Special Tissues: Local Immune Responses

Review

Tissue-Specific Immunity at
the Oral Mucosal Barrier
Niki M. Moutsopoulos1,* and Joanne E. Konkel2,3

The oral mucosal barrier is constantly exposed to a plethora of triggers requiring Highlights
immune control, including a diverse commensal microbiome, ongoing damage Unique signals tailor immune function-
ality at the gingiva compared to other
from mastication, and dietary and airborne antigens. However, how these tissue-
barrier sites.
specific cues participate in the training of immune responsiveness at this site is
minimally understood. Moreover, the mechanisms mediating homeostatic immu- Ongoing damage from mastication is a
tissue-specific cue that trains immune
nity at this interface are not yet fully defined. Here we present basic aspects of the function at the gingiva.
oral mucosal barrier and discuss local cues that may modulate and train local
immune responsiveness. We particularly focus on the immune cell network The oral microbiome provides key sig-
nals for the regulation of oral innate
mediating immune surveillance at a specific oral barrier, the gingiva – a constantly defenses.
stimulated and dynamic environment where homeostasis is often disrupted,
Dysbiosis of the oral microbiome trig-
resulting in the common inflammatory disease periodontitis.
gers the inflammatory disease period-
ontitis at the gingiva.
The Oral Barrier – Gateway into the Human Body
At the gingiva, a specialized immune
The oral mucosa is a site of first encounters. Commensal microbes, airborne antigens/aller- cell network polices this dynamic
gens, and food are all initially encountered here before entry into the gastrointestinal (GI) and barrier.
often respiratory tracts. As is the case with other barrier sites, the local immune system strikes a
Better understanding of immune cell
delicate balance in that it performs effective immune surveillance without exuberant inflamma-
training and function at the gingival
tory responses, while tolerating commensals and innocuous antigens [1]. However, although barrier will support the development
extensive work has focused on the regulation of barrier immunity at sites such as the of barrier-targeted immune therapies.
gastrointestinal tract and skin, training and regulation of homeostatic immune responsiveness
is much less explored at the oral barrier (see Outstanding Questions). In the current review we
present unique aspects of the oral mucosal barrier and discuss current knowledge of the local
immune cell network mediating immune homeostasis. Moreover, we outline recent data on
tissue-specific cues involved in training immune function at this site, with a focus on gingival
(see Glossary) barrier immunity. 1
Oral Immunity and Inflammation Unit,
Oral and Pharyngeal Cancer Branch,
National Institute of Dental and
Home to a Rich and Diverse Microbiome Craniofacial Research (NIDCR),
National Institutes of Health (NIH),
The oral barrier is one of the main ecological habitats of the human body [2]. Oral microbial Bethesda, MD 20892, USA
communities are distinct from those at other barrier sites and are among the most diverse in 2
Faculty of Biology, Medicine and
terms of community membership [3]. Dominant phyla detected are Firmicutes, Proteobacteria, Health, Manchester Academic Health
Science Centre, University of
Actinobacteria, and Bacteroidetes, with varying levels of representation in distinct ecological Manchester, Manchester M13 9PT,
niches within the oral cavity, with the clearest distinction between shedding epithelia (oral UK
3
mucosa) and non-shedding surfaces (tooth-adherent biofilm) [4]. At the species level, over 600 Manchester Collaborative Centre for
Inflammation Research (MCCIR),
prevalent taxa have been described in the oral cavity [5]. Interestingly, tooth-adherent microbial University of Manchester, Manchester
communities are among the most rich and diverse [6,7], and have been shown to form biofilms M13 9NT, UK
with complex structural organization [8]. However, despite extensive characterization of the oral
microbiome, the host–microbiome interplay at the oral mucosa is much less well understood
*Correspondence:
than at the intestinal mucosa. In this section we highlight three key areas of ongoing nmoutsop@mail.nih.gov
investigation. (N.M. Moutsopoulos).

276 Trends in Immunology, April 2018, Vol. 39, No. 4 http://dx.doi.org/10.1016/j.it.2017.08.005

Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Do Microbial Signals Train Homeostatic Immunity at the Oral Barrier? Glossary
Commensal microbiota have been shown to play crucial roles in the development and conditioning Crevicular epithelium: the
of local immunity at barrier sites [1–9], with specific microbes playing significant roles in tailoring epithelium lining the gingival sulcus.
immune cell function [10,11]. At the oral barrier, the role of the microbiome, and its metabolites, in Dental caries: breakdown of tooth
structure caused by acid-producing
the training of local immune cells has not been fully elucidated, but current data suggest both bacteria.
microbiome-dependent and independent regulation of immune homeostasis. In this regard, Dysbiosis: imbalance of microbial
germfree (GF) mice have been shown to have a broadly undisrupted immune cell network, with communities and the host.
Gingiva: the mucosal tissue that
comparable frequencies of CD45+ hematopoietic cells and T cells compared to specific patho-
surrounds and supports the teeth.
gen-free (SPF) controls [12], suggesting that microbiome-independent mechanisms support the Gingival crevicular fluid (GCF):
establishment of homeostatic immunity. However, clear roles for commensal colonization have fluid exiting the gingival tissues into
been demonstrated in the induction of innate defenses at the oral barrier. While neutrophils have the gingival sulcus containing local
inflammatory mediators.
been detected in GF mice, they are found at lower numbers compared to their SPF counterparts,
Gingival sulcus: the space between
suggesting that both microbiome-dependent and -independent mechanisms promote steady- the gingiva and teeth.
state neutrophil recruitment to the oral barrier [13]. Select innate epithelial antimicrobial oral Junctional epithelium (JE): the
defenses have also been reported to depend on commensal colonization, similarly to the epithelium connecting the oral
mucosa directly with the tooth
gastrointestinal tract [9]. Epithelial expression of growth arrest specific 6 (GAS6), a ligand of
surface through hemidesmosome
the TYRO3–AXL–MERTK signaling system, was shown to be commensal-dependent and to play connections.
a role in the control of inflammatory tone and host–microbiome symbiosis at the oral mucosa [14]. Lining mucosa: stratified squamous
These insights indicate that at steady-state the oral microbiota locally influence immune function, epithelium (non-keratinized) covering
the oral mucosa.
but it is becoming increasingly clear that immunological defense of this barrier is also mounted Masticatory epithelium: oral
irrespective of commensal colonization. epithelium (partially keratinized) that
lines the areas subjected to
What Immunological Mechanisms Regulate Commensalism in the Oral Environment? mechanical forces of mastication.
Host–microbe coexistence at barriers depends on homeostatic mechanisms that safeguard Periodontitis: common chronic
commensalism. In this regard, IL-17 signaling mediates control of the commensal oral fungus inflammatory disease that leads to
destruction of tooth supporting
Candida albicans. Elegant studies in animal models, as well as examination of patients with
structures, resulting in alveolar bone
genetic defects in IL-17 signaling and type 17 T helper (Th17) cell differentiation, have loss.
revealed a vital role for IL-17 in oral antifungal immunity [15,16]. Indeed, IL-17 secreting cells, Regulatory T cells (Tregs): a
both Th17 and T cell receptor (TCR) gd T cells [17,18], are implicated in protection against subset of CD4+ T cells defined by
their expression of the transcription
fungal infection. IL-17-signaling, particularly in epithelial cells, is crucial for the induction of factor Foxp3.
innate antimicrobial defenses, with b-defensin 3 being best-characterized for its role in Saliva: watery substance secreted
surveillance of C. albicans [19,20]. The importance of innate defenses in the control of oral by salivary glands and containing
microorganisms is also revealed in studies of patients with xerostomia (salivary dysfunction electrolytes, mucus, enzymes,
glycoproteins, and antimicrobial
leading to low or lack of saliva) [21]. Saliva is the watery fluid produced by the salivary glands agents.
and contains a plethora of innate antimicrobial agents (immunoglobulins IgA, IgM, and IgG, and Type 17 T helper (Th17) cells: a
antimicrobial peptides histatins, lysozyme, lactoferrin, peroxidases, SLPI) [22]. Patients with subset of CD4+ T cells which
produce the cytokine IL-17.
reduced or no saliva (and related reduction in innate antimicrobial defenses) present with
increased susceptibility to oral candidiasis [23]. In addition, xerostomic patients also present
with rampant dental caries caused by increases in acid-producing oral microbes, revealing a
role for innate defenses in the control of caries-associated oral bacteria [24]. However, specific
immune mediators involved in the surveillance of commensals involved in the oral inflammatory
disease periodontitis have not been defined. Therefore, with the exception of IL-17-mediated
epithelial defenses being recognized for C. albicans surveillance, whether and how specific
aspects of immune functionality participate in the constraint of given bacterial commensals or
pathobionts has yet to be determined at the oral mucosa.
Can Microbial Stimuli Prime Local and Systemic Immunity?
Given that a plethora of commensal microbes as well as food and airborne antigens are
encountered for the first time at the oral barrier, it is conceivable that immunological responses
to microbes and antigens are primed at this site and may influence not only local immunity but
also subsequent recall responses at distant locations. Support for this concept arises from the

Trends in Immunology, April 2018, Vol. 39, No. 4 277

fact that sublingual (and mucosal) delivery of antigens for vaccination produces efficient local
and systemic protection in experimental models [25], indicating priming of systemic immune
responses to orally encountered antigens. Whether oral commensals trigger specific local
immunity in health is not well detailed, but characterization of lymphocytes in healthy oral
tissues reveals a predominance of memory populations [26], suggesting responsiveness to
local antigens. Additional evidence for local responses to oral commensals comes from the
detection of salivary IgA/IgG which are specific for oral commensals [27,28]. It is also appre-
ciated that oral commensals alter their functionality in the context of inflammatory periodontitis
[29] and contribute to the local inflammatory reaction [30,31]. As such, dysbiotic microbial
communities arising in periodontitis are known to perpetuate local inflammatory pathology [32].
In the context of periodontitis, increased immune-responsiveness to oral commensals is
evident by the presence of systemic antibody responses to periodontitis-associated microbes
[33]. Finally, oral microbes are known to gain access to the circulation [34,35] (or enter the
gastrointestinal tract) and have been recovered in disease lesions at distal locations (including
atherosclerotic plaques, RA joints, and colorectal cancer lesions), potentially contributing to
disease pathology at sites away from the mouth [32,33,36].

A Barrier Surface Exposed to a Plethora of Environmental Stimuli

The oral mucosa is lined by stratified squamous epithelia (Figure 1), which are primarily non-
keratinized (lining mucosa), allowing direct interaction with microbes/antigens and environ-
mental stimuli. Some areas are particularly thin, such as the sublingual area, and are highly
vascularized, thus serving as a target for vaccination, while sites subjected to the mechanical
stimulation/injury of chewing (masticatory epithelia) bear a layer of keratin protection [37]. A
particularly vulnerable site of the oral barrier is the epithelium of the gingival crevice which lines
the inside of the gingiva (the tissues surrounding teeth). The wall of the gingival sulcus is lined
with non-keratinized epithelium (crevicular epithelium) that progressively thins towards the
base of the sulcus. At the base of the sulcus where the mucosa meets the tooth, the epithelium
transitions to an incompletely differentiated epithelium, the junctional epithelium (JE). The JE
is considered a vulnerable point in an otherwise continuous epithelium. It tapers down to 3–5
layers of thickness and is attached to the tooth by hemi-desmosomes. The connection of the
JE to the tooth is highly permeable, allowing constant passage of tissue fluid termed gingival
crevicular fluid (GCF) which contains host factors including plasma proteins, cytokines,
immunoglobulins, and cells [38,39]. In fact, it is through the JE that neutrophils continuously
transmigrate into the oral cavity (see below for details). Importantly, the constituents of this local
fluid reflect the inflammatory state of the neighboring gingiva [38,39].

The Gingival Crevice: A Site of Constant Immune Activation

The barrier of the gingival crevice is constantly exposed to environmental stimulation by (i) the
rich and diverse tooth adherent microbiome and (ii) the continuous barrier damage arising from
chewing and hygiene regimens. These constant local triggers necessitate the activation of
immune mechanisms that can cope with the ongoing demands of surveillance, regulation, and
healing. In fact, histological studies reveal accumulations of inflammatory cells at steady-state in
the gingiva [40], and more recent flow cytometric analysis of oral mucosal tissue revealed an
increased level of inflammatory cells at the gingiva compared to other oral mucosal sites in
health [26]. As discussed above, a likely recruiter of immune cells is the oral microbiome.
Indeed, control of the microbiome is vital for maintaining immune homeostasis. Numerous
clinical studies have demonstrated that increases in microbial load stimulate gingival inflam-
mation and, conversely, that reduction in microbial load (through antibiotics or oral hygiene) can
reverse inflammatory states [41]. Early studies in which healthy volunteers abstained from oral
hygiene have demonstrated that increases and shifts in microbial populations [42] lead to

278 Trends in Immunology, April 2018, Vol. 39, No. 4

Figure 1. The Oral and Gingival Barrier. The oral mucosa is lined by stratified squamous epithelia of varying thickness and level of keratinization. Most the oral
mucosa is covered by a lining of non-keratinized epithelium (the floor of mouth being particularly thin and vascular). The areas related to mastication (hard palate, outer
surface of gingiva) are partially keratinized epithelia, and the tongue is covered with a specialized epithelium that incorporates the taste buds. The gingival crevice is a
particularly open and vulnerable site. It is lined by the sulcular epithelium that is non-keratinized and becomes progressively thinner, transitioning to the junctional
epithelium which connects to the tooth surface and is constantly exposed to the microbial biofilm and experiences trauma, leading to constant immune activation.

clinically detectable gingival inflammation [43]. These inflammatory changes occurred over a
period of days to a few weeks and were reversible, underscoring the ability of this site to
continuously remodel and perform an active but delicate form of homeostasis.

The gingival barrier is also a site of constant mechanical damage due to mastication/hygiene.
The vulnerable connection between the JE and tooth is routinely breached during physiologic
functions such as chewing and brushing, allowing transient microbial translocation [44]. In fact,
microbial translocation of oral microbes is reported after chewing and during dental procedures
[34,35]. Interestingly, one of the remarkable properties of the JE is that it readily regenerates if
damaged or surgically excised in health [37], suggesting the presence of a unique immunologi-
cal system tailored for both surveillance and repair programs. The delicate balance between

Trends in Immunology, April 2018, Vol. 39, No. 4 279

microbiome/tissue injury and host responses at this interface is best reflected by the fact that
this homeostasis is often lost, leading to destructive inflammation; specifically the development
of the common inflammatory disease, periodontitis. In periodontitis a dysbiotic oral microbiome
is considered to be the trigger of a chronic inflammatory response in the surrounding soft
tissues [45], which causes destruction of supporting tissues and structures [46,47]. In fact,
40% of the adult population displays some level of periodontal immunopathology [48], sug-
gesting that a state of mildly altered homeostasis is a norm [49]. Nevertheless, 10% of the
general population will develop severe disease, linked to significant tissue destruction, reflect-
ing increased host susceptibility [48,49]. Moreover, severe periodontal destruction is associ-
ated with systemic translocation of periodontal microbes and is linked to numerous systemic
inflammatory conditions [32,33,36], indicating that local immune/microbiome imbalance may
affect distal inflammatory processes (either through increased microbial translocation, systemic
inflammation, or shared immunopathological mechanisms) [36,32]. The commonality of this
disease and its potential for systemic inflammatory consequences makes understanding the
immunological pathways implicated in gingival health and periodontitis of increased interest to
the general community of immunologists and clinicians.

Homeostatic Immunity at the Gingival barrier

The Immunological Network at the Gingival Barrier
Despite our increasingly sophisticated understanding of the bacterial communities present at
the oral/gingival barrier [6], how these microbes, alongside diet and other tissue-specific cues,
tailor immune cell function at the gingiva remains minimally explored. Moreover, how local
education combined with potentially distinct ontogenies of gingival resident immune popula-
tions participate in the generation of a unique mucosal immune system is poorly understood.
We will outline here the current understanding and outstanding questions regarding the local
immunosurveillance network operating at the gingival barrier in health (Figure 2).

Neutrophils: Gatekeepers of Oral Immunity

The vast majority of cells recruited to the gingival crevice in health are neutrophils [50], constituting
95% of total leukocytes, and increasing to even higher numbers during inflammation [26,51].
Neutrophils constantly extravasate from the circulation into gingival tissue and traffic into the
gingival crevice through the JE. An estimated 30 000 neutrophils undertake this journey every
minute in humans [52] and can be found within the oral cavity, exhibiting varying levels of activation
and functional states depending on the presence of oral inflammation [51,53]. Whether the
extravasated neutrophils, within and outside of the tissue, mediate roles in microbial surveillance
through phagocytosis, degranulation, and the secretion of antimicrobial peptides and/or neutro-
phil extracellular traps is not yet fully defined [54,55]. However, it has become clear that, within the
gingiva, neutrophils have functions beyond microbial surveillance. Neutrophils are present in the
gingiva of GF mice in the absence of live microbes, and studies in immunodeficient patients
suggest additional regulatory roles of tissue neutrophils beyond microbial killing.

The crucial role of tissue neutrophils in oral/periodontal immunity has been revealed in patients
with single-gene mutations related to granulopoiesis or defective neutrophil recruitment/extrav-
asation, including ELANE (neutrophil elastase), WAS (Wiskott–Aldrich syndrome), LYST (lyso-
somal trafficking regulator, mutation are responsible for Chediak–Higashi syndrome), CXCR4
(WHIM syndrome), and ITGB2 (integrin b2, involved in leukocyte adhesion deficiency) muta-
tions, all of which present with severe/aggressive periodontal immunopathology [54,56].
Studies in such patients have revealed crucial functions for tissue neutrophils in periodontal
homeostasis that extend beyond microbial killing. In fact, in patients with neutrophil defects a
dysregulated IL-17/Th17 response has been shown to drive immunopathology. In this context

280 Trends in Immunology, April 2018, Vol. 39, No. 4

Figure 2. The Immunological Network of the Gingiva. The gingiva is home to a rich immunological network.
Neutrophils continuously transmigrate through the junctional epithelium. Resident lymphocytes are predominately T cells,
with some B cells and innate lymphoid cells (ILCs). Diverse mononuclear phagocytes are also present at this site.
Abbreviations: APC, antigen-presenting cell; DC, dendritic cell; ILC, innate immune cell; SSC, side scatter.

neutrophils play roles beyond microbial surveillance and related to immunoregulation [57].
Efferocytosis (uptake of apoptotic cells) of tissue neutrophils by macrophages has been shown
to be crucial in the resolution of inflammation [58,59] by downregulating production of IL-23, a
key trigger of Th17 responses [60]. In the context of tissue neutropenia, exacerbated IL-23/IL-
17 axis responses become a pathogenic driver mediating immunopathology [59,61,62].

Importantly, a ‘goldilocks’ balance of neutrophils must be established within the gingiva, with both
too few and too many neutrophils contributing to periodontal immunopathology [26,63–65].
However, the pathways leading to excessive neutrophil recruitment and activation in periodontitis
are not completely detailed, neither are their specific functions that are crucial in immune regulation,
suggesting that the gingival barrier is an ideal site of study to better understand neutrophil biology.

Other Granulocytes
Additional granulocytes reported to be present in the gingiva predominately include mast cells,
with limited demonstrations that eosinophils or basophils are resident in the gingiva during

Trends in Immunology, April 2018, Vol. 39, No. 4 281

health. Mast cells constitute a little over 5% of granulocytes in health [26] and are expanded in
settings of gingival inflammation [66]. Whether mast cells are poised for immune surveillance
against pathogens [67] and/or contribute to immunopathology through degranulation and
secretion of proinflammatory mediators is not conclusively established.

Mononuclear Phagocytes
The gingival mononuclear phagocyte compartment is composed of an elaborate network of
dendritic cells (DCs) [68], macrophages, and recruited monocytes [26], each subset likely
exhibiting contextual roles in defending the barrier and promoting immune regulation. Mono-
cytes expressing the chemokine receptor CX3CR1 are recruited to the gingiva in response to
bacterial infection [69], suggesting that these cells function similarly in the gingiva and other
barrier sites by being recruited in response to barrier inflammation. However, the relationship
between recruited monocytes and resident macrophages has not been fully explored in the
gingiva. Indeed, although tissue-resident macrophages are key gatekeepers of mucosal
immunity at other barriers [70], the ontogeny, heterogeneity, functionality, and niche location
of macrophages in the gingiva remain to be elucidated. Given the importance of tissue location
in shaping macrophage function [71], it is likely that gingival macrophages will exhibit distinct
functional properties compared to other barriers. These cells likely mediate key antimicrobial
functions at the gingiva but may also participate in ongoing wound healing and repair given the
high levels of barrier damage occurring at this site and its potential for rapid healing [72]. Despite
minimal information on gingival conditioning of macrophage populations, it has been reported
that recruited monocytes can give rise to CD45+CD11c+CD11b+EpCAM+langerin+ cells in the
gingiva, which share transcriptional traits with skin-resident Langerhan cells (LCs) [73]. Intrigu-
ingly, gingiva-resident LC-like cells with a similar phenotype to those derived from monocytes
could also be generated from precursors to DCs [73], highlighting the impact of adopting
gingival residence on cell function and phenotype.

Within the DC network, multiple DC populations have been reported to reside in the gingiva and
are increased during gingival inflammation [74,75]. In mouse, CD11b+, CD103+ and, as already
discussed, langerin+ DCs have been identified [68,76]. Similarly, in human CD1c+, CD141+,
and CD1a+EpCAM+ Langerhans-like cells constitute the gingiva DC network [26]. However, the
transcription factor dependency and origin of these DC subsets has not yet been ascertained,
and whether the transcriptional signatures and functional capabilities of gingival DCs align with
the better-defined gastrointestinal and skin DCs remains to be established [77,78]. Moreover, in
other barrier environments specific subsets of DCs have been shown to support particular T cell
populations [79–81]. Whether these DC subsets perform similar functions within the gingiva
remains to be explored.

Lymphocytes
T cells, B cells, and innate lymphoid cells (ILCs), as at other barriers, reside within the gingiva. B
cells are present in gingiva in health, and commensal-specific IgA and IgG have been detected
in oral fluids; however, their contribution to maintenance of gingival immune homeostasis has
not been fully elucidated [27]. Nevertheless, in the context of periodontitis, B cells have been
shown to have both protective and detrimental roles in settings of immunopathology [82,83].
ILC populations have also been described in human gingiva – with a predominance of ILC1 and
natural killer (NK) cells – although functions for ILCs in both health and disease remain to be
established [26] and the ILC subsets resident in mouse gingiva await exploration. By contrast,
much work has focused on gingival T cell populations, mainly because of the early demon-
stration in mouse models that T cells, particularly CD4+ T cells, are key mediators of periodon-
titis pathology [84,85]. Indeed, both CD4+ and CD8+ T cells expand in settings of periodontitis.

282 Trends in Immunology, April 2018, Vol. 39, No. 4

In health, in both mouse and man, CD4+ T cells dominate over CD8+ T cells, and most CD4+
and CD8+ T cells have a memory phenotype [26,86]. In both cell populations a proportion of
gingiva-resident T cells exhibit a resident terminally differentiated memory cell phenotype.
Resident effector CD4+ and CD8+ T cell populations in the gingiva in mice and humans produce
the canonical type 1 and 17 effector cytokines IFN-g and IL-17 [26,86]. Increased proportions
of resident memory T cells are common at barrier sites, where they have been reported to
support early/immediate defense mechanisms, providing site-specific protection from patho-
gen challenge [87].

Similar to effector T cell populations, gingival resident Foxp3+ regulatory T cells (Tregs) have
also been described [26,12]. However, little is known about specialization of Tregs in the
gingiva, although studies in other tissues have shown that Treg phenotypes are typically
exquisitely tailored by tissue location [88,89]. Regardless of specialization, it is clear that Tregs
play key roles in maintaining periodontal homeostasis [90,76]. In the gastrointestinal tract,
generation of Tregs toward orally encountered antigens is a well-described mechanism of
tolerance [91]; however, it appears unlikely this would be a dominant tolerance mechanism at
the gingiva. Indeed, fewer Tregs reside in the gingiva at steady-state compared to the
gastrointestinal tract [26,92], and in addition the DC subset preferentially supporting Treg
generation, CD103+ DCs, constitutes the smallest proportion of gingival DCs [68,93].

For all gingival resident lymphocyte populations, a key unanswered question is how these cells
traffic to this barrier. In the gastrointestinal tract, skin, lung and nasal mucosa, crucial chemo-
kine and integrin interactions support trafficking of lymphocytes to, and residence at, the barrier
site [94,95]. Studies on gingival Tregs have indicated that CCR4–CCL22 supports Treg
trafficking to the gingiva [90,96]. Determining the recruitment and developmental requirements
for residence of gingival lymphocytes in health and disease is an important outstanding
question with clear therapeutic implications. Beyond this, it is important to consider the vital
functions mediated by these different lymphocytes at the gingiva. Gingiva-resident effector and
memory T cells are present in both mouse and man [26,86], and their residence at the barrier
suggests that effective, antigen-specific responses are mounted at this site. However, no data
are available on the specificity of any gingival resident T cell population, and therefore under-
standing their contribution to controlling and curtailing gingival inflammatory reactions during
steady-state remains limited. However, a crucial function for T/NKT cell immunity in oral viral
protection has been documented in patients with combined immunodeficiencies and T/NKT
cell defects [56,97].

Tissue-Specific Training of Gingival Immune Function: Ongoing Damage Due to Mastication

Promotes Local Th17 Immunity
The gingiva is exposed to diverse signals including (i) commensal bacteria, viruses, and fungi, (ii)
metabolites, (iii) diet, and (iv) tissue injury (Figure 3). However, the relative contributions of each
of these signals to the induction and training of local immunity are poorly understood. Recently
the tissue-specific cues responsible for development of Th17 cells have been interrogated at
the gingiva. Th17 cells have emerged as crucial regulators of tissue homeostasis and immu-
nopathology at the oral barrier [98,99]. Physiologic roles of Th17 cells are well documented in
fungal immunosurveillance (above), but their deregulation has been associated with periodontal
immunopathology in experimental periodontitis [63,61] and in genetic forms of periodontitis in
humans [61]. Interestingly, recent evidence from our group revealed that Th17 cells expand
with age in the gingiva. This occurred independently of microbial colonization, with GF mice
having comparable numbers of gingival Th17 cells to SPF mice [12]. These data starkly contrast
the developmental pathway for Th17 cells at other barrier sites such as the skin and gut, with

Trends in Immunology, April 2018, Vol. 39, No. 4 283

 Outstanding Questions
How do local, tissue-specific cues tai-
lor immune responsiveness at the oral
barrier?

Do oral microbial communities contrib-

ute to local training of immunity at the
oral barrier?

What are the key mechanisms ensur-

ing immune surveillance?

What regulatory networks mediate

tolerance?

Does local priming of immune

responses at the oral barrier affect dis-
tal and/or systemic immune
responses?

Figure 3. Tissue-Specific Cues Tailoring Immunity at the Oral Barrier. Diverse microbial commensal communities
and ongoing damage have been established to educate immune function at the gingiva, while dietary elements and
airborne allergens/particles are speculated to play a role in the training of local immunity.

Th17 cell development at these barriers being dependent upon commensal colonization
[10,11]. Thus, residence of Th17 cells at the gingiva takes place via mechanisms distinct from
those employed at other barrier sites. At the gingiva, accumulation of Th17 cells occurred in
response to the physiological barrier damage that results from mastication/chewing [12]. Thus,
ongoing mechanical damage was revealed as a tissue-specific cue capable of triggering
immune responsiveness. Underscoring the vital role of mastication-induced barrier damage
in the regulation of the local immune function, mice placed on a soft diet, and thus having
reduced levels of gingival barrier damage, had reduced numbers of gingival Th17 cells. By
contrast, mice on a hardened diet, or following acute gingival injury, exhibited elevated
frequencies of gingival Th17 cells. Damage-induced Th17 cells were shown to arise in an
IL-6- and antigen-dependent manner, and were, importantly, able to promote the induction of
protective innate barrier defenses [12,100]. These data demonstrate the pivotal role of a
physiological function such as mastication as a central regulator of barrier immunity, and
highlight the importance of understanding unique local cues in the study of tissue immunity.

Concluding Remarks
The oral mucosa is a barrier site that is constantly exposed to a multitude of environmental stimuli,
but the mechanisms that mediate immunological surveillance and tolerance, thus safeguarding
tissue homeostasis, are not well defined. As the immunological network of the oral barrier is
starting to be deciphered, recent studies highlight some similarities in the cellular subsets detected
compared to other barrier sites. However, in the oral and gingival environments the developmental
requirements and functional roles of specific immune cell subsets remain largely unknown.
Importantly, the unique aspects of the immune network policing the oral barrier may be of
importance and could potentially reflect specialized functional capabilities that are necessary
to maintain homeostasis in this environment. As such, the continuous recruitment and extrava-
sation of neutrophils within gingival tissues in health, and the severe inflammatory oral phenotypes

284 Trends in Immunology, April 2018, Vol. 39, No. 4

in patients with neutrophil defects, highlight a vital role for this subset in oral homeostatic immunity.
Indeed, both antimicrobial and anti-inflammatory functions of neutrophils appear to be crucial for
periodontal homeostasis. More broadly, specific adaptations in the immune cell populations
reflect the specialized tissue-specific cues operating in the oral environment. In this regard, the oral
barrier is exposed to unique and diverse communities of commensal microbial communities that
are known to play immune-stimulatory roles particularly in the setting of the oral inflammatory
disease periodontitis. Moreover, an ongoing tissue-specific cue at the oral/gingival barrier is the
continuous damage from mastication, which acts as a trigger for local immunity and tones
homeostatic Th17-dependent barrier-protective immune responsiveness. Nevertheless, how
the combination of these diverse signals participates in the regulation of homeostatic immunity
at this important barrier and whether local responses influence systemic immune functioning
awaits further exploration.

Acknowledgments
The authors would like to thank Alan Hoofring (Lead Medical Illustrator, NIH Medical Arts) for creating figure illustrations. We
also would like to thank Dr John Grainger, Dr Eva Mezey, and Ms Teresa Wild for providing input on our manuscript. This
work was funded in part by the Intramural Program of the NIDCR (to N.M.), by the Biotechnology and Biological Sciences
Research Council (BBSRC; BB/M025977/1 to J.E.K), and by the Manchester Collaborative Centre for Inflammation
Research (to J.E.K).

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