heat shock proteins are recent diagnostic markers

1. HEAT SHOCK PROTEINS AND PERIODONTIUM
NIRANJANA J MOHAN
IIND YEAR POSTGRADUATE
DEPARTMENT OF PERIODONTICS

2. CONTENTS
• INTRODUCTION
• ROLE OF AUTOIMMUNITY
• HEAT SHOCK PROTEINS
• HISTORY
• CLASSIFICATION, LOCATION AND ROLE
• PRODUCTION
• ROLE OF HSP IN HUMAN INFLAMMATORY DISEASES
• HSPS & AUTOIMMUNE RESPONSE
• MICROBIAL HSP AND INDUCTION OF T CELL REGULATION
• IMMUNE INTERACTIONS AND SIGNALLING

3. • HSP60 AND INNATE IMMUNITY
• HSPS OF ORAL MICRO-ORGANISMS
• HSP90 PROTEINS
• HEAT-SHOCK PROTEINS IN CARDIOVASCULAR DISEASE
• MOLECULAR MIMICRY OF HSP6031
• SEQUENCE HOMOLOGY OF HEAT SHOCK PROTEIN
• HSP AND PERIODONTITIS
• HSP60 & PERIODONTITIS
• HSP60 VACCINE IN PERIODONTITIS
• HSP60-BASED THERAPEUTIC APPROACHES FOR SYSTEMIC DISORDERS
• CONCLUSION
• References

4. INTRODUCTION
• Periodontitis is a biofilm-induced chronic inflammatory disease characterized by loss of
bone support of the dentition
• The tooth-associated biofilm is required but is not sufficient by itself to induce periodontitis.
• It is the host inflammatory response to microbial challenge that primarily and ultimately
causes the degradation of the periodontium.
Darveau, 2010; Hajishengallis,
2014

5. • The precise mechanisms of periodontal pathogenesis are incompletely understood but
disease initiation and progression invariably involves the breakdown of periodontal host–
microbe homeostasis
• Several models over the years
• The latest consensus - alterations in host microbial crosstalk and defects in the
immunoinflammatory status of the host leading to dysbiosis of the periodontal microbiota is
one of the main factors in pathogenesis
Darveau, 2010; Hajishengallis, 2014

6. Thomas Van Dyke et al 2020
inflammation-mediated polymicrobial dysbiosis and tissue damage can be exacerbated
if no treatment is provided or can be driven toward resolution of inflammation and
tissue repair/regeneration if treatment is given

7. • The histopathology of periodontitis shows that the disease includes elements of both innate
and adaptive immunity, which form a complex network of interactions leading eventually to
inflammatory bone loss
INNATE IMMUNITY
First line of defense
Instructs the development of the
adaptive arm of immunity.

8. Muñoz-Carrillo JL, Hernández-Reyes VE, García-Huerta OE, Chávez-Ruvalcaba F, Chávez-Ruvalcaba MI, Chávez-
Ruvalcaba KM, Díaz-Alfaro L. Pathogenesis of Periodontal Disease. InPeriodontal Disease-Diagnose Considerations
2019 Jun 6. IntechOpen

9. ROLE OF AUTOIMMUNITY
Autoimmunity can be defined as breakdown of mechanism responsible for self-
tolerance and induction of an immune response against components of the
self.
May not always be harmful (eg:-Antiidiotype antibodies).
However, in numerous autoimmune diseases it is well recognized that products of
the immune system cause damage to the self (Jiang And Lechler 2003)

10. BRANDTZAEG
& KRAUS
1965
The autoimmune basis in the pathogenesis of
periodontal disease
Reflect an imbalance between effector and regulatory immune responses, typically develop
through stages of initiation and propagation, and often show phases of resolution (indicated
by clinical remissions) and exacerbations (indicated by symptomatic flares)
Autoreactive T cells, natural killer cells, ANCA, heat shock proteins, autoantibodies, and
genetic factors are reported to have an important role in the autoimmune component of
periodontal disease

11. POSSIBLE CAUSES OF AUTOIMMUNITY
(1) Enhanced presentation
of self-antigens through
increased expression of the
molecule associated with
antigen presentation,
namely, the IgA antigen;
(2) altered T helper or T
suppressor cell function;
(3) polyclonal activation of
cells which have the
ability, for reasons unclear,
to produce autoantibodies
Anusaksathien et al 1992

12. (4) idiosyncrasies of
the antigen idiotype
network;
(5) bacterial or viral
cross reactivity with
self-antigens leading to
production of cross-
reactive antibodies;
(6) genetic
predisposition factors.
Anusaksathien et al 1992

13. • A deep understanding of the Heat shock proteins (Hsp60), and their role in the
etiopathogenesis of periodontitis has the clinical implications of helping to identify patients
who are at risk for developing periodontal disease based on their inability to mount an
immune response to specific Hsp or Hsp epitopes
Significant interplay exists between autoimmune mechanisms and Oral Microbial Heat
Shock Proteins/stress proteins

14. HEAT SHOCK PROTEINS
When exposed to a large array of environmental stresses like temperature, pH, redox
potential; prokaryotic and eukaryotic cells respond by inducing the synthesis of specific
proteins
Important functions in the cell such as folding, assembly, and translocation of polypeptides
across membranes and play a main role in protein repair after cell damage

15. FERUCCIO
RITOSSA 1st discovered heat shock response
Observed an enlargement of special sections of Drosophila melanogaster chromosomes
(heat shock puffs) after heat treatment of the flies
The first products of these genes was identified in 1974 and the term “HEAT
SHOCK PROTEIN” was adopted.

16. CLASSIFICATION, LOCATION AND ROLE
Gaston JS. Heat shock proteins and innate immunity. Clinical and experimental immunology. 2002 Jan;127(1):1.

17. PRODUCTION
Heat shock factor 1 (HSF1) is changed to the activated form
by phosphorylation and this translocates into nucleus to
bind heat shock elements (HSEs). This process yields
various types of HSPs to maintain or improve the
homeostasis of living body

18. ROLE OF HSP IN HUMAN INFLAMMATORY
DISEASES

19. HSPS & AUTOIMMUNE RESPONSE
Three models have been proposed to link microbial infections to subsequent
autoimmune reactions involving Hsps . These models are based on:-
a. molecular mimicry between microbial Hsps and Hsps or constitutive
proteins from the host
b. inflammation-induced exposure of cryptic cell epitopes that could be a
target for immune reactions
c. antigen persistence in infected sites leading to chronic immunological
reactions

20. Immune responses to bacterial Hsps may generate
cross reacting immunity to self-Hsp and precipitate
damaging inflammatory responses.
Young and Elliott (1989) showed that through these
cross-reactive epitopes, Tcells with specificity for
self-Hsp can be activated during infection.

21. • The first report of antibodies against Hsps in a human disease is that of Jarjour et al (1991),
who suggested that the difference in the levels of anti-Hsps antibodies seen between patients
with diseases compared to healthy, could be an indicator of polyclonal B cell activation

22. • A second involvement of hsp in T cell-mediated immunity was demonstrated by the
pioneering studies of Srivastava and colleagues, who showed that the chaperone function of
many hsp (their ability to bind to and protect other polypeptides) allows them to deliver
tumour antigens very effectively to antigen presenting cells .This delivery appears to be
receptor mediated, and hsp receptors are now being characterized, such as CD91 which
binds several different hsp including two members of the hsp90 family and hsp70

23. • The third immunological role of hsp, namely their ability to stimulate cells of the innate
immune system, particularly antigen presenting cells, though interactions with other myeloid
cells and endothelial cells have also been described.

24. Gaston JS. Heat shock proteins and innate immunity. Clinical and experimental immunology. 2002 Jan;127(1):1.

25. MICROBIAL HSPAND INDUCTION OF T CELL
REGULATION
• Immunization with whole (heat-killed) mycobacteria in rats leads to an autoimmune arthritis
known as adjuvant arthritis.
• The analysis of T cell responses in rats with adjuvant arthritis revealed the presence of T
cells recognizing a mycobacterial antigen,which had a regulatory activity in the
inflammatory process.
• Later on, these T cells were seen to recognize the so-called 65-kDa antigen of mycobacteria,
which happened to be the mycobacterial Hsp60
Ragno et al

26. • The protective effect of mycobacterial Hsp60 as a naked DNA vaccine in adjuvant arthritis
has also been demonstrated
• Studies on the potential of repetitive oral administration of mycobacterial Hsp60 to suppress
adjuvant arthritis, have revealed that in the presence of soybeen trypsin inhibitor, very low
dosages of Hsp60 (30 micro g) can suppress disease
Ragno et al

27. IMMUNE INTERACTIONS AND SIGNALLING
Hsp60 is pleiotropic in its interactions with the immune system.
• Recognized by the antigen receptors (T cell receptor; TCR) of regulatory
and effector T cells and by the BCR of B cells
• Hsp60 is also a ligand for innate TLR signaling in various immune cells

28. • Human Hsp60 can induce proinflammatory responses in mouse or human macrophages and
dendritic cells
• Such interactions can upregulate inflammation.
( FLOHE, S.B. et al. 2003)

29. • Hsp60-treated Tregs suppressed target T cells both by cell-to-cell contact and by
secretion of IL-10.
• Thus, Hsp60 can downregulate adaptive immune responses by upregulating Tregs
innately through TLR2 signaling.
(ZANIN-ZHOROV, A. et al. 2006
• Hsp60 also acts as a costimulator of human CD4+CD25+ Tregs.
• Treatment of Tregs with Hsp60, or its peptide p277, before anti-CD3 activation significantly
enhanced the ability of relatively low concentrations of the Tregs to downregulate
CD4+CD25− or CD8+ effector T cells, detected as inhibition of target T cell proliferation
and IFN and tumor necrosis factor (TNF)-secretion.

30. • Hsp60 also activates B cells innately.
• Human Hsp60 induced native mouse B cells to proliferate and to secrete IL-10 and IL-6.
• Hsp60-treated B cells upregulated their expression of MHCII and accessory molecules
CD69, CD40, and B7–2.
• The cells that respond to Hsp60 using adaptive receptors are T effector cells (Th1), T
regulatory cells of various types (Th2, Tregs), and B cells; the cells that respond innately
to Hsp60 are dendritic cells, macrophages, Tregs, and B cells.
• Some of these responses upregulate inflammation and some downregulate inflammation.
QUINTANA, F.J. & I.R. COHEN. 2005

31. HSP60 AND INNATE IMMUNITY
• Circulating Hsp60 (soluble Hsp60–sHsp60) can be found in the peripheral blood of all
human beings.
• However, it has also been shown that Hsp60 can bind to aggregates of TLR-4and CD14 as
well as TLR-2/TLR-6,82,83 respectively, entailing the transcription of genes coding for
proinflammatory cytokines, such as TNF-and IFN.

32. HSPS OF ORAL MICRO-ORGANISMS
• Oral micro-organisms are subjected to a wide range of stresses that may affect their growth
and virulence and induce a stress response.
• The stress response to heat shocks has been studied in several oral micro-organisms the
syntheses of HSP’S are all up-regulated following a heat stress.

33. GROES AND GROEL PROTEINS
• In molecular biology, molecular CHAPERONES are proteins that assist the
conformational folding or unfolding and the assembly or disassembly of other
macromolecular structures
• The group I chaperonin GroEL and its cofactor GroES are essential components of the
cellular machinery of protein folding in bacteria

34. BASIC STRUCTURE
• GroEL is a large double-ring cylinder with ATPase activity that binds non-native substrate
protein (SP) via hydrophobic residues exposed towards the ring center.
• Basically GroEL is a dual-ringed tetradecamer, with both the cis and trans rings consisting
of seven subunits each. The two GroEL rings (cis and trans) stack back-to-back, forming a
channel in the centre of the rings, in the unliganded GroEL structure

35. • GroEL-like protein belonging to the hsp60 family can be expressed by periodontopathic
bacteria such as Porphyromonas gingivalis [Hotokezaka et al 1997, Maeda et al] and
Actinobacillus actinomycetemcomitans [Nakano et al 1995].

36. • A. actinomycetemcomitans cells subjected to a heat stress (42 or 50°C) in the presence of
radiolabeled amino acids have been shown by autofluorography to up-regulate the synthesis
of a major 64-kDa protein belonging to the GroEL family (Koga et al., 1993).
• This was confirmed by two-dimensional SDS-PAGE (Goulhen et al., 2003) and Western
immunoblotting (Vayssier et al., 1994).
• Immunolocalization by transmission electron microscopy of A. actinomycetemcomitans
GroEL shows that this HSP is located on the cell surface, in surface-associated material, and
on outer membrane vesicles produced by the bacterium
Kirby et al., 1995; Goulhen et al., 1998; Paju et al., 2000

37. • Native A. actinomycetemcomitans GroEL consists of two stacked heptameric rings (Fig. 2)
with 64-kDa subunits (Goulhen et al., 1998).
• To date, all known GroELs interact with a smaller co-chaperone protein with 10-kDa
subunits (GroES).
• In A. actinomycetemcomitans, the genes coding for GroES and GroEL are arranged in an
operon
A. actinomycetemcomitans GroEL shares 85% identity with E. coli GroEL (Goulhen, 2001).
In addition, the N-terminal amino acid sequence of A. actinomycetemcomitans GroEL
shares a high degree of homology with E. coli GroEL (Nakano et al., 1995)

39. DNAJ AND DNAK PROTEINS
• Also known as Hsp40 (heat shock protein 40 kD)
• Is a molecular chaperone protein
• BASIC STRUCTURE
• DnaJ can be subdivided into four domains on the basis of its primary amino acid sequence
• The N terminus has the J domain which is a 70 amino acid alpha helical region that interacts
with HSP 70 and stimulates its ATP-ase activity.
• This is separated from the rest of the molecule by a 30-40 amino acid glycine/phenylalanine
rich region that appears to be a flexible linker.

40. • DNAK comprises two main domains: a 44-kDa N-terminal nucleotide-binding domain
(NBD) that contains ATPase activity,
• a 25-kDa substrate-binding domain (SBD) that harbors the substrate-binding site.

41. FUNCTIONS
• Role in regulating the ATPase activity of Hsp70 heat-shock proteins.
• Besides stimulating the ATPase activity of DnaK through its J-domain, DnaJ also associates
with unfolded polypeptide chains and prevents their aggregation.
• The DnaK chaperone system is involved in various cellular processes such as the control of
the folded and oligomeric state of proteins under stress and non-stress conditions

42. • Yoshida et al. (1997) characterized two open reading frames(ORF) in
A.actinomycetemcomitans that code for DnaK and DnaJ.
• These results have been confirmed by Minami et al. (1998).
• The complete amino acid sequence of A. actinomycetemcomitans DnaK shares 84%, 55%,
and 48% identity with E. coli, M. tuberculosis, and human homologues, respectively
• A. actinomycetemcomitans DnaJ shares 70%, 36%, and 32% identity with the E. coli, M.
tuberculosis, and human homologues, respectively
Yoshida et al., 1997

43. HSP90 PROTEINS
• The members belonging to HSP90 protein family are highly conserved ubiquitous molecules
with an approximate molecular weight of 90-kDa.
• They are molecular chaperones promoting the folding of de novo synthesized or incorrectly
folded proteins, thus counteracting their aggregation.
BASIC STRUCTURE
• Three functional domains, the ATP-binding, protein-binding, and dimerizing domain, each
of which playing a crucial role in the function of the protein

44. The HSP90s of even the most distantly related eukaryotes (human and yeast) share
over 40% identity with E. coli HtpG (HSP90) (Lindquist and Craig, 1988).
Lopatin et al. (1999a)found a 68-kDa HSP90 protein in P. gingivalis that cross-
reacts with antibodies to human HSP90.
They also reported the presence of antibodies in the sera of periodontitis patients
thatcross-react with P. gingivalis HSP90

45. • P. gingivalis HSP90 is mostly membrane-associated, and significant levels of this protein
have been detected in extracellular vesicles.
• It has been suggested that membrane-associated HSP90 may act as cell receptors or serve to
stabilize or transport bacterial virulence factors.
(Lopatin et al., 1999a, 2000)

46. HEAT-SHOCK PROTEINS IN CARDIOVASCULAR
DISEASE
• According to the consensus report of the proceedings of the workshop jointly organised by
the EFP and the World Heart Federation (WHF)in 2019 there is a clear link between
cardiovascular diseases and periodontal disease and recommendations have been made
concerning the periodontal treatment in patients with CVS disorders.
• Strengthened by various studies by Beck et al, Mendez et al ,Joshipura et al and so on

47. • HSP expression is modulated by different stimuli involved in all steps of atherogenesis
including oxidative stress, proteolytic aggression, or inflammation.
• Also, antibodies to HSPs may be used to monitor the response to different types of stress
able to induce changes in HSP levels.
• In particular, oxidized LDLs are reported to induce HSP expression .
• Also, erythrophagocytosis was shown to induce the synthesis of different HSPs in human
monocytes/macrophages .
• Injection of lysed blood was reported to induce HSP70 expression in the brain , suggesting
that free hemoglobin is able to trigger HSP expression.
• In response, HSPs may protect vascular cells against different types of aggression within
the atherothrombotic plaque

49. AS BIOMARKERS IN CVD

51. • According to Yamazaki et al in 2005 HSP 60 and P gingivalis GroEl reactive T cell
populations were found in the peripheral circulation of atherosclerotic patients
• The results of a study by Hasan et al in 2005 suggest an autoimmune or cross-reactive
CD4(+) class II-restricted T cell response to the human HSP60 in Periodontitis and coronary
heart disease
• According to a study by Yamazaki et al in 2012 peripheral blood T cells from coronary heart
disease patients with gingivitis and those with periodontitis showed a distinct proliferative
response to bacterial HSP65

52. MOLECULAR MIMICRY OF HSP60
• defined as the theoretical possibility that sequence similarities between foreign and self-
peptides are sufficient to result in the cross-activation of autoreactive T or B cells by
pathogen-derived peptides.
• In autoimmune disorders it is a process where a foreign antigen shares sequence or
structural similarities with self-antigens.
• typically been characterized on an antibody or T cell level

53. • Inflammation is a significant component of atherosclerosis lesions.
• Bacteria, including periodontopathogens, have been demonstrated in atherosclerotic plaques
and cross-reactivity of the immune response to bacterial GroEL with human heat shock
protein 60 has been suggested as a link between infections and atherosclerosis.
• Owing to molecular mimicry, periodontal pathogen carriage may result in a systemic cross-
reactive immune response with the host.

54. Seymour GJ, Ford PJ, Cullinan MP, Leishman S, West MJ, Yamazaki K. Infection or inflammation: the
link between periodontal and cardiovascular diseases.

55. SEQUENCE HOMOLOGY OF HEAT SHOCK
PROTEIN
The sequence homology between the human Heat shock protein 60 (Hsp60) and
that of the periodontopathic bacteria like Porphyromonas gingivalis or A
actinomycetemcomitans at an amino acid level is 49% and 52%, respectively.
Despite being highly homologous between prokaryotic and eukaryotic cells,
Hsp60s are considered to be very immunogenic, and immune reactions to
microbial Hsp60s may be the cause for the initiation of chronic inflammatory
diseases, wherein the autoimmune response to human Hsp60 could be touted as
the main factor in pathogenesis of disease.
Jee H. Size dependent classification of heat shock proteins: a mini-review. Journal of exercise rehabilitation. 2016
Aug;12(4):255.

56. • GroEL-like protein belonging to the hsp60 family can be expressed by periodontopathic
bacteria such as Porphyromonas gingivalis [Hotokezaka et al 1997, Maeda et al] and
Actinobacillus actinomycetemcomitans [Nakano et al 1995].
• Antibodies against P. gingivalis GroEL are present in serum from periodontitis patients
[Maeda et al].
• Ando et al. demonstrated that hsp60 is expressed in periodontitis tissues using an antihuman
hsp60 antibody which cross-reacted with bacterial GroEL
HSP AND PERIODONTITIS

57. • Pleguezuelos et al (2005) has hypothesized that pathogenic bacteria stimulate periodontal
cells to increase Hsp60 expression that could in turn initiate macrophages,to start producing
proinflammatory cytokines.
• Due to their high conservation among various microbial pathogens and their ability to
induce very strong cellular and humoral immune responses, Hsp60s are thought to play a
role as candidate antigens in periodontal disease.
• A significant temperature elevation up to 2°C is observed in inflamed periodontal pocket.
• The cytokines in turn may cause an elevation of heat shock proteins levels in the inflamed
periodontium

58. • Lundqvist et al. (1994)found the expression of Hsp60 to be higher in gingival epithelial cells
of inflamed tissue samples from periodontitis patients compared with samples from
periodontally healthy individuals.
• Petit et al. (1999) suggested that the higher responsiveness to Hsp60 and Hsp70 observed in
gingivitis subjects may prevent the conversion from gingivitis to periodontitis.

59. • Ueki et al (2002)demonstrated that Human Hsp60 is expressed abundantly in periodontitis
lesions and, also stimulate tumour necrosis factor (TNF) - α production from macrophages
• According to a study by Nethravathy et al 2014 Circulatory HSP 60 was significantly
increased in periodontal disease compared to health .
• According to a study by Jung et al in 2016 Tannerella forsythia GroEL induces
inflammatory bone resorption and synergizes with interleukin-17.
• According to a study by Kwon et al in 2017 Pep19 (HSP 60)drives epitope spreading in
periodontitis and periodontitis-associated autoimmune diseases.

60. • A study by Wolf et al in 2019 indicated a regulatory role for HSP70 protein in hPDL cell
biology.
• Kyrklund et al in 2020 studied the Immune response to HSP60 of Aggregatibacter
actinomycetemcomitans and cross-reactivity with MAA-LDL .According to the study Aa-
HSP60 shares molecular mimicry with oxidized MAA epitopes, by which the spatial
confirmation may be preferred to induce antibody cross reaction thus giving new insights
into understanding how the immune system responds to virulence factors of periodontal
pathogens

61. HSPAND AGGRESSIVE PERIODONTITIS
• Mizuno et al in 2012 conducted a Proteome analysis of proteins related to aggressive
periodontitis.
• Four proteins, lactoferrin, caldesmon, heat shock protein 70, and stac, displayed a higher
protein expression level in the neutrophils from the patients suffering from Ag‐P
One of the most intriguing groups of potential biomarkers for
aggressive periodontitits

62. • Rizzo et al in 2012 found elevated levels of circulating Hsp60 as predictor of risk for
cardiovascular disease when associated to dyslipidemia in aggressive periodontitis patients.
• Frank Kaiser et al in 2018 studied the Association between circulating levels of heat-shock
protein 27and aggressive periodontitis and found that Hsp27 may be differentially expressed
and regulated in AgP patients as compared with CP patients and healthy individuals

66. • On the other hand some evidence also point out poor association between HsP and
periodontitis.
• Rzeszutko et al in 2006 found that There was no relationship between the significantly
elevated levels of p−ANCA and antibodies to Hsp 60 and clinical measurements of
periodontitis.
• No consistent temporal patterns of changes of Hsp27 concentration were detected across
AgP patients following periodontal treatment in a study by Donos et al in 2014

67. HSP60 VACCINE IN PERIODONTITIS
• Heat shock protein (Hsp) can be possibly explored as a candidate for vaccination against
periodontitis
• Choi et al (2005) found that P. gingivalis Hsp60 could potentially be developed as a vaccine
against multiple periodontopathic bacteria

68. • Lee et al (2006) found that there was a very strong inverse relationship between post
immune anti-P. gingivalis HSP immunoglobulin G (IgG) levels and the amount of alveolar
bone loss produced by bacterial infections

70. HSP60-BASED THERAPEUTIC APPROACHES FOR
SYSTEMIC DISORDERS
• Maron et al. showed in atherosclerosis-prone LDL-R KO mice, which were fed a
cholesterol-rich diet, that nasal administration of mHsp65 caused a decrease of
atherosclerotic plaques in the aortic arch
• Harats et al.studied the effect of oral tolerance induced with mHsp65.
• In this case, early atherosclerosis was attenuated and the effects seem to be mediated by IL-4

71. • Similar results were obtained by van Puyvelde et al.in LDL-R KO mice on a high-
cholesterol diet, where a cuff is placed around the carotic artery.
• In this model, low-dose oral mHsp65 caused a dramatic drop in the size of atherosclerotic
plaques
Limitation- no human studies for the same.

73. CONCLUSION
• Although infectious diseases, by and large have a microbial aetiology, it is now an
established fact that the hosts immune response to this microbial assault can itself cause
destruction to host tissues.
• Heat shock proteins are stress proteins, and many studies have demonstrated their increased
levels in periodontal disease
• Potential as a vaccine
• Knowledge about Hsp60 and further studies establishing their role in the etiopathogenesis of
periodontal disease would aid in diagnosing and also treating periodontal disease.

74. REFERENCES
• Indumathy P, Arun KV. HEAT SHOCK PROTEIN (HSP60) IN PERIODONTAL DISEASE: A
REVIEW. International Journal of Current Research and Review. 2014 Dec 1;6(23):18.
• Van Eden W, Wick G, Albani S, Cohen I. Stress, heat shock proteins, and autoimmunity: how immune
responses to heat shock proteins are to be used for the control of chronic inflammatory diseases.
Annals of the New York Academy of Sciences. 2007 Oct;1113(1):217-37.
• Marciniak J, Lossdörfer S, Kirschneck C, Deschner J, Jäger A, Wolf M. Heat shock protein 70
dampens the inflammatory response of human PDL cells to mechanical loading in vitro. Journal of
periodontal research. 2019 Oct;54(5):481-8.
• Ando T, Kato T, Ishihara K, Ogiuchi H, Okuda K. Heat shock proteins in the human periodontal
disease process. Microbiology and immunology. 1995;39(5):321-7.
• Hasan A, Sadoh D, Palmer R, Foo M, Marber M, Lehner T. The immune responses to human and
microbial heat shock proteins in periodontal disease with and without coronary heart disease.
Clinical & Experimental Immunology. 2005 Dec;142(3):585-94.

75. • Gaston JS. Heat shock proteins and innate immunity. Clinical and experimental immunology. 2002
Jan;127(1):1.
• Muñoz-Carrillo JL, Hernández-Reyes VE, García-Huerta OE, Chávez-Ruvalcaba F, Chávez-
Ruvalcaba MI, Chávez-Ruvalcaba KM, Díaz-Alfaro L. Pathogenesis of Periodontal Disease.
InPeriodontal Disease-Diagnose Considerations 2019 Jun 6. IntechOpen.
• Kilic A, Mandal K. Heat shock proteins: pathogenic role in atherosclerosis and potential therapeutic
implications. Autoimmune diseases. 2012;2012.
• Lamb DJ, El-Sankary W, Ferns GA. Molecular mimicry in atherosclerosis: a role for heat shock
proteins in immunisation. Atherosclerosis. 2003 Apr 1;167(2):177-85.
• Alfakry H, Paju S, Sinisalo J, Nieminen MS, Valtonen V, Saikku P, Leinonen M, Pussinen PJ.
Periodontopathogen‐and host‐derived immune response in acute coronary syndrome. Scandinavian
journal of immunology. 2011 Oct;74(4):383-9.
• Seymour GJ, Ford PJ, Cullinan MP, Leishman S, West MJ, Yamazaki K. Infection or inflammation:
the link between periodontal and cardiovascular diseases.
•