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Doshi TL, Dorsey SG, Huang W, Kane MA, Lim M. Proteomic Analysis to Identify Prospective Biomarkers of Treatment Outcome After Microvascular Decompression for Trigeminal Neuralgia: A Preliminary Study. THE JOURNAL OF PAIN 2024; 25:781-790. [PMID: 37838347 PMCID: PMC10922145 DOI: 10.1016/j.jpain.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/16/2023]
Abstract
Trigeminal neuralgia (TN) is a severe neuropathic facial pain disorder, often caused by vascular or neuronal compression of the trigeminal nerve. In such cases, microvascular decompression (MVD) surgery can be used to treat TN, but pain relief is not guaranteed. The molecular mechanisms that affect treatment response to MVD are not well understood. In this exploratory study, we performed label-free quantitative proteomic profiling of plasma and cerebrospinal fluid samples from patients undergoing MVD for TN, then compared the proteomic profiles of patients graded as responders (n = 7) versus non-responders (n = 9). We quantified 1,090 proteins in plasma and 1,087 proteins in the cerebrospinal fluid, of which 12 were differentially regulated in the same direction in both sample types. Functional analyses of differentially regulated proteins in protein-protein interaction networks suggested pathways of the immune system, axon guidance, and cellular stress response to be associated with response to MVD. These findings suggest potential biomarkers of response to MVD, as well as possible mechanisms of variable treatment success in TN patients. PERSPECTIVE: This exploratory study evaluates proteomic profiles in plasma and cerebrospinal fluid of patients undergoing microvascular decompression surgery for trigeminal neuralgia. Differential expression of proteins between surgery responders versus non-responders may serve as biomarkers to predict surgical success and provide insight into surgical mechanisms of pain relief in trigeminal neuralgia.
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Affiliation(s)
- Tina L. Doshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Susan G. Dorsey
- Department of Pain and Translational Symptom Science, University of Maryland, Baltimore, MD
| | - Weiliang Huang
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, MD
| | - Maureen A. Kane
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, MD
| | - Michael Lim
- Department of Neurosurgery, Stanford University, Palo Alto, CA
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Al Turkestani N, Li T, Bianchi J, Gurgel M, Prieto J, Shah H, Benavides E, Soki F, Mishina Y, Fontana M, Rao A, Zhu H, Cevidanes L. A comprehensive patient-specific prediction model for temporomandibular joint osteoarthritis progression. Proc Natl Acad Sci U S A 2024; 121:e2306132121. [PMID: 38346188 PMCID: PMC10895339 DOI: 10.1073/pnas.2306132121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 01/03/2024] [Indexed: 02/15/2024] Open
Abstract
Temporomandibular joint osteoarthritis (TMJ OA) is a prevalent degenerative disease characterized by chronic pain and impaired jaw function. The complexity of TMJ OA has hindered the development of prognostic tools, posing a significant challenge in timely, patient-specific management. Addressing this gap, our research employs a comprehensive, multidimensional approach to advance TMJ OA prognostication. We conducted a prospective study with 106 subjects, 74 of whom were followed up after 2 to 3 y of conservative treatment. Central to our methodology is the development of an innovative, open-source predictive modeling framework, the Ensemble via Hierarchical Predictions through Nested cross-validation tool (EHPN). This framework synergistically integrates 18 feature selection, statistical, and machine learning methods to yield an accuracy of 0.87, with an area under the ROC curve of 0.72 and an F1 score of 0.82. Our study, beyond technical advancements, emphasizes the global impact of TMJ OA, recognizing its unique demographic occurrence. We highlight key factors influencing TMJ OA progression. Using SHAP analysis, we identified personalized prognostic predictors: lower values of headache, lower back pain, restless sleep, condyle high gray level-GL-run emphasis, articular fossa GL nonuniformity, and long-run low GL emphasis; and higher values of superior joint space, mouth opening, saliva Vascular-endothelium-growth-factor, Matrix-metalloproteinase-7, serum Epithelial-neutrophil-activating-peptide, and age indicate recovery likelihood. Our multidimensional and multimodal EHPN tool enhances clinicians' decision-making, offering a transformative translational infrastructure. The EHPN model stands as a significant contribution to precision medicine, offering a paradigm shift in the management of temporomandibular disorders and potentially influencing broader applications in personalized healthcare.
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Affiliation(s)
- Najla Al Turkestani
- Department of Restorative Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah21589, Saudi Arabia
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI48109
| | - Tengfei Li
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC27599
| | - Jonas Bianchi
- Department of Orthodontics, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA94103
| | - Marcela Gurgel
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI48109
| | - Juan Prieto
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC27599
| | - Hina Shah
- Department of Psychiatry, The University of North Carolina at Chapel Hill, Chapel Hill, NC27599
| | - Erika Benavides
- Department of Periodontics & Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI48109
| | - Fabiana Soki
- Department of Periodontics & Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI48109
| | - Yuji Mishina
- Department of Biologic and Materials Sciences & Prosthodontics, School of Dentistry, University of Michigan, Ann Arbor, MI48109
| | - Margherita Fontana
- Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Ann Arbor, MI48109
| | - Arvind Rao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI48109
- Department of Computational Medicine & Bioinformatics, School of Dentistry, University of Michigan, Ann Arbor, MI48109
| | - Hongtu Zhu
- Department of Radiology and Biomedical Research Imaging Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC27599
| | - Lucia Cevidanes
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI48109
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Latypov TH, So MC, Hung PSP, Tsai P, Walker MR, Tohyama S, Tawfik M, Rudzicz F, Hodaie M. Brain imaging signatures of neuropathic facial pain derived by artificial intelligence. Sci Rep 2023; 13:10699. [PMID: 37400574 DOI: 10.1038/s41598-023-37034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/13/2023] [Indexed: 07/05/2023] Open
Abstract
Advances in neuroimaging have permitted the non-invasive examination of the human brain in pain. However, a persisting challenge is in the objective differentiation of neuropathic facial pain subtypes, as diagnosis is based on patients' symptom descriptions. We use artificial intelligence (AI) models with neuroimaging data to distinguish subtypes of neuropathic facial pain and differentiate them from healthy controls. We conducted a retrospective analysis of diffusion tensor and T1-weighted imaging data using random forest and logistic regression AI models on 371 adults with trigeminal pain (265 classical trigeminal neuralgia (CTN), 106 trigeminal neuropathic pain (TNP)) and 108 healthy controls (HC). These models distinguished CTN from HC with up to 95% accuracy, and TNP from HC with up to 91% accuracy. Both classifiers identified gray and white matter-based predictive metrics (gray matter thickness, surface area, and volume; white matter diffusivity metrics) that significantly differed across groups. Classification of TNP and CTN did not show significant accuracy (51%) but highlighted two structures that differed between pain groups-the insula and orbitofrontal cortex. Our work demonstrates that AI models with brain imaging data alone can differentiate neuropathic facial pain subtypes from healthy data and identify regional structural indicates of pain.
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Affiliation(s)
- Timur H Latypov
- Division of Brain, Imaging & Behaviour, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Collaborative Program in Neuroscience, University of Toronto, Toronto, ON, Canada
| | - Matthew C So
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Shih-Ping Hung
- Division of Brain, Imaging & Behaviour, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Collaborative Program in Neuroscience, University of Toronto, Toronto, ON, Canada
| | - Pascale Tsai
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew R Walker
- Division of Brain, Imaging & Behaviour, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Sarasa Tohyama
- A.A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA, USA
| | - Marina Tawfik
- Collaborative Program in Neuroscience, University of Toronto, Toronto, ON, Canada
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
- Faculty of Computer Science, Dalhousie University, Halifax, NS, Canada
| | - Mojgan Hodaie
- Division of Brain, Imaging & Behaviour, Krembil Research Institute, University Health Network, Toronto, ON, Canada.
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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The practical limits of high-quality magnetic resonance imaging for the diagnosis and classification of trigeminal neuralgia. Clin Neurol Neurosurg 2022; 221:107403. [PMID: 35933966 DOI: 10.1016/j.clineuro.2022.107403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Neurovascular compression (NVC) has been the primary hypothesis for the underlying mechanism of classical trigeminal neuralgia (TN). However, a substantial body of literature has emerged highlighting notable exceptions to this hypothesis. The purpose of this study is to assess the reliability and diagnostic accuracy of high resolution, high contrast MRI-determined neurovascular contact for TN. METHODS We performed a retrospective, randomized, and blinded parallel characterization of neurovascular interaction and diagnosis in a population of TN patients and controls using four expert reviewers. Performance statistics were calculated, as well as assessments for generalizability using shuffled bootstraps. RESULTS Fair to moderate agreement (ICC: 0.32-0.68) about diagnosis between reviewers was observed using MRIs from 47 TN patients and 47 controls. On average reviewers performed no better than chance when diagnosing participants, with an accuracy of 0.57 (95% CI 0.40, 0.59) per patient. CONCLUSION While MRI is useful in determining structural causes in secondary TN, expert reviewers do no better to only slightly better than chance with distinguishing TN with MRI, despite moderate agreement. Further, the causal role of NVC for TN is not clear, limiting the applicability of MRI to diagnose or prognosticate treatment of TN.
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Diaz MM, Caylor J, Strigo I, Lerman I, Henry B, Lopez E, Wallace MS, Ellis RJ, Simmons AN, Keltner JR. Toward Composite Pain Biomarkers of Neuropathic Pain—Focus on Peripheral Neuropathic Pain. FRONTIERS IN PAIN RESEARCH 2022; 3:869215. [PMID: 35634449 PMCID: PMC9130475 DOI: 10.3389/fpain.2022.869215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/21/2022] [Indexed: 01/09/2023] Open
Abstract
Chronic pain affects ~10–20% of the U.S. population with an estimated annual cost of $600 billion, the most significant economic cost of any disease to-date. Neuropathic pain is a type of chronic pain that is particularly difficult to manage and leads to significant disability and poor quality of life. Pain biomarkers offer the possibility to develop objective pain-related indicators that may help diagnose, treat, and improve the understanding of neuropathic pain pathophysiology. We review neuropathic pain mechanisms related to opiates, inflammation, and endocannabinoids with the objective of identifying composite biomarkers of neuropathic pain. In the literature, pain biomarkers typically are divided into physiological non-imaging pain biomarkers and brain imaging pain biomarkers. We review both types of biomarker types with the goal of identifying composite pain biomarkers that may improve recognition and treatment of neuropathic pain.
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Affiliation(s)
- Monica M. Diaz
- Department of Neurology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
- *Correspondence: Monica M. Diaz
| | - Jacob Caylor
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Irina Strigo
- Department of Psychiatry, San Francisco Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Imanuel Lerman
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Brook Henry
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Eduardo Lopez
- Department of Psychiatry, San Francisco Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Mark S. Wallace
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Ronald J. Ellis
- Department of Neurosciences, University of California, San Diego, San Diego, CA, United States
| | - Alan N. Simmons
- Department of Psychiatry, San Diego & Center of Excellence in Stress and Mental Health, Veteran Affairs Health Care System, University of California, San Diego, San Diego, CA, United States
| | - John R. Keltner
- Department of Psychiatry, San Diego & San Diego VA Medical Center, University of California, San Diego, San Diego, CA, United States
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Mulford KL, Moen SL, Grande AW, Nixdorf DR, Van de Moortele PF. Identifying symptomatic trigeminal nerves from MRI in a cohort of trigeminal neuralgia patients using radiomics. Neuroradiology 2022; 64:603-609. [PMID: 35043225 DOI: 10.1007/s00234-022-02900-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Trigeminal neuralgia (TN) is a devastating neuropathic condition. This work tests whether radiomics features derived from MRI of the trigeminal nerve can distinguish between TN-afflicted and pain-free nerves. METHODS 3D T1- and T2-weighted 1.5-Tesla MRI volumes were retrospectively acquired for patients undergoing stereotactic radiosurgery to treat TN. A convolutional U-net deep learning network was used to segment the trigeminal nerves from the pons to the ganglion. A total of 216 radiomics features consisting of image texture, shape, and intensity were extracted from each nerve. Within a cross-validation scheme, a random forest feature selection method was used, and a shallow neural network was trained using the selected variables to differentiate between TN-affected and non-affected nerves. Average performance over the validation sets was measured to estimate generalizability. RESULTS A total of 134 patients (i.e., 268 nerves) were included. The top 16 performing features extracted from the masks were selected for the predictive model. The average validation accuracy was 78%. The validation AUC of the model was 0.83, and sensitivity and specificity were 0.82 and 0.76, respectively. CONCLUSION Overall, this work suggests that radiomics features from MR imaging of the trigeminal nerves correlate with the presence of pain from TN.
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Affiliation(s)
- Kellen L Mulford
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA.
| | - Sean L Moen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Donald R Nixdorf
- Department of Diagnostic and Biological Science, University of Minnesota, Minneapolis, MN, USA
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A comprehensive review on biomarkers associated with painful temporomandibular disorders. Int J Oral Sci 2021; 13:23. [PMID: 34326304 PMCID: PMC8322104 DOI: 10.1038/s41368-021-00129-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023] Open
Abstract
Pain of the orofacial region is the primary complaint for which patients seek treatment. Of all the orofacial pain conditions, one condition that possess a significant global health problem is temporomandibular disorder (TMD). Patients with TMD typically frequently complaints of pain as a symptom. TMD can occur due to complex interplay between peripheral and central sensitization, endogenous modulatory pathways, and cortical processing. For diagnosis of TMD pain a descriptive history, clinical assessment, and imaging is needed. However, due to the complex nature of pain an additional step is needed to render a definitive TMD diagnosis. In this review we explicate the role of different biomarkers involved in painful TMD. In painful TMD conditions, the role of biomarkers is still elusive. We believe that the identification of biomarkers associated with painful TMD may stimulate researchers and clinician to understand the mechanism underlying the pathogenesis of TMD and help them in developing newer methods for the diagnosis and management of TMD. Therefore, to understand the potential relationship of biomarkers, and painful TMD we categorize the biomarkers as molecular biomarkers, neuroimaging biomarkers and sensory biomarkers. In addition, we will briefly discuss pain genetics and the role of potential microRNA (miRNA) involved in TMD pain.
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Abstract
Trigeminal neuralgia (TN) is a severe facial pain disease of unknown cause and unclear genetic background. To examine the existing knowledge about genetics in TN, we performed a systematic study asking about the prevalence of familial trigeminal neuralgia, and which genes that have been identified in human TN studies and in animal models of trigeminal pain. MedLine, Embase, Cochrane Library and Web of Science were searched from inception to January 2021. 71 studies were included in the systematic review. Currently, few studies provide information about the prevalence of familial TN; the available evidence indicates that about 1–2% of TN cases have the familial form. The available human studies propose the following genes to be possible contributors to development of TN: CACNA1A, CACNA1H, CACNA1F, KCNK1, TRAK1, SCN9A, SCN8A, SCN3A, SCN10A, SCN5A, NTRK1, GABRG1, MPZ gene, MAOA gene and SLC6A4. Their role in familial TN still needs to be addressed. The experimental animal studies suggest an emerging role of genetics in trigeminal pain, though the animal models may be more relevant for trigeminal neuropathic pain than TN per se. In summary, this systematic review suggests a more important role of genetic factors in TN pathogenesis than previously assumed.
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Affiliation(s)
| | - Aslan Lashkarivand
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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MALDI-TOF MS profiling in the discovery and identification of salivary proteomic patterns of temporomandibular joint disorders. OPEN CHEM 2020. [DOI: 10.1515/chem-2020-0174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractThis research aimed to identify differences in polypeptide/protein profiles of the unstimulated whole saliva between patients with temporomandibular joint disorders (TMDs) and healthy individuals. A fraction of the polypeptides/proteins (<30 kDa) was analyzed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. The spectra were recovered from methanoic acid/acetonitrile salivary samples overlaid with an α-cyano-4-hydroxy-cinnamic acid matrix in positive linear mode at an interval of 1,500–20,000 m/z mass acquisition range. The data were analyzed for the selection of characteristic peaks by using the ClinProTools 3.0 software. Discriminative classification models were generated by using a quick classifier, supervised neural network, and genetic algorithms. From the 23 peaks exhibiting the highest discriminatory power, the ten top-scored peaks with the area under the receiver operating characteristic >0.8 were selected. A panel of salivary markers that predicted the patients with TMDs was selected (2728.0, 4530.2, 5174.2, 5193.3, 6303.4, 6886.7, 8141.7, 8948.7, 10663.2, 10823.7 and 11009.0 m/z). Although carried out on relatively small datasets, the classification algorithm used in this study allows the differentiation between salivary samples from subjects with TMDs and healthy individuals and confirms the usefulness of a proteomic profiling approach in the monitoring of the disease.
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Zwiri A, Al-Hatamleh MAI, W. Ahmad WMA, Ahmed Asif J, Khoo SP, Husein A, Ab-Ghani Z, Kassim NK. Biomarkers for Temporomandibular Disorders: Current Status and Future Directions. Diagnostics (Basel) 2020; 10:E303. [PMID: 32429070 PMCID: PMC7277983 DOI: 10.3390/diagnostics10050303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/08/2020] [Indexed: 12/17/2022] Open
Abstract
Numerous studies have been conducted in the previous years with an objective to determine the ideal biomarker or set of biomarkers in temporomandibular disorders (TMDs). It was recorded that tumour necrosis factor (TNF), interleukin 8 (IL-8), IL-6, and IL-1 were the most common biomarkers of TMDs. As of recently, although the research on TMDs biomarkers still aims to find more diagnostic agents, no recent study employs the biomarker as a targeting point of pharmacotherapy to suppress the inflammatory responses. This article represents an explicit review on the biomarkers of TMDs that have been discovered so far and provides possible future directions towards further research on these biomarkers. The potential implementation of the interactions of TNF with its receptor 2 (TNFR2) in the inflammatory process has been interpreted, and thus, this review presents a new hypothesis towards suppression of the inflammatory response using TNFR2-agonist. Subsequently, this hypothesis could be explored as a potential pain elimination approach in patients with TMDs.
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Affiliation(s)
- Abdalwhab Zwiri
- School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (A.Z.); (W.M.A.W.A.); (J.A.A.); (A.H.)
| | - Mohammad A. I. Al-Hatamleh
- Department of Immunology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
| | - Wan Muhamad Amir W. Ahmad
- School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (A.Z.); (W.M.A.W.A.); (J.A.A.); (A.H.)
| | - Jawaad Ahmed Asif
- School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (A.Z.); (W.M.A.W.A.); (J.A.A.); (A.H.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Suan Phaik Khoo
- Department of Oral Diagnostic and Surgical Sciences, School of Dentistry, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia;
| | - Adam Husein
- School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (A.Z.); (W.M.A.W.A.); (J.A.A.); (A.H.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Zuryati Ab-Ghani
- School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (A.Z.); (W.M.A.W.A.); (J.A.A.); (A.H.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Nur Karyatee Kassim
- School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (A.Z.); (W.M.A.W.A.); (J.A.A.); (A.H.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
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