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Hu W, Chen S, Zou X, Chen Y, Luo J, Zhong P, Ma D. Oral microbiome, periodontal disease and systemic bone-related diseases in the era of homeostatic medicine. J Adv Res 2024:S2090-1232(24)00362-X. [PMID: 39159722 DOI: 10.1016/j.jare.2024.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 08/03/2024] [Accepted: 08/12/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Homeostasis is a state of self-regulation and dynamic equilibrium, maintaining the good physiological functions of each system in living organisms. In the oral cavity, the interaction between the host and the oral microbiome forms oral microbial homeostasis. Physiological bone remodeling and renewal can occur under the maintenance of oral microbial homeostasis. The imbalance of bone homeostasis is a key mechanism leading to the occurrence of systemic bone-related diseases. Considering the importance of oral microbial homeostasis in the maintenance of bone homeostasis, it still lacks a complete understanding of the relationship between oral microbiome, periodontal disease and systemic bone-related diseases. AIM OF REVIEW This review focuses on the homeostatic changes, pathogenic routes and potential mechanisms in the oral microbiome in periodontal disease and systemic bone-related diseases such as rheumatoid arthritis, osteoarthritis, osteoporosis and osteomyelitis. Additionally, this review discusses oral microbiome-based diagnostic approaches and explores probiotics, mesenchymal stem cells, and oral microbiome transplantation as promising treatment strategies. KEY SCIENTIFIC CONCEPTS OF REVIEW This review highlights the association between oral microbial homeostasis imbalance and systemic bone-related diseases, and highlights the possibility of remodeling oral microbial homeostasis for the prevention and treatment of systemic bone-related diseases.
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Affiliation(s)
- Weiqi Hu
- Department of Endodontics, Stomatological Hospital, School of Stomatology, Southern Medical University, No 366 Jiangnan Avenue South, Guangzhou, Guangdong Province 510280, China
| | - Shuoling Chen
- Department of Endodontics, Stomatological Hospital, School of Stomatology, Southern Medical University, No 366 Jiangnan Avenue South, Guangzhou, Guangdong Province 510280, China
| | - Xianghui Zou
- Department of Endodontics, Stomatological Hospital, School of Stomatology, Southern Medical University, No 366 Jiangnan Avenue South, Guangzhou, Guangdong Province 510280, China
| | - Yan Chen
- Department of Pediatric Dentistry, Stomatological Hospital, School of Stomatology, Southern Medical University, No 366 Jiangnan Avenue South, Guangzhou, Guangdong Province 510280, China
| | - Jiayu Luo
- Department of Endodontics, Stomatological Hospital, School of Stomatology, Southern Medical University, No 366 Jiangnan Avenue South, Guangzhou, Guangdong Province 510280, China
| | - Peiliang Zhong
- Department of Endodontics, Stomatological Hospital, School of Stomatology, Southern Medical University, No 366 Jiangnan Avenue South, Guangzhou, Guangdong Province 510280, China
| | - Dandan Ma
- Department of Endodontics, Stomatological Hospital, School of Stomatology, Southern Medical University, No 366 Jiangnan Avenue South, Guangzhou, Guangdong Province 510280, China.
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Tsigalou C, Tsolou A, Stavropoulou E, Konstantinidis T, Zafiriou E, Dardiotis E, Tsirogianni A, Bogdanos D. Unraveling the intricate dance of the Mediterranean diet and gut microbiota in autoimmune resilience. Front Nutr 2024; 11:1383040. [PMID: 38818135 PMCID: PMC11137302 DOI: 10.3389/fnut.2024.1383040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 05/07/2024] [Indexed: 06/01/2024] Open
Abstract
The nutritional habits regulate the gut microbiota and increase risk of an autoimmune disease. Western diet is rich in sugars, meat, and poly-unsaturated fatty acids, which lead to dysbiosis of intestinal microbiota, disruption of gut epithelial barrier and chronic mucosal inflammation. In contrast, the Mediterranean Diet (MedDiet) is abundant in ω3 fatty acids, fruits, and vegetables, possessing anti-inflammatory properties that contribute to the restoration of gut eubiosis. Numerous studies have extensively examined the impact of MedDiet and its components on both health and various disease states. Additionally, specific investigations have explored the correlation between MedDiet, microbiota, and the risk of autoimmune diseases. Furthermore, the MedDiet has been linked to a reduced risk of cardiovascular diseases, playing a pivotal role in lowering mortality rates among individuals with autoimmune diseases and comorbidities. The aim of the present review is to specifically highlight current knowledge regarding possible interactions of MedDiet with the patterns of intestinal microbiota focusing on autoimmunity and a blueprint through dietary modulations for the prevention and management of disease's activity and progression.
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Affiliation(s)
- Christina Tsigalou
- Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, University Hospital, Alexandroupolis, Greece
| | - Avgi Tsolou
- Laboratory of Molecular Cell Biology, Cell Cycle and Proteomics, Department of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elisavet Stavropoulou
- Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, University Hospital, Alexandroupolis, Greece
| | - Theocharis Konstantinidis
- Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, University Hospital, Alexandroupolis, Greece
| | - Efterpi Zafiriou
- Department of Dermatology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Efthymios Dardiotis
- Department of Neurology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandra Tsirogianni
- Department of Immunology-Histocompatibility, Evangelismos General Hospital, Athens, Greece
| | - Dimitrios Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Lee JA, Mikuls TR, Sayles HR, Thiele GM, Duryee MJ, Payne JB. Associations between periodontitis and serum anti-malondialdehyde-acetaldehyde antibody concentrations in rheumatoid arthritis: A case-control study. J Periodontol 2024. [PMID: 38728106 DOI: 10.1002/jper.23-0604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Malondialdehyde-acetaldehyde (MAA) adducts lead to generation of anti-MAA autoantibodies and have been independently identified in inflamed periodontal and rheumatoid arthritis (RA) tissues. This study evaluates serum samples from RA cases and osteoarthritis (OA) controls to quantify associations between periodontal clinical measures, alveolar bone loss (ABL), and anti-Porphyromonas gingivalis, anti-Prevotella intermedia, and anti-Fusobacterium nucleatum antibody concentrations with anti-MAA antibody concentrations. METHODS Participants (n = 284 RA cases, n = 330 OA controls) underwent periodontal clinical assessments and ABL measurements. Serum immunoglobulin (Ig) A, IgG, and IgM anti-MAA and serum IgG antibacterial antibody concentrations were quantified by enzyme-linked immunosorbent assay (ELISA). Analyses utilized simple linear regression and multivariable adjusted models. RESULTS No significant associations of periodontal clinical measures with serum anti-MAA were found. Moderate (p = 0.038 and p = 0.036, respectively) and high ABL (p = 0.012 and p = 0.014, respectively) in RA cases (but not in OA) were positively associated with IgG and IgM anti-MAA. Anti-P. gingivalis and anti-P. intermedia antibody concentrations were positively associated with IgA (p = 0.001 for both), IgG (p = 0.007 and p = 0.034, respectively), and IgM anti-MAA antibody concentrations (p < 0.001 and p = 0.020, respectively), while anti-F. nucleatum was positively associated with IgG anti-MAA (p = 0.042), findings that were similar across groups. CONCLUSIONS A positive association was demonstrated between ABL and serum IgG and IgM anti-MAA antibody concentrations that was unique to RA and not observed in OA. Serum anti-P. gingivalis, anti-P. intermedia, and anti-F. nucleatum antibody concentrations displayed significant associations with anti-MAA antibody in both groups. These findings suggest MAA may play a role in the interrelationship between the periodontium and RA.
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Affiliation(s)
- Joyce A Lee
- Department of Surgical Specialties, Division of Periodontics, College of Dentistry, University of Nebraska Medical Center, Lincoln, Nebraska, USA
| | - Ted R Mikuls
- Department of Internal Medicine, Division of Rheumatology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Medicine, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA
| | - Harlan R Sayles
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Geoffrey M Thiele
- Department of Internal Medicine, Division of Rheumatology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Medicine, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA
| | - Michael J Duryee
- Department of Internal Medicine, Division of Rheumatology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Medicine, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA
| | - Jeffrey B Payne
- Department of Surgical Specialties, Division of Periodontics, College of Dentistry, University of Nebraska Medical Center, Lincoln, Nebraska, USA
- Department of Internal Medicine, Division of Rheumatology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Lopez-Oliva I, Malcolm J, Culshaw S. Periodontitis and rheumatoid arthritis-Global efforts to untangle two complex diseases. Periodontol 2000 2024. [PMID: 38411247 DOI: 10.1111/prd.12530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/07/2023] [Accepted: 09/01/2023] [Indexed: 02/28/2024]
Abstract
Understanding the impact of oral health on rheumatoid arthritis (RA) will inform how best to manage patients with both periodontitis and RA. This review seeks to provide an update on interventional and mechanistic investigations, including a brief summary of European Research programs investigating the link between periodontitis and RA. Recent clinical studies are described that evaluate how the treatment of one disease impacts on the other, as are studies in both humans and animal models that have sought to identify the potential mechanisms linking the two diseases.
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Affiliation(s)
- Isabel Lopez-Oliva
- Department of Periodontology, Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jennifer Malcolm
- Oral Sciences, University of Glasgow Dental School, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Centre for Immunobiology, School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Shauna Culshaw
- Oral Sciences, University of Glasgow Dental School, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Centre for Immunobiology, School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Clinic for Periodontology, Endodontology and Cariology, University Center of Dental Medicine, University of Basel, Basel, Switzerland
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Oliveira SR, de Arruda JAA, Corrêa JD, Carvalho VF, Medeiros JD, Schneider AH, Machado CC, Duffles LF, Fernandes GDR, Calderaro DC, Júnior MT, Abreu LG, Fukada SY, Oliveira RDR, Louzada-Júnior P, Cunha FQ, Silva TA. Methotrexate and Non-Surgical Periodontal Treatment Change the Oral-Gut Microbiota in Rheumatoid Arthritis: A Prospective Cohort Study. Microorganisms 2023; 12:68. [PMID: 38257895 PMCID: PMC10820502 DOI: 10.3390/microorganisms12010068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/24/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
This study evaluated the changes in the composition of oral-gut microbiota in patients with rheumatoid arthritis (RA) caused by methotrexate (MTX) and non-surgical periodontal treatment (NSPT). Assessments were performed at baseline (T0), 6 months after MTX treatment (T1), and 45 days after NSPT (T2). The composition of the oral and gut microbiota was assessed by amplifying the V4 region of the 16S gene from subgingival plaques and stools. The results of the analysis of continuous variables were presented descriptively and non-parametric tests and Spearman's correlation were adopted. A total of 37 patients (27 with periodontitis) were evaluated at T0; 32 patients (24 with periodontitis) at T1; and 28 patients (17 with periodontitis) at T2. MTX tended to reduce the alpha diversity of the oral-gut microbiota, while NSPT appeared to increase the number of different species of oral microbiota. MTX and NSPT influenced beta diversity in the oral microbiota. The relative abundance of oral microbiota was directly influenced by periodontal status. MTX did not affect the periodontal condition but modified the correlations that varied from weak to moderate (p < 0.05) between clinical parameters and the microbiota. MTX and NSPT directly affected the composition and richness of the oral-gut microbiota. However, MTX did not influence periodontal parameters.
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Affiliation(s)
- Sicília Rezende Oliveira
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte 31270-901, MG, Brazil; (S.R.O.); (J.A.A.d.A.)
| | - José Alcides Almeida de Arruda
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte 31270-901, MG, Brazil; (S.R.O.); (J.A.A.d.A.)
| | - Jôice Dias Corrêa
- Department of Dentistry, Pontifical Catholic University, Belo Horizonte 30535-901, MG, Brazil;
| | - Valessa Florindo Carvalho
- Department of Oral and Maxillofacial Surgery and Periodontology, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (V.F.C.); (M.T.J.)
| | - Julliane Dutra Medeiros
- Department of Biology, Federal University of Juiz de Fora, Juiz de Fora 36036-900, MG, Brazil;
| | - Ayda Henriques Schneider
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (A.H.S.); (F.Q.C.)
| | - Caio Cavalcante Machado
- Division of Clinical Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (C.C.M.); (R.D.R.O.); (P.L.-J.)
| | - Letícia Fernanda Duffles
- Department of BioMolecular Sciences, School of Pharmaceutical Science, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (L.F.D.); (S.Y.F.)
| | | | - Débora Cerqueira Calderaro
- Department of Locomotor Apparatus, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte 31270-901, MG, Brazil;
| | - Mario Taba Júnior
- Department of Oral and Maxillofacial Surgery and Periodontology, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (V.F.C.); (M.T.J.)
| | - Lucas Guimarães Abreu
- Department of Child and Adolescent Oral Health, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte 31270-901, MG, Brazil;
| | - Sandra Yasuyo Fukada
- Department of BioMolecular Sciences, School of Pharmaceutical Science, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (L.F.D.); (S.Y.F.)
| | - Renê Donizeti Ribeiro Oliveira
- Division of Clinical Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (C.C.M.); (R.D.R.O.); (P.L.-J.)
| | - Paulo Louzada-Júnior
- Division of Clinical Immunology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (C.C.M.); (R.D.R.O.); (P.L.-J.)
| | - Fernando Queiroz Cunha
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14040-900, SP, Brazil; (A.H.S.); (F.Q.C.)
| | - Tarcília Aparecida Silva
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte 31270-901, MG, Brazil; (S.R.O.); (J.A.A.d.A.)
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Kobayashi T, Bartold PM. Periodontitis and periodontopathic bacteria as risk factors for rheumatoid arthritis: A review of the last 10 years. JAPANESE DENTAL SCIENCE REVIEW 2023; 59:263-272. [PMID: 37674898 PMCID: PMC10477376 DOI: 10.1016/j.jdsr.2023.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/31/2023] [Accepted: 08/09/2023] [Indexed: 09/08/2023] Open
Abstract
Rheumatoid arthritis (RA) is characterized by chronic inflammatory destruction of joint tissue and is caused by an abnormal autoimmune response triggered by interactions between genetics, environmental factors, and epigenetic and posttranslational modifications. RA has been suggested to be interrelated with periodontitis, a serious form or stage of chronic inflammatory periodontal disease associated with periodontopathic bacterial infections, genetic predisposition, environmental factors, and epigenetic influences. Over the last decade, a number of animal and clinical studies have been conducted to assess whether or not periodontitis and associated periodontopathic bacteria constitute risk factors for RA. The present review introduces recent accumulating evidence to support the associations of periodontitis and periodontopathic bacteria with the risk of RA or the outcome of RA pharmacological treatment with disease-modifying antirheumatic drugs. In addition, the results from intervention studies have suggested an improvement in RA clinical parameters after nonsurgical periodontal treatment. Furthermore, the potential causal mechanisms underlying the link between periodontitis and periodontopathic bacteria and RA are summarized.
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Affiliation(s)
- Tetsuo Kobayashi
- General Dentistry and Clinical Education Unit, Faculty of Dentistry & Medical and Dental Hospital, Niigata University, 2-5274 Gakkocho-dori, Chuo-ku, Niigata 951-8514, Japan
- Division of Periodontology, Department of Oral Biological Science, Niigata University Graduate School of Medical and Dental Sciences, 2-5274 Gakkocho-dori, Chuo-ku, Niigata 951-8514, Japan
| | - Peter Mark Bartold
- Adelaide Dental School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia 5005, Australia
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Ozanne J, Lewis M, Schwenzer A, Kurian D, Brady J, Pritchard D, McLachlan G, Farquharson C, Midwood KS. Extracellular matrix complexity in biomarker studies: a novel assay detecting total serum tenascin-C reveals different distribution to isoform-specific assays. Front Immunol 2023; 14:1275361. [PMID: 38077374 PMCID: PMC10703424 DOI: 10.3389/fimmu.2023.1275361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/26/2023] [Indexed: 12/18/2023] Open
Abstract
Serum biomarkers are the gold standard in non-invasive disease diagnosis and have tremendous potential as prognostic and theranostic tools for patient stratification. Circulating levels of extracellular matrix molecules are gaining traction as an easily accessible means to assess tissue pathology. However, matrix molecules are large, multimodular proteins that are subject to a vast array of post-transcriptional and post-translational modifications. These modifications often occur in a tissue- and/or disease-specific manner, generating hundreds of different variants, each with distinct biological roles. Whilst this complexity can offer unique insight into disease processes, it also has the potential to confound biomarker studies. Tenascin-C is a pro-inflammatory matrix protein expressed at low levels in most healthy tissues but elevated in, and associated with the pathogenesis of, a wide range of autoimmune diseases, fibrosis, and cancer. Analysis of circulating tenascin-C has been widely explored as a disease biomarker. Hundreds of different tenascin-C isoforms can be generated by alternative splicing, and this protein is also modified by glycosylation and citrullination. Current enzyme-linked immunosorbent assays (ELISA) are used to measure serum tenascin-C using antibodies, recognising sites within domains that are alternatively spliced. These studies, therefore, report only levels of specific isoforms that contain these domains, and studies on the detection of total tenascin-C are lacking. As such, circulating tenascin-C levels may be underestimated and/or biologically relevant isoforms overlooked. We developed a highly specific and sensitive ELISA measuring total tenascin-C down to 0.78ng/ml, using antibodies that recognise sites in constitutively expressed domains. In cohorts of people with different inflammatory and musculoskeletal diseases, levels of splice-specific tenascin-C variants were lower than and distributed differently from total tenascin-C. Neither total nor splice-specific tenascin-C levels correlated with the presence of autoantibodies to citrullinated tenascin-C in rheumatoid arthritis (RA) patients. Elevated tenascin-C was not restricted to any one disease and levels were heterogeneous amongst patients with the same disease. These data confirm that its upregulation is not disease-specific, instead suggest that different molecular endotypes or disease stages exist in which pathology is associated with, or independent of, tenascin-C. This immunoassay provides a novel tool for the detection of total tenascin-C that is critical for further biomarker studies. Differences between the distribution of tenascin-C variants and total tenascin-C have implications for the interpretation of studies using isoform-targeted assays. These data highlight the importance of assay design for the detection of multimodular matrix molecules and reveal that there is still much to learn about the intriguingly complex biological roles of distinct matrix proteoforms.
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Affiliation(s)
- James Ozanne
- The Roslin Institute, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, United Kingdom
| | - Mel Lewis
- R&D Department Axis-Shield Diagnostics, Axis-Shield Diagnostics Ltd, Dundee, United Kingdom
| | - Anja Schwenzer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kennedy Institute of Rheumatology, Oxford University, Oxford, United Kingdom
| | - Dominic Kurian
- The Roslin Institute, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, United Kingdom
| | - Jeff Brady
- R&D Department Axis-Shield Diagnostics, Axis-Shield Diagnostics Ltd, Dundee, United Kingdom
| | - David Pritchard
- R&D Department Axis-Shield Diagnostics, Axis-Shield Diagnostics Ltd, Dundee, United Kingdom
| | - Gerry McLachlan
- The Roslin Institute, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, United Kingdom
| | - Colin Farquharson
- The Roslin Institute, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, United Kingdom
| | - Kim S. Midwood
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kennedy Institute of Rheumatology, Oxford University, Oxford, United Kingdom
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Afrasiabi S, Chiniforush N, Partoazar A, Goudarzi R. The role of bacterial infections in rheumatoid arthritis development and novel therapeutic interventions: Focus on oral infections. J Clin Lab Anal 2023:e24897. [PMID: 37225674 DOI: 10.1002/jcla.24897] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) represents a primary public health challenge, which is a major source of pain, disability, and socioeconomic effects worldwide. Several factors contribute to its pathogenesis. Infections are an important concern in RA patients, which play a key role in mortality risk. Despite major advances in the clinical treatment of RA, long-term use of disease-modifying anti-rheumatic drugs can cause serious adverse effects. Therefore, effective strategies for developing novel prevention and RA-modifying therapeutic interventions are sorely needed. OBJECTIVE This review investigates the available evidence on the interplay between various bacterial infections, particularly oral infections and RA, and focuses on some potential interventions such as probiotics, photodynamic therapy, nanotechnology, and siRNA that can have therapeutic effects.
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Affiliation(s)
- Shima Afrasiabi
- Laser Research Center of Dentistry, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Chiniforush
- Laser Research Center of Dentistry, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Partoazar
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramin Goudarzi
- Division of Research and Development, Pharmin USA, LLC, San Jose, California, USA
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9
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Lee JA, Mikuls TR, Deane KD, Sayles HR, Thiele GM, Edison JD, Wagner BD, Feser ML, Moss LK, Kelmenson LB, Robinson WH, Payne JB. Serum antibodies to periodontal pathogens prior to rheumatoid arthritis diagnosis: A case-control study. Semin Arthritis Rheum 2023; 59:152176. [PMID: 36812865 PMCID: PMC10243205 DOI: 10.1016/j.semarthrit.2023.152176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/17/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVES 1) To quantify the association between anti-Porphyromonas gingivalis serum antibody concentrations and the risk of developing rheumatoid arthritis (RA), and 2) to quantify the associations among RA cases between anti-P. gingivalis serum antibody concentrations and RA-specific autoantibodies. Additional anti-bacterial antibodies evaluated included anti-Fusobacterium nucleatum and anti-Prevotella intermedia. METHODS Serum samples were acquired pre- and post- RA diagnosis from the U.S. Department of Defense Serum Repository (n = 214 cases, 210 matched controls). Using separate mixed-models, the timing of elevations of anti-P. gingivalis, anti-P. intermedia, and anti-F. nucleatum antibody concentrations relative to RA diagnosis were compared in RA cases versus controls. Associations were determined between serum anti-CCP2, ACPA fine specificities (vimentin, histone, and alpha-enolase), and IgA, IgG, and IgM RF in pre-RA diagnosis samples and anti-bacterial antibodies using mixed-effects linear regression models. RESULTS No compelling evidence of case-control divergence in serum anti-P. gingivalis, anti-F. nucleatum, and anti-P. intermedia was observed. Among RA cases, including all pre-diagnosis serum samples, anti-P. intermedia was significantly positively associated with anti-CCP2, ACPA fine specificities targeting vimentin, histone, alpha-enolase, and IgA RF (p<0.001), IgG RF (p = 0.049), and IgM RF (p = 0.004), while anti-P. gingivalis and anti-F. nucleatum were not. CONCLUSIONS No longitudinal elevations of anti-bacterial serum antibody concentrations were observed in RA patients prior to RA diagnosis compared to controls. However, anti-P. intermedia displayed significant associations with RA autoantibody concentrations prior to RA diagnosis, suggesting a potential role of this organism in progression towards clinically-detectable RA.
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Affiliation(s)
- Joyce A Lee
- Department of Surgical Specialties, Division of Periodontics, College of Dentistry, University of Nebraska Medical Center, Lincoln, NE, USA
| | - Ted R Mikuls
- Department of Internal Medicine, Division of Rheumatology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Medicine, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Kevin D Deane
- Department of Internal Medicine, Division of Rheumatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Harlan R Sayles
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE USA
| | - Geoffrey M Thiele
- Department of Internal Medicine, Division of Rheumatology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Medicine, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Jess D Edison
- Department of Internal Medicine, Rheumatology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marie L Feser
- Department of Internal Medicine, Division of Rheumatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura K Moss
- Department of Internal Medicine, Division of Rheumatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lindsay B Kelmenson
- Department of Internal Medicine, Division of Rheumatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William H Robinson
- Geriatrics Research Education and Clinical Center, Veterans Affairs Palo Alto Healthcare System and Division of Immunology/Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jeffrey B Payne
- Department of Surgical Specialties, Division of Periodontics, College of Dentistry, University of Nebraska Medical Center, Lincoln, NE, USA; Department of Internal Medicine, Division of Rheumatology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
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10
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Kim YR, Nam SH. A randomized, placebo-controlled clinical trial evaluating of a mouthwash containing Sambucus williamsii var. coreana extract for prevention of gingivitits. Sci Rep 2022; 12:11250. [PMID: 35851584 PMCID: PMC9293903 DOI: 10.1038/s41598-022-15445-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/23/2022] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study is to verify the clinical applicability by applying a mouthwash containing Sambucus williamsii var. coreana extract for preventing periodontal disease. A randomized, double-blind, placebo-controlled study was conducted on 64 patients, excluding those with insufficient data, who visited M dental clinic located in Busan, Korea. Thirty-two people were assigned respectively to the saline solution gargle group and the Sambucus williamsii var. coreana extract gargle group to conduct the O'Leary index, plaque index (PI), gingival index (GI), and subgingival plaques. For the homogeneity of the two groups, scaling was carried out one week before the experiment, and the participants were taught for oral care to conduct during the study period. SPSS 24.0 for Windows (IBM Corp., Armonk, NY, USA) was used to compare the saline solution gargle group and the Sambucus williamsii var. coreana extract gargle group as well as to analyze Baseline (before gargle application), Treatment (immediately after gargle application), and After 5 Days (5 days after gargle application). There was a significant difference in the O'Leary index, PI, GI and subgingival plaques after Treatment and After 5 days (p < 0.05). Also, the periodontal-related indexes improved as the application time increased in the Sambucus williamsii var. coreana extract gargle group. The antibacterial effect was also shown for gram-positive bacteria and gram-negative bacteria in subgingival plaques as the application time increased. The use of the mouthwash containing Sambucus williamsii var. coreana extract was found to be effective for oral periodontal-related indicators and bacteria causing periodontal disease. Therefore, using a mouthwash containing Sambucus williamsii var. coreana extract, a natural drug, will possibly maintain healthy periodontal health by inhibiting and preventing the progression of periodontal disease.
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Affiliation(s)
- Yu-Rin Kim
- Department of Dental Hygiene, Silla University, 140 Baegyang-daero 700beon-gil, Sasang-gu, Busan, 46958, Republic of Korea
| | - Seoul-Hee Nam
- Department of Dental Hygiene, College of Health Sciences, Kangwon National University, 346 Hwangjo-gil, Dogye-up, Samcheok-si, Gangwon-do, 25945, Republic of Korea.
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11
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de Jesus VC, Singh M, Schroth RJ, Chelikani P, Hitchon CA. Association of Bitter Taste Receptor T2R38 Polymorphisms, Oral Microbiota, and Rheumatoid Arthritis. Curr Issues Mol Biol 2021; 43:1460-1472. [PMID: 34698096 PMCID: PMC8929115 DOI: 10.3390/cimb43030103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/02/2021] [Accepted: 10/05/2021] [Indexed: 02/06/2023] Open
Abstract
The association of taste genetics and the oral microbiome in autoimmune diseases such as rheumatoid arthritis (RA) has not been reported. We explored a novel oral mucosal innate immune pathway involving the bitter taste G protein-coupled receptor T2R38. This case–control study aimed to evaluate whether T2R38 polymorphisms associate with the buccal microbial composition in RA. Genomic DNA was obtained from buccal swabs of 35 RA patients and 64 non-RA controls. TAS2R38 genotypes were determined by Sanger sequencing. The buccal microbiome was assessed by Illumina MiSeq sequencing of the V4-16S rRNA gene. Bacterial community differences were analyzed with alpha and beta diversity measures. Linear discriminant analysis effect size identified taxa discriminating between RA versus non-RA and across TAS2R38 genotypes. TAS2R38 genotype frequency was similar between RA and non-RA controls (PAV/PAV; PAV/AVI; AVI/AVI: RA 42.9%; 45.7%; 11.4% versus controls 32.8%; 48.4%; 18.8%, chi-square (2, N = 99) = 2.1, p = 0.35). The relative abundance of Porphyromonas, among others, differed between RA and non-RA controls. The relative abundance of several bacterial species also differed across TAS2R38 genotypes. These findings suggest an association between T2R38 polymorphisms and RA buccal microbial composition. However, further research is needed to understand the impact of T2R38 in oral health and RA development.
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Affiliation(s)
- Vivianne Cruz de Jesus
- Manitoba Chemosensory Biology Research Group, Department of Oral Biology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0W4, Canada; (V.C.d.J.); (R.J.S.)
- Children’s Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB R3E 3P4, Canada
| | - Manu Singh
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada;
| | - Robert J. Schroth
- Manitoba Chemosensory Biology Research Group, Department of Oral Biology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0W4, Canada; (V.C.d.J.); (R.J.S.)
- Children’s Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB R3E 3P4, Canada
- Department of Preventive Dental Science, Rady Faculty of Health Sciences, Dr. Gerald Niznick College of Dentistry, University of Manitoba, Winnipeg, MB R3E 0W4, Canada
| | - Prashen Chelikani
- Manitoba Chemosensory Biology Research Group, Department of Oral Biology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0W4, Canada; (V.C.d.J.); (R.J.S.)
- Children’s Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB R3E 3P4, Canada
- Correspondence: (P.C.); (C.A.H.); Tel.: +1-204-789-3539 (P.C.); +1-204-787-1851 (C.A.H.); Fax: +1-204-789-3913 (P.C.); +1-204-787-2475 (C.A.H.)
| | - Carol A. Hitchon
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1M4, Canada
- Correspondence: (P.C.); (C.A.H.); Tel.: +1-204-789-3539 (P.C.); +1-204-787-1851 (C.A.H.); Fax: +1-204-789-3913 (P.C.); +1-204-787-2475 (C.A.H.)
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12
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González-Febles J, Sanz M. Periodontitis and rheumatoid arthritis: What have we learned about their connection and their treatment? Periodontol 2000 2021; 87:181-203. [PMID: 34463976 DOI: 10.1111/prd.12385] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Rheumatoid arthritis and periodontitis are chronic inflammatory diseases defined respectively by the destruction of the articular cartilage and tooth-supporting periodontal tissues. Although the epidemiologic evidence for an association between these two diseases is still scarce, there is emerging scientific information linking specific bacterial periodontal pathogens, such as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, in the citrullination process, leading to autoantibody formation and compromised immunotolerance of the susceptible patient to rheumatoid arthritis. In this review, we update the existing information on the evidence, not only regarding the epidemiologic association, but also the biologic mechanisms linking these two diseases. Finally, we review information emerging from intervention studies evaluating whether periodontal treatment could influence the initiation and progression of rheumatoid arthritis.
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Affiliation(s)
- Jerián González-Febles
- Departament of Dental Clinical Specialties, Faculty of Odontology, University Complutense, Madrid, Spain.,Research Group on the Aetiology and Treatment of Periodontal and Periimplant Diseases (ETEP), Faculty of Odontology, University Complutense, Madrid, Spain
| | - Mariano Sanz
- Departament of Dental Clinical Specialties, Faculty of Odontology, University Complutense, Madrid, Spain.,Research Group on the Aetiology and Treatment of Periodontal and Periimplant Diseases (ETEP), Faculty of Odontology, University Complutense, Madrid, Spain
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13
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Thomas C, Minty M, Vinel A, Canceill T, Loubières P, Burcelin R, Kaddech M, Blasco-Baque V, Laurencin-Dalicieux S. Oral Microbiota: A Major Player in the Diagnosis of Systemic Diseases. Diagnostics (Basel) 2021; 11:1376. [PMID: 34441309 PMCID: PMC8391932 DOI: 10.3390/diagnostics11081376] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023] Open
Abstract
The oral cavity is host to a complex and diverse microbiota community which plays an important role in health and disease. Major oral infections, i.e., caries and periodontal diseases, are both responsible for and induced by oral microbiota dysbiosis. This dysbiosis is known to have an impact on other chronic systemic diseases, whether triggering or aggravating them, making the oral microbiota a novel target in diagnosing, following, and treating systemic diseases. In this review, we summarize the major roles that oral microbiota can play in systemic disease development and aggravation and also how novel tools can help investigate this complex ecosystem. Finally, we describe new therapeutic approaches based on oral bacterial recolonization or host modulation therapies. Collaboration in diagnosis and treatment between oral specialists and general health specialists is of key importance in bridging oral and systemic health and disease and improving patients' wellbeing.
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Affiliation(s)
- Charlotte Thomas
- INSERM UMR 1297 Inserm, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Avenue Jean Poulhès 1, CEDEX 4, 31432 Toulouse, France; (A.V.); (P.L.); (R.B.); (V.B.-B.)
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
- Service d’Odontologie Rangueil, CHU de Toulouse, 3 Chemin des Maraîchers, CEDEX 9, 31062 Toulouse, France
| | - Matthieu Minty
- INSERM UMR 1297 Inserm, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Avenue Jean Poulhès 1, CEDEX 4, 31432 Toulouse, France; (A.V.); (P.L.); (R.B.); (V.B.-B.)
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
- Service d’Odontologie Rangueil, CHU de Toulouse, 3 Chemin des Maraîchers, CEDEX 9, 31062 Toulouse, France
| | - Alexia Vinel
- INSERM UMR 1297 Inserm, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Avenue Jean Poulhès 1, CEDEX 4, 31432 Toulouse, France; (A.V.); (P.L.); (R.B.); (V.B.-B.)
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
- Service d’Odontologie Rangueil, CHU de Toulouse, 3 Chemin des Maraîchers, CEDEX 9, 31062 Toulouse, France
| | - Thibault Canceill
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
- Service d’Odontologie Rangueil, CHU de Toulouse, 3 Chemin des Maraîchers, CEDEX 9, 31062 Toulouse, France
- UMR CNRS 5085, Centre Interuniversitaire de Recherche et d’Ingénierie des Matériaux (CIRIMAT), Université Paul Sabatier, 35 Chemin des Maraichers, CEDEX 9, 31062 Toulouse, France
| | - Pascale Loubières
- INSERM UMR 1297 Inserm, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Avenue Jean Poulhès 1, CEDEX 4, 31432 Toulouse, France; (A.V.); (P.L.); (R.B.); (V.B.-B.)
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
| | - Remy Burcelin
- INSERM UMR 1297 Inserm, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Avenue Jean Poulhès 1, CEDEX 4, 31432 Toulouse, France; (A.V.); (P.L.); (R.B.); (V.B.-B.)
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
| | - Myriam Kaddech
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
- Service d’Odontologie Rangueil, CHU de Toulouse, 3 Chemin des Maraîchers, CEDEX 9, 31062 Toulouse, France
| | - Vincent Blasco-Baque
- INSERM UMR 1297 Inserm, Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), Avenue Jean Poulhès 1, CEDEX 4, 31432 Toulouse, France; (A.V.); (P.L.); (R.B.); (V.B.-B.)
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
- Service d’Odontologie Rangueil, CHU de Toulouse, 3 Chemin des Maraîchers, CEDEX 9, 31062 Toulouse, France
| | - Sara Laurencin-Dalicieux
- Faculté de Chirurgie Dentaire, Université Paul Sabatier III (UPS), 118 Route de Narbonne, CEDEX 9, 31062 Toulouse, France; (T.C.); (M.K.); (S.L.-D.)
- Service d’Odontologie Rangueil, CHU de Toulouse, 3 Chemin des Maraîchers, CEDEX 9, 31062 Toulouse, France
- INSERM UMR 1295, Centre d’Epidémiologie et de Recherche en Santé des Populations de Toulouse (CERPOP), Epidémiologie et Analyse en Santé Publique, Risques, Maladies Chroniques et Handicaps, 37 Allées Jules Guesdes, 31000 Toulouse, France
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14
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Tar I, Csősz É, Végh E, Lundberg K, Kharlamova N, Soós B, Szekanecz Z, Márton I. Salivary citrullinated proteins in rheumatoid arthritis and associated periodontal disease. Sci Rep 2021; 11:13525. [PMID: 34188155 PMCID: PMC8241986 DOI: 10.1038/s41598-021-93008-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/11/2021] [Indexed: 01/22/2023] Open
Abstract
Periodontal disease (PD) can be an important precipitating factor in the production of citrullinated proteins. Its importance is emphasized, but it is not the only way to produce citrullinated proteins. The aim of the current study was to determine the periodontal conditions and the salivary citrullinated protein content in patients with rheumatoid arthritis (RA) compared to healthy controls. We also wished to correlate citrullinated protein levels in the saliva and serum biomarkers with the periodontal status and temporomandibular joint (TMJ) involvement of patients with RA. Twenty-three patients with RA and 17 healthy controls participated the study. Saliva samples were taken: citrulline content of saliva was measured. Blood test results for patients with RA were collected. TMJ disorders were described. Cariological and periodontal indices were registered. Periodontal conditions and periodontal staging were also registered. Comparison of measured values between groups was performed. Intragroup correlation of patients’ values was counted. The prevalence of TMJ complaints was significantly higher in the RA group (8/23) versus controls (1/17). The patients with RA had worse periodontal condition because more patients with RA had gingivitis with a significantly higher bleeding on probing (BOP) (RA: 22.4 ± 25.0%; controls: 6.36 ± 11.6%; p = 0.018). Gingival index (GI) was also significantly higher in the patients than in controls (RA: 0.68 ± 0.58; controls: 0.19 ± 0.38; p = 0.010). The citrullinated protein (relative) content of saliva did not differ significantly (p = 0.147) between patients with RA (1102.2 ± 530.8) and healthy controls (1873.1 ± 1594.9). In RA, the salivary anti-CCP levels positively correlated with PD staging (R = 0.464, p = 0.039)
. Control subjects more commonly had healthy gingiva than RA patients. Moreover, in the control group more individuals had intact and reduced height periodontium than periodontitis compared to the RA group. There was no significant difference in the levels of salivary citrulline between patients with RA and controls, despite the significant differences in their periodontal status. Thus, salivary citrulline levels are not associated with RA disease severity.
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Affiliation(s)
- Ildikó Tar
- Department of Oral Medicine, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Éva Csősz
- Centre for Molecular Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Edit Végh
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str 98, Debrecen, 4032, Hungary
| | - Karin Lundberg
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Nastya Kharlamova
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Boglárka Soós
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str 98, Debrecen, 4032, Hungary
| | - Zoltán Szekanecz
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str 98, Debrecen, 4032, Hungary.
| | - Ildikó Márton
- Department of Restorative Dentistry and Endodontics, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
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15
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Location, location, location: how the tissue microenvironment affects inflammation in RA. Nat Rev Rheumatol 2021; 17:195-212. [PMID: 33526927 DOI: 10.1038/s41584-020-00570-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 01/30/2023]
Abstract
Current treatments for rheumatoid arthritis (RA) do not work well for a large proportion of patients, or at all in some individuals, and cannot cure or prevent this disease. One major obstacle to developing better drugs is a lack of complete understanding of how inflammatory joint disease arises and progresses. Emerging evidence indicates an important role for the tissue microenvironment in the pathogenesis of RA. Each tissue is made up of cells surrounded and supported by a unique extracellular matrix (ECM). These complex molecular networks define tissue architecture and provide environmental signals that programme site-specific cell behaviour. In the synovium, a main site of disease activity in RA, positional and disease stage-specific cellular diversity exist. Improved understanding of the architecture of the synovium from gross anatomy to the single-cell level, in parallel with evidence demonstrating how the synovial ECM is vital for synovial homeostasis and how dysregulated signals from the ECM promote chronic inflammation and tissue destruction in the RA joint, has opened up new ways of thinking about the pathogenesis of RA. These new ideas provide novel therapeutic approaches for patients with difficult-to-treat disease and could also be used in disease prevention.
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16
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Li H, Li L, Liu C, Cheng L, Yan S, Chen H, Li Y. Diagnostic value of anti-citrullinated α-enolase peptide 1 antibody in patients with rheumatoid arthritis: A systematic review and meta-analysis. Int J Rheum Dis 2021; 24:633-646. [PMID: 33713557 PMCID: PMC8252446 DOI: 10.1111/1756-185x.14093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/18/2021] [Accepted: 02/15/2021] [Indexed: 12/27/2022]
Abstract
Aim To evaluate the diagnostic value of anti‐citrullinated α‐enolase peptide 1 (anti‐CEP 1) antibody in patients with rheumatoid arthritis (RA) by conducting a systematic review and meta‐analysis. Methods The PubMed, Web of Science, Embase, Scopus, and Cochrane Library databases were searched for relevant studies published until September 23, 2020. A bivariate mixed‐effects model was used to calculate the diagnostic indices from primary data of eligible studies. We performed meta‐regression and subgroup analysis to explore the sources of heterogeneity. Results Twenty‐four articles, with a total of 17 380 patients with RA and 7505 control participants, met the criteria for inclusion in the meta‐analysis. The pooled sensitivity, specificity, and positive and negative likelihood ratios for the anti‐CEP 1 antibody were 44% (95% CI: 38%‐51%), 97% (95% CI: 96%‐98%), and 14.81 (95% CI: 10.66‐20.57) and 0.57 (95% CI: 0.52‐0.64), respectively. The pooled positive and negative predictive values were 0.96 (95% CI: 0.95‐0.97) and 0.53 (95% CI: 0.43‐0.63), respectively. The area under the summary receiver operating characteristic curve was 0.86. Meta‐regression indicated that the anti‐CEP 1 antibody detection method may be a source of heterogeneity. The subgroup analysis of the group in which the anti‐CEP 1 antibody was detected by using a commercial enzyme‐linked immunosorbent assay (ELISA) kit had a sensitivity of 59% (95% CI: 50%‐68%) and a specificity of 93% (95% CI: 85%‐97%). Conclusions The anti‐CEP 1 antibody had moderate RA diagnostic value with relatively low sensitivity and high specificity. An ELISA may increase the RA diagnostic sensitivity.
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Affiliation(s)
- Haolong Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Liubing Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Chenxi Liu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Linlin Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Songxin Yan
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Haizhen Chen
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China.,Department of Clinical Laboratory, The First Hospital of Jilin University, Jilin, China
| | - Yongzhe Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
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17
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Evaluation of autoantibodies against vimentin and α-enolase in rheumatoid arthritis patients. Reumatologia 2021; 58:350-356. [PMID: 33456077 PMCID: PMC7792540 DOI: 10.5114/reum.2020.101276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 10/20/2020] [Indexed: 12/05/2022] Open
Abstract
Introduction Rheumatoid arthritis (RA) is categorized as an autoimmune disease with a frequency of 0.2–1% worldwide. It is reported that various autoantibodies are produced in the RA population, particularly against citrullinated peptides. Among various candidate markers for RA diagnosis, the citrullinated proteins have the highest specificity and sensitivity for both diagnosis and prognosis of RA. Anti-mutated citrullinated vimentin and α-enolase constitute a new class of autoantibodies for early detection of RA. Material and methods 45 serum samples and 19 synovial fluid (SF) specimens collected from RA patients were considered for American College of Rheumatology criteria and 20 serum samples and 10 SF specimens were provided from healthy subjects as a control group. To assess the quantity of anti-citrullinated protein antibodies (ACPA), anti-mutated citrullinated vimentin (MCV) and anti-α-enolase in the serum and SF of RA patients were determined by the enzyme-linked immunosorbent assay (ELISA) method. For the evaluation of disease activity and joint destruction, we used the Disease Activity Score of 28 joints based on erythrocyte sedimentation rate (ESR) Disease Activity Score 28 (DAS28). Furthermore, to measure the molecular weight of vimentin and α-enolase, electrophoresis on 10% SDS-PAGE was performed as described before. Results The anti-α-enolase level among serum samples from RA patients was significantly higher than in healthy subjects (4.49 ±0.20 ng/ml vs. 0.76 ±0.12 ng/ml) (p < 0.001). There was a direct relation between α-enolase quantity and (rheumatoid factor) RF and C-reactive protein (CRP) levels. The mean ESR value in positive and negative ACPA patients was 38.2 ±22.6 mm/h and 9.2 ±5.8 mm/h respectively (p < 0.0001). The mean DAS28-ESR was 3.3. The level of anti-MCV in the serum of RA patients (244.6 ±53.3 U/ml) was higher than in serum of the healthy group (148.73 ±71.8) (p < 0.0001). The level of anti-MCV in the SF of patients was 687.5 ±148.4 U/ml. Conclusions In conclusion, both autoantibodies against MCV and α-enolase are two important markers that increase in serum and SF of RA patients and are specific for diagnosis of RA disease.
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18
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Cheng Z, Do T, Mankia K, Meade J, Hunt L, Clerehugh V, Speirs A, Tugnait A, Emery P, Devine D. Dysbiosis in the oral microbiomes of anti-CCP positive individuals at risk of developing rheumatoid arthritis. Ann Rheum Dis 2020; 80:162-168. [PMID: 33004333 DOI: 10.1136/annrheumdis-2020-216972] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES An increased prevalence of periodontitis and perturbation of the oral microbiome has been identified in patients with rheumatoid arthritis (RA). The periodontal pathogen Porphyromonas gingivalis may cause local citrullination of proteins, potentially triggering anti-citrullinated protein antibody production. However, it is not known if oral dysbiosis precedes the onset of clinical arthritis. This study comprehensively characterised the oral microbiome in anti-cyclic citrullinated peptide (anti-CCP) positive at-risk individuals without clinical synovitis (CCP+at risk). METHODS Subgingival plaque was collected from periodontally healthy and diseased sites in 48 CCP+at risk, 26 early RA and 32 asymptomatic healthy control (HC) individuals. DNA libraries were sequenced on the Illumina HiSeq 3000 platform. Taxonomic profile and functional capability of the subgingival microbiome were compared between groups. RESULTS At periodontally healthy sites, CCP+at risk individuals had significantly lower microbial richness compared with HC and early RA groups (p=0.004 and 0.021). Microbial community alterations were found at phylum, genus and species levels. A large proportion of the community differed significantly in membership (523 species; 35.6%) and structure (575 species; 39.1%) comparing CCP+at risk and HC groups. Certain core species, including P. gingivalis, had higher relative abundance in the CCP+at risk group. Seventeen clusters of orthologous gene functional units were significantly over-represented in the CCP+at risk group compared with HC (adjusted p value <0.05). CONCLUSION Anti-CCP positive at-risk individuals have dysbiotic subgingival microbiomes and increased abundance of P. gingivalis compared with controls. This supports the hypothesis that the oral microbiome and specifically P. gingivalis are important in RA initiation.
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Affiliation(s)
- Zijian Cheng
- Division of Oral Biology, University of Leeds, School of Dentistry, Leeds, UK.,The Affiliated Stomatology Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Oral Biomedical Research of Zhejiang Province, Zhejiang University School of Stomatology, Hangzhou, China
| | - Thuy Do
- Division of Oral Biology, University of Leeds, School of Dentistry, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, School of Medicine, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Josephine Meade
- Division of Oral Biology, University of Leeds, School of Dentistry, Leeds, UK
| | - Laura Hunt
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, School of Medicine, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Val Clerehugh
- Division of Restorative Dentistry, University of Leeds, School of Dentistry, Leeds, UK
| | - Alastair Speirs
- Leeds Dental Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Aradhna Tugnait
- Division of Restorative Dentistry, University of Leeds, School of Dentistry, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, School of Medicine, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Deirdre Devine
- Division of Oral Biology, University of Leeds, School of Dentistry, Leeds, UK
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19
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Hasegawa M, Yoshida T, Sudo A. Tenascin-C in Osteoarthritis and Rheumatoid Arthritis. Front Immunol 2020; 11:577015. [PMID: 33101302 PMCID: PMC7554343 DOI: 10.3389/fimmu.2020.577015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/15/2020] [Indexed: 12/12/2022] Open
Abstract
Tenascin-C (TNC) is a large multimodular glycoprotein of the extracellular matrix that consists of four distinct domains. Emerging evidence suggests that TNC may be involved in the pathogenesis of osteoarthritis (OA) and rheumatoid arthritis (RA). In this review, we summarize the current understanding of the role of TNC in cartilage and in synovial biology, across both OA and RA. TNC is expressed in association with the development of articular cartilage; the expression decreases during maturation of chondrocytes and disappears almost completely in adult articular cartilage. TNC expression is increased in diseased cartilage, synovium, and synovial fluid in OA and RA. In addition, elevated circulating TNC levels have been detected in the blood of RA patients. Thus, TNC could be used as a novel biochemical marker for OA and RA, although it has no specificity as a biochemical marker for these joint disorders. In a post-traumatic OA model of aged joints, TNC deficiency was shown to enhance cartilage degeneration. Treatment with TNC domains results in different, domain-specific effects, which are also dose-dependent. For instance, some TNC fragments including the fibrinogen-like globe domain might function as endogenous inducers of synovitis and cartilage matrix degradation through binding with toll-like receptor-4, while full-length TNC promotes cartilage repair and prevents the development of OA without exacerbating synovitis. The TNC peptide TNIIIA2 also prevents cartilage degeneration without causing synovial inflammation. The clinical significance of TNC effects on cartilage and synovium is unclear and understanding the clinical significance of TNC is not straightforward.
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Affiliation(s)
- Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Toshimichi Yoshida
- Department of Pathology & Matrix Biology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
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20
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Möller B, Kollert F, Sculean A, Villiger PM. Infectious Triggers in Periodontitis and the Gut in Rheumatoid Arthritis (RA): A Complex Story About Association and Causality. Front Immunol 2020; 11:1108. [PMID: 32582191 PMCID: PMC7283532 DOI: 10.3389/fimmu.2020.01108] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/07/2020] [Indexed: 12/12/2022] Open
Abstract
Rheumatoid arthritis (RA) is a systemic immune mediated inflammatory disease of unknown origin, which is predominantly affecting the joints. Antibodies against citrullinated peptides are a rather specific immunological hallmark of this heterogeneous entity. Furthermore, certain sequences of the third hypervariable region of human leukocyte antigen (HLA)-DR class II major histocompatibility (MHC) molecules, the so called "shared epitope" sequences, appear to promote autoantibody positive types of RA. However, MHC-II molecule and other genetic associations with RA could not be linked to immune responses against specific citrullinated peptides, nor do genetic factors fully explain the origin of RA. Consequently, non-genetic factors must play an important role in the complex interaction of endogenous and exogenous disease factors. Tobacco smoking was the first environmental factor that was associated with onset and severity of RA. Notably, smoking is also an established risk factor for oral diseases. Furthermore, smoking is associated with extra-articular RA manifestations such as interstitial lung disease in anatomical proximity to the airway mucosa, but also with subcutaneous rheumatoid nodules. In the mouth, Porphyromonas gingivalis is a periodontal pathogen with unique citrullinating capacity of foreign microbial antigens as well as candidate RA autoantigens. Although the original hypothesis that this single pathogen is causative for RA remained unproven, epidemiological as well as experimental evidence linking periodontitis (PD) with RA is rapidly accumulating. Other periopathogens such as Aggregatibacter actinomycetemcomitans and Prevotella intermedia were also proposed to play a specific immunodominant role in context of RA. However, demonstration of T cell reactivity against citrullinated, MHC-II presented autoantigens from RA synovium coinciding with immunity against Prevotella copri (Pc.), a gut microbe attracted attention to another mucosal site, the intestine. Pc. was accumulated in the feces of clinically healthy subjects with citrulline directed immune responses and was correlated with RA onset. In conclusion, we retrieved more than one line of evidence for mucosal sites and different microbial taxa to be potentially involved in the development of RA. This review gives an overview of infectious agents and mucosal pathologies, and discusses the current evidence for causality between different exogenous or mucosal factors and systemic inflammation in RA.
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Affiliation(s)
- Burkhard Möller
- Department for Rheumatology, Immunology and Allergology, Inselspital-University Hospital of Bern, Bern, Switzerland
| | - Florian Kollert
- Department for Rheumatology, Immunology and Allergology, Inselspital-University Hospital of Bern, Bern, Switzerland
| | - Anton Sculean
- Department of Periodontology, School of Dental Medicine, University of Bern, Bern, Switzerland
| | - Peter M Villiger
- Department for Rheumatology, Immunology and Allergology, Inselspital-University Hospital of Bern, Bern, Switzerland
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21
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Desclos-Theveniau M, Bonnaure-Mallet M, Meuric V. [Protein arginine deiminase of oral microbiome plays a causal role in the polyarthritis rheumatoid initiating]. Med Sci (Paris) 2020; 36:465-471. [PMID: 32452368 DOI: 10.1051/medsci/2020078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In the last decade, the association between the periodontitis and rheumatoid arthritis (RA) has been established, suggesting that oral microbiome plays a causal role by initiating this chronic autoimmune inflammatory disease of articulation. Both pathogenesis are similar in term of chronic inflammation, tissue breakdown and bone resorption. Molecular aspects have also revealed that citrullination, a post-translational modification catalyzed by peptidyl-arginine deiminases (PADs), is involved in both diseases. For RA, citrullinated proteins production leads to the synthesis the of anti-citrullinated protein antibodies triggering the loss of immune tolerance. In humans, five PADs have been identified. Recently, studies have found that only Porphyromonas species possess PAD. Thus, a major periodontal pathogen, Porphyromonas gingivalis, is able to generate citrullinated epitopes, and could consequently induce anti-citrullinated protein antibodies. In this review, citrullination process, periodontitis and RA are described to put them in relation with molecular, clinical and epidemiological studies establishing the association between periodontitis and RA.
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Affiliation(s)
- Marie Desclos-Theveniau
- Inserm, INRAE, Univ Rennes 1, CHU de Rennes, Nutrition, Métabolismes et Cancer, 2 avenue du professeur Léon Bernard, 35043 Rennes, France
| | - Martine Bonnaure-Mallet
- Inserm, INRAE, Univ Rennes 1, CHU de Rennes, Nutrition, Métabolismes et Cancer, 2 avenue du professeur Léon Bernard, 35043 Rennes, France
| | - Vincent Meuric
- Inserm, INRAE, Univ Rennes 1, CHU de Rennes, Nutrition, Métabolismes et Cancer, 2 avenue du professeur Léon Bernard, 35043 Rennes, France
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22
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Bartold PM, Lopez‐Oliva I. Periodontitis and rheumatoid arthritis: An update 2012‐2017. Periodontol 2000 2020; 83:189-212. [DOI: 10.1111/prd.12300] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Peter Mark Bartold
- Department of Dentistry University of Adelaide Adelaide South Australia Australia
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23
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Jang B, Kim M, Lee Y, Ishigami A, Kim Y, Choi E. Vimentin citrullination probed by a novel monoclonal antibody serves as a specific indicator for reactive astrocytes in neurodegeneration. Neuropathol Appl Neurobiol 2020; 46:751-769. [DOI: 10.1111/nan.12620] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/23/2020] [Indexed: 01/11/2023]
Affiliation(s)
- B. Jang
- Ilsong Institute of Life Science Hallym University Anyang Gyeonggi‐doRepublic of Korea
| | - M.J. Kim
- Ilsong Institute of Life Science Hallym University Anyang Gyeonggi‐doRepublic of Korea
- Department of Biomedical Gerontology Graduate School of Hallym University Chuncheon Gangwon‐do Republic of Korea
| | - Y.J. Lee
- Ilsong Institute of Life Science Hallym University Anyang Gyeonggi‐doRepublic of Korea
| | - A. Ishigami
- Molecular Regulation of Aging Tokyo Metropolitan Institute of Gerontology Itabashi‐ku Tokyo Japan
| | - Y.S. Kim
- Ilsong Institute of Life Science Hallym University Anyang Gyeonggi‐doRepublic of Korea
- Department of Microbiology College of Medicine Hallym University Chuncheon Gangwon‐do Republic of Korea
| | - E.K. Choi
- Ilsong Institute of Life Science Hallym University Anyang Gyeonggi‐doRepublic of Korea
- Department of Biomedical Gerontology Graduate School of Hallym University Chuncheon Gangwon‐do Republic of Korea
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24
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Maldonado A, Pirracchio L, Imber JC, Bürgin W, Möller B, Sculean A, Eick S. Citrullination in periodontium is associated with Porphyromonas gingivalis. Arch Oral Biol 2020; 114:104695. [PMID: 32315811 DOI: 10.1016/j.archoralbio.2020.104695] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/19/2020] [Accepted: 03/03/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To analyse the citrulline level in the periodontium in association with the presence of or antibody levels against Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis. DESIGN Gingival crevicular fluid (GCF), subgingival biofilm and blood serum were sampled from 98 subjects (26 with RA, 72 without RA (NoRA)). GCF was analyzed for the level of citrulline, for interleukin (IL)-1β, IL-17, IL-10 and monocyte-chemoattractant protein (MCP)-1. Microorganisms were identified in subgingival biofilms. Antibodies againstP. gingivalis, and Aggregatibacter actinomycetemcomitans were quantified in serum. RESULTS GCF citrulline level was the lowest (by trend) in NoRA group without periodontitis. In NoRA, but not in RA an association between GCF citrulline level and P. gingivalis antibody levels was found and the GCF citrulline levels were higher in P. gingivalis positive samples. Any association of A. actinomycetemcomitans with GCF citrulline level did not exist. A model of univariate variance analysis (p = 0.001) showed a dependence of GCF citrulline level from the number of sites with PD (probing depth) ≥5 mm (p = 0.003) and the GCF MCP-1/CCL2 level (p = 0.019). Compared with NoRA in RA the number of teeth was lower, the number of sites with PD ≥ 5 mm was less, GCF levels of interleukin-17 and MCP-1/CCL2 were higher and those of IL-10 lower. Yeasts were only cultured in 15 RA patients (p < 0.001). CONCLUSION Citrullination in periodontium might be associated with P. gingivalis supporting the potential role as a trigger in the development of RA. Pathogenesis of periodontal disease in RA patients seems to differ from that in NoRA and should be investigated further.
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Affiliation(s)
- Alejandra Maldonado
- Department of Periodontology, University of Bern, School of Dental Medicine, Switzerland.
| | - Luca Pirracchio
- Department of Periodontology, University of Bern, School of Dental Medicine, Switzerland
| | - Jean-Claude Imber
- Department of Periodontology, University of Bern, School of Dental Medicine, Switzerland
| | - Walter Bürgin
- Ressort Research, University of Bern, School of Dental Medicine, Freiburgstrasse 7, 3010, Bern, Switzerland
| | - Burkhard Möller
- Clinic of Rheumatology, Immunology and Allergology, University Hospital Bern, Freiburgstrasse 15, 3010, Bern, Switzerland
| | - Anton Sculean
- Department of Periodontology, University of Bern, School of Dental Medicine, Switzerland
| | - Sigrun Eick
- Department of Periodontology, University of Bern, School of Dental Medicine, Switzerland
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25
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Rahajoe PS, de Smit M, Schuurmans G, Raveling-Eelsing E, Kertia N, Vissink A, Westra J. Increased IgA anti-citrullinated protein antibodies in the periodontal inflammatory exudate of healthy individuals compared to rheumatoid arthritis patients. J Clin Periodontol 2020; 47:552-560. [PMID: 32141631 PMCID: PMC7318198 DOI: 10.1111/jcpe.13277] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 02/06/2023]
Abstract
Aim To assess rheumatoid arthritis (RA)‐associated autoantibodies in the gingivocrevicular fluid (GCF) of RA patients and healthy controls with or without periodontal disease, as chronic mucosal inflammation in periodontal disease is hypothesized to contribute to the formation of these autoantibodies. Materials and methods Anti‐citrullinated protein antibodies (ACPA), rheumatoid factor (RF), and their IgA isotypes were assessed in the serum and GCF of RA patients (n = 72) and healthy controls (HC, n = 151). The presence and levels of these antibodies were studied in relation to interleukin (IL)‐8 and periodontal disease. Results In contrast to the HC, the levels of ACPA and RF in the serum and GCF of the RA patients were strongly correlated (p < .0001). The HC with high levels of IgA‐ACPA (n = 27) also had significantly higher levels of total IgG, total IgA, and IL‐8 in the GCF than the HC with low levels of IgA‐ACPA in the GCF (n = 124). Periodontal inflammation and smoking were seen more frequently in the group with high levels of IgA‐ACPA compared to the group with low IgA‐ACPA. Conclusion The IgA‐ACPA in the GCF of HC may be associated with periodontal inflammation and smoking, and could be involved in the progression to RA.
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Affiliation(s)
| | - Menke de Smit
- Department of Oral Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gerbrich Schuurmans
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Elisabeth Raveling-Eelsing
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nyoman Kertia
- Department of Rheumatology, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Arjan Vissink
- Department of Oral Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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26
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Möller B, Bender P, Eick S, Kuchen S, Maldonado A, Potempa J, Reichenbach S, Sculean A, Schwenzer A, Villiger PM, Wong A, Midwood KS. Treatment of severe periodontitis may improve clinical disease activity in otherwise treatment-refractory rheumatoid arthritis patients. Rheumatology (Oxford) 2020; 59:243-245. [PMID: 31292632 PMCID: PMC9900607 DOI: 10.1093/rheumatology/kez287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2019] [Indexed: 01/19/2023] Open
Affiliation(s)
- Burkhard Möller
- Department of Rheumatology, Immunology and Allergology, Inselpital – University Hospital Bern, Bern, Switzerland
| | - Philip Bender
- School of Dental Medicine, Department of Periodontology, University of Bern, Bern, Switzerland
| | - Sigrun Eick
- School of Dental Medicine, Department of Periodontology, University of Bern, Bern, Switzerland
| | - Stefan Kuchen
- Department of Rheumatology, Immunology and Allergology, Inselpital – University Hospital Bern, Bern, Switzerland
| | - Alejandra Maldonado
- School of Dental Medicine, Department of Periodontology, University of Bern, Bern, Switzerland
| | - Jan Potempa
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
- Department of Oral Immunology and Infectious Diseases, University of Louisville School of Dentistry, Louisville, KY, USA
| | - Stephan Reichenbach
- Department of Rheumatology, Immunology and Allergology, Inselpital – University Hospital Bern, Bern, Switzerland
| | - Anton Sculean
- School of Dental Medicine, Department of Periodontology, University of Bern, Bern, Switzerland
| | - Anja Schwenzer
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - Peter M Villiger
- Department of Rheumatology, Immunology and Allergology, Inselpital – University Hospital Bern, Bern, Switzerland
| | - Alicia Wong
- Department of Oral Immunology and Infectious Diseases, University of Louisville School of Dentistry, Louisville, KY, USA
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - Kim S Midwood
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
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27
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Fert-Bober J, Darrah E, Andrade F. Insights into the study and origin of the citrullinome in rheumatoid arthritis. Immunol Rev 2019; 294:133-147. [PMID: 31876028 DOI: 10.1111/imr.12834] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/08/2019] [Indexed: 12/11/2022]
Abstract
The presence of autoantibodies and autoreactive T cells to citrullinated proteins and citrullinating enzymes in patients with rheumatoid arthritis (RA), together with the accumulation of citrullinated proteins in rheumatoid joints, provides substantial evidence that dysregulated citrullination is a hallmark feature of RA. However, understanding mechanisms that dysregulate citrullination in RA has important challenges. Citrullination is a normal process in immune and non-immune cells, which is likely activated by different conditions (eg, inflammation) with no pathogenic consequences. In a complex inflammatory environment such as the RA joint, unique strategies are therefore required to dissect specific mechanisms involved in the abnormal production of citrullinated proteins. Here, we will review current models of citrullination in RA and discuss critical components that, in our view, are relevant to understanding the accumulation of citrullinated proteins in the RA joint, collectively referred to as the RA citrullinome. In particular, we will focus on potential caveats in the study of citrullination in RA and will highlight methods to precisely detect citrullinated proteins in complex biological samples, which is a confirmatory approach to mechanistically link the RA citrullinome with unique pathogenic pathways in RA.
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Affiliation(s)
- Justyna Fert-Bober
- The Smidt Heart Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Erika Darrah
- Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Felipe Andrade
- Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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28
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Linkage of Periodontitis and Rheumatoid Arthritis: Current Evidence and Potential Biological Interactions. Int J Mol Sci 2019; 20:ijms20184541. [PMID: 31540277 PMCID: PMC6769683 DOI: 10.3390/ijms20184541] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/07/2019] [Accepted: 08/20/2019] [Indexed: 02/06/2023] Open
Abstract
The association between rheumatoid arthritis (RA) and periodontal disease (PD) has been the focus of numerous investigations driven by their common pathological features. RA is an autoimmune disease characterized by chronic inflammation, the production of anti-citrullinated proteins antibodies (ACPA) leading to synovial joint inflammation and destruction. PD is a chronic inflammatory condition associated with a dysbiotic microbial biofilm affecting the supporting tissues around the teeth leading to the destruction of mineralized and non-mineralized connective tissues. Chronic inflammation associated with both RA and PD is similar in the predominant adaptive immune phenotype, in the imbalance between pro- and anti-inflammatory cytokines and in the role of smoking and genetic background as risk factors. Structural damage that occurs in consequence of chronic inflammation is the ultimate cause of loss of function and disability observed with the progression of RA and PD. Interestingly, the periodontal pathogen Porphyromonas gingivalis has been implicated in the generation of ACPA in RA patients, suggesting a direct biological intersection between PD and RA. However, more studies are warranted to confirm this link, elucidate potential mechanisms involved, and ascertain temporal associations between RA and PD. This review is mainly focused on recent clinical and translational research intends to discuss and provide an overview of the relationship between RA and PD, exploring the similarities in the immune-pathological aspects and the possible mechanisms linking the development and progression of both diseases. In addition, the current available treatments targeting both RA and PD were revised.
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29
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Periodontal bacteria and the rheumatoid arthritis-related antigen RA-A47: the cross-reactivity potential. Curr Opin Rheumatol 2019; 31:542-545. [DOI: 10.1097/bor.0000000000000611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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30
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Gómez-Bañuelos E, Mukherjee A, Darrah E, Andrade F. Rheumatoid Arthritis-Associated Mechanisms of Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans. J Clin Med 2019; 8:jcm8091309. [PMID: 31454946 PMCID: PMC6780899 DOI: 10.3390/jcm8091309] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 12/19/2022] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease of unknown etiology characterized by immune-mediated damage of synovial joints and antibodies to citrullinated antigens. Periodontal disease, a bacterial-induced inflammatory disease of the periodontium, is commonly observed in RA and has implicated periodontal pathogens as potential triggers of the disease. In particular, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans have gained interest as microbial candidates involved in RA pathogenesis by inducing the production of citrullinated antigens. Here, we will discuss the clinical and mechanistic evidence surrounding the role of these periodontal bacteria in RA pathogenesis, which highlights a key area for the treatment and preventive interventions in RA.
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Affiliation(s)
- Eduardo Gómez-Bañuelos
- Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Amarshi Mukherjee
- Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Erika Darrah
- Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Felipe Andrade
- Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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31
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Corrêa JD, Fernandes GR, Calderaro DC, Mendonça SMS, Silva JM, Albiero ML, Cunha FQ, Xiao E, Ferreira GA, Teixeira AL, Mukherjee C, Leys EJ, Silva TA, Graves DT. Oral microbial dysbiosis linked to worsened periodontal condition in rheumatoid arthritis patients. Sci Rep 2019; 9:8379. [PMID: 31182740 PMCID: PMC6557833 DOI: 10.1038/s41598-019-44674-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 03/27/2019] [Indexed: 12/14/2022] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease characterized by joint inflammation. Individuals with RA have a higher risk of periodontitis and periodontitis has been linked to RA through the production of enzymes by periodontal pathogens that citrullinate proteins. This linkage is supported by findings that periodontitis is associated with increased RA severity and treatment of periodontitis can improve the symptoms of RA. The possible mechanism for this association is through dysbiosis of the oral microbiota triggered by RA-induced systemic inflammation. We examined the RA status of subjects by measuring the number of tender and swollen joints, anti-citrullinated protein antibody and rheumatoid factor. Periodontal disease status and salivary cytokine levels were measured, and dental plaque analyzed by 16S rRNA high throughput sequencing. RA patients had a higher bacterial load, a more diverse microbiota, an increase in bacterial species associated with periodontal disease, more clinical attachment loss, and increased production of inflammatory mediators including IL-17, IL-2, TNF, and IFN-γ. Furthermore, changes in the oral microbiota were linked to worse RA conditions. Our study provides new insights into the bi-directional relationship between periodontitis and RA and suggest that monitoring the periodontal health of RA patients is particularly important.
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Affiliation(s)
- Jôice Dias Corrêa
- Faculty of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Gabriel R Fernandes
- Oswaldo Cruz Fundation, René Rachou Research Center, Belo Horizonte, MG, Brazil
| | | | | | - Janine Mayra Silva
- Faculty of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Fernando Q Cunha
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - E Xiao
- Penn Dental School, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Eugene J Leys
- The Ohio State University, College of Dentistry, Columbus, OH, USA
| | | | - Dana T Graves
- Penn Dental School, University of Pennsylvania, Philadelphia, PA, USA.
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32
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Multiple hit infection and autoimmunity: the dysbiotic microbiota-ACPA connection in rheumatoid arthritis. Curr Opin Rheumatol 2019. [PMID: 29538012 DOI: 10.1097/bor.0000000000000503] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW This review highlights the most recent data obtained in this field and provides clues toward the better understanding of the close interplay between microbiota and host, leading to autoimmune diseases. RECENT FINDINGS A well-described model of microbiota/host interaction of relevance to autoimmunity is linking anti-citrullinated peptide antibody positive rheumatoid arthritis and alterations of microbiota largely concentrating on Porphyromonas gingivalis and more recently of Aggregatibacter actinomycetemcomitans and Prevotella copri. SUMMARY The perception of the classical link between microbial infection and development of autoimmune disease has evolved to the more recent concept of the connection between the microbiome/dysbiosis and breaking of immunological tolerance.
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33
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Marietta E, Horwath I, Balakrishnan B, Taneja V. Role of the intestinal microbiome in autoimmune diseases and its use in treatments. Cell Immunol 2019; 339:50-58. [DOI: 10.1016/j.cellimm.2018.10.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/11/2018] [Accepted: 10/18/2018] [Indexed: 02/06/2023]
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du Teil Espina M, Gabarrini G, Harmsen HJM, Westra J, van Winkelhoff AJ, van Dijl JM. Talk to your gut: the oral-gut microbiome axis and its immunomodulatory role in the etiology of rheumatoid arthritis. FEMS Microbiol Rev 2019; 43:1-18. [PMID: 30219863 DOI: 10.1093/femsre/fuy035] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/13/2018] [Indexed: 02/07/2023] Open
Abstract
Microbial communities inhabiting the human body, collectively called the microbiome, are critical modulators of immunity. This notion is underpinned by associations between changes in the microbiome and particular autoimmune disorders. Specifically, in rheumatoid arthritis, one of the most frequently occurring autoimmune disorders worldwide, changes in the oral and gut microbiomes have been implicated in the loss of tolerance against self-antigens and in increased inflammatory events promoting the damage of joints. In the present review, we highlight recently gained insights in the roles of microbes in the etiology of rheumatoid arthritis. In addition, we address important immunomodulatory processes, including biofilm formation and neutrophil function, which have been implicated in host-microbe interactions relevant for rheumatoid arthritis. Lastly, we present recent advances in the development and evaluation of emerging microbiome-based therapeutic approaches. Altogether, we conclude that the key to uncovering the etiopathogenesis of rheumatoid arthritis will lie in the immunomodulatory functions of the oral and gut microbiomes.
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Affiliation(s)
- Marines du Teil Espina
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Hanzeplein 1, 9700 RB Groningen, the Netherlands
| | - Giorgio Gabarrini
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Hanzeplein 1, 9700 RB Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Center for Dentistry and Oral Hygiene, Antonius Deusinglaan 1, 9713 AV Groningen, the Netherlands
| | - Hermie J M Harmsen
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Hanzeplein 1, 9700 RB Groningen, the Netherlands
| | - Johanna Westra
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, Hanzeplein 1, 9700 RB Groningen, the Netherlands
| | - Arie Jan van Winkelhoff
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Hanzeplein 1, 9700 RB Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Center for Dentistry and Oral Hygiene, Antonius Deusinglaan 1, 9713 AV Groningen, the Netherlands
| | - Jan Maarten van Dijl
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Hanzeplein 1, 9700 RB Groningen, the Netherlands
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Acharya A, Li S, Liu X, Pelekos G, Ziebolz D, Mattheos N. Biological links in periodontitis and rheumatoid arthritis: Discovery via text‐mining PubMed abstracts. J Periodontal Res 2018; 54:318-328. [DOI: 10.1111/jre.12632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/01/2018] [Accepted: 11/18/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Aneesha Acharya
- Faculty of DentistryThe University of Hong Kong Sai Yin Pun Hong Kong
- Department of PeriodontologyDr. D.Y. Patil Vidyapeeth Pune India
| | - Simin Li
- Department of Cariology, Endodontology, and PeriodontologyUniversity Leipzig Liebigstr Germany
| | - Xiangqiong Liu
- Shanghai Genomap Technologies Shanghai China
- College of Bioinformatics Science and TechnologyHarbin Medical University Harbin China
| | - George Pelekos
- Faculty of DentistryThe University of Hong Kong Sai Yin Pun Hong Kong
| | - Dirk Ziebolz
- Department of Cariology, Endodontology, and PeriodontologyUniversity Leipzig Liebigstr Germany
| | - Nikos Mattheos
- Faculty of DentistryThe University of Hong Kong Sai Yin Pun Hong Kong
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Vitkov L, Hannig M, Minnich B, Herrmann M. Periodontal sources of citrullinated antigens and TLR agonists related to RA. Autoimmunity 2018; 51:304-309. [DOI: 10.1080/08916934.2018.1527907] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Ljubomir Vitkov
- Department of Biosciences Vascular & Exercise Biology Unit, University of Salzburg, Salzburg, Austria
- Clinic of Operative Dentistry, Periodontology and Preventive Dentistry, Saarland University, Homburg, Germany
| | - Matthias Hannig
- Clinic of Operative Dentistry, Periodontology and Preventive Dentistry, Saarland University, Homburg, Germany
| | - Bernd Minnich
- Department of Biosciences Vascular & Exercise Biology Unit, University of Salzburg, Salzburg, Austria
| | - Martin Herrmann
- Department of Internal Medicine 3 – Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
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Schwenzer A, Quirke AM, Montgomery AB, Venables PJ, Sayles HR, Schlumberger W, Payne JB, Mikuls TR, Midwood KS. Time to Include Fine Specificity Anti-Citrullinated Protein Antibodies in the Routine Diagnosis and Management of Rheumatoid Arthritis? Arthritis Rheumatol 2018; 71:476-478. [PMID: 30378761 PMCID: PMC6393168 DOI: 10.1002/art.40767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | | | | | | | | | | | | | - Ted R Mikuls
- University of Nebraska Medical Center and Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
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