Use of TNF Inhibitors in Rheumatoid Arthritis and Implications for the Periodontal Status: For the Benefit of Both?

Systemic Factors Affecting Prognosis and Outcomes in Periodontal Disease

This review delves into the effects of autoimmune conditions like rheumatoid arthritis, inflammatory disorders such as irritable bowel syndrome, cardiovascular disease, diabetes, infectious ailments like human immunodeficiency virus, and their medications on periodontal therapy outcomes. It also explores the influence of hormones. Understanding these systemic factors is crucial for optimizing periodontal health and treatment efficacy. The review underscores the necessity of considering these variables in periodontal care. Other vital systemic factors are addressed elsewhere in this special edition.

Inhibition of DCUN1D1 attenuates periodontitis by suppressing NF-κB signaling

Nuclear factor kappa-B (NF-κB) signaling-mediated inflammation contributes greatly to the pathogenesis of periodontitis. Neddylation, a ubiquitin-like posttranslational modification, is known to regulate NF-κB signaling. DCUN1D1 (defective in cullin neddylation 1 domain containing 1) is a critical factor in neddylation and has been shown to regulate NF-κB activation. However, the previse roles of DCUN1D1 in periodontitis are not fully elucidated. To explore the roles of DCUN1D1 in periodontitis, the expression of DCUN1D1 was measured in gingival tissues of patients with periodontitis. We inhibited DCUN1D1 by siRNA knocking down or using inhibitor in gingival fibroblasts and the lipopolysaccharides (LPS)-induced expression of IL-6 and TNF-α, and activation of NF-κB were measured. The expression of DCUN1D1 was increased in gingival tissues of patients with periodontitis. Knocking down or inhibiting DCUN1D1 suppressed LPS-induced production of IL-6 and TNF-α, decreased NF-κB activity, and inhibited LPS-induced activation of NF-κB. Inhibiting DCUN1D1 ameliorates periodontitis by suppressing NF-κB signaling.

Anti TNF-Alpha Treatment Improves Microvascular Endothelial Dysfunction in Rheumatoid Arthritis Patients

Nailfold capillaroscopy is a non-invasive investigation, which allows for the study of the microvasculature (anatomical and functional). Rheumatoid arthritis (RA) is associated with a high risk of cardiovascular atherosclerotic diseases, with endothelial dysfunction (macrovascular and microvascular) representing the first step in atherosclerosis development. The aim of this study is represented by the assessment of microvascular endothelial dysfunction in RA patients by means of nailfold capillaroscopy and to assess its evolution after a period of 12 months of anti TNF-alpha treatment. The study included 70 consecutive patients with RA and 70 healthy subjects, matched for age and gender, as the control group. Rheumatoid factor, anti-cyclic citrullinated peptide antibodies, serum TNF-α, C reactive protein, and erythrocytes sedimentation rate were evaluated in all patients, but in controls, only rheumatoid factor, serum TNF-α, C reactive protein, and erythrocytes sedimentation rate were measured. The RA activity was measured by DAS28. Nailfold capillaroscopy was carried out in all patients and controls, determining the baseline nailfold capillary density (Db), nailfold capillary density during reactive hyperemia (Dh), and nailfold capillary density after venous congestion (Dc). Data were presented as mean ± standard deviation. Statistical analysis was performed using ANOVA and Pearson's correlation, with p < 0.05 being statistically significant. Db, Dh, and Dc were lower in RA patients than in controls (p < 0.0001), correlating with RA activity and TNF-α (p < 0.05). After 12 months of anti TNF-α treatment, microvascular endothelial dysfunction improved (p < 0.0001). Microvascular endothelial dysfunction can be assessed by nailfold capillaroscopy, with anti TNF-α medication contributing to its improvement.

Reduction of osteoclast formation and survival following suppression of cytokines by diacerein in periodontitis

Periodontitis causes an increase in several bioactive agents such as interleukins (IL), tumor necrosis factor (TNF)-α and receptor activator of NF-kB ligand (RANKL), which induce the osteoclast formation and activity. Since diacerein exerts anti-TNF-α and anti-IL-1 effects, alleviating bone destruction in osteoarthritis, we investigated whether this drug inhibits the formation and survival of osteoclast in the periodontitis. Rats were distributed into 3 groups: 1) group with periodontitis treated with 100 mg/kg diacerein (PDG), 2) group with periodontitis treated with saline (PSG) and group control (CG) without any treatment. After 7, 15 and 30 days, the maxillae were collected for light and transmission electron microscopy analyses. Gingiva samples were collected to evaluate the mRNA levels for Tnf, Il1b, Tnfsf11 and Tnfrsf11b by RT-qPCR. In PDG, the expression of Tnf and Il1b genes reduced significantly compared to PSG, except for Tnf expression at 7 days. The number of osteoclasts reduced significantly in the PDG in comparison with PSG at 7 and 15 days. In all periods, the IL-6 immunoexpression, RANKL/OPG immunoexpression and mRNA levels of Tnfsf11/Tnfrsf11b ratio were significantly lower in PDG than in PSG. PDG exhibited significantly higher frequency of TUNEL-positive osteoclasts than in PSG and CG at all time points. Osteoclasts with caspase-3-immunolabelled cytoplasm and nuclei with masses of condensed chromatin were observed in PDG, confirming osteoclast apoptosis. Diacerein inhibits osteoclastogenesis by decreasing Tnf and Il1b mRNA levels, resulting in decreased RANKL/OPG ratio, and induces apoptosis in osteoclasts of alveolar process of rat molars with periodontitis.

Periodontal disease as a model to study chronic inflammation in aging

Periodontal disease is a chronic inflammatory condition that results in the destruction of the teeth supporting tissues, eventually leading to the loss of teeth and reduced quality of life. In severe cases, periodontal disease can limit proper nutritional intake, cause acute pain and infection, and cause a withdrawal from social situations due to esthetic and phonetic concerns. Similar to other chronic inflammatory conditions, periodontal disease increases in prevalence with age. Research into what drives periodontal disease pathogenesis in older adults is contributing to our general understanding of age-related chronic inflammation. This review will present periodontal disease as an age-related chronic inflammatory disease and as an effective geroscience model to study mechanisms of age-related inflammatory dysregulation. The current understanding of the cellular and molecular mechanisms that drive inflammatory dysregulation as a function of age will be discussed with a focus on the major pathogenic immune cells in periodontal disease, which include neutrophils, macrophages, and T cells. Research in the aging biology field has shown that the age-related changes in these immune cells result in the cells becoming less effective in the clearance of microbial pathogens, expansion of pathogenic subpopulations, or an increase in pro-inflammatory cytokine secretions. Such changes can be pathogenic and contribute to inflammatory dysregulation that is associated with a myriad of age-related disease including periodontal disease. An improved understanding is needed to develop better interventions that target the molecules or pathways that are perturbed with age in order to improve treatment of chronic inflammatory conditions, including periodontal disease, in older adult populations.

Galangin: A Promising Flavonoid for the Treatment of Rheumatoid Arthritis-Mechanisms, Evidence, and Therapeutic Potential

Rheumatoid Arthritis (RA) is a chronic autoimmune disease characterized by progressive joint inflammation and damage. Oxidative stress plays a critical role in the onset and progression of RA, significantly contributing to the disease's symptoms. The complex nature of RA and the role of oxidative stress make it particularly challenging to treat effectively. This article presents a comprehensive review of RA's development, progression, and the emergence of novel treatments, introducing Galangin (GAL), a natural flavonoid compound sourced from various plants, as a promising candidate. The bioactive properties of GAL, including its anti-inflammatory, antioxidant, and immunomodulatory effects, are discussed in detail. The review elucidates GAL's mechanisms of action, focusing on its interactions with key targets such as inflammatory cytokines (e.g., TNF-α, IL-6), enzymes (e.g., SOD, MMPs), and signaling pathways (e.g., NF-κB, MAPK), which impact inflammatory responses, immune cell activation, and joint damage. The review also addresses the lack of comprehensive understanding of potential treatment options for RA, particularly in relation to the role of GAL as a therapeutic candidate. It highlights the need for further research and clinical studies to ascertain the effectiveness of GAL in RA treatment and to elucidate its mechanisms of action. Overall, this review provides valuable insights into the potential of GAL as a therapeutic option for RA, shedding light on its multifaceted pharmacological properties and mechanisms of action, while suggesting avenues for future research and clinical applications.

Treatment of periodontitis ameliorates the severity and extent of psoriasis-A randomized clinical trial

AIM

To assess the impact of non-surgical periodontitis treatment over conventional dermatological treatment on the severity and extent of psoriasis in patients affected by comorbid psoriasis and periodontitis.

METHODS

Seventy-four patients affected by both psoriasis and Stages I-IV periodontitis were randomized to receive either Steps 1-2 (non-surgical) of periodontal therapy (test group; n = 37) or no treatment (control group; n = 37). The two groups were balanced in terms of psoriasis medications, with the majority of the included patients undergoing biologics (74.0%) as monotherapy, while minor proportions were under systemic medications (13.7%) or none/topical/phototherapy (12.3%). The psoriasis area severity index (PASI) was regarded as the primary outcome. The Body Surface Area (BSA) and the Dermatology Life Quality Index (DLQI) were additionally considered as dermatological outcomes. Probing pocket depth, recession depth, clinical attachment level, periodontal inflamed surface area, and full-mouth plaque and bleeding scores were also measured. [Correction added on July 5, 2024, after first online publication: The preceding sentence has been revised].

RESULTS

Periodontal therapy in the test group led to statistically significant lower PASI scores at 10 weeks (mean = 3.15; standard deviation [SD] = 3.78) compared to the control group (mean = 7.11; SD = 6.09) (mean difference [MD] = -4.0; 95% confidence interval [CI]: -6.3, -1.6; p = .001). The test group also showed improvements in BSA (MD = -4.3) and periodontal parameters compared to the control group. DLQI only showed a non-statistically significant tendency (MD = -2.0).

CONCLUSION

Steps 1-2 of periodontal therapy showed an additional effect over conventional dermatological treatment in reducing the severity and extent of psoriasis (Clinicaltrials.gov: NCT05311501).

[The Miao medicine Sidaxue alleviates rheumatoid arthritis in rats possibly by downregulating matrix metalloproteinases]

OBJECTIVE

To explore the inhibitory effect of Sidaxue, a traditional Miao herbal medicine formula, on articular bone and cartilage destruction and synovial neovascularization in rats with collagen-induced arthritis (CIA).

METHODS

In a SD rat model of CIA, we tested the effects of daily gavage of Sidaxue at low, moderate and high doses (10, 20, and 40 g/kg, respectively) for 21 days, with Tripterygium glycosides (GTW) as the positive control, on swelling in the hind limb plantar regions by arthritis index scoring. Pathologies in joint synovial membrane of the rats were observed with HE staining, and serum TNF-α and IL-1β levels were detected with ELISA. The expressions of NF-κB p65, matrix metalloproteinase 1 (MMP1), MMP2 and MMP9 at the mRNA and protein levels in the synovial tissues were detected using real-time PCR and Western blotting. Network pharmacology analysis was conducted to identify the important target proteins in the pathways correlated with the therapeutic effects of topical Sidaxue treatment for RA, and the core target proteins were screened by topological analysis.

RESULTS

Treatment with GTW and Sidaxue at the 3 doses all significantly alleviated plantar swelling, lowered arthritis index scores, improved cartilage and bone damage and reduced neovascularization in CIA rats (P<0.05), and the effects of Sidaxue showed a dose dependence. Both GTW and Sidaxue treatments significantly lowered TNF-α, IL-1β, NF-κB p65, MMP1, MMP2, and MMP9 mRNA and protein expressions in the synovial tissues of CIA rats (P<0.05). Network pharmacological analysis identified MMPs as the core proteins associated with topical Sidaxue treatment of RA.

CONCLUSION

Sidaxue alleviates articular bone and cartilage damages and reduces synovial neovascularization in CIA rats possibly by downregulating MMPs via the TNF-α/IL-1β/NF-κB-MMP1, 2, 9 signaling pathway, and MMPs probably plays a key role in mediating the effect of Sidaxue though the therapeutic pathways other than oral administration.

Antibacterial and DNA-Based Hydrogels In Situ Block TNF-α to Promote Diabetic Alveolar Bone Rebuilding

Alveolar bone injury under diabetic conditions can severely impede many oral disease treatments. Rebuilding diabetic alveolar bone in clinics is currently challenging due to persistent infection and inflammatory response. Here, an antibacterial DNA-based hydrogel named Agantigel is developed by integrating silver nanoclusters (AgNCs) and tumor necrosis factor-alpha (TNF-α) antibody into DNA hydrogel to promote diabetic alveolar bone regeneration. Agantigel can effectively inhibit bacterial growth through AgNCs while exhibiting negligible cytotoxicity in vitro. The sustained release of TNF-α antibody from Agantigel effectively blocks TNF-α and promotes M2 polarization of macrophages, ultimately accelerating diabetic alveolar bone regeneration in vivo. After 21 days of treatment, Agantigel significantly accelerates the defect healing rate of diabetic alveolar bone up to 82.58 ± 8.58% and improves trabecular architectures compared to free TNF-α (42.52 ± 15.85%). The results imply that DNA hydrogels are potential bio-scaffolds helping the sustained release of multidrug for treating DABI or other oral diseases.

Six-Month Follow-Up of Periodontal Condition in Rheumatoid Arthritis and Ankylosing Spondylitis Arthritis Patients Undergoing Anti-Tumour Necrosis Factor-α Therapy

In our present study, we aimed to assess the effects of anti-TNF therapy on periodontal condition in a mixed cohort of patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Moreover, we wished to determine whether the baseline dental condition of these patients would affect response to biological therapy. A cohort of 24 arthritis patients was consecutively recruited before starting anti-TNFα therapy. After the dropout of six patients, we evaluated the dental status of 18 subjects at baseline and after 6 months of biological therapy. Clinical responder (R) and non-responder (NR) status was determined after 6 months of anti-TNF treatment. Plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing pocket depth (PPD), PPDmax, clinical attachment loss (CAL), and CALmax were determined. During the 6-month treatment period, six patients (3 RA and 3 AS) terminated the study prematurely as they did not respond to treatment (NR). Therefore, 18 patients were included in the full analysis. There were no major differences in PI, BOP, PPD, PPD max, CAL, and CALmax, among R and NR patients. TNF inhibition resulted in increased GI (0.65 ± 0.34 vs. 0.88 ± 0.30; p < 0.05), as well as decreased PPDmax (4 ± 1.94 vs. 2.72 ± 1.36; p < 0.05) and CALmax (5.22 ± 2.56 vs. 2.72 ± 1.36; p < 0.05) after 6 months. Eight patients had incomplete canal fillings or dead pulps and/or apical periodontitis; six in the R and two in the NR group. In our present study, anti-TNF therapy seemed to worsen the extent of gingival inflammation (GI); however our results also do not support the reduction of mean CPD and CAL as reported by others.

Emerging drug delivery systems with traditional routes - A roadmap to chronic inflammatory diseases

Inflammation is prevalent and inevitable in daily life but can generally be accommodated by the immune systems. However, incapable self-healing and persistent inflammation can progress to chronic inflammation, leading to prevalent or fatal chronic diseases. This review comprehensively covers the topic of emerging drug delivery systems (DDSs) for the treatment of chronic inflammatory diseases (CIDs). First, we introduce the basic biology of the chronic inflammatory process and provide an overview of the main CIDs of the major organs. Next, up-to-date information on various DDSs and the associated strategies for ensuring targeted delivery and stimuli-responsiveness applied to CIDs are discussed extensively. The implementation of traditional routes of drug administration to maximize their therapeutic effects against CIDs is then summarized. Finally, perspectives on future DDSs against CIDs are presented.

Metabolic Effects of Anti-TNF-α Treatment in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is associated with high cardiovascular mortality. It is not clear whether the metabolic consequences of chronic inflammation are involved. Biological disease-modifying anti-rheumatic drugs (bDMARDs) are highly efficient in the treatment of inflammation in RA. In this study, we aimed to describe the metabolic effects of anti-TNF-α treatment in RA patients. The clinical status of 16 patients was assessed using disease activity score-28 (DAS28) and C-reactive protein (CRP). Plasma samples were collected before treatment with anti-TNF-α treatment as well as after three and six months of treatment. Markers of lipid and glucose metabolism, as well as renal biomarkers, were assessed using standard biochemistry. ELISA was used for the quantification of insulin, leptin, and adiponectin. Although fasting insulin decreased by 14% at the end of the study, most of the analyzed parameters did not show any statistically or clinically significant dynamics. The exception was total bilirubin and cholesterol, which increased by 53% and 14%, respectively, after six months of treatment with anti-TNF-α treatment. Anti-TNF-α treatment did not induce major metabolic changes despite the strong anti-inflammatory and clinical symptoms of RA. Further studies will show whether longer observations are required for the detection of the metabolic effects of the anti-inflammatory treatment. Additional research is needed to understand the observed effect of bilirubin as an important endogenous antioxidant.

Correlation of anti-TNF-a biological therapy with periodontal conditions and osteonecrosis in autoimmune patients: A systematic review

Objectives

This systematic review aims to investigate the impact of tumor necrotic factor alpha inhibitors in suppressing bone resorption in periodontitis, and its potential to cause osteonecrosis. Extensive electronic research was conducted following the PRISMA guidelines, which connected various aspects of anti-TNF-a (anti-tumor necrosis factor-a) to periodontitis and osteonecrosis patients.

Background

TNF-a inhibitors are broadly indicated in the treatment of autoimmune patients with possible joint resorption and increased inflammatory processes such as rheumatoid arthritis and inflammatory bowel disease, where they reduce bone loss and certain mediators. As rheumatoid arthritis and periodontitis share many characteristics, these medications may also be helpful in the treatment of coexisting periodontitis. However, besides medical benefits, anti-TNF-a also exhibits several adverse effects, ranging from dizziness to tuberculosis. Osteonecrosis is considered a recent adverse impact.

Methods

An extensive electronic systematic review following the PRISMA guidelines was performed for English-language papers using the following databases as sources of information: PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Library Genesis, Worldwide Science, National Rheumatoid Arthritis Society (NRAS), and other related articles. This systematic review is registered on the PROSPERO platform under registration number CRD42022341753.

Results

Twenty articles were identified after the exclusion criteria were applied. These include systematic reviews, case reports, retrospective cohort studies, case report series, meta-analyses, clinical trials, randomised clinical trials, cross-sectional and longitudinal analyses, longitudinal observational studies, and prospective clinical trials. All these were included in the quantitative and qualitative analyses.

Conclusions

Anti-TNF-a drugs show promising results in treating patients with rheumatoid arthritis and periodontitis but could be considered a risk factor for osteonecrosis. Hence, patients receiving such medications should be closely monitored by the dentist and physician before, during, and after administration.

Inflammatory Cytokines in Psoriatic Arthritis: Understanding Pathogenesis and Implications for Treatment

Psoriatic arthritis (PsA) is a persistent, inflammatory disease that affects individuals with psoriasis, arthritis, and enthesitis. Research has demonstrated that inflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-23 (IL-23), and interleukin-17 (IL-17) play a pivotal role in both the onset and progression of PsA. These cytokines are generated by activated immune cells and stimulate the attraction of inflammatory cells to the synovium and joint tissues, resulting in the deterioration of cartilage and bone. The blocking of these cytokines has become a successful treatment strategy for PsA, as biological drugs that inhibit TNF-α, IL-23, and IL-17 have demonstrated notable clinical benefits. The association between PsA and other types of inflammatory cytokines or chemokines, excluding TNF-α, IL-23, and IL-17, has been extensively investigated in numerous studies. These findings may provide a chance for the discovery of novel therapeutic agents targeting other molecules, distinct from the currently approved biologics and targeted synthetic disease-modifying anti-rheumatic drugs. In this review, we discuss the current understanding of the role of inflammatory cytokines in PsA pathogenesis and clinical implications of targeting these cytokines for PsA treatment.

Mural cell composition and functional analysis in the healing process of human gingiva from periodontal intrabony defects

OBJECTIVE

To evaluate the composition and function of mural cell populations in human gingival tissues DESIGN: A cross-sectional study was conducted on seven periodontitis (stage Ⅲ) patients. Gingival tissues were collected two months after scaling and root planing and divided into 3 groups: 1, h_h group (horizontal bone resorption, residual pocket depth ≤3 mm); 2, v_h group (vertical bone resorption >4 mm, residual pocket depth ≤3 mm); 3, v_i group (vertical bone resorption >4 mm, residual pocket depth ≥6 mm). Single-cell RNA sequencing (10X genomics) and subsequent bioinformatics analysis were performed. Protein expression of selected genes was confirmed by histological staining.

RESULTS

Two mural cell clusters, RGS5⁺THY1⁺ and ACTA2⁺MYH11⁺ subpopulations, were identified and confirmed by histological staining and cross-validation with three different single-cell RNA sequencing datasets in the GEO database. RGS5⁺THY1⁺ cluster in perivascular areas possessed cellular protrusions and exhibited immunomodulatory and synthetic phenotypes. In contrast, the ACTA2⁺MYH11⁺ cluster strictly distributed around vessel walls was characterized by a contractile phenotype. Mural cells closely interacted with endothelial cells through PDGF and NOTCH3 signaling. Mural cell loss was detected in the v_i group and in hopeless periodontal teeth, which might be caused by tumor necrosis factor-alpha induced apoptosis.

CONCLUSIONS

Gingival mural cells can be classified into two distinct clusters according to their gene signatures and cell morphology. The loss of mural cells may indicate periodontitis progression.

Inhibition of tumor necrosis factor receptor 1 and the risk of periodontitis

Aim

To investigate the effect of genetically proxied inhibition of tumor necrosis factor receptor 1 (TNFR1) on the risk of periodontitis.

Materials and methods

Genetic instruments were selected from the vicinity of TNFR superfamily member 1A (TNFRSF1A) gene (chromosome 12; base pairs 6,437,923-6,451,280 as per GRCh37 assembly) based on their association with C-reactive protein (N= 575,531). Summary statistics of these variants were obtained from a genome-wide association study (GWAS) of 17,353 periodontitis cases and 28,210 controls to estimate the effect of TNFR1 inhibition on periodontitis using a fixed-effects inverse method.

Results

Considering rs1800693 as an instrument, we found no effect of TNFR1 inhibition on periodontitis risk (Odds ratio (OR) scaled per standard deviation increment in CRP: 1.57, 95% confidence interval (CI): 0.38;6.46). Similar results were derived from a secondary analysis that used three variants (rs767455, rs4149570, and rs4149577) to index TNFR1 inhibition.

Conclusions

We found no evidence of a potential efficacy of TNFR1 inhibition on periodontitis risk.

BML-111 inhibits osteoclast differentiation by suppressing the MAPK and NF-κB pathways, alleviating deterioration of the knee joints in a CIA rat model

Irreversible destruction of joints is the hallmark of rheumatoid arthritis (RA). Osteoclasts are the only bone-resorbing cells and play an important role in joint rebuilding. BML-111 (5(S),6(R),7-trihydroxyheptanoic acid methyl ester, C₈ H₁₆ O₅ ) is a synthetic lipoxin A4 agonist with antioxidant and anti-inflammatory properties. The present study aimed to investigate the effect of BML-111 on osteoclasts in vivo and in vitro, to investigate its therapeutic effect on joint destruction in RA. Cell Counting Kit-8 assay and flow cytometry were used to exclude cytotoxic effects of BML-111 to bone marrow-derived macrophages (BMMs). Then, osteoclasts were differentiated in vitro from BMMs by used macrophage colony-stimulating factor and receptor activator of nuclear factor-κB ligand, and osteoclasts were observed following tartrate-resistant acid phosphatase staining with or without BML-111 treatment. Meanwhile, absorption pit assay and immunofluorescence staining of the fibrous actin ring were used to observe osteoclast function. Moreover, we examined mitogen-activated protein kinase (MAPK) and nuclear factor-κB (NF-κB) activation. We established collagen-induced arthritis in a rat model and, after treatment with BML-111, joint swelling was measured and the knee joints were processed for histology. We also examined serum and tissue for osteoclastogenesis-related markers. BML-111 inhibited osteoclast formation and differentiation in a time- and concentration-dependent manner, and downregulated the expression levels of MAPK and NF-κB in vitro. Meanwhile, BML-111 effectively alleviated joint structural damage and inhibited osteoclast formation in vivo. BML-111 inhibited osteoclast formation and differentiation in vitro and in vivo, and delayed the progression of joint destruction.

Adalimumab for the Treatment of Periodontitis in a 35-Year-Old Woman with Hidradenitis Suppurativa

Increasing evidence suggests an association between chronic inflammatory conditions and oral health. Herein, we present a case of a 35-year-old woman with concomitant hidradenitis suppurativa (HS) and periodontitis, who was treated successfully with adalimumab. After 3 months of treatment, a marked improvement was observed in her clinical scores of HS, quality of life, as well as her gingival pain and signs of inflammation. This finding calls for a closer collaboration between dermatologists and dentists to further explore the possible beneficial role of biologic therapy for chronic inflammatory skin conditions as well as periodontitis.

The Effectiveness of Laser Applications and Photodynamic Therapy on Relevant Periodontal Pathogens (Aggregatibacter actinomycetemcomitans) Associated with Immunomodulating Anti-rheumatic Drugs

Considering the current context of the increasing resistance of bacterial species to antibiotics and other antimicrobial agents, a major objective is to develop other antimicrobial approaches, which would be able to inactivate pathogens with considerable effectiveness. Two such methods are photodynamic disinfection therapy and laser irradiation. In view of the immunocompromised status of some patients under immunosuppressive therapy and potential drug interactions that can be established between systemic antimicrobial agents, the research of local, minimally invasive methods of inactivating periodontal pathogens in the context of these systemic therapies with modifying drugs of the immune response is justified. This in vitro study evaluated the antimicrobial action of a diode laser, wavelength 940 nm, and photodisinfection therapy at 670 nm (photosensitizer, 3,7 dimethyl phenothiazine chloride) on a type strain of Aggregatibacter actinomycetemcomitans, a known periodontal pathogen, in the presence and absence of active substances used in autoimmune disease therapy (Etanercept, Infliximab, Metothrexate). The association of a conventional antirheumatic drug with anti-TNF-α therapy determined a significantly greater inhibition of the strain of A. actinomycetemcomitans compared to monotherapy, in vitro. Photodisinfection caused a significant reduction in bacterial burden after a 30 s exposure in vitro, regardless of the pharmaceutical associations of biological and conventional disease-modifying antirheumatic drugs (DMARDs). Irradiation with a diode laser for 30 s at a power of 5 W caused a greater reduction compared to irradiation with 1 W. The application of laser and photodisinfection induced a significant reduction in Aggregatibacter actinomycetemcomitans in vitro and could be considered important adjunctive measures for the eradication of this oral pathogen in the context of immunomodulating therapy.

Immune senescence and periodontitis: From mechanism to therapy

Periodontitis is one of the most prevalent infectious inflammatory diseases, characterized by irreversible destruction of the supporting tissues of teeth, which is correlated with a greater risk of multiple systemic diseases, thus regarded as a major health concern. Dysregulation between periodontal microbial community and host immunity is considered to be the leading cause of periodontitis. Comprehensive studies have unveiled the double-edged role of immune response in the development of periodontitis. Immune senescence, which is described as age-related alterations in immune system, including a diminished immune response to endogenous and exogenous stimuli, a decline in the efficiency of immune protection, and even failure in immunity build-up after vaccination, leads to the increased susceptibility to infection. Recently, the intimate relationship between immune senescence and periodontitis has come into focus, especially in the aging population. In this review, both periodontal immunity and immune senescence will be fully introduced, especially their roles in the pathology and progression of periodontitis. Furthermore, novel immunotherapies targeting immune senescence are presented to provide potential targets for research and clinical intervention in the future.

Normalization of Neuroinflammation: A New Strategy for Treatment of Persistent Pain and Memory/Emotional Deficits in Chronic Pain

Chronic pain, which affects around 1/3 of the world population and is often comorbid with memory deficit and mood depression, is a leading source of suffering and disability. Studies in past decades have shown that hyperexcitability of primary sensory neurons resulting from abnormal expression of ion channels and central sensitization mediated pathological synaptic plasticity, such as long-term potentiation in spinal dorsal horn, underlie the persistent pain. The memory/emotional deficits are associated with impaired synaptic connectivity in hippocampus. Dysregulation of numerous endogenous proteins including receptors and intracellular signaling molecules is involved in the pathological processes. However, increasing knowledge contributes little to clinical treatment. Emerging evidence has demonstrated that the neuroinflammation, characterized by overproduction of pro-inflammatory cytokines and glial activation, is reliably detected in humans and animals with chronic pain, and is sufficient to induce persistent pain and memory/emotional deficits. The abnormal expression of ion channels and pathological synaptic plasticity in spinal dorsal horn and in hippocampus are resulting from neuroinflammation. The neuroinflammation is initiated and maintained by the interactions of circulating monocytes, glial cells and neurons. Obviously, unlike infectious diseases and cancer, which are caused by pathogens or malignant cells, chronic pain is resulting from alterations of cells and molecules which have numerous physiological functions. Therefore, normalization (counterbalance) but not simple inhibition of the neuroinflammation is the right strategy for treating neuronal disorders. Currently, no such agent is available in clinic. While experimental studies have demonstrated that intracellular Mg²⁺ deficiency is a common feature of chronic pain in animal models and supplement Mg²⁺ are capable of normalizing the neuroinflammation, activation of upregulated proteins that promote recovery, such as translocator protein (18k Da) or liver X receptors, has a similar effect. In this article, relevant experimental and clinical evidence is reviewed and discussed.

Immunomodulation—What to Modulate and Why? Potential Immune Targets

Despite over 50 years of research into the immunology of periodontal disease, the precise mechanisms and the role of many cell types remains an enigma. Progress has been limited by the inability to determine disease activity clinically. Understanding the immunopathogenesis of periodontal disease however is fundamental if immunomodulation is to be used as a therapeutic strategy. It is important for the clinician to understand what could be modulated and why. In this context, potential targets include different immune cell populations and their subsets, as well as various cytokines. The aim of this review is to examine the role of the principal immune cell populations and their cytokines in the pathogenesis of periodontal disease and their potential as possible therapeutic targets.

Outside the limits of bacterial viability: postbiotics in the management of periodontitis

Periodontitis is a major cause of tooth loss in adults worldwide and is caused by an unbalanced oral microbiota in a susceptible host, ultimately leading to tissue breakdown and bone loss. Traditionally, the treatment for periodontitis is scaling and root planing; however, some cases require adjuvant therapy, such as antibiotics administration or surgery. Various factors are involved in the pathogenesis and interact in an unpredictable way, increasing the complexity of the disease and making it difficult to manage. In this context, the administration of probiotics aimed at resolving bacterial dysbiosis and the associated dysregulation of the immune system has been employed in clinical trials with encouraging results. However, the use of viable microorganisms is not risk-free, and immunocompromised patients may develop adverse effects. Therefore, the use of inactivated microbial cells, cell fractions, or soluble products and metabolites of probiotics, known as postbiotics, has gained increasing attention. In this commentary, we present the current literature assessing the impact of postbiotics on the growth and metabolism of periodontal pathogens, as well as on the progression of periodontitis in rodents and humans. We also discuss the limitations of the available data and what the scientific community should consider in order to transfer this innovative therapeutic modality from the bench to the bedside.

Diabetes Medication Metformin Inhibits Osteoclast Formation and Activity in In Vitro Models for Periodontitis

Diabetes and periodontitis are comorbidities and may share common pathways. Several reports indicate that diabetes medication metformin may be beneficial for the periodontal status of periodontitis patients. Further research using appropriate cell systems of the periodontium, the tissue that surrounds teeth may reveal the possible mechanism. Periodontal ligament fibroblasts anchor teeth in bone and play a role in the onset of both alveolar bone formation and degradation, the latter by inducing osteoclast formation from adherent precursor cells. Therefore, a cell model including this type of cells is ideal to study the influence of metformin on both processes. We hypothesize that metformin will enhance bone formation, as described for osteoblasts, whereas the effects of metformin on osteoclast formation is yet undetermined. Periodontal ligament fibroblasts were cultured in the presence of osteogenic medium and 0.2 or 1 mM metformin. The influence of metformin on osteoclast formation was first studied in PDLF cultures supplemented with peripheral blood leukocytes, containing osteoclast precursors. Finally, the effect of metformin on osteoclast precursors was studied in cultures of CD14⁺ monocytes that were stimulated with M-CSF and receptor activator of Nf-κB ligand (RANKL). No effects of metformin were observed on osteogenesis: not on alkaline phosphatase activity, Alizarin red deposition, nor on the expression of osteogenic markers RUNX-2, Collagen I and Osteonectin. Metformin inhibited osteoclast formation and accordingly downregulated the genes involved in osteoclastogenesis: RANKL, macrophage colony stimulating factor (M-CSF) and osteoclast fusion gene DC-STAMP. Osteoclast formation on both plastic and bone as well as bone resorption was inhibited by metformin in M-CSF and RANKL stimulated monocyte cultures, probably by reduction of RANK expression. The present study unraveling the positive effect of metformin in periodontitis patients at the cellular level, indicates that metformin inhibits osteoclast formation and activity, both when orchestrated by periodontal ligament fibroblasts and in cytokine driven osteoclast formation assays. The results indicate that metformin could have a systemic beneficiary effect on bone by inhibiting osteoclast formation and activity.

Rheumatoid Arthritis: Pathogenic Roles of Diverse Immune Cells

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease associated with synovial tissue proliferation, pannus formation, cartilage destruction, and systemic complications. Currently, advanced understandings of the pathologic mechanisms of autoreactive CD4+ T cells, B cells, macrophages, inflammatory cytokines, chemokines, and autoantibodies that cause RA have been achieved, despite the fact that much remains to be elucidated. This review provides an updated pathogenesis of RA which will unveil novel therapeutic targets.

Machine learning to identify immune-related biomarkers of rheumatoid arthritis based on WGCNA network

OBJECTIVES

This study was designed to identify the potential diagnostic biomarkers of rheumatoid arthritis (RA) and to explore the potential pathological relevance of immune cell infiltration in this disease.

METHODS

Three previously published datasets containing gene expression data from 35 RA patients and 29 controls (GSE55235, GSE55457, and GSE12021) were downloaded from the GEO database, after which a weighted correlation network analysis (WGCNA) approach was utilized to clarify differentially abundant genes. Candidate biomarkers of RA were then identified via the use of a LASSO regression model and support vector machine recursive feature elimination (SVM-RFE) analyses. Data were validated based upon the area under the receiver operating characteristic curve (AUC) values, with hub genes being identified as those with an AUC > 85% and a P value < 0.05. Lastly, the CIBERSORT algorithm was used to assess immune cell infiltration of RA tissues, and correlations between immune cell infiltration and disease-related diagnostic biomarkers were assessed.

RESULTS

The green-yellow module containing 87 genes was found to be highly correlated with RA positivity. FADD, CXCL2, and CXCL8 were identified as potential RA diagnostic biomarkers (AUC > 0.85), and these results were validated using the GSE77298 dataset. Immune cell infiltration analyses revealed the expression of hub genes to be correlated with mast cells, monocytes, activated NK cells, CD8 T cells, resting dendritic cells, and plasma cells.

CONCLUSION

These data indicate that FADD, CXCL2, and CXCL8 are valuable diagnostic biomarkers of RA, offering new insight that can guide future studies of RA incidence and progression.

Effect of Anti-Rheumatic Treatment on the Periodontal Condition of Rheumatoid Arthritis Patients

Periodontitis, a bacterial-induced infection of the supporting soft and hard tissues of the teeth (the periodontium), is common in patients with rheumatoid arthritis (RA). As RA and periodontitis underlie common inflammatory pathways, targeting the progression of RA might mediate both periodontitis and RA. On the other hand, patients with RA on immunosuppressive medication have an increased risk of infection. Therefore, the objective of this longitudinal observation study was to assess the effect of methotrexate (MTX) and anti-tumor necrosis factor-α (anti-TNF, etanercept) treatment on the periodontal condition of RA patients. Overall, 14 dentate treatment-naive RA patients starting with MTX and 12 dentate RA patients starting with anti-TNF therapy in addition to MTX were included. Follow-up was scheduled matching the routine protocol for the respective treatments. Prior to the anti-rheumatic treatment with MTX or the anti-TNF therapy in addition to MTX, and during follow-up, i.e., 2 months for MTX, and 3 and 6 months for the anti-TNF therapy in addition to MTX, the periodontal inflamed surface area (PISA) was measured. The efficacy of the anti-rheumatic treatment was assessed by determining the change in RA disease activity (DAS28-ESR). Furthermore, the erythrocyte sedimentation rates were determined and the levels of C-reactive protein, IgM-rheumatoid factor, anti-cyclic citrullinated protein antibodies, and antibodies to the periodontal pathogen Porphyromonas gingivalis, were measured. Subgingival sampling and microbiological characterization of the subgingival microflora was done at baseline. MTX or anti-TNF treatment did not result in an improvement of the periodontal condition, while both treatments significantly improved DAS28 scores (both p < 0.01), and reduced C-reactive protein levels and erythrocyte sedimentation rates (both p < 0.05). It is concluded that anti-rheumatic treatment (MTX and anti-TNF) has negligible influence on the periodontal condition of RA patients.

Host Modulation and Treatment of Periodontal Disease

Periodontitis is the sixth-most prevalent disease in the world and the first cause for tooth loss in adults. With focus shifted to the inflammatory/immune response in the pathogenesis of periodontitis, there is a critical need to evaluate host modulatory agents. Synthetic and biological disease-modifying antirheumatic drugs are a cornerstone for the treatment of inflammatory diseases. Recent prospective cohort studies showed that synthetic disease-modifying antirheumatic drugs improved periodontal clinical parameters following nonsurgical periodontal treatment in patients with rheumatoid arthritis. Treatment with recombinant humanized monoclonal antibodies against CD20 (rituximab) and IL-6 receptor (tocilizumab), the latter also in clinical trials for the treatment of COVID-19 pneumonia, resulted in decreased periodontal inflammation and improved periodontal status. Studies on the effect of TNF-α inhibitors in patients with periodontitis yielded inconsistent results. Recent data suggest that probiotics provide anti-inflammatory clinical benefit, as do nutritional supplements, such as n-3 fatty acids, when combined with periodontal therapy. Probiotics reduce the production of proinflammatory cytokines/chemokines by suppressing NF-κB pathways and promote the accumulation of T regulatory cells. Statins, like aspirin, have been shown to exhibit anti-inflammatory and bone-preserving actions by upregulating production of Specialized Proresolving Mediators (SPMs). Currently, there is insufficient scientific support for the topical delivery of statins or bisphosphonates as adjuncts to periodontal therapy. Here, we present a critical review of the most recent host modulatory agents applied in humans and the key immune pathways that they target. Emerging evidence from novel drug candidates, including SPMs and complement inhibitors as previously studied in animal models and currently in human clinical trials, suggests future availability of adjunctive therapeutic strategies for the management of periodontitis.

Investigating the relationship between the severity of periodontitis and rheumatoid arthritis: a cross-sectional study

OBJECTIVES

This paper evaluates the prevalence and severity of periodontitis (PD) in patients with rheumatoid arthritis (RA), focusing on the link between the severity of PD with RA disease activity/disability scores, the influence of RA treatment on PD, and levels of vitamin D.

METHODS

A total of 93 RA patients were enrolled in the cross-sectional study and analyzed accordingly as RA-PD (N = 63, 67.8%) and RA-only (N = 30, 32.2%) groups. A number of associations between rheumatological clinical data, i.e., Disease Activity Score (DAS28 CRP), health assessment questionnaires, and PD severity (measured by periodontal outcome parameters) with regard to serum levels of vitamin D were assessed. The outcome variables were compared by parametric and non-parametric tests.

RESULTS

A total of 29% of RA patients were diagnosed with severe PD. The RA-PD group presented a higher mean DAS28 CRP score in moderate-severe PD compared to periodontally healthy-initial stage PD subjects (4.49 ± 1.22 vs. 3.86 ± 1.58, p = 0.033). RA patients treated with biologic disease-modifying antirheumatic drugs (bDMARDs) were less likely to be diagnosed with PD (p = 0.022) and revealed significantly lower PD outcome parameters, i.e., bleeding on probing (%) and bone loss (%) (p < 0.05). Vitamin D concentration was significantly lower in RA-PD group with diagnosed advanced severe PD (IV stage) compared to moderate PD (II stage) (39.61 ± 17.12 vs. 52.07 ± 18.23 nmol/l, p = 0.031).

CONCLUSIONS

The study revealed a high prevalence of severe PD in RA patients, being significantly associated with higher RA disease activity and lower vitamin D level in RA-PD group, while bDMARD treatment was related to lower PD outcome parameters. Key Points • Severe PD is prevalent amongst RA patients and is associated with RA disease activity. The higher RA DAS28 CRP score is associated with moderate-severe PD compared to periodontally healthy-initial stage PD in RA patients. • Biologic DMARDs treatment used for RA is linked to lower PD rates and PD outcome parameters. • Significantly lower vitamin D level is found in advanced severe PD compared to moderate PD stage in RA-PD subjects.

Exploring the Role of Interleukin-6 Receptor Inhibitor Tocilizumab in Patients with Active Rheumatoid Arthritis and Periodontal Disease

BACKGROUND

The aim of our study was to explore the influence of weekly subcutaneous administration of interleukin-6 (IL-6) receptor inhibitor tocilizumab (TCZ) on periodontal status in a local longitudinal study of patients with rheumatoid arthritis (RA) and periodontal disease (PD).

METHODS

We performed a 6-month prospective study in 51 patients with chronic periodontitis and moderate-to-severe RA starting TCZ in accordance with local recommendations. Extensive rheumatologic (clinical activity, inflammatory, serological biomarkers) and periodontal (visible plaque index, gingival index, bleeding on probing, probing pocket depth, clinical attachment loss) assessments were done. Changes in RA activity and periodontal status were reassessed after 3 and 6 months.

RESULTS

We demonstrated significant correlations between periodontal status, disease activity, and serologic biomarkers (p < 0.05). Tocilizumab significantly improved the gingival index scores and decreased the number of sites with bleeding on probing after only 3 months (p < 0.05), while the probing pocket depth significantly decreased after 6 months; overall, clinical attachment loss presented only slight changes without any statistical significance as well as teeth count and plaque levels (p > 0.05).

CONCLUSION

IL-6 inhibition is able to improve periodontal outcomes in patients with RA and concomitant PD, which is essentially related to a dramatic decrease in serum inflammatory mediators.

Evaluation of Oxidative Stress before and after Using Laser and Photoactivation Therapy as Adjuvant of Non-Surgical Periodontal Treatment in Patients with Rheumatoid Arthritis

(1) Background: The aim of this split-mouth design study was to analyze the clinical periodontal indexes and oxidative stress markers in gingival crevicular fluid modifications after three periodontal disease treatment possibilities (scaling and root planning-SRP; SRP and diode laser-L; SRP and photodynamic therapy-PDT). (2) Methods: The study was conducted on 52 patients: systemically healthy subjects with periodontal disease-non-RA (n = 26); and test group (n = 26) subjects with rheumatoid arthritis and periodontal disease-RA. Clinical periodontal measurements (probing depth-PD; Löe and Silness gingival index-GI; papillary bleeding index-PBI; and periodontal community index of treatment needs-CPITN) and oxidative stress markers (8-hydroxy-2'-deoxyguanosine (8-OHdG) and 4 hydroxynonenal (4-HNE)) were analyzed at baseline (T0), after three sessions of periodontal treatment (T1), and 6 months after treatment (T2). (3) Results: Periodontal therapy improved clinical periodontal measurements and oxidative stress markers in both analyzed groups, with supplementary benefits for laser- and PDT-treated periodontal pockets. (4) Conclusions: The analyzed oxidative stress markers decreased significantly following non-surgical periodontal therapy in both rheumatoid arthritis and systemically healthy patients. All the periodontal disease treatment possibilities analyzed in this study offered clinical and paraclinical improvements; however, the association of laser with SRP and photodisinfection with SRP yielded the best clinical and paraclinical outcomes when compared to SRP alone.

Nicotine in E-Cigarettes Dysregulates Pulmonary Inflammation and MMP-12 Expression without Effecting Respiratory Syncytial Virus Virulence

The safety of electronic cigarettes (e-cigarettes) is a major topic of discussion. The key goals of this study were to examine the contents of e-cigarette vapor and determine if nicotine altered inflammatory responses against respiratory syncytial virus (RSV) infection. E-cigarette vapor was passed through a hollow 3D-model of an adult lung, and gas chromatography detected over 50 compounds passed through the 3D model, including nicotine, propylene glycol (PG), ethanol, methanol, and diacetyl. The murine alveolar macrophage cell line MH-S cells were exposed to nicotine and e-cigarette vapor with and without nicotine. Nicotine significantly induced the expression of matrix metalloprotease (Mmp) 12 and reduced expression of Ifnβ and Tnfα. To examine the role of nicotine in lung defense against RSV infection, A/J mice were exposed to PBS, e-cigarette vapor with and without nicotine for 2 months before RSV infection. E-cigarette vapor did not influence RSV infection-induced animal weight loss, RSV infectivity, airway hyperresponsiveness during methacholine challenge, or immune cell infiltration into the lungs. However, e-cigarette vapor containing nicotine enhanced obstruction and induced secretion of MMP12 and reduced levels of Ifnβ and TNFα. In conclusion, nicotine in vaping products modulates immune responses that may impact the lungs during a respiratory infection.