Influence of chronic severe periodontitis in the face of metabolic control, and of periodontal therapyin the immune response of diabetic type 2 individuals

Orientadores: Getulio da Rocha Nogueira Filho, Maria Cristina Foss de FreitasTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de PiracicabaResumo: Este estudo objetiva verificar a influência sistêmica da periodontite crônica severa frente ao controle metabólico bem como do tratamento periodontal na resposta imunológica de indivíduos diabéticos tipo 2 através da análise da expressão gênica e protéica de citocinas por células mononucleares aderentes de sangue periférico. Foram selecionados 20 pacientes divididos em: grupo teste - 10 diabéticos tipo 2 com periodontite crônica severa e controle metabólico inadequado; grupo controle - 10 diabéticos tipo 2 sem periodontite e controle metabólico inadequado. Primeiramente, os pacientes foram hospitalizados por 8 dias para a obtenção de um controle metabólico adequado, permanecendo inalterada a condição periodontal nesta fase. Posteriormente, o grupo teste foi submetido à terapia mecânica em estágio único associada à antibioticoterapia sistêmica com amoxicilina e metronidazol. Amostras sanguíneas foram obtidas no primeiro e último dias de hospitalização, e 4 a 6 semanas após o tratamento periodontal para a análise imunológica. Para avaliação dos parâmetros laboratoriais relacionados ao controle metabólico, como HbA1c, foram obtidas amostras sanguíneas antes e após a hospitalização, e 3 a 6 semanas após o tratamento periodontal. Culturas de um total de 2,5x106 células/mL mononucleares aderentes, foram realizadas por 24h na presença e ausência de LPS (5µg/mL). As citocinas TNF- a, IL-1 ß, IL-8 e IL-6 foram detectadas nos sobrenadantes das culturas através do ELISA, enquanto que a sua expressão gênica foi verificada por PCR em tempo real. Enquanto o controle metabólico diminuiu a secreção de TNF- a (p=0,02), IL-1ß(p=0,03), IL-8 (p=0,04) e IL-6 (p=0,02) nos sobrenadantes das células estimuladas do grupo controle, os pacientes do grupo teste apresentaram níveis maiores destas citocinas após o controle metabólico quando comparados ao grupo controle (p<0,01 ou p=0,01). O controle metabólico bem como a infecção periodontal severa, apesar de não terem influenciado a expressão gênica das citocinas próinflamatórias pelas células estimuladas de ambos os grupos, aumentou a expressão gênica em 2 vezes da IL-8 (p=0,04) pelas células basais do grupo teste, evidenciando-se uma hipoexpressão, respectivamente, de 4, 3 e 11 vezes, da IL-1 ß, IL-8 e IL-6 (p<0,01 ou p=0,01) por estas células no grupo teste em relação ao grupo controle, antes do controle metabólico. Enquanto o tratamento periodontal promoveu uma diminuição da secreção de TNF-?(p=0,04) pelas células estimuladas do grupo teste, o mesmo não influenciou a expressão gênica das citocinas nestas condições. O controle metabólico associado ao tratamento periodontal promoveu um aumento da expressão gênica em 6 e 5 vezes, respectivamente da IL-1 a e IL-6 (p<0,01), pelas células basais do grupo teste. Enquanto, o controle metabólico promoveu reduções na HbA1c de 1% no grupo controle (p=0,04) e 1,1% no grupo teste (p=0,03), o tratamento periodontal promoveu uma redução adicional de 1,6% na HbA1c do grupo teste. Assim, demonstrou-se o papel modulador da periodontite crônica severa na resposta imunológica dos pacientes diabéticos tipo 2, mantendo a capacidade reativa próinflamatória das células mononucleares frente ao controle metabólico, e que o tratamento desta infecção local pode exercer efeitos sistêmicos, diminuindo o potencial próinflamatório das células mononucleares circulantes, contribuindo para a melhor sensibilidade insulínica e facilitando o controle metabólico destes indivíduosAbstract: The purpose of this study was to evaluate the systemic influence of chronic severe periodontitis in relation to metabolic control and of periodontal therapy in the immune response of diabetic type 2 patients through the evaluation of cytokine protein and gene expression in human adherent peripheral blood mononuclear cells. Twenty patients were studied, distributed in 2 groups: test group - 10 type 2 diabetic patients with severe chronic periodontitis and inadequate metabolic control; control group - 10 type 2 diabetic patients without periodontitis and inadequate metabolic control. First, all participants were hospitalized for 8 to 10 days to obtain adequate metabolic control, without any periodontal condition alterations. Afterwards, the test group received one-stage non-surgical eriodontal therapy associated with Amoxicilin and Metronidazole. Blood samples were obtained on he first and last day of hospitalization, and 4 to 6 weeks after periodontal therapy for immunological analyses. For metabolic parameters analyses, like HbA1c, blood samples were obtained before and after hospitalization, and 3 to 6 weeks after periodontal therapy. Mononuclear cells were isolated by gradient density using Ficoll-Hypaque?. A total of 2.5 X 106 adherent cells/mL were cultivated during 24hs in the presence or absence of LPS. The cytokines TNF-a, IL-1ß, IL-8, IL-6 were quantified in cell culture supernatants using ELISA, while their gene expression was verified by Real Time PCR. It was demonstrated that metabolic control promoted a reduction of TNF- a (p=0,02), IL-1? (p=0,03), IL-8 (p=0,04) and IL-6 (p=0,02) levels in control group supernatants stimulated cells, while the test group showed increased levels of that cytokines compared to the control group after metabolic control (p<0,01 or p=0,01). The metabolic control as the presence of chronic severe periodontal infection, although did not affect the gene expression of that cytokines by stimulated cells from both groups, increased IL-8 gene expression 2 times (p=0,04) by test group unstimulated cells while it was verified a lower gene expression respectively of IL-1 ß, IL-8 and IL-6 (p<0,01 or p=0,01) by 4, 3, and 11 times related to the control group, before metabolic control. Moreover, periodontal therapy promoted a reduction of TNF- a (p=0,04) levels in test group supernatants stimulated cells, although did not affect the gene expression of the cytokines studied by these cells. There was observed combined effect of metabolic control and periodontal therapy on IL-1 ß and IL-6 (p<0,01) gene expression, that were increased by 6 and 5 times, respectively, by test group unstimulated cells. While metabolic control promoted reductions of 1% and 1,1% in HbA1c levels of control and test group respectively, periodontal therapy promoted an additional reduction of 1,6% in HbA1c levels of test group. Therefore, it was suggested that chronic severe periodontal infection can modulate the immunological response of type 2 diabetic patients, through the maintenance of the inflammatory reactive capacity of mononuclear cells even if in the presence of metabolic control, and that the local infection treatment can promote systemic effects, through decreasing the pro-inflammatory potential of mononuclear circulating cells, helping to restore insulin sensitivity, resulting in an improved glycemic control in those individualsDoutoradoPeriodontiaDoutor em Clínica Odontológic

Dental care challenges in Sturge-Weber syndrome: a case report

Introduction: Sturge-Weber syndrome (SWS) is a rare condition characterized by facial capillary malformation, involves ocular, neurological, and cutaneous alterations. Associated with unilateral characteristic port-wine stains, gingival growth and purple-red coloration. Aim: his case aims to report dental treatment challenges in patients with SWS and importance of oral health maintenance in these individuals. Case report: a 20-year-old woman with an established diagnosis of SWS, presented bad breath and spontaneous gingival bleeding, with gingival growth and reddish-purple spots spread to labial and alveolar mucosa, tongue, and palate. Conditioning of the patient’s oral environment by supra and subgingival scraping, dental unit extraction was performed. A conservative treatment plan was adopted for management adequacy of oral environment owing to possible complications inherent to the condition. Conclusion: it is important to emphasize the importance of dental surgeon’s performance in relation to a multidisciplinary health team, as well as cooperation of patient, to obtain better results from the proposed therap

USO DA HEMOGLOBINA GLICADA NO DIAGNÓSTICO DE DIABETES MELLITUS – REVISÃO DE LITERATURA USE OF GLYCATED HEMOGLOBIN IN THE DIAGNOSIS OF DIABETES MELLITUS - LITERATURE REVIEW

A Organização Mundial de Saúde considera Diabetes Mellitus (DM) umapandemia e, consequentemente, um sério problema de saúde pública.Classicamente, os exames laboratoriais Glicemia em Jejum e TesteOral de Tolerância à Glicose são realizados para o diagnóstico de DM.Recentemente, a Associação Americana de Diabetes (ADA) preconizou ouso da Hemoglobina Glicada (HbA1C), com limiar de 6,5%, para essa finalidade.Esse trabalho tem como objetivo revisar a literatura acerca da utilizaçãode Hemoglobina Glicada no diagnóstico de pacientes diabéticos.A HbA1C é o exame laboratorial padrão ouro para o acompanhamentometabólico de diabéticos e apresenta várias vantagens, como: representaa média glicêmica no período de 30 a 90 dias precedente à realizaçãodo exame; apresenta uma maior comodidade para o paciente porqueprescinde o jejum; possui uma maior estabilidade pré-analítica quandocomparado aos outros exames utilizados com essa função; é menos susceptívelà perturbações cotidianas. Entretanto, existem várias limitaçõespara seu uso. O resultado do exame pode ser alterado por diversos fatores,como: presença de hemoglobinas variantes, anemias hemolíticas,anemias nutricionais, uremia, gravidez e perda aguda de sangue. Alémdisso, a literatura mostra diferenças de sensibilidade e especificidade deHbA1C quando avaliados pacientes de diferentes etnias e faixas etária.O limiar de 6,5% não deve ser considerado ideal para todas populações.Até a determinação de valores de corte que apresentem comprovada eficácia diagnóstica, é mais sensato o uso de Glicemia em Jejum e do Teste Oral de Tolerância à Glicose para avaliação de pacientes com suspeita de DM. The World Health Organization considers Diabetes Mellitus (DM) apandemic and, consequently, a serious public health issue. Classically,laboratory tests of Fasting Glucose and Oral Glucose Tolerance Test areperformed for the diagnosis of DM. Recently, the American Diabetes Association(ADA) advocated the use of Glycated Hemoglobin (HbA1C),with a threshold of 6.5%, for this purpose. This work aims to review theliterature on the use of Glycated Hemoglobin in the diagnosis of diabeticpatients. HbA1C is the gold standard laboratory test for the metabolicfollow-up of diabetics patients and presents several advantages, such as:it represents the glycemic mean in the period from 30 to 90 days precedingthe test; presents a greater convenience because the patient doesnot need to fast; has a greater pre-analytical stability when compared tothe other tests used with this function; is less susceptible to daily disturbances.However, there are several limitations to its use. The result of theexamination can be altered by several factors, such as the presence ofvariant hemoglobins, hemolytic anemias, nutritional anemias, uremia,pregnancy and acute blood loss. In addition, the literature shows differencesin sensitivity and specificity of HbA1C when evaluated in patientsof different ethnicities and age groups. The 6.5% threshold should not beconsidered ideal for all populations. Until a determination of cutoff valuesthat have proven diagnostic efficacy, the use of Fasting Glucose andthe Oral Glucose Tolerance Test is more reasonable for the evaluation ofpatients with suspected of DM

Impact of Periodontitis on the Diabetes-Related Inflammatory Status

Wide-ranging activation of the innate immune system causing chronic low-grade inflammation is closely involved not only in the pathogenesis of type 2 diabetes mellitus and its complications, through an ongoing cytokine-induced acute-phase response, but also in the pathogenesis of periodontal diseases, whereby cytokines play a central role in the host's response to the periodontal biofilm. Although there is extensive knowledge about the pathways through which diabetes affects periodontal status, less is known about the impact of periodontal diseases on the diabetes-related inflammatory state. This review attempts to explain the immunobiological connection between periodontal diseases and type 2 diabetes mellitus, exploring the mechanisms through which periodontal infection can contribute to the low-grade general inflammation associated with diabetes (thus aggravating insulin resistance) and discussing the impact of periodontal treatment on glycemic control in people living with both diabetes and periodontal disease

GoldLeish: gold(I) Complexes as Oral Drug Candidates to Treat Leishmaniasis are Potent Trypanothione Reductase Inhibitors and Exert in vivo Efficacy

The drugs currently used to treat leishmaniasis have limitations concerning cost, efficacy and safety, making urgent the search for new therapeutic approaches. Here we report the antileishmanial activity of 14 gold(I) complexes. We found that the complexes were active against L. infantum and L. braziliensis intracellular amastigotes with IC50 values ranging from 0.5 to 5.5 μM. All complexes were potent inhibitors of trypanothione reductase (TR), with IC50 ranging from 1 to 7.8 μM. Triethylphosphine-derived complexes enhanced ROS production and decreased mitochondrial respiration after 2 h exposure, indicating that gold(I) complexes cause oxidative stress by direct ROS production, by causing mitochondrial damage or by impairing TR activity and thus accumulating ROS. There was no cross-resistance to antimony; in fact, SbR (antimony-resistant mutants) strains were hypersensitive to some of the complexes. BALB/c mice infected with luciferase-expressing L. braziliensis or L. amazonensis and treated orally with 12.5 mg/kg/day of AdT Et (3) or AdO Et (4) presented reduced lesion size and parasite burden, as revealed by bioimaging. Combination of (3) and miltefosine allowed for a 50 % reduction in miltefosine treatment time. Complexes (3) and (4) presented favorable pharmacokinetic and toxicity profiles that encourage further drug development studies. Gold(I) complexes are promising antileishmanial agents, with potential for therapeutic use, including in leishmaniasis caused by antimony-resistant parasites.<br /

Preclinical Gold Complexes as Oral Drug Candidates to Treat Leishmaniasis Are Potent Trypanothione Reductase Inhibitors

The drugs currently used to treat leishmaniases have limitations concerning cost, e!cacy, and safety, making the search for new therapeutic approaches urgent. We found that the gold(I)-derived complexes were active against L. infantum and L. braziliensis intracellular amastigotes with IC50 values ranging from 0.5 to 5.5 !M. All gold(I) complexes were potent inhibitors of trypanothione reductase (TR), with enzyme IC50 values ranging from 1 to 7.8 !M. Triethylphosphine-derived complexes enhanced reactive oxygen species (ROS) production and decreased mitochondrial respiration after 2 h of exposure, indicating that gold(I) complexes cause oxidative stress by direct ROS production, by causing mitochondrial damage or by impairing TR activity and thus accumulating ROS. There was no cross-resistance to antimony; in fact, SbR (antimony-resistant mutants) strains were hypersensitive to some of the complexes. BALB/c mice infected with luciferase-expressing L. braziliensis or L. amazonensis and treated orally with 12.5 mg/kg/day of AdT Et (3) or AdO Et (4) presented reduced lesion size and parasite burden, as revealed by bioimaging. The combination of (3) and miltefosine allowed for a 50% reduction in miltefosine treatment time. Complexes 3 and 4 presented favorable pharmacokinetic and toxicity pro"les that encourage further drug development studies. Gold(I) complexes are promising antileishmanial agents, with a potential for therapeutic use, including in leishmaniasis caused by antimony-resistant parasites.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)CNPq: 424729/2018FAPESP: 2018/09948-