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Ikeda S, Saito S, Hosoki S, Tonomura S, Yamamoto Y, Ikenouchi H, Ishiyama H, Tanaka T, Hattori Y, Friedland RP, Carare RO, Kuriyama N, Yakushiji Y, Hara H, Koga M, Toyoda K, Nomura R, Takegami M, Nakano K, Ihara M. Harboring Cnm-expressing Streptococcus mutans in the oral cavity relates to both deep and lobar cerebral microbleeds. Eur J Neurol 2023; 30:3487-3496. [PMID: 36708081 DOI: 10.1111/ene.15720] [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: 04/26/2022] [Revised: 10/03/2022] [Accepted: 01/26/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Cerebral microbleeds (CMBs) influence long-term prognoses of stroke patients. Streptococcus mutans expressing the collagen-binding protein Cnm induces cerebrovascular inflammation, impairing blood brain barrier integrity and causing cerebral bleeding. Here, we examine the association of Cnm-positive S. mutans with CMBs. METHODS Acute stroke patients were selected from a single-center registry database. Oral carriage of Cnm-positive or Cnm-negative S. mutans was determined using polymerase chain reaction assays. The associations of Cnm-positive S. mutans with CMB number and specifically the presence of >10 CMBs were examined using quasi-Poisson and logistic regression models, respectively. RESULTS This study included 3154 stroke patients, of which 428 patients (median [interquartile range] age, 73.0 [63.0-81.0] years; 269 men [62.9%]) underwent oral bacterial examinations. In total, 326 patients harbored S. mutans. After excluding four patients without imaging data, we compared patients with Cnm-positive (n = 72) and Cnm-negative (n = 250) S. mutans. Harboring Cnm-positive S. mutans was independently associated with the presence of >10 CMBs (adjusted odds ratio 2.20 [1.18-4.10]) and higher numbers of deep and lobar CMBs (adjusted risk ratio 1.61 [1.14-2.27] for deep; 5.14 [2.78-9.51] for lobar), but not infratentorial CMBs, after adjusting for age, sex, hypertension, stroke type, National Institutes of Health Stroke Scale score, and cerebral amyloid angiopathy. CONCLUSIONS Harboring Cnm-positive S. mutans was independently associated with a higher number of CMBs in deep and lobar locations. Reducing Cnm-positive S. mutans in the oral cavity may serve as a novel therapeutic approach for stroke.
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Affiliation(s)
- Shuhei Ikeda
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Satoshi Saito
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Satoshi Hosoki
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shuichi Tonomura
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yumi Yamamoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hajime Ikenouchi
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroyuki Ishiyama
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yorito Hattori
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Robert P Friedland
- Department of Neurology, University of Louisville, Louisville, Kentucky, USA
| | - Roxana O Carare
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Nagato Kuriyama
- Shizuoka Graduate University of Public Health, Shizuoka, Japan
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
- Department of Neurology, Kansai Medical University Medical Center, Hirakata, Japan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Ryota Nomura
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan
- Department of Pediatric Dentistry, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuhiko Nakano
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
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2
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Hallikainen J, Pessi T, Vehkalahti M, Suominen AL, Pyysalo M, Frösen J. Unlike severe periodontitis, caries does not associate with intracranial aneurysms or aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:169-175. [PMID: 36416942 PMCID: PMC9840572 DOI: 10.1007/s00701-022-05406-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/26/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Periodontal diseases and caries are common oral diseases that predispose to tooth loss if untreated. In this study, we investigated whether loss of teeth or caries associate with intracranial aneurysm (IA) pathology similar to periodontal diseases. METHODS A total of 166 patients with either IA or aneurysmal subarachnoid hemorrhage (aSAH) underwent oral examination in Kuopio University Hospital and Tampere University Hospital. Findings were compared to geographically matched controls acquired from cross-sectional Health2000 survey. This study consisted of three sequential steps. First, we compared the number of missing teeth and prevalence of caries in IA and aSAH patients and geographically matched control population, second step was a multivariate analysis including other risk factors, and third step was a 13-year follow-up of the Health2000 survey participants with missing teeth or caries at baseline. RESULTS Loss of teeth did not significantly differ between IA patients and controls. In logistic regression model adjusted for known risk factors and demographic data, 1-4 caries lesions (OR: 0.40 95%Cl 0.2-0.9, p = 0.031) was associated with lack of IAs, while age (OR: 1.03 95%Cl 1.01.1 p = 0.024), current smoking (OR: 2.7 95%Cl 1.4-5.1, p = 0.003), and severe periodontitis (OR: 5.99 95%Cl 2.6-13.8, p < 0.001) associated to IA formation. In the cox-regression, severe periodontitis at baseline increased the risk of aSAH (HR: 14.3, 95%Cl 1.5-135.9, p = 0.020) during a 13-year follow-up, while caries or missing teeth did not. CONCLUSION Unlike severe periodontitis, caries does not increase the risk of IAs and aSAHs. However, cariogenic bacteria may participate to IA pathology by disseminating to circulation via inflamed gingival tissue.
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Affiliation(s)
- Joona Hallikainen
- Hemorrhagic Brain Pathology Research Group, University of Tampere, Tampere, Finland.
- Oral and Maxillofacial Diseases, Kuopio University Hospital, Kuopio, Finland.
- Oral and Maxillofacial Diseases, Central Finland Central Hospital, Helsinki, Finland.
| | - Tanja Pessi
- Hemorrhagic Brain Pathology Research Group, University of Tampere, Tampere, Finland
| | - Miira Vehkalahti
- Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| | - Anna Liisa Suominen
- Oral and Maxillofacial Diseases, Kuopio University Hospital, Kuopio, Finland
- Finnish Institute for Health and Welfare, Helsinki, Finland
- Institute of Dentistry, University of Eastern Finland, Kuopio, Finland
| | - Mikko Pyysalo
- Hemorrhagic Brain Pathology Research Group, University of Tampere, Tampere, Finland
- Oral Health Services, City of Tampere, Finland
| | - Juhana Frösen
- Hemorrhagic Brain Pathology Research Group, University of Tampere, Tampere, Finland
- Neurosurgery, Tampere University Hospital, Tampere, Finland
- Department of Neurosurgery, Tampere University, Tampere, Finland
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3
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Otsugu M, Mikasa Y, Kitamura T, Suehiro Y, Matayoshi S, Nomura R, Nakano K. Clinical characteristics of children and guardians possessing CBP-positive Streptococcus mutans strains: a cross-sectional study. Sci Rep 2022; 12:17510. [PMID: 36266432 PMCID: PMC9585102 DOI: 10.1038/s41598-022-22378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/13/2022] [Indexed: 01/12/2023] Open
Abstract
Streptococcus mutans is a major etiological agent for dental caries. We previously demonstrated that S. mutans strains expressing collagen-binding proteins (CBPs) were related to the pathogenesis of systemic diseases. However, their acquisition and colonization remain unknown. Here, we investigated the detection rates of CBP-positive S. mutans strains in children and their guardians to clarify the background for the acquisition and colonization in children. Saliva samples were collected from children and their mothers, and detection of S. mutans and collagen-binding genes (cnm, cbm) was performed by PCR after DNA extraction. The oral status of each child was examined, and their mothers were asked to complete a questionnaire. The isolation rate of Cnm-positive S. mutans was significantly higher in mothers than in children. Notably, the possession rates of CBP-positive strains in children were significantly higher in children whose mothers had CBP-positive strains than in children whose mothers did not have these strains. Furthermore, children with CBP-positive strains had a significantly shorter breastfeeding period than children without these strains. The present results suggest that nutritional feeding habits in infancy are one of the factors involved in the acquisition and colonization of CBP-positive S. mutans strains.
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Affiliation(s)
- Masatoshi Otsugu
- grid.136593.b0000 0004 0373 3971Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871 Japan
| | - Yusuke Mikasa
- grid.136593.b0000 0004 0373 3971Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871 Japan
| | - Takahiro Kitamura
- grid.136593.b0000 0004 0373 3971Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871 Japan
| | - Yuto Suehiro
- grid.136593.b0000 0004 0373 3971Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871 Japan
| | - Saaya Matayoshi
- grid.136593.b0000 0004 0373 3971Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871 Japan
| | - Ryota Nomura
- grid.136593.b0000 0004 0373 3971Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871 Japan ,grid.257022.00000 0000 8711 3200Department of Pediatric Dentistry, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Kazuhiko Nakano
- grid.136593.b0000 0004 0373 3971Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, 1-8 Yamada-Oka, Suita, Osaka, 565-0871 Japan
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Hosoki S, Hattori Y, Saito S, Takegami M, Tonomura S, Yamamoto Y, Ikeda S, Hosomi N, Oishi N, Morita Y, Miyamoto Y, Nomura R, Nakano K, Ihara M. Risk Assessment of Cnm-Positive Streptococcus mutans in Stroke Survivors (RAMESSES): Protocol for a Multicenter Prospective Cohort Study. Front Neurol 2022; 13:816147. [PMID: 35645961 PMCID: PMC9133813 DOI: 10.3389/fneur.2022.816147] [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: 11/16/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The role of commensal microbiota in systemic diseases, including brain diseases, has attracted increasing attention. Oral infectious diseases, such as dental caries and periodontitis, are also involved in cerebrovascular diseases and cognitive impairment. Cerebral microbleeds (CMBs) and intracerebral hemorrhage due to small vessel disease (SVD), are presumably associated with a high risk of vascular cognitive impairment and stroke. We previously reported that Streptococcus mutans (S. mutans, the main pathogen of dental caries), harboring the cnm gene that encodes the collagen-binding protein Cnm, is associated with the development of hypertensive intracerebral hemorrhage and aggravation of CMBs. We also proposed a mechanism by which the circulating Cnm-expressing S. mutans causes intracerebral hemorrhage or CMBs; it binds to denuded basement membranes mainly composed of collagen IV through damaged tight junctions or it directly invades endothelial cells, resulting in blood-brain barrier injury. In November 2018, we initiated a multicenter, prospective cohort study (RAMESSES: Risk Assessment of Cnm-positive S. mutans in Stroke Survivors; UMIN Clinical Trials Registry: UMIN000045559) to explore the longitudinal association between Cnm-positive S. mutans and CMBs with comprehensive dental findings, which should determine the effect of Cnm-positive S. mutans in the oral cavity on the risk of CMB development and cognitive decline. Methods Fifteen domestic institutes will be enlisted to enroll 230 patients who have at least one CMB in the deep brain area and develop a stroke within the past year. The prevalence of Cnm-positive S. mutans based on oral specimens and dental hygiene will be examined. The primary outcome is the number of newly developed deep CMBs. The secondary outcomes include the new development of lobar, subtentorial, or any type of CMBs; symptomatic intracerebral hemorrhage or ischemic stroke; changes in cognitive function or frailty; major bleeding; all-cause mortality; and antibody titers against periodontal pathogens. The observation period will be 2 years. Discussion The 2-year longitudinal prospective cohort study is expected to establish the role of Cnm-positive S. mutans in SVD including CMBs and intracerebral hemorrhage from the perspective of the “brain-oral axis” and provide guidance for novel prophylactic strategies against Cnm-positive S. mutans-induced SVD.
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Affiliation(s)
- Satoshi Hosoki
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yorito Hattori
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
- *Correspondence: Yorito Hattori
| | - Satoshi Saito
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shuichi Tonomura
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yumi Yamamoto
- Department of Molecular Innovation in Lipidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shuhei Ikeda
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naohisa Hosomi
- Department of Neurology, Chikamori Hospital, Kochi, Japan
- Department of Disease Model, Research Institute of Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Naoya Oishi
- Medical Innovation Center, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Ryota Nomura
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Kazuhiko Nakano
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
- Masafumi Ihara
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5
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Hossain MS, Alam S, Nibir YM, Tusty TA, Bulbul SM, Islam M, Hossain MS. Genotypic and phenotypic characterization of Streptococcus mutans strains isolated from patients with dental caries. IRANIAN JOURNAL OF MICROBIOLOGY 2021; 13:449-457. [PMID: 34557272 PMCID: PMC8421573 DOI: 10.18502/ijm.v13i4.6968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background and Objectives The oral cavity harbors numerous Streptococcus mutans strains which display remarkable genotypic and phenotypic diversity. This study evaluated the genotypic and phenotypic diversity of 209 S. mutans strains isolated from 336 patients with dental caries and compared with the universal reference strain, UA159. Materials and Methods Selective cultivation on mitis-salivaries-bacitracin agar and species-specific polymerase chain reaction (PCR) was carried out to isolate and identify the 209 S. mutans isolates from 336 patients with dental caries. Arbitrarily primed polymerase chain reaction (AP-PCR), PCR amplification of specific gene, acid production and biofilm formation capacity were performed to evaluate the genotypic and phenotypic variation. Student's t-test and Chi-square test were used for analysis of variables and a probability (P) of <0.05 was considered as significant. Results Our study revealed a high degree of genotypic and phenotypic variability among the clinical strains. We observed significant differences in colony morphology, generation time, biofilm formation, and acid production while growing in culture medium. All the clinical isolates were able to lower pH while growing in Todd-Hewitt broth. Consistent with phenotypic variations, we also observed genotypic variation by AP-PCR and gene specific PCR. AP-PCR analysis suggested that most of the patients with dental caries have distinct type of S. mutans strains. Genes related to various two component systems were highly conserved among the isolated strains, however, bacteriocin encoding genes such as nlmAB, nlmC were absent in nearly half of the clinical isolates. Conclusion Our results support that S. mutans clinical isolates have wide genotypic diversity and show variation in growth kinetics, acid production, acid tolerance and biofilm formation capacity and indicates the presence of diverse mechanism to initiate and establish the biofilm lifestyle which leads to tooth decay.
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Affiliation(s)
- Mohammad Shahadat Hossain
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh.,Department of Genetic Engineering & Biotechnology, Noakhali Science & Technology University, Noakhali, Bangladesh
| | - Sadab Alam
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh
| | - Yead Morshed Nibir
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh
| | - Tahrima Arman Tusty
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh
| | - Sayyeed Mahmud Bulbul
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh
| | - Mirajul Islam
- Department of Statistics, Faculty of Sciences, University of Dhaka, Dhaka, Bangladesh
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Cerebral microbleeds in vascular dementia from clinical aspects to host-microbial interaction. Neurochem Int 2021; 148:105073. [PMID: 34048844 DOI: 10.1016/j.neuint.2021.105073] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 05/15/2021] [Accepted: 05/16/2021] [Indexed: 12/30/2022]
Abstract
Vascular dementia is the second leading cause of dementia after Alzheimer's disease in the elderly population worldwide. Cerebral microbleeds (CMBs) are frequently observed in MRI of elderly subjects and considered as a possible surrogate marker. The number and location of CMBs reflect the severity of diseases and the underlying pathologies may involve cerebral amyloid angiopathy or hypertensive vasculopathy. Accumulating evidence demonstrated the clinicopathological discrepancies of CMBs, the clinical significance of CMBs associated with other MRI markers of cerebral small vessel disease, cognitive impairments, serum, and cerebrospinal fluid biomarkers. Moreover, emerging evidence has shown that genetic factors and gene-environmental interactions might shed light on the underlying etiologies of CMBs, focusing on blood-brain-barrier and inflammation. In this review, we introduce recent genetic and microbiome studies as a cutting-edge approach to figure out the etiology of CMBs through the "microbe-brain-oral axis" and "microbiome-brain-gut axis." Finally, we propose novel concepts, "microvascular matrisome" and "imbalanced proteostasis," which may provide better perspectives for elucidating the pathophysiology of CMBs and future development of therapeutics for vascular dementia using CMBs as a surrogate marker.
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7
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Hosoki S, Saito S, Tonomura S, Ishiyama H, Yoshimoto T, Ikeda S, Ikenouchi H, Yamamoto Y, Hattori Y, Miwa K, Friedland RP, Carare RO, Nakahara J, Suzuki N, Koga M, Toyoda K, Nomura R, Nakano K, Takegami M, Ihara M. Oral Carriage of Streptococcus mutans Harboring the cnm Gene Relates to an Increased Incidence of Cerebral Microbleeds. Stroke 2020; 51:3632-3639. [PMID: 33148146 PMCID: PMC7678651 DOI: 10.1161/strokeaha.120.029607] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Supplemental Digital Content is available in the text. Cerebral microbleeds (CMB) are associated with stroke and cognitive impairment. We previously reported a high prevalence of CMB in people with Streptococcus mutans expressing Cnm, a collagen-binding protein in the oral cavity. S.mutans is a major pathogen responsible for dental caries. Repeated challenge with S.mutans harboring the cnm gene encoding Cnm induced cerebral bleeding in stroke-prone spontaneously hypertensive rats. The purpose of this longitudinal study is to examine the relationship of cnm-positive S.mutans to the development of CMB.
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Affiliation(s)
- Satoshi Hosoki
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Neurology, Keio University School of Medicine, Tokyo, Japan (S.H., J.N., N.S., K.T.)
| | - Satoshi Saito
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan (S.S., R.N., K.N.).,Faculty of Medicine, University of Southampton, United Kingdom (S.S., R.O.C.)
| | - Shuichi Tonomura
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Neurology, Graduate School of Medicine, Kyoto University, Japan (S.T.)
| | - Hiroyuki Ishiyama
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Yoshimoto
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shuhei Ikeda
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hajime Ikenouchi
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yumi Yamamoto
- Department of Molecular Innovation in Lipidemiology (Y.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yorito Hattori
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine (K.M., M.K., K.T.), National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Roxana O Carare
- Faculty of Medicine, University of Southampton, United Kingdom (S.S., R.O.C.)
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan (S.H., J.N., N.S., K.T.)
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan (S.H., J.N., N.S., K.T.)
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine (K.M., M.K., K.T.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine (K.M., M.K., K.T.), National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Neurology, Keio University School of Medicine, Tokyo, Japan (S.H., J.N., N.S., K.T.)
| | - Ryota Nomura
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan (S.S., R.N., K.N.)
| | - Kazuhiko Nakano
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Suita, Japan (S.S., R.N., K.N.)
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiology (M.T.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masafumi Ihara
- Department of Neurology (S.H., S.S., S.T., H. Ishiyama, T.Y., S.I., H. Ikenouchi, Y.H., M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
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