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Yi X, Song Y, Xu J, Wang L, Liu L, Huang D, Zhang L. NLRP10 promotes AGEs-induced NLRP1 and NLRP3 inflammasome activation via ROS/MAPK/NF-κB signaling in human periodontal ligament cells. Odontology 2024; 112:100-111. [PMID: 37043073 DOI: 10.1007/s10266-023-00813-0] [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: 11/01/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023]
Abstract
Diabetes mellitus (DM), characterized by production and accumulation of advanced glycation end products (AGEs), induces and promotes chronic inflammation in tissues, including periodontal tissue. Increasing amount of epidemiological and experimental evidence demonstrated that more extensive inflammatory reaction and bone resorption occurred in periodontal tissues in diabetic patients with periodontitis, which is speculated to be related to NLRP3 inflammasome. NLRP10 is the only NOD-like receptor protein lacking leucine-rich repeats, suggesting that NLRP10 may be a regulatory protein. The aim of this study was to investigate the regulatory role of NLRP10 on NLRP1 and NLRP3 inflammasome in human periodontal ligament cells (HPDLCs) under AGEs treatment. Expression of NLRP10 in HPDLCs stimulated with 100 ug/mL AGEs for 24 h was observed. Detection of TRIM31 is conducted, and in TRIM31-overexpressed HPDLCs, the interaction between NLRP10 with TRIM31 as well as NLRP10 with ubiquitination were explored by immunoprecipitation. Under AGEs stimulation, the activation of reactive oxidative stress (ROS) and inflammatory signaling pathway (NF-κB, MAPK pathway) was detected by biomedical microscope and western blot (WB), respectively. After stimulation with AGEs for 24 h with or without silencing NLRP10, inflammatory cytokines (IL-6 and IL-1β), NF-κB, MAPK pathway, ROS, and components of inflammasome were assessed. In HPDLCs, we found AGEs induced NLRP10 and inhibited TRIM31. TRIM31 overexpression significantly enhanced interaction between TRIM31 and NLRP10, then induced proteasomal degradation of NLRP10. Moreover, under AGEs stimulation, NLRP10 positively regulates NLRP1, NLRP3 inflammasomes by activating NF-κB, MAPK pathway, and increasing ROS, finally promoting the expression of inflammatory cytokines. Together, we, for the first time, confirmed that NLRP10 could promote inflammatory response induced by AGEs in HPDLCs via activation of NF-κB, and MAPK pathway and increasing ROS.
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Affiliation(s)
- Xiaowei Yi
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14# Third Section, Renmin Nan Road, Chengdu, 610041, China
| | - Yao Song
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14# Third Section, Renmin Nan Road, Chengdu, 610041, China
| | - Jialei Xu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14# Third Section, Renmin Nan Road, Chengdu, 610041, China
| | - Liu Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14# Third Section, Renmin Nan Road, Chengdu, 610041, China
| | - Liu Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14# Third Section, Renmin Nan Road, Chengdu, 610041, China
| | - Dingming Huang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14# Third Section, Renmin Nan Road, Chengdu, 610041, China
| | - Lan Zhang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14# Third Section, Renmin Nan Road, Chengdu, 610041, China.
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Galindo-Moreno P, Montalvo-Acosta S, Martín-Morales N, Carrillo-Gálvez AB, González-Rey E, O'Valle F, Padial-Molina M. Inflammasomes NLRP3 and AIM2 in peri-implantitis: A cross-sectional study. Clin Oral Implants Res 2023; 34:1342-1353. [PMID: 37642257 DOI: 10.1111/clr.14174] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/18/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Inflammasome components NLRP3 and AIM2 contribute to inflammation development by the activation of caspase-1 and IL-1β. They have not been yet evaluated in samples from patients with active peri-implantitis. Thus, the aim of the present study is to analyze the expression of inflammasomes NLRP3 and AIM2 and subsequent caspase 1 and IL-1β assessing the microenvironment of leukocyte subsets in samples from patients with active peri-implantitis. METHODS Biopsies were collected from 33 implants in 21 patients being treated for peri-implantitis. Biopsies from gingival tissues from 15 patients with healthy periodontium were also collected for control. These tissues were evaluated through conventional histological stainings. Then, immunohistochemical detection was performed to analyze NLRP3, AIM2, caspase-1, and IL-1β and markers of different leukocyte subsets. PCR for inflammasomes and related genes was also done. RESULTS This manuscript reveals a high immunohistochemical and mRNA expression of NLRP3 and AIM2 inflammasomes, caspase-1, and IL-1β in biopsies collected from human peri-implantitis. The expression of the tested markers was significantly correlated with the increase in inflammatory infiltrate, probing depth, presence of biofilm, and bleeding on probing. In these peri-implantitis lesions, the area of biopsy tissue occupied by inflammatory infiltrate was intense while the area occupied by collagen was significantly lower. In comparison with periodontal healthy tissues, the inflammatory infiltrate was statistically significantly higher in the peri-implantitis biopsies and was mainly composed of plasma cells, followed by T and B lymphocytes. CONCLUSION In human peri-implantitis, chronic inflammation can be explained in part by the action of IL-1β/caspase 1 induced through NLRP3 and AIM2 inflammasome activation.
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Affiliation(s)
- Pablo Galindo-Moreno
- Department of Oral Surgery and Implant Dentistry, School of Dentistry, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
| | - Saray Montalvo-Acosta
- PhD Program in Clinical Medicine and Public Health, University of Granada, Granada, Spain
| | - Natividad Martín-Morales
- Department of Oral Surgery and Implant Dentistry, School of Dentistry, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
- PhD Program in Biomedicine, University of Granada, Granada, Spain
- Department of Pathology, School of Medicine, University of Granada, Granada, Spain
| | | | - Elena González-Rey
- Institute of Parasitology and Biomedicine Lopez-Neyra, IPBLN-CSIC, Parque Tecnologico de la Salud, Granada, Spain
| | - Francisco O'Valle
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
- Department of Pathology, School of Medicine, University of Granada, Granada, Spain
- Institute of Biopathology and Regenerative Medicine (IBIMER, CIBM), University of Granada, Granada, Spain
| | - Miguel Padial-Molina
- Department of Oral Surgery and Implant Dentistry, School of Dentistry, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
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Sheng N, Xing F, Wang J, Zhang QY, Nie R, Li-Ling J, Duan X, Xie HQ. Recent progress in bone-repair strategies in diabetic conditions. Mater Today Bio 2023; 23:100835. [PMID: 37928253 PMCID: PMC10623372 DOI: 10.1016/j.mtbio.2023.100835] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 10/02/2023] [Accepted: 10/14/2023] [Indexed: 11/07/2023] Open
Abstract
Bone regeneration following trauma, tumor resection, infection, or congenital disease is challenging. Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia. It can result in complications affecting multiple systems including the musculoskeletal system. The increased number of diabetes-related fractures poses a great challenge to clinical specialties, particularly orthopedics and dentistry. Various pathological factors underlying DM may directly impair the process of bone regeneration, leading to delayed or even non-union of fractures. This review summarizes the mechanisms by which DM hampers bone regeneration, including immune abnormalities, inflammation, reactive oxygen species (ROS) accumulation, vascular system damage, insulin/insulin-like growth factor (IGF) deficiency, hyperglycemia, and the production of advanced glycation end products (AGEs). Based on published data, it also summarizes bone repair strategies in diabetic conditions, which include immune regulation, inhibition of inflammation, reduction of oxidative stress, promotion of angiogenesis, restoration of stem cell mobilization, and promotion of osteogenic differentiation, in addition to the challenges and future prospects of such approaches.
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Affiliation(s)
- Ning Sheng
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Fei Xing
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Jie Wang
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Qing-Yi Zhang
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Rong Nie
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Jesse Li-Ling
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
- Frontier Medical Center, Tianfu Jincheng Laboratory, Chengdu, 610212, China
- Department of Medical Genetics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Duan
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
| | - Hui-Qi Xie
- Department of Orthopedic Surgery and Orthopedic Research Institute, Laboratory of Stem Cell and Tissue Engineering, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
- Frontier Medical Center, Tianfu Jincheng Laboratory, Chengdu, 610212, China
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Ji J, Wu S, Bao X, Liu S, Ye Y, Liu J, Guo J, Liu J, Wang X, Xia Z, Wei L, Zhang Y, Hao D, Huang D. Mediating oxidative stress through the Palbociclib/miR-141-3p/STAT4 axis in osteoporosis: a bioinformatics and experimental validation study. Sci Rep 2023; 13:19560. [PMID: 37949959 PMCID: PMC10638393 DOI: 10.1038/s41598-023-46813-6] [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: 09/23/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023] Open
Abstract
Osteoporosis is a common bone disease characterized by loss of bone mass, reduced bone strength, and deterioration of bone microstructure. ROS-induced oxidative stress plays an important role in osteoporosis. However, the biomarkers and molecular mechanisms of oxidative stress are still unclear. We obtained the datasets from the Gene Expression Omnibus (GEO) database, and performed differential analysis, Venn analysis, and weighted correlation network analysis (WGCNA) analysis out the hub genes. Then, the correlation between inflammatory factors and hub genes was analyzed, and a Mendelian randomization (MR) analysis was performed on cytokines and osteoporosis outcomes. In addition, "CIBERSORT" was used to analyze the infiltration of immune cells and single-cell RNA-seq data was used to analyze the expression distribution of hub genes and cell-cell communications. Finally, we collected human blood samples for RT-qPCR and Elisa experiments, the miRNA-mRNA network was constructed using the miRBase database, the 3D structure was predicted using the RNAfold, Vfold3D database, and the drug sensitivity analysis was performed using the RNAactDrug database. We obtained three differentially expressed genes associated with oxidative stress: DBH, TAF15, and STAT4 by differential, WGCNA clustering, and Venn screening analyses, and further analyzed the correlation of these 3 genes with inflammatory factors and immune cell infiltration and found that STAT4 was significantly and positively correlated with IL-2. Single-cell data analysis showed that the STAT4 gene was highly expressed mainly in dendritic cells and monocytes. In addition, the results of RT-qPCR and Elisa experiments verified that the expression of STAT4 was consistent with the previous analysis, and a significant causal relationship between IL-2 and STAT4 SNPs and osteoporosis was found by Mendelian randomization. Finally, through miRNA-mRNA network and drug sensitivity analysis, we analyzed to get Palbociclib/miR-141-3p/STAT4 axis, which can be used for the prevention and treatment of osteoporosis. In this study, we proposed the Palbociclib/miR-141-3p/STAT4 axis for the first time and provided new insights into the mechanism of oxidative stress in osteoporosis.
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Affiliation(s)
- Jiajia Ji
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Shaobo Wu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Xueyuan Bao
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, China
| | - Shixuan Liu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Yuxing Ye
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Jiayuan Liu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Jinniu Guo
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Jiateng Liu
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Xi Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Zhihao Xia
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Liangliang Wei
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Yan Zhang
- Center for Translational Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China.
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China.
| | - Dageng Huang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China.
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Li X, Ji L, Men X, Chen X, Zhi M, He S, Chen S. Pyroptosis in bone loss. Apoptosis 2023; 28:293-312. [PMID: 36645574 PMCID: PMC9842222 DOI: 10.1007/s10495-022-01807-z] [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] [Accepted: 12/28/2022] [Indexed: 01/17/2023]
Abstract
Pyroptosis could be responsible for the bone loss from bone metabolic diseases, leading to the negative impact on people's health and life. It has been shown that osteoclasts, osteoblasts, macrophages, chondrocytes, periodontal and gingival cells may be involved in bone loss linked with pyroptosis. So far, the involved mechanisms have not been fully elucidated. In this review, we introduced the related cells involved in the pyroptosis associated with bone loss and summarized the role of these cells in the bone metabolism during the process of pyroptosis. We also discuss the clinical potential of targeting mechanisms in the osteoclasts, osteoblasts, macrophages, chondrocytes, periodontal and gingival cells touched upon pyroptosis to treat bone loss from bone metabolic diseases as well as the challenges of avoiding potential side effects and producing efficient treatment methods.
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Affiliation(s)
- Xinyi Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan China
| | - Ling Ji
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan China
| | - Xinrui Men
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan China
| | - Xinyi Chen
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan China
| | - Maohui Zhi
- Functional Laboratory, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan China
| | - Shushu He
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan China
| | - Song Chen
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan China
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Zhao W, Cao Y, Chen Y, Chen Y, Wang T, Li L, Xu Y, Yuan H, Wang H, Wang R, Sun W. NLRP3 Regulates Mandibular Healing through Interaction with UCHL5 in MSCs. Int J Biol Sci 2023; 19:936-949. [PMID: 36778113 PMCID: PMC9910010 DOI: 10.7150/ijbs.78174] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/01/2023] [Indexed: 02/04/2023] Open
Abstract
NLRP3 has been involved in several physiological and pathological processes. However, the role and mechanism of NLRP3 activation in mandibular healing remain unclear. Here, a full-thickness mandibular defect model by osteotomy was established in wild-type (WT) and Prx1-Cre/ROSAnTnG mice to demonstrate the NLRP3 inflammasome activation in mandibular healing. We found that NLRP3 was activated in mesenchymal stem cells (MSCs)-mediated mandibular healing and was prominent in Prx1+ cells. Inhibition of NLRP3 exerted a positive effect on bone formation without changing the number of Prx1-cre+ cells in the defect areas. In addition, NLRP3 deficiency promoted osteoblast differentiation. We next screened for the deubiquitinating enzymes that were previously reported to be associated with NLRP3, and identified UCHL5 as a regulator of NLRP3 activation in mandibular healing. Mechanistically, NLRP3 directly bound to UCHL5 and maintained its stability through reducing ubiquitin-proteasome pathway degradation in mandibular MSCs. At last, UCHL5 inhibition enhanced osteoblast differentiation by promoting NLRP3 ubiquitination and degradation. Thus, our results provided the proof that NLRP3 acted as a negative modulator in mandibular healing and extended the current knowledge regarding posttranslational modification of NLRP3 by UCHL5.
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Affiliation(s)
- Wenhua Zhao
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China.,Department of Dental Implantology, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Yanan Cao
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China.,Department of Dental Implantology, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Yue Chen
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Yuyi Chen
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Tianxiao Wang
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Lu Li
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Yan Xu
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Hua Yuan
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Hua Wang
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Ruixia Wang
- Department of Dental Implantology, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
| | - Wen Sun
- Department of Basic Science of Stomatology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Province Key Laboratory of Oral Diseases, Nanjing, China; Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing, China
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Zhu L, Zhou C, Chen S, Huang D, Jiang Y, Lan Y, Zou S, Li Y. Osteoporosis and Alveolar Bone Health in Periodontitis Niche: A Predisposing Factors-Centered Review. Cells 2022; 11:3380. [PMID: 36359775 PMCID: PMC9657655 DOI: 10.3390/cells11213380] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/26/2023] Open
Abstract
Periodontitis is a periodontal inflammatory condition that results from disrupted periodontal host-microbe homeostasis, manifested by the destruction of tooth-supporting structures, especially inflammatory alveolar bone loss. Osteoporosis is characterized by systemic deterioration of bone mass and microarchitecture. The roles of many systemic factors have been identified in the pathogenesis of osteoporosis, including endocrine change, metabolic disorders, health-impaired behaviors and mental stress. The prevalence rate of osteoporotic fracture is in sustained elevation in the past decades. Recent studies suggest that individuals with concomitant osteoporosis are more vulnerable to periodontal impairment. Current reviews of worse periodontal status in the context of osteoporosis are limited, mainly centering on the impacts of menopausal and diabetic osteoporosis on periodontitis. Herein, this review article makes an effort to provide a comprehensive view of the relationship between osteoporosis and periodontitis, with a focus on clarifying how those risk factors in osteoporotic populations modify the alveolar bone homeostasis in the periodontitis niche.
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Affiliation(s)
| | | | | | | | | | | | | | - Yuyu Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
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Tseng HW, Samuel SG, Schroder K, Lévesque JP, Alexander KA. Inflammasomes and the IL-1 Family in Bone Homeostasis and Disease. Curr Osteoporos Rep 2022; 20:170-185. [PMID: 35567665 PMCID: PMC9209354 DOI: 10.1007/s11914-022-00729-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Inflammasomes are multimeric protein structures with crucial roles in host responses against infections and injuries. The importance of inflammasome activation goes beyond host defense as a dysregulated inflammasome and subsequent secretion of IL-1 family members is believed to be involved in the pathogenesis of various diseases, some of which also produce skeletal manifestations. The purpose of this review is to summarize recent developments in the understanding of inflammasome regulation and IL-1 family members in bone physiology and pathology and current therapeutics will be discussed. RECENT FINDINGS Small animal models have been vital to help understand how the inflammasome regulates bone dynamics. Animal models with gain or loss of function in various inflammasome components or IL-1 family signaling have illustrated how these systems can impact numerous bone pathologies and have been utilized to test new inflammasome therapeutics. It is increasingly clear that a tightly regulated inflammasome is required not only for host defense but for skeletal homeostasis, as a dysregulated inflammasome is linked to diseases of pathological bone accrual and loss. Given the complexities of inflammasome activation and redundancies in IL-1 activation and secretion, targeting these pathways is at times challenging. Ongoing research into inflammasome-mediated mechanisms will allow the development of new therapeutics for inflammasome/IL-1 diseases.
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Affiliation(s)
- Hsu-Wen Tseng
- Mater Research Institute, Translational Research Institute, The University of Queensland, 37 Kent Street, Woolloongabba, QLD, Australia
| | - Selwin Gabriel Samuel
- Mater Research Institute, Translational Research Institute, The University of Queensland, 37 Kent Street, Woolloongabba, QLD, Australia
| | - Kate Schroder
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, QLD, Australia
| | - Jean-Pierre Lévesque
- Mater Research Institute, Translational Research Institute, The University of Queensland, 37 Kent Street, Woolloongabba, QLD, Australia
| | - Kylie A Alexander
- Mater Research Institute, Translational Research Institute, The University of Queensland, 37 Kent Street, Woolloongabba, QLD, Australia.
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Murakami T, Nakaminami Y, Takahata Y, Hata K, Nishimura R. Activation and Function of NLRP3 Inflammasome in Bone and Joint-Related Diseases. Int J Mol Sci 2022; 23:ijms23105365. [PMID: 35628185 PMCID: PMC9141484 DOI: 10.3390/ijms23105365] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 12/12/2022] Open
Abstract
Inflammation is a pivotal response to a variety of stimuli, and inflammatory molecules such as cytokines have central roles in the pathogenesis of various diseases, including bone and joint diseases. Proinflammatory cytokines are mainly produced by immune cells and mediate inflammatory and innate immune responses. Additionally, proinflammatory cytokines accelerate bone resorption and cartilage destruction, resulting in the destruction of bone and joint tissues. Thus, proinflammatory cytokines are involved in regulating the pathogenesis of bone and joint diseases. Interleukin (IL)-1 is a representative inflammatory cytokine that strongly promotes bone and cartilage destruction, and elucidating the regulation of IL-1 will advance our understanding of the onset and progression of bone and joint diseases. IL-1 has two isoforms, IL-1α and IL-1β. Both isoforms signal through the same IL-1 receptor type 1, but the activation mechanisms are completely different. In particular, IL-1β is tightly regulated by protein complexes termed inflammasomes. Recent research using innovative technologies has led to a series of discoveries about inflammasomes. This review highlights the current understanding of the activation and function of the NLRP3 (NOD-like receptor family, pyrin domain-containing 3) inflammasome in bone and joint diseases.
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Nrf2 in the Field of Dentistry with Special Attention to NLRP3. Antioxidants (Basel) 2022; 11:antiox11010149. [PMID: 35052653 PMCID: PMC8772975 DOI: 10.3390/antiox11010149] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/06/2022] [Accepted: 01/09/2022] [Indexed: 02/06/2023] Open
Abstract
The aim of this review article was to summarize the functional implications of the nuclear factor E2-related factor or nuclear factor (erythroid-derived 2)-like 2 (Nrf2), with special attention to the NACHT (nucleotide-binding oligomerization), LRR (leucine-rich repeat), and PYD (pyrin domain) domains-containing protein 3 (NLRP3) inflammasome in the field of dentistry. NLRP3 plays a crucial role in the progression of inflammatory and adaptive immune responses throughout the body. It is already known that this inflammasome is a key regulator of several systemic diseases. The initiation and activation of NLRP3 starts with the oral microbiome and its association with the pathogenesis and progression of several oral diseases, including periodontitis, periapical periodontitis, and oral squamous cell carcinoma (OSCC). The possible role of the inflammasome in oral disease conditions may involve the aberrant regulation of various response mechanisms, not only in the mouth but in the whole body. Understanding the cellular and molecular biology of the NLRP3 inflammasome and its relationship to Nrf2 is necessary for the rationale when suggesting it as a potential therapeutic target for treatment and prevention of oral inflammatory and immunological disorders. In this review, we highlighted the current knowledge about NLRP3, its likely role in the pathogenesis of various inflammatory oral processes, and its crosstalk with Nrf2, which might offer future possibilities for disease prevention and targeted therapy in the field of dentistry and oral health.
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Liu X, Wang B. Fuscoside Attenuates Bone Loss in Bone Defects by Regulating The Rankl/Nlrp3/Opg Pathway in Rats. CELL JOURNAL 2021; 23:451-456. [PMID: 34455721 PMCID: PMC8405081 DOI: 10.22074/cellj.2021.7736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/13/2020] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study evaluated the beneficial effect of fuscoside in the repair of bone defects (BDs) and the possible molecular mechanism thereof. MATERIALS AND METHODS In this experimental study, a BD was induced by drilling the rat tibia. The rats were then administered oral fuscoside, at 200 or 300 mg/kg, for 2 weeks. The effect of treatment was assessed based on the bone formation score and on the levels of cytokines and biochemical markers in serum. Tibial expression of the proteins involved in the Rankl/Nlrp3/Opg pathway was determined by quantitative reverse-transcription polymerase chain reaction and western blot assay, and histopathological changes by haematoxylin and eosin and TRAP staining. RESULTS In the fuscoside-treated BD rats, the bone formation score improved and inflammatory cytokine levels were reduced. The levels of biochemical markers improved as well, as did the expression of apoptosis proteins. Fuscoside also attenuated the expression of Rankl, Opg, Nlrp3, Runx2, Osterix, and Osteocalcin (Oc) proteins in the tibial tissue of the BD rats and reversed the abnormal histopathological changes. CONCLUSION These results suggest that fuscoside improves BD repair by reducing the differentiation of osteoclasts and by regulating the Rankl/Nlrp3/Opg pathway.
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Affiliation(s)
- Xiangwei Liu
- Department of Traumatic Orthopedics, Chifeng Municipal Hospital, Chifeng, Inner Mongolia, China
| | - Binfeng Wang
- Department of Traumatic Orthopedics, Chifeng Municipal Hospital, Chifeng, Inner Mongolia, China.
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12
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Li H, Wang Y, Zhang D, Chen T, Hu A, Han X. Glycemic fluctuation exacerbates inflammation and bone loss and alters microbiota profile around implants in diabetic mice with experimental peri-implantitis. Int J Implant Dent 2021; 7:79. [PMID: 34401982 PMCID: PMC8368769 DOI: 10.1186/s40729-021-00360-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The impact of glycemic fluctuation under diabetic condition on peri-implantitis in diabetic patients remains unclear. We hypothesized that glycemic fluctuation has greater adverse effect on experimental peri-implantitis, compared with sustained high blood glucose in diabetes. RESULTS Maxillary left first and second molars of diabetic db/db mice were extracted and were replaced with one dental implant in the healed edentulous space. Glycemic control or fluctuation were managed by constant or interrupted oral administration of rosiglitazone to these mice. Meanwhile, experimental peri-implantitis was induced by ligation around implants. After 14 weeks, inflammatory responses, and peri-implant bone loss, together with oral microbiota profile were analyzed. Diabetic mice with glycemic fluctuation showed greater peri-implant bone loss, inflammatory cell infiltration, and osteoclastogenesis, compared with mice with sustained hyperglycemia. Compared to sustained hyperglycemia, glycemic fluctuation led to further increase in IL-1β, TNFα, RANKL, TLR2/4, IRAK1, and TRAF6 mRNA expression in peri-implant gingival tissues. Both rosiglitazone-induced glycemic control and glycemic fluctuation caused microbiota profile change in diabetic mice compared to that in uncontrolled hyperglycemic mice. CONCLUSIONS This study suggests that glycemic fluctuation may aggravate peri-implantitis inflammation and bone loss, which may be associated with a shift in peri-implant microbial profile towards dysbiotic changes and the activation of TLR2/4-IRAK1-TRAF6 signaling.
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Affiliation(s)
- Hao Li
- Department of Prosthodontics, the Affiliated Hospital of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, People's Republic of China
- Department of Immunology and Infectious Diseases, The Forsyth Institute, 245 First Street, Cambridge, 02142, USA
| | - Yufeng Wang
- Department of Immunology and Infectious Diseases, The Forsyth Institute, 245 First Street, Cambridge, 02142, USA
- Department of Oral Mucosal Diseases, Ninth People's Hospital, College of Stomatology, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Dong Zhang
- Department of Immunology and Infectious Diseases, The Forsyth Institute, 245 First Street, Cambridge, 02142, USA
- Department of Oral Surgery, Qilu Hospital of Shandong University, Jinan, 250012, People's Republic of China
| | - Tsute Chen
- Department of Microbiology, The Forsyth Institute, 245 First Street, Cambridge, 02142, USA
- Department of Oral Medicine, Infection and Immunity, Harvard University School of Dental Medicine, 188 Longwood Avenue, Boston, 02115, USA
| | - Arthur Hu
- Department of Immunology and Infectious Diseases, The Forsyth Institute, 245 First Street, Cambridge, 02142, USA
| | - Xiaozhe Han
- Department of Immunology and Infectious Diseases, The Forsyth Institute, 245 First Street, Cambridge, 02142, USA.
- Department of Oral Medicine, Infection and Immunity, Harvard University School of Dental Medicine, 188 Longwood Avenue, Boston, 02115, USA.
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Zhang Y, Zhuang S, Jiang S, Zhang J, Chen Y. Preparation of Nanocomposite Peptide and Its Inhibitory Effect on Myocardial Injury in Type-II Diabetic Rats. JOURNAL OF NANOSCIENCE AND NANOTECHNOLOGY 2021; 21:1378-1384. [PMID: 33183487 DOI: 10.1166/jnn.2021.18652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Complications of diabetes are the main cause of death and disability in diabetic patients. Cardiovascular diseases, especially diabetic cardiomyopathy, are one of the major complications and causes of death in type 2 diabetes. Peptide drugs have a better effect on improving cellular oxidative damage, reducing tissue inflammation and inhibiting intracellular calcium overload. The application of nanotechnology to the preparation of peptide drugs and myocardial injury can effectively improve myocardial stun, arrhythmia and myocardial systolic dysfunction in patients with type 2 diabetes. The use of nanotechnology to develop more stable Glucagon-like peptide 1 analogues or sustained-release preparations, improve patient compliance and improve the efficacy of diabetes, is of great significance for the prevention and treatment of diabetic cardiomyopathy. Therefore, this study used nanotechnology to prepare PLGA-GLP-1 nanoparticles using polyglycolic acid glycolic acid as a drug carrier, which achieved long-acting drug and its morphology by transmission electron microscopy. At the same time, this study explored the anti-cardiomyocyte injury and anti-myocardial damage of PLGA-GLP-1 nanocomposite peptide and its molecular mechanism by using animal models and cell models. Experimental studies have shown that PLGA-GLP-1 nanocomposite peptide has a protective effect on myocardial injury in diabetic rats. Its mechanism is related to the PLGA-GLP-1 nanocomposite peptide enhancing the body's antioxidant capacity, anti-cardiomyocyte apoptosis, and promoting mitochondrial DNA repair in cardiomyocytes.
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Affiliation(s)
- Yang Zhang
- Department of Cardiology, Shanghai Deji Hospital, Shanghai, 200331, China
| | - Shaowei Zhuang
- Department of Cardiology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 200131, China
| | - Shengyang Jiang
- Department of Cardiology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 200131, China
| | - Jiehan Zhang
- Department of Cardiology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 200131, China
| | - Yu Chen
- Department of Cardiology, Sixth People's Hospital Affiliated from Medical School of Shanghai Jiaotong University, Shanghai, 200233, China
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Yu C, Zhang C, Kuang Z, Zheng Q. The Role of NLRP3 Inflammasome Activities in Bone Diseases and Vascular Calcification. Inflammation 2020; 44:434-449. [PMID: 33215255 PMCID: PMC7985100 DOI: 10.1007/s10753-020-01357-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/24/2020] [Accepted: 10/02/2020] [Indexed: 02/07/2023]
Abstract
Continuous stimulation of inflammation is harmful to tissues of an organism. Inflammatory mediators not only have an effect on metabolic and inflammatory bone diseases but also have an adverse effect on certain genetic and periodontal diseases associated with bone destruction. Inflammatory factors promote vascular calcification in various diseases. Vascular calcification is a pathological process similar to bone development, and vascular diseases play an important role in the loss of bone homeostasis. The NLRP3 inflammasome is an essential component of the natural immune system. It can recognize pathogen-related molecular patterns or host-derived dangerous signaling molecules, recruit, and activate the pro-inflammatory protease caspase-1. Activated caspase-1 cleaves the precursors of IL-1β and IL-18 to produce corresponding mature cytokines or recognizes and cleaves GSDMD to mediate cell pyroptosis. In this review, we discuss the role of NLRP3 inflammasome in bone diseases and vascular calcification caused by sterile or non-sterile inflammation and explore potential treatments to prevent bone loss.
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Affiliation(s)
- Chenyang Yu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China.,Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
| | - Caihua Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China.,Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
| | - Zhihui Kuang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China.,Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
| | - Qiang Zheng
- Department of Orthopedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China. .,Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China.
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Sasso GRDS, Florencio-Silva R, da Fonseca CCN, Cezar LC, Carbonel AAF, Gil CD, Simões MDJ, Girão MJBC. Effects of estrogen deficiency followed by streptozotocin-induced diabetes on periodontal tissues of female rats. J Mol Histol 2020; 51:353-365. [PMID: 32488735 DOI: 10.1007/s10735-020-09885-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/29/2020] [Indexed: 01/18/2023]
Abstract
Although both estrogen deficiency and diabetes contribute to periodontal tissue deterioration, the combined effects of these conditions on periodontium is unknown. Thus, we analyzed the combined effects of ovariectomy followed by streptozotocin (STZ)-induced diabetes on periodontal tissues of rats. Twenty adult rats were ovariectomized (OVX) or SHAM-operated (SHAM). After 3 weeks, the rats received an intraperitoneal injection of STZ (60 mg/kg/body weight) to induce diabetes or vehicle (blank) solution. The groups were assigned as follows (n = 5): SHAM-vehicle (SHAM), OVX-vehicle (OVX), SHAM + STZ (SHAM-Di), and OVX + STZ (OVX-Di). Seven weeks post-diabetes induction, the rats were euthanized. Blood samples were collected for glucose measurements and maxillae were processed for paraffin embedding. Sections stained with hematoxylin/eosin, Masson's trichrome, and picrosirius-red were used for alveolar bone loss and collagen fiber analysis in the lamina propria. Immunohistochemistry was performed for runt-related transcription factor 2 (Runx2), matrix metalloproteinase 9 (MMP-9), and tryptase detection. Alveolar bone loss and fewer collagen fibers were observed in the OVX-Di group, collagen fibers with irregular organization, and MMP-9 immunoreactivity were more evident in diabetic groups, and MMP-9-positive osteoclasts on alveolar bone surface were noticed in all groups. The OVX-Di group showed lower Runx2 immunoreactivity (osteoblast formation marker), and more tryptase-positive cells (mast cell marker) in the alveolar bone marrow. Our results indicate that estrogen depletion, followed by STZ-induced diabetes, promotes periodontal tissue deterioration that is more evident than both interventions applied alone. Furthermore, our results points to a possible participation of bone-derived mast cells in this process.
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Affiliation(s)
- Gisela Rodrigues da Silva Sasso
- Departamento de Ginecologia, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil.
- Departamento de Morfologia e Genética, Disciplina de Histologia e Biologia Estrutural, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil.
| | - Rinaldo Florencio-Silva
- Departamento de Morfologia e Genética, Disciplina de Histologia e Biologia Estrutural, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Caio Cesar Navarrete da Fonseca
- Departamento de Morfologia e Genética, Disciplina de Histologia e Biologia Estrutural, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Luana Carvalho Cezar
- Faculdade de Medicina Veterinária e Zootecnia, Patologia Experimental e Comparada, Universidade de São Paulo, São Paulo, Brazil
| | - Adriana Aparecida Ferraz Carbonel
- Departamento de Morfologia e Genética, Disciplina de Histologia e Biologia Estrutural, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Cristiane Damas Gil
- Departamento de Morfologia e Genética, Disciplina de Histologia e Biologia Estrutural, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Manuel de Jesus Simões
- Departamento de Ginecologia, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
- Departamento de Morfologia e Genética, Disciplina de Histologia e Biologia Estrutural, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
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