Resident cells in pulpal and periapical inflammation

In addition to immune cells, resident cells in the dental pulp and periapical tissue may play important roles in
regulation of immune and inflammatory responses. Odontoblasts are the primary cells that encounter exogenous
stimuli, including bacteria, in the pulpodentin complex. In addition to dentin formation, odontoblasts potentially
regulate inflammatory responses because these cells constitutively express toll-like receptors (TLRs) that interact
with bacterial components to initiate inflammatory responses. 79 In this study, exposure of odontoblasts to bacterial
lipoteichoic acid activated an inflammatory pathway that is dependent on upregulation of TLR-2 and resulted in
expression of chemokines CCL2 and CXCL10. Concomitantly, lipoteichoic acid inactivated pathways associated
with dentin formation, including the expression of type I collagen, dentin sialophosphoprotein, and TGF-β. In
another study, the expression of TGF-β and SMADs (TGF- β signal transduction molecules) was also significantly
downregulated in mouse incisor dental pulp stimulated with LPS. 80 Odontoblast-specific TGF-β receptor 2–deficient
mice exhibited extremely rapid and severe inflammatory cell infiltration and tissue destruction in responses to LPS
stimulation, whereas wild-type controls exhibited only mild inflammatory responses. 81 This finding demonstrates an
important anti-inflammatory action of TGF-β. Taken together, these findings suggest that TLR-induced
inflammatory responses in odontoblasts may play a role in immunopathology in the pulp.
Other resident cells, including fibroblasts, osteoblasts, and cementoblasts, also express TLRs and may
participate in infection-stimulated inflammatory bone loss, particularly via TLR-2. 82–84 Human periodontal ligament
fibroblasts exhibited greater expression of TLR-2 and released high levels of IL-8 in response to TLR-2–stimulating
peptidoglycan from Staphylococcus epidermidis, but not TLR-4–stimulating LPS, than did human gingival
fibroblasts.82 In osteoblasts, in vitro stimulation by LPS or IFN-γ significantly reduced the expression of
osteoprotegerin, which is the decoy receptor of bone resorptive receptor activator of nuclear factor κB ligand
(RANKL), and increased expression of IL-6 and prostaglandin E 2 (PGE2), which promote bone resorption.83 In
cementoblasts, expression of RANKL, monocyte chemoattractant peptide 1, IL-6, CCL5, and macrophage
inflammatory protein 1α was significantly upregulated in response to TLR-2–stimulating P gingivalis LPS and TLR-
4–stimulating Escherichia coli LPS.84 These findings indicate that resident cells in dental pulp and periapical tissue
may play important regulatory roles in immunity and inflammation in these tissues.

Protective Immunity to Pulpal Infections

From the foregoing discussion, it is apparent that the mixed inflammatory cell infiltrate in both the dental pulp and
in periapical lesions is potentially capable of mediating the entire spectrum of immunologic responses. These
include antibody-mediated phenomena (antigen-antibody complex formation, complement-dependent cell lysis and
chemotaxis, and immediate-type hypersensitivity), delayed-type hypersensitivity, cytotoxicity, and cytokine and
prostaglandin production (Box 12-1). However, the critical question is not which antibacterial responses are present
but rather which antibacterial responses actually function to protect the host as well as the pulpal and periapical
tissues. To answer this question, animals with various immunodeficiencies have been studied to identify which
immune functions are critical in reducing or preventing infection and periapical bone resorption.
Immunodeficiencies fall into two broad categories, depending on whether they primarily affect innate or
specific (adaptive) immune responses. In general, humans and animals with defects in phagocytic leukocytes,
including neutrophils and monocytes, have increased susceptibility to bacterial infections. Although the effect of
these deficiencies on pulpal infections has not been reported in humans, they clearly increase the severity of
marginal periodontitis.85,86 In contrast, patients with defects in specific immunity and/or diminished T- or B-cell
numbers or function exhibit marginal periodontitis that is similar to or milder than that seen in normal age-matched
individuals.87–91 An exception may be the marginal periodontitis that occurs in some individuals infected with human
immunodeficiency virus (HIV), although the disease appears to be somewhat atypical and may not be identical to
other periodontal diseases.92

Deficiencies in innate immune responses

Individuals with PMN defects, including chronic granulomatous disease, cyclic neutropenia, Papillon- Lefèvre
syndrome, Chédiak-Higashi syndrome, and leukocyte adhesion deficiencies (LADs), have an increased incidence
and severity of bacterial infection, including oral (periodontal) infections. 93–95 Best studied are the LADs, of which
there are two recognized types. 96–98 LAD-1 is due to a genetic defect in the β chain of integrins, which are important
for leukocyte transmigration across the blood vessel wall. LAD-2 is due to a defect in the sialyl Lewis X ligand on
leukocytes to which P- and E-selectins on endothelial cells bind, an interaction that mediates the initial “rolling
adhesion” of leukocytes to the blood vessel wall (see Fig 11-2). In both conditions, the adhesion deficiency
significantly reduces the ability of PMNs to migrate from the vascular system into tissues.
Patients present with severe infections and elevated numbers of circulating PMNs and macrophages
(leukocytosis), yet no pus is formed. In addition, they exhibit early-onset or prepubertal marginal periodontitis. 98–102
Based on these considerations, it is not surprising that a recent case report of a patient with an LAD-1
immunodeficiency described numerous examples of infected, necrotic teeth with apical periodontitis. 103 Others have
provided case reports of patients with cyclic neutropenia who showed an increased prevalence of apical
periodontitis.
104
Older studies have attempted to determine the role of innate immune cells such as PMNs and
monocyte/macrophages in periapical responses to infection. The administration of cyclophosphamide, which causes
severe neutropenia, was reported to increase periapical bone destruction. 105 In cyclophosphamide-treated animals,
bacteria were observed both in the pulp and in the periapical lesion, suggesting increased bacterial invasion in the
absence of PMNs. However, methotrexate treatment, which also causes neutropenia, has been reported to inhibit the
development of apical peri-unclear; however, although the effects of the immunosuppressive agents are correlated
with neutropenia, both cyclophosphamide and methotrexate also profoundly affect the production and responses of
lymphocytes, so these effects could not be solely attributed to PMNs.
Knockout mice deficient in both P- and E-selectins (P/E –/–) have been developed as a model of human
LAD-2. P/E–/– mice have defective rolling adhesion and leukocytosis and increased susceptibility to various
infections, but few reported defects in adaptive immunity.107 Interestingly, P/E–/– mice have been shown to develop
much larger periapical lesions than their normal, wild-type counterparts (Fig 12-8), which correlated with both
decreased PMN infiltration of periapical tissues and increased periapical expression of the bone resorptive cytokine
IL-1.108
Another experimental approach has been to use immunomodulators to increase the number and
function of innate immune cells and subsequently to determine the effect on pulpal and periapical resistance to
infection. Granulocyte colony-stimulating factor (G-CSF) is a cytokine that stimulates the production of
granulocytes by the bone marrow and increases the antimicrobial function of mature neutrophils. The effect of G-
CSF was recently examined in a rat pulpitis model following methotrexate-induced neutropenia. 109 Pulpal
inflammation, necrosis, and abscesses rapidly progressed in animals with neutropenia, and pulpal inflammation
rapidly extended to the periapical area after pulpal exposure. In contrast, G-CSF injection increased PMN counts
and reduced pulpal necrosis and limited intrapulpal abscesses to a small area adjacent to the site of pulpal exposure.
However, generalized pulpal and periapical inflammation was absent.
Poly-β-1-6-glucotriosyl-β-1-3-glucopyranose (PGG) glucan is a biologic-response modifier derived from
yeast that effectively increases host antibacterial responses without inducing inflammation, including a complete
lack of proinflammatory cytokine production (IL-1 and tumor necrosis factor α [TNF-α]) by macrophages and other
cells.110–112 Systemic administration of PGG glucan increased PMN production and primed phagocytic and
bactericidal activity in vivo113 and prevented postsurgical infections in humans.114
In the pulpal exposure model, PGG glucan reduced periapical bone destruction by 40% 19 (Fig 12-9).
Animals in which PGG glucan was administered had increased numbers of circulating PMNs and monocytes, which
possessed enhanced phagocytic activity ex vivo. The protective effect on periapical bone was secondary to
decreased pulpal necrosis; only 3% of pulps exhibited complete pulpal necrosis in PGG glucan–treated animals
compared with 41% of pulps in control animals. These results clearly indicate that PMNs are predominantly
protective against pulpal infections and as a consequence reduce periapical bone destruction.
Osteopontin (OPN) is a multifunctional cytokine that regulates inflammation, bone metabolism, tumor
progression, and metastasis. OPN–/– mice exhibit larger periapical lesions than do wild-type animals (Fig 12-10); this
difference is accompanied by a larger area of PMN infiltration and upregulation of neutrophil elastase gene
compared to that found in wild-type controls. 20 However, OPN also affects the development of T H1 and possibly
other immune responses, so it is possible that the increased PMN infiltration in this study was compensating for the
lack of another protective immune function. Further studies are needed to dissect the mechanism underlying the
observed increase in bone loss.
PMNs clearly protect the host and host tissues against pulpal infections. 115,116 At the same time, recent data
indicate that LPS-stimulated PMNs have the capacity to express surface RANKL via TLR- 4 signaling, which
potentially could stimulate osteoclastogenesis and bone resorption. 117 Furthermore, PMNs may play a role in
neurogenic inflammation, which has been described in inflamed pulp and periradicular lesions. 118–121 Substance P,
which is secreted by sensory nerves, affects vascular permeability and the release of histamine from mast cells. 122
Substance P also enhances immune complex inflammation.123 This mediator is highly expressed by PMNs in human
periapical lesions.119 Therefore, PMN-derived substance P could mediate neurogenic inflammation via this pathway,
leading to a hyperoxidative burst124 and upregulation of proinflammatory cytokines.125
Given that these data represent correlations that have not yet been confirmed by functional studies, it is
uncertain at this time whether PMN RANKL expression or neurogenic inflammatory responses play a major role in
periapical pathogenesis.