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Alqedari H, Altabtbaei K, Espinoza JL, Bin-Hasan S, Alghounaim M, Alawady A, Altabtabae A, AlJamaan S, Devarajan S, AlShammari T, Ben Eid M, Matsuoka M, Jang H, Dupont CL, Freire M. Host-microbiome associations in saliva predict COVID-19 severity. PNAS NEXUS 2024; 3:pgae126. [PMID: 38617584 PMCID: PMC11010653 DOI: 10.1093/pnasnexus/pgae126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 03/07/2024] [Indexed: 04/16/2024]
Abstract
Established evidence indicates that oral microbiota plays a crucial role in modulating host immune responses to viral infection. Following severe acute respiratory syndrome coronavirus 2, there are coordinated microbiome and inflammatory responses within the mucosal and systemic compartments that are unknown. The specific roles the oral microbiota and inflammatory cytokines play in the pathogenesis of coronavirus disease 2019 (COVID-19) are yet to be explored. Here, we evaluated the relationships between the salivary microbiome and host parameters in different groups of COVID-19 severity based on their oxygen requirement. Saliva and blood samples (n = 80) were collected from COVID-19 and from noninfected individuals. We characterized the oral microbiomes using 16S ribosomal RNA gene sequencing and evaluated saliva and serum cytokines and chemokines using multiplex analysis. Alpha diversity of the salivary microbial community was negatively associated with COVID-19 severity, while diversity increased with health. Integrated cytokine evaluations of saliva and serum showed that the oral host response was distinct from the systemic response. The hierarchical classification of COVID-19 status and respiratory severity using multiple modalities separately (i.e. microbiome, salivary cytokines, and systemic cytokines) and simultaneously (i.e. multimodal perturbation analyses) revealed that the microbiome perturbation analysis was the most informative for predicting COVID-19 status and severity, followed by the multimodal. Our findings suggest that oral microbiome and salivary cytokines may be predictive of COVID-19 status and severity, whereas atypical local mucosal immune suppression and systemic hyperinflammation provide new cues to understand the pathogenesis in immunologically compromised populations.
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Affiliation(s)
- Hend Alqedari
- Department of Public Health and Community Service, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA
- Dasman Diabetes Institute, 1180 Dasman, 9XQV+V9 Kuwait City, Kuwait
| | - Khaled Altabtbaei
- Faculty of Medicine and Dentistry, School of Dentistry, University of Alberta, Edmonton, AB T6G 2L7, Canada
| | - Josh L Espinoza
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Saadoun Bin-Hasan
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, 7XF4+WPJ Al Farwaniyah, Kuwait
| | - Mohammad Alghounaim
- Department of Pediatrics, Amiri Hospital, Ministry of Health, 9XQQ+42 Kuwait City, Kuwait
| | - Abdullah Alawady
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, 7XF4+WPJ Al Farwaniyah, Kuwait
| | - Abdullah Altabtabae
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, 7XF4+WPJ Al Farwaniyah, Kuwait
| | - Sarah AlJamaan
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, 7XF4+WPJ Al Farwaniyah, Kuwait
| | | | | | - Mohammed Ben Eid
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, 7XF4+WPJ Al Farwaniyah, Kuwait
| | - Michele Matsuoka
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Hyesun Jang
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Christopher L Dupont
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Marcelo Freire
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
- Division of Infectious Diseases and Global Public Health Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
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Ngo VL, Lieber CM, Kang HJ, Sakamoto K, Kuczma M, Plemper RK, Gewirtz AT. Intestinal microbiota programming of alveolar macrophages influences severity of respiratory viral infection. Cell Host Microbe 2024; 32:335-348.e8. [PMID: 38295788 PMCID: PMC10942762 DOI: 10.1016/j.chom.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/05/2023] [Accepted: 01/08/2024] [Indexed: 02/12/2024]
Abstract
Susceptibility to respiratory virus infections (RVIs) varies widely across individuals. Because the gut microbiome impacts immune function, we investigated the influence of intestinal microbiota composition on RVI and determined that segmented filamentous bacteria (SFB), naturally acquired or exogenously administered, protected mice against influenza virus (IAV) infection. Such protection, which also applied to respiratory syncytial virus and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was independent of interferon and adaptive immunity but required basally resident alveolar macrophages (AMs). In SFB-negative mice, AMs were quickly depleted as RVI progressed. In contrast, AMs from SFB-colonized mice were intrinsically altered to resist IAV-induced depletion and inflammatory signaling. Yet, AMs from SFB-colonized mice were not quiescent. Rather, they directly disabled IAV via enhanced complement production and phagocytosis. Accordingly, transfer of SFB-transformed AMs into SFB-free hosts recapitulated SFB-mediated protection against IAV. These findings uncover complex interactions that mechanistically link the intestinal microbiota with AM functionality and RVI severity.
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Affiliation(s)
- Vu L Ngo
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA 30303, USA
| | - Carolin M Lieber
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA 30303, USA
| | - Hae-Ji Kang
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA 30303, USA
| | - Kaori Sakamoto
- Department of Pathology, University of Georgia College of Veterinary Science, Athens, GA 30602, USA
| | - Michal Kuczma
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA 30303, USA
| | - Richard K Plemper
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA 30303, USA.
| | - Andrew T Gewirtz
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA 30303, USA.
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3
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Rizzello F, Viciani E, Gionchetti P, Filippone E, Imbesi V, Melotti L, Dussias NK, Salice M, Santacroce B, Padella A, Velichevskaya A, Marcante A, Castagnetti A. Signatures of disease outcome severity in the intestinal fungal and bacterial microbiome of COVID-19 patients. Front Cell Infect Microbiol 2024; 14:1352202. [PMID: 38510960 PMCID: PMC10952111 DOI: 10.3389/fcimb.2024.1352202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024] Open
Abstract
Background COVID-19, whose causative pathogen is the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), was declared a pandemic in March 2020. The gastrointestinal tract is one of the targets of this virus, and mounting evidence suggests that gastrointestinal symptoms may contribute to disease severity. The gut-lung axis is involved in the immune response to SARS-CoV-2; therefore, we investigated whether COVID-19 patients' bacterial and fungal gut microbiome composition was linked to disease clinical outcome. Methods In May 2020, we collected stool samples and patient records from 24 hospitalized patients with laboratory-confirmed SARS-CoV-2 infection. Fungal and bacterial gut microbiome was characterized by amplicon sequencing on the MiSeq, Illumina's integrated next generation sequencing instrument. A cohort of 201 age- and sex-matched healthy volunteers from the project PRJNA661289 was used as a control group for the bacterial gut microbiota analysis. Results We observed that female COVID-19 patients had a lower gut bacterial microbiota richness than male patients, which was consistent with a different latency in hospital admittance time between the two groups. Both sexes in the COVID-19 patient study group displayed multiple positive associations with opportunistic bacterial pathogens such as Enterococcus, Streptococcus, and Actinomyces. Of note, the Candida genus dominated the gut mycobiota of COVID-19 patients, and adult patients showed a higher intestinal fungal diversity than elderly patients. We found that Saccharomycetales unassigned fungal genera were positively associated with bacterial short-chain fatty acid (SCFA) producers and negatively associated with the proinflammatory genus Bilophila in COVID-19 patients, and we observed that none of the patients who harbored it were admitted to the high-intensity unit. Conclusions COVID-19 was associated with opportunistic bacterial pathogens, and Candida was the dominant fungal taxon in the intestine. Together, we found an association between commensal SCFA-producers and a fungal genus that was present in the intestines of patients who did not experience the most severe outcome of the disease. We believe that this taxon could have played a role in the disease outcome, and that further studies should be conducted to understand the role of fungi in gastrointestinal and health protection.
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Affiliation(s)
- Fernando Rizzello
- IBD Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
- Department of Medical and Surgical and Sciences, University of Bologna, Bologna, Italy
| | | | - Paolo Gionchetti
- IBD Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
- Department of Medical and Surgical and Sciences, University of Bologna, Bologna, Italy
| | - Eleonora Filippone
- IBD Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
- Department of Medical and Surgical and Sciences, University of Bologna, Bologna, Italy
| | - Veronica Imbesi
- IBD Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
| | - Laura Melotti
- IBD Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
- Department of Medical and Surgical and Sciences, University of Bologna, Bologna, Italy
| | - Nikolas Konstantine Dussias
- IBD Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
- Department of Medical and Surgical and Sciences, University of Bologna, Bologna, Italy
| | - Marco Salice
- IBD Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
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Ngo VL, Lieber CM, Kang HJ, Sakamoto K, Kuczma M, Plemper RK, Gewirtz AT. Intestinal microbiota programming of alveolar macrophages influences severity of respiratory viral infection. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.09.21.558814. [PMID: 37790571 PMCID: PMC10542499 DOI: 10.1101/2023.09.21.558814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Susceptibility to respiratory virus infections (RVIs) varies widely across individuals. Because the gut microbiome impacts immune function, we investigated the influence of intestinal microbiota composition on RVI and determined that segmented filamentous bacteria (SFB), naturally acquired or exogenously administered, protected mice against influenza virus (IAV) infection. Such protection, which also applied to respiratory syncytial virus and SARS-CoV-2, was independent of interferon and adaptive immunity but required basally resident alveolar macrophages (AM). In SFB-negative mice, AM were quickly depleted as RVI progressed. In contrast, AM from SFB-colonized mice were intrinsically altered to resist IAV-induced depletion and inflammatory signaling. Yet, AM from SFB-colonized mice were not quiescent. Rather, they directly disabled IAV via enhanced complement production and phagocytosis. Accordingly, transfer of SFB-transformed AM into SFB-free hosts recapitulated SFB-mediated protection against IAV. These findings uncover complex interactions that mechanistically link the intestinal microbiota with AM functionality and RVI severity. One sentence summary Intestinal segmented filamentous bacteria reprogram alveolar macrophages promoting nonphlogistic defense against respiratory viruses.
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Alqedari H, Altabtbaei K, Espinoza JL, Bin-Hasan S, Alghounaim M, Alawady A, Altabtabae A, AlJamaan S, Devarajan S, AlShammari T, Eid MB, Matsuoka M, Jang H, Dupont CL, Freire M. Host-Microbiome Associations in Saliva Predict COVID-19 Severity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.02.539155. [PMID: 37205528 PMCID: PMC10187185 DOI: 10.1101/2023.05.02.539155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Established evidence indicates that oral microbiota plays a crucial role in modulating host immune responses to viral infection. Following Severe Acute Respiratory Syndrome Coronavirus 2 - SARS-CoV-2 - there are coordinated microbiome and inflammatory responses within the mucosal and systemic compartments that are unknown. The specific roles that the oral microbiota and inflammatory cytokines play in the pathogenesis of COVID-19 are yet to be explored. We evaluated the relationships between the salivary microbiome and host parameters in different groups of COVID-19 severity based on their Oxygen requirement. Saliva and blood samples (n = 80) were collected from COVID-19 and from non-infected individuals. We characterized the oral microbiomes using 16S ribosomal RNA gene sequencing and evaluated saliva and serum cytokines using Luminex multiplex analysis. Alpha diversity of the salivary microbial community was negatively associated with COVID-19 severity. Integrated cytokine evaluations of saliva and serum showed that the oral host response was distinct from the systemic response. The hierarchical classification of COVID-19 status and respiratory severity using multiple modalities separately (i.e., microbiome, salivary cytokines, and systemic cytokines) and simultaneously (i.e., multi-modal perturbation analyses) revealed that the microbiome perturbation analysis was the most informative for predicting COVID-19 status and severity, followed by the multi-modal. Our findings suggest that oral microbiome and salivary cytokines may be predictive of COVID-19 status and severity, whereas atypical local mucosal immune suppression and systemic hyperinflammation provide new cues to understand the pathogenesis in immunologically naïve populations.
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Affiliation(s)
- Hend Alqedari
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, 02115, USA; Dasman Diabetes Institute, Kuwait
- Dasman Diabetes Institute, 1180, Dasman, Kuwait
| | - Khaled Altabtbaei
- School of Dentistry, Faculty of Medicine and Dentistry. University of Alberta. Edmonton AB, T6G 2L7, Canada
| | - Josh L. Espinoza
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Saadoun Bin-Hasan
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, Kuwait
| | | | - Abdullah Alawady
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, Kuwait
| | | | - Sarah AlJamaan
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, Kuwait
| | | | | | - Mohammed Ben Eid
- Department of Pediatrics, Farwaniyah Hospital, Ministry of Health, Kuwait
| | - Michele Matsuoka
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Hyesun Jang
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Christopher L. Dupont
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
| | - Marcelo Freire
- Department of Genomic Medicine and Infectious Diseases, J. Craig Venter Institute, La Jolla, CA 92037, USA
- Division of Infectious Diseases and Global Public Health Department of Medicine, University of California San Diego, La Jolla, CA, USA
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Longitudinal alterations of the gut mycobiota and microbiota on COVID-19 severity. BMC Infect Dis 2022; 22:572. [PMID: 35751044 PMCID: PMC9233337 DOI: 10.1186/s12879-022-07358-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 04/01/2022] [Indexed: 12/15/2022] Open
Abstract
Background The impact of SARS-CoV-2 infection on the gut fungal (mycobiota) and bacterial (microbiota) communities has been elucidated individually. This study analyzed both gut mycobiota and microbiota and their correlation in the COVID-19 patients with severe and mild conditions and follow-up to monitor their alterations after recovery. Methods We analyzed the gut mycobiota and microbiota by bacterial 16S and fungal ITS1 metagenomic sequencing of 40 severe patients, 38 mild patients, and 30 healthy individuals and reanalyzed those of 10 patients with severe COVID-19 approximately 6 months after discharge. Results The mycobiota of the severe and mild groups showed lower diversity than the healthy group, and in some, characteristic patterns dominated by a single fungal species, Candida albicans, were detected. Lower microbial diversity in the severe group was observed, but no differences in its diversity or community structure were detected between the mild and healthy groups. The microbiota of the severe group was characterized by an increase in Enterococcus and Lactobacillus, and a decrease in Faecalibacterium and Bacteroides. The abundance of Candida was positively correlated with that of Enterococcus in patients with COVID-19. After the recovery of severe patients, alteration of the microbiota remained, but the mycobiota recovered its diversity comparable to that of mild and healthy groups. Conclusion In mild cases, the microbiota is stable during SARS-CoV-2 infection, but in severe cases, alterations persist for 6 months after recovery. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07358-7.
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The Concept of Intrauterine Programming and the Development of the Neonatal Microbiome in the Prevention of SARS-CoV-2 Infection. Nutrients 2022; 14:nu14091702. [PMID: 35565670 PMCID: PMC9104449 DOI: 10.3390/nu14091702] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/07/2022] [Accepted: 04/14/2022] [Indexed: 02/06/2023] Open
Abstract
The process of intrauterine programming is related to the quality of the microbiome formed in the fetus and the newborn. The implementation of probiotics, prebiotics, and psychobiotics shows immunomodulatory potential towards the organism, especially the microbiome of the pregnant woman and her child. Nutrigenomics, based on the observation of pregnant women and the developing fetus, makes it possible to estimate the biological effects of active dietary components on gene expression or silencing. Nutritional intervention for pregnant women should consider the nutritional status of the patient, biological markers, and the potential impact of dietary intervention on fetal physiology. The use of a holistic model of nutrition allows for appropriately targeted and effective dietary prophylaxis that can impact the physical and mental health of both the mother and the newborn. This model targets the regulation of the immune response of the pregnant woman and the newborn, considering the clinical state of the microbiota and the pathomechanism of the nervous system. Current scientific reports indicate the protective properties of immunobiotics (probiotics) about the reduction of the frequency of infections and the severity of the course of COVID-19 disease. The aim of this study was to test the hypothesis that intrauterine programming influences the development of the microbiome for the prevention of SARS-CoV-2 infection based on a review of research studies.
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Pihurov M, Păcularu-Burada B, Cotârleţ M, Vasile MA, Bahrim GE. Novel Insights for Metabiotics Production by Using Artisanal Probiotic Cultures. Microorganisms 2021; 9:2184. [PMID: 34835310 PMCID: PMC8624174 DOI: 10.3390/microorganisms9112184] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/16/2021] [Accepted: 10/16/2021] [Indexed: 01/15/2023] Open
Abstract
Wild probiotic consortia of microorganisms (bacteria and yeasts) associated in the artisanal cultures' microbiota (milk kefir grains, water kefir grains and kombucha) are considered valuable promoters for metabiotics (prebiotics, probiotics, postbiotics and paraprobiotics) production. The beneficial effects of the fermented products obtained with the artisanal cultures on human well-being are described by centuries and the interest for them is continuously increasing. The wild origin and microbial diversity of these above-mentioned consortia give them extraordinary protection capacity against microbiological contaminants in unusual physico-chemical conditions and unique fermentative behaviour. This review summarizes the state of the art for the wild artisanal cultures (milk and water kefir grains, respectively, kombucha-SCOBY), their symbiotic functionality, and the ability to ferment unconventional substrates in order to obtain valuable bioactive compounds with in vitro and in vivo beneficial functional properties. Due to the necessity of the bioactives production and their use as metabiotics in the modern consumer's life, artisanal cultures are the perfect sources able to biosynthesize complex functional metabolites (bioactive peptides, antimicrobials, polysaccharides, enzymes, vitamins, cell wall components). Depending on the purposes of the biotechnological fermentation processes, artisanal cultures can be used as starters on different substrates. Current studies show that the microbial synergy between bacteria-yeast and/or bacteria-offers new perspectives to develop functional products (food, feeds, and ingredients) with a great impact on life quality.
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Affiliation(s)
| | | | | | | | - Gabriela Elena Bahrim
- Faculty of Food Science and Engineering, Dunarea de Jos University of Galati, Domneasca Street No. 111, 800201 Galati, Romania; (M.P.); (B.P.-B.); (M.C.); (M.A.V.)
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Plemper RK. Editorial overview: Special issue on antiviral strategies in Current Opinion in Virology. Curr Opin Virol 2021; 50:95-96. [PMID: 34419858 PMCID: PMC8376291 DOI: 10.1016/j.coviro.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Richard K Plemper
- Center for Translational Antiviral Research, Georgia State University, Atlanta, GA, USA.
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10
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Srinivasan M. Taste Dysfunction and Long COVID-19. Front Cell Infect Microbiol 2021; 11:716563. [PMID: 34336725 PMCID: PMC8317431 DOI: 10.3389/fcimb.2021.716563] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/28/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Mythily Srinivasan
- Department of Oral Pathology, Medicine and Radiology, Indiana University School of Dentistry, Indiana University Purdue University at Indianapolis, Indianapolis, IN, United States
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