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Krishna-Naik V, Palmer A, Hodson NA, Tugnait A, O'Connor DB. Utilisation of a think-aloud protocol to validate a self-reported periodontitis questionnaire. J Dent 2024:105381. [PMID: 39349094 DOI: 10.1016/j.jdent.2024.105381] [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: 09/02/2024] [Revised: 09/26/2024] [Accepted: 09/27/2024] [Indexed: 10/02/2024] Open
Abstract
OBJECTIVES The gold standard approach to diagnose periodontitis is based on clinical examination and radiographic investigations. This, however, is expensive, tedious, and not feasible in population-level assessments. The self-reported periodontitis questionnaire offers great benefit to facilitate larger epidemiological surveys. There is limited evidence on cognitive validation of self-reported periodontitis questionnaire. This study employed a think aloud approach to investigate if participants interpreted, comprehended, and understood the items in a self-reported periodontitis questionnaire, in the same way as researchers' intended. METHODS 20 adults, resident of the UK and fluent in English participated in online recorded think aloud interviews. The self-reported periodontitis questionnaire consists of 15 questions and 2 open ended questions. The interviews were then transcribed and coded by two independent researchers according to predefined categories representing comprehension and conventional content analysis was used to analyse open-ended data. RESULTS The think aloud approach revealed that most of the questions in the self-reported periodontitis questionnaire were well understood by the participants. Two items, however, were identified as problematic: one was misinterpreted, and another question was not understood by most of the participants. Qualitative conventional content analysis of open-ended questions reiterated and complemented the findings of the think aloud study. Further questions coded as problematic for 3 or more participants were then considered for rephrasing. CONCLUSIONS This study revealed the interpretation and understanding of self-reported periodontitis questions by English speaking UK residents and highlighted the probable reason for lower sensitivity values of the self-reported periodontitis questionnaire. CLINICAL SIGNIFICANCE This study employed think-aloud approach to capture the thought process of the participants as they answered questions on self-reported periodontitis questionnaire. Overall, the questionnaire was well received by the participants, however, some questions were misunderstood/misinterpreted. This study highlights the potential information bias if participants do not understand the questions in epidemiological surveys.
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Affiliation(s)
- Vanaja Krishna-Naik
- Department of Restorative Dentistry, School of Dentistry, Faculty of Medicine & Health University of Leeds, Level 6, Worsley Building, Clarendon Way, Leeds LS2 9LU.
| | - Amy Palmer
- School of Psychology, University of Leeds, LS29JT, UK..
| | - Nicholas A Hodson
- Department of Restorative Dentistry, School of Dentistry, Faculty of Medicine & Health University of Leeds, Level 6, Worsley Building, Clarendon Way, Leeds LS2 9LU.
| | - Aradhna Tugnait
- Department of Restorative Dentistry, School of Dentistry, Faculty of Medicine & Health University of Leeds, Level 6, Worsley Building, Clarendon Way, Leeds LS2 9LU.
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Lu L, Zhao D, Li C, Sun Y, Geng F, Zhang S, Li W, Wang S, Pan Y. The role of periodontitis in the development of atherosclerotic cardiovascular disease in participants with the components of metabolic syndrome: a systematic review and meta-analysis. Clin Oral Investig 2024; 28:339. [PMID: 38801482 DOI: 10.1007/s00784-024-05731-1] [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: 02/27/2024] [Accepted: 05/18/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Prevention of atherosclerotic cardiovascular disease (ASCVD) is important in individuals with metabolic syndrome components (MetS), and periodontitis may play an important role in this process. This study aims to evaluate the association between periodontitis and ASCVD in participants with the components of MetS, including obesity, dysglycemia, hypertension, and dyslipidemia. MATERIALS AND METHODS This study conducted followed the MOOSE reporting guidelines and the PRISMA 2020 guidelines. EMBASE, MEDLINE, Web of Science, Cochrane Library, PubMed and OpenGrey were searched for observational studies about the linkage of periodontitis to ASCVD in people with MetS components up to April 9, 2023. Cohort, case-control and cross-sectional studies were included after study selection. Quality evaluation was carried out using the original and modified Newcastle-Ottawa Scale as appropriate. Random-effects model was employed for meta-analysis. RESULTS Nineteen studies were finally included in the quality analysis, and all of them were assessed as moderate to high quality. Meta-analyses among fifteen studies revealed that the participants with periodontitis were more likely to develop ASCVD in those who have dysglycemia (RR = 1.25, 95% CI = 1.13-1.37; p < 0.05), obesity (RR = 1.13, 95% CI = 1.02-1.24; p < 0.05), dyslipidemia (RR = 1.36, 95% CI = 1.13-1.65; p < 0.05), or hypertension (1.20, 95% CI = 1.05-1.36; p < 0.05). CONCLUSIONS Periodontitis promotes the development of ASCVD in participants with one MetS component (obesity, dysglycemia, hypertension or dyslipidemia). CLINICAL RELEVANCE In people with MetS components, periodontitis may contribute to the ASCVD incidence.
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Affiliation(s)
- Lijie Lu
- Department of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang, China
- Liaoning Provincial Key Laboratory of Oral Diseases, Shenyang, China
| | - Dan Zhao
- Department of Implant Dentistry, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Chen Li
- Department of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang, China
- Liaoning Provincial Key Laboratory of Oral Diseases, Shenyang, China
| | - Yangyang Sun
- Department of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang, China
- Liaoning Provincial Key Laboratory of Oral Diseases, Shenyang, China
| | - Fengxue Geng
- Department of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang, China
- Liaoning Provincial Key Laboratory of Oral Diseases, Shenyang, China
| | - Shuwei Zhang
- Department of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang, China
- Liaoning Provincial Key Laboratory of Oral Diseases, Shenyang, China
| | - Weiqi Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, Sichuan University, Chengdu, China
| | - Songlin Wang
- Salivary Gland Disease Center, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, Beijing Laboratory of Oral Health and Beijing Stomatological Hospital, Capital Medical University, Beijing, 100050, China.
| | - Yaping Pan
- Department of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang, China.
- Liaoning Provincial Key Laboratory of Oral Diseases, Shenyang, China.
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Hu J, Ou-Yang ZY, Zhao YQ, Zhao J, Tan L, Liu Q, Wang MY, Ye Q, Feng Y, Zhong MM, Chen NX, Su XL, Zhang Q, Feng YZ, Guo Y. Evaluation of the Efficacy of Stem Cells Therapy in the Periodontal Regeneration: A Meta-Analysis and Mendelian Randomization Study. Stem Cell Rev Rep 2024; 20:980-995. [PMID: 38388709 DOI: 10.1007/s12015-024-10690-x] [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] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
Stem cell therapy for periodontal defects has shown good promise in preclinical studies. The purpose of this study was to evaluate the impact of stem cell support on the regeneration of both soft and hard tissues in periodontal treatment. PubMed, Cochrane Library, Embase, and Web of Science were searched and patients with periodontal defects who received stem cell therapy were included in this study. The quality of the included articles was assessed using Cochrane's tool for evaluating bias, and heterogeneity was analyzed using the I2 method. An Mendelian randomization investigation was conducted using abstract data from the IEU public databases obtained through GWAS. Nine articles were included for the meta-analysis. Stem cell therapy effectively rebuilds periodontal tissues in patients with periodontal defects, as evidenced by a reduction in probing depth, clinical attachment level and bone defect depth . And delta-like homolog 1 is a protective factor against periodontal defects alternative indicator of tooth loosening. The findings of this research endorse the utilization of stem cell treatment for repairing periodontal defects in individuals suffering from periodontitis. It is recommended that additional extensive clinical investigations be carried out to validate the efficacy of stem cell therapy and encourage its widespread adoption.
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Affiliation(s)
- Jing Hu
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ze-Yue Ou-Yang
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ya-Qiong Zhao
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jie Zhao
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Li Tan
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qiong Liu
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Min-Yuan Wang
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qin Ye
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yao Feng
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Meng-Mei Zhong
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ning-Xin Chen
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiao-Lin Su
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qian Zhang
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yun-Zhi Feng
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
| | - Yue Guo
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
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Ghanem AS, Németh O, Móré M, Nagy AC. Role of oral health in heart and vascular health: A population-based study. PLoS One 2024; 19:e0301466. [PMID: 38635852 PMCID: PMC11025934 DOI: 10.1371/journal.pone.0301466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/17/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND AIM Conditions such as hypertension, cardiovascular diseases, and hypercholesterolemia, are a major public health challenge. This study investigates the influence of oral health indicators, including gum bleeding, active dental caries, tooth mobility, and tooth loss, on their prevalence in Hungary, considering socioeconomic, demographic, and lifestyle factors. MATERIALS AND METHODS Data from the 2019 Hungarian European Health Interview Survey with 5,603 participants informed this analysis. Data were accessed from the records maintained by the Department of Health Informatics at the University of Debrecen between September and November 2023. Variable selection employed elastic net regularization and k-fold cross-validation, leading to high-performing predictors for weighted multiple logistic regression models. Sensitivity analysis confirmed the findings' validity. RESULTS Significant links were found between poor oral health and chronic cardiac conditions. Multiple teeth extractions increased hypertension risk (OR = 1.67, 95% CI: [1.01-2.77]); dental prosthetics had an OR of 1.45 [1.20-1.75]. Gum bleeding was associated with higher cardiovascular disease (OR = 1.69 [1.30-2.21]) and hypercholesterolemia risks (OR = 1.40 [1.09-1.81]). CONCLUSIONS Oral health improvement may reduce the risk of cardiac conditions. This underscores oral health's role in multidisciplinary disease management.
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Affiliation(s)
- Amr Sayed Ghanem
- Department of Health Informatics, Institute of Health Sciences, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Orsolya Németh
- Department of Community Dentistry, Faculty of Dentistry, Semmelweis University, Budapest, Hungary
| | - Marianna Móré
- Institute of Social and Sociological Sciences, Faculty of Health Sciences, University of Debrecen, Nyíregyháza, Hungary
| | - Attila Csaba Nagy
- Department of Health Informatics, Institute of Health Sciences, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
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Guo X, Li X, Liao C, Feng X, He T. Periodontal disease and subsequent risk of cardiovascular outcome and all-cause mortality: A meta-analysis of prospective studies. PLoS One 2023; 18:e0290545. [PMID: 37682950 PMCID: PMC10490928 DOI: 10.1371/journal.pone.0290545] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/10/2023] [Indexed: 09/10/2023] Open
Abstract
Studies reported periodontal disease (PD) periodontal disease is associated with many systemic diseases, including cardiovascular outcomes and all-cause mortality. However, the precise mechanistic link for these relationship remained unclear. We therefore performed a meta-analysis of cohort studies to investigate the association of PD with the risk of cardiovascular outcomes and all-cause mortality. We systematically searched the databases of PubMed, EmBase, and the Cochrane library to identify eligible studies until April 2023. The investigated outcomes included major adverse cardiovascular events (MACEs), coronary heart disease (CHD), myocardial infarction (MI), stroke, cardiac death, and all-cause mortality. The summary relative risk (RR) with 95% confidence interval (CI) were calculated using the random-effects model. Thirty-nine cohort studies with 4,389,263 individuals were selected for final meta-analysis. We noted PD were associated with elevated risk of MACEs (RR: 1.24; 95%CI: 1.15-1.34; P<0.001), CHD (RR: 1.20; 95%CI: 1.12-1.29; P<0.001), MI (RR: 1.14; 95%CI: 1.06-1.22; P = 0.001), stroke (RR: 1.26; 95%CI: 1.15-1.37; P<0.001), cardiac death (RR: 1.42; 95%CI: 1.10-1.84; P = 0.007), and all-cause mortality (RR: 1.31; 95%CI: 1.07-1.61; P = 0.010). Sensitivity analyses indicated the pooled conclusions for cardiovascular outcomes and all-cause mortality are robustness. The associations of PD with the risk of ardiovascular outcomes and all-cause mortality could affected by region, study design, PD definition, follow-up duration, and study quality. This study found the risk of cardiovascular outcomes and all-cause mortality were elevated in PD patients, and the intervention for PD should be applied to prevent the risk of cardiovascular outcomes.
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Affiliation(s)
- Xiangyu Guo
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral DiseasesWest China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Xue Li
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral DiseasesWest China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Chunjuan Liao
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral DiseasesWest China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Xingyu Feng
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral DiseasesWest China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Tao He
- State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral DiseasesWest China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
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Jin R, Ning X, Liu X, Zhao Y, Ye G. Porphyromonas gingivalis-induced periodontitis could contribute to cognitive impairment in Sprague–Dawley rats via the P38 MAPK signaling pathway. Front Cell Neurosci 2023; 17:1141339. [PMID: 37056710 PMCID: PMC10086325 DOI: 10.3389/fncel.2023.1141339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundPeriodontitis is one of the most common oral diseases and has been shown to be a risk factor for systemic diseases. Our aim was to investigate the relationship between periodontitis and cognitive impairment and to explore the role of the P38 MAPK signaling pathway in this process.MethodsWe established a periodontitis model by ligating the first molars of SD rats with silk thread and injecting Porphyromonas gingivalis (P. gingivalis) or P. gingivalis plus the P38 MAPK inhibitor SB203580 at the same time for ten weeks. We assessed alveolar bone resorption and spatial learning and memory using microcomputed tomography and the Morris water maze test, respectively. We used transcriptome sequencing to explore the genetic differences between the groups. The gingival tissue, peripheral blood and hippocampal tissue were assessed for the cytokines TNF-α, IL-1β, IL-6, IL-8 and C reactive protein (CRP) with enzyme-linked immunosorbent assay (ELISA) and reverse transcription polymerase chain reaction (RT–PCR). We observed the presence of P. gingivalis in the hippocampus of rats by paraffin-fluorescence in situ hybridization (FISH). We determined the activation of microglia by immunofluorescence. Finally, Western blot analysis was employed to determine the expression of amyloid precursor protein (APP), β-site APP-cleaving enzyme 1 (BACE1) and P38MAPK pathway activation.ResultsWe demonstrated that silk ligature-induced periodontitis plus injection of P. gingivalis into subgingival tissue could lead to memory and cognitive impairment. Transcriptome sequencing results suggested that there were neurodegenerative diseases in the P. gingivalis group, and the MWM test showed that periodontitis reduced the spatial learning and memory ability of mild cognitive impairment (MCI) model rats. We found high levels of inflammatory factors (TNF-α, IL-1β, IL-6, and IL-8) and CRP in the gingiva, peripheral blood and hippocampus, and the expression of APP and BACE1 was upregulated, as was the P38 MAPK pathway activation. Activated microglia and the presence of P. gingivalis were also found in the hippocampus. P38 MAPK inhibitors mitigated all of these changes.ConclusionOur findings strongly suggest that topical application of P. gingivalis increases the inflammatory burden in the peripheral and central nervous systems (CNS) and that neuroinflammation induced by activation of P38 MAPK leads to impaired learning and memory in SD rats. It can also modulate APP processing. Therefore, P38 MAPK may serve as a linking pathway between periodontitis and cognitive impairment.
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Affiliation(s)
- Ru Jin
- Chongqing Key Laboratory of Oral Disease and Biomedical Sciences and Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Stomatological Hospital, Chongqing Medical University, Chongqing, China
| | - Xiaoqiao Ning
- The First People’s Hospital of Wanzhou, Chongqing, China
| | - Xiang Liu
- Chongqing Key Laboratory of Oral Disease and Biomedical Sciences and Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Stomatological Hospital, Chongqing Medical University, Chongqing, China
| | - Yueyang Zhao
- Department of Anatomy, Chongqing Medical University, Chongqing, China
| | - Guo Ye
- Chongqing Key Laboratory of Oral Disease and Biomedical Sciences and Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Stomatological Hospital, Chongqing Medical University, Chongqing, China
- *Correspondence: Guo Ye,
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Yildirim BG, Aksit C, Mutlu M, Ainola M, Eklund KK, Leskelä J, Pussinen P, Beklen A. Severity and progression rate of periodontitis are associated with an increased risk of hypertension of patients attending a university clinic. BMC Oral Health 2022; 22:627. [PMID: 36550459 PMCID: PMC9784004 DOI: 10.1186/s12903-022-02637-w] [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: 10/06/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although periodontitis is associated with increased risk of hypertension, studies based on new periodontal disease classification is limited. We investigated whether periodontitis severity and progression rate are linked with self-reports on doctor-diagnosed hypertension in a large cohort of patients attending the periodontology clinic at the faculty of dentistry. METHODS Archived patient files, including radiographic image records and results from full-mouth clinical periodontal examination were screened for inclusion. Data on socioeconomic factors, smoking and oral hygiene habits, and medical history were collected with a questionnaire. RESULTS Diagnosis and background data were available for 7008 patients. The median (IQR) age was 31.0 (21.0) years; 60.1% (n = 4211) were female. Hypertension was diagnosed in 6.2% (n = 435) of patients. Both periodontitis stage and grade differed (p < 0.001) between patients with or without hypertension. Increased periodontal disease severity was associated with a 20% increasing risk for hypertension; the odds ratio (OR) was 2.63 (95% confidence interval [CI] 1.48-4.68, p < 0.001) in stage IV periodontitis. Increasing periodontitis progression rate was associated with a 35% increased risk for hypertension; the OR was 2.22 (95% CI 1.45-3.40, p < 0.001) in grade C periodontitis. CONCLUSION Severity and progression rate of periodontitis may be independent risk factors for hypertension in this large cohort of patients attending the university periodontal department.
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Affiliation(s)
- Burak G. Yildirim
- grid.164274.20000 0004 0596 2460Department of Periodontology, Faculty of Dentistry, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Cemilenur Aksit
- grid.411739.90000 0001 2331 2603Faculty of Dentistry, Erciyes University, Kayseri, Turkey
| | - Mesut Mutlu
- grid.8302.90000 0001 1092 2592Faculty of Dentistry, Ege University, Izmir, Turkey
| | - Mari Ainola
- grid.7737.40000 0004 0410 2071Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Immunology Research Program (TRIMM), Research Program Unit (RPU), University of Helsinki, Helsinki, Finland
| | - Kari K. Eklund
- grid.7737.40000 0004 0410 2071Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Immunology Research Program (TRIMM), Research Program Unit (RPU), University of Helsinki, Helsinki, Finland ,grid.15485.3d0000 0000 9950 5666Inflammation Center, Division of Rheumatology, Helsinki University Hospital, Helsinki, Finland ,ORTON Orthopaedic Hospital of the Orton Foundation, Helsinki, Finland
| | - Jaakko Leskelä
- grid.7737.40000 0004 0410 2071Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| | - Pirkko Pussinen
- grid.7737.40000 0004 0410 2071Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland ,grid.9668.10000 0001 0726 2490Institute of Dentistry, University of Eastern Finland, Kuopio, Finland
| | - Arzu Beklen
- grid.164274.20000 0004 0596 2460Department of Periodontology, Faculty of Dentistry, Eskisehir Osmangazi University, Eskisehir, Turkey ,grid.7737.40000 0004 0410 2071Translational Immunology Research Program (TRIMM), Research Program Unit (RPU), University of Helsinki, Helsinki, Finland
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