CYTOKINE EXPRESSION

IN PERIODONTAL HEALTH AND DISEASE

H. Okada*
S. Murakami
Department of Periodontology and Endodontology, Osaka University Faculty of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565, Japan
*corresponding author
ABSTRACT: Soluble proteins that serve as mediators of cell function and are produced by various cell types, such as structural
and inflammatory cells, are collectively called cytokines. Several lines of evidence have revealed that cytokines play important
roles not only in tissue homeostasis but also in the pathogenesis of many infectious diseases. Recent research on biological
activities in normal periodontium and the pathogenesis of periodontal diseases has clarified the involvement of various
cytokines in the biological activities observed in the sites. Cytokines play crucial roles in the maintenance of tissue homeostasis,
a process which requires a delicate balance between anabolic and catabolic activities. In particular, growth factors-such as
fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), insulin-like growth factor (IGF), transforming growth fac-
tor-f (TGF-1)-are thought to play important roles in modulating the proliferation and/or migration of structural cells in the
periodontium and the production of various extracellular matrices by these cells. On the other hand, there is little doubt that
excessive and/or continuous production of cytokines in inflamed periodontal tissues is responsible for the progress of peri-
odontitis and periodontal tissue destruction. Particularly, inflammatory cytokines-such as IL-lox, IL-13, IL-6, and IL-8-are
present in the diseased periodontal tissues, and their unrestricted production seems to play a role in chronic leukocyte recruit-
ment and tissue destruction. It is possible that monitoring cytokine production or its profile may allow us to diagnose an indi-
vidual's periodontal disease status and/or susceptibility to the disease. In addition, although the hypothesis is still controver-
sial, it has been suggested that discrete T-cell subsets (Thl and Th2) with different cytokine profiles play specific roles in the
immunopathogenesis of periodontal diseases.

Key words. Cytokine, periodontal tissue, homeostasis, periodontitis.

Introduction constitutively so that they can react to a wide spectrum

Many biological events are strictly regulated by cell-
cell interactions, which are categorized into two
forms: cognate (adhesive) interactions, achieved by
mutual recognition between membrane-bound cell-sur-
face molecules; and cytokine-mediated interactions.
Cytokines are small soluble proteins produced by a cell
that alter the behavior or properties of another cell local-
ly or systemically. Included in the cytokine molecule
group are interleukins, interferons, growth factors, cyto-
toxic factors, activating or inhibitory factors, colony-
stimulating factors, and intercrines. Cytokines are
responsible for the maintenance of an intricate commu-
nication network between the homotypic and heterotyp-
ic cell types. Thus, cytokines play an important role in
numerous biological activities including proliferation,
development, differentiation, homeostasis, regenera-
tion, repair, and inflammation.
As a rule, the synthesis of cytokines is inducible,
although some factors are known to be produced consti-
tutively. Appropriately activated cells usually synthesize
many different cytokines at the same time. Most of these
cells also express specific receptors either inducibly or
of cytokines. Many cytokines were originally classified
based on their cellular origin or their functions. However,
it is now known that cytokines are usually multifunction-
al and are produced by many cell types and that their
biological activities clearly overlap.
At present, the mechanisms by which cytokines act
on the target cells are classified into four types:
autocrine, intracrine, juxtacrine, and paracrine
(Idelgaufts, 1995) (Fig. 1).
For tissue homeostasis, a primary role can be
ascribed to cytokines which are constitutively secreted
by resident cells composing the tissue. On the other
hand, in diseased states, cytokines may be secreted not
only by resident cells but also by locally infiltrated
immunocompetent cells. In this review paper, we sum-
marize cytokine expression in periodontal tissues and its
importance in tissue homeostasis and, in particular, in
the pathogenesis of periodontal diseases.
Cytokine Expression in Periodontal Health
Tissue homeostasis represents a delicate balance
between anabolic and catabolic activities. The regula-
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 cytokine

internalization

receptor

(a) autocrine (b) intracrine

cytokine receptor

extracellular membrane-bound
matrix-associated cytokine

(c) juxtacrine (d) paracrine

Figure 1. The mechanisms by which cytokines act on the target cells. (a) Autocrine: a mechanism involving the synthesis of a cytokine by
one cell that influences the growth and functional activities of the cells producing the cytokine via a specific receptor on its surface. (b)
Intracrine: a mechanism involving the direct action of a cytokine within a cell. Cytokines, such as bFGF, EGF, and PDGF, produce
cytokine/receptor complexes that are rapidly internalized by the cells and translocated to the nucleus without being degraded. bFGF con-
tains a nuclear transport sequence that mediates the transport of this cytokine into the nucleus. (c) Juxtacrine: a mechanism involving spe-
cific cell-to-cell contacts. It occurs via an interaction of a membrane-bound form of a cytokine that is normally secreted with a receptor on
an adjacent cell. Another mode of juxtacrine interaction involves extracellular matrix-associated rather than membrane-anchored forms
of cytokines. (d) Paracrine: a mechanism involving the synthesis of a cytokine by one cell that influences the rowth and functional activ-
ities of nearby cells expressing the receptor for this cytokine. Therefore, this mechanism differs from that mediated by endocrine factors,
which are transported to the site of action by the circulation.

tions of migration, proliferation, and differentiation of
resident cells and of the production of tissue matrix in a
healthy state are major aspects of periodontal tissue
homeostasis. There is abundant evidence that cytokines,
which are secreted by fibroblasts (Moscatelli et al., 1986),
endothelial cells, and epithelial cells, play a crucial role
in tissue homeostasis.
When we examined mRNA expression of cytokines in
clinically healthy gingival tissues by reverse-transcrip-
tion/polymerase chain-reaction (RT-PCR), mRNA expres-
sion of a variety of growth factors-such as epidermal
growth factor (EGF), platelet-derived growth factor
(PDGF), and transforming growth factor-r (TGF-1)-was
observed (T. Nozaki, unpublished data). Interestingly,
mRNA of so-called inflammatory cytokines (such as IL-1,
IL-6, and TNF-cx) was also detected in the clinically
healthy gingival tissues, although their density was rela-
tively low compared with that in the inflamed sites. This
suggests that myriad cytokines may be involved in the
maintenance of periodontal tissue turnover or integrity.
In this section, we focus mainly on the biological activi-
ties of FGF, PDGF, insulin-like growth factor (IGF), TGF-j, and
cementum-derived growth factor (CGF), because these
cytokines have been relatively well-characterized through the
research of periodontal regeneration. In addition, it has been
confirmed at mRNA and/or protein levels that those mole-
cules are constitutively expressed in normal periodontal tis-
sues as described above. However, it is important to note
that the majority of their in vivo roles have thus far been spec-
ulated based mainly on the findings from in vitro studies.

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Crit Rev Oral Biol Med 249

 (I) FIBROBLAST GROWTH FACTOR (FGF)
Fibroblast growth factors (FGF) is one of the well-charac-
terized cytokine families that can be found in many tis-
sues. Two of nine isoforms of FGF have been characterized
in some detail: One is acidic (aFGF; FGF-1), and the other
is basic fibroblast growth factor (bFGF; FGF-2). The two
FGFs are products of different genes (Mergia et al., 1986)
but are similar in structure and biological activities. Both
FGFs bind to heparan sulfate, heparin, and fibronectin in
the extracellular matrix. It has been reported that the FGF
mRNA levels in cells are normally very low, possibly
because of mRNA instability, but tissue levels are relative-
ly high (Hefti, 1993). Acidic fibroblast growth factor (aFGF)
is primarily known for its effect on endothelial cell replica-
tion and neovascularization. In bone tissue cultures, aFGF
stimulates DNA synthesis and cell replication, which
results in increased protein synthesis (Idelgaufts, 1995),
especially of collagen type 1. Like aFGF, bFGF has angio-
genic properties and is highly chemotactic and mitogenic
for a variety of cell types. It stimulates bone cell replica-
tion and increases the number of cells of the osteoblastic
lineage. However, the FGFs have no direct stimulatory
effect on mature osteoblasts and have been shown to
decrease alkaline phosphatase activity (Canalis et al.,
1988). FGF is a potent stimulator of periodontal ligament
(PDL) cell migration and mitogenesis (Terranova et al.,
1989). We have confirmed, by immunohistochemistry, that
bFGF not only exists in the gingival lamina propria but
also is stored in intercellular spaces of gingival epithelial
cells, probably through adherence to glycosaminoglycans
(S. Murakami, unpublished data). Takayama et al. (1997)
also demonstrated that bFGF inhibited the induction of
alkaline phosphatase activity and the mineralized nodule
formation by PDL cells (Takayama et al., 1997). In addition,
it was also shown that the levels of laminin mRNA of
human PDL cells were specifically up-regulated but that
those of type I collagen mRNA were down-regulated by
bFGF. Furthermore, we recently observed that the topical
application of bFGF to experimentally prepared alveolar
bone defects in beagle dogs significantly enhanced the
periodontal regeneration at those sites (Miki et al., 1994).
Thus, we hypothesized that by converting cytodifferentia-
tion of PDL cells into mineralized-tissue-forming cells,
bFGF may induce growth of immature PDL cells, which, in
turn, accelerates periodontal regeneration.
(2) PLATELET-DERIVED GROWTH FACTOR
(PDGF-AA, -AB, -BB)
Platelet-derived growth factor (PDGF), which was original-
ly detected in the a-granules of platelets, is a potent
growth factor for various connective tissue cells (Kohler
and Lipton, 1974; Ross et al., 1974; Westermark and
Wasteson, 1976). A plethora of other cell types also syn-
thesize PDGF, including macrophages, endothelial cells,
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fibroblasts, glial cells, astrocytes, myoblasts, and
smooth-muscle cells. The PDGF molecule consists of two
disulfide-bonded polypeptide chains, denoted A and B
(Grant et at., 1987). Platelets synthesize a mixture of the
three possible isoforms (70% AB, 20% BB, 10% AA), while
EGF-stimulated fibroblasts synthesize AA homodimers.
Activated macrophages and placental cytotrophoblasts
produce the BB homodimer. The binding of PDGF to sev-
eral plasma proteins and extracellular matrix facilitates
local concentration of the factor.
PDGF functions as a local autocrine and paracrine
growth factor. PDGF binds to specific high-affinity recep-
tors expressed on the surfaces of various cell types
(Heldin et al., 1981), including fibroblasts, glial cells, and
vascular smooth-muscle cells. PDGF is a powerful pro-
moter of cell migration and proliferation. It has been
shown that all isoforms of PDGF induce the proliferation
of PDL cells in vitro (Piche et al., 1989; Matsuda et al., 1992;
Oates et al., 1993; Dennison et al., 1994). PDGF is also
chemotactic for PDL cells and stimulates collagen and
hyaluronate synthesis (Matsuda et al., 1992; Bartold,
1993). It was also reported that PDGF promotes DNA syn-
thesis and chemotaxis in bone organ culture (Graves et al.,
1989; Hughes et at., 1992; Hock and Canalis, 1994) but
down-regulates alkaline phosphatase activity and osteo-
calcin in osteoblast-like cells in vitro (Giannobile et al.,
1994b). It has been shown that topical application of a
combination of PDGF/IGF-I (see below) (Lynch et at., 1989,
1991; Rutherford et al., 1992; Giannobile et al., 1994a, 1996)
or PDGF/dexamethasone promoted periodontal tissue
regeneration in vivo (Rutherford et at., 1993).
(3) INSULIN-LIKE GROWTH FACTORS
(IGF-I AND -11)
Two different IGFs (IGF-I and IGF-II) have been described
(AAP, 1996). Both were isolated initially as serum factors
with insulin-like activities that could not be inhibited by
anti-insulin antibodies (Idelgaufts, 1995). IGF-I and IGF-
II are encoded by two different genes which are
expressed differentially in different tissues. The structure
of both IGFs is homologous to human pro-insulin.
However, IGFs do not cross-react immunologically with
each other. IGF is constitutively produced in many tis-
sues, including liver, kidney, heart, lung, fat tissues, and
various glandular tissues. IGF-I is also produced by chon-
droblasts, fibroblasts, and osteoblasts. In addition, IGF-
1 stimulates bone formation by inducing cellular prolif-
eration, differentiation, and type I collagen biosynthesis
(Canalis, 1980; Hock et al., 1988). It is generally suggest-
ed that IGF-I is usually a stronger mitogen than IGF-II. In
periodontal research, it was shown that IGF-I is chemo-
tactic and mitogenic for PDL cells (Matsuda et al., 1992).
Although a single application of IGF-l only slightly
induces periodontal tissue regeneration, several lines of
evidence suggest that IGF-I combined with other growth
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factors-such as bFGF, PDGF, and TGF-3-may augment
the osseous wound-healing process (AAP, 1996).
(4) TRANSFORMING GROWTH FACTOR I (TGF-D)
Transforming growth factor D (TGF-3) was originally puri-
fied from human placenta, platelets, and bovine kidney
(Hefti, 1993). TGF-3 appears to be synthesized by all nor-
mal cells studied to date. The different isoforms of TGF-
f (TGF-31, TGF-32, TGF- 13) are encoded by different
genes. TGF-C isotypes share many biological activities,
and their actions on cells are qualitatively similar in
most cases. TGF-3 is the most potent known growth
inhibitor for epithelial cells, endothelial cells, fibroblasts,
neuronal cells, lymphocytes, and hepatocytes. TGF-1
stimulates the synthesis of connective tissue matrix
components, such as collagen (Fine and Goldstein, 1987;
Schweigerer et at., 1988), fibronectin (Varga et al., 1987),
proteoglycan (Chen et al., 1987), glycosaminoglycan
(Westergren-Thorsson et al., 1990), osteonectin
(Pfeilschifter et al., 1990), and osteopontin in many cell
types, including PDL cells (Matsuda et al., 1992). It also
inhibits the degradation of matrix proteins by inhibiting
the synthesis of metalloproteinases such as collagenase
(Laiho and Keski-Oja, 1989; Overall et al., 1991) and by
increasing the synthesis of proteinase inhibitors
(Edwards et al., 1987; Overall et al., 1989). TGF-4 has sig-
nificant effects on bone formation, though the effects
appear to be highly dependent on bone cell source, dose
applied, and local environment, as shown in studies that
demonstrate either stimulation or inhibition of
osteoblast proliferation.
(5) CEMENTUM-DERIVED GROWTH FACTOR (CGF)
Interestingly, cementum has been shown to contain
substances that influence the biological activities of
fibroblasts of adjacent soft tissues. One of the biologically
active molecules, that was designated as cementum-
derived growth factor (CGF), was detected exclusively in
cementum and was shown to be the major cementum
mitogen for PDL cells and gingival fibroblasts
(Narayanan and Yonemura, 1993). It has been suggested
that CGF may promote the migration and growth of
progenitor cells present in structures adjacent to the
dentin matrix and participate in their differentiation
into cementoblasts. Recently, Ikezawa et al. (1997) report-
ed that CCF was an IGF-I-like molecule because the activ-
ity of CGF was similar to that of IGF- I and it was inhibit-
ed by anti-IGF-I antibodies. The sequence of one 15-
amino-acid-long peptide was the same as that of the
receptor-binding domain of IGF-I, and another 9-amino-
acid peptide had 78% homology to a sequence derived
from an untranslated region of sheep IGF- 1 exon 1.
However, four other peptides sequenced had no apparent
homology with IGF-I. Further molecular characterization,
including molecular cloning, would be of great value.
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The interesting and important fact is that cytokines
described above in this section are also shown to have a
significant effect in inflammatory responses (Alexander
and Damoulis, 1994). It was reported that PDGF-AB and
-BB, but not -AA, stimulated Ca2+ release from neonatal
mouse calvaria by a prostaglandin-mediated mechanism
(Cochran et al., 1993). IGF-I was also shown to have an
effect on bone resorption by enhancing the generation of
osteoclasts (Mochizuki et al., 1992; Slootweg et al., 1992).
In addition, it was reported that TGF-3 induced leukocyte
recruitment and activation and was responsible for
inflammatory cell accumulation (Wahl et al., 1993a,b).
These facts imply that tissue homeostasis is maintained
by a delicate balance among a variety of cytokines.
Cytokine Expression in Periodontal Diseases
Extensive research in the past decades has demonstrated
that cytokines play important roles in tissue homeostasis.
In addition, it has been shown that increased production
of cytokine(s) can lead to disease onset and/or tissue
damage (Idelgaufts, 1995). For example, elevated
amounts of IL-1 are found in the synovial fluid of
patients with rheumatoid arthritis and osteoarthritis
(Bomford and Henderson, 1989; Dinarello and Worff,
1993), and several diseases have been reported to be
associated with the aberrant expression of IL-2 or IL-2
receptors, including Hodgkin's disease, graft-vs.-host
reaction, multiple sclerosis, rheumatoid arthritis, sys-
temic lupus erythematosis, and lepromatous leprosy
(Blaise et al., 1991; Waxman and Balkwill, 1992; Waldmann
et al., 1993; ldelgaufts, 1995). The excessive production of
IL-6 has been observed in various pathological conditions,
such as rheumatoid arthritis, multiple myeloma, Lennert
syndrome, Castleman's disease, cardiac myxomas, and
chronic polyarthritis (Yoshizaki et al., 1989; Kishimoto,
1990; Bauer and Herrmann, 1991; Hsu et al, 1993). IL-8
probably plays a role in the pathogenesis of chronic pol-
yarthritis, since excessive amounts of this factor are found
in synovial fluid (Peichl et al., 1991).
ROLE OF INFLAMMATORY CYTOKINES
IN PERIODONTAL DISEASES
Periodontal diseases, especially periodontitis, are chron-
ic infectious diseases which are characterized by a
destructive inflammatory process affecting the support-
ing tissues of the tooth, resorption of the alveolar bone,
formation of periodontal pockets, and eventual tooth
loss (Williams, 1990). Histologically, periodontal disease
is also characterized by inflammatory cell accumulation
in the extravascular gingival connective tissues (Mackler
et al., 1977; Okada et al., 1983; Taubman et al., 1984;
Seymour, 1987; Williams, 1990). Numerous bacterial
species have been isolated from subgingival plaque, and
some of those are thought to be closely associated with
disease onset and progression (AAP, 1996). Since the
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TABLE 1
Pathophysiological Roles of Inflammatory Cytokines
in Periodontal issue Destruction
Cytokine Functions
IL-l Enhancement of bone resorption
Stimulation of metalloproteinase production
Stimulation of plasminogen activator
Stimulation of prostaglandin synthesis
IL-6 B-cell activation, resulting in non-specific antibody pr oduction
and IL-1 production
Enhancement of bone resorption
IL-8 Stimulation to attract and activate neutrophils
TNF-ot Enhancement of bone resorption, showing synergistic
effects with IL-1
majority of periodontopathic bacteria reside in periodontal
pockets and do not invade the periodontal tissues, the
immune system can never efficiently eliminate the micro-
organisms. This unique situation leads to a chronic inflam-
mation and continuous/excessive host responses, resulting
in tissue destruction. The local host response to these bac-
teria includes the recruitment of leukocytes and the subse-
quent release of inflammatory mediators and cytokines,
which appear to play crucial roles in the pathogenesis of
periodontal diseases.
An inflammatory cytokine is defined as a cytokine
which is induced during the course of an inflammatory
response and is closely associated with its onset and/or
progression. Thus far, IL-lcx, IL- I13, IL-6, IL-8, and TNF-cx
are generally classified as inflammatory cytokines. Since
one prominent feature of periodontal disease is resorp-
tion of alveolar bone, particular attention has been paid
to the roles of IL-lot, IL-1f, IL-6, IL-8, and TNF-ox in the
pathogenesis process, due to their enhancement of bone
resorption (Table 1). Noteworthy is the fact that
cytokines that play important roles in inflammatory
responses are also prominent regulators of normal tis-
sue homeostasis. In fact, mRNA expression of cytokines
that have been associated with periodontitis was consti-
tutively detected, to some extent, in clinically healthy
gingival tissues (Okada et al., 1996). For instance, in
healthy periodontal tissue, IL-1 stimulates the prolifera-
tion of keratinocytes, fibroblasts, and endothelial cells
(Hefti, 1993). In addition, IL-I enhances fibroblast synthe-
sis of Type I procollagen, collagenase, hyaluronate, and
fibronectin. Although cytokines are produced by locally
infiltrated immunocompetent cells such as T-cells and
monocytes at the diseased sites, cell types that normally
compose the tissue-such as fibroblasts, epithelial cells,
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and endothelial cells-are also involved in
cytokine production during the inflammato-
ry response. In this section, the biological
activities of those cytokines that appear to
be closely related to the pathogenesis of
periodontal diseases are summarized
(Table 1).
BIOLOGICAL ACTIVITIES
OF THE INFLAMMATORY CYTOKINES
(1) Interleukin-1 (IL-1)
IL-I is a polypeptide with a great number of
diverse activities and roles in immunity,
inflammation, tissue breakdown, and tissue
homeostasis (Mizel et al., 1981; Schmidt et
al., 1982; Gowen et al., 1986; Stashenko et al.,
1987a,b; Dinarello, 1988; Mizel, 1989;
Nguyen et al., 1991; Tatakis, 1993; Havemose-
Poulsen and Holmstrup, 1997). Following
activation, it is synthesized by various cell
types, including macrophages, monocytes, lymphocytes,
vascular cells, brain cells, skin cells, and fibroblasts. IL-
Icx and IL-13 share only 27% homology at the amino acid
level, but they have similar biological functions. It has
been demonstrated that IL-lcx remains largely cell-asso-
ciated, whereas IL-13 is released from the cell (Hazuda et
al., 1988). The two interleukin forms bind to the same
receptor, which is found on many cell types in various
densities.
IL-1 is known to stimulate the proliferation of ker-
atinocytes, fibroblasts, and endothelial cells and to
enhance fibroblast synthesis of type I procollagen, colla-
genase, hyaluronate, fibronectin, and prostaglandin E 2
IL-I is, therefore, a critical component in the homeosta-
sis of periodontal tissues. However, unrestricted produc-
tion of IL-1 may lead to tissue damage (Table 1). The
local excessive production of IL- I by cells composing the
periodontium appears to be capable of stimulating gin-
gival and periodontal ligament fibroblasts, in an
autocrine or paracrine fashion, to induce the production
of other cytokines, matrix-degrading enzymes, and
prostaglandin E2. These mediators may be responsible
for effecting connective tissue destruction, leading to
loss of attachment. Thus, IL-1 has been suggested to
play a key role in the pathogenesis of various bone dis-
eases, including periodontitis.
IL-hx, IL-13, and tumor necrosis factor-alpha (TNF-
x) stimulate bone resorption and inhibit bone formation
(Stashenko et al., 1987b; Nguyen et al., 1991; Tatakis,
1993). In addition, IL-1 synergizes the bone-resorptive
actions of TNF-ox (Bertolini et al., 1986; van der Pluijm et
al., 1991). Several in vitro studies have found that IL-1I3 is
significantly more potent than either IL-1(X or TNF-a in
mediating effects on bone (Alexander and Damoulis,
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1994). Another important activity of IL- I in the patholog-
ical process of periodontitis is to induce the production
of matrix metalloproteinases (MMPs) (Havemose-
Poulsen and Holmstrup, 1997). IL-1 gives rise to an ele-
vated level of procollagenase in both gingival fibroblasts
and periodontal ligament (PDL) cells (Meikle et al., 1989;
Lark et al., 1990; Richards and Rutherford, 1990; Tewari et
al., 1994). No significant change in tissue inhibitors of
metalloproteinase (TIMP) synthesis was observed after
treatment of gingival fibroblasts and PDL cells with IL- I D
(Meikle et al., 1989) as well as no change in TIMP mRNA
level in PDL cells (Alvares et al., 1995). In addition, IL-1
stimulate plasminogen activator in gingival fibroblasts,
resulting in the generation of plasmin which is a puta-
tive, naturally occurring, activator of several matrix met-
alloproteinases (Mochan et al., 1988). Furthermore,
Stashenko and co-workers reported a positive correlation
between IL-1f3 levels in gingival tissues and recent
attachment loss (Stashenko et al., 1991).
(2) Interleukin-6 (IL-6)
IL-6 is a pleiotropic cytokine influencing immune
responses and inflammatory reactions (Hirano, 1991). IL-
6 is produced by many different cell types. The main
sources in vivo are stimulated monocytes, fibroblasts, and
endothelial cells. Macrophages, T- and B-cells, and ker-
atinocytes also produce IL-6 after stimulation. It was
reported that IL-6 levels in inflamed gingival tissues were
higher than those in healthy control tissues (Bartold and
Haynes, 1991). One of the major functions of IL-6 is the
induction of the final maturation of B-cells into
immunoglobulin-secreting plasma cells. It stimulates the
secretion of antibodies to such a degree that serum IgGi
levels can rise 120-400-fold. In inflammatory periodontal
lesions, a variety of cell types-such as T-cells,
macrophages, endothelial cells, and fibrobalsts-was
shown to express IL-6 at both mRNA and protein levels
(Kono et al., 1991; Matsuki et al., 1992; Fujihashi et al.,
1993a; Gemmell and Seymour, 1993; Yamazaki et al.,
1994). Since IL-6 is of particular importance in human B-
cell responses, it has been speculated that the expansion
of B-cells/plasma cells seen in periodontitis lesions may
result from an increased production of IL-6 at diseased
sites (Fujihashi et al., 1993b). In addition, it is suggested
that IL-6 plays an important role in the local regulation
of bone turnover (Lowik et al., 1989; Ishimi et al., 1990;
Kurihara et al., 1990) and appears to be essential for bone
loss caused by estrogen deficiency (Horowitz, 1993). In
vitro studies also demonstrated that simultaneous treat-
ment of mouse osteoblastic cells and bone marrow cells
with IL-6 and soluble IL-6 receptor strikingly induced
osteoclast formation (Tamura et al., 1993). Furthermore, it
was also suggested that IL-6 may act as an autocrine
and/or paracrine factor in bone resorption in pathologic
states by stimulating the formation of osteoclasts and
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the activation of osteoclastic bone resorption (Ohasaki et
al., 1992). These findings imply the involvement of IL-6 in
the pathogenesis of periodontal tissue destruction in
periodontitis (Table 1). Recently, the IL-6/IL-6 receptor
complex has been shown to stimulate gingival fibroblasts
in vitro (Y. Murayama, personal communication).
(3) Interleukin-8 (IL-8)
IL-8, formerly known as neutrophil-activating peptide-i
(NAP-1), is a potent chemotactic factor for leukocytes
(Bickel, 1993; Skerka et al., 1993). IL-8 is secreted by a
variety of cells, including monocytes, fibroblasts, lym-
phocytes, and endothelial cells. In inflamed gingival tis-
sues, it was observed that IL-8 was expressed in epithe-
lial cells and macrophages. It was also reported that IL-
1- or TNIF-u-stimulated gingival fibroblasts expressed
IL-8 mRNA (Odake et al., 1993). Because of its pro-inflam-
matory and neutrophil chemotactic properties, IL-8 may
play a significant role in the pathogenesis of periodonti-
tis (Table 1). It is likely that locally secreted IL-8 induces
neutrophil extravasation at the site of inflammation and
that the numerous neutrophils present in the lamina
propria and the epithelium of inflamed gingiva may be
directed there by IL-8. It is known that the patients who
suffer from systemic diseases characterized in part by
neutrophil dysfunction, such as Chediak-Higashi syn-
drome and leukocyte adhesion deficiency (LAD), dis-
play increased severity in periodontal breakdown. This
suggests that the infiltrates of neutrophils play a cru-
cial role as the first line of defense against the insult of
periodontopathic bacteria. However, continuous and
excessive IL-8-mediated chemotactic and activation
effects on neutrophils in the inflamed gingiva may con-
tribute to local tissue destruction of the periodontal
tissues. IL-8 may also attract T-cells and induce motil-
ity in the CD45RO+ y8 and o43 T-cells present in
inflamed gingiva (Lundqvist and Hammarstrom, 1993;
Gemmell and Seymour, 1995).
(4) Tumor necrosis factor a (TNF-oL)
TNF-x is a pro-inflammatory cytokine that is secreted
mainly by monocytes and macrophages. It induces the
secretion of collagenase by fibroblasts, resorption of car-
tilage and bone, and has been implicated in the destruc-
tion of periodontal tissue in periodontitis (Elias et al.,
1987; Meikle et al., 1989; Chaudhary et al., 1992; Alexander
and Damoulis, 1994). In resting macrophages, TNF-c-
induces the synthesis of IL-I and prostaglandin E2. TNF-cx
also activates osteoclasts and thus induces bone resorp-
tion (van der Pluijm et al., 1991; Bertolini et al., 1986;
Johnson et al., 1989). Although both forms of IL-1 are at
least 10 times more potent on a molar basis than TNF-cx
in the induction of bone demineralization, TNF-ot has
synergistic effects with the bone-resorptive actions of IL-I
(Bertolini et al., 1986; Johnson et al., 1989; Mundy, 1989;
253
Med
Med 253
van der Pluijm et al., 1991). Lipopolysaccharide (LPS)
obtained from periodontal Gram-negative bacteria can
initiate the production of TNF-ox by peripheral blood
monocytes (Van Dyke et al., 1993), which in turn leads not
only to alveolar bone resorption but also to the
enhanced synthesis of collagenase by human gingival
fibroblasts. In fact, it has previously been demonstrated
that gingival fibroblasts stimulated in vitro with TNF-o are
able to degrade collagen (Meikle et al., 1989).
CELL TYPES PRODUCING CYTOKINES
IN INFLAMMATORY PERIODONTAL LESIONS
(1) Monocytes/macrophages
Macrophages constitute from 5 to 30% of the infiltrating
cells in inflamed periodontal lesions. In vitro studies have
shown that macrophages produce cytokines such as IL- 1,
IL-6, IL-10, IL-12, IL-13, TNF-cx, and IFN-oc. In particular, it
is believed that macrophages play a central role in the
production of IL-1 in inflamed sites (Oppenheim et al.,
1986; Le and Vilcek, 1987; Page, 1991). Most human IL- I
produced by stimulated macrophages is IL-13. Matsuki
and co-workers (1992) also demonstrated, by in situ
hybridization, that IL-Lx or IL-13 mRNA-expressing cells
in the inflamed gingival tissues were mostly
macrophages. Furthermore, mRNA expression of TNF-cx,
IL-6, and IL-8 was also detected in the macrophages in
inflamed periodontal tissue.
Several studies have shown that periodontopathic
bacteria-such as Porphyromonas gingivalis (Pg),
Actinobacillus actinomycetemcomitans (Aa), and Fusobacterium
nucleatum (Fn)-induce expression of IL-1 in mononu-
clear cells/monocytes (Lindemann and Economou, 1988;
Lindemann et al., 1988; Garrison and Nichols, 1989;
Walsh et al., 1989; Bom-van Noorloos et al., 1990;
McFarlane et al., 1990; Hanazawa et al., 1991; Gemmell
and Seymour, 1993). These investigators have also
shown that whole Gram-negative bacteria, their LPS,
lipoteichoic acid, and fimbriae had stimulatory effects on
IL-1 production by monocytes. A study of peripheral
mononuclear cells from periodontitis patients demon-
strated that unstimulated monocytes and monocytes
stimulated by LPS derived from Aa produced more IL-1 i
than did similarly stimulated monocytes from healthy
controls (McFarlane et al., 1990).
(2) Lymphocytes (T-cells and B-cells)
Naive T-cell recognizes antigen on the surface of a pro-
fessional antigen-presenting cell (APC) and receives the
required two signals (one is via T-cell receptor, and the
other is via co-stimulatory molecules such as CD28),
becomes activated, and clonally expands by secreting
and responding to IL-2. Activated lymphocytes, particu-
larly helper T-cells, are known to produce a variety of
cytokines, including inflammatory cytokines (discussed
Grit Rev
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Oral Biol Med
254 Crit
above). Owing to the presence of numerous lymphocytes
in inflammatory periodontal lesions, cytokines produced
from the locally infiltrated lympocytes may be deeply
involved not only in the protection against an offending
agent but also in the onset and progression of periodon-
titis. In established periodontitis lesions, the majority of
infiltrating cells are B-cells/plasma cells (Okada et al.,
1983). Seymour and co-workers (1996) proposed that a
local expansion of the B-cell population would result in
production of IL-I by B-cells and, hence, subsequent tis-
sue destruction. Many investigators have confirmed that
T-cells with an activated phenotype are often present in
inflamed periodontal lesions (Okada et al., 1983;
Yamazaki et al., 1993). As discussed in more detail below,
activated T-cells with a helper (CD4+) phenotype secrete
a variety of cytokines, including IL-1, IL-6, and TNF-ox.
More specifically, IL-6 production by T-cells in inflamed
periodontal lesions has been confirmed at both the
mRNA and protein levels (Fujihashi et al., 1993a;
Yamamoto et al., 1997; Yamazaki et al., 1994). These find-
ings have contributed to the speculation about the
involvement of IL-6 not only in bone destruction but also
in the establishment of B-cell-rich lesions in inflamma-
tory periodontal lesions.
(3) Gingival fibroblasts
Gingival fibroblasts are the most abundant cells in periodontal
tissues, with the capacity for local production of cytokines
with immune-regulatory and catabolic functions. Recent
observations demonstrated that gingival fibroblasts
secrete a variety of cytokines (IL-lot, IL-13, IL-6, IL-8,
TNF-o) and chemical mediators when they are activated
with physiological and pathological stimuli in vitro
(Takada et al., 1991; Matsuki et al., 1992; Shimizu et al.,
1992; Takashiba et al., 1992; Odake et al., 1993). It has been
reported that cultured gingival fibroblasts stimulated
with LPS from Prevotella and Porphyromonas species pro-
duce IL-1 and IL-6 (Takada et al., 1991). Interestingly, a
comparison of the effects of LPS from different bacteria
showed that the LPS preparations from Prevotella interme-
dia and Pg were more effective inducers of IL-8 mRNA in
fibroblasts than were LPS from other bacteria (Tamura et
al., 1992). There is also evidence that Aa-challenged gin-
gival fibroblasts from early-onset periodontitis (EOP)
patients were capable of secreting considerable amounts
of IL-6 and IL-8 in vitro (Dongari-Bagtzoglou and
Ebersole, 1996). In addition, gingival fibroblasts can be
stimulated with a variety of cytokines, such as IL-1, IL-6,
and IFN-,y, to secrete IL-1, IL-8, and TNF-cu. Interestingly,
it has been shown that PDL cells respond to mechanical
tension forces by elevated synthesis of IL-13 (Shimizu et
al., 1994). Recently, Murakami and co-workers (Murakami
and Okada, 1997; Murakami et al., 1997a) reported that
direct interaction between lymphocytes and gingival
fibroblasts could stimulate gingival fibroblasts to induce
9(3):248-266
9(3):248-266 (1998)
cytokine mRNA expression, including IL-la, IL-1l3, and
IL-6, in gingival fibroblasts. mRNA expression of IL-13 in
gingival fibroblasts increased synergistically when gingi-
val fibroblasts adhesively interacted with lymphocytes in
the presence of exogenous IL-lI3 (Murakami et al., 1998).
Furthermore, it was also reported that CD40, which plays
a crucial role in cognate-type interactions with T-cells
expressing the CD40 ligand, on gingival fibroblasts trans-
duces the signals which induce IL-6 production (Blieden
et al., 1997), and fibroblast-like cells have been shown to
stain positively for IL-6 at the protein level (Yamazaki et al.,
1994). These new findings imply that gingival fibroblast-
lymphocyte interactions may facilitate the cytokine net-
work in inflamed gingival tissues.
(4) Gingival epithelial cells (keratinocytes)
Gingival epithelial cells play an important role as the first
barrier against the offending bacterial agents in periodontal
pockets. Using RT-PCR, Lundqvist and co-workers (1994)
showed that gingival epithelial cells freshly isolated from
normal and inflamed gingiva expressed IL-13, IL-6, IL-8,
TNF-ac, and TGF-31 and that the cytokine profiles of
epithelial cells from normal and inflamed gingiva were
similar. We recently established SV40-transformed
epithelial cell lines, OBA-9, and examined the cytokine
expression of OBA-9 and untransformed gingival epithe-
lial cell lines which were cultured in the presence or
absence of sonic extract, purified fimbriae, and LPS of Pg
or IL-1IO in vitro. We found increased expression of IL-1I3,
IL-6, IL-8, TNF-a, and monocyte chemoattractant pro-
tein- (MCP- 1) mRNA in the activated gingival epithelial
cell lines. The increase in IL-8 and MCP-1 mRNA expres-
sion was particularly noteworthy (Saito et al., 1997). Since
IL-8 and MCP-I are chemotactic for neutrophils and
monocytes, respectively, one could speculate that
epithelial cells confronting periodontopathic bacteria
may activate the recruitment of immunocompetent cells
by secreting these cytokines.
(5) Endothelial cells
It was thought that the most important property of
endothelial cells was to act as a non-thrombogenic sub-
strate for blood. However, recent evidence has revealed
that endothelial cells play important roles in the active
extravasation of leukocytes and cytokine expression
(Mantovani et al., 1997). In vitro studies showed that
endothelial cells can secrete cytokines (including vari-
ous chemokines such as IL-8), MCP-1, IL-1, and IL-6
when the cells were stimulated with LPS, TNF-ox, IL- 1, IL-
4, IL- 13, or the IL-6-soluble IL-6 receptor complex
(Mantovani et al., 1997). In inflammatory periodontal
lesions, investigators have shown that activated
endothelial cells express cell adhesion molecules which
facilitate leukocyte extravasation into the site (Moughal
et al., 1992). Cytokine expression by endothelial cells in
9(3) 248 266 (1998)
9(3):248-266 1998)
Grit
Crit Rev Oral
Rev
inflamed gingival tissues has also been confirmed
(Matsuki et al., 1992).
CYTOKINE EXPRESSION
AND PERIODONTAL DISEASE STATUS
When inflammatory responses are generated in any given
tissue, the expression of a variety of cytokines is generally
increased at the site and then down-regulated to control
the local inflammatory response. As repeatedly stated
above, it has been observed that unrestricted production
of cytokine(s) can lead to onset and progression of certain
diseases. This raises the possibility that we may objec-
tively diagnose the severity of inflammation by monitoring
the cytokine level or profile at the inflamed site. In order
to diagnose the disease activity of periodontal tissues,
researchers have investigated the possible relationships
between levels of various inflammatory cytokines in gin-
gival crevicular fluid (GCF) and the periodontal disease
status or condition.
It has been shown by many investigators that IL-lo-,
IL-11, IL-6, IL-8, and TNF-ot can be detected in GCF
(Rossomando et al., 1990; Geivelis et al., 1993; Payne et al.,
1993). Some of those reports suggested that the cytokine
levels in GCF were closely associated with the severity of
inflammatory responses and/or periodontal tissue
destruction (Masada et al., 1990; Stashenko et al., 1991).
Masada and co-workers (1990) demonstrated that IL-1
levels were elevated in GCF at periodontitis sites and
that marked reductions of total IL- 1 levels were observed
following effective treatment. They also commented that
IL-l3 was detected more frequently than IL-lcx in GCF
from untreated patients with periodontitis. Reinhardt
and colleagues (1993) reported that elevated levels of IL-
ha, IL-hI , and IL-6 were detected in the GCF of patients
with refractory periodontitis. Since IL-6 levels detected in
GCF were higher than IL- I levels, they suggested that IL-
6 may play a role in the identification of patients exhibit-
ing refractory periodontitis and its underlying mecha-
nisms. In addition, it was also reported that IL-8 was
detectable in the GCF of periodontitis patients, and that
IL-8 and IL-1f GCF levels were significantly correlated
with one another (Payne et al., 1993). Others, however,
have reported that IL- 13 concentrations did not correlate
with GCF volume or clinical measurements of plaque
index, bleeding index, or probing depth (Wilton et al.,
1993). TNF-cx has also been detected in GCF but did not
correlate with gingival index, plaque index, or probing
depth (Rossomando et al., 1990). It has been suggested
that TNF-a may be a marker of early inflammatory activ-
ity because of the lack of correlation of clinical inflam-
mation with the TNF-oa levels. Although a sensitive
method, i.e., immunoadsorption-magnetic separation
technology, for the detection of TNF-a in GCF was also
used, a correlation between TNF-a level and clinical
parameters was still not evident (Rossomando and
Oral Bid Med
Biol Med 255
TABLE 2
Thl and Th2 Cytokine Patterns of Various Cell Types
Cell Type Th 1 -type
ThO IL-2*, IFN-y, LT
ThI IL-2, IFN-y, LT
Th2
Tcl IL-2, IFN--y, LT
Tc2
CD4+y8T IFN--y
CD8+y8T IFN--y
B-cell
l1-10, and IL-1 3 is not as tightly restricted to a single subset as in mouse T-cells.
*In human T-cells, the synthesis of IL-2, IL-6,
(Adapted and modified from Mosmann and Sad [1996].)
White, 1993). A possible correlation among bleeding
index, probing depth, and the IL-6 levels of the crevicu-
lar fluid has also been demonstrated (Geivelis et al.,
1993). However, further research is needed for the eval-
uation of IL-6 as a possible marker of periodontal
breakdown.
As discussed above, inflammatory responses in
periodontal tissues are regulated by an orchestrated
cytokine network. At the present time, there are no
reports on the expression of multiple, not just a few,
cytokines in the periodontal tissues at any given time.
Monitoring the expression of multiple cytokines in
inflamed periodontal tissues might be an objective way
of evaluating disease activity in periodontitis. Recently,
we have examined mRNA expression of multiple
cytokines and enzymes in gingival tissues by combining
a needle biopsy method and the reverse-transcrip-
tion/polymerase chain-reaction (RT-PCR) technique
(Okada et al., 1996; Nozaki et al., 1997). In this procedure,
the periodontal tissue specimens (less than 1 mg) were
obtained from patients with adult periodontitis (AP) or
EOP without serious tissue damage at the sampling site.
Also, this procedure allows us to collect the gingival
specimens at any phase of periodontal treatment. To
date, we have obtained the following information
(Nozaki et al., 1997):
(1) mRNA expression of IL-1ct, IL-1f3, IL-1 receptor
antagonist (IL-IRA), IL-6, IL-8, IL-10, IL-15, TNF-cx, IFN-'y,
and TGF-j was detectable in both clinically healthy and
inflamed gingival tissue from AP patients;
(2) mRNA expression of IL-lax, IL-1p3, IL-6, IL-8, IL-
10, IL-15, TNF-ax, and IFN--y tended to be higher in
inflamed than in healthy sites of AP patients; and
(3) interestingly, IL-8 mRNA expression was low or
undetectable in disease sites of EOP patients, compared
with that of AP patients.
256
256
Th2-type Common
IL-4/-,5, -6,-9, -0l,o 13* IL-3, GM-CSF, TNF, CK
IL-3, GM-CSF, TNF, CK
IL-4, -5, -6, -9, -10, -13 IL-3, GM-CSF, TNF, CK
GM-CSF, TNF, CK
IL-A, -5, -6, -9, -10, -13 IL-3, GM-CSF, TNF, CK
IL-6 TNF
IL-4A -10
These results suggest that unique characteristics of EOP
may be explained, at least in part, by impaired IL-8 pro-
duction. The approach described above may provide
insight toward a better understanding of the character-
istic features of each type of periodontal disease based
on the cytokine profile, and possible establishment of a
specific "cytokine therapy" for each type of periodontal
disease.
Recently, Kornman et al. (1997) reported that a spe-
cific genotype in the IL-1 gene cluster, that includes a
locus associated with increased IL-1 production, corre-
lates with severe periodontitis. This suggests that a
genetic mechanism exists by which some individuals, if
challenged by bacterial accumulations, may have a more
vigorous immuno-inflammatory response, leading to
more severe periodontitis. These findings suggest a cor-
relation between the level of cytokine production and
susceptibility to severe periodontitis. It is expected that
the susceptibility to severe periodontitis may be diag-
nosed, at least in part, by genetic analysis.
CYTOKINE (LYMPHOKINE) EXPRESSION
BY T-CELLS IN PERIODONTAL DISEASE
Among the immunocompetent cells, T-cells (particularly
helper T-cells) play crucial roles in regulating a variety of
immune responses by secreting various cytokines, for-
merly known as lymphokines. It has been reported that
approximately 40-50% of cells in the gingival mononu-
clear cells of patients with adult periodontitis are CD3+
T-cells (Yamamoto et al., 1997). Furthermore, when the
gingival mononuclear cells were stained for T-cell sub-
sets, the number of CD4+ (helper) T-cells ranged from 20-
30%, while approximately 10-20% of the cells were CD8+
(cytotoxic/suppressor) T-cells. Although it has been
revealed that B-cells and plasma cells are dominant in
progressive periodontal lesions (Genco et al., 1977;
ritRev ralBiolMed9(3)48-66 (998
Crit Rev Oral Biol Med 9(3):248-266 (1998)
 (IL-12) IL-10

Macrophage K

IL-12 IFNy
IFNy Thl
TGFp( - o DTH response
(induction)
L4(suppression)
IFNyH IL-10
-b-o
periodontal
V ThO /(suppression) (suppression) tissue
destruction
N, IFNY,TGFR3
(suppression)
IL-4
(induction) unrestricted
Th2 B cell activation
IL6 (non-specific antibody production
IL-13 and IL-1 production)
Figure 2. Induction of Thl and Th2 cells and their possible involvement in periodontal tissue destruction. Both ThI and Th2 cells are thought
to go through a common intermediate stage, ThO. IL-4 stimulates differentiation of ThO cells into Th2 cells, whereas IL-i 2, IFN--y, and TGF-
l enhance differentiation into ThI cells. Macrophages are thought to play a central role in the production of IL-12, which stimulates Thl
cell generation. Furthermore, cellular functions of both ThI and Th2 cells are mutually regulate. IFN-y, secreted by Thl cells, selectively
inhibits proliferation of Th2 cells; IL-1 0, secreted by Th2 cells, inhibits cytokine synthesis by ThI cells. Recent observations have demon-
strated that IL-10 can be secreted by Thl and Th2 cells (Gerosa et aI., 1996; Windhagen et a/., 1996). This hypothesis suggests the pos-
sible involvement of unrestricted activation of Thl or Th2 cells in periodontal tissue destruction.

Mackler et al., 1977; Okada et al., 1983), the findings
presented above suggest that T-cells probably play a
crucial role in regulating or modulating local immune
responses at diseased sites.
ROLE OF TH I- AND TH2-TYPE CYTOKINES
(LYMPHOKINES) IN PERIODONTAL DISEASE
Mosmann and Sad (1996) reported that most cloned
lines of murine CD4+ T-cells can be classified into two
groups, ThI and Th2, based on their cytokine profiles
and their related functional activities (Table 2). Later,
Thl and Th2 patterns of cytokine production were also
observed among human T-cells (Del Prete et al., 1991).
The differentiation of CD4+ T-cells into Th 1 or Th2 is the
crucial event in determining whether humoral or cell-
mediated immunity will predominate. CD4+ T-cells can
differentiate into either Thl or Th2 cells, and the final
decision on which of these fates the cell will follow is
made during their first encounter with antigen. As CD4+
T-cells differentiate, they are thought to go through an
intermediate stage, known as ThO (Fig. 2). ThO cells
express some differentiated effector functions that are
characteristic of both the inflammatory and the helper
T-cells. Several lines of evidence have demonstrated
that IL-4 stimulates differentiation into Th2 cells, where-
as IFN--y, IL-12, and TGF-P enhance Thl development
(Mosmann and Sad, 1996). Mouse Thl cells produce
interleukin 2 (IL-2), interferon-y (IFN--y), and lymphotox-
in (LT), whereas Th2 cells produce IL-4, IL-5, IL-6, IL-9, IL-
10, and IL- 13 (Table 1). Human Th I and Th2 cells produce
similar patterns, although the synthesis of IL-2, IL-6, IL-
10, and IL- 13 is not as tightly restricted to a single subset
as in mouse T-cells. Several other proteins are secreted by
both Thl and Th2 cells, including IL-3, TNF-ox, granulo-
cyte-macrophage colony-stimulating factor (GM-CSF),
and members of the chemokine (CK) families (Table 2).
The characteristic cytokine products of Th I and Th2
cells are mutually inhibitory for the differentiation and
effector functions of the reciprocal phenotype. Thus, IFN-
-y selectively inhibits proliferation of Th2 cells (Mosmann
and Coffman, 1989), and IL-10 inhibits cytokine synthesis
by Thl cells (Fiorentino et al., 1989) (Fig. 2). This cross-
regulation may partly explain the strong biases toward
Th 1 or Th2 responses in many infectious diseases. In sev-
eral cases, alteration of these patterns by cytokine or
anti-cytokine reagents reverses host resistance or sus-
ceptibility to infection. Thus, there is ample evidence
(Mosmann and Sad, 1996) that these cytokine patterns

257
9(3) 248-266 (1998)
9(3):248-266 Rev Oral
Crit Rev
Crit Biol Med
Oral Biol Med 257
are important in mediating resistance to several infec-
tious agents. In addition, it has been suggested that ThI
cells contribute to the pathogenesis of organ-specific
autoimmune diseases, while Th2 cells prevent them
(Liblau et al., 1995).
In general, the Thl and Th2 cell responses protect
the host from intracellular and extracellular pathogens
and/or toxins, respectively. In the bacterial infection lep-
rosy, analysis of Th 1 and Th2 cytokine mRNA expression
revealed that a predominant Th 1 cytokine-specific mRNA
was associated with patients who were immunologically
resistant to Mycobacterium leprae (Yamamura et al., 1991). In
contrast, a dominant Th2 cytokine-specific mRNA was
seen in the advanced disease stage of leprosy patients
(Yamamura et al., 1991). In the parasitic disease
Leishmania major, a Thl cell response is induced that acti-
vates macrophages and results in effective parasite
killing in C57BL/6 mice. In contrast, a Th2 cell response
is induced in susceptible BALB/c mice that cannot elim-
inate the organism although they produce anti-para-
sitic antibodies (Scott et al., 1989). These results clearly
suggest the possibility that the disease activities of
periodontitis and/or susceptibility to the disease may
be caused by a preferential or skewed induction of Th 1
or Th2 cells.
Yamamoto et al. (1997) examined Thl- and Th2-type
cytokine production in inflamed gingival tissue by RT-PCR
and reported two distinct cytokine profiles based on the
expression of selected Th 1 and Th2 cytokines. One pattern
was represented by the expression of mRNA for IFN-y,
IL-6, IL-10, and IL-13, while the other case consisted of
mRNA for IFN--y, IL-6, and IL-1 3. In addition, messages for
IL-2, IL-4, and IL-5 were not detected. The authors
implied that the dominant expression of Th2 cytokines,
such as IL-6, IL-10, and IL-13, may contribute to the
induction of high B-cell responses in local disease sites.
Earlier, these investigators reported that high levels of IL-
6 were produced spontaneously by gingival mononuclear
cells (Fujihashi et al., 1993a). Furthermore, they speculat-
ed that the lack of IL-4 may be responsible for the accu-
mulation of macrophages in diseased periodontium,
because IL-4 has been shown to induce programmed cell
death (apoptosis) in stimulated peripheral blood cells
(Yamamoto et al., 1997). In fact, they demonstrated that
the addition of exogenous IL-4 induced apoptosis in
macrophages isolated from inflamed gingival tissues. The
investigators also suggested that the effect of IL-4 on B-
cell responses in inflammatory periodontal lesions could
be compensated for by the production of IL-13, which
also induces B-cell proliferation and differentiation and
isotype switching (Yamamoto et al., 1997).
There are, however, reports which contradict the
aforementioned findings. Manhart et al. (1994) reported
that a higher percentage of gingival mononuclear cells
from (EOP) patients, relative to age- and gender-similar
258 Crit Rev
Crit
Rev Oral Biot Med
gingivitis controls, were IL-4+ and that a higher percent-
age of gingival mononuclear cells from EOP patients were
IL-2+ when stimulated with Pg outer membrane. They
detected these cytokines at the protein level by means of
a cell-blotting assay. Yamazaki et al. (1994) presented
immunohistochemical data indicating the presence of
IL-4-producing cells within the CD45RO+ subset in
periodontal lesions, despite the fact that no IL-4
mRNA could be detected by means of an in situ
hybridization technique. Their explanation for this finding
is that IL-4 mRNA is transient and very short-lived. There
are also contradictory reports relative to IL-5 expression in
gingival mononuclear cells (Fujihashi et al., 1993a). These
discrepancies could be caused by differences in (1) assay
systems (protein level vs. mRNA level), (2) sensitivities of
the assay system, and (3) the specimens (racial difference,
at what treatment phase the specimens were collected,
etc.). For these problems to be overcome, it would be valu-
able if a standard assay system were established.
Among various cytokines produced by helper T-
cells, interferon-y (IFN-y) is unique, because it acts
not only on immunocompetent cells but also on non-
immunocompetent cells, such as endothelial cells and
fibroblasts. High levels of IFN-y mRNA are detectable
in inflamed gingival tissue (Shimabukuro et al., 1996).
Recently, Lundqvist et at. (1994) reported that not only
cx3 T-cells but also y6 T-cells from adult periodontitis
patients expressed mRNA for IFN-,y. They commented
that no spontaneous secretion of IFN-y was detected
in supernatants of cultured gingival mononuclear cells
from adult periodontitis gingiva. In addition, IFN-y
could be demonstrated in the supernatant of gingival
mononuclear cells from patients with rapidly progres-
sive periodontitis and also in low concentrations in
one of two juvenile periodontitis samples tested. They
speculated that IFN-,y produced by T-cells in adult
periodontitis gingiva is bound to IFN-y receptor-
expressing cells. This could mean that a balance
between local IFN-y production and consumption
exists in adult periodontitis, whereas excess IFN--y
may be produced in the more acute and aggressive
diseases such as rapidly progressive periodontitis and
juvenile periodontitis. Interestingly, Murakami and
Okada (1997) demonstrated that IFN-y-stimulated
human gingival fibroblasts, which were HLA-DR-positive,
not only enhanced the binding ability of fibroblasts to
lymphocytes but also regulated T-cell proliferation both
positively and negatively in vitro (Shimabukuro et al.,
1992; Murakami and Okada, 1997). Moreover, the find-
ing (Barber et al., 1984) that gingival fibroblasts
derived from explants of periodontally diseased tissue
expressed HLA-DR suggests that gingival fibroblasts may
be affected by locally secreted IFN-,y and may regulate
local T-cell responses in inflammatory periodontal
lesions.
(1998)
Oral Biol
Med 9(3):248-266 (1998)
 Are Th 1 and/or Th2 Involved in
Destructive or Protective
Periodontal Lesions?
As discussed above, it has been suggested
: 2periodontopathic bacteria
6

that the production of selected cytokines,

in the course of local Thl- or Th2-type
immune response to micro-organisms,
plays a crucial role in the development of (Co intinuous
specific disease. stimulation)
Immunological studies (Mackler et al.,
1977; Okada et al., 1983) clearly estab-
lished the B-cell/plasma cell dominance of (exc:essive host response)
the periodontitis lesion. Subsequently, the
T-cell nature of the putative stable lesion
was suggested by the finding of large num-
bers of T-cells in gingivitis in children
(Seymour et al., 1982) and in experimental
gingivitis in young adults (Seymour et al., IL-4?
IL-6, IL-10 ...etc HLA DR
1983). Based on these observations,
Gemmell and Seymour (1994) proposed
that the stable lesion is mediated principally M hI
-0-
by cells with the Thl cytokine profile, while IFNy
the progressive lesion involves Th2 cells A
I
,A mnt; h lAhl
uaLiouUy
r
t#kuI CD40V/
which secrete cytokines mainly acting on B- IL-6
cells. If the B-cell population in periodontitis TNFa ... etc (non-specific Ab
lesions could produce protective antibodies, production)
it could result in elimination of the patho- IL-1
genic bacteria, and disease progression IL-6
would cease. However, if those cells were TNFa
excessively activated by Th2 cells and pro- tissue destruction
duced non-protective antibodies and/or periodontal
IL-I, continuous connective tissue break-
down may result (Fig. 3). The possible
mechanism of polyclonal B-cell activation
by periodontopathic bacteria may also
support the idea that excessive B-cell acti-
vation may be responsible for periodontal
tissue destruction.
Taubman et al. (1994) detected the pre-
C
dominant expression of IFN--y but not of IL-
4 and of little IL-5 mRNA by RT-PCR in cells Figure 3. Sp eculative model of the immunopathogenesis of periodontitis. Continuous stimuli
directly extracted from gingival tissues with from periodc)ntopathic bacteria in periodontal pockets cause continuous and/or excessive
periodontitis, suggesting that Th I cells were host responseas which include cellular activation of resident cells such as gingival epithelial cells
prominent in the diseased sites. Ebersole and fibroblasstsThisand locally infiltrated immunocompetent cells such as macrophages, T-cells,
T leads to the unrestricted hyper-production or skewed production of various
and Taubman (I1994) have proposed that Th 1 and B-cells. inflamed periodontal tissues, resulting in tissue destruction.
cells are involved in destructive periodontal cytokines in
lesions, while Th2 cells are rather protective
(Fig. 3). Their idea has been supported
mainly by adoptive transfer experiments with rat Th 1 or Th2 Since many investigators have detected both Thl-
Aa-specific T-cell clones. Adoptive transfer of Th2 clones and Th2-type cytokines in inflamed periodontal lesions,
into rats infected with Aa ameliorates the progression of it is reasonable to speculate that both ThI and Th2 cells
periodontal disease (Yamashita et al., 1991; Eastcott et al., (although they might not demonstrate typical cytokine
1994). In contrast, adoptive transfer of Th I cells specific for profiles) would transmigrate into the periodontal lesions
29-kDa Aa outer membrane protein produced periodontal and lodge there through active interactions with
bone loss in the Aa-infected rat (Kawai et al., 1997). endothelial cells and fibroblasts (Murakami and Okada,

9(3) 248-266 (1998)

9(3):248-266
Oral Biol Med
Crit Rev Oral Biol Med 259
1997). However, skewed or hyper-production of selected
cytokines derived from the ThI and/or Th2 cells, as dis-
cussed above, may be responsible for the destruction of
periodontal tissue through humoral and/or cellular
hyperimmune responses. The pathophysiological
importance of Th 1 and Th2 cells in periodontal disease
progression is not mutually exclusive. Unregulated
stimulation of both types may potentially participate in
periodontal tissue destruction (Fig. 3).
Cytokine Expression by CD8+ T-cells
As previously discussed, CD8+ (cytotoxic/suppressor) T-
cells are present in inflamed periodontal lesions. Recent
evidence clearly demonstrates that CD8+ cytotoxic T-
cells (Tc) are also divided into Tcl and Tc2 cells based on
the cytokine pattern they produce (Mosmann and Sad,
1996). As with ThI and Th2 cells, Tcl cells secrete IL-2
and IFN-,y and Tc2 cells secrete IL-4, IL-5, and IL-10.
Furthermore, it was also reported (Salgame et al., 1991)
that cytotoxic CD8+ T-cells produce IL-10 and IFN-y, and
suppressor CD8+ T-cells produce mainly IL-4. To date, how-
ever, cytokine production by CD8+ T-cells in periodontal
lesions has not yet been fully examined. Since it has been
reported (Salgame et al., 1991; Romagnani et al., 1994; Coyle
et al., 1995) that Tcl or Tc2 cells are preferentially detect-
ed during various infections, it may be worthwhile to
examine the cytokine profile of CD8+ T-cells in inflam-
matory periodontal lesions.
Cytokine Expression by y8 T-cells
T-cell receptors (TCR) are composed of either ot3 or -y8
heterodimers (janeway and Travers, 1994). The majority
of T-cells in the blood and lymphoid tissues have the up
TCR phenotype, while y8-bearing T-cells comprise the
major cell population in certain epithelial tissues.
Although the importance of antigen-specific y8 T-cells in
response to pathogens is unknown, there are indications
that these cells play a role in response to several infec-
tious organisms. Previous studies demonstrated that
abnormal proportions of y8 T-cells are frequently found
in the peripheral blood of patients with periodontal dis-
ease, and a role for these cells in the first line of defense
against infection has been suggested. Gemmell and
Seymour (1995) demonstrated an increase in the propor-
tion of -y8 T-cells compared with up3 T-cells with increas-
ing size of infiltrate in both gingivitis and periodontitis
lesions. It is postulated that these cells recognize a self-
protein that is expressed by infected but not by normal
cells in gingival epithelium, and that the y8 T-cells kill
the infected cell to prevent spread of infection.
Candidate targets are MHC Class IB molecules, peptides
of heat-shock proteins. It was recently reported
(Lundqvist and Hammarstrom, 1993) that y8 T-cells are
also located within the epithelium in both normal and
inflamed gingiva. Those y8 T-cells show the phenotype of
260 Crit Rev
Crit
Rev Oral
activated cells (CD45RO+, CD4+, or CD8+). CD4+ y8 T-
cells expressed IFN--y mRNA only, whereas CD8+ y6 T-
cells expressed IFN-y, TNF-ot, TGF-p1, and IL-6 mRNA
(Table 2). It has been suggested (Lundqvist et al., 1994)
that y6 T-cells constitute a first line of defense in the
gingiva, preventing entrance of pathogens by cytotoxicity
against infected and stressed epithelial cells, and by
control of epithelial cell growth through secretion of
regulatory cytokines.
Concluding Remarks
In this review, we summarized the recent information
regarding cytokine expression in the periodontium and
its possible relationship with tissue homeostasis and
inflammatory disease progression (Fig. 3). Our knowl-
edge of the physiological, biochemical, and molecular
biological properties and actions of cytokines and their
receptors has grown tremendously over the last decade.
However, despite the progress that has been made, we
do not fully understand the pathogenesis of periodontal
diseases at the molecular level. Clarification of how var-
ious cytokines contribute to the problem and/or solution
of pathological situations such as periodontal diseases
may enable us to diagnose and treat the disease at the
molecular and cellular levels to an extent previously
thought to be impossible. Thus, great excitement awaits
further studies in this field.
Acknowledgments
Some of the work reported in this review manuscript was supported in
part by a Grant-in-Aid from the Ministry of Education, Science and
Culture (Nos. 09671950, 09307043, 09771609, and 09771611).
We would like to thank Dr. T. Saho for his valuable suggestions in
reviewing this manuscript. We are grateful to Drs. Y. Shimabukuro, H.
Hirano, Y. Kusumoto, T. Nozaki, E. Hino, D. Kasai, T. Hashikawa, K.
Saito, T. Kawai, T. Nagasawa, and K. Yamazaki for their helpful dis-
cussions and for providing much useful information.
REFERENCES
AAP (1996). The potential role of growth and differentia-
tion factors in periodontal regeneration. J Periodontol
67:545-553.
Alexander MB, Damoulis PD (1994). The role of cytokines
in the pathogenesis of periodontal disease. Curr Opin
Periodontol 1:39-53.
Alvares 0, Klebe R, Grant G, Cochran DL (1995). Growth
factor effects on the expression of collagenase and
TIMP-1 in periodontal ligament cells. I Periodontol
66:552-558.
Barber S, Powell RN, Seymour GJ (1984). Surface markers
of human gingival fibroblasts in vitro. I Oral Pathol
13:221-230.
Bartold PM (1993). Platelet-derived growth factor stimu-
Oral Biol
Med
Biol Med
9(3):248-266
9(3):248-266 (1998)
 lates hyaluronate but not proteoglycan synthesis by
human gingival fibroblasts in vitro. J Dent Res 72:1473-
1480.
Bartold PM, Haynes DR (1991). Interleukin-6 production
by human gingival fibroblasts. I Periodont Res 26:339-
345.
Bauer J, Herrmann F (1991). Interleukin-6 in clinical med-
icine. Ann Hematol 62:203-2 10.
Bertolini DR, Nedwin GE, Bringman TS, Smith DD,
Mundy GR (1986). Stimulation of bone resorption and
inhibition of bone formation in vitro by human tumor
necrosis factors. Nature 319:516-518.
Bickel M (1993). The role of interleukin-8 in inflammation
and mechanisms of regulation. J Periodontol 64:456-
460.
Blaise D, Olive D, Hirn M, Viens P, Lafage M, Attal M, et al.
(1991). Prevention of acute GVHD by in vivo use of
anti-interleukin-2 receptor monoclonal antibody
(33B3.1): a feasibility trial in 15 patients. Bone Marrow
Transplant 8:105- 111.
Blieden TM, Semponski GD, Padilla J, Suchkova VN,
Chess P, Phipps RP (1997). Periodontal fibroblast acti-
vation via CD40 (abstract). J Dent Res 76(Spec Iss): 176.
Bom-van Noorloos AA, van der Meer JWM, van der Gevel
IS, Schepens E, van Steenbergen TIM, Burger EH
(1990). Bacteroides gingivalis stimulates bone resorption
via interleukin-l production by mononuclear cells.
The relative role for B. gingivalis endotoxin. J Clin
Periodontol 1 7:409-413.
Bomford R, Henderson BE (1989). Interleukin-l, inflam-
mation and disease. New York: Elsevier.
Canalis E (1980). Effect of insulin-like growth factor-I on
DNA synthesis in cultured rat calvaria. I Clin Invest
66:709-719.
Canalis E, McCarthy T, Centrella M (1988). Effects of
basic fibroblast growth factor on bone formation in
vitro. J Clin Invest 81:1572-1577.
Chaudhary LR, Spelsberg TC, Riggs BL (1992).
Production of various cytokines by normal human
osteoblast-like cells in response to interleukin-fl1
and tumor necrosis factor-(x: lack of regulation by
173-estradiol. Endocrinology 130:2528-2534.
Chen IK, Hoshi H, McKeehan WL (1987). Transforming
growth factor type ( specifically stimulates synthesis
of proteoglycan in human adult arterial smooth mus-
cle cells. Proc Natl Acad Sci USA 84:5287-5291.
Cochran DL, Rouse CA, Lynch SE, Graves DT (1993).
Effects of platelet-derived growth factor isoforms on
calcium release from neonatal mouse calvaria. Bone
14:53-58
Coyle AJ, Erard F, Bertrand C, Walti S, Pircher H, Le Gros
G (1995). Virus-specific CD8+ cells can switch to inter-
leukin 5 production and induce airway eosinophilia. I
Exp Med 181:1229-1233.
Del Prete GF. De Carli M! Mastromauro C, Biagiotti R,
9)3) 248 266 1998)
1998) Crit Rev Oral Biol Med
Crit
9(3):248-266
Macchia D, Falagiani P, et al. (1991). Purified protein
derivative of Mycobacterium tuberculosis and excretory-
secretory antigen(s) of Toxocara canis expand in vitro
human T cells with stable and opposite (type 1 T
helper or type 2 T helper) profile of cytokine produc-
tion. I Clin Invest 88:346-350.
Dennison DK, Vallone DR, Pinero GJ, Rittman B, Caffesse
RG (1994). Differential effect of TGF- (1 and PDGF on
proliferation of periodontal ligament cells and gingi-
val fibroblast. I Periodontol 65:641-648.
Dinarello CA (1988). Biology of interleukin 1. FASEB 1 2:
108-115.
Dinarello CA and Worff SM (1993). The role of inter-
leukin- I in disease. N Engl I Med 328: 106-113.
Dongari-Bagtzoglou Al and Ebersole IL (1996). Gingival
fibroblast cytokine profiles in Actinobacillus actino-
mycetemcomitans-associated periodontitis. I Periodontol
67: 871-878.
Eastcott JW, Yamashita K, Taubman MA, Harada Y, Smith
DJ (1994). Adoptive transfer of cloned T helper cells
ameliorates periodontal disease in nude rats. Oral
Microbiol Immunol 9:284-289.
Ebersole IL, Taubman MA (1994). The protective nature
of host responses in periodontal diseases.
Periodontology 2000 5:112-141.
Edwards DR, Murphy G, Reynolds JI, Whitham SE,
Docherty AJ, Angel P, et al. (1987). Transforming
growth factor beta. J Bone Miner Res 6:1899-1904.
Elias JA, Gustilo K, Baeder W, Freundlich B (1987).
Synergistic stimulation of fibroblast prostaglandin
production by recombinant interleukin 1 and tumor
necrosis factor. J Immunol 138:3812-3816.
Fine A, Goldstein RH (1987). The effect of transforming
growth factor-j on cell proliferation and collagen for-
mation by lung fibroblasts. J Biol Chem 262:3897-3902.
Fiorentino DF, Bond MW, Mosmann TR (1989). Two types
of mouse T helper cell. IV. Th2 clones secrete a factor
that inhibits cytokine production by Th 1 clones. J Exp
Med 170:2081-2095.
Fujihashi K, Beagley KW, Kono Y, Aicher WK, Yamamoto
M, DiFabio S, et al. (1993a). Gingival mononuclear
cells from chronic inflammatory periodontal tissues
produce interleukin (IL)-5 and IL-6 but not IL-2 and
IL-4. Am J Pathol 142:1239-1250.
Fujihashi K, Kono Y, Beagley KW, Yamamoto M, McGhee
JR, Mestecky J, et al. (1993b). Cytokines and periodon-
tal disease: Immunopathological role of interleukins
for B cell responses in chronic inflamed gingival tis-
sues. J Periodontol 64:400-406.
Garrison SW, Nichols FC (1989). LPS-elicited secretory
responses in monocytes: altered release of PGE2 but
not IL-l1 in patients with adult periodontitis. J
Periodont Res 24:88-95.
Geivelis M, Turner DW, Peterson ED, Lamberts BL (1993).
Measurements of interleukin-6 in gingival crevicular
Rev Oral 261
261
 fluid from adults with destructive periodontal dis-
ease. I Periodontol 64: 980-983.
Gemmell E, Seymour G0 (1993). Interleukin-1, inter-
leukin-6 and transforming growth factor-1 production
by human gingival mononuclear cells following stim-
ulation with Porphyromonas gingivalis and Fusobacterium
nucleatum. I Periodont Res 28:122-129.
Gemmell E, Seymour GL (1994). Modulation of immune
responses to periodontal bacteria. Curr Opin Periodont
2:28-38.
Gemmell E, Seymour G1 (1995). y6 T lymphocytes in
human periodontal disease tissue. I Periodontol 66:780-
785.
Genco RI, Mashimo PA, Kreggier G, Ellison SA (1977).
Antibody-mediated effects on the periodontium. J
Periodontol 45:330-337.
Gerosa F, Paganin C, Peritt D, Paiola F, Scupoli MT, Aste
Amezaga M, et al. (1996). Interleukin- 12 primes human
CD4 and CD8 T cell clones for high production of both
interferon-gamma and interleukin-10. J Exp Med
183:2559-2569.
Giannobile WV, Finkelman RD, Lynch SE (1994a).
Comparison of canine and non-human primate ani-
mal models for periodontal regenerative therapy:
Results following a single administration of
PDGF/IGF-I. J Periodont Res 65:1158-1168.
Giannobile WV, Whitson SW, Lynch SE (1994b).
Synergistic effects of insulin-like growth factor-I (IGF-
I) with other growth factors on bone formation in vitro
(abstract). I Dent Res 73(Spec Iss):205.
Giannobile WV, Hernandez RA, Finkelman RD, Ryan S,
Kiritsy CP, D'Andrea M, et al. (1996). Comparative
effects of platelet-derived growth factor-BB, insulin-
like growth factor-I alone and in combination on
periodontal regeneration in Macaca fascicularis. I
Periodont Res 31:301-312.
Gowen M, Nedwin GE, Mundy GR (1986). Preferential
inhibition of cytokine-stimulated bone resorption by
recombinant interferon gamma. J Bone Miner Res 1:469-
474.
Grant GA, Eisen AZ, Marmer BL, Roswit WT, Goldberg GI
(1987). The activation of human skin fibroblast pro-
collagenase. I Biol Chem 262:5886-5889.
Graves DT, Valentin-Opran A, Delgado R, Valente AJ,
Mundy G, Piche J (1989). The potential role of
platelet-derived growth factor as an autocrine and
paracrine factor for bone cells. Connect Tissue Res
23:209-218.
Hanazawa S, Murakami Y, Hirose K, Amano S, Ohmori Y,
Higuchi H, et al. (1991). Bacteroides (Porphyromonas) gin-
givalis fimbriae activate mouse peritoneal
macrophages and induce gene expression and pro-
duction of interleukin- 1. Infect Immun 59:1972-1977.
Havemose-Poulsen A, Holmstrup P (1997). Factors
affecting IL-1-mediated collagen metabolism by
262 Crit
Crit Rev
Rev Oral
Oral Biol
Biol Med
fibroblasts and the pathogenesis of periodontal dis-
ease: a review of the literature. Crit Rev Oral Biol Med
8:217-236.
Hazuda DI, Lee IC, Young PR (1988). The kinetics of inter-
leukin-l secretion from activated monocytes.
Differences between interleukin-lox and interleukin-
I f. I Biol Chem 263:8473-8479.
Hefti A (1993). Aspects of cell biology of the normal
periodontium. Periodontology 2000 3:64-75.
Heldin CH, Westermark B, Wasteson A (1981). Specific
receptors for platelet-derived growth factor on cells
derived from connective tissue and glia. Proc Natl Acad
Sci USA 78:3663-3668.
Hirano T (1991). Interleukin-6. In: The cytokine hand-
book. 1st ed. Thomson A, editor. New York: Academic
Press, pp. 169-190.
Hock IM, Canalis E (1994). Platelet-derived growth factor
enhances bone cell replication but not differentiated
function of osteoblast. Endocrinology 134:1423-1428.
Hock JM, Centrella M, Canalis E (1988). Insulin-like
growth factor I has independent effects on bone
matrix formation and replication. Endocrinology
122:254-260.
Horowitz MC (1993). Cytokines and estrogen in bone:
Anti-osteoporotic effects. Science 260:626-627.
Hsu SM, Waldron JA, Xie SS, Barlogie B (1993).
Expression of interleukin-6 in Castleman's disease.
Hum Pathol 24:833-839.
Hughes EJ, Aubin JE, Heersche JN (1992). Differential
chemotactic responses of different populations of
fetal rat calvaria cells to platelet-derived growth fac-
tor and transforming growth factor beta. Bone Miner
19:63-74.
Idelgaufts H (1995). Dictionary of cytokine. 1st ed.
Weinheim, Germany: VCH.
Ikezawa K, Hart CE, Williams DC, Narayanan AS (1997).
Characterization of cementum derived growth factor
as an insulin-like growth factor-I like molecule.
Connect Tissue Res 36:309-319.
Ishimi Y, Miyaura C, Jin CH, Akatsu T, Abe E, Nakamura Y,
et al. (1990). IL-6 is produced by osteoblasts and
induces bone resorption. J Immunol 145:3297-3303.
laneway CA Ir, Travers P (1994). Immunobiology-The
immune system in health and disease. 1st rev. ed.
Garland Publishing Inc.
Johnson RA, Boyce BF, Mundy GR, Roodman GD (1989).
Tumors producing human tumor necrosis factor
induce hypercalcemia and osteoclastic bone resorp-
tion in nude mice. Endocrinology 124:1424-1427.
Kawai T, Wilson ME, Nagasawa T, Watanabe H, Eastcott JW,
Smith DJ, et al. (1997). Adoptive transfer of cloned anti-
gen-specific Th 1 lymphocytes produces periodontal
bone loss (abstract). J Dent Res 76(Spec Iss):231.
Kishimoto T (1990). The biology of interleukin-6. Blood
74: 1-10.
Med
9(3):248-266
9(3):248-266 (1998)
Kohler N, Lipton A (1974). Platelet as a source of
fibroblast growth-promoting activity. Exp Cell Res
87:297-301.
Kono Y, Beagley KW, Fujihashi K, McGhee IR, Taga T,
Hirano T, et al. (1991). Cytokine regulation of localized
inflammation: induction of activated B cells and IL-6-
mediated polyclonal IgG and IgA synthesis in
inflamed human gingiva. J Immunol 146:1812-1821.
Kornman KS, Crane A, Wang HY, di Giovine FS, Newman
MG, Pirk FW, et al. (1997). The interleukin-l genotype
as a severity factor in adult periodontal disease. I Clin
Periodontol 24:72-77.
Kurihara N, Bertolini D, Suda T, Akiyama Y, Roodman GD
(1990). IL-6 stimulates osteoclast-like multinucleated
cell formation in long term human marrow cultures
by inducing IL-l release. Immunol 144:4226-4230.
Laiho M, Keski-Oja J (1989). Growth factors in the regu-
lation of pericellular proteolysis: a review. Cancer Res
49:2533-2553.
Lark MW, Walakovits LA, Shah TK, Vanmiddlesworth J,
Cameron PM, Lin T-Y (1990). Production and purifica-
tion of prostromelysin and procollagenase from IL-1
beta-stimulated human gingival fibroblasts. Connect
Tissue Res 25:49-65.
Le J, Vilcek 1 (1987). Biology of disease. Tumor necrosis
factor and interleukin 1: Cytokines with multiple over-
lapping biological activities. Lab Invest 56:234-248.
Liblau RS, Singer SM, McDevitt HO (1995). Thl and Th2
CD4+ T cells in the pathogenesis of organ-specific
autoimmune diseases. Immunol Today 16:34-38.
Lindemann RA, Economou 1S (1988). Actinobacillus actino-
mycetemcomitans and Bacteroides gingivalis activate
human peripheral monocytes to produce interleukin-
I and tumor necrosis factor. I Periodontol 59:728-730.
Lindemann RA, Economou IS, Rothermel H (1988).
Production of interleukin- and tumor necrosis factor
by human peripheral monocytes activated by peri-
odontal bacteria and extracted lipopolysaccharides. J
Dent Res 67:1131-1135.
Lowik CWGM, Van der Pluijm G, Bloys H, Hoekman K,
Bijvoet LM, Aarden LA, et al. (1989). Parathyroid hor-
mone (PTH) and PTH like protein (PLP) stimulate
interleukin-6 production by osteogenic cells: a possi-
ble role of interleukin-6 in osteoclastogenesis.
Biochem Biophys Res Commun 162:1546-1552.
Lundqvist C, Hammarstrom M-L (1993). T-cell receptor
y8-expressing intraepithelial lymphocytes are pre-
sent in normal and chronically inflamed human gin-
giva. Immunology 79:38-45.
Lundqvist C, Baranov V, Teglund S, Hammarstrom S,
Hammarstrom M-L (1994). Cytokine profile and ultra-
structure of intraepithelial y8 T cells in chronically
inflamed human gingiva suggest a cytotoxic effector
function I lImmunol 153:2302-2312.
Lynch SE, Williams RC, Polson AM, Howell TH, Reddy MS,
9(3) 248 266 1998)
9(3)- 248-266 Crit Rev Oral Biol Med
Crit Rev
Zappa UE, et al. (I1989). A combination of platelet-derived
and insulin-like growth factors enhances periodontal
regeneration. I Clin Periodontol 16:545-548.
Lynch SE, de Castilla GR, Williams RC, Kiritsy CP, Howell
TH, Reddy MS, et al. (1991). The effects of short-term
application of a combination of platelet-derived and
insulin-like growth factors on periodontal wound
healing. J Periodontol 62:458-467.
Mackler BF, Frostad KB, Robertson PB, Levy B (1977).
Immunoglobulin bearing lymphocytes and plasma
cells in human periodontal disease. I Periodont Res
12:37-45.
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.
Mantovani A, Bussolino F, Introna M (1997). Cytokine
regulation of endothelial cell function: from molecu-
lar level to the bedside. Immunol Today 18:231-240.
Masada MP, Persson R, Kenny IS, Lee SW, Page RC,
Allison AC (1990). Measurement of interleukin-lcx
and -13 in gingival crevicular fluid: Implications for
the pathogenesis of periodontal disease. I Periodont
Res 25:156-163.
Matsuda N, Lin WL, Kumar NM, Cho Ml, Genco RI (1992).
Mitogenic, chemotactic, and synthetic responses of
rat periodontal ligament cells to polypeptide growth
factors in vitro. J Periodontol 63:515-525.
Matsuki Y, Yamamoto T, Hara K (1992). Detection of
inflammatory cytokine messenger RNA (mRNA)-
expressing cells in human inflamed gingiva by com-
bined in situ hybridization and immunohistochem-
istry. Immunology 76:42-47.
McFarlane CG, Reynolds JJ, Meikle MC (1990). The
release of interleukin- 11 , tumor necrosis factor-cx and
interferon-y by cultured peripheral blood mononu-
clear cells from patients with periodontitis. Periodont
Res 25:207-214.
Meikle MC, Atkinson SJ, Ward RV, Murphy G, Reynolds JJ
(1989). Gingival fibroblasts degrade type I collagen
films when stimulated with tumor necrosis factor and
interleukin 1: evidence that breakdown is mediated by
metalloproteinases. J Periodont Res 24:207-2 13.
Mergia A, Eddy R, Abraham IA, Fiddes IC, Shows TB
(1986). The genes for basic and acidic fibroblast
growth factors are on different human chromosomes.
Biochem Biophys Res Commun 138:644-65 1.
Miki Y, Shimabukuro Y, Kitamura M, Takayama S, Yanagi
K, Ikezawa K, et al. (1994). The effect of application of
bFGF on regeneration of the periodontal tissues
(abstract). J Dent Res 73:354.
Mizel SB (1989). The interleukins. FASEB 1 3:2379-2388.
Mizel SB, Dayer IM, Krane SM, Mergenhagen SE (1981).
Stimulation of rheumatoid synovial cell collagenase
and prostaglandin production by partially purified
263
Oral Biol
263
 lymphocyte-activation factor (Interleukin 1). Proc Natl
Acad Aci USA 78:2474.
Mochan E, Armor L, Sporer R (1988). Interleukin 1 stim-
ulation of plasminogen activator production in cul-
tured gingival fibroblasts. I Periodont Res 23:28-32.
Mochizuki H, Hakeda Y, Wakatuki N, Usui N, Akashi S,
Sato T, et al. (1992). Insulin-like growth factor-I sup-
ports formation and activation of osteoclasts.
Endocrinology 131 :2297-2305.
Moscatelli D, Presta M, Joseph-Silverstein J, Rifkin DB
(1986). Both normal and tumor cells produce basic
fibroblast growth factors. I Cell Physiol 129:273-276.
Mosmann TR, Coffman RL (1989). Thl and Th2 cells:
Different patterns of lymphokine secretion lead to dif-
ferent functional properties. Ann Rev Immunol 7:145-
173.
Mosmann TR, Sad S (1996). The expanding universe of T-
cell subsets: Th 1, Th2 and more. Immunol Today 17:138-
146.
Moughal NA, Adonogianaki E, Thornhill MH, Kinane DF
(1992). Endothelial cell leucocyte adhesion molecule-
1 (ICAM- 1) expression in gingival tissue during health
and experimentally-induced gingivitis. J Periodont Res
27:623-630.
Mundy GR (1989). Local factors in bone remodeling. Rec
Progr Horm Res 45:507-531.
Murakami S, Okada H (1997). Lymphocyte-fibroblast
interactions. Crit Rev Oral Biol Med 8:40-50.
Murakami S, Shimabukuro Y, Saho T, Hino E, Kasai D,
Hashikawa T, et al. (1997). Immunoregulatory roles of
adhesive interactions between lymphocytes and gin-
gival fibroblasts. J Periodont Res 32:110-114.
Murakami S, Hino E, Shimabukuro Y, Nozaki T, Kusumoto
Y, Saho T, et al. (1998). Direct interaction between gin-
gival fibroblasts and lymphoid cells induces inflam-
matory cytokine mRNA expression in gingival fibrob-
lasts. J Dent Res (in press).
Narayanan SA, Yonemura K (1993). Purification and char-
acterization of a novel growth factor from cementum.
I Periodont Res 28:563-565.
Nguyen 1, Dewhirst FE, Hauschka PV, Stashenko P (1991).
Interleukin- 13 stimulates bone resorption and
inhibits bone formation in vivo. Lymphokine Cytokine Res
10:15-21.
Nozaki T, Kusumoto Y, Kitamura M, Murakami S, Okada
H (1997). Differential mRNA expression of inflamma-
tory cytokines in inflamed gingival tissues (abstract).
I Dent Res 76:301.
Oates TW, Rouse CA, Cochran DL (1993). Mitogenic
effects of growth factors on human periodontal liga-
ment cells in vitro. I Periodontol 64:142-148.
Odake H, Koizumi F, Hatakeyama S, Furuta I, Nakagawa
H (1993). Production of cytokines belonging to the
interleukin-8 family by human gingival fibroblasts
264 Grit
Crit Rev Oral
Rev Oral
stimulated with interleukin-1J3 in culture. Exp Mol
Pathol 58:14-24.
Ohasaki Y, Takahashi S, Scarcez T, Demulder A, Nishihara
T, Williams R, et al. (1992). Evidence of an
autocrine/paracrine role for interleukin-6 in bone
resorption by giant cells from giant cell tumors of
bone. Endocrinology 131:2229-2234.
Okada H, Kida T, Yamagami H (1983). Identification and
distribution of immunocompetent cells in inflamed
gingiva of human chronic periodontitis. Infect Immun
41:365-374.
Okada H, Murakami S, Kitamura M, Nozaki T, Kusumoto Y,
Hirano H, et al. (1996). Diagnostic strategies of periodon-
titis based on the molecular mechanisms of periodontal
tissue destruction. Oral Diseases 2:87-95.
Oppenheim 11, Kovacs EJ, Matsushima K, Durum SK
(1986). There is more than one interleukin 1. Immunol
Today 7:45-56.
Overall CM, Wrana IL, Sodek 1 (1989). Independent reg-
ulation of collagenase 72-kDa progelatinase, and
metalloproteinase inhibitor expression in human
fibroblasts by transforming growth factor-P. J Biol
Chem 264:1860-1869.
Overall CM, Wrana JL, Sodek 1 (1991). Induction of for-
mative and resorptive cellular phenotypes in human
gingival fibroblasts by TGF-P1 and concanavalin A:
regulation of matrix metalloproteinases and TIMP. I
Periodont Res 26:279-282.
Page RC (1991). The role of inflammatory mediators in
the pathogenesis of periodontal disease. I Periodont
Res 26:230-242.
Payne JB, Reinhardt RA, Masada MP, DuBois LM, Allison
AC (1993). Gingival crevicular fluid IL-8: correlation
with local IL-13 levels and patient estrogen status.
Periodont Res 28:451-453.
Peichl P, Ceska M, Effenberger F, Haberhauer G, Broell H,
Lindley I1 (1991). Presence of NAP-1/IL-8 in synovial
fluids indicates a possible pathogenic role in rheuma-
toid arthritis. Scand I Immunol 34:333-339.
Pfeilschifter J, Oeschsner M, Naumann A, Gronwald RG,
Minne HW, Ziegler R (1990). Stimulation of bone
matrix apposition in vitro by local growth factors. A
comparison between insulin-like growth factor-I,
platelet-derived growth factor and transforming
growth factor-P. Endodontology 127:69-75.
Piche JE, Carnes DL, Graves DT (1989). Initial characteri-
zation of cells derived from the human periodontia. J
Dent Res 68:761-767.
Reinhardt RA, Masada MP, Kaldahl WB, DuBois LM,
Kornman KS, Choi J-I, et al. (1993). Gingival fluid IL-I
and IL-6 levels in refractory periodontitis. J Clin
Periodontol 20:225-23 1.
Richards D, Rutherford RB (1990). Interleukin-I regulation
of procollagenase mRNA and protein in periodontal
fibroblasts in vitro. J Periodont Res 25:222-229.
(1998)
Biol Med
Biol Med 9(3):248-266 (1998)
Romagnani S, Maggi E, Del Prete G (1994). An alternative
view of the Thl/Th2 switch hypothesis in HIV infec-
tion. AIDS Res Hum Retroviruses 10:iii-ix.
Ross R, Glomset 1, Kariya B, Harku L (1974). A platelet-
dependent serum factor that stimulates the prolifera-
tion of arterial smooth muscle cells in vitro. Proc Natl
Acad Sci USA 71:1207-1210.
Rossomando EF, White L (1993). A novel method for the
detection of TNF-alpha in gingival crevicular fluid. 1
Periodontol 64:445-449.
Rossomando EF, Kennedy IE, Hadjimichael 1 (1990).
Tumor necrosis factor alpha in gingival crevicular
fluid as a possible indicator of periodontal disease in
humans. Arch Oral Biol 35:431-434.
Rutherford RB, Niekrash CE, Kennedy JE, Charette MF
(1992). Platelet-derived and insulin-like growth fac-
tors stimulate regeneration of periodontal attach-
ment in monkeys. J Periodont Res 27:285-290.
Rutherford RB, Ryan ME, Kennedy JE, Tucker MM,
Charett MF (1993). Platelet-derived growth factor and
dexamethasone combined with a collagen matrix
induce regeneration of the periodontium in monkeys.
I Clin Periodontol 20:537-544.
Saito K, Kusumoto Y, Hirano H, Hirano F, Nozaki T, Ogo
H, et at. (1997). Inflammatory cytokine mRNA expres-
sion in human gingival epithelial cells (abstract).
Dent Res 76:441.
Salgame P, Abrams JS, Clayberger C, Goldstein H, Convit
J1 Modlin RL, et al. (1991). Differing lymphokine pro-
files of functional subsets of human CD4 and CD8 T
cell clones. Science 254:279-282.
Schmidt IA, Mizel SB, Cohen D, Green I (1982).
Interleukin 1. a potential regulator of fibroblast prolif-
eration. In'imunol 128:2177-2182.
Schweigerer L, Ferrara N, Haaparanta T, Neufeld G,
Gospodarowicz D (1988). Basic fibroblast growth fac-
tor expression in cultured cells derived from corneal
endothelium and lens epithelium. Exp Eye Res 46:71-80.
Scott P, Pearce E, Cheever AW, Coffman RL, Sher A
(1989). Role of cytokines and CD4+ T-cell subsets in
the regulation of parasite immunity and disease.
Imiunol Rev 112:161-182.
Seymour GJ (1987). Possible mechanisms involved in the
immunoregulation of chronic inflammatory periodon-
tal disease. I Dent Res 66:2-9.
Seymour GI Crouch MS, Powell RN, Brooks D, Beckman
1, Zola H et al. (1982). The identification of lymphoid
cell subpopulations in sections of human lymphoid
tissue and gingivitis in children using monoclonal
antibodies. I Periodont Res 17:247-256.
Seymour GI, Powell RN, Cole KL, Aitken IF, Brooks D,
Beckman 1, et al. (1983). Experimental gingivitis in
humans a histochemical and immunological charac-
terisation of the lymphoid cell subpopulations. I
Periodont Res 18:375-385.
9(3)248 266 (11998)
9(3):248-266 (1998)
Oral
Crit Rev Oral Biol Med
Seymour GL, Gemmell E, Kjeldsen M, Yamazaki K,
Nakajima T, Hara K (1996). Cellular immunity and
hypersensitivity as components of periodontal
destruction. Oral Diseases 2:96- 101.
Shimabukuro Y, Murakami S, Okada H (1992). Interferon-
gamma-dependent immunosuppressive effects of
human gingival fibroblasts. Immunology 76:344-347.
Shimabukuro Y, Murakami S, Okada H (1996). Antigen-
presenting cell function of IFN-y-treated human gingi-
val fibroblasts. J Periodont Res 31:217-228.
Shimizu N, Ogura N, Yamaguchi H (1992). Stimulation by
interleukin-l of interleukin-6 production by human
periodontal ligament cells. Arch Oral Biol 37:743-748.
Shimizu N, Yamaguchi H, Goseki T, Ogura N, Saito K,
Takiguchi H, et al. (1994). Cyclic-tension force stimu-
lates interleukin-1Il production by human periodon-
tal ligament cells. J Periodont Res 29:328-333.
Skerka C, Irving SG, Bialonski A, Zipfel PF (1993). Cell
type specific expression of members of the IL-8/NAP-
1 gene family. Cytokine 5:112-116.
Slootweg MC, Most WW, van Beek E, Schot LP,
Papopoulos SE, Lowick CW (1992). Osteoclast form-
ing together with interleukin-6 production in mouse
long bones is increased by insulin-like growth factor-
I. I Endocrinol 132:433-438.
Stashenko P, Dewhirst FE, Peros WJ, Kent RL, Age IM
(1987a). Synergistic interactions between interleukin-
1, tumor necrosis factor and lymphotoxin in bone
resorption. I Immunol 138:1464-1468.
Stashenko P, Dewhirst FE, Rooney ML, Desiardins LA,
Heeley ID (1987b). Interleukin-1I is a potent inhibitor
of bone formation in vitro. J Bone Miner Res 2:559-565.
Stashenko P, Fujiyoshi P Obernesser MS, Prostak L,
Haffajee AD, Socransky SS (1991). Levels of inter-
leukin 13 in tissue from sites of active periodontal
disease. J Clin Periodontol 18:548-554.
Takada H, Mihara JI Morisaki 1, Hamada S (1991).
Induction of interleukin-l and -6 in human gingival
fibroblast cultures stimulated with Bacteroides
lipopolysaccharides. Infect Immun 59:295-301.
Takashiba S, Takigawa M, Myokai F, Nishimura F, Chihara
T, Kurihara H, et al. (1992). Interleukin-8 is a major
neutrophil chemotactic factor derived from cultured
human gingival fibroblasts stimulated with inter-
leukin-l or tumor necrosis factor at. Infect Immun
60:5253-5258.
Takayama S, Murakami S, Miki Y, Ikezawa K, Tasaka S,
Terashima A, et al. (1997). Effects of basic fibroblast
growth factor on human periodontal ligament cells.
Periodont Res 32:667-675.
Tamura M, Tokuda M, Nagaoka S, Takada H (1992).
Lipopolysaccharides of Bacteroides intermedius (Prevotella
intermedia) and Bacteroides (Porphyromonas) gingivalis
induce interleukin-8 gene expression in human gingi-
val fibroblast cultures. Infect Immun 60:4932-4937.
Biol
Med
265
Tamura T, Udagawa N, Takahashi N, Miyaura C, Tanaka S,
Yamada Y, et al. (1993). Soluble interleukin-6 receptor
triggers osteoclast formation by interleukin-6. Proc
Natl Acad Sci USA 90:11924-11928.
Tatakis DN (1993). Interleukin-l bone metabolism: A
review. J Periodontol 64:416-431.
Taubman M, Eastcott JW, Shimauchi H, Takeichi 0,
Smith DI (1994). Modulatory role of T lymphocytes in
periodontal inflammation. In: Molecular pathogenesis
of periodontal diseases. Genco R, Hamada S, Lehner
T, McGhee J, Mergenhagen S, editors. Washington,
DC: ASM Press, pp. 147-157.
Taubman MA, Stoufi ED, Ebersole JL, Smith DJ (1984).
Phenotypic studies of cells from periodontal disease
tissues. J Periodont Res 19:587-590.
Terranova VP, Odziemiec C, Tweden KS, Spadone DP
(1989). Repopulation of dentin surfaces by periodon-
tal ligament cells and endothelial cells: Effect of basic
fibroblast growth factor. I Periodontol 60:293-301.
Tewari DS, Qian Y, Tewari M, Pieringer 1 (1994).
Mechanistic features associated with induction of
metalloproteinases in human gingival fibroblasts by
interleukin-1. Arch Oral Biol 39:657-664.
van der Pluijm G, Most W, van der Wee-Pals L, De Groot
H, Papapoulos S, Lowic C (1991). Two distinct effects
of recombinant human tumor necrosis factor-cx on
osteoclast development and subsequent resorption
of mineralized matrix. Endocrinology 129:1596-1604.
Van Dyke TE, Lester MA, Shapira L (1993). The role of the
host response in periodontal disease progression. J
Periodontol 64:792-806.
Varga J, Rosenbloom J, Jimenez SA (1987). Transforming
growth factor-3 (TGF-P) causes a persistent increase
in steady-state amounts of type I and type III collagen
and fibronectin mRNAs in normal human dermal
fibroblasts. Biochem J 247:597-604.
Wahl SM, Allen JB, Costa GL, Wong HL, Dasch JR (1993a).
Reversal of acute and chronic synovial inflammation
by anti-transforming growth factor beta. J Exp Med
177:225-230.
Wahl SM, Costa GL, Mizel DE, Allen IB, Skaleric U,
Mangan DF (1993b). Role of transforming growth beta
in the pathophysiology of chronic inflammation. J
Periodontol 64:450-455.
Waldmann TA, Goldman C, Top L, Grant A, Burton J,
Bamford R, et al. (1993). The interleukin-2 receptor: a
target for immunotherapy. Ann NY Acad Sci 685:603-
610.
266 Grit Rev
Crit Rev Oral
Oral Biol
Biol Med
Walsh Li, Stritzel F, Yamazaki K, Bird PS, Gemmell E,
Seymour GJ (1989). Interleukin-1 and interleukin-I
inhibitor production by human adherent cells stimu-
lated with periodontopathic bacteria. Arch Oral Biol
34:679-683.
Waxman J, Balkwill F, editors (1992). Interleukin 2.
Oxford: Blackwell Scientific Publ.
Westergren-Thorsson G, Sarnstrand B, Fransson L-A,
Malmstrbm A (1990). TGF-4 enhances the produc-
tion of hyaluronan in human lung but not in skin
fibroblasts. Exp Cell Res 186:192-195.
Westermark B, Wasteson A (1976). A platelet factor stimu-
lating human normal glial cells. Exp Cell Res 98:170-174.
Williams RC (1990). Periodontal disease. N Engl i Med
322:373-376.
Wilton JMA, Bampton JLM, Hurst Ti, Caves I, Powell JR
(1993). Interleukin-143 and IgG subclass concentra-
tions in gingival crevicular fluid from patients with
adult periodontitis. Arch Oral Biol 38:55-60.
Windhagen A, Anderson DE, Carrizosa A, Williams RE,
Hafler DA (1996). IL-12 induces human T cells secret-
ing IL- IO with IFN-gamma. I Immunol 157:1127-1131.
Yamamoto M, Fuijihashi K, Hiroi T, McGhee JR, Van Dyke
TE, Kiyono H (1997). Molecular and cellular mecha-
nisms for periodontal diseases: role of Thl and Th2
type cytokines in induction of mucosal inflammation.
J Periodont Res 32:115-119.
Yamamura M, Uyemura K, Deans RI, Weinberg K, Rea T,
Bloom B, et al. (1991). Defining protective responses
to pathogens: cytokine profiles in leprosy lesions.
Science 254:277-279.
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. Infect Immun 59:1529-
1534.
Yamazaki K, Nakajima T, Aoyagi T, Hara K (1993).
Immunohistological analysis of memory T lympho-
cytes and activated B lymphocytes in tissues with
periodontal disease. J Periodont Res 28:324-334.
Yamazaki K, Nakajima T, Gemmell E, Polak B, Seymour
GJ, Hara K (1994). IL-4 and IL-6-producing cells in
human periodontal disease tissue. J Oral Pathol Med
23: 347-353.
Yoshizaki K, Matsuda T, Nishimoto N, Kuritani T, Taeho L,
Aozasa K, et al. (1989). Pathogenic significance of
interleukin-6 (IL-6/BSF-2) in Castleman's disease.
Blood 74:1360-1367.
Med
9(31.248-266
9(3):248-266 (1998)