Figure 3 Proposed mechanisms underlying the links

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Figure 3 Proposed mechanisms underlying the links between periodontal disease and the pathogenesis of rheumatoid arthritis Figure 3 | Proposed mechanisms underlying the links between periodontal disease and the pathogenesis of rheumatoid arthritis. a | In response to Porphyromonas gingivalis infection, neutrophils can release neutrophil extracellular traps (NETs), structures characterized by active proteases and peptidylarginine deiminases (PADs). The concomitant action of these enzymes generates citrullinated epitopes and triggers the synthesis of anti-citrullinated protein antibodies (ACPAs). The production of citrullinated epitopes is accelerated by the synergistic action of gingipains and P. gingivalis peptidylarginine deiminase (PPAD), both of which are unique to P. gingivalis. Molecular mimicry by some bacterial proteins (such as bacterial enolase with human α-enolase) is also involved in the breakdown of immune tolerance to host molecules. A secondary signal directed against citrullinated epitopes in the joints leads to increased production of rheumatoid factor and ACPAs, leading to the accumulation of immune complexes. b | Neutrophils attracted to the gingival crevice undergo necrosis, thereby releasing damage-associated molecular patterns (DAMPs), which accelerate local and systemic inflammation. c | In the infected periodontium, virulence factors expressed by P. gingivalis, such as lipopolysaccharide, fimbriae, gingipains and lipoproteins, are recognized by Toll-like receptors, protease activated receptors and/or nucleotide-binding oligomerization domain-containing 2 (NOD2) receptors on gingival epithelial cells and phagocytes, such as dendritic cells. In response to pathogens, the host cells release cytokines (such as IL-6) and chemokines that activate the complement system, receptor activator for nuclear factor-κB ligand (RANKL) signalling pathways and the differentiation of T helper cells, which contribute towards osteoclastogenesis. Potempa, J. et al. (2017) The case for periodontitis in the pathogenesis of rheumatoid arthritis Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2017.132