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Kabacaoğlu B, Öztürk Özener H. Evaluation of inflammasomes as biomarker following non-surgical periodontal treatment. Arch Oral Biol 2024; 164:105987. [PMID: 38723420 DOI: 10.1016/j.archoralbio.2024.105987] [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: 01/04/2024] [Revised: 04/17/2024] [Accepted: 04/28/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVE The purpose of this study was to investigate interleukin (IL)-1β, IL-18, nod-like receptor pyrin domain-containing protein 3 (NLRP3), apoptosis-related speck-like protein containing a caspase activation and recruitment domain (ASC), and caspase-1 levels in saliva and serum in different periodontal diseases and to evaluate the changes after non-surgical periodontal treatment (NSPT). DESIGN A total of 45 participants, 15 healthy, 15 gingivitis, and 15 stage III grade C (SIIIGC) periodontitis patients, were included in the study. Periodontal parameters were assessed, and salivary and serum samples were collected at baseline in all groups and one and three months after NSPT in gingivitis and periodontitis groups. An enzyme-linked immunosorbent assay was used to analyse IL-1β, IL-18, NLRP3, ASC, and caspase-1 levels. RESULTS After NSPT, improvement was observed in all clinical parameters, along with periodontal inflamed surface area (PISA) in gingivitis and periodontitis groups. PISA scores were positively correlated with IL-1β, NLRP3, and caspase-1 at baseline (p < 0.05). Salivary and serum IL-1β, NLRP3 levels were higher in periodontitis compared to healthy controls at baseline and reduced after treatment (p < 0.05). Receiver operating characteristic analysis revealed that salivary IL-1β, NLRP3, and caspase-1 had the ability to discriminate SIIIGC periodontitis patients from healthy subjects (p < 0.05). CONCLUSION In conclusion, salivary IL-1β, NLRP3, and caspase-1 are at aberrantly high levels in SIIIGC periodontitis and are remarkably decreased following NSPT; these inflammasome biomarkers may show potential utility in diagnosing and monitoring periodontitis.
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Affiliation(s)
- Bilge Kabacaoğlu
- Department of Periodontology, Institute of Health Sciences, Marmara University, Istanbul, Turkiye
| | - Hafize Öztürk Özener
- Department of Periodontology, Faculty of Dentistry, Marmara University, Istanbul, Turkiye.
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Li Y, Li X, Guo D, Meng L, Feng X, Zhang Y, Pan S. Immune dysregulation and macrophage polarization in peri-implantitis. Front Bioeng Biotechnol 2024; 12:1291880. [PMID: 38347915 PMCID: PMC10859439 DOI: 10.3389/fbioe.2024.1291880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
The term "peri-implantitis" (peri-implantitis) refers to an inflammatory lesion of the mucosa surrounding an endosseous implant and a progressive loss of the peri-implant bone that supports the implant. Recently, it has been suggested that the increased sensitivity of implants to infection and the quick elimination of supporting tissue after infection may be caused by a dysregulated peri-implant mucosal immune response. Macrophages are polarized in response to environmental signals and play multiple roles in peri-implantitis. In peri-implantitis lesion samples, recent investigations have discovered a considerable increase in M1 type macrophages, with M1 type macrophages contributing to the pro-inflammatory response brought on by bacteria, whereas M2 type macrophages contribute to inflammation remission and tissue repair. In an effort to better understand the pathogenesis of peri-implantitis and suggest potential immunomodulatory treatments for peri-implantitis in the direction of macrophage polarization patterns, this review summarizes the research findings related to macrophage polarization in peri-implantitis and compares them with periodontitis.
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Affiliation(s)
- Yue Li
- Department of Prosthodontics, Peking University School and Hospital of Stomatology and National Center for Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices and Beijing Key Laboratory of Digital Stomatology and Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health and NMPA Key Laboratory for Dental Materials, Beijing, China
| | - Xue Li
- Stem Cell and Regenerative Medicine Lab, Beijing Institute of Radiation Medicine, Beijing, China
| | - Danni Guo
- Department of Prosthodontics, Peking University School and Hospital of Stomatology and National Center for Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices and Beijing Key Laboratory of Digital Stomatology and Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health and NMPA Key Laboratory for Dental Materials, Beijing, China
| | - Lingwei Meng
- Department of Prosthodontics, Peking University School and Hospital of Stomatology and National Center for Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices and Beijing Key Laboratory of Digital Stomatology and Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health and NMPA Key Laboratory for Dental Materials, Beijing, China
| | - Xianghui Feng
- Department of Periodontology, Peking University School and Hospital of Stomatology and National Center for Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices and Beijing Key Laboratory of Digital Stomatology and Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health and NMPA Key Laboratory for Dental Materials, Beijing, China
| | - Yi Zhang
- Stem Cell and Regenerative Medicine Lab, Beijing Institute of Radiation Medicine, Beijing, China
| | - Shaoxia Pan
- Department of Prosthodontics, Peking University School and Hospital of Stomatology and National Center for Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Research Center of Oral Biomaterials and Digital Medical Devices and Beijing Key Laboratory of Digital Stomatology and Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health and NMPA Key Laboratory for Dental Materials, Beijing, China
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3
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Koca-Ünsal RB, Şehirli AÖ, Sayıner S, Aksoy U. Relationship of NLRP3 inflammasome with periodontal, endodontic and related systemic diseases. Mol Biol Rep 2022; 49:11123-11132. [DOI: 10.1007/s11033-022-07894-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022]
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Metcalfe S, Anselmi N, Escobar A, Visser MB, Kay JG. Innate Phagocyte Polarization in the Oral Cavity. Front Immunol 2022; 12:768479. [PMID: 35069541 PMCID: PMC8770816 DOI: 10.3389/fimmu.2021.768479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/14/2021] [Indexed: 12/24/2022] Open
Abstract
The oral cavity is a complex environment constantly exposed to antigens from food and the oral microbiota. Innate immune cells play an essential role in maintaining health and homeostasis in the oral environment. However, these cells also play a significant role in disease progression. This review will focus on two innate phagocytes in the oral cavity: macrophages and neutrophils, and examine their roles during homeostasis and disease development, with a focus on periodontal disease and cancer. Macrophages have a well-known ability to polarize and be activated towards a variety of phenotypes. Several studies have found that macrophages’ polarization changes can play an essential role in maintaining health in the oral cavity and contribute to disease. Recent data also finds that neutrophils display phenotypic heterogeneity in the oral cavity. In both cases, we focus on what is known about how these cellular changes alter these immune cells’ interactions with the oral microbiota, including how such changes can lead to worsening, rather than improving, disease states.
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Affiliation(s)
- Sarah Metcalfe
- Department of Oral Biology, School of Dental Medicine, University at Buffalo, Buffalo, NY, United States
| | - Natalie Anselmi
- Department of Oral Biology, School of Dental Medicine, University at Buffalo, Buffalo, NY, United States
| | - Alejandro Escobar
- Instituto de Investigación en Ciencias Odontológicas, Facultad de Odontología, Universidad de Chile, Santiago, Chile
| | - Michelle B Visser
- Department of Oral Biology, School of Dental Medicine, University at Buffalo, Buffalo, NY, United States
| | - Jason G Kay
- Department of Oral Biology, School of Dental Medicine, University at Buffalo, Buffalo, NY, United States
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5
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Zhu X, Huang H, Zhao L. PAMPs and DAMPs as the Bridge Between Periodontitis and Atherosclerosis: The Potential Therapeutic Targets. Front Cell Dev Biol 2022; 10:856118. [PMID: 35281098 PMCID: PMC8915442 DOI: 10.3389/fcell.2022.856118] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 02/11/2022] [Indexed: 12/31/2022] Open
Abstract
Atherosclerosis is a chronic artery disease characterized by plaque formation and vascular inflammation, eventually leading to myocardial infarction and stroke. Innate immunity plays an irreplaceable role in the vascular inflammatory response triggered by chronic infection. Periodontitis is a common chronic disorder that involves oral microbe-related inflammatory bone loss and local destruction of the periodontal ligament and is a risk factor for atherosclerosis. Periodontal pathogens contain numerous pathogen-associated molecular patterns (PAMPs) such as lipopolysaccharide, CpG DNA, and Peptidoglycan, that initiate the inflammatory response of the innate immunity depending on the recognition of pattern-recognition receptors (PRRs) of host cells. The immune-inflammatory response and destruction of the periodontal tissue will produce a large number of damage-associated molecular patterns (DAMPs) such as neutrophil extracellular traps (NETs), high mobility group box 1 (HMGB1), alarmins (S100 protein), and which can further affect the progression of atherosclerosis. Molecular patterns have recently become the therapeutic targets for inflammatory disease, including blocking the interaction between molecular patterns and PRRs and controlling the related signal transduction pathway. This review summarized the research progress of some representative PAMPs and DAMPs as the molecular pathological mechanism bridging periodontitis and atherosclerosis. We also discussed possible ways to prevent serious cardiovascular events in patients with periodontitis and atherosclerosis by targeting molecular patterns.
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Affiliation(s)
- Xuanzhi Zhu
- State Key Laboratory of Oral Diseases, Department of Periodontics, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hanyao Huang
- State Key Laboratory of Oral Diseases, Department of Oral and Maxillofacial Surgery, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- *Correspondence: Hanyao Huang, ; Lei Zhao,
| | - Lei Zhao
- State Key Laboratory of Oral Diseases, Department of Periodontics, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- *Correspondence: Hanyao Huang, ; Lei Zhao,
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6
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Irwandi RA, Kuswandani SO, Harden S, Marletta D, D'Aiuto F. Circulating inflammatory cell profiling and periodontitis: A systematic review and meta-analysis. J Leukoc Biol 2022; 111:1069-1096. [PMID: 35199874 DOI: 10.1002/jlb.5ru1021-524r] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 12/13/2022] Open
Abstract
Inflammation is a key driver of common noncommunicable diseases. Among common triggers of inflammation, chronic gingival inflammation (periodontitis) triggers a consistent humoral host inflammatory response, but little is known on its impact on circulating inflammatory cell profiles. We aimed to systematically appraise all the evidence linking periodontitis and its treatment to circulating inflammatory cell profiles. From 6 databases, 157 studies were eligible for qualitative synthesis and 29 studies for meta-analysis. Our meta-analysis showed that participants with periodontitis exhibited a significant mean increase in circulating CD4+ , CD4+ CD45RO+ , IFNγ-expressing CD4+ and CD8+ T cells, CD19+ CD27+ and CD5+ B cells, CD14+ CD16+ monocytes, and CD16+ neutrophils but decrease in CD8+ T and CD14++ CD16- monocytes. Our qualitative synthesis revealed that peripheral blood neutrophils of patients with periodontitis consistently showed elevated production of reactive oxygen species (ROS) when compared with those of healthy controls. Some evidence suggested that the treatment of periodontitis reversed the exaggerated ROS production, but limited and inconclusive data were found on several circulating inflammatory cell profiling. We conclude that periodontitis and its treatment are associated with minor but consistent alterations in circulating inflammatory cell profiles. These changes could represent key mechanisms explaining the association of periodontitis with other comorbidities such as cardiovascular disease, diabetes, and rheumatoid arthritis.
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Affiliation(s)
- Rizky A Irwandi
- Periodontology Unit, Eastman Dental Institute, University College London, London, United Kingdom
| | - Sandra O Kuswandani
- Periodontology Unit, Eastman Dental Institute, University College London, London, United Kingdom.,Department of Periodontology, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia
| | - Simon Harden
- Department of Statistical Science, University College London, London, United Kingdom
| | - Debora Marletta
- Cruciform Hub, University College London, London, United Kingdom
| | - Francesco D'Aiuto
- Periodontology Unit, Eastman Dental Institute, University College London, London, United Kingdom
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Isola G, Polizzi A, Santonocito S, Alibrandi A, Williams RC. Periodontitis activates the NLRP3 inflammasome in serum and saliva. J Periodontol 2022; 93:135-145. [PMID: 34008185 DOI: 10.1002/jper.21-0049] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Nod-like receptor family pyrin domain-containing protein-3 (NLRP3) complex inflammasome has potentially been shown to play an important role in the development of periodontitis and diabetes. The objective of this study was to analyze the association between serum and salivary NLRP3 concentrations in patients with periodontitis and type-II diabetes mellitus (DM) and to evaluate whether this association was influenced by potential confounders. METHODS For the present study, a cohort of healthy controls (n = 32), and patients with periodontitis (n = 34), type-II DM (n = 33), and a combination of periodontitis + type-II DM (n = 34) were enrolled. Patients were characterized on the basis of their periodontal status and analyzed for demographic characteristics, serum mediators, and for serum and salivary concentrations of NLRP3. A uni- and multivariate model was established to analyze whether periodontitis, type-II DM, and CRP influenced serum and salivary NLRP3 concentrations. RESULTS In comparison to type-II DM patients and healthy controls, patients with periodontitis (serum, P = 0.003; saliva P = 0.012) and periodontitis + type-II DM (serum, P = 0.028; saliva, P = 0.003) had elevated serum and salivary NLRP3 concentrations. The multivariate regression model showed that periodontitis (P = 0.029) and HDL-cholesterol (P = 0.012) were significant predictors of serum NLRP3 concentrations whereas periodontitis (P = 0.036) and CRP (P = 0.012) were significant predictors of salivary NLRP3. CONCLUSION The results of the present study showed that periodontitis and periodontitis + type-II DM patients had higher serum and salivary NLRP3 concentrations in comparison to healthy controls and patients with type-II DM. Periodontitis was demonstrated to be a significant predictor of both serum and salivary NLRP3 concentrations.
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Affiliation(s)
- Gaetano Isola
- Department of General Surgery and Surgical-Medical Specialties, Unit of Oral Surgery and Periodontology, School of Dentistry, University of Catania, Catania, Italy
| | - Alessandro Polizzi
- Department of General Surgery and Surgical-Medical Specialties, Unit of Oral Surgery and Periodontology, School of Dentistry, University of Catania, Catania, Italy
| | - Simona Santonocito
- Department of General Surgery and Surgical-Medical Specialties, Unit of Oral Surgery and Periodontology, School of Dentistry, University of Catania, Catania, Italy
| | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy
| | - Ray C Williams
- Department of Periodontology, UNC-Chapel Hill School of Dentistry, Chapel Hill, North Carolina, USA
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Li Y, Ling J, Jiang Q. Inflammasomes in Alveolar Bone Loss. Front Immunol 2021; 12:691013. [PMID: 34177950 PMCID: PMC8221428 DOI: 10.3389/fimmu.2021.691013] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/18/2021] [Indexed: 12/18/2022] Open
Abstract
Bone remodeling is tightly controlled by osteoclast-mediated bone resorption and osteoblast-mediated bone formation. Fine tuning of the osteoclast-osteoblast balance results in strict synchronization of bone resorption and formation, which maintains structural integrity and bone tissue homeostasis; in contrast, dysregulated bone remodeling may cause pathological osteolysis, in which inflammation plays a vital role in promoting bone destruction. The alveolar bone presents high turnover rate, complex associations with the tooth and periodontium, and susceptibility to oral pathogenic insults and mechanical stress, which enhance its complexity in host defense and bone remodeling. Alveolar bone loss is also involved in systemic bone destruction and is affected by medication or systemic pathological factors. Therefore, it is essential to investigate the osteoimmunological mechanisms involved in the dysregulation of alveolar bone remodeling. The inflammasome is a supramolecular protein complex assembled in response to pattern recognition receptors and damage-associated molecular patterns, leading to the maturation and secretion of pro-inflammatory cytokines and activation of inflammatory responses. Pyroptosis downstream of inflammasome activation also facilitates the clearance of intracellular pathogens and irritants. However, inadequate or excessive activity of the inflammasome may allow for persistent infection and infection spreading or uncontrolled destruction of the alveolar bone, as commonly observed in periodontitis, periapical periodontitis, peri-implantitis, orthodontic tooth movement, medication-related osteonecrosis of the jaw, nonsterile or sterile osteomyelitis of the jaw, and osteoporosis. In this review, we present a framework for understanding the role and mechanism of canonical and noncanonical inflammasomes in the pathogenesis and development of etiologically diverse diseases associated with alveolar bone loss. Inappropriate inflammasome activation may drive alveolar osteolysis by regulating cellular players, including osteoclasts, osteoblasts, osteocytes, periodontal ligament cells, macrophages, monocytes, neutrophils, and adaptive immune cells, such as T helper 17 cells, causing increased osteoclast activity, decreased osteoblast activity, and enhanced periodontium inflammation by creating a pro-inflammatory milieu in a context- and cell type-dependent manner. We also discuss promising therapeutic strategies targeting inappropriate inflammasome activity in the treatment of alveolar bone loss. Novel strategies for inhibiting inflammasome signaling may facilitate the development of versatile drugs that carefully balance the beneficial contributions of inflammasomes to host defense.
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Affiliation(s)
- Yang Li
- Department of Endodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, China
| | - Junqi Ling
- Department of Endodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, China.,Guangdong Province Key Laboratory of Stomatology, Department of Operative Dentistry and Endodontics, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Qianzhou Jiang
- Department of Endodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, China
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Kawahara Y, Kaneko T, Yoshinaga Y, Arita Y, Nakamura K, Koga C, Yoshimura A, Sakagami R. Effects of Sulfonylureas on Periodontopathic Bacteria-Induced Inflammation. J Dent Res 2020; 99:830-838. [PMID: 32202959 DOI: 10.1177/0022034520913250] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Interleukin-1β (IL-1β) is an inflammatory cytokine produced by monocytes/macrophages and is closely associated with periodontal diseases. The NLRP3 inflammasome is involved in IL-1β activation through pro-IL-1β processing and pyroptotic cell death in bacterial infection. Recently, glyburide, a hypoglycemic sulfonylurea, has been reported to reduce IL-1β activation by suppressing activation of the NLRP3 inflammasome. Therefore, we evaluated the possibility of targeting the NLRP3 inflammasome pathway by glyburide to suppress periodontal pathogen-induced inflammation. THP-1 cells (a human monocyte cell line) were differentiated to macrophage-like cells by treatment with phorbol 12-myristate 13-acetate and stimulated by periodontopathic bacteria, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, or Fusobacterium nucleatum, in the presence of glyburide. IL-1β and caspase-1 expression in the cells and culture supernatants were analyzed by Western blotting and enzyme-linked immunosorbent assay, and cell death was analyzed by lactate dehydrogenase assay. Stimulation of THP-1 macrophage-like cells with every periodontopathic bacteria induced IL-1β secretion without cell death, which was suppressed by the NLRP3 inhibitor, MCC950, and caspase-1 inhibitor, z-YVAD-FMK. Glyburide treatment suppressed IL-1β expression in culture supernatants and enhanced intracellular IL-1β expression, suggesting that glyburide may have inhibited IL-1β secretion. Subsequently, a periodontitis rat model was generated by injecting periodontal bacteria into the gingiva, which was analyzed histologically. Oral administration of glyburide significantly suppressed the infiltration of inflammatory cells and the number of osteoclasts in the alveolar bone compared with the control. In addition to glyburide, glimepiride was shown to suppress the release of IL-1β from THP-1 macrophage-like cells, whereas other sulfonylureas (tolbutamide and gliclazide) or other hypoglycemic drugs belonging to the biguanide family, such as metformin, failed to suppress IL-1β release. Our results suggest that pharmacological targeting of the NLRP3 pathway may be a strategy for suppressing periodontal diseases.
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Affiliation(s)
- Y Kawahara
- Section of Periodontology, Department of Odontology, Fukuoka Dental College, Fukuoka, Japan
| | - T Kaneko
- Center for Oral Diseases, Fukuoka Dental College, Fukuoka, Japan
| | - Y Yoshinaga
- Section of Periodontology, Department of Odontology, Fukuoka Dental College, Fukuoka, Japan.,Oral Medicine Research Center, Fukuoka Dental College, Fukuoka, Japan
| | - Y Arita
- Section of Periodontology, Department of Odontology, Fukuoka Dental College, Fukuoka, Japan
| | - K Nakamura
- Center for Oral Diseases, Fukuoka Dental College, Fukuoka, Japan
| | - C Koga
- Center for Oral Diseases, Fukuoka Dental College, Fukuoka, Japan
| | - A Yoshimura
- Department of Periodontology and Endodontology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - R Sakagami
- Section of Periodontology, Department of Odontology, Fukuoka Dental College, Fukuoka, Japan
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