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Zhang Z, Zhang Y, Cai Y, Li D, He J, Feng Z, Xu Q. NAT10 regulates the LPS-induced inflammatory response via the NOX2-ROS-NF-κB pathway in macrophages. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2023; 1870:119521. [PMID: 37307924 DOI: 10.1016/j.bbamcr.2023.119521] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/08/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023]
Abstract
Periodontitis is a chronic osteolytic inflammatory disease resulting from complex dynamic interactions among bacterial pathogens and the host immune response. Macrophages play a vital role in the pathogenesis of periodontitis by triggering periodontal inflammation and inducing periodontium destruction. N-Acetyltransferase 10 (NAT10) is an acetyltransferase that has been shown to catalyse N4-acetylcytidine (ac4C) mRNA modification and is related to cellular pathophysiological processes, including the inflammatory immune response. Nevertheless, whether NAT10 regulates the inflammatory response of macrophages in periodontitis remains unclear. In this study, the expression of NAT10 in macrophages was found to decrease during LPS-induced inflammation. NAT10 knockdown significantly reduced the generation of inflammatory factors, while NAT10 overexpression had the opposite effect. RNA sequencing revealed that the differentially expressed genes were enriched in the NF-κB signalling pathway and oxidative stress. Both the NF-κB inhibitor Bay11-7082 and the ROS scavenger N-acetyl-L-cysteine (NAC) could reverse the upregulation of inflammatory factors. NAC inhibited the phosphorylation of NF-κB, but Bay11-7082 had no effect on the production of ROS in NAT10-overexpressing cells, suggesting that NAT10 activated the LPS-induced NF-κB signalling pathway by regulating ROS generation. Furthermore, the expression and stability of Nox2 was promoted after NAT10 overexpression, indicating that Nox2 may be a potential target of NAT10. In vivo, the NAT10 inhibitor Remodelin reduced macrophage infiltration and bone resorption in ligature-induced periodontitis mice. In summary, these results showed that NAT10 accelerated LPS-induced inflammation via the NOX2-ROS-NF-κB pathway in macrophages and that its inhibitor Remodelin might be of potential therapeutic significance in periodontitis treatment.
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Affiliation(s)
- Zhanqi Zhang
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou 510055, China
| | - Yiwen Zhang
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou 510055, China
| | - Yongjie Cai
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou 510055, China
| | - Di Li
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou 510055, China
| | - Jinlin He
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou 510055, China
| | - Zhihui Feng
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou 510055, China.
| | - Qiong Xu
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou 510055, China; Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou 510055, China.
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2
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Panahipour L, Botta S, Abbasabadi AO, Afradi Z, Gruber R. Enamel Matrix Derivative Suppresses Chemokine Expression in Oral Epithelial Cells. Int J Mol Sci 2023; 24:13991. [PMID: 37762294 PMCID: PMC10530986 DOI: 10.3390/ijms241813991] [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: 08/23/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Epithelial cells in periodontitis patients increasingly express chemokines, suggesting their active involvement in the inflammatory process. Enamel matrix derivative (EMD) is an extract of porcine fetal tooth germs clinically applied to support the regrowth of periodontal tissues. Periodontal regeneration might benefit from the potential anti-inflammatory activity of EMD for epithelial cells. Our aim was, therefore, to set up a bioassay where chemokine expression is initiated in the HSC2 oral squamous carcinoma cell line and then test EMD for its capacity to lower the inflammatory response. To establish the bioassay, HSC2 cells being exposed to TNFα and LPS from E. coli (Escherichia coli) or P. gingivalis (Porphyromonas gingivalis) were subjected to RNAseq. Here, TNFα but not LPS caused a robust increase of chemokines, including CXCL1, CXCL2, CXCL8, CCL5, and CCL20 in HSC2 cells. Polymerase chain reaction confirmed the increased expression of the respective chemokines in cells exposed to TNFα and IL-1β. Under these conditions, EMD reduced the expression of all chemokines at the transcriptional level and CXCL8 by immunoassay. The TGF-β receptor type I kinase-inhibitor SB431542 reversed the anti-inflammatory activity. Moreover, EMD-activated TGF-β-canonical signaling was visualized by phosphorylation of smad3 and nuclear translocation of smad2/3 in HSC2 cells and blocked by SB431542. This observation was confirmed with primary oral epithelial cells where EMD significantly lowered the SB431542-dependent expression of CXCL8. In summary, our findings suggest that TGF-β signaling mediates the effects of EMD to lower the forced expression of chemokines in oral epithelial cells.
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Affiliation(s)
- Layla Panahipour
- Department of Oral Biology, University Clinic of Dentistry, Medical University of Vienna, Sensengasse 2a, 1090 Vienna, Austria; (L.P.); (S.B.); (A.O.A.); (Z.A.)
| | - Sara Botta
- Department of Oral Biology, University Clinic of Dentistry, Medical University of Vienna, Sensengasse 2a, 1090 Vienna, Austria; (L.P.); (S.B.); (A.O.A.); (Z.A.)
| | - Azarakhsh Oladzad Abbasabadi
- Department of Oral Biology, University Clinic of Dentistry, Medical University of Vienna, Sensengasse 2a, 1090 Vienna, Austria; (L.P.); (S.B.); (A.O.A.); (Z.A.)
| | - Zohreh Afradi
- Department of Oral Biology, University Clinic of Dentistry, Medical University of Vienna, Sensengasse 2a, 1090 Vienna, Austria; (L.P.); (S.B.); (A.O.A.); (Z.A.)
| | - Reinhard Gruber
- Department of Oral Biology, University Clinic of Dentistry, Medical University of Vienna, Sensengasse 2a, 1090 Vienna, Austria; (L.P.); (S.B.); (A.O.A.); (Z.A.)
- Department of Periodontology, School of Dental Medicine, University of Bern, 3010 Bern, Switzerland
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria
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3
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Lu EMC. The role of vitamin D in periodontal health and disease. J Periodontal Res 2023; 58:213-224. [PMID: 36537578 DOI: 10.1111/jre.13083] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/20/2022] [Accepted: 11/27/2022] [Indexed: 12/24/2022]
Abstract
Vitamin D plays an essential role in calcium and bone metabolism, immune regulation and possesses profound anti-inflammatory effects. Evidence suggests that low serum vitamin D is associated with increased severity of periodontitis, a chronic inflammatory condition characterised by destruction of the supporting tissues surrounding the tooth, which has several shared risk factors with other chronic non-communicable diseases. The biological functions of vitamin D are mediated by its strong anti-microbial, anti-inflammatory, and host modulatory properties. Experimental periodontitis models involving targeted deletion of 1α-hydroxylase, the enzyme responsible for the conversion of inactive substrate to active 1,25(OH)2 D3 (calcitriol), showed augmented alveolar bone loss and gingival inflammation. Vitamin D receptor (VDR) gene polymorphisms have also been associated with increased severity of periodontitis. Thus, the involvement of vitamin D in the pathogenesis of periodontitis is biological plausible. Clinical studies have consistently demonstrated an inverse relationship between serum 25OHD3 and periodontal disease inflammation. However, due to the paucity of well-designed longitudinal studies, there is less support for the impact of vitamin D status on periodontal disease progression and tooth loss. The evidence emphasises the importance of maintaining vitamin D sufficiency in supporting periodontal health. This review aims to first examine the biological mechanisms by which vitamin D might influence the pathogenesis of periodontal disease and second, discuss the clinical evidence which implicate the role of vitamin D in periodontal disease.
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Affiliation(s)
- Emily Ming-Chieh Lu
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, Guy's Hospital, London, UK
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The Critical Role of Acyl Hydrocarbon Receptor on the Combined Benefits of Postbiotic Propionate on Active Vitamin D3-Orchestrated Innate Immunity in Salmonella Colitis. Biomedicines 2023; 11:biomedicines11010195. [PMID: 36672703 PMCID: PMC9855671 DOI: 10.3390/biomedicines11010195] [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: 12/01/2022] [Revised: 12/28/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Our recent study observed the combined beneficial effects of postbiotic butyrate on active vitamin D3-orchestrated innate immunity to Salmonella Colitis. There is increasing interest in the role of acyl hydrocarbon receptor (AhR) on colitis and innate immunity. Therefore, we investigated the involvement of AhR in the effects. Salmonella colitis model is conducted with 6-8 w/o male C57BL/6 mice: Streptomycin (20 mg/mouse p.o.)-pretreated C57BL/6 mice were mock infected with sterile PBS or infected orally with 1 × 108 CFU of an S. typhimurium wild-type strain SL1344 for 48 h. Before and after the colitis induction, mice were oral gavage with active vitamin D3 0.2 μg/25 g mice (VD3) and/or postbiotics propionate (PP), in the absence of the presence of intraperitoneal injection of AhR inhibitor for 4 and 7 days, respectively. We observed AhR inhibitor counteracted the synergistic effects of PP and VD3 on reducing the severity of Salmonella colitis and body weight loss in C57BL/6 mice, reducing the cecal inflammatory but enhancing antimicrobial peptide mRNAs expression, and reducing the bacterial translocation in liver/spleen, compared to single treatment. It suggests the involvement of AhR on the synergistic effects of postbiotics PP and VD3 on the antibacterial and anti-inflammatory responses in Salmonella colitis and the potential biological treatment of Salmonella colitis.
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Baciu SF, Mesaroș AȘ, Kacso IM. Chronic Kidney Disease and Periodontitis Interplay-A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1298. [PMID: 36674052 PMCID: PMC9859404 DOI: 10.3390/ijerph20021298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 06/17/2023]
Abstract
Periodontitis (PO), a chronic microbially-induced inflammation of the supporting tissues of the tooth, is linked to various systemic diseases. We analyze its bidirectional relationship to chronic kidney disease (CKD), a major health-care problem with impressive excess mortality. Overwhelming associative relationship between CKD and PO are analyzed. Major pathophysiologic mechanisms that link CKD to PO are then presented: systemic inflammation, endothelial dysfunction, and imbalance of oxidative stress characteristic of CKD have a role in PO development and might influence escape mechanisms of oral microbiota. Subclinical local and systemic inflammation induced by PO might influence in turn CKD outcomes. Homeostatic changes induced by CKD such as mineral bone disorders, acidosis, uremic milieu, or poor salivary flow are also relevant for the occurrence of PO. There is insufficient evidence to recommend a standardized diagnostic and therapeutic approach regarding association of PO to CKD.
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Affiliation(s)
- Sorana Florica Baciu
- Department of Dental Propaedeutics and Esthetics, Faculty of Dentistry, “Iuliu Hațieganu” University of Medicine and Pharmacy, 32 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Anca-Ștefania Mesaroș
- Department of Dental Propaedeutics and Esthetics, Faculty of Dentistry, “Iuliu Hațieganu” University of Medicine and Pharmacy, 32 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Ina Maria Kacso
- Department of Nephrology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 2 Babes Street, 400012 Cluj-Napoca, Romania
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The Impact of Chronic Kidney Disease on Nutritional Status and Its Possible Relation with Oral Diseases. Nutrients 2022; 14:nu14102002. [PMID: 35631140 PMCID: PMC9143067 DOI: 10.3390/nu14102002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/02/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023] Open
Abstract
Several studies have demonstrated a strong relation between periodontal diseases and chronic kidney disease (CKD). The main mechanisms at the base of this link are malnutrition, vitamin dysregulation, especially of B-group vitamins and of C and D vitamins, oxidative stress, metabolic acidosis and low-grade inflammation. In particular, in hemodialysis (HD) adult patients, an impairment of nutritional status has been observed, induced not only by the HD procedures themselves, but also due to numerous CKD-related comorbidities. The alteration of nutritional assessment induces systemic manifestations that have repercussions on oral health, like oral microbiota dysbiosis, slow healing of wounds related to hypovitaminosis C, and an alteration of the supporting bone structures of the oral cavity related to metabolic acidosis and vitamin D deficiency. Low-grade inflammation has been observed to characterize periodontal diseases locally and, in a systemic manner, CKD contributes to the amplification of the pathological process, bidirectionally. Therefore, CKD and oral disease patients should be managed by a multidisciplinary professional team that can evaluate the possible co-presence of these two pathological conditions, that negatively influence each other, and set up therapeutic strategies to treat them. Once these patients have been identified, they should be included in a follow-up program, characterized by periodic checks in order to manage these pathological conditions.
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Gatera VA, Lesmana R, Musfiroh I, Judistiani RTD, Setiabudiawan B, Abdulah R. Vitamin D Inhibits Lipopolysaccharide (LPS)-Induced Inflammation in A549 Cells by Downregulating Inflammatory Cytokines. Med Sci Monit Basic Res 2021; 27:e931481. [PMID: 34103463 PMCID: PMC8202123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/11/2021] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Studies have shown that lung inflammation affects lung function, with life-threatening results. Vitamin D may play an important role in inhibiting inflammatory cytokines. Vitamin D deficiency is related to several lung problems, including respiratory distress syndrome, alveolar inflammation, epithelial damage, and hypoxia. Few studies have evaluated the benefits of vitamin D in preventing inflammation in alveolar cells. MATERIAL AND METHODS We developed a cell inflammation model induced by lipopolysaccharide (LPS) treatment. The effects of vitamin D on LPS-induced inflammation in A549 cells were examined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, and the anti-inflammatory mechanism of vitamin D was evaluated using western blot analysis. RESULTS Our results indicated that vitamin D promoted A549 cell survival following LPS-induced inflammation by downregulating nuclear factor nuclear factor kappa light chain enhancer of activated B cells, tumor necrosis factor-alpha, interleukin (IL)-1ß, IL-6, and IL-12. CONCLUSIONS Our results indicated that vitamin D has the potential to manage lung inflammation, although further studies are needed.
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Affiliation(s)
- Vesara A. Gatera
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Department of Pharmacy, Faculty of Health, Singaperbangsa University, Karawang, Indonesia
| | - Ronny Lesmana
- Division of Physiology, Department of Biomedical Science, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Division of Biological Activity, Central Laboratory, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Ida Musfiroh
- Department of Pharmaceutical Analysis and Medicinal Chemistry, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | | | - Budi Setiabudiawan
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rizky Abdulah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
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Anderson G, Carbone A, Mazzoccoli G. Tryptophan Metabolites and Aryl Hydrocarbon Receptor in Severe Acute Respiratory Syndrome, Coronavirus-2 (SARS-CoV-2) Pathophysiology. Int J Mol Sci 2021; 22:ijms22041597. [PMID: 33562472 PMCID: PMC7915649 DOI: 10.3390/ijms22041597] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023] Open
Abstract
The metabolism of tryptophan is intimately associated with the differential regulation of diverse physiological processes, including in the regulation of responses to severe acute respiratory syndrome, coronavirus-2 (SARS-CoV-2) infection that underpins the COVID-19 pandemic. Two important products of tryptophan metabolism, viz kynurenine and interleukin (IL)4-inducible1 (IL41)-driven indole 3 pyruvate (I3P), activate the aryl hydrocarbon receptor (AhR), thereby altering the nature of immune responses to SARS-CoV-2 infection. AhR activation dysregulates the initial pro-inflammatory cytokines production driven by neutrophils, macrophages, and mast cells, whilst AhR activation suppresses the endogenous antiviral responses of natural killer cells and CD8+ T cells. Such immune responses become further dysregulated by the increased and prolonged pro-inflammatory cytokine suppression of pineal melatonin production coupled to increased gut dysbiosis and gut permeability. The suppression of pineal melatonin and gut microbiome-derived butyrate, coupled to an increase in circulating lipopolysaccharide (LPS) further dysregulates the immune response. The AhR mediates its effects via alterations in the regulation of mitochondrial function in immune cells. The increased risk of severe/fatal SARS-CoV-2 infection by high risk conditions, such as elderly age, obesity, and diabetes are mediated by these conditions having expression levels of melatonin, AhR, butyrate, and LPS that are closer to those driven by SARS-CoV-2 infection. This has a number of future research and treatment implications, including the utilization of melatonin and nutraceuticals that inhibit the AhR, including the polyphenols, epigallocatechin gallate (EGCG), and resveratrol.
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Affiliation(s)
- George Anderson
- CRC Scotland & London, Eccleston Square, London SW1V 1PX, UK
| | - Annalucia Carbone
- Department of Medical Sciences, Division of Internal Medicine and Chronobiology Laboratory, Fondazione IRCCS "Casa Sollievo della Sofferenza", 71013 San Giovanni Rotondo, Italy
| | - Gianluigi Mazzoccoli
- Department of Medical Sciences, Division of Internal Medicine and Chronobiology Laboratory, Fondazione IRCCS "Casa Sollievo della Sofferenza", 71013 San Giovanni Rotondo, Italy
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Botelho J, Machado V, Proença L, Delgado AS, Mendes JJ. Vitamin D Deficiency and Oral Health: A Comprehensive Review. Nutrients 2020; 12:E1471. [PMID: 32438644 PMCID: PMC7285165 DOI: 10.3390/nu12051471] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/15/2022] Open
Abstract
Vitamin D (VD) levels have been gaining growing attention in Oral Health. During growth and adulthood, VD deficiency (VDD) is associated with a wide variety of oral health disorders, and impaired VD synthesis may expedite some of these conditions. In children, severe VDD can induce defective tooth mineralization, resulting in dentin and enamel defects. As a consequence, these defects may increase the risk of the onset and progression of dental caries. Further, VDD has been associated with higher prevalence of periodontitis and gingival inflammation, and several recent preclinical and clinical studies have unveiled potential pathways through which Vitamin D may interact with the periodontium. VDD correction through supplementation may contribute to a successful treatment of periodontitis; however, alveolar bone regeneration procedures performed in baseline VDD patients seem more prone to failure. Vitamin D may also be linked with some oral pathology entities such as certain oral cancers and events of osteonecrosis of the jaw. This review aims to provide comprehensive evidence of how VD levels should be considered to promote good oral health, and to summarize how VDD may hamper oral development and its role in certain oral conditions.
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Affiliation(s)
- João Botelho
- Periodontology Department, Clinical Research Unit (CRU), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal;
- CRU, CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal; (A.S.D.); (J.J.M.)
| | - Vanessa Machado
- Periodontology Department, Clinical Research Unit (CRU), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal;
- CRU, CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal; (A.S.D.); (J.J.M.)
- Orthodontics Department, CRU, CiiEM, Egas Moniz–Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal
| | - Luís Proença
- Quantitative Methods for Health Research Unit (MQIS), CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal;
| | - Ana Sintra Delgado
- CRU, CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal; (A.S.D.); (J.J.M.)
- Orthodontics Department, CRU, CiiEM, Egas Moniz–Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal
| | - José João Mendes
- CRU, CiiEM, Egas Moniz—Cooperativa de Ensino Superior, 2829-511 Caparica, Almada, Portugal; (A.S.D.); (J.J.M.)
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