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Vaernewyck V, Arzi B, Sanders NN, Cox E, Devriendt B. Mucosal Vaccination Against Periodontal Disease: Current Status and Opportunities. Front Immunol 2021; 12:768397. [PMID: 34925337 PMCID: PMC8675580 DOI: 10.3389/fimmu.2021.768397] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Approximately 9 out of 10 adults have some form of periodontal disease, an infection-induced inflammatory disease of the tooth-supporting tissues. The initial form, gingivitis, often remains asymptomatic, but this can evolve into periodontitis, which is typically associated with halitosis, oral pain or discomfort, and tooth loss. Furthermore, periodontitis may contribute to systemic disorders like cardiovascular disease and type 2 diabetes mellitus. Control options remain nonspecific, time-consuming, and costly; largely relying on the removal of dental plaque and calculus by mechanical debridement. However, while dental plaque bacteria trigger periodontal disease, it is the host-specific inflammatory response that acts as main driver of tissue destruction and disease progression. Therefore, periodontal disease control should aim to alter the host's inflammatory response as well as to reduce the bacterial triggers. Vaccines may provide a potent adjunct to mechanical debridement for periodontal disease prevention and treatment. However, the immunopathogenic complexity and polymicrobial aspect of PD appear to complicate the development of periodontal vaccines. Moreover, a successful periodontal vaccine should induce protective immunity in the oral cavity, which proves difficult with traditional vaccination methods. Recent advances in mucosal vaccination may bridge the gap in periodontal vaccine development. In this review, we offer a comprehensive overview of mucosal vaccination strategies to induce protective immunity in the oral cavity for periodontal disease control. Furthermore, we highlight the need for additional research with appropriate and clinically relevant animal models. Finally, we discuss several opportunities in periodontal vaccine development such as multivalency, vaccine formulations, and delivery systems.
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Affiliation(s)
- Victor Vaernewyck
- Laboratory of Immunology, Department of Translational Physiology, Infectiology and Public Health, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Boaz Arzi
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA, United States
- Veterinary Institute for Regenerative Cures (VIRC) School of Veterinary Medicine, University of California, Davis, CA, United States
| | - Niek N. Sanders
- Laboratory of Gene Therapy, Department of Veterinary and Biosciences, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Eric Cox
- Laboratory of Immunology, Department of Translational Physiology, Infectiology and Public Health, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Bert Devriendt
- Laboratory of Immunology, Department of Translational Physiology, Infectiology and Public Health, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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2
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Teng YTA. Protective and Destructive Immunity in the Periodontium: Part 2—T-cell-mediated Immunity in the Periodontium. J Dent Res 2016; 85:209-19. [PMID: 16498066 DOI: 10.1177/154405910608500302] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Based on the results of recent research in the field and Part 1 of this article (in this issue), the present paper will discuss the protective and destructive aspects of the T-cell-mediated adaptive immunity associated with the bacterial virulent factors or antigenic determinants during periodontal pathogenesis. Attention will be focused on: (i) osteoimmunology and periodontal disease; (ii) some molecular techniques developed and applied to identify critical microbial virulence factors or antigens associated with host immunity (with Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis as the model species); and (iii) summarizing the identified virulence factors/antigens associated with periodontal immunity. Thus, further understanding of the molecular mechanisms of the host’s T-cell-mediated immune responses and the critical microbial antigens related to disease pathogenesis will facilitate the development of novel therapeutics or protocols for future periodontal treatments. Abbreviations used in the paper are as follows: A. actinomycetemcomitans ( Aa), Actinobacillus actinomycetemcomitans; Ab, antibody; DC, dendritic cells; mAb, monoclonal antibody; pAb, polyclonal antibody; OC, osteoclast; PAMP, pathogen-associated molecular patterns; P. gingivalis ( Pg), Porphyromonas gingivalis; RANK, receptor activator of NF-κB; RANKL, receptor activator of NF-κB ligand; OPG, osteoprotegerin; TCR, T-cell-receptors; TLR, Toll-like receptors.
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Affiliation(s)
- Y-T A Teng
- Laboratory of Molecular Microbial Immunity, Eastman Department of Dentistry, Eastman Dental Center, Box-683, 625 Elmwood Ave., Rochester, NY 14620, USA.
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Zhang M, Sun C, Gu J, Yan X, Wang B, Cui Z, Sun X, Tong C, Feng X, Lei L, Han W. Salmonella Typhimurium strain expressing OprF-OprI protects mice against fatal infection by Pseudomonas aeruginosa. Microbiol Immunol 2016; 59:533-44. [PMID: 26249788 DOI: 10.1111/1348-0421.12291] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/29/2015] [Accepted: 08/02/2015] [Indexed: 01/16/2023]
Abstract
Pseudomonas aeruginosa poses a major threat to human health and to the mink industry. Thus, development of vaccines that elicit robust humoral and cellular immunity against P. aeruginosa is greatly needed. In this study, a recombinant attenuated Salmonella vaccine (RASV) that expresses the outer membrane proteins fusion OprF190-342 -OprI21-83 (F1I2) from P. aeruginosa was constructed and the potency of this vaccine candidate assessed by measuring F1I2-specific humoral immune responses upon vaccination through s.c. or oral routes. S.C. administration achieved higher serum IgG titers and IgA titers in the intestine and induced stronger F1I2-specific IgG and IgA titers in lung homogenate than did oral administration, which resulted in low IgG titers and no local IgA production. High titers of IFN-γ, IL-4, and T-lymphocyte subsets induced a mixed Th1/Th2 response in mice immunized s.c., indicating elicitation of cellular immunity. Importantly, when immunized mice were challenged with P. aeruginosa by the intranasal route 30 days after the initial immunization, s.c. vaccination achieved 77.78% protection, in contrast to 41.18% via oral administration and 66.67% via Escherichia coli-expressed F1I2 (His-F1I2) vaccination. These results indicate that s.c. vaccination provides a better protective response against P. aeruginosa infection than do oral administration and the His-F1I2 vaccine.
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Affiliation(s)
| | | | | | - Xinwu Yan
- College of Animal Science, Jilin University, No. 5333, Xi'an Street, Changchun, Jilin, 130062
| | | | | | | | | | | | | | - Wenyu Han
- College of Veterinary Medicine.,Jiangsu Co-innovation Center for the Prevention and Control of Important Animal Infectious Disease and Zoonoses, Yangzhou, 225009, People's Republic of China
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Pathangey L, Kohler JJ, Isoda R, Brown TA. Effect of expression level on immune responses to recombinant oral Salmonella enterica serovar Typhimurium vaccines. Vaccine 2009; 27:2707-11. [PMID: 19428883 DOI: 10.1016/j.vaccine.2009.02.072] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 01/30/2009] [Accepted: 02/05/2009] [Indexed: 10/21/2022]
Abstract
Live, attenuated Salmonella has been used to express heterologous antigens for development of oral vaccines. Often, expression must be regulated because of deleterious effects on the Salmonella vector. The effect of varying expression levels on immune response parameters has not been well defined. In this study we introduced mutations in the -10 region of the trc promoter in the expression plasmid to generate series of vaccine strains with different levels of expression of a model antigen, the hemagglutinin HagB from Porphyromonas gingivalis. There was no difference in growth rates of the Salmonella vaccine strains containing the wild-type, the mutant plasmids or the empty expression vector. The primary IgG response in serum in mice orally immunized with the wild-type strain peaked 3-4 weeks earlier than the intermediate expression level strains, suggesting that high expression levels may favor an earlier response. While there was a trend for anti-HagB recall responses to correlate with higher expression level, the peak levels were not significantly different even for expression levels as low as 33% of wild-type. A similar trend in terms of response level was seen with serum and salivary IgA. The subclass of the IgG response was predominately IgG2a regardless of expression level, consistent with a Th1 response. These data suggest that isotype distribution, immune response level and T helper cell profile are largely unaffected over a wide range of expression levels.
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Affiliation(s)
- Latha Pathangey
- Department of Oral Biology, University of Florida, Gainesville, FL 32610, United States
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5
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Sharma DCG, Prasad SBM, Karthikeyan BV. Vaccination against periodontitis: the saga continues. Expert Rev Vaccines 2007; 6:579-90. [PMID: 17669011 DOI: 10.1586/14760584.6.4.579] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Periodontal disease can be considered to be one of the most common chronic inflammatory diseases inflicting humans. With the advent of advanced molecular diagnostic techniques, a better understanding of the role of specific pathogens and the contributory role of the host immune response in the initiation and progression of periodontal disease has been possible - although not completely. However, successful vaccine development that fully utilizes the current level of understanding has not yet occurred for human use. This paper reviews various in vitro, animal studies and human trials undertaken to develop a vaccine against periodontal disease, with emphases on the shortfalls of these efforts and future prospects of developing a successful vaccine against periodontal disease.
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Affiliation(s)
- Dileep C G Sharma
- Department of Periodontics, KGF College of Dental Sciences, Kolar Gold Fields, Karnataka, India.
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6
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Isoda R, Simanski SP, Pathangey L, Stone AES, Brown TA. Expression of a Porphyromonas gingivalis hemagglutinin on the surface of a Salmonella vaccine vector. Vaccine 2007; 25:117-26. [PMID: 16942819 DOI: 10.1016/j.vaccine.2006.06.085] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Revised: 06/19/2006] [Accepted: 06/23/2006] [Indexed: 10/24/2022]
Abstract
Live, attenuated Salmonella strains can serve as vectors for the delivery of recombinant vaccine antigens for development of oral mucosal vaccines. Various vaccine parameters can affect the immune responses elicited by Salmonella vectors, including the expression level, location and timing of expressed antigens. We have previously established immunogenic Salmonella enterica serovar Typhimurium strains which cytoplasmically express hemagglutinin B (HagB) of Porphyromonas gingivalis, a putative periodontal pathogen. In this study, we sought to determine whether the 39 kDa HagB protein could be stably expressed on the surface of an avirulent Salmonella vaccine strain. The hagB gene was cloned into an expression plasmid as a C-terminal fusion with Lpp-OmpA, a hybrid surface display system. High expression of Lpp-OmpA-HagB proved to be toxic to the vaccine strain, and it was necessary to introduce attenuating mutations in the trc promoter. Stable expression was obtained in transformants with promoter mutations that resulted in low levels of expression. The expression of Lpp-OmpA-HagB was confirmed by ELISA and Western blot. Localization to the outer membrane/periplasm was confirmed by transmission electron microscopy using immunogold labeling, surface labeling of whole mounts using electron microscopy, flow cytometry, and by quantitation of HagB in cytoplasmic, as well as inner and outer cell membrane fractions. When delivered orally in mice, the surface-expressing strain induced higher serum IgG and IgA responses to HagB than a cytoplasmic expressing strain, while responses in secretions were comparable. These results suggest that surface localization may differentially enhance the immunogenicity of antigens expressed by live, avirulent Salmonella vaccine vectors.
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Affiliation(s)
- Ryutaro Isoda
- Department of Oral Biology, P.O. Box 100424, University of Florida, Gainesville, FL 32610, United States
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7
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Zhang P, Martin M, Michalek SM, Katz J. Role of mitogen-activated protein kinases and NF-kappaB in the regulation of proinflammatory and anti-inflammatory cytokines by Porphyromonas gingivalis hemagglutinin B. Infect Immun 2005; 73:3990-8. [PMID: 15972486 PMCID: PMC1168622 DOI: 10.1128/iai.73.7.3990-3998.2005] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hemagglutinin B (HagB) is a nonfimbrial adhesin expressed on the surface of Porphyromonas gingivalis and has been implicated as a potential virulence factor involved in mediating the attachment of the bacteria to host cells. However, the molecular mechanisms underlying host responses to HagB and their roles in pathogenesis have yet to be elucidated. Mitogen-activated protein kinases (MAPKs) are activated following engagement of a variety of cell surface receptors via dual tyrosine and threonine phosphorylation and are thought to be involved in various cellular responses. The purpose of this study was to determine the role of intracellular signaling pathways including the MAPKs and NF-kappaB in regulating the production of proinflammatory and anti-inflammatory cytokines following stimulation of murine macrophages with recombinant HagB (rHagB). Stimulation of peritoneal macrophages with rHagB resulted in the production of the proinflammatory cytokines interleukin-12p40 (IL-12p40), gamma interferon (IFN-gamma), and tumor necrosis factor alpha, as well as the anti-inflammatory cytokine IL-10. We also demonstrated the activation of extracellular signal-related kinase (ERK), c-Jun NH2-terminal protein kinase (JNK), and p38 MAPKs by rHagB-stimulated macrophages. Furthermore, blocking of the ERK and p38 signaling pathways by using specific inhibitors revealed differential regulatory roles in the rHagB-mediated production of proinflammatory and anti-inflammatory cytokines. ERK and p38 were important in down-regulation of IL-12p40 and IFN-gamma production and up-regulation of IL-10 production. The enhanced levels of IL-12p40 in rHagB-stimulated macrophages by inhibition of ERK or p38 activity were partially attributable to the inhibition of IL-10 production. Moreover, NF-kappaB was found to be critical for up-regulation of IL-12p40 and down-regulation of IL-10 production in rHagB-stimulated macrophages. Taken together, our results demonstrate a role for the p38 and ERK pathways and the transcription factor NF-kappaB in modulating key immunoregulatory cytokines involved in the development of immune responses to P. gingivalis HagB.
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Affiliation(s)
- Ping Zhang
- Department of Pediatric Dentistry, University of Alabama at Birmingham, 845 19th Street South, BBRB 258/5, Birmingham, Alabama 35294-2170, USA
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8
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Antigen Delivery Systems II: Development of Live Recombinant Attenuated Bacterial Antigen and DNA Vaccine Delivery Vector Vaccines. Mucosal Immunol 2005. [DOI: 10.1016/b978-012491543-5/50060-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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9
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O'Brien-Simpson NM, Veith PD, Dashper SG, Reynolds EC. Antigens of bacteria associated with periodontitis. Periodontol 2000 2004; 35:101-34. [PMID: 15107060 DOI: 10.1111/j.0906-6713.2004.003559.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Neil M O'Brien-Simpson
- Centre for Oral Health Science, School of Dental Science, The University of Melbourne, Victoria, Australia
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10
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Gemmell E, Seymour GJ. Immunoregulatory control of Th1/Th2 cytokine profiles in periodontal disease. Periodontol 2000 2004; 35:21-41. [PMID: 15107056 DOI: 10.1111/j.0906-6713.2004.003557.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Erica Gemmell
- Oral Biology and Pathology, The University of Queensland, Brisbane, Australia
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11
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Zhang P, Martin M, Yang QB, Michalek SM, Katz J. Role of B7 costimulatory molecules in immune responses and T-helper cell differentiation in response to recombinant HagB from Porphyromonas gingivalis. Infect Immun 2004; 72:637-44. [PMID: 14742503 PMCID: PMC321589 DOI: 10.1128/iai.72.2.637-644.2004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
In addition to antigen-specific signals mediated through the T-cell receptor, T cells also require antigen nonspecific costimulation for activation. The B7 family of molecules on antigen-presenting cells, which include B7-1 (CD80) and B7-2 (CD86), play important roles in providing costimulatory signals required for development of antigen-specific immune responses. Hemagglutinin B (HagB) is a nonfimbrial adhesin of the periodontopathic microorganism Porphyromonas gingivalis and is thought to be involved in the attachment of the bacterium to host tissues. However, the immune mechanisms involved in responses to HagB and their roles in pathogenesis have yet to be elucidated. Therefore, the purpose of this study was to determine the role of B7 costimulatory molecules on T-helper-cell differentiation for the induction of immune responses to HagB. Mice deficient in either or both of the costimulatory molecules B7-1 and B7-2 were used to explore their role in immune responses to HagB after subcutaneous immunization. B7-1(-/-) mice had levels of immunoglobulin G (IgG) anti-HagB antibody activity in serum similar to those of wild-type mice, whereas lower serum IgG anti-HagB antibody responses were seen in B7-2(-/-) mice. Moreover, significantly lower numbers of IgG antibody-secreting cells and lower levels of CD4(+)-T-cell proliferation were observed in B7-2(-/-) mice compared to wild-type mice. No serum IgG response to HagB was detected in B7-1/B7-2(-/-) mice. Analysis of the subclass of the serum IgG responses and the cytokines induced in response to HagB revealed that B7-2(-/-) mice had significantly lower IgG1 and higher IgG2a anti-HagB antibody responses compared to wild-type mice. The B7-2(-/-) mice also had significantly reduced levels of interleukin-4 (IL-4) and IL-5 and enhanced level of gamma interferon. Furthermore, assessment of B7-1 and B7-2 expression on B cells and macrophages derived from wild-type BALB/c mice after in vitro stimulation with HagB revealed a predominant upregulation in the expression of the B7-2 costimulatory molecule on B cells and macrophages. Essentially no change was seen in the expression of B7-1. Taken together, these results suggest a critical role for B7, especially B7-2, for the preferential induction of a Th2-like response to HagB.
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Affiliation(s)
- Ping Zhang
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
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12
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Gemmell E, Winning TA, Carter CL, Ford PJ, Bird PS, Ashman RB, Grieco DA, Seymour GJ. Differences in mouse strain influence leukocyte and immunoglobulin phenotype response to Porphyromonas
gingivalis. ACTA ACUST UNITED AC 2003; 18:364-70. [PMID: 14622342 DOI: 10.1046/j.0902-0055.2002.00098.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study examined the nature of the infiltrating cells in Porphyromonas gingivalis-induced lesions and immunoglobulins in the serum samples of BALB/c (H-2d), C57BL6 (H-2b), DBA/2J (H-2d) and CBA/CaH (H-2k) mice. Mice were immunized intraperitoneally with P. gingivalis outer membrane antigens or sham-immunized with phosphate-buffered saline followed by subcutaneous challenge with live organisms 1 week after the final immunization. The resulting skin abscesses were excised 7 days later, cryostat sections cut and an immunoperoxidase method used to detect the presence of CD4+ and CD8+ T-cell subsets, CD14+ macrophages and CD19+ B cells. Peroxidase positive neutrophils and IgG1- and IgG2a-producing plasma cells were also identified. Anti P. gingivalis IgG1 and IgG2a subclass antibodies were determined in serum obtained by cardiac puncture. Very few CD8+ T cells and CD19+ B cells were found in any of the lesions. The percentages of CD4+ cells, CD14+ cells and neutrophils were similar in lesions of immunized BALB/c and C57BL6 mice, with a trend towards a higher percentage of CD14+ cells in sham-immunized mice. The percentage of CD14+ cells was higher than that of CD4+ cells in immunized compared with sham-immunized DBA/2J mice. The percentages of CD4+ and CD14+ cells predominated in immunized CBA/CaH mice and CD4+ cells in sham-immunized CBA/CaH mice. The percentage of neutrophils in immunized CBA/CaH mice was significantly lower than that of CD14+ cells and CD4+ cells in sham-immunized mice. IgG1+ plasma cells were more dominant than IgG2a+ cells in immunized BALB/c, C57BL6 and DBA/2J mice, whereas IgG2a+ plasma cells were more obvious in sham-immunized mice. IgG2a+ plasma cells were predominant in immunized and sham-immunized CBA/CaH mice. In the serum, specific anti-P. gingivalis IgG2a antibody levels (Th1 response) were higher than IgG1 levels (Th2 response) in sham-immunized CBA/CaH and DBA/2J mice. In immunized BALB/c mice, IgG2a levels were lower than IgG1 levels, while IgG2a levels were higher in immunized C57BL6 mice. In conclusion, this study has shown differences in the proportion of infiltrating leukocytes and in the subclasses of immunoglobulin produced locally and systemically in response to P. gingivalis in different strains of mice, suggesting a degree of genetic control over the response to P. gingivalis.
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Affiliation(s)
- E Gemmell
- Immunopathology Laboratory, Oral Biology and Pathology, School of Dentistry, The University of Queensland, Brisbane, Australia.
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Chen H, Schifferli DM. Construction, characterization, and immunogenicity of an attenuated Salmonella enterica serovar typhimurium pgtE vaccine expressing fimbriae with integrated viral epitopes from the spiC promoter. Infect Immun 2003; 71:4664-73. [PMID: 12874347 PMCID: PMC165986 DOI: 10.1128/iai.71.8.4664-4673.2003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Transmissible gastroenteritis virus (TGEV) is a porcine coronavirus that causes diarrhea, leading to near 100% mortality in neonatal piglets with corresponding devastating economic consequences. For the protection of neonatal and older animals, oral live vaccines present the attractive property of inducing desired mucosal immune responses, including colostral antibodies in sows--an effective means to passively protect suckling piglets. Newly attenuated Salmonella vaccine constructs expressing TGEV S protein epitopes were studied and evaluated for improved humoral immune response to TGEV. The macrophage-inducible Salmonella ssaH and spiC/ssaB promoters were compared for their ability to express the TGEV C and A epitopes in the context of the heterologous 987P fimbriae on Salmonella vaccines. Compared to the ssaH promoter, the Salmonella cya crp vector elicited significantly higher levels of mucosal and systemic antibodies in orally immunized mice when the chimeric fimbriae were expressed from the spiC promoter. The Salmonella spiC promoter construct induced the highest level of chimeric fimbriae after being taken up by the J774A.1 macrophagelike cells. The Salmonella cya crp vaccine vector was shown to incorporate into 987P partially degraded chimeric subunits lacking the TGEV epitopes. In contrast, its isogenic pgtE mutant produced fimbriae consisting exclusively of intact chimeric subunits. Mice immunized orally with the Salmonella pgtE vaccine expressing chimeric fimbriae from the spiC promoter elicited significantly higher systemic and mucosal antibody titers against the TGEV epitopes compared to the parental vaccine. This study indicates that the Salmonella cya crp pgtE vector and the spiC promoter can be used successfully to improve immune responses toward heterologous antigens.
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MESH Headings
- Adhesins, Escherichia coli/genetics
- Adhesins, Escherichia coli/immunology
- Amino Acid Sequence
- Animals
- Antibodies, Viral/biosynthesis
- Antigens, Bacterial/genetics
- Antigens, Bacterial/immunology
- Antigens, Viral/genetics
- Bacterial Proteins/genetics
- Base Sequence
- DNA, Bacterial/genetics
- Endopeptidases/genetics
- Endopeptidases/immunology
- Epitopes/genetics
- Female
- Fimbriae Proteins/genetics
- Fimbriae Proteins/immunology
- Fimbriae, Bacterial/genetics
- Fimbriae, Bacterial/immunology
- Gastroenteritis, Transmissible, of Swine/immunology
- Gastroenteritis, Transmissible, of Swine/prevention & control
- Genes, Bacterial
- Immunization, Secondary
- Mice
- Mice, Inbred BALB C
- Molecular Sequence Data
- Mutation
- Promoter Regions, Genetic
- Recombinant Fusion Proteins/genetics
- Recombinant Fusion Proteins/immunology
- Salmonella Vaccines/genetics
- Salmonella Vaccines/immunology
- Salmonella typhimurium/genetics
- Salmonella typhimurium/immunology
- Transmissible gastroenteritis virus/genetics
- Transmissible gastroenteritis virus/immunology
- Vaccines, Attenuated/genetics
- Vaccines, Attenuated/immunology
- Viral Vaccines/genetics
- Viral Vaccines/immunology
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Affiliation(s)
- Huaiqing Chen
- Department of Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania 19104, USA
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Yang QB, Martin M, Michalek SM, Katz J. Mechanisms of monophosphoryl lipid A augmentation of host responses to recombinant HagB from Porphyromonas gingivalis. Infect Immun 2002; 70:3557-65. [PMID: 12065496 PMCID: PMC128110 DOI: 10.1128/iai.70.7.3557-3565.2002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Porphyromonas gingivalis, a gram-negative, black-pigmented anaerobe, is among the microorganisms implicated in the etiology of adult periodontal disease. This bacterium possesses a number of factors, including hemagglutinins, of potential importance in virulence. Our laboratory has shown the induction of protection to P. gingivalis infection after subcutaneous immunization with recombinant hemagglutinin B (rHagB). The purpose of this study was to determine if humoral antibody responses are induced after intranasal (i.n.) immunization of rHagB and if monophosphoryl lipid A (MPL), a nontoxic derivative of the lipid A region of lipopolysaccharide, acts as a mucosal adjuvant and potentiates responses to rHagB. Further, the effects of MPL on the nature of the response to HagB and on the costimulatory molecules B7-1 and B7-2 on different antigen-presenting cells (APC) were evaluated. Groups of BALB/c mice were immunized three times (2-week intervals) by the i.n. route with HagB (20 microg) alone or with MPL (25 microg). A group of nonimmunized mice served as control. Serum and saliva samples were collected prior to immunization and at approximately 2-week intervals and evaluated for serum immunoglobulin G (IgG) and IgG subclass and for salivary IgA antibody activity by enzyme-linked immunosorbent assay. Mice immunized with rHagB plus MPL had significantly higher salivary IgA (P < 0.05) and serum IgG (P < 0.05) anti-HagB responses than mice immunized with rHagB alone. The IgG1 and IgG2a subclass responses seen in mice immunized with rHagB plus MPL were significantly higher (P < 0.05) than those seen in mice immunized with rHagB only. Further, the IgG2a/IgG1 ratio in the latter group was approximately 1, whereas in mice immunized with rHagB plus MPL the ratio was <1. These results provide evidence for the participation of T helper (Th) 1 and Th2 cells in responses to rHagB and that MPL potentiates a type 2 response to HagB. MPL was also shown to preferentially up-regulate B7-2 expression on B cells, whereas a preferential increase in B7-1 costimulatory molecule was seen on macrophages and dendritic cells. These results provide evidence that MPL exerts a differential regulation in the expression of costimulatory molecules on APC.
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Affiliation(s)
- Qiu-Bo Yang
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
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Gemmell E, Bird PS, Carter CL, Drysdale KE, Seymour GJ. Effect of Fusobacterium nucleatum on the T and B cell responses to Porphyromonas gingivalis in a mouse model. Clin Exp Immunol 2002; 128:238-44. [PMID: 11985513 PMCID: PMC1906396 DOI: 10.1046/j.1365-2249.2002.01852.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
T cell cytokine profiles and specific serum antibody levels in five groups of BALB/c mice immunized with saline alone, viable Fusobacterium nucleatum ATCC 25586, viable Porphyromonas gingivalis ATCC 33277, F. nucleatum followed by P. gingivalis and P. gingivalis followed by F. nucleatum were determined. Splenic CD4 and CD8 cells were examined for intracytoplasmic interleukin (IL)-4, interferon (IFN)-gamma and IL-10 by dual colour flow cytometry and the levels of serum anti-F. nucleatum and anti-P. gingivalis antibodies determined by an ELISA. Both Th1 and Th2 responses were demonstrated by all groups, and while there were slightly lower percentages of cytokine positive T cells in mice injected with F. nucleatum alone compared with the other groups immunized with bacteria, F. nucleatum had no effect on the T cell production of cytokines induced by P. gingivalis in the two groups immunized with both organisms. However, the percentages of cytokine positive CD8 cells were generally significantly higher than those of the CD4 cells. Mice immunized with F. nucleatum alone had high levels of serum anti-F. nucleatum antibodies with very low levels of P. gingivalis antibodies, whereas mice injected with P. gingivalis alone produced anti-P. gingivalis antibodies predominantly. Although the levels of anti-F. nucleatum antibodies in mice injected with F. nucleatum followed by P. gingivalis were the same as in mice immunized with F. nucleatum alone, antibody levels to P. gingivalis were very low. In contrast, mice injected with P. gingivalis followed by F. nucleatum produced equal levels of both anti-P. gingivalis and anti-F. nucleatum antibodies, although at lower levels than the other three groups immunized with bacteria, respectively. Anti-Actinobacillus actinomycetemcomitans, Bacteroides forsythus and Prevotella intermedia serum antibody levels were also determined and found to be negligible. In conclusion, F. nucleatum immunization does not affect the splenic T cell cytokine response to P. gingivalis. However, F. nucleatum immunization prior to that of P. gingivalis almost completely inhibited the production of anti-P. gingivalis antibodies while P. gingivalis injection before F. nucleatum demonstrated a partial inhibitory effect by P. gingivalis on antibody production to F. nucleatum. The significance of these results with respect to human periodontal disease is difficult to determine. However, they may explain in part differing responses to P. gingivalis in different individuals who may or may not have had prior exposure to F. nucleatum. Finally, the results suggested that P. gingivalis and F. nucleatum do not induce the production of cross-reactive antibodies to other oral microorganisms.
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Affiliation(s)
- E Gemmell
- Immunopathology Laboratory, Oral Biology and Pathology, School of Dentistry, University of Queensland, Brisbane, Australia.
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16
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Michalek SM, Katz J, Childers NK, Martin M, Balkovetz DF. Microbial/host interactions: mechanisms involved in host responses to microbial antigens. Immunol Res 2002; 26:223-34. [PMID: 12403360 DOI: 10.1385/ir:26:1-3:223] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The indigenous oral microflora and the host are normally in a state of equilibrium; however, the introduction of a pathogen can result in innate and adaptive immune responses that either contribute to the development of the disease or lead to host immunity. The interactions between the microorganisms and the host are very dynamic, thus allowing the complex interplay between host molecules and bacterial antigens. In this article, we focus on the mechanisms involved in the pathogenesis of and host responses to two oral pathogens: the Gram-negative bacterium Porphyromonas gingivalis, implicated in the etiology of periodontal disease, and the Gram-positive Streptococcus mutans, a primary agent involved in dental caries formation. Furthermore, we address mechanisms involved in the ability of select adjuvants and delivery systems to potentiate mucosal and systemic immune responses to microbial vaccine antigens.
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Affiliation(s)
- Suzanne M Michalek
- Department of Microbiology, University of Alabama at Birmingham, 35294-2170, USA.
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17
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Lamont RJ, Jenkinson HF. Subgingival colonization by Porphyromonas gingivalis. ORAL MICROBIOLOGY AND IMMUNOLOGY 2000; 15:341-9. [PMID: 11154429 DOI: 10.1034/j.1399-302x.2000.150601.x] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Porphyromonas gingivalis, a gram-negative anaerobe, is a major causative agent in the initiation and progression of severe forms of periodontal disease. In order to cause periodontal disease, P. gingivalis must colonize the subgingival region, a process that involves several distinct steps and multiple gene products. The organism must first navigate within the oral fluids in order to reach the hard or soft tissues of the mouth. Retention and growth of bacteria on these surfaces is facilitated by a repertoire of adhesins including fimbriae, hemagglutinins and proteinases. Once established subgingivally, P. gingivalis cells participate in intercellular communication networks with other oral prokaryotic cells and with eukaryotic cells. The establishment of these multiple interactive interfaces can lead to biofilm formation, invasion of root dentin and internalization within gingival epithelial cells. The resulting bacterial and host cellular locations, products and fate contribute to the success of P. gingivalis in colonizing the periodontal region.
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Affiliation(s)
- R J Lamont
- Department of Oral Biology, Box 357132, University of Washington, Seattle, WA 98195-7132, USA
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18
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Childers NK, Miller KL, Tong G, Llarena JC, Greenway T, Ulrich JT, Michalek SM. Adjuvant activity of monophosphoryl lipid A for nasal and oral immunization with soluble or liposome-associated antigen. Infect Immun 2000; 68:5509-16. [PMID: 10992447 PMCID: PMC101499 DOI: 10.1128/iai.68.10.5509-5516.2000] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The effectiveness of monophosphoryl lipid A (MPL) as a mucosal adjuvant was investigated following oral or intranasal (i.n.) administration of an aqueous adjuvant formulation of MPL (MPL-AF) added to soluble antigen or liposomal antigen or incorporated into liposomal antigen membranes. Groups of BALB/c female mice were immunized with 50 to 100 microg of free or liposomal Streptococcus mutans crude glucosyltransferase (C-GTF) with or without MPL-AF added to the vaccine or incorporated into the liposomal membrane. Plasma, saliva, vaginal wash, and fecal extract samples were collected biweekly following immunization and assessed for antigen-specific antibody activity by enzyme-linked immunosorbent assay (ELISA). Mice immunized by the i.n. route had higher levels of salivary, plasma, and vaginal immunoglobulin A (IgA) anti-C-GTF responses and higher levels of plasma IgG anti-C-GTF than the orally immunized groups. A second administration of the vaccine 14 weeks after the initial immunization resulted in an anamnestic response to C-GTF resulting in 10- and 100-fold increases in saliva and plasma IgA and plasma IgG, respectively (in the i.n. immunized groups). Mice receiving a second i.n. immunization with liposomal antigen and MPL-AF had higher salivary IgA anti-C-GTF responses than mice immunized with antigen plus MPL-AF or liposomal antigen (P < 0.05). Plasma IgG anti-C-GTF activity was highest in mice immunized by the i.n. route with antigen formulations containing MPL-AF (P < 0.05). These results demonstrate the effectiveness of MPL-AF as an adjuvant for potentiating mucosal and systemic immune responses to liposomal C-GTF following i.n. immunization.
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MESH Headings
- Adjuvants, Immunologic/administration & dosage
- Administration, Intranasal
- Administration, Oral
- Animals
- Antibodies, Bacterial/analysis
- Antibodies, Bacterial/biosynthesis
- Antibodies, Bacterial/blood
- Antigens, Bacterial/administration & dosage
- Antigens, Bacterial/immunology
- Female
- Glucosyltransferases/immunology
- Glucosyltransferases/metabolism
- Immunity, Mucosal
- Immunization
- Immunoglobulin A/analysis
- Immunoglobulin A/blood
- Immunoglobulin A, Secretory/analysis
- Immunoglobulin G/blood
- Lipid A/administration & dosage
- Lipid A/analogs & derivatives
- Lipid A/immunology
- Liposomes/immunology
- Mice
- Mice, Inbred BALB C
- Saliva/immunology
- Solubility
- Streptococcus mutans/enzymology
- Streptococcus mutans/immunology
- Vagina/immunology
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Affiliation(s)
- N K Childers
- Department of Pediatric Dentistry, School of Dentistry, University of Alabama at Birmingham, Birmingham, Alabama 35294-0007, USA.
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Kohler JJ, Pathangey L, Hasona A, Progulske-Fox A, Brown TA. Long-term immunological memory induced by recombinant oral Salmonella vaccine vectors. Infect Immun 2000; 68:4370-3. [PMID: 10858264 PMCID: PMC101775 DOI: 10.1128/iai.68.7.4370-4373.2000] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We have previously shown that Salmonella enterica serovar Typhimurium expressing the hagB hemagglutinin gene from Porphyromonas gingivalis can induce primary and recall immune responses in serum and secretions in mice; however, the longevity of memory induced by oral Salmonella carriers has not been adequately demonstrated. In this study, we examined the capacity of mice to mount a recall response 52 weeks after primary immunization. Recall responses were seen in serum immunoglobulin G (IgG) and IgA following boosting at week 52, and in most cases, they were equal to or greater than the primary responses. Significant mucosal IgA recall responses in saliva and vaginal wash were also detected following boosting at week 52. In addition, there was a considerable residual response in secretions at week 51, prior to boosting. These results indicate that oral Salmonella vectors can induce long-term memory to recombinant HagB and are particularly effective at inducing long-lasting mucosal responses as well as at inducing the capacity for mucosal recall responses.
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Affiliation(s)
- J J Kohler
- Department of Oral Biology, University of Florida, Gainesville, Florida 32610, USA
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20
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Gemmell E, Winning TA, Grieco DA, Bird PS, Seymour GJ. The influence of genetic variation on the splenic T cell cytokine and specific serum antibody responses to Porphyromonas gingivalis in mice. J Periodontol 2000; 71:1130-8. [PMID: 10960020 DOI: 10.1902/jop.2000.71.7.1130] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND T cell cytokine profiles in the spleens and anti-Porphyromonas gingivalis antibodies in the sera of P. gingivalis-immunized BALB/c (H-2d), CBA/CaH (H-2k), C57BL6 (H-2b), and DBA/2J (H-2d, C5 deficient) mice were examined. METHODS Mice were immunized either by intraperitoneal injections of P. gingivalis outer membrane antigens and Freund's incomplete adjuvant weekly for 3 weeks or sham-immunized with PBS and adjuvant, followed by subcutaneous challenge with live organisms 1 week after the final immunization. Spleens were excised and blood samples collected by heart puncture at 0 and 7 days after challenge. Splenic CD4 and CD8 cells were stained for intracytoplasmic interleukin (IL)-4, interferon (IF)-gamma, and IL-10 and levels of anti-P. gingivalis antibodies in the serum samples determined by ELISA. RESULTS Lesion sizes in immunized BALB/c mice remained stable for the 7-day experimental period. Immunized CBA/CaH and C57BL6 mice exhibited large lesions at day 1 reducing by day 7 particularly in the latter strain. Lesions in immunized DBA/2J mice were still larger than the other strains at day 7. With the exception of DBA/2J mice, sham-immunized mice demonstrated lesions which did not show signs of healing by day 7. T cell cytokine responses in sham-immunized mice at day 0 were low, increasing to a variable degree by day 7 after challenge in the 4 strains. Immunized BALB/c mice demonstrated intermediate T cell responses while generally exhibiting a stronger IFN-gamma response than IL-4 or IL-10. Immunized CBA/CaH and C57BL6 mice showed weak T cell cytokine responses while immunized DBA/2J displayed the strongest T cell responses particularly in regard to IL-4 positive cells. Sham-immunized mice had low levels of serum anti-P. gingivalis antibody levels at day 0 with levels increasing significantly by day 7 after challenge. Antibody levels in immunized mice seemed to correlate with lesion sizes. Immunized C57BL6 mice had the highest antibody levels followed by CBA/CaH, BALB/c with DBA/2J exhibiting low levels. The T cell and B cell antibody responses in each strain appeared to exhibit an inverse relationship. CONCLUSIONS This study has shown that genetic differences at the level of H-2 haplotype induce variations in the local and T and B cell responses to P. gingivalis antigens. The responses of DBA/2J mice which have the same haplotype as BALB/c mice suggest that factors other than H-2 haplotype such as the C5 deficiency may influence this immune response. The significance of the specific antibody and T cell responses and of their inverse relationship to susceptibility to periodontal disease remains to be determined.
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Affiliation(s)
- E Gemmell
- Immunopathology Laboratory, Oral Biology and Pathology, School of Dentistry, University of Queensland, Brisbane, Australia.
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21
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Kohler JJ, Pathangey LB, Gillespie SR, Brown TA. Effect of preexisting immunity to Salmonella on the immune response to recombinant Salmonella enterica serovar typhimurium expressing a Porphyromonas gingivalis hemagglutinin. Infect Immun 2000; 68:3116-20. [PMID: 10816452 PMCID: PMC97541 DOI: 10.1128/iai.68.6.3116-3120.2000] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recombinant Salmonella strains expressing foreign heterologous genes have been extensively studied as live oral vaccine delivery vectors. We have investigated the mucosal and systemic immune responses following oral immunization with a recombinant Salmonella enterica serovar Typhimurium expressing the hemagglutinin HagB from Porphyromonas gingivalis, a suspected etiological agent of adult periodontal disease. We have previously shown a primary mucosal and systemic response following oral immunization with chi4072/pDMD1 and recall responses following boosting at 14 weeks after primary immunization. In this study, we examined the effects of earlier boosting as well as the effects of deliberately induced immunity to the Salmonella carrier strain on subsequent immune responses. Mice boosted at week 7 following immunization, a point which corresponded to the peak of the primary response, generally showed lower responses than those boosted at week 14. When mice were preimmunized with the Salmonella carrier alone and then immunized with the recombinant strain 7 or 14 weeks later, significant reductions were seen for serum immunoglobulin G (IgG) antibodies at week 14 and for salivary IgA at week 7. No reductions were seen in serum IgA or vaginal wash IgA antibodies. Mice appear to be refractory to boosting with orally administered salmonellae at 7 weeks. Deliberate immunization with the carrier strain did not appreciably affect recall responses at 14 weeks, with the exception of the serum IgG responses, nor did it affect colonization of the Peyer's patches.
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Affiliation(s)
- J J Kohler
- Department of Oral Biology, University of Florida, Gainesville, Florida 32610, USA
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22
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Katz J, Black KP, Michalek SM. Host responses to recombinant hemagglutinin B of Porphyromonas gingivalis in an experimental rat model. Infect Immun 1999; 67:4352-9. [PMID: 10456874 PMCID: PMC96752 DOI: 10.1128/iai.67.9.4352-4359.1999] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Porphyromonas gingivalis, a gram-negative, black-pigmented anaerobe, is among the microorganisms implicated in the etiology of adult periodontal disease. This bacterium possesses a number of factors, including hemagglutinins, of potential importance in virulence. Several hemagglutinin genes have been identified, cloned, and expressed in Escherichia coli. The purpose of this study was to characterize host responses to purified recombinant hemagglutinin B (rHag B), using the conventional Fischer rat as the experimental animal model. The effectiveness of immunization with rHag B on protection against experimental periodontal bone loss following infection with P. gingivalis was also evaluated. Groups of rats were immunized by the subcutaneous route with rHag B in complete Freund's adjuvant, immunized with rHag B and orally infected with P. gingivalis, nonimmunized and noninfected, or orally infected with P. gingivalis only. Serum and saliva samples were collected throughout the experiment and evaluated for serum immunoglobulin G (IgG) and IgM and salivary IgA antibody activity by enzyme-linked immunosorbent assay. No salivary IgA anti-Hag B activity was detected in the various groups of rats. A slight serum IgM response similar to that seen in preimmune samples was observed. Serum IgG antibody activity to Hag B was detected only in samples from rats immunized with rHag B. This response was primarily of the IgG1 and IgG2a subclasses, followed by IgG2b and low levels of IgG2c. Supernatants from rHag B-stimulated splenic lymphoid cell cultures from immunized rats contained high levels of gamma interferon, followed by interleukin-2 (IL-2), IL-10, and then IL-4. These results are consistent with the induction of T helper type 1 (Th1)- and Th2-like responses. Western blot analysis of sera derived from rHag B-immunized rats reacted with trichloroacetic acid (TCA) precipitates of P. gingivalis 33277, 381, A7A1-28, and W50, revealing a 50-kDa band reflective of Hag B. However, sera derived from rats immunized with P. gingivalis whole cells or from rats infected with P. gingivalis only did not react with rHag B but did react with TCA precipitates of P. gingivalis strains. Finally, radiographic measurements of periodontal bone loss indicated that rats immunized with rHag B had less bone loss than those infected with P. gingivalis only. These results demonstrate the effectiveness of purified rHag B in inducing a protective immune response and support the potential usefulness of this component of P. gingivalis in the development of a vaccine against adult periodontitis.
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Affiliation(s)
- J Katz
- Department of Oral Biology, School of Dentistry, The University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
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23
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Nagasawa T, Aramaki M, Takamatsu N, Koseki T, Kobayashi H, Ishikawa I. Oral administration of Porphyromonas gingivalis fimbriae with cholera toxin induces anti-fimbriae serum IgG, IgM, IgA and salivary IgA antibodies. J Periodontal Res 1999; 34:169-74. [PMID: 10384405 DOI: 10.1111/j.1600-0765.1999.tb02238.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- T Nagasawa
- Tokyo Medical and Dental University, Department of Periodontology, Japan
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