synthase at serine (Ser)1177,
Ser116, and threonine (Thr)495 in rat molar epithelial
rests
of
Malassez.
J
Periodontol.
2005
Sep;76(9):1513-9.
24
Ohshima M, Nishiyama T, Tokunaga K, Sato S, Maeno M,
Otsuka K. Profiles of cytokine expression in radicular
cyst-lining epithelium examined by RT-PCR. J Oral Sci.
2000 Dec;42(4):239-46
25
Leonardi R, Villari L, Caltabiano M, Travali S. Heat shock
protein 27 expression in the epithelium of periapical
lesions. J Endod. 2001 Feb;27(2):89-92.
26
Zhang L, Pelech S, Uitto VJ. Long-term effect of heat shock
protein 60 from Actinobacillus actinomycetemcomitans
on epithelial cell viability and mitogen-activated protein
kinases. Infect Immun. 2004 Jan;72(1):38-45
27
Lin S, Sela G, Sprecher H. Periopathogenic Bacteria in
Persistent Periapical Lesions: An In Vivo Prospective
Study. J Periodontol. 2007 May;78(5):905-908.
28
Schauber J, Gallo RL. Expanding the roles of antimicrobial
peptides in skin: alarming and arming keratinocytes. J
Invest Dermatol. 2007 Mar;127(3):594-604.
29
Niyonsaba F, Ushio H, Nakano N, Ng W, Sayama K,
Hashimoto K, Nagaoka I, Okumura K, Ogawa H.
Antimicrobial peptides human beta-defensins stimulate
epidermal keratinocyte migration. J Invest Dermatol.
2007 Mar;127(3):594-604.
30
Liu F, Abiko Y, Nishimura M, Kusano K, Shi S, Kaku T.
Expression of inflammatory cytokines and beta-defensin 1
mRNAs in porcine epithelial rests of Malassez in vitro.
Med Electron Microsc. 2001 Sep;34(3):174-8.
31
Huang FM, Tsai CH, Yang SF, Chang YC. Induction of
interleukin-6 and interleukin-8 gene expression by root
canal sealers in human osteoblastic cells. J Endod. 2005
Sep;31(9):679-83.
32
Kvinnsland IH, Tadokoro O, Heyeraas KJ, Kozawa Y,
Vandevska-Radunovic V. Neuroendocrine cells in
Malassez epithelium and gingiva of the cat. Acta
Odontol Scand. 2000 Jun;58(3):107-12
33
Yamashiro T, Fujiyama K, Fukunaga T, Wang Y, TakanoYamamoto T. Epithelial rests of Malassez express
immunoreactivity of TrkA and its distribution is regulated
by sensory nerve innervation. J Histochem Cytochem.
2000 Jul;48(7):979-84.
34
Ingham PW, McMahon AP. Hedgehog signaling in animal
development: paradigms and principles. Genes Dev.
2001 Dec 1;15(23):3059-87.
35
Grachtchouk M, Liu J, Wang A, Wei L, Bichakjian CK,
Garlick J, Paulino AF, Giordano T, Dlugosz AA.
Odontogenic keratocysts arise from quiescent epithelial
rests and are associated with deregulated hedgehog
signaling in mice and humans. Am J Pathol. 2006
Sep;169(3):806-14.