MOLECULAR MEDICINE REPORTS 18: 4895-4903, 2018

Oral microbial flora of patients with Sicca syndrome

SHUANG ZHOU1*, YE CAI2*, MIN WANG3, WEI‑DONG YANG2 and NING DUAN4

1
Department of Microbiological Examination, Jiangsu Institute for Food and Drug Control;
2
Department of Endodontics, Nanjing Stomatological Hospital, Medical School of Nanjing University,
Nanjing, Jiangsu 210008; 3School of Life Science and Technology, China Pharmaceutical University,
Nanjing, Jiangsu 211198; 4Department of Oral Mucosa, Nanjing Stomatological Hospital,
Medical School of Nanjing University, Nanjing, Jiangsu 210008, P.R. China

Received January 26, 2018; Accepted August 13, 2018

DOI: 10.3892/mmr.2018.9520

Abstract. Primary sicca syndrome (pSS) is a systemic auto- immune and digestive systems were significantly upregulated
immune disease. However, its exact etiology and pathogenesis in the pSS group compared with those in the control group. In
remain elusive. Various infectious factors have been identified conclusion, the present study provided basic data on the flora
to be closely associated with the occurrence and development of the oral cavity in patients with pSS from East China and
of PSS. The present study aimed to assess the composition may serve as a reference for the treatment of this condition.
of the oral microbial flora of patients with pSS in China in
order to provide guidance for treatment. The microbial flora Introduction
of nine patients with pSS and five healthy controls from East
China was evaluated in saliva samples using high‑throughput Sicca syndrome (SS), also known as Sjögren's syndrome, is a
sequencing. A high microbial diversity was detected in the systemic autoimmune disease that mainly affects the exocrine
pSS and control groups, with bacteroidetes, firmicutes and glands, including salivary and lacrimal glands. In SS, the local
proteobacteria constituting the largest phyla in the two groups. tissue is infiltrated with lymphocytes, affecting the normal
Compared with the control group, bacteroidetes and actino- function of the glands (1). SS that is not accompanied by any
bacteria were significantly more abundant in the pSS group, other autoimmune diseases is called primary SS (pSS). Its
whereas proteobacteria were significantly less abundant. exact etiology and pathogenesis remain elusive, and no cure
However, no significant differences in bacterial richness and is currently available for this disease (2). At present, environ-
diversity were observed between the two groups. According mental factors are considered to have an important role in
to a Kyoto Encyclopedia of Genes and Genomes linear pSS (3). Multiple studies have demonstrated that various infec-
discriminant analysis, genes regulating cell apoptosis and the tious factors in the environment, including Helicobacter pylori,
Epstein‑Barr virus and Mycoplasma, are closely associated
with the occurrence and development of pSS (4).
The clinical manifestations of pSS are complex. Altered
Correspondence to: Dr Min Wang, School of Life Science and salivary gland function typically causes xerostomia with
Technology, China Pharmaceutical University, 24 Tongjiaxiang, significantly reduced saliva, which changes the inherent
Nanjing, Jiangsu 211198, P.R. China balance of the oral microbial flora (5). Microbes occur in large
E‑mail: minwang@cpu.edu.cn numbers in the oral cavity. The saliva comprises a variety
Dr Wei‑Dong Yang, Department of Endodontics, Nanjing of proteins, enzymes and antibodies, which help lubricate
Stomatological Hospital, Medical School of Nanjing University, and clean the mouth and regulate the pH. Hence, it is vital in
30 Zhongyang Road, Nanjing, Jiangsu 210008, P.R. China controlling the location of microbes on the surface of teeth and
E‑mail: ywdong2001@163.com soft tissues (6). Primary SS may increase the odds of acquiring
microbial diseases, including caries and periodontal disease.
*
Contributed equally Epidemiological data have indicated that the incidence of
caries was significantly higher in patients with pSS than that in
Abbreviations: pSS, primary Sicca syndrome; HTS,
the healthy population (7). Previous studies analyzing typical
high‑throughput sequencing; OTUs, operational units; PCoA,
pathogenic microbes in oral samples from patients with pSS
principal co‑ordinate analysis; LDA, linear discriminant analysis;
KEGG‑Lefse, Kyoto Encyclopedia of Genes and Genomes linear have demonstrated that the numbers of Lactobacillus and
discriminant analysis; TLR, Toll‑like receptor Actinomyces are significantly different in patients with pSS
compared with those in healthy populations (8). Selective
Key words: high‑throughput sequencing, Kyoto Encyclopedia of media are usually used to identify culturable microbial organ-
Genes and Genomes linear discriminant analysis, microbial flora, isms. At present, the composition and changes in the oral
oral cavity, Sicca syndrome microbial flora in pSS, as well as the role of bacteria in the
pathogenesis of this autoimmune disease, are poorly under-
stood. It is important to investigate the composition of the
4896 ZHOU et al: ORAL MICROBIAL FLORA IN PATIENTS WITH SICCA SYNDROME

oral microbial flora of patients with pSS and comprehensively Polymerase chain reaction (PCR) amplification, product
analyze changes compared to healthy individuals, in order to quantification and homogenization. The V4‑V5 region of the
provide guidance for the clinical treatment of pSS. gene encoding for the bacterial 16S ribosomal RNA was ampli-
The aim of the present study was to assess differences in the fied with the specific barcode primers by PCR using an ABI
composition of the oral microbial flora of patients with pSS and GeneAmpMidel 9700 amplifier (Applied Biosystems; Thermo
healthy individuals in China using high‑throughput sequencing Fisher Scientific, Inc., Waltham, MA, USA). The thermocy-
(HTS) (9) and provide a reference for treatment strategies. cling conditions were as follows: 95˚C for 2 min, followed by
27 cycles of denaturation for 95˚C for 30 sec, annealing at 55˚C
Patients and methods for 30 sec and extension at 72˚C for 30 sec, and a final exten-
sion at 72˚C for 5 min. The primers 515F 5'‑barcode‑GTG​
Patients and controls. According to the new diagnostic CCA​G CM​G CC​G CG​G ‑3' and 907R 5'‑CCG​TCA​ATT​CMT​
criteria published by the American College of Rheumatology TTR​AGT​TT‑3', where the barcode is an eight‑base sequence
in 2012 based on a cohort study of the Sjögren's International unique to each sample, were used. PCR was performed using
Collaborative Clinical Alliance (5), nine patients with pSS TransGen AP221‑02 (TransGen Biotech Co., Ltd, Beijing,
were selected whose clinical manifestations were in accor- China) with TransStart FastPfu DNA Polymerase in a 20‑µl
dance with at least two of the three diagnostic criteria (Table I). mixture containing 4 µl 5XFastPfu Buffer, 2 µl 2.5 mM
The patients with pSS were newly diagnosed cases with no deoxynucleoside triphosphates, 0.8 µl of each primer (5 µM),
previous treatment, no antibiotic use in the last 3 months and 0.4 µl FastPfu Polymerase and 10 ng template DNA. All
no systemic diseases, including hepatitis, tuberculosis and experiments were performed in triplicate according to standard
diabetes. Dental and periodontal diseases were eliminated procedures. The PCR products from each tagged primer were
through oral examination. A total of five individuals without pooled and detected using 2% agarose gel electrophoresis. The
any oral diseases were selected as the healthy control group. PCR products were excised from the gel and isolated with
pSS is more common in females (10); therefore, female healthy an AxyPrep DNA Gel Extraction kit (cat. no. AP‑GX‑250;
individuals and patients were selected in order to avoid sex Axygen Biosciences, Union City, CA, USA), eluted with Tris
bias. No significant difference in age was present between HCl and detected using 2% agarose gel electrophoresis. Finally,
the pSS and control group. The mean age of the patient and according to the preliminary results of the electrophoresis, the
control group was 51.4 and 50.5 years, respectively (P=0.795). PCR products were quantified using QuantiFluor ST (Promega
Patients with pSS and healthy controls were selected by Corp., Madison, WI, USA) according to the manufacturer's
professional immunologists and dentists according to the protocols and then mixed according to the quantity require-
new diagnostic criteria. Saliva samples from nine patients ment for sequencing of each sample.
with pSS and five healthy volunteers were assessed by
HTS using the Illumina MiSeq platform (Illumina, Inc., Sequencing data optimization. For data optimization, Qiime
San Diego, CA, USA), which was performed by Shanghai (version 1.17; http://qiime.org) was used with the following
Biozeron Co., Ltd. (Shanghai, China). Written informed parameters: i) The 250‑bp reads were truncated at any site
consent was provided by all patients and healthy volunteers. receiving an average quality score of <20 over a 1‑bp sliding
The study was approved by the Medical Ethics Committee window, discarding the truncated reads that were <50 bp in
of Nanjing Stomatological Hospital (Nanjing, China). All length. ii) Exact barcode matching, two‑nucleotide mismatch
procedures were performed in accordance with the relevant in primer matching and reads containing ambiguous characters
guidelines and regulations. were removed. iii) Only sequences that overlapped by >10 bp
were assembled according to their overlap sequence. Reads
Sample collection. The patients with pSS and controls were that could not be assembled were discarded. iv) Chimeric
instructed to rinse their mouth with water and requested not to sequences were identified and removed using Usearch
consume any food or water, to smoke or use chewing gum for (version 6.1; http://drive5.com/usearch).
30 min prior to saliva collection. Saliva was collected using a
collector kit (cat. no. 401001; Xiamen Zhishan Biotechnology Bioinformatics analysis. Operational taxonomic units
Co., Ltd., Fujian, China) according to the manufacturer's (OTUs) were clustered with 97% similarity cutoff using
protocol, mixed with 1:1 saliva storage solution and stored Usearch (version 7.1 http://drive5.com/uparse/) and
at room temperature (a sealed tube and the storage solution taxonomied using Qiime. Mothur v.1.21.1 (11) was used for
were provided in the collector kit, with no requirement for rarefaction curve analysis, community richness analysis
cryopreservation; DNA integrity was good and no degradation [Chao1 (http://www.mothur.org/wiki/chao) and ACE
was observed). (http://www.mothur.org/wiki/Ace)], community diversity
analysis [Shannon (http://www.mothur.org/wiki/shannon) and
DNA extraction and purification. Microbial DNA was Simpon (https://mothur.org/wiki/Simpson)], coverage analysis
extracted from the 14 saliva samples using the E.Z.N.A. stool (http://www.mothur.org/wiki/coverage) and species accumula-
DNA kit (cat. no. D4015‑02; Omega BioTek, Inc., Norcross, tion curve analysis (https://rdrr.io/rforge/vegan/man/specaccum.
GA, USA) according to the manufacturer's protocols and html). Beta diversity analysis was performed using
purified using the MoBioPowerClean DNA Clean‑up kit UniFrac (12) to compare principal component analysis (PCA)
(cat. no. 12877‑50; MoBio Laboratories Inc., Carlsbad, CA, results, using the community ecology package R‑forge (https://
USA). Subsequently, the purified genomic DNA was detected r‑forge.r‑project.org/; Vegan 2.0 was used for PCA). The heat
using 1% agarose gel electrophoresis. map was generated in the Vegan package in R. Clustering of the
 MOLECULAR MEDICINE REPORTS 18: 4895-4903, 2018 4897

Table I. Clinical manifestations and laboratory diagnostic indexes in the two groups.

Index Patient group (n=9) Control group (n=5)

Systemic diseases, includinghepatitis, tuberculosis and diabetes 0 (0) 0 (0)

RF(+) with ANA >1:320, serum SSA and/or SSB antibodies (+)a 9 (100) 0 (0)
Corneo‑conjunctival staining score ≥3a 9 (100) 0 (0)
Lymphocytic foci appearing in labial gland biopsy ≥1/4 mm2a 9 (100) 0 (0)
Xerophthalmia and xerostomia 9 (100) 0 (0)

New diagnostic criteria of the American College of Rheumatology from 2012. Values are expressed as n (%). ANA, antinuclear antibodies;
a

SSA, Sjögren's syndrome A antibody; RF, rheumatoid factor.

phyla were assessed using the independent‑samples t‑test. All

of the statistical analyses were performed using SPSS 13.0
(SPSS, Inc., Chicago, IL, USA).
The PICRUSt (Bioinformatics Software Package) was
used to predict the metagenomic function of high‑throughput
sequencing results for patients and controls. The detailed
prediction process can be viewed at http://picrust.github.
io/picrust/tutorials/algorithm_description.html. The 16S
sequencing data from this experiment was used for functional
prediction based on the KEGG database.
Kyoto Encyclopedia of Genes and Genomes (KEGG) linear
discriminant analysis (LEfSe; http://huttenhower.sph.harvard.
edu/lefse/) is software for discovering high‑dimensional
biological markers and revealing genomic features, including
genes, metabolism and classification, and was used to distin-
guish significant differences between the patients and controls.
LEfSe uses linear discriminant analysis (LDA) to estimate the
effect of species abundance on the difference between patients
Figure 1. Species accumulation curve. The box plots reflect the rate of new and controls.
OTUs/species under continuous sampling. OTU, operational units.
Results

genera obtained from the Ribosomal Database Project classifier Species accumulation and Shannon‑Wiener curve. A total of
was obtained using the complete linkage hierarchical clustering 535,846 sequences were identified as valid sequences through
technique in the R package Hclust (http://sekhon.berkeley. analysis of the HTS results. These sequences were attributed to
edu/stats/html/hclust.html) (13). To examine dissimilarities 16 phyla, 29 classes, 53 orders, 83 families and 179 genera. The
in microbial flora composition, principal co‑ordinate analysis valid sequences of all samples were divided into 2,486 OTUs.
(PCoA) was performed in Qiime. PCoA, with a distance matrix Species accumulation curves were used to analyze the adequacy
employed to plot n samples in an (n‑1)‑dimensional space, was of sample size. As indicated in Fig. 1, the interquartile range
used to compare groups based on unweighted and weighted became smaller and the number of OTUs detected was closer
UniFrac distance metrics. to 350, as the sample size increased. The curve began to plateau
Hierarchical clustering analysis is based on community when the sample size reached 12, indicating that the sample
composition between samples: Qiime was utilized to calculate size selected for sequencing was sufficient. Therefore, the
the β‑diversity distance matrix using the Bray‑Curtis algorithm experimental data were suitable for further analysis.

= BC1‑2 Composition, diversity and richness of the bacterial flora of

the oral cavity in patients with pSS and controls. A total of
where SAi is the sequence number of the ith OTU in the oral 16 bacterial phyla were detected in all of the tested samples.
microbial flora of patients with pSS and SBi is the sequence Of these, Bacteroidetes, Firmicutes and Proteobacteria
number of the ith OTU in the oral microbial. Finally, R were more abundant than the remaining phyla. Bacteroides
language was used as the sample clustering tree. accounted for 35.63% of the total effective count in the pSS
group and 18.82% in the control group. Firmicutes had an
Statistical analysis. Differences in age between the two abundance of 34.08% in the pSS group and 28.02% in the
groups were determined using the independent‑samples t‑test. control group. Proteobacteria accounted for 16.51 and 42.95%
Differences in the relative abundance of individual genera and in the pSS and control groups, respectively. These results
4898 ZHOU et al: ORAL MICROBIAL FLORA IN PATIENTS WITH SICCA SYNDROME

Figure 2. Combined analysis of the sample clustering tree. The similarity of a sample cluster is indicated by the length of the tree and that of the vertical line
(left side): The length of the tree represents the distance between samples and vertical lines indicating samples that are highly similar. Qiime was utilized to
calculate the β‑diversity distance matrix using the Bray‑Curtis algorithm. The yellow and green bars represent proteobacteria and bacteroides, and flora of
the controls respectively, the levels of which are higher in the pSS group compared with the control group (right side). OTU, operational units; P, patient; CK,
control; pSS, primary Sicca syndrome.

indicated that Bacteroidetes and Firmicutes were significantly

more abundant in the pSS group compared with the control
group, whereas Proteobacteria were significantly less abun-
dant (P<0.05; Fig. 2, right panel). Other major bacterial phyla
were Actinobacillus and Fusobacterium, which exhibited no
significant differences in relative abundance between the two
groups. The hierarchical cluster analysis also indicated that the
flora of oral salivary bacteria in the two groups was obviously
different (Fig. 2, left panel).
The richness (indicated by Ace and Chao) and the diver-
sity (indicated by Shannon and Simpon) of the bacterial flora
in saliva samples was not significantly different between
patients with pSS and healthy controls (data not shown). pSS
was not associated with any significant differences in the
oral bacterial richness and diversity from that in the normal
controls.

PCoA analysis of the oral bacterial flora in patients with pSS

and healthy controls. Analysis of dissimilarities in the micro-
bial flora composition of 14 samples using PCoA indicated that
the samples generally appeared to cluster into 2 groups on the
abscissa, according to the presence or absence of pSS (PC1,
accounting for 30.93% of the total variation) (Fig. 3). As PC1 Figure 3. Multiple‑sample PCoA. PCoA analysis of the oral bacterial flora
mainly comprises different types of environmental substrates, was performed on 14 saliva samples, including patients with pSS (red dot)
and healthy controls (blue square). All the samples clustered into two distinct
the differences may be due to changes in the oral environment groups. The scales of the horizontal and vertical axes are relative distances.
caused by pSS. All 14 samples exhibited a trend of dispersion PC1 and PC2 represent the suspected influencing factors for the offset of the
along the PC2axis. microbial composition of the two samples. P, patients; CK, controls; PCoA,
principal co‑ordinate analysis. PC, principal component.
Differences in the composition of oral bacterial flora
between patients with pSS and healthy controls. The
aforementioned results indicated no significant differences Genomes (KEGG) linear discriminant analysis (Lefse)
in bacterial abundance and diversity between patients with (http://huttenhower.sph.harvard.edu/lefse/) was used to
pSS and healthy controls. However, certain differences perform a linear discriminant analysis (LDA) to examine
were observed between the two groups even at the 'phylum' any differences between the two groups (Fig. 4). According
level. Therefore, a Kyoto Encyclopedia of Genes and to the cladogram (Fig. 4A), only Bacteroidetes (including
 MOLECULAR MEDICINE REPORTS 18: 4895-4903, 2018 4899

Figure 4. (A) Cladogram of bacterial lineages with significantly different levels in humans with or without pSS. (B) Histogram of LDA scores computed for
differentially abundant bacterial taxa between healthy controls and patients with pSS. P, patients; CK, controls; pSS, primary Sicca syndrome; LDA, linear
discriminant analysis.

the class Bacteroidia and the order Bacteroidales) and KEGG‑Lefse analysis of functional differences. Functional
Actinobacteria (including the class Coriobacteriia, the analysis indicated that genes regulating cell proliferation and
order Coriobacteriales and the family Coriobacteriaceae) apoptosis, signal transduction, biosynthesis, metabolism and
were more abu nd a nt i n t he pSS g roup, whereas enzyme secretion, and those associated with the immune and
Proteobacteria (including the class Betaproteobacteria, digestive systems, were significantly upregulated in the pSS
the orders Burkholderiales and Neisseriales, the families group compared with those in the controls (Fig. 6).
Burkholderiaceae and Neisseriaceae, and certain bacterial
genera) had higher abundance levels in the control group. Discussion
Certain bacterial genera among the Firmicutes were more
abundant in the pSS group, while others had higher levels in Microbial infection occurs prior to the upregulation of auto-
the control group despite no significant differences between immune factors in autoimmune diseases, including pSS (4,14).
the two groups. Van der Meulen et al (15) proposed that environmental
Multiple biomarkers in the pSS and control groups were factors, particularly microbes, are vital in the development and
detected using Lefse analysis (LDA score >2.0, P<0.05) progression of autoimmune diseases.
(Fig. 4B). According to the column graph displaying the results Assessing microbial diversity and structure is the basis
of the LDA analysis, 13 significantly more abundant bacterial of complex micro‑ecological analysis (16). The association
genera were identified in the pSS group, whereas 20 genera between disease and changes in the microbial flora may be
with a significantly higher abundance were detected in the revealed by analyzing changes in the abundance and composi-
control group. tion of oral microbial communities, thus providing reasonable
theoretical evidence for preventing and treating oral diseases.
Distribution of oral microbial flora components in pSS patients The present study analyzed the microbial diversity and abun-
at the genus level. Using heat map analysis of hierarchical dance in saliva samples from patients with pSS in Eastern China
clustering (Fig. 5), the similarities and differences in ‘genus’ using HTS technology. The results expanded on the current
were examined between the two groups. A total of 80 major knowledge on the oral microbial flora of Chinese patients
bacterial genera were listed in all of the tested samples. Of with pSS. Gu et al (17) reported that the major oral microbial
these, six genera, including Prevotella, in Bacteroidetes and phyla were Actinobacteria, Bacteroidetes, Proteobacteria,
four genera, including Actinomyces, in Actinobacteria were Firmicutes and Fusobacterium, accounting for up to 97.1%
significantly more abundant in the pSS group than in the of the oral microbial flora. According to the aforementioned
control group. Furthermore, 17 bacterial genera, including sequencing data, these five genera were all present in the
Neisseria (Proteobacteria) were significantly less abundant pSS and control groups, without any significant differences
in the pSS group than in the control group. The relative between the two groups, indicating that the microbial diversity
abundance levels of major bacterial genera of Firmicutes were in patients with pSS was not seriously damaged. This may be
different between the two groups. For instance, Streptococcus because the patients included in the present study were all new
was abundant in healthy controls, whereas Peptostreptococcus cases. However, the relative abundance levels of the major oral
was more abundant in the pSS group. microbial groups were significantly different between the two
4900 ZHOU et al: ORAL MICROBIAL FLORA IN PATIENTS WITH SICCA SYNDROME

Figure 5. Heat map: Changes in the abundance of the major bacterial genera were visually detected by color changes in the graph. As an example, as indicated
at the top of the graph, the abundance of Neisseria was markedly lower in the patient group compared with that in the control group. P, patients; CK, controls.
 MOLECULAR MEDICINE REPORTS 18: 4895-4903, 2018 4901

Figure 6. KEGG linear discriminant analysis results. Red and green regions represent different groups; red nodes in branches represent the importance of the
KEGG function in the control group. Similarly, green nodes represent the importance of KEGG functions in the patient group. Yellow nodes represent KEGG
functions with no important role between the two groups. P, patients; CK, controls; KEGG, Kyoto Encyclopedia of Genes and Genomes.

groups, as indicated by the Lefse analysis. It is well known Bacteroides and Actinobacillus, which were significantly more
that Bacteroides and associated bacterial genera are mostly abundant in the pSS group, are the most abundant microbes
anaerobes that are sensitive to oxygen. Of these, Prevotella has in healthy humans and animals. They have complex and
the highest levels, and the genus Actinobacillus includes facul- subtle associations with other microbes and the host, and an
tative anaerobic microbes (17‑19). The results of the present important impact on the host's health. However, Bacteroides
study suggested that changes in the oral microbial community and Actinobacillus are also opportunistic pathogens that may
in patients with pSS may be associated with decreased saliva cause endogenous infections when the normal microecolog-
secretion caused by exocrine gland damage, which affected the ical balance is disrupted (21). Increasing attention is paid to
oxygen content of the oral environment as well as the levels of microbial factors that may cause autoimmune diseases (22).
associated functional proteins. In the present study, the classifi- Although these observations are confirmed in certain autoim-
cation of salivary gland injury in the pSS group was Grade III mune diseases, including rheumatic fever, no clear evidence is
for all subjects. Prevotella (Bacteroides) is a causative factor available to confirm that pSS is induced by the infectious envi-
of periodontal disease and periodontal abscess (7,20), whereas ronment. Previous studies have indicated that viruses affect
Actinomyces (Actinobacillus) produces a sticky polysaccha- the exocrine tissue through plasma cell‑like dendritic cells
ride that promotes the development of caries (8). These results and Toll‑like receptors (TLRs) in diseases of the oral mucosa,
suggested that changes in the composition of the oral microbial which may be a pathogenetic factor for pSS (23,24). Studies
community in patients with pSS were associated with caries have also indicated that commensal microbiota, including
and periodontal disease, which is in line with the notion that Bacteroides, have a pivotal effect on the dynamic balance of
patients with pSS tend to have caries and extensive periodontal the intestinal mucosa and TLRs in intestinal diseases (25,26).
disease in clinical practice (7); however, this requires confir- The results of the present study indicated that the significantly
mation by further in‑depth studies. increased abundance of Bacteroides and Actinomycetes in
According to the KEGG‑Lefse analysis of functional patients with pSS may affect the dynamic balance of the oral
differences, genes associated with the immune function were mucosa and induce an autoimmune response via TLRs, thus
significantly upregulated in the pSS group, indicating an affecting the function of exocrine glands.
enhanced autoimmune response in patients with pSS, consis- Furthermore, the KEGG‑Lefse analysis revealed that
tent with the notion that pSS is an autoimmune disease (3). genes regulating multiple cell functions were significantly
4902 ZHOU et al: ORAL MICROBIAL FLORA IN PATIENTS WITH SICCA SYNDROME

upregulated in the pSS group. These results suggested the China; no. 2017NL‑041(KS)]. Written informed consent was
existence of possible factors during pSS development that provided by all subjects.
altered the dynamic balance of Bacteroides and Actinomycetes
in the oral microbe community and significantly increased Patient consent for publication
the abundance levels of Bacteroides and Actinomycetes, thus
inducing an autoimmune response in the salivary gland. This Not applicable.
resulted in increased cell proliferation and apoptosis and
enhanced energy metabolism. Mounting experimental evidence Competing interests
suggests the importance of autophagy during infection and in
certain autoimmune diseases. Indeed, autophagy is involved All authors declare that they have no competing interests.
in multiple important cellular processes (27), including
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