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Santamaria P, Jin Y, Ghuman M, Shoaie S, Spratt D, Troiano G, Nibali L. Microbiological and molecular profile of furcation defects in a population with untreated periodontitis. J Clin Periodontol 2024; 51:1421-1432. [PMID: 39109387 DOI: 10.1111/jcpe.14034] [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: 03/16/2024] [Revised: 05/03/2024] [Accepted: 06/10/2024] [Indexed: 10/19/2024]
Abstract
AIM To describe the microbiological composition of subgingival dental plaque and molecular profile of gingival crevicular fluid (GCF) of periodontal furcation-involved defects. MATERIALS AND METHODS Fifty-seven participants with periodontitis contributed with a degree II-III furcation involvement (FI), a non-furcation (NF) periodontal defect and a periodontally healthy site (HS). Subgingival plaque was analysed by sequencing the V3-V4 region of the 16S rRNA gene, and a multiplex bead immunoassay was carried out to estimate the GCF levels of 18 GCF biomarkers. Aiming to explore inherent patterns and the intrinsic structure of data, an AI-clustering method was also applied. RESULTS In total, 171 subgingival plaque and 84 GCF samples were analysed. Four microbiome clusters were identified and associated with FI, NF and HS. A reduced aerobic microbiota (p = .01) was detected in FI compared with NF; IL-6, MMP-3, MMP-8, BMP-2, SOST, EGF and TIMP-1 levels were increased in the GCF of FI compared with NF. CONCLUSIONS This is the first study to profile periodontal furcation defects from a microbiological and inflammatory standpoint using conventional and AI-based analyses. A reduced aerobic microbial biofilm and an increase of several inflammatory, connective tissue degradation and repair markers were detected compared with other periodontal defects.
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Affiliation(s)
- Pasquale Santamaria
- Periodontology Unit, Centre for Host Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
| | - Yi Jin
- Periodontology Unit, Centre for Host Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
| | - Mandeep Ghuman
- Periodontology Unit, Centre for Host Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
| | - Saeed Shoaie
- Periodontology Unit, Centre for Host Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
| | - David Spratt
- Microbial Diseases, Eastman Dental Institute, University College London, London, UK
| | - Giuseppe Troiano
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Luigi Nibali
- Periodontology Unit, Centre for Host Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
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Yang Z, He F, Huang H, Xu J, Ruan Y, Cui K, Zhou H, Chen Y, Liu D, Xiao Z, Chen F, Liao Y, Bin J, Chen Y. Association of Oral Microbiome Diversity and All-Cause Mortality in the General US Population and in Individuals With Chronic Diseases: A Prospective Cohort Study. J Clin Periodontol 2024; 51:1490-1501. [PMID: 39152675 DOI: 10.1111/jcpe.14056] [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: 12/26/2023] [Revised: 07/20/2024] [Accepted: 07/23/2024] [Indexed: 08/19/2024]
Abstract
AIM To investigate whether oral microbiome diversity is associated with all-cause mortality in the general US population and in individuals with chronic diseases. MATERIALS AND METHODS We included 8224 individuals with oral microbiome diversity data from the National Health and Nutrition Examination Survey (2009-2012), representing 164,000,205 US adults, using a survey-weighted analysis method. Cox regression analyses were performed to identify the association between oral microbiome diversity and all-cause mortality. RESULTS During a survey-weighted mean follow-up period of 8.86 years, 429 all-cause deaths (survey-weighted number: 7,124,920) occurred in 8224 participants. Cox regression analysis revealed that higher oral microbiome diversity was significantly associated with a lower all-cause mortality risk. Significant differences in all-cause mortality risk were observed among the different clusters based on oral microbiome β-diversity (log-rank p < 0.001). Subgroup analyses revealed that the oral microbiome diversity was independently associated with all-cause mortality in individuals with diabetes mellitus and hypertension. A multivariate logistic regression model showed that current smoking and antibiotic use were significantly associated with lower oral microbiome α diversity. CONCLUSIONS Higher oral microbiome diversity was significantly associated with a lower all-cause mortality risk in the general US population and in individuals with diabetes mellitus and hypertension.
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Affiliation(s)
- Zhiwen Yang
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fengling He
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Haoxiang Huang
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junyang Xu
- Department of Stomatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yifei Ruan
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kai Cui
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - HuiLei Zhou
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yijin Chen
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Dan Liu
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiwen Xiao
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Feng Chen
- Department of Cardiology, Ganzhou People's Hospital, Guangzhou, China
| | - Yulin Liao
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangzhou, China
| | - Jianping Bin
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangzhou, China
| | - Yanmei Chen
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangzhou, China
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Kendlbacher FL, Bloch S, Hager-Mair FF, Schäffer C, Andrukhov O. Red-complex bacteria exhibit distinctly different interactions with human periodontal ligament stromal cells compared to Fusobacterium nucleatum. Arch Oral Biol 2024; 164:106004. [PMID: 38776586 DOI: 10.1016/j.archoralbio.2024.106004] [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: 02/23/2024] [Revised: 04/17/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE The red-complex bacteria Porphyromonas gingivalis and Tannerella forsythia together with Fusobacterium nucleatum are essential players in periodontitis. This study investigated the bacterial interplay with human periodontal ligament mesenchymal stromal cells (hPDL-MSCs) which act in the acute phase of periodontal infection. DESIGN The capability of the bacteria to induce an inflammatory response as well as their viability, cellular adhesion and invasion were analyzed upon mono- and co-infections of hPDL-MSCs to delineate potential synergistic or antagonistic effects. The expression level and concentration of interleukin (IL)-6, IL-8 and monocyte chemoattractant protein (MCP)-1 were measured using qRT-PCR and ELISA. Viability, invasion, and adhesion were determined quantitatively using agar plate culture and qualitatively by confocal microscopy. RESULTS Viability of P. gingivalis and T. forsythia but not F. nucleatum was preserved in the presence of hPDL-MSCs, even in an oxygenated environment. F. nucleatum significantly increased the expression and concentration of IL-6, IL-8 and MCP-1 in hPDL-MSCs, while T. forsythia and P. gingivalis caused only a minimal inflammatory response. Co-infections in different combinations had no effect on the inflammatory response. Moreover, P. gingivalis mitigated the increase in cytokine levels elicited by F. nucleatum. Both red-complex bacteria adhered to and invaded hPDL-MSCs in greater numbers than F. nucleatum, with only a minor effect of co-infections. CONCLUSIONS Oral bacteria of different pathogenicity status interact differently with hPDL-MSCs. The data support P. gingivalis' capability to manipulate the inflammatory host response. Further research is necessary to obtain a comprehensive picture of the role of hPDL-MSCs in more complex oral biofilms.
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Affiliation(s)
- Fabian L Kendlbacher
- NanoGlycobiology Research Group, Institute of Biochemistry, Department of Chemistry, Universität für Bodenkultur Wien, Vienna, Austria
| | - Susanne Bloch
- NanoGlycobiology Research Group, Institute of Biochemistry, Department of Chemistry, Universität für Bodenkultur Wien, Vienna, Austria
| | - Fiona F Hager-Mair
- NanoGlycobiology Research Group, Institute of Biochemistry, Department of Chemistry, Universität für Bodenkultur Wien, Vienna, Austria
| | - Christina Schäffer
- NanoGlycobiology Research Group, Institute of Biochemistry, Department of Chemistry, Universität für Bodenkultur Wien, Vienna, Austria.
| | - Oleh Andrukhov
- Competence Center for Periodontal Research, University Clinic of Dentistry, Medical University of Vienna, A-1090 Vienna, Austria.
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Loeurng V, Puth S, Hong SH, Lee YS, Radhakrishnan K, Koh JT, Kook JK, Rhee JH, Lee SE. A Flagellin-Adjuvanted Trivalent Mucosal Vaccine Targeting Key Periodontopathic Bacteria. Vaccines (Basel) 2024; 12:754. [PMID: 39066392 PMCID: PMC11281409 DOI: 10.3390/vaccines12070754] [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: 05/30/2024] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
Periodontal disease (PD) is caused by microbial dysbiosis and accompanying adverse inflammatory responses. Due to its high incidence and association with various systemic diseases, disease-modifying treatments that modulate dysbiosis serve as promising therapeutic approaches. In this study, to simulate the pathophysiological situation, we established a "temporary ligature plus oral infection model" that incorporates a temporary silk ligature and oral infection with a cocktail of live Tannerella forsythia (Tf), Pophyromonas gingivalis (Pg), and Fusobacterium nucleatum (Fn) in mice and tested the efficacy of a new trivalent mucosal vaccine. It has been reported that Tf, a red complex pathogen, amplifies periodontitis severity by interacting with periodontopathic bacteria such as Pg and Fn. Here, we developed a recombinant mucosal vaccine targeting a surface-associated protein, BspA, of Tf by genetically combining truncated BspA with built-in adjuvant flagellin (FlaB). To simultaneously induce Tf-, Pg-, and Fn-specific immune responses, it was formulated as a trivalent mucosal vaccine containing Tf-FlaB-tBspA (BtB), Pg-Hgp44-FlaB (HB), and Fn-FlaB-tFomA (BtA). Intranasal immunization with the trivalent mucosal vaccine (BtB + HB + BtA) prevented alveolar bone loss and gingival proinflammatory cytokine production. Vaccinated mice exhibited significant induction of Tf-tBspA-, Pg-Hgp44-, and Fn-tFomA-specific IgG and IgA responses in the serum and saliva, respectively. The anti-sera and anti-saliva efficiently inhibited epithelial cell invasion by Tf and Pg and interfered with biofilm formation by Fn. The flagellin-adjuvanted trivalent mucosal vaccine offers a novel method for modulating dysbiotic bacteria associated with periodontitis. This approach leverages the adjuvant properties of flagellin to enhance the immune response, aiming to restore a balanced microbial environment and improve periodontal health.
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Affiliation(s)
- Vandara Loeurng
- Clinical Vaccine R&D Center, Chonnam National University, Hwasun-gun 58128, Republic of Korea (S.P.)
- Combinatorial Tumor Immunotherapy MRC, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
- Department of Microbiology, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
- National Immunotherapy Innovation Center, Hwasun-gun 58128, Republic of Korea
| | - Sao Puth
- Clinical Vaccine R&D Center, Chonnam National University, Hwasun-gun 58128, Republic of Korea (S.P.)
- National Immunotherapy Innovation Center, Hwasun-gun 58128, Republic of Korea
| | - Seol Hee Hong
- Clinical Vaccine R&D Center, Chonnam National University, Hwasun-gun 58128, Republic of Korea (S.P.)
- National Immunotherapy Innovation Center, Hwasun-gun 58128, Republic of Korea
- Department of Pharmacology and Dental Therapeutics, School of Dentistry, Chonnam National University, Gwangju 61186, Republic of Korea
| | - Yun Suhk Lee
- Clinical Vaccine R&D Center, Chonnam National University, Hwasun-gun 58128, Republic of Korea (S.P.)
- National Immunotherapy Innovation Center, Hwasun-gun 58128, Republic of Korea
- Department of Pharmacology and Dental Therapeutics, School of Dentistry, Chonnam National University, Gwangju 61186, Republic of Korea
| | | | - Jeong Tae Koh
- Department of Pharmacology and Dental Therapeutics, School of Dentistry, Chonnam National University, Gwangju 61186, Republic of Korea
| | - Joong-Ki Kook
- Korean Collection of Oral Microbiology and Department of Oral Biochemistry, School of Dentistry, Chosun University, Gwangju 61452, Republic of Korea
| | - Joon Haeng Rhee
- Clinical Vaccine R&D Center, Chonnam National University, Hwasun-gun 58128, Republic of Korea (S.P.)
- Combinatorial Tumor Immunotherapy MRC, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
- Department of Microbiology, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
| | - Shee Eun Lee
- Clinical Vaccine R&D Center, Chonnam National University, Hwasun-gun 58128, Republic of Korea (S.P.)
- National Immunotherapy Innovation Center, Hwasun-gun 58128, Republic of Korea
- Department of Pharmacology and Dental Therapeutics, School of Dentistry, Chonnam National University, Gwangju 61186, Republic of Korea
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Chen YY, Tan L, Su XL, Chen NX, Liu Q, Feng YZ, Guo Y. NOD2 contributes to Parvimonas micra-induced bone resorption in diabetic rats with experimental periodontitis. Mol Oral Microbiol 2024. [PMID: 38757737 DOI: 10.1111/omi.12467] [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: 02/15/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) may affect the oral microbial community, exacerbating periodontal inflammation; however, its pathogenic mechanisms remain unclear. As nucleotide-binding oligomerization domain 2 (NOD2) plays a crucial role in the activation during periodontitis (PD), it is hypothesized that changes in the oral microbial community due to diabetes enhance periodontal inflammation through the activation of NOD2. METHODS We collected subgingival plaque from 180 subjects who were categorized into two groups based on the presence or absence of T2DM. The composition of oral microbiota was detected by 16S rRNA high-throughput sequencing. In animal models of PD with or without T2DM, we assessed alveolar bone resorption by micro-computerized tomography and used immunohistochemistry to detect NOD2 expression in alveolar bone. Primary osteoblasts were cultured in osteogenic induction medium with high or normal glucose and treated with inactivated bacteria. After 24 h of inactivated bacteria intervention, the osteogenic differentiation ability was detected by alkaline phosphatase (ALP) staining, and the expressions of NOD2 and interleukin-12 (IL-6) were detected by western blot. RESULTS The relative abundance of Parvimonas and Filifactor in the T2DM group was increased compared to the group without T2DM. In animal models, alveolar bone mass was decreased in PD, particularly in T2DM with PD (DMPD) group, compared to controls. Immunohistochemistry revealed NOD2 in osteoblasts from the alveolar bone in both the PD group and DMPD group, especially in the DMPD group. In vitro, intervention with inactivated Parvimonas significantly reduced ALP secretion of primary osteoblasts in high glucose medium, accompanied by increased expression of NOD2 and IL-6. CONCLUSIONS The results suggest that T2DM leading to PD may be associated with the activation of NOD2 by Parvimonas.
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Affiliation(s)
- Ying-Yi Chen
- Hunan Provincial Clinical Research Center for Oral Diseases, Hunan Provincial Engineering Research Center of Digital Oral and Maxillofacial Defect Repair, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Stomatology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences(Qingdao Central Hospital), Qingdao, China
| | - Li Tan
- Hunan Provincial Clinical Research Center for Oral Diseases, Hunan Provincial Engineering Research Center of Digital Oral and Maxillofacial Defect Repair, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiao-Lin Su
- Hunan Provincial Clinical Research Center for Oral Diseases, Hunan Provincial Engineering Research Center of Digital Oral and Maxillofacial Defect Repair, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ning-Xin Chen
- Hunan Provincial Clinical Research Center for Oral Diseases, Hunan Provincial Engineering Research Center of Digital Oral and Maxillofacial Defect Repair, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiong Liu
- Hunan Provincial Clinical Research Center for Oral Diseases, Hunan Provincial Engineering Research Center of Digital Oral and Maxillofacial Defect Repair, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yun-Zhi Feng
- Hunan Provincial Clinical Research Center for Oral Diseases, Hunan Provincial Engineering Research Center of Digital Oral and Maxillofacial Defect Repair, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yue Guo
- Hunan Provincial Clinical Research Center for Oral Diseases, Hunan Provincial Engineering Research Center of Digital Oral and Maxillofacial Defect Repair, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, China
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Rosier BT, Johnston W, Carda-Diéguez M, Simpson A, Cabello-Yeves E, Piela K, Reilly R, Artacho A, Easton C, Burleigh M, Culshaw S, Mira A. Nitrate reduction capacity of the oral microbiota is impaired in periodontitis: potential implications for systemic nitric oxide availability. Int J Oral Sci 2024; 16:1. [PMID: 38177101 PMCID: PMC10767001 DOI: 10.1038/s41368-023-00266-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/13/2023] [Accepted: 12/05/2023] [Indexed: 01/06/2024] Open
Abstract
The reduction of nitrate to nitrite by the oral microbiota has been proposed to be important for oral health and results in nitric oxide formation that can improve cardiometabolic conditions. Studies of bacterial composition in subgingival plaque suggest that nitrate-reducing bacteria are associated with periodontal health, but the impact of periodontitis on nitrate-reducing capacity (NRC) and, therefore, nitric oxide availability has not been evaluated. The current study aimed to evaluate how periodontitis affects the NRC of the oral microbiota. First, 16S rRNA sequencing data from five different countries were analyzed, revealing that nitrate-reducing bacteria were significantly lower in subgingival plaque of periodontitis patients compared with healthy individuals (P < 0.05 in all five datasets with n = 20-82 samples per dataset). Secondly, subgingival plaque, saliva, and plasma samples were obtained from 42 periodontitis patients before and after periodontal treatment. The oral NRC was determined in vitro by incubating saliva with 8 mmol/L nitrate (a concentration found in saliva after nitrate-rich vegetable intake) and compared with the NRC of 15 healthy individuals. Salivary NRC was found to be diminished in periodontal patients before treatment (P < 0.05) but recovered to healthy levels 90 days post-treatment. Additionally, the subgingival levels of nitrate-reducing bacteria increased after treatment and correlated negatively with periodontitis-associated bacteria (P < 0.01). No significant effect of periodontal treatment on the baseline saliva and plasma nitrate and nitrite levels was found, indicating that differences in the NRC may only be revealed after nitrate intake. Our results suggest that an impaired NRC in periodontitis could limit dietary nitrate-derived nitric oxide levels, and the effect on systemic health should be explored in future studies.
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Affiliation(s)
- Bob T Rosier
- Department of Genomics and Health, FISABIO Foundation, Center for Advanced Research in Public Health, Valencia, Spain
| | - William Johnston
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
- Oral Sciences, University of Glasgow Dental School, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Miguel Carda-Diéguez
- Department of Genomics and Health, FISABIO Foundation, Center for Advanced Research in Public Health, Valencia, Spain
| | - Annabel Simpson
- Sport and Physical Activity Research Institute, University of the West of Scotland, Blantyre, Scotland
| | - Elena Cabello-Yeves
- Department of Genomics and Health, FISABIO Foundation, Center for Advanced Research in Public Health, Valencia, Spain
- Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas (IBV-CSIC), Valencia, Spain
| | - Krystyna Piela
- Oral Sciences, University of Glasgow Dental School, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Robert Reilly
- Oral Sciences, University of Glasgow Dental School, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alejandro Artacho
- Department of Genomics and Health, FISABIO Foundation, Center for Advanced Research in Public Health, Valencia, Spain
| | - Chris Easton
- Sport and Physical Activity Research Institute, University of the West of Scotland, Blantyre, Scotland
| | - Mia Burleigh
- Sport and Physical Activity Research Institute, University of the West of Scotland, Blantyre, Scotland
| | - Shauna Culshaw
- Oral Sciences, University of Glasgow Dental School, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alex Mira
- Department of Genomics and Health, FISABIO Foundation, Center for Advanced Research in Public Health, Valencia, Spain.
- CIBER Center for Epidemiology and Public Health, Madrid, Spain.
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