Changes in the Biomarkers of Oxidative/Nitrosative Stress and Endothelial Dysfunction Are Associated with Cardiovascular Risk in Periodontitis Patients

Effect of non-surgical periodontal therapy on risk markers of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in the world. Patients with periodontitis have a higher risk of CVD, although a causal relationship between these conditions remains unclear. Non-surgical periodontal therapy (NSPT) is able to control inflammation at local and systemic levels. This study aimed to analyze the effect of NSPT on CVD risk markers.

METHODS

Four electronic databases were searched from their inception to April 1, 2023, to identify and select articles without any language restrictions. Eleven CVD-related markers (e.g., C-reactive protein [CRP], Interleukin-6 [IL-6]) were selected. Meta-analyses were performed using random and fixed effect models. The differences were expressed as weighted mean differences (WMD) and 95% confidence interval (95% CI).

RESULTS

From 1353 studies, twenty-one randomized controlled clinical trials were included in the meta-analysis. Results showed a significant decrease in CRP, IL-6, and systolic blood pressure (SBP) after NSPT.

CONCLUSION

Moderate certainty evidence shows that NSPT has a positive effect on the reduction of IL-6 and SBP in patients with periodontitis, while low certainty evidence shows that NSPT is effective for reduction of CRP. Moderate certainty evidence showed that NSPT did not show a positive effect on low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC) and triglycerides (TG), and low certainty evidence showed that NSPT did not show a positive effect on Interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α), diastolic blood pressure (DBP), and flow-mediated dilatation (FMD).

PROTOCOL REGISTRATION

The protocol was registered in the PROSPERO (International Prospective Register of Systematic Reviews), number CRD42022377565.

The Role of Oxidative Stress and Inflammatory Parameters in Heart Failure

Heart failure (HF) remains a major medical and social problem. The NT-pro-brain natriuretic peptide (NT-proBNP) and its active form, brain-type natriuretic peptide (BNP), in a simple blood test are the gold-standard biomarkers for HF diagnosis. However, even good biomarkers such as natriuretic peptides fail to predict all the risks associated with HF due to the diversity of the mechanisms involved. The pathophysiology of HF is determined by numerous factors, including oxidative stress, inflammation, neuroendocrine activation, pathological angiogenesis, changes in apoptotic pathways, fibrosis and vascular remodeling. High readmission and mortality rates prompt a search for new markers for the diagnosis, prognosis and treatment of HF. Oxidative-stress-mediated inflammation plays a crucial role in the development of subsequent changes in the failing heart and provides a new insight into this complex mechanism. Oxidative stress and inflammatory biomarkers appear to be a promising diagnostic and prognostic tool in patients with HF. This systematic review provides an overview of the current knowledge about oxidative stress and inflammation parameters as markers of HF.

Association between Nfr2, HO-1, NF-kB Expression, Plasma ADMA, and Oxidative Stress in Metabolic Syndrome

Endothelial dysfunction is one of the major factors in the pathogenesis of metabolic syndrome (MetS), and its molecular mechanisms are not completely understood. The present study aimed to examine the connection between nuclear factor2-related factor2 (Nrf2), nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), heme oxygenase 1 (HO-1), and plasma asymmetric dimethylarginine (ADMA) and malondialdehyde (MDA) in people with MetS. Participants in the study were as follows: with MetS (n = 30) and without MetS (Control) (n = 14). Expression of Nrf2, NF-kB, and HO-1 was measured in peripheral blood mononuclear cells (PBMCs). Plasma ADMA was determined using the ELISA technique and MDA via the thiobarbituric acid method. Our study showed that mRNA of NF-kB, Nrf2, and HO-1 levels in PBMCs in the MetS group were significantly higher than in the controls by 53%, 130%, and 185% (p < 0.05), respectively. Similarly, elevated levels of MDA (by 78%, p < 0.001) and ADMA (by 18.7%, p < 0.001) were established in the MetS group. Our findings show the importance of transcription factor Nrf2, playing an integral role in the protection of the endothelium, and of NF-κB, a transcription factor mediating the inflammatory response in MetS. Knowledge of complex cellular-molecular mechanisms would allow the use of biomarkers such as Nrf2, NF-kB, HO-1, and ADMA for the assessment of endothelial dysfunction in clinical practice.

Association between oral function and nutrition in gastric cancer patients undergoing chemotherapy

OBJECTIVES

This study aimed to clarify the relationship between the oral assessment guide (OAG), a simple method for assessing oral function and poor nutrition in gastric cancer patients and investigate the reduction of oral mucositis through appropriate oral function management.

SUBJECTS AND METHODS

Gastric cancer patients who underwent chemotherapy at the Nagoya Ekisaikai Hospital between January 2015 and December 2020 were evaluated. The prognostic nutritional index (PNI), as the objective variable, was used to assess nutritional status. The explanatory variables were sex, age, smoking status, body mass index (BMI), number of remaining teeth, cancer stage, albumin level, C-reactive protein level, white blood cell count and the OAG score.

RESULTS

PNI was significantly associated with age, number of remaining teeth, cancer stage and the OAG score (p < 0.05) among the 217 patients. There were significant differences in age, BMI, cancer stage and the OAG score among the patients. An abnormal BMI and an advanced cancer stage were more common in older patients, and abnormal OAG scores were associated with a lower PNI.

CONCLUSIONS

For gastric cancer patients undergoing postoperative chemotherapy, worse oral functional status is associated with worse PNI and nutritional status.

Thymoquinone, a Novel Multi-Strike Inhibitor of Pro-Tumorigenic Breast Cancer (BC) Markers: CALR, NLRP3 Pathway and sPD-L1 in PBMCs of HR+ and TNBC Patients

Breast cancer (BC) is not only a mass of malignant cells but also a systemic inflammatory disease. BC pro-tumorigenic inflammation has been shown to promote immune evasion and provoke BC progression. The NOD-like receptor (NLR) family pyrin domain-containing protein 3 (NLRP3) inflammasome is activated when pattern recognition receptors (PRRs) sense danger signals such as calreticulin (CALR) from damaged/dying cells, leading to the secretion of interleukin-1β (IL-1β). CALR is a novel BC biological marker, and its high levels are associated with advanced tumors. NLRP3 expression is strongly correlated with an elevated proliferative index Ki67, BC progression, metastasis, and recurrence in patients with hormone receptor-positive (HR+) and triple-negative BC (TNBC). Tumor-associated macrophages (TAMs) secrete high levels of IL-1β promoting endocrine resistance in HR+ BC. Recently, an immunosuppressive soluble form of programmed death ligand 1 (sPD-L1) has been identified as a novel prognostic biomarker in triple-negative breast cancer (TNBC) patients. Interestingly, IL-1β induces sPD-L1 release. BC Patients with elevated IL-1β and sPD-L1 levels show significantly short progression-free survival. For the first time, this study aims to investigate the inhibitory impact of thymoquinone (TQ) on CALR, the NLRP3 pathway and sPD-L1 in HR+ and TNBC. Blood samples were collected from 45 patients with BC. The effect of differing TQ concentrations for different durations on the expression of CALR, NLRP3 complex components and IL-1β as well as the protein levels of sPD-L1 and IL-1β were investigated in the peripheral blood mononuclear cells (PBMCs) and TAMs of TNBC and HR+ BC patients, respectively. The findings showed that TQ significantly downregulated the expression of CALR, NLRP3 components and IL-1β together with the protein levels of secreted IL-1β and sPD-L1. The current findings demonstrated novel immunomodulatory effects of TQ, highlighting its potential role not only as an excellent adjuvant but also as a possible immunotherapeutic agent in HR+ and TNBC patients.

Role of oxidative stress in the relationship between periodontitis and systemic diseases

Periodontitis is a common inflammatory disease. It is characterized by destruction of the supporting structures of the teeth and could lead to tooth loss and systemic inflammation. Bacteria in inflamed gingival tissue and virulence factors are capable of entering the bloodstream to induce systemic inflammatory response, thus influencing the pathological process of many diseases, such as cardiovascular diseases, diabetes, chronic kidney disease, as well as liver injury. An increasing body of evidence show the complex interplay between oxidative stress and inflammation in disease pathogenesis. When periodontitis occurs, increased reactive oxygen species accumulation leads to oxidative stress. Oxidative stress contributes to major cellular components damage, including DNA, proteins, and lipids. In this article, the focus will be on oxidative stress in periodontal disease, the relationship between periodontitis and systemic inflammation, and the impact of periodontal therapy on oxidative stress parameters.

Increased Circulating ADMA in Young Male Rats Caused Cognitive Deficits and Increased Intestinal and Hippocampal NLRP3 Inflammasome Expression and Microbiota Composition Alterations: Effects of Resveratrol

Endothelial dysfunction is characterized by disturbances in nitric oxide (NO) bioavailability and increased circulating asymmetric dimethylarginine (ADMA) due to the enormous release of free radicals. Increased circulating ADMA may cause endothelial dysfunction and a variety of clinical disorders, such as liver and kidney disease. Young male Sprague-Dawley rats at postnatal day 17 ± 1 received continuous ADMA infusion via an intraperitoneal pump to induce endothelial dysfunction. Four groups of rats (n = 10 per group) were allocated: control, control and resveratrol, ADMA infusion, and ADMA infusion and resveratrol groups. Spatial memory, NLR family pyrin-domain-containing 3 (NLRP3) inflammasome, cytokine expression, tight junction proteins in the ileum and dorsal hippocampus, and microbiota composition were examined. We found cognitive deficits; increased NLRP3 inflammasome in the plasma, ileum, and dorsal hippocampus; decreased ileum and dorsal hippocampal cytokine activation and tight junction proteins; and microbiota composition alterations in the ADMA-infusion young male rats. Resveratrol had beneficial effects in this context. In conclusion, we observed NLRP3 inflammasome activation in peripheral and central dysbiosis in young male rats with increased circulating ADMA, and found that resveratrol had beneficial effects. Our work adds to the mounting evidence that inhibiting systemic inflammation is a promising therapeutic avenue for cognition impairment, probably via the gut-brain axis.

Relationship between Oxidative Stress and Left Ventricle Markers in Patients with Chronic Heart Failure

Oxidative stress is proposed in the literature as an important player in the development of CHF and correlates with left ventricle (LV) dysfunction and hypertrophy in the failing heart. In this study, we aimed to verify if the serum oxidative stress markers differ in chronic heart failure (CHF) patients' groups depending on the LV geometry and function. Patients were stratified into two groups according to left ventricular ejection fraction (LVEF) values: HFrEF (<40% (n = 27)) and HFpEF (≥40% (n = 33)). Additionally, patients were stratified into four groups according to LV geometry: NG-normal left ventricle geometry (n = 7), CR-concentric remodeling (n = 14), cLVH-concentric LV hypertrophy (n = 16), and eLVF-eccentric LV hypertrophy (n = 23). We measured protein (protein carbonyl (PC), nitrotyrosine (NT-Tyr), dityrosine), lipid (malondialdehyde (MDA), oxidizes (HDL) oxidation and antioxidant (catalase activity, total plasma antioxidant capacity (TAC) markers in serum. Transthoracic echocardiogram analysis and lipidogram were also performed. We found that oxidative (NT-Tyr, dityrosine, PC, MDA, oxHDL) and antioxidative (TAC, catalase) stress marker levels did not differ between the groups according to LVEF or LV geometry. NT-Tyr correlated with PC (r_s = 0.482, p = 0.000098), and oxHDL (r_s = 0.278, p = 0.0314). MDA correlated with total (r_s = 0.337, p = 0.008), LDL (r_s = 0.295, p = 0.022) and non-HDL (r_s = 0.301, p = 0.019) cholesterol. NT-Tyr negatively correlated with HDL cholesterol (r_s = -0.285, p = 0.027). LV parameters did not correlate with oxidative/antioxidative stress markers. Significant negative correlations were found between the end-diastolic volume of the LV and the end-systolic volume of the LV and HDL-cholesterol (r_s = -0.935, p < 0.0001; r_s = -0.906, p < 0.0001, respectively). Significant positive correlations between both the thickness of the interventricular septum and the thickness of the LV wall and the levels of triacylglycerol in serum (r_s = 0.346, p = 0.007; r_s = 0.329, p = 0.010, respectively) were found. In conclusions, we did not find a difference in serum concentrations of both oxidant (NT-Tyr, PC, MDA) and antioxidant (TAC and catalase) concentrations in CHF patients' groups according to LV function and geometry was found. The geometry of the LV could be related to lipid metabolism in CHF patients, and no correlation between oxidative/antioxidant and LV markers in CHF patients was found.

Efficacy of non-surgical periodontal treatment on patients with coronary artery disease: a meta-analysis of randomized controlled trials

BACKGROUND

Coronary artery disease (CAD) is defined as one of the most common cardiovascular diseases (CVDs). Periodontitis is one of the risk factors for CAD.

MATERIAL AND METHODS

PubMed, Embase and Cochrane Library databases were carefully and thoroughly retrieved until October 2021. On the basis of the inclusion and exclusion criteria, eligible articles were selected strictly to identify randomized controlled trials (RCTs). Using Cochran's Q statistic, Review Manager 5.4 and Stata 16, data were extracted, and a comprehensive analysis was carried out.

RESULTS

Six RCTs of 619 patients were included in this study, including 360 in the intervention group (IG) and 259 in the control group (CG). Meta-analysis showed significant difference for C-reactive protein (CRP) (1.20mg/L, 95% CI: 1.13 to 1.27, p < 0.00001) after non-surgical periodontal therapy (NSPT), but showed no significant difference for interleukin-6 (IL-6) (1.19mg/L, 95% CI: -1.03 to 3.40, p=0.29), flow-mediated dilation (FMD) (-1.64%, 95% CI: -4.95 to 1.67, p=0.33), triacylglycerol (TG) (-0.02mg/dL, 95% CI: -0.31 to 0.27, p=0.90), total cholesterol (TC) (0.04mg/dL, 95% CI: -0.25 to 0.33, p=0.90), low-density lipoprotein cholesterol (LDL-C) (0.00mg/dL, 95% CI: -0.29 to 0.29, p=0.99) and high-density lipoprotein cholesterol (HDL-C) (0.11mg/dL, 95% CI: -0.18 to 0.40, p=0.46).

CONCLUSIONS

The impact of NSPT on the reduction of CRP in patients of CAD with periodontitis is significant. NSPT can be considered as an important preventive strategy for major cardiovascular events in CAD.

Intensive Periodontal Treatment Does Not Affect the Lipid Profile and Endothelial Function of Patients with Type 2 Diabetes: A Randomized Clinical Trial

Background: Local eradication of periodontal infection could potentially have a much broader impact on the diabetic condition by also contributing to the modification of the lipid profile, which is directly compromised in the alteration of endothelium-dependent vasodilation. The aim of this trial was to assess the benefits of intensive periodontal treatment (IPT) on the lipid profile and endothelial function of diabetic patients. Methods: This was a 6-month, randomized controlled trial involving diabetic patients with generalized periodontitis. The study group comprised 290 individuals who were randomly assigned to receive Intensive Periodontal Treatment (IPT, Intervention Group) or conventional adult prophylaxis (Control Periodontal Treatment, CPT, Control Group). Outcomes encompassed lipid profile involving serum total cholesterol, serum triglyceride, low-density lipoprotein cholesterol, high-density lipo-protein cholesterol, and flow-mediated vasodilation (FMD) as an index of endothelium-dependent vasodilation (primary outcomes); periodontal indices and high-sensitive C-reactive protein were evaluated at baseline, 3 and 6 months after periodontal treatment. Results: An increase in endothelium-dependent flow-mediated dilatation (FMD) was observed in the Intensive Periodontal Treatment group in comparison with Control (p < 0.001), but results are not statistically different. There were no differences in lipid profile in individuals of both groups. Conclusions: An intensive periodontal treatment might improve endothelial function, suggesting a direct beneficial effect on the vasculature, possibly mediated by systemic inflammatory reduction. However, no statistically significant differences between groups were observed, and no benefits were proved on lipid profile.

The Impact of Periodontal Inflammation on Endothelial Function Assessed by Circulating Levels of Asymmetric Dimethylarginine: A Single-Blinded Randomized Clinical Trial

Background: Endothelial dysfunction is one of the early pathogenic events of the atherosclerotic process. Severe periodontitis is considered to be an independent contributing risk factor for the pathophysiology of endothelial dysfunction. High blood concentration of asymmetric dimethylarginine (ADMA), an L-arginine analogue that inhibits nitric oxide (NO) formation, has emerged as one of the most powerful independent risk predictors of cardiovascular disease. Abrogation of periodontal inflammation might have clinical relevance, affecting the ADMA. Insufficient clinical evidence exists for drawing clear conclusions regarding the long-term effects of periodontal disease on endothelial function, and even less evidence is available specifically on ADMA concentrations and their relationship with periodontitis. The objective of this study was to evaluate the effects of intensive periodontal treatment in modulating the endothelial function via the assessment of plasma ADMA concentration in patients diagnosed severe periodontitis. Methods: This was a 6-month randomized controlled trial, including 140 patients between 41 and 63 years old who were diagnosed with severe periodontitis, free from cardiovascular disease (CVD), and had traditional cardiovascular risk factors. All patients underwent a complete medical and clinical periodontal examination, a laboratory analysis of ADMA, and an ultrasound assessment of FMD of the right brachial artery. After the screening, they were randomly assigned to receive either intensive periodontal treatment (test group, n = 70) or community-based periodontal care (control group, n = 70). A full examination was carried out at baseline, 3 and 6 months after the periodontal treatment. Results: A total of 236 individuals diagnosed with periodontitis were screened. One hundred forty participants were enrolled. No statistically significant difference was observed over the time in ADMA concentration after the intensive periodontal treatment within the test group. No differences were revealed between the groups in the ADMA concentration at baseline and during follow-up. Conclusions: Intensive periodontal treatment does not affect the plasma levels of ADMA in patients without any risk for cardiovascular disease.

Nitrotyrosine, Nitrated Lipoproteins, and Cardiovascular Dysfunction in Patients with Type 2 Diabetes: What Do We Know and What Remains to Be Explained?

Diabetes mellitus (DM) is a strong risk factor for the development of cardiovascular diseases (CVDs), which are the most important cause of morbidity and mortality in the population of patients living with DM. DM is associated with lipid metabolism disorders characterized by a decrease in the high-density lipoprotein blood concentration, an increase in the triglyceride blood concentration, and the presence of modified lipoproteins not routinely measured in clinical practice. Nitrated lipoproteins are produced by the nitration of the tyrosyl residues of apolipoproteins by myeloperoxidase. There is some evidence from the research conducted showing that nitrated lipoproteins may play a role in the development of cardiovascular dysfunction, but this issue requires further investigation. It was found that the nitration of HDL particles was associated with a decrease in caspase-3 and paraoxonase-1 activity, as well as a decrease in the activity of cholesterol transport via ABCA1, which reduces the protective effect of HDL particles on the cardiovascular system. Less information has been collected about the role of nitrated LDL particles. Thus far, much more information has been obtained on the relationship of nitrotyrosine expression with the presence of cardiovascular risk factors and the development of cardiovascular dysfunction. The purpose of this paper is to provide an extensive review of the literature and to present the most important information on the current state of knowledge on the association between nitrotyrosine and nitrated lipoproteins with dysfunction of the cardiovascular system, especially in patients living with DM. Moreover, directions for future research in this area were discussed.

Factors associated with a reduced food intake after third molar extraction among adults: a cross-sectional study

Background

Functional impairment after third molar extraction may decrease the food intake. Elucidation of associated factors will contribute to a more appropriate postoperative nutritional management, and was the aim of the present study.

Methods

Adults aged < 60 years who were admitted for an extraction of one or more mandibular third molars were included. Those with diabetes mellitus, anemia, metabolic diseases, mental retardation, altered dietary intake, and postoperative paralysis of the lower lip and tongue were excluded. Patient-specific risk factors were compared in relation to a decrease in the food intake on postoperative day 1. Multivariate analysis took into account the patients’ background factors.

Results

A total of 254 patients were included (median age: 26.8 ± 9.3 years, 142 women); 508 third molars were extracted. Postoperative dietary intake reduction was more common (p < 0.05) after an exclusively mandibular extraction (16.0%) than after an extraction including the maxilla (29.4%). The reduction was also more common (p < 0.05) for an extraction difficulty of Pell–Gregory class III (39.5%) than for extraction difficulties of Pell–Gregory classes I (22.6%) and II (21.3%). The reduction was also more common (p < 0.05) in patients who experienced postoperative pain (66.7%) than in those who did not (23.3%). Significant differences were observed in sex (women: 34.5%, men: 11.6%) and age (young patients [< 26 years]: 31.1%, adult patients [≥ 26 years]: 17.2%); however, no significant difference was found in terms of experiencing trismus (p < 0.11). Simple regression analysis showed significant differences between patients who did and did not have a reduced postoperative food intake depending on the sex, age, extraction site, degree of extraction difficulty, trismus, and postoperative pain. Reduced dietary intake was significantly associated with sex (odds ratio [OR]: 0.30; 95% confidence interval [CI]: 0.14–0.38), age (OR: 1.6; 95% CI: 1.0–2.5), extraction site (OR: 0.51; 95% CI: 0.31–0.83), difficulty of extraction (OR: 0.66; 95% CI: 0.50–0.88), and postoperative pain (OR: 0.12; 95% CI: 0.04–0.37).

Conclusions

A younger age, female sex, extraction including the maxilla with deep implantation, and complaints of pain on postoperative day 1 were factors associated with a decreased food intake after third molar extraction.

Periodontal Inflammation and Systemic Diseases: An Overview

Periodontitis is a common inflammatory disease of infectious origins that often evolves into a chronic condition. Aside from its importance as a stomatologic ailment, chronic periodontitis has gained relevance since it has been shown that it can develop into a systemic condition characterized by unresolved hyper-inflammation, disruption of the innate and adaptive immune system, dysbiosis of the oral, gut and other location's microbiota and other system-wide alterations that may cause, coexist or aggravate other health issues associated to elevated morbi-mortality. The relationships between the infectious, immune, inflammatory, and systemic features of periodontitis and its many related diseases are far from being fully understood and are indeed still debated. However, to date, a large body of evidence on the different biological, clinical, and policy-enabling sources of information, is available. The aim of the present work is to summarize many of these sources of information and contextualize them under a systemic inflammation framework that may set the basis to an integral vision, useful for basic, clinical, and therapeutic goals.