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Macrophages Subpopulations in Chronic Periapical Lesions According to Clinical and Morphological Aspects ORIGINAL RESEARCH Oral Pathology Macrophages subpopulations in chronic periapical lesions according to clinical and morphological aspects Glória Maria de FRANÇA(a) Abstract: The aim of this study was to evaluate macrophage M1 (a) Andréia Ferreira do CARMO and M2 subpopulations in radicular cysts (RCs) and periapical Hugo COSTA NETO(a) Ana Luiza Dias Leite de granulomas (PGs) and relate them to clinical and morphological ANDRADE(b) aspects. M1 macrophages were evaluated by the percentage of CD68 (a) Kenio Costa de LIMA immunostaining associated with the inflammatory cytokine TNF-α, Hébel Cavalcanti GALVÃO(a) and M2 macrophages, by its specific CD163 antibody. The CD68+/ CD163+ ratio was adopted to distinguish between the two macrophage subpopulations. Clinical, radiographic, symptomatology, treatment, and morphological parameters of lesions were collected and a (a) Universidade Federal do Rio Grande do significance level of p = 0.05 was adopted for statistical analysis. The Norte – UFRN, Departament of Dentistry, results showed that the CD68+/CD163 + ratio was higher in the RCs Natal, RN, Brazil. (median = 1.22, p = 0.002), and the highest TNF-α immunostaining (b) Universidade Federal de Alfenas – Unifal, scores were found in RCs (p = 0.018); in PGs, the CD68+/CD163 + ratio Departament of Anatomy, Alfenas, MG, + Brazil. was lower and associated with a greater CD163 immunostaining (median = 1.02, p <0.001). The TNF-α in cyst epithelium had a score of 3 in 10 cases and predominance of M1 macrophages by CD68+/CD163 + (median = 2.23). In addition, CD68+ cells had higher percentage of immunostaining in smaller RCs (p = 0.034). Our findings suggest that increased CD68 immunostaining associated with TNF-α cytokine in RCs results in a greater differentiation of the M1 phenotype. The higher CD163 immunostaining in PGs results in greater differentiation of the Declaration of Interests: The authors M2 phenotype. Therefore, the inflammatory state promoted by M1 certify that they have no commercial or associative interest that represents a conflict macrophages is related to growth and progression of RCs; on the other of interest in connection with the manuscript. hand, the immunomodulatory state of M2 macrophages is related to maintenance of PGs. Corresponding Author: Keywords: Radicular Cyst; Periapical Granuloma; Macrophages. Hébel Cavalcanti Galvão E-mail: [email protected] Introduction https://doi.org/10.1590/1807-3107bor-2019.vol33.0047 Radicular cysts (RCs) and periapical granulomas (PGs) are chronic lesions that develop in response to inflammatory mediators that originate from dental pulp necrosis1. The etiopathogenesis of RCs has three phases: initiation, formation, and growth. It is thought that RCs originate from granular tissue in the periapex, where epithelial rests of Malassez (ERM) Submitted: October 29, 2018 or Hertwig epithelial sheath remnants are stimulated, resulting in the Accepted for publication: April 8, 2019 Last revision: April 29, 2019 formation of a cystic lumen2,3. Braz. Oral Res. 2019;33:e047 1 Macrophages subpopulations in chronic periapical lesions according to clinical and morphological aspects Three theories have been postulated to explain RC TNF-α is an inflammatory cytokine released enlargement. The osmotic pressure theory explains mainly by M1 macrophages and is responsible progressive RC growth, which occurs through for regulating cystic epithelium cell proliferation, increasing exudate permeability through the cyst differentiation, and apoptosis10. In addition, TNF-α is lumen due to the necrosis of central epithelial cells. a recognized bone resorption modulator3. Thus, due The abscess theory, on the other hand, suggests a to significant interactions with the cyst epithelium, proliferative ability of epithelial tissue involving the studies investigating TNF-α are of significant interest. periapical abscess area. Finally, the immunological CD68 is a 110-K-Da intracellular glycoprotein theory suggests that ERM can acquire antigenic that recognizes M1 and M2 macrophages due to properties due to the expression of molecules not its location in the primary granules of macrophage produced in their quiescent state. Thus, a cross reaction lysosomes, playing a role in endocytosis and lysosomal 11 occurs between ERM and bacterial products through movement . CD163 is a 130-k-Da glycoprotein antibodies, complement system, natural killers cells, belonging to the scavenger receptor group and is cytotoxic T lymphocytes, and macrophages4. present, specifically, in M2 macrophages. M2 cells Macrophages participate in host protective usually display high levels of scavenger receptors, as response against chronic periapical lesions, its polarization occurs though the mannose-binding lectin-dependent pathway 9,12. as well as in the development and perpetuation of Previous studies have suggested that macrophage inflammatory reactions. These cells play complex roles polarization contributes to the formation, development, in phagocytosis and in the production of inflammatory and growth of both RCs and PGs6,13. However, mediators, activation of humoral and cellular immune information regarding the specific location of M1 responses, and lesion repair, while also acting as and M2 macrophages, the phenotypes associated antigen-presenting cells (APCs). Macrophages can with TNF-α in RC epithelium, and the relationship of directly interact with the cyst epithelium through these cells with clinical aspects and lesion stage and the release of certain cytokines, such as TNF-α, size have not yet been investigated. Thus, the aim of that regulate bone growth and resorption. Thus, this study was to quantitatively and comparatively macrophages could be associated to and explain the evaluate M1 and M2 macrophages in RCs and PGs immunological theory of RC formation5,6. through the expression of CD68, TNF-α, and CD163. Macrophages can be classified into two different In addition, the roles of macrophages and TNF-α in phenotypes: M1 and M2. The M1 phenotype produces inflammatory infiltrates and cyst epithelial lining potent effector molecules, such as reactive oxygen were also assessed. species and nitrogen intermediates, as well as inflammatory cytokines (IL-1, IL-6, and TNF-α), and Material and methods polarizes Th1 lymphocyte responses, participating in proinflammatory states. M2 macrophages, on the Study design and tissue samples other hand, release growth factors, such as TGF-β Sixty tissue specimens, 30 PGs and 30 RCs, and immunosuppressive cytokines (IL-10 and IL-13), archived at the Federal University of Rio Grande leading to the activation of Th2 lymphocyte responses, do Norte (UFRN) Oral Pathology Department were participating in immunomodulatory states6,7. randomly selected. Only excisional biopsies from The activation of the classical complement surgical resections in paraffin blocks containing pathway can occur in the presence of IFN-γ and sufficient material for histopathological analyses were TNF-α mediators after recognition of pathogen- included in the study. For RCs, lesions with sufficient associated molecular patterns (PAMPs). Macrophages epithelium and fibrous capsule were selected. For originating from this activation are called M18. The PGs, any specimens presenting epithelium were activation of the alternative complement pathway excluded, in order to discard epithelized granulomas, leads to M2 phenotype polarization9. since they were not the focus of this investigation. 2 Braz. Oral Res. 2019;33:e047 França GM, Carmo AF, Costa Neto H, Andrade ALDL, Lima KC, Galvão HC Data regarding gender, age, lesion location, size, Immunohistochemical analyses radiographic data, symptomatology, and treatment CD68 monoclonal antibody staining (DAKO, were obtained from biopsy records. Cases presenting Carpinteria, CA, USA) was performed to confirm the incomplete information were excluded. The study was macrophage nature. In addition, monoclonal TNF-α approved by the Federal University of Rio Grande (Abcam; Cambridge, MA, USA) and CD163 antibody do Norte Research Ethics Committee for Human staining (Abcam; Cambridge, MA, USA) were used Stidues (Protocol 1,998,683). to verify the polarization profiles for M1 and M2, respectively. The specifications for each antibody Morphological analyses are displayed in Table 1. Specimens were stained with hematoxylin and For all antibodies, 3-μm thick sections were eosin and examined at 5-μm thickness under light obtained from paraffin blocks, dewaxed, and microscopy (Olympus BX41, Olympus Japan Co., submitted to antigenic retrieval. After, the specimens Tokyo, Japan) at 40x, 100x, and 400x magnifications. The were submitted to the Trilogy process (Cell Marque, intensity of the inflammatory infiltrates was analyzed CA, USA) at a 1:100 ratio of distilled water in a Pascal at 400x and classified according to Tsai et al. (2004) vessel for 10 minutes. Subsequently, the samples were criteria14. Nine microscopic fields divided into three blocked by endogenous peroxidase with hydrogen consecutive fields were selected for RC analysis. The peroxide and then incubated with protein block analysis began in the epithelium and extended deep (Thermo Scientific, Runcorn, UK) for 5 minutes, in into the capsule. Lesions presenting inflammatory order to prevent non-specific binding. Two washes infiltrates restricted to 1/3 of the microscopic field were performed with a Tween 20 solution at 1% were classified as Grade I (low infiltrate), lesions in TRIS-HCl (tris-hydroxymethyl-aminomethane, presenting inflammatory
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