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Liu S, Chen Y, Jiang Y, Du J, Guo L, Xu J, Liu Y, Liu Y. The bidirectional effect of neutrophils on periodontitis model in mice: A systematic review. Oral Dis 2023. [PMID: 37927000 DOI: 10.1111/odi.14803] [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: 10/03/2022] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To evaluate the regulatory role of neutrophils as the first line of host immune defense in the periodontal microenvironment of mice. METHODS A systematic search was performed using PubMed, Web of Science, and ScienceDirect databases for articles published between 2012 and 2023. In this review, articles investigating the effect of neutrophils on alveolar bone resorption in a mouse model of periodontitis were selected and evaluated according to eligibility criteria. Important variables that may influence outcomes were analyzed. RESULTS Eleven articles were included in this systematic review. The results showed that because of their immune defense functions, the functional homeostasis of local neutrophils is critical for periodontal health. Neutrophil deficiency aggravates alveolar bone loss. However, several studies have shown that excessive neutrophil infiltration is positively correlated with alveolar bone resorption caused by periodontitis in mice. Therefore, the homeostasis of neutrophil function needs to be considered in the treatment of periodontitis. CONCLUSIONS Pooled analysis suggests that neutrophils play a bidirectional role in periodontal tissue remodeling in mouse periodontitis models. Therefore, targeted regulation of local neutrophil function provides a novel strategy for the treatment of periodontitis.
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Affiliation(s)
- Siyan Liu
- Laboratory of Tissue Regeneration and Immunology and Department of Periodontics, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, School of Stomatology, Capital Medical University, Beijing, China
| | - Yingyi Chen
- Laboratory of Tissue Regeneration and Immunology and Department of Periodontics, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, School of Stomatology, Capital Medical University, Beijing, China
| | - Yiyang Jiang
- Laboratory of Tissue Regeneration and Immunology and Department of Periodontics, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, School of Stomatology, Capital Medical University, Beijing, China
| | - Juan Du
- Laboratory of Tissue Regeneration and Immunology and Department of Periodontics, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, School of Stomatology, Capital Medical University, Beijing, China
| | - Lijia Guo
- Department of Orthodontics School of Stomatology, Capital Medical University, Beijing, China
| | - Junji Xu
- Laboratory of Tissue Regeneration and Immunology and Department of Periodontics, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, School of Stomatology, Capital Medical University, Beijing, China
| | - Yitong Liu
- Laboratory of Tissue Regeneration and Immunology and Department of Periodontics, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, School of Stomatology, Capital Medical University, Beijing, China
| | - Yi Liu
- Laboratory of Tissue Regeneration and Immunology and Department of Periodontics, Beijing Key Laboratory of Tooth Regeneration and Function Reconstruction, School of Stomatology, Capital Medical University, Beijing, China
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2
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Hajishengallis G. Illuminating the oral microbiome and its host interactions: animal models of disease. FEMS Microbiol Rev 2023; 47:fuad018. [PMID: 37113021 PMCID: PMC10198557 DOI: 10.1093/femsre/fuad018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 04/29/2023] Open
Abstract
Periodontitis and caries are driven by complex interactions between the oral microbiome and host factors, i.e. inflammation and dietary sugars, respectively. Animal models have been instrumental in our mechanistic understanding of these oral diseases, although no single model can faithfully reproduce all aspects of a given human disease. This review discusses evidence that the utility of an animal model lies in its capacity to address a specific hypothesis and, therefore, different aspects of a disease can be investigated using distinct and complementary models. As in vitro systems cannot replicate the complexity of in vivo host-microbe interactions and human research is typically correlative, model organisms-their limitations notwithstanding-remain essential in proving causality, identifying therapeutic targets, and evaluating the safety and efficacy of novel treatments. To achieve broader and deeper insights into oral disease pathogenesis, animal model-derived findings can be synthesized with data from in vitro and clinical research. In the absence of better mechanistic alternatives, dismissal of animal models on fidelity issues would impede further progress to understand and treat oral disease.
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Affiliation(s)
- George Hajishengallis
- Department of Basic and Translational Sciences, Laboratory of Innate Immunity and Inflammation, School of Dental Medicine, University of Pennsylvania, 240 S. 40th Street, Philadelphia, PA 19104-6030, USA
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3
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Chang AM, Kantrong N, Darveau RP. Maintaining homeostatic control of periodontal epithelial tissue. Periodontol 2000 2021; 86:188-200. [PMID: 33690934 DOI: 10.1111/prd.12369] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Years of coevolution with resident microbes has made them an essential component of health. Yet, little is known about oral commensal bacteria's contribution to and role in the maintenance of oral health and homeostasis. Commensal bacteria are speculated to play a host protective role in the maintenance of health. In this review, we describe and provide examples of the coordinate regulation that occurs between oral commensal bacteria and the host innate immune response to modulate and maintain oral homeostasis.
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Affiliation(s)
- Ana M Chang
- Department of Periodontics, University of Washington, Seattle, Washington, USA
| | - Nutthapong Kantrong
- Department of Periodontics, University of Washington, Seattle, Washington, USA.,Oral Biology Research Unit, Faculty of Dentistry, Khon Kaen University, Khon Kaen, Thailand
| | - Richard P Darveau
- Department of Periodontics, University of Washington, Seattle, Washington, USA
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4
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Kang J, Kwon EJ, Ha M, Lee H, Yu Y, Kang JW, Kim Y, Lee EY, Joo JY, Heo HJ, Kim EK, Kim TW, Kim YH, Park HR. Identification of Shared Genes and Pathways in Periodontitis and Type 2 Diabetes by Bioinformatics Analysis. Front Endocrinol (Lausanne) 2021; 12:724278. [PMID: 35145474 PMCID: PMC8822582 DOI: 10.3389/fendo.2021.724278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/20/2021] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION It is well known that the presence of diabetes significantly affects the progression of periodontitis and that periodontitis has negative effects on diabetes and diabetes-related complications. Although this two-way relationship between type 2 diabetes and periodontitis could be understood through experimental and clinical studies, information on common genetic factors would be more useful for the understanding of both diseases and the development of treatment strategies. MATERIALS AND METHODS Gene expression data for periodontitis and type 2 diabetes were obtained from the Gene Expression Omnibus database. After preprocessing of data to reduce heterogeneity, differentially expressed genes (DEGs) between disease and normal tissue were identified using a linear regression model package. Gene ontology and Kyoto encyclopedia of genes and genome pathway enrichment analyses were conducted using R package 'vsn'. A protein-protein interaction network was constructed using the search tool for the retrieval of the interacting genes database. We used molecular complex detection for optimal module selection. CytoHubba was used to identify the highest linkage hub gene in the network. RESULTS We identified 152 commonly DEGs, including 125 upregulated and 27 downregulated genes. Through common DEGs, we constructed a protein-protein interaction and identified highly connected hub genes. The hub genes were up-regulated in both diseases and were most significantly enriched in the Fc gamma R-mediated phagocytosis pathway. DISCUSSION We have identified three up-regulated genes involved in Fc gamma receptor-mediated phagocytosis, and these genes could be potential therapeutic targets in patients with periodontitis and type 2 diabetes.
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Affiliation(s)
- Junho Kang
- Medical Research Institute, Pusan National University, Busan, South Korea
| | - Eun Jung Kwon
- Interdisciplinary Program of Genomic Data Science, Pusan National University, Busan, South Korea
| | - Mihyang Ha
- Interdisciplinary Program of Genomic Data Science, Pusan National University, Busan, South Korea
| | - Hansong Lee
- Interdisciplinary Program of Genomic Data Science, Pusan National University, Busan, South Korea
| | - Yeuni Yu
- Interdisciplinary Program of Genomic Data Science, Pusan National University, Busan, South Korea
| | - Ji Wan Kang
- Interdisciplinary Program of Genomic Data Science, Pusan National University, Busan, South Korea
| | - Yeongjoo Kim
- Interdisciplinary Program of Genomic Data Science, Pusan National University, Busan, South Korea
| | - Eun Young Lee
- Department of Oral Pathology, School of Dentistry, Pusan National University, Yangsan, South Korea
| | - Ji-Young Joo
- Department of Periodontology, School of Dentistry, Pusan National University, Yangsan, South Korea
| | - Hye Jin Heo
- Departmment of Anatomy, School of Medicine, Pusan National University, Yangsan, South Korea
| | - Eun Kyoung Kim
- Departmment of Anatomy, School of Medicine, Pusan National University, Yangsan, South Korea
| | - Tae Woo Kim
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, South Korea
| | - Yun Hak Kim
- Departmment of Anatomy, School of Medicine, Pusan National University, Yangsan, South Korea
- Department of Biomedical Informatics, School of Medicine, Pusan National University, Yangsan, South Korea
- *Correspondence: Yun Hak Kim, ; Hae Ryoun Park,
| | - Hae Ryoun Park
- Department of Oral Pathology, School of Dentistry, Pusan National University, Yangsan, South Korea
- *Correspondence: Yun Hak Kim, ; Hae Ryoun Park,
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5
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Yuh DY, Maekawa T, Li X, Kajikawa T, Bdeir K, Chavakis T, Hajishengallis G. The secreted protein DEL-1 activates a β3 integrin-FAK-ERK1/2-RUNX2 pathway and promotes osteogenic differentiation and bone regeneration. J Biol Chem 2020; 295:7261-7273. [PMID: 32280065 PMCID: PMC7247308 DOI: 10.1074/jbc.ra120.013024] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/08/2020] [Indexed: 12/25/2022] Open
Abstract
The integrin-binding secreted protein developmental endothelial locus-1 (DEL-1) is involved in the regulation of both the initiation and resolution of inflammation in different diseases, including periodontitis, an oral disorder characterized by inflammatory bone loss. Here, using a mouse model of bone regeneration and in vitro cell-based mechanistic studies, we investigated whether and how DEL-1 can promote alveolar bone regeneration during resolution of experimental periodontitis. Compared with WT mice, mice lacking DEL-1 or expressing a DEL-1 variant with an Asp-to-Glu substitution in the RGD motif ("RGE point mutant"), which does not interact with RGD-dependent integrins, exhibited defective bone regeneration. Local administration of DEL-1 or of its N-terminal segment containing the integrin-binding RGD motif, but not of the RGE point mutant, reversed the defective bone regeneration in the DEL-1-deficient mice. Moreover, DEL-1 (but not the RGE point mutant) promoted osteogenic differentiation of MC3T3-E1 osteoprogenitor cells or of primary calvarial osteoblastic cells in a β3 integrin-dependent manner. The ability of DEL-1 to promote in vitro osteogenesis, indicated by induction of osteogenic genes such as the master transcription factor Runt-related transcription factor-2 (Runx2) and by mineralized nodule formation, depended on its capacity to induce the phosphorylation of focal adhesion kinase (FAK) and of extracellular signal-regulated kinase 1/2 (ERK1/2). We conclude that DEL-1 can activate a β3 integrin-FAK-ERK1/2-RUNX2 pathway in osteoprogenitors and promote new bone formation in mice. These findings suggest that DEL-1 may be therapeutically exploited to restore bone lost due to periodontitis and perhaps other osteolytic conditions.
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Affiliation(s)
- Da-Yo Yuh
- Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Tomoki Maekawa
- Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Research Center for Advanced Oral Science, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8514, Japan
| | - Xiaofei Li
- Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Tetsuhiro Kajikawa
- Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Khalil Bdeir
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Triantafyllos Chavakis
- Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, Technische Universität Dresden, 001069 Dresden, Germany
| | - George Hajishengallis
- Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104.
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6
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Sima C, Viniegra A, Glogauer M. Macrophage immunomodulation in chronic osteolytic diseases-the case of periodontitis. J Leukoc Biol 2019; 105:473-487. [PMID: 30452781 PMCID: PMC6386606 DOI: 10.1002/jlb.1ru0818-310r] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022] Open
Abstract
Periodontitis (PD) is a chronic osteolytic disease that shares pathogenic inflammatory features with other conditions associated with nonresolving inflammation. A hallmark of PD is inflammation-mediated alveolar bone loss. Myeloid cells, in particular polymorphonuclear neutrophils (PMN) and macrophages (Mac), are essential players in PD by control of gingival biofilm pathogenicity, activation of adaptive immunity, as well as nonresolving inflammation and collateral tissue damage. Despite mounting evidence of significant innate immune implications to PD progression and healing after therapy, myeloid cell markers and targets for immune modulation have not been validated for clinical use. The remarkable plasticity of monocytes/Mac in response to local activation factors enables these cells to play central roles in inflammation and restoration of tissue homeostasis and provides opportunities for biomarker and therapeutic target discovery for management of chronic inflammatory conditions, including osteolytic diseases such as PD and arthritis. Along a wide spectrum of activation states ranging from proinflammatory to pro-resolving, Macs respond to environmental changes in a site-specific manner in virtually all tissues. This review summarizes the existing evidence on Mac immunomodulation therapies for osteolytic diseases in the broader context of conditions associated with nonresolving inflammation, and discusses osteoimmune implications of Macs in PD.
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Affiliation(s)
- Corneliu Sima
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ana Viniegra
- Dental Research Institute, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Michael Glogauer
- Dental Research Institute, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
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Viniegra A, Goldberg H, Çil Ç, Fine N, Sheikh Z, Galli M, Freire M, Wang Y, Van Dyke T, Glogauer M, Sima C. Resolving Macrophages Counter Osteolysis by Anabolic Actions on Bone Cells. J Dent Res 2018; 97:1160-1169. [PMID: 29993312 PMCID: PMC6169030 DOI: 10.1177/0022034518777973] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Progression of inflammatory osteolytic diseases, including rheumatoid arthritis and periodontitis, is characterized by increased production of proinflammatory mediators and matrix-degrading enzymes by macrophages and increased osteoclastic activity. Phenotypic changes in macrophages are central to the healing process in virtually all tissues. Using a murine model of periodontitis, we assessed the timing of macrophage phenotypic changes and the impact of proresolving activation during inflammatory osteolysis and healing. Proinflammatory macrophage activation and TNF-α overproduction within 3 wk after induction of periodontitis was associated with progressing bone loss. Proresolving activation within 1 wk of stimulus removal and markers of resolving macrophages (IL-10, TGF-β, and CD206) correlated strongly with bone levels. In vivo macrophage depletion with clodronate liposomes prevented bone resorption but impaired regeneration. Induction of resolving macrophages with rosiglitazone, a PPAR-γ agonist, led to reduced bone resorption during inflammatory stimulation and increased bone formation during healing. In vitro assessment of primary bone marrow-derived macrophages activated with either IFN-γ and LPS (proinflammatory activation) or IL-4 (proresolving activation) showed that IL-4-activated cells have enhanced resolving functions (production of anti-inflammatory cytokines; migration and phagocytosis of aged neutrophils) and exert direct anabolic actions on bone cells. Cystatin C secreted by resolving but not inflammatory macrophages explained, in part, the macrophage actions on osteoblasts and osteoclasts. This study supports the concept that therapeutic induction of proresolving functions in macrophages can recouple bone resorption and formation in inflammatory osteolytic diseases.
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Affiliation(s)
- A. Viniegra
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - H. Goldberg
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Ç. Çil
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - N. Fine
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Z. Sheikh
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - M. Galli
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - M. Freire
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA, USA
| | - Y. Wang
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - T.E. Van Dyke
- Center for Clinical and Translational Research, The Forsyth Institute, Cambridge, MA, USA
- Department of Oral Medicine Infection and Immunity, Harvard School of Dental Medicine, Harvard Medical School, Boston, MA, USA
| | - M. Glogauer
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - C. Sima
- Center for Clinical and Translational Research, The Forsyth Institute, Cambridge, MA, USA
- Department of Oral Medicine Infection and Immunity, Harvard School of Dental Medicine, Harvard Medical School, Boston, MA, USA
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8
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Gao JR, Qin XJ, Jiang H, Gao YC, Guo MF, Jiang NN. Potential role of lncRNAs in contributing to pathogenesis of chronic glomerulonephritis based on microarray data. Gene 2017; 643:46-54. [PMID: 29199037 DOI: 10.1016/j.gene.2017.11.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/04/2017] [Accepted: 11/29/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic glomerulonephritis (CGN) is the most common form of primary glomerular disease with unclear molecular mechanisms, which related to immune-mediated inflammatory diseases. Our study intended to identify potential long non-coding RNAs (lncRNAs) and genes, and to determine the potential molecular mechanisms of CGN pathogenesis. METHODS The microarray of GSE64265 and GSE46295 were downloaded from the Gene Expression Omnibus database, GSE64265 including 3 rats control kidney tissues and 5 rats model kidney tissues, GSE46295 including 3 rats control kidney tissues and 3 rats model kidney tissues, which was on the basis of GPL1355 platform. Identification of differentially expressed lncRNAs and mRNAs were performed between the 2 groups. Gene ontology (GO) and pathway enrichment analyses were performed to analyze the biological functions and pathways for the differentially expressed mRNAs. LncRNA-mRNA weighted co-expression network was constructed using the WGCNA package to analyses for the genes in the modules. The protein-protein interaction (PPI) network was visualized. RESULTS A total of 40 significantly up-regulated and 24 down-regulated lncRNAs, 653 up-regulated and 128 down-regulated mRNAs were identified. Additionally, Cdk1, with the highest connectivity degree in PPI network, was noteworthy enriched in cell cycle. Seven lncRNAs: NONRATT026650, LOC102547664, NONRATT77021989, NONRATT012453, LOC102551856, LOC102553536 and NONRATT7047175 were observed in the modules of lncRNA-mRNA weighted co-expression network. CONCLUSIONS LncRNAs NONRATT026650, LOC102547664, NONRATT77021989, NONRATT012453, LOC102551856, LOC102553536 and NONRATT7047175 were differentially expressed and might play important roles in the development of CGN. Key genes, such as Cd44, Rftn1, Runx1, may be crucial biomarkers for CGN.
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Affiliation(s)
- Jia-Rong Gao
- Department of Pharmacy, The first affiliated hospital of Anhui university of Chinese medicine, 117 Meishan Road, Hefei, China.
| | - Xiu-Juan Qin
- Department of Pharmacy, The first affiliated hospital of Anhui university of Chinese medicine, 117 Meishan Road, Hefei, China
| | - Hui Jiang
- Department of Pharmacy, The first affiliated hospital of Anhui university of Chinese medicine, 117 Meishan Road, Hefei, China
| | - Ya-Chen Gao
- Department of Nephrology, The first affiliated hospital of Anhui university of Chinese medicine, 117 Meishan Road, Hefei, China
| | - Ming-Fei Guo
- Department of Pharmacy, The first affiliated hospital of Anhui university of Chinese medicine, 117 Meishan Road, Hefei, China
| | - Nan-Nan Jiang
- Department of Pharmacy, The first affiliated hospital of Anhui university of Chinese medicine, 117 Meishan Road, Hefei, China
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9
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Wellappuli N, Fine N, Lawrence H, Goldberg M, Tenenbaum H, Glogauer M. Oral and Blood Neutrophil Activation States during Experimental Gingivitis. JDR Clin Trans Res 2017; 3:65-75. [DOI: 10.1177/2380084417742120] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Polymorphonuclear neutrophils (PMNs) are the primary leukocytes present in the healthy and inflamed oral cavity. While unique PMN activation states have been shown to differentiate health and periodontitis, little is known about the changes in PMN activation states that occur during the transition from periodontal health to gingivitis. The objective of this study was to characterize oral and circulatory PMNs during induction and resolution of experimental gingivitis. Healthy volunteers were recruited to undergo experimental gingivitis. Clinical assessment of pocket depths, bleeding on probing, gingival index, and plaque index, as well as flow cytometric analysis of CD (cluster of differentiation) activation markers on blood and oral PMNs, was performed weekly. All clinical parameters increased significantly during the induction period and returned to baseline levels during the resolution phase. During the induction phase, while oral PMN counts increased, oral PMN activation state based on surface expression of CD63, CD11b, CD16, and CD14 was diminished compared to those seen in health and during the resolution phase. PMNs in circulation during onset showed increased activation based on CD55, CD63, CD11b, and CD66a. Using clinical parameters and oral PMN counts assessed at day 21, we noted 2 unique disease patterns where one-third of subjects displayed an exaggerated influx of oral PMNs with severe inflammation compared to the majority of the population who experienced a moderate level of inflammation and PMN influx. This supports the notion that PMN influx and severe inflammatory changes during gingivitis could identify subjects at risk for the development of severe gingival inflammation and progression toward destructive periodontitis. This study demonstrates that oral PMN activation states are reduced in gingivitis and suggest that only in periodontitis do PMNs become hyperactivated and tissue damaging. Knowledge Transfer Statement: Our article creates a paradigm for future studies of the evolution of essential oral and circulatory biomarkers to identify individuals at risk to develop periodontitis at an early stage of periodontal disease, which is reversible upon proper oral hygiene practices and dental treatments.
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Affiliation(s)
- N.C. Wellappuli
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - N. Fine
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - H.P. Lawrence
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - M. Goldberg
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
- Severe and Refractory Periodontal Disease Research and Treatment, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - H.C. Tenenbaum
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
- Mt. Sinai Hospital, Center for Advanced Dental Research and Care, Toronto, ON, Canada
| | - M. Glogauer
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
- Mt. Sinai Hospital, Center for Advanced Dental Research and Care, Toronto, ON, Canada
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10
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Filifactor alocis Promotes Neutrophil Degranulation and Chemotactic Activity. Infect Immun 2016; 84:3423-3433. [PMID: 27647870 DOI: 10.1128/iai.00496-16] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/12/2016] [Indexed: 12/25/2022] Open
Abstract
Filifactor alocis is a recently recognized periodontal pathogen; however, little is known regarding its interactions with the immune system. As the first-responder phagocytic cells, neutrophils are recruited in large numbers to the periodontal pocket, where they play a crucial role in the innate defense of the periodontium. Thus, in order to colonize, successful periodontal pathogens must devise means to interfere with neutrophil chemotaxis and activation. In this study, we assessed major neutrophil functions, including degranulation and cell migration, associated with the p38 mitogen-activated protein kinase (MAPK) signaling pathway upon challenge with F. alocis. Under conditions lacking a chemotactic gradient, F. alocis-challenged neutrophils had increased migration compared to uninfected cells, indicating that F. alocis increases chemokinesis in human neutrophils. In addition, neutrophil chemotaxis induced by interleukin-8 was significantly enhanced when cells were challenged with F. alocis, compared to noninfected cells. Similar to live bacteria, heat-killed F. alocis induced both random and directed migration of human neutrophils. The interaction of F. alocis with Toll-like receptor 2 induced granule exocytosis along with a transient ERK1/2 and sustained p38 MAPK activation. Moreover, F. alocis-induced secretory vesicle and specific granule exocytosis were p38 MAPK dependent. Blocking neutrophil degranulation with TAT-SNAP23 fusion protein significantly reduced the chemotactic and random migration induced by F. alocis Therefore, we propose that induction of random migration by F. alocis will prolong neutrophil traffic time in the gingival tissue, and subsequent degranulation will contribute to tissue damage.
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11
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Screening and functional analysis of differentially expressed genes in chronic glomerulonephritis by whole genome microarray. Gene 2016; 589:72-80. [DOI: 10.1016/j.gene.2016.05.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/28/2016] [Accepted: 05/20/2016] [Indexed: 12/19/2022]
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12
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Sima C, Aboodi GM, Lakschevitz FS, Sun C, Goldberg MB, Glogauer M. Nuclear Factor Erythroid 2-Related Factor 2 Down-Regulation in Oral Neutrophils Is Associated with Periodontal Oxidative Damage and Severe Chronic Periodontitis. THE AMERICAN JOURNAL OF PATHOLOGY 2016; 186:1417-26. [PMID: 27070823 DOI: 10.1016/j.ajpath.2016.01.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 01/11/2016] [Accepted: 01/19/2016] [Indexed: 12/12/2022]
Abstract
The balance between reactive oxygen species and antioxidants plays an important role in periodontal health. We previously demonstrated that high reactive oxygen species production by oral polymorphonuclear neutrophils (oPMNs) in chronic periodontitis (CP) refractory to conventional therapy is associated with severe destruction of periodontium. Herein, we show that inhibition of antioxidant production through down-regulation of nuclear factor erythroid 2-related factor 2 (Nrf2) pathway in oPMN, despite enhanced recruitment in the oral cavity, is associated with severe CP. Twenty-four genes in the Nrf2-mediated oxidative stress response pathway were down-regulated in PMNs of diseased patients. Downstream of Nrf2, levels of oPMN superoxide dismutase 1 and catalase were decreased in severe CP, despite increased recruitment. Nrf2(-/-) mice had more severe loss of periodontium in response to periodontitis-inducing subgingival ligatures compared with wild-types. Levels of 8-hydroxy-deoxyguanosine were increased in periodontal lesions of Nrf2(-/-) mice, indicating high oxidative damage. We report, for the first time, Nrf2 pathway down-regulation in oPMNs of patients with severe CP. PMNs of CP patients may be primed for low antioxidant response in the context of high recruitment in the oral cavity, resulting in increased oxidative tissue damage.
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Affiliation(s)
- Corneliu Sima
- Department of Applied Oral Sciences, The Forsyth Institute, Cambridge, Massachusetts; Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts.
| | - Guy M Aboodi
- Department of Periodontology, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada; Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Flavia S Lakschevitz
- Department of Periodontology, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada; Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Chunxiang Sun
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Michael B Goldberg
- Department of Periodontology, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Michael Glogauer
- Department of Periodontology, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada; Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
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13
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Zamakhchari MF, Sima C, Sama K, Fine N, Glogauer M, Van Dyke TE, Gyurko R. Lack of p47(phox) in Akita Diabetic Mice Is Associated with Interstitial Pneumonia, Fibrosis, and Oral Inflammation. THE AMERICAN JOURNAL OF PATHOLOGY 2016; 186:659-70. [PMID: 26747235 PMCID: PMC4816692 DOI: 10.1016/j.ajpath.2015.10.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 10/06/2015] [Accepted: 10/29/2015] [Indexed: 01/22/2023]
Abstract
Excess reactive oxygen species production is central to the development of diabetic complications. The contribution of leukocyte reactive oxygen species produced by the NADPH oxidase to altered inflammatory responses associated with uncontrolled hyperglycemia is poorly understood. To get insight into the role of phagocytic superoxide in the onset of diabetic complications, we used a model of periodontitis in mice with chronic hyperglycemia and lack of leukocyte p47(phox) (Akita/Ncf1) bred from C57BL/6-Ins2(Akita)/J (Akita) and neutrophil cytosolic factor 1 knockout (Ncf1) mice. Akita/Nfc1 mice showed progressive cachexia starting at early age and increased mortality by six months. Their lungs developed infiltrative interstitial lesions that obliterated air spaces as early as 12 weeks when fungal colonization of lungs also was observed. Neutrophils of Akita/Ncf1 mice had normal degranulation and phagocytic efficiency when compared with wild-type mice. Although Akita/Ncf1 mice had increased prevalence of oral infections and more severe periodontitis compared with wild-type mice, bone loss was only marginally higher compared with Akita and Ncf1 null mice. Altogether these results indicate that lack of leukocyte superoxide production in mice with chronic hyperglycemia results in interstitial pneumonia and increased susceptibility to infections.
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Affiliation(s)
- Mai F Zamakhchari
- Department of Periodontology and Oral Biology, Henry M. Goldman School of Dental Medicine, Boston University, Boston, Massachusetts
| | - Corneliu Sima
- Department of Applied Oral Sciences, The Forsyth Institute, Cambridge, Massachusetts; Department of Oral Medicine, Infection, Immunity, Harvard School of Dental Medicine, Boston, Massachusetts
| | - Kishore Sama
- Department of Periodontology and Oral Biology, Henry M. Goldman School of Dental Medicine, Boston University, Boston, Massachusetts
| | - Noah Fine
- The Matrix Dynamics Group, University of Toronto, Toronto, Ontario, Canada
| | - Michael Glogauer
- The Matrix Dynamics Group, University of Toronto, Toronto, Ontario, Canada
| | - Thomas E Van Dyke
- Department of Applied Oral Sciences, The Forsyth Institute, Cambridge, Massachusetts; Department of Oral Medicine, Infection, Immunity, Harvard School of Dental Medicine, Boston, Massachusetts
| | - Robert Gyurko
- Department of Periodontology and Oral Biology, Henry M. Goldman School of Dental Medicine, Boston University, Boston, Massachusetts; Department of Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts.
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14
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Immune and regulatory functions of neutrophils in inflammatory bone loss. Semin Immunol 2016; 28:146-58. [PMID: 26936034 DOI: 10.1016/j.smim.2016.02.002] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/06/2016] [Accepted: 02/14/2016] [Indexed: 02/06/2023]
Abstract
Although historically viewed as merely anti-microbial effectors in acute infection or injury, neutrophils are now appreciated to be functionally versatile with critical roles also in chronic inflammation. Periodontitis, a chronic inflammatory disease that destroys the tooth-supporting gums and bone, is particularly affected by alterations in neutrophil numbers or function, as revealed by observations in monogenic disorders and relevant mouse models. Besides being a significant debilitating disease and health burden in its own right, periodontitis is thus an attractive model to dissect uncharted neutrophil-associated (patho)physiological pathways. Here, we summarize recent evidence that neutrophils can contribute to inflammatory bone loss not only through the typical bystander injury dogma but intriguingly also through their absence from the affected tissue, where they normally perform important immunomodulatory functions. Moreover, we discuss recent advances in the interactions of neutrophils with the vascular endothelium and - upon extravasation - with bacteria, and how the dysregulation of these interactions leads to inflammatory tissue damage. Overall, neutrophils have both protective and destructive roles in periodontitis, as they are involved in both the maintenance of periodontal tissue homeostasis and the induction of inflammatory bone loss. This highlights the importance of developing approaches that promote or sustain a fine balance between homeostatic immunity and inflammatory pathology.
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15
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Sima C, Cheng Q, Rautava J, Levesque C, Sherman P, Glogauer M. Identification of quantitative trait loci influencing inflammation-mediated alveolar bone loss: insights into polygenic inheritance of host-biofilm disequilibria in periodontitis. J Periodontal Res 2015; 51:237-49. [PMID: 26126603 DOI: 10.1111/jre.12303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE The relative contribution of genetic and environmental factors to the onset and progression of periodontitis is inconclusive. Despite the high prevalence, phenotypic heterogeneity and significant local and systemic implications of this disease, early detection and individualized therapy are problematic. Using a murine model of periodontitis in a panel of 17 recombinant inbred mice, the current study addressed the heritability of, and oral dysbiosis associated with, inflammation-mediated alveolar bone loss (iABL), the hallmark of periodontitis. MATERIAL AND METHODS Quantitative trait locus (QTL) genomics and quantitative PCR for over 99% of known murine oral microbiota were used. RESULTS It was found that iABL is a polygenic trait with 32.7% heritability. One suggestive QTL, nicknamed inflammation-mediated alveolar bone loss locus (iABLL), was identified on chromosome 2. Eleven genes involved in innate immune responses and bone metabolism, particularly related to macrophage and osteoblast function, namely Etl4, Pdss1, Cobll1, 9330158F14Rik, Xirp2, Stk39, Mettl5, Metapl1, Itga6, Pdk1 and Sp3, were found in the iABLL using cis expression QTL and nonsynonymous single nucleotide polymorphism analyses. Specific oral microbiome shifts in saliva and tongue mucosa are associated with disease in this model. CONCLUSION Our results indicate that complex host-biofilm interactions generate pathogenic states that extend beyond subgingival biofilms and periodontal tissues. Although no temporal relationship between the onset of iABL and microbiome changes were established, our findings suggest that host factors may be responsible for pathogenic shifts in subgingival biofilms when persistent and undisturbed.
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Affiliation(s)
- C Sima
- Department of Applied Oral Sciences, The Forsyth Institute, Cambridge, MA, USA.,Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA.,Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Q Cheng
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - J Rautava
- Department of Oral Pathology and Oral Radiology, Institute of Dentistry, University of Turku, Turku, Finland.,Cell Biology Program, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - C Levesque
- Department of Oral Microbiology, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - P Sherman
- Cell Biology Program, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - M Glogauer
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
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16
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Jiang H, Wang Y, Viniegra A, Sima C, McCulloch CA, Glogauer M. Adseverin plays a role in osteoclast differentiation and periodontal disease-mediated bone loss. FASEB J 2015; 29:2281-91. [PMID: 25681458 DOI: 10.1096/fj.14-265744] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/23/2015] [Indexed: 01/27/2023]
Abstract
Osteoclast differentiation and function are highly dependent on the assembly and turnover of actin filaments, but little is known about the roles of actin binding proteins in these processes. Adseverin (Ads), a member of the gelsolin superfamily of actin capping and severing proteins, regulates actin filament turnover and can regulate the turnover of cortical actin filaments of chromaffin cells during exocytosis. Using a conditional Ads knockout mouse model, we confirmed our previous finding in cultured cells that Ads plays a role in osteoclastogenesis (OCG) and actin cytoskeletal organization in osteoclasts. Here we show that Ads is required for osteoclast formation and that when alveolar bone resorption is experimentally induced in mice, genetic deletion of Ads prevents osteoclast-mediated bone loss. Further, when Ads-null osteoclasts are cultured, they exhibit defective OCG, disorganized podosome-based actin filament superstructures, and decreased bone resorption. Reintroduction of Ads into Ads-null osteoclast precursor cells restored these osteoclast defects. Collectively, these data demonstrate a unique and osteoclast-specific role for Ads in OCG and osteoclast function.
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Affiliation(s)
- Hongwei Jiang
- *Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Ontario, Canada; and Department of Operative Dentistry and Endodontics, Guanghua School of Stomatology, Sun Yat-sen University, and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Yongqiang Wang
- *Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Ontario, Canada; and Department of Operative Dentistry and Endodontics, Guanghua School of Stomatology, Sun Yat-sen University, and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Ana Viniegra
- *Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Ontario, Canada; and Department of Operative Dentistry and Endodontics, Guanghua School of Stomatology, Sun Yat-sen University, and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Corneliu Sima
- *Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Ontario, Canada; and Department of Operative Dentistry and Endodontics, Guanghua School of Stomatology, Sun Yat-sen University, and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Christopher A McCulloch
- *Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Ontario, Canada; and Department of Operative Dentistry and Endodontics, Guanghua School of Stomatology, Sun Yat-sen University, and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
| | - Michael Glogauer
- *Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Ontario, Canada; and Department of Operative Dentistry and Endodontics, Guanghua School of Stomatology, Sun Yat-sen University, and Guangdong Provincial Key Laboratory of Stomatology, Guangzhou, China
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Hajishengallis G, Chavakis T, Hajishengallis E, Lambris JD. Neutrophil homeostasis and inflammation: novel paradigms from studying periodontitis. J Leukoc Biol 2014; 98:539-48. [PMID: 25548253 DOI: 10.1189/jlb.3vmr1014-468r] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 11/28/2014] [Indexed: 12/30/2022] Open
Abstract
Once viewed as simply antibacterial effector cells packed with antimicrobials, neutrophils are now increasingly appreciated for their regulatory roles in immunity and inflammation. The homeostatic regulation of neutrophils is thus crucial for optimal operation of the immune system. An attractive model to understand mechanistically the role of neutrophils is periodontitis, an oral inflammatory disease that is particularly sensitive to neutrophil alterations in numbers or function. The recruitment and proper activation of neutrophils are largely dependent on leukocyte integrins and complement. This review discusses how these processes are affected by host genetic or microbial factors leading to the development of periodontitis. For instance, both hypo- and hyper-recruitment of neutrophils as a result of deficiencies in the expression of β2 integrins or their negative regulators, respectively, causes unwarranted IL-17-dependent inflammatory bone loss. Moreover, microbial hijacking of C5aR (CD88) signaling in neutrophils impairs their antimicrobial function while promoting destructive inflammatory responses. These studies not only support the concept that neutrophil homeostasis is key to periodontal health but also reveal promising, new therapeutic targets as discussed in the review.
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Affiliation(s)
- George Hajishengallis
- Departments of *Microbiology and Preventive and Restorative Sciences, Division of Pediatric Dentistry, Penn Dental Medicine, and Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; and Technische Universität Dresden, Faculty of Medicine, Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Dresden, Germany
| | - Triantafyllos Chavakis
- Departments of *Microbiology and Preventive and Restorative Sciences, Division of Pediatric Dentistry, Penn Dental Medicine, and Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; and Technische Universität Dresden, Faculty of Medicine, Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Dresden, Germany
| | - Evlambia Hajishengallis
- Departments of *Microbiology and Preventive and Restorative Sciences, Division of Pediatric Dentistry, Penn Dental Medicine, and Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; and Technische Universität Dresden, Faculty of Medicine, Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Dresden, Germany
| | - John D Lambris
- Departments of *Microbiology and Preventive and Restorative Sciences, Division of Pediatric Dentistry, Penn Dental Medicine, and Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; and Technische Universität Dresden, Faculty of Medicine, Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Dresden, Germany
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Hajishengallis G, Moutsopoulos NM. Etiology of leukocyte adhesion deficiency-associated periodontitis revisited: not a raging infection but a raging inflammatory response. Expert Rev Clin Immunol 2014; 10:973-5. [PMID: 24931458 DOI: 10.1586/1744666x.2014.929944] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In leukocyte adhesion deficiency type I, neutrophils fail to adhere to blood vessel walls and thus cannot transmigrate to peripheral tissues. Leukocyte adhesion deficiency type I patients invariably experience an aggressive form of generalized periodontitis, which has been historically attributed to defective neutrophil surveillance of the periodontal infection. This time-honored notion has now been challenged by a recent study, which showed that the underlying etiology involves a dysregulated host response that leads to overexpression of the proinflammatory and bone-resorptive cytokine IL-17.
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Affiliation(s)
- George Hajishengallis
- Department of Microbiology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA 19104, USA
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Sima C, Glogauer M. Neutrophil Dysfunction and Host Susceptibility to Periodontal Inflammation: Current State of Knowledge. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s40496-014-0015-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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