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Zhao J, Jia Y, Zeng L, Huang H, Liang G, Hong K, Sha B, Luo M, Liu J, Yang W. Interplay of Systemic Immune-Inflammation Index and Serum Klotho Levels: Unveiling a New Dimension in Rheumatoid Arthritis Pathology. Int J Med Sci 2024; 21:396-403. [PMID: 38169796 PMCID: PMC10758150 DOI: 10.7150/ijms.89569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
Aim: The association between the systemic immune-inflammation index (SII) and serum Klotho concentrations (pg/ml) in patients with rheumatoid arthritis (RA) has not been elucidated. The purpose of this study was to clarify the relationship between the SII and serum Klotho concentrations in RA patients. Methods: All data come from the National Health and Nutrition Examination Survey (NHANES) database in the United States, which included 982 RA patients (age range: 40 to 79 years). The measurement data of the SII and serum Klotho are all from the NHANES mobile examination centre. We constructed a multivariate linear regression model to evaluate the association between the SII and serum Klotho levels in RA patients and conducted a subgroup analysis to test the stability of the statistical results. Results: Multivariate linear regression results indicated a negative linear relationship between the SII and serum Klotho concentrations in RA patients (β = -6.33, 95% CI [confidence interval]: -10.15 to -2.53). Compared to the quartile 1 group, the quartile 4 group was associated with significantly lower (P<0.001) serum Klotho concentrations (β = -120.93, 95% CI: -174.84 to -67.02). Compared with the quartile 1 group, with the increase in the SII, the β value showed a decreasing trend (P trend < 0.001). The subgroup analysis showed that none of the covariates affected the stability of these results (all P for interaction ≥ 0.05). Conclusion: There is a significant negative linear association between the SII and serum Klotho concentrations in RA patients. The SII can serve as a predictive indicator of serum Klotho concentrations in RA patients, and Klotho may be a potential anti-inflammatory target for RA treatment.
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Affiliation(s)
- Jinlong Zhao
- The Second Clinical College/State Key Laboratory of Traditional Chinese Medicine Syndrome of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
| | - Yifan Jia
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Lingfeng Zeng
- The Second Clinical College/State Key Laboratory of Traditional Chinese Medicine Syndrome of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
| | - Hetao Huang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
| | - Guihong Liang
- The Second Clinical College/State Key Laboratory of Traditional Chinese Medicine Syndrome of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
| | - Kunhao Hong
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
- Guangdong Second Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou 510095, China
| | - Bangxin Sha
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Minghui Luo
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
| | - Jun Liu
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
- Guangdong Second Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou 510095, China
| | - Weiyi Yang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
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Zhang W, Zhang Y, Zhang J, Deng C, Zhang C. Naringenin ameliorates collagen-induced arthritis through activating AMPK-mediated autophagy in macrophages. Immun Inflamm Dis 2023; 11:e983. [PMID: 37904715 PMCID: PMC10588338 DOI: 10.1002/iid3.983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Naringenin is widely recognized for its notable attributes, including anti-inflammatory, anti-cancer, and immunomodulatory activities. However, its specific implications for rheumatoid arthritis (RA) and the underlying mechanisms remain to be explored. This study aimed to investigate the therapeutic efficacy and pharmacological mechanism of Naringenin in the treatment of collagen-induced arthritis (CIA). METHODS A CIA model was established in DBA/1 mice, and various doses of Naringenin were administered orally to assess its impact on RA. The study also involved lipopolysaccharides (LPS)-induced RAW264.7 cells to further evaluate the effects of Naringenin. Mechanistic studies were conducted to elucidate the signaling pathways involved in Naringenin's actions. RESULTS Naringenin significantly alleviated foot inflammation in DBA/1 CIA mice and attenuated the levels of pro-inflammatory cytokines in serum. It also enhanced antioxidant capacity in the CIA model. In vitro studies with LPS-induced RAW264.7 cells demonstrated that Naringenin attenuated pro-inflammatory cytokines and reactive oxygen species (ROS) levels. Mechanistic studies confirmed that Naringenin activated autophagy and increased autophagic flux. Blocking autophagy, either by silencing Atg5 or inhibiting autophagolysosome using chloroquine, effectively counteracted the impact of Naringenin on pro-inflammatory cytokines. Further exploration revealed that Naringenin activated the AMPK/ULK1 signaling pathway, and inhibition of AMPK reversed the initiation of autophagy and reduced pro-inflammatory cytokine secretion induced by Naringenin. CONCLUSIONS This study unveils a novel mechanism by which Naringenin may be used to treat RA. It demonstrates the therapeutic efficacy of Naringenin in a CIA model by reducing inflammation, modulating cytokine levels, and enhancing antioxidant capacity. Moreover, the activation of autophagy through the AMPK/ULK1 signaling pathway appears to play a critical role in Naringenin's anti-inflammatory effects. These findings suggest potential strategies for the development of anti-rheumatic medications based on Naringenin.
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Affiliation(s)
- Wei Zhang
- Department of OrthopedicAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
| | - Yuan Zhang
- Department of OrthopedicAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
| | - Jianguang Zhang
- Department of OrthopedicAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
| | - Chunbiao Deng
- Department of OrthopedicAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
| | - Chao Zhang
- Department of OrthopedicAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
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Abstract
BACKGROUND "Cytokine storm" has been used to implicate increased cytokine levels in the pathogenesis of serious clinical conditions. Similarities with Severe Acute Respiratory Syndrome Coronoavirus-2 (SARS CoV-2) and the 2012 Middle Eastern Respiratory Syndrome led early investigators to suspect a "cytokine storm" resulting in an unregulated inflammatory response associated with the significant morbidity and mortality induced by SARS CoV-2. The threshold of blood cytokines necessary to qualify as a "cytokine storm" has yet to be defined. METHODS A literature review was conducted to identify cytokine levels released during 11 assorted clinical conditions or diseases. Weighted averages for various cytokines were calculated by multiplying the number of patients in the paper by the average concentration of each cytokine. Correlation between cytokine levels for individual conditions or diseases were assessed using Pearson correlation coefficient. RESULTS The literature was reviewed to determine blood levels of cytokines in a wide variety of clinical conditions. These conditions ranged from exercise and autoimmune disease to septic shock and therapy with chimeric antigen receptor T cells. The most frequently measured cytokine was IL-6 which ranged from 24,123 pg/mL in septic shock to 11 pg/mL after exercise. In patients with severe SARS CoV-2 infections, blood levels of IL-6 were only 43 pg/mL, nearly three magnitudes lower than IL-6 levels in patients with septic shock. The clinical presentations of these different diseases do not correlate with blood levels of cytokines. Additionally, there is poor correlation between the concentrations of different cytokines among the different diseases. Specifically, blood levels of IL-6 did not correlate with levels of IL-8, IL-10, or TNF. Septic shock had the highest concentrations of cytokines, yet multiple cytokine inhibitors have failed to demonstrate improved outcomes in multiple clinical trials. Patients with autoimmune diseases have very low blood levels of cytokines (rheumatoid arthritis, IL-6 = 34 pg/mL; Crohn's disease, IL-6 = 5 pg/mL), yet respond dramatically to cytokine inhibitors. CONCLUSION The misleading term "cytokine storm" implies increased blood levels of cytokines are responsible for a grave clinical condition. Not all inflammatory conditions resulting in worsened disease states are correlated with significantly elevated cytokine levels, despite an association with the term "cytokine storm". "Cytokine storm" should be removed from the medical lexicon since it does not reflect the mediators driving the disease nor does it predict which diseases will respond to cytokine inhibitors.
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Affiliation(s)
- Allan E Stolarski
- Department of Surgery, Boston Medical Center, Boston University, Boston, Massachusetts
- Department of Pathology and Laboratory Medicine, Boston University, Boston, Massachusetts
| | - Jiyoun Kim
- Department of Pathology and Laboratory Medicine, Boston University, Boston, Massachusetts
| | - Qiuyang Zhang
- Department of Pathology and Laboratory Medicine, Boston University, Boston, Massachusetts
| | - Daniel G Remick
- Department of Pathology and Laboratory Medicine, Boston University, Boston, Massachusetts
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Albrecht K, de Pablo P, Eidner T, Hoese G, Wassenberg S, Zink A, Callhoff J. Association Between Rheumatoid Arthritis Disease Activity and Periodontitis Defined by Tooth Loss: Longitudinal and Cross-Sectional Data From Two Observational Studies. Arthritis Care Res (Hoboken) 2021. [PMID: 34590439 DOI: 10.1002/acr.24799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To analyze the effect of tooth loss/periodontitis on disease activity in early and established rheumatoid arthritis (RA). METHODS Participants of the Course And Prognosis of Early Arthritis (CAPEA) early arthritis cohort reported their number of teeth at baseline. The number of teeth had been validated as a predictor of periodontitis. Clinical end points, including disease activity score (Disease Activity Score in 28 joints using the erythrocyte sedimentation rate [ESR]), swollen joint count (SJC), ESR, and C-reactive protein level were collected at baseline, 3, 6, 12, 18, and 24 months. We used linear mixed regression models to estimate the association between tooth loss and clinical end points over time in early arthritis. For established RA, we analyzed cross-sectional data from the German National Database (NDB). All models accounted for age, sex, smoking, seropositivity, education level, and disease duration (only NDB). RESULTS Among 1,124 CAPEA participants with early arthritis, those with higher tooth loss were older, more often male, smokers, and seropositive, and they had higher disease activity and inflammation markers at baseline. Tooth loss was associated with higher disease activity and ESR values over time. Inflammatory markers decreased comparably across tooth loss categories. Glucocorticoid use was higher among those with more tooth loss, whereas dose reduction was similar across tooth loss categories. Among 7,179 NDB participants with longstanding RA, disease activity and inflammation markers but not SJC were significantly higher in patients with more tooth loss. CONCLUSION Although we observed an association between tooth loss and disease activity scores and inflammation markers in early and established RA, longitudinal results suggest that tooth loss does not hamper treatment response.
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Affiliation(s)
- Katinka Albrecht
- German Rheumatism Research Centre, Programme Area of Epidemiology and Health Care Research, Berlin, Germany
| | - Paola de Pablo
- University of Birmingham, Institute of Inflammation and Ageing, Research into Inflammatory Arthritis Center Versus Arthritis and MRC-Versus Arthritis Centre für Muskuloskeletal Ageing Research, Birmingham, West Midlands, UK
| | | | | | | | - Angela Zink
- German Rheumatism Research Centre, Programme Area of Epidemiology and Health Care Research, Berlin, Germany
| | - Johanna Callhoff
- German Rheumatism Research Centre, Charité-Universitätsmedizin Berlin, Institute for Social Medicine, Berlin, Germany
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Rodríguez‐Montaño R, Bernard‐Medina AG, Oregon‐Romero E, Martínez‐Rodríguez VMDC, Pita‐López ML, Gómez‐Meda BC, Guerrero‐Velázquez C. IL-23/IL-17 axis and soluble receptors isoforms sIL-23R and sIL-17RA in patients with rheumatoid arthritis-presenting periodontitis. J Clin Lab Anal 2021; 35:e23963. [PMID: 34403509 PMCID: PMC8418468 DOI: 10.1002/jcla.23963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/21/2021] [Accepted: 08/07/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) and periodontitis (P) are chronic inflammatory diseases characterized by joint and radiographic bone loss, respectively. IL-23 and IL-17 have an essential role in the immunopathogenesis of RA, and P. IL-23 stimulates Th17 cells through which produces IL-17, IL-21, and RANKL. IL-17 stimulates fibroblasts to produce RANKL, which initiates bone loss in the joints in RA and the periodontal tissue in periodontitis. The aim of this study was to determine the expression pattern of IL-23/IL-17 axis and soluble receptors isoforms sIL-23R and sIL-17RA of patients with RA presenting P (RAP). MATERIAL AND METHODS Healthy subjects (HS) (n = 42), patients with P (n = 40), RA (n = 20), and patients with RAP (n = 40) were included. Plasma samples were obtained to evaluate the IL-23, IL-17A, sIL-23R, and sIL-17RA by ELISA technique. A nonparametric Mann-Whitney U test was used to compare the differences between groups. A Chi-square was used to compare gender, grade and stage of periodontitis, and DAS28-ESR between the groups. Spearman's rank correlation coefficient was used to study the association between the molecules and clinical parameters. RESULTS IL-23 levels were increased in the RAP group, and lower sIL-23R levels were found in the RAP groups. However, IL-17A was lower in the P and RAP group but not in RA patients. RAP group showed a decrease IL-17A levels in advanced stages of the periodontal disease. CONCLUSION These results suggest that IL-23 and IL-17A tend to downregulate their expression patterns when patients present both rheumatoid arthritis and periodontitis.
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Affiliation(s)
- Ruth Rodríguez‐Montaño
- Instituto de Investigación en OdontologíaDepartamento de Clínicas Odontológicas IntegralesCentro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
- Doctorado en Ciencias Biomédicas (Orientación Inmunología)Centro Universitario de Ciencias de la Salud. Universidad de GuadalajaraGuadalajaraMéxico
| | | | - Edith Oregon‐Romero
- Instituto de Investigación en Ciencias BiomédicasDepartamento de Biología Molecular y GenómicaCentro Universitario de Ciencias de la Salud. Universidad de GuadalajaraGuadalajaraMéxico
| | | | - María Luisa Pita‐López
- Centro de Investigación en Biología Molecular de las Enfermedades Crónicas (CIBIMEC)Departamento de Ciencias Básicas para la SaludCentro Universitario del Sur. Universidad de GuadalajaraGuadalajaraMéxico
| | - Belinda Claudia Gómez‐Meda
- Departamento de Biología Molecular y GenómicaInstituto de Genética Humana “Dr. Enrique Corona Rivera”Centro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
| | - Celia Guerrero‐Velázquez
- Instituto de Investigación en OdontologíaDepartamento de Clínicas Odontológicas IntegralesCentro Universitario de Ciencias de la SaludUniversidad de GuadalajaraGuadalajaraMéxico
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Schmalz G, Bartl M, Schmickler J, Patschan S, Patschan D, Ziebolz D. Tooth Loss Is Associated with Disease-Related Parameters in Patients with Rheumatoid Arthritis and Ankylosing Spondylitis-A Cross-Sectional Study. J Clin Med 2021; 10:jcm10143052. [PMID: 34300218 PMCID: PMC8305486 DOI: 10.3390/jcm10143052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/03/2021] [Accepted: 07/07/2021] [Indexed: 11/22/2022] Open
Abstract
Background: The aim of this cross-sectional study was to investigate potential associations between periodontal inflamed surface area (PISA) and tooth loss with disease-related parameters in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Methods: Patients who attended the Department of Nephrology and Rheumatology, University Medical Centre Goettingen, Germany, were included. The oral examination comprised the detection of the number of remaining teeth and periodontal condition based on staging and grading matrix. Based on periodontal pockets with positive bleeding on probing, the periodontal inflamed surface area (PISA) was determined. Disease related parameters were extracted from the patients’ records. Results: In total, 101 (RA) and 32 participants (AS) were included. Patients with RA had 22.85 ± 4.26 and AS patients 24.34 ± 5.47 remaining teeth (p < 0.01). Periodontitis stage III and IV was present in 91% (RA) and 81.2% (AS) of patients (p = 0.04). Associations between PISA and disease-related parameters were not found in both groups (p > 0.05). In RA, a higher age (p < 0.01), C-reactive protein (p = 0.02), disease activity (p < 0.01) and prednisolone intake (p < 0.01) were associated with fewer remaining teeth. In AS, a higher age (p = 0.02) and increased Bath Ankylosing Spondylitis Metrology Index (p = 0.02) were associated with a lower number of remaining teeth. Conclusions: Tooth loss is associated with disease activity, especially in RA individuals. Dental care to prevent tooth loss might be recommendable to positively influence oral health condition and disease activity in RA and SA patients.
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Affiliation(s)
- Gerhard Schmalz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany; (G.S.); (M.B.); (J.S.)
| | - Markus Bartl
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany; (G.S.); (M.B.); (J.S.)
| | - Jan Schmickler
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany; (G.S.); (M.B.); (J.S.)
| | - Susann Patschan
- Department of Cardiology, Angiology and Nephrology, Klinikum Brandenburg, Medizinische Hochschule Brandenburg, 16816 Brandenburg, Germany; (S.P.); (D.P.)
| | - Daniel Patschan
- Department of Cardiology, Angiology and Nephrology, Klinikum Brandenburg, Medizinische Hochschule Brandenburg, 16816 Brandenburg, Germany; (S.P.); (D.P.)
| | - Dirk Ziebolz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103 Leipzig, Germany; (G.S.); (M.B.); (J.S.)
- Correspondence: ; Tel.: +49-341-97-21211
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de Smit MJ, Westra J, Posthumus MD, Springer G, van Winkelhoff AJ, Vissink A, Brouwer E, Bijl M. Effect of Anti-Rheumatic Treatment on the Periodontal Condition of Rheumatoid Arthritis Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052529. [PMID: 33806304 PMCID: PMC7967392 DOI: 10.3390/ijerph18052529] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
Periodontitis, a bacterial-induced infection of the supporting soft and hard tissues of the teeth (the periodontium), is common in patients with rheumatoid arthritis (RA). As RA and periodontitis underlie common inflammatory pathways, targeting the progression of RA might mediate both periodontitis and RA. On the other hand, patients with RA on immunosuppressive medication have an increased risk of infection. Therefore, the objective of this longitudinal observation study was to assess the effect of methotrexate (MTX) and anti-tumor necrosis factor-α (anti-TNF, etanercept) treatment on the periodontal condition of RA patients. Overall, 14 dentate treatment-naive RA patients starting with MTX and 12 dentate RA patients starting with anti-TNF therapy in addition to MTX were included. Follow-up was scheduled matching the routine protocol for the respective treatments. Prior to the anti-rheumatic treatment with MTX or the anti-TNF therapy in addition to MTX, and during follow-up, i.e., 2 months for MTX, and 3 and 6 months for the anti-TNF therapy in addition to MTX, the periodontal inflamed surface area (PISA) was measured. The efficacy of the anti-rheumatic treatment was assessed by determining the change in RA disease activity (DAS28-ESR). Furthermore, the erythrocyte sedimentation rates were determined and the levels of C-reactive protein, IgM-rheumatoid factor, anti-cyclic citrullinated protein antibodies, and antibodies to the periodontal pathogen Porphyromonas gingivalis, were measured. Subgingival sampling and microbiological characterization of the subgingival microflora was done at baseline. MTX or anti-TNF treatment did not result in an improvement of the periodontal condition, while both treatments significantly improved DAS28 scores (both p < 0.01), and reduced C-reactive protein levels and erythrocyte sedimentation rates (both p < 0.05). It is concluded that anti-rheumatic treatment (MTX and anti-TNF) has negligible influence on the periodontal condition of RA patients.
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Affiliation(s)
- Menke J. de Smit
- Department of Oral and Maxillofacial Surgery, University of Groningen and University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands;
- Department of Rheumatology and Clinical Immunology, University of Groningen and University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (J.W.); (E.B.)
- Center for Dentistry and Oral Hygiene, University of Groningen and University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University of Groningen and University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (J.W.); (E.B.)
| | - Marcel D. Posthumus
- Department of Internal Medicine and Rheumatology, Martini Hospital Groningen, Van Swietenplein 1, 9728 NT Groningen, The Netherlands; (M.D.P.); (M.B.)
| | - Gerald Springer
- Department of Oral and Maxillofacial Surgery, Martini Hospital Groningen, Van Swietenplein 1, 9728 NT Groningen, The Netherlands;
| | - Arie Jan van Winkelhoff
- Center for Dentistry and Oral Hygiene, University of Groningen and University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands;
| | - Arjan Vissink
- Department of Oral and Maxillofacial Surgery, University of Groningen and University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands;
- Correspondence: ; Tel.: +31-50-3613841
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen and University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (J.W.); (E.B.)
| | - Marc Bijl
- Department of Internal Medicine and Rheumatology, Martini Hospital Groningen, Van Swietenplein 1, 9728 NT Groningen, The Netherlands; (M.D.P.); (M.B.)
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