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Balachandran DD, Bashoura L, Sheshadri A, Manzullo E, Faiz SA. The Impact of Immunotherapy on Sleep and Circadian Rhythms in Patients with Cancer. Front Oncol 2023; 13:1295267. [PMID: 38090501 PMCID: PMC10711041 DOI: 10.3389/fonc.2023.1295267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/06/2023] [Indexed: 02/01/2024] Open
Abstract
Immunotherapy has revolutionized treatments for both early and advanced cancers, and as their role evolves, their impact on sleep and circadian rhythms continues to unfold. The recognition, evaluation, and treatment of sleep and circadian rhythm disturbance leads to improved symptom management, quality of life and treatment outcomes. An intricate complex relationship exists in the microenvironment with immunity, sleep and the tumor, and these may further vary based on the cancer, addition of standard chemotherapy, and pre-existing patient factors. Sleep and circadian rhythms may offer tools to better utilize immunotherapy in the care of cancer patients, leading to better treatment outcome, reduced symptom burden, and increased quality of life.
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Affiliation(s)
- Diwakar D. Balachandran
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ellen Manzullo
- Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Saadia A. Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Lokes K, Lychman V, Izmailova O, Shlykova O, Avetikov D, Kaidashev I. Expression of periferal core molecular clock genes in oral mucosa depends on the chronotype in patients with maxillofacial cellulitis. J Oral Biol Craniofac Res 2023; 13:517-521. [PMID: 37361670 PMCID: PMC10285524 DOI: 10.1016/j.jobcr.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/24/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Accurate determination of the patient's chronotype is one of the problems of personalized medicine. Recent studies have shown that determining of the expression of timing genes is a valuable method that can help gain molecular insight into a patient's intrinsic circadian timing. Odontogenic cellulitis is very common pathology. Since acute inflammatory diseases are an urgent pathology, the time of surgical intervention can correspond depend on the time of the patient's hospitalization. Materials and methods The level of mRNA expression of peripheral circadian clock genes clock and bmal1, per1, cry1 in buccal epithelial cells in patients with odontogenic purulent inflammatory diseases of maxillofacial area in the morning and evening was investigated. Results During analyzing the results of the mRNA expression study of the genes of the negative regulatory link of the peripheral molecular clock, per1 and cry1, in patients with Cellulitis of the maxillofacial area, a significant decrease (P = 0.0003) in the mRNA expression level of the cry1 gene by 2.61 times in the evening compared to its morning mRNA expression values. Conclusion The obtained data indicate that in patients with odontogenic purulent inflammatory diseases of the maxillofacial area with an evening chronotype, a violation of the expression profile of the per1 gene in the cells of the buccal epithelium is noted, which is manifested by an increase in its evening expression in comparison with patients with a morning chronotype.
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Potential Role of the Circadian Clock in the Regulation of Cancer Stem Cells and Cancer Therapy. Int J Mol Sci 2022; 23:ijms232214181. [PMID: 36430659 PMCID: PMC9698777 DOI: 10.3390/ijms232214181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
Abstract
Circadian rhythms, including sleep/wake cycles as well as hormonal, immune, metabolic, and cell proliferation rhythms, are fundamental biological processes driven by a cellular time-keeping system called the circadian clock. Disruptions in these rhythms due to genetic alterations or irregular lifestyles cause fundamental changes in physiology, from metabolism to cellular proliferation and differentiation, resulting in pathological consequences including cancer. Cancer cells are not uniform and static but exist as different subtypes with phenotypic and functional differences in the tumor microenvironment. At the top of the heterogeneous tumor cell hierarchy, cancer stem cells (CSCs), a self-renewing and multi-potent cancer cell type, are most responsible for tumor recurrence and metastasis, chemoresistance, and mortality. Phenotypically, CSCs are associated with the epithelial-mesenchymal transition (EMT), which confers cancer cells with increased motility and invasion ability that is characteristic of malignant and drug-resistant stem cells. Recently, emerging studies of different cancer types, such as glioblastoma, leukemia, prostate cancer, and breast cancer, suggest that the circadian clock plays an important role in the maintenance of CSC/EMT characteristics. In this review, we describe recent discoveries regarding how tumor intrinsic and extrinsic circadian clock-regulating factors affect CSC evolution, highlighting the possibility of developing novel chronotherapeutic strategies that could be used against CSCs to fight cancer.
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Lee Y. Roles of circadian clocks in cancer pathogenesis and treatment. Exp Mol Med 2021; 53:1529-1538. [PMID: 34615982 PMCID: PMC8568965 DOI: 10.1038/s12276-021-00681-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/29/2021] [Accepted: 08/06/2021] [Indexed: 12/24/2022] Open
Abstract
Circadian clocks are ubiquitous timing mechanisms that generate approximately 24-h rhythms in cellular and bodily functions across nearly all living species. These internal clock systems enable living organisms to anticipate and respond to daily changes in their environment in a timely manner, optimizing temporal physiology and behaviors. Dysregulation of circadian rhythms by genetic and environmental risk factors increases susceptibility to multiple diseases, particularly cancers. A growing number of studies have revealed dynamic crosstalk between circadian clocks and cancer pathways, providing mechanistic insights into the therapeutic utility of circadian rhythms in cancer treatment. This review will discuss the roles of circadian rhythms in cancer pathogenesis, highlighting the recent advances in chronotherapeutic approaches for improved cancer treatment.
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Affiliation(s)
- Yool Lee
- grid.30064.310000 0001 2157 6568Department of Translational Medicine and Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202 USA
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Zhang M, Liang J, Yang Y, Liang H, Jia H, Li D. Current Trends of Targeted Drug Delivery for Oral Cancer Therapy. Front Bioeng Biotechnol 2020; 8:618931. [PMID: 33425881 PMCID: PMC7793972 DOI: 10.3389/fbioe.2020.618931] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/19/2020] [Indexed: 12/29/2022] Open
Abstract
Oral cancer is an aggressive tumor that invades the local tissue and can cause metastasis and high mortality. Conventional treatment strategies, e.g., surgery, chemotherapy, and radiation therapy alone or in combinations, possess innegligible issues, and significant side and adverse effects for the clinical applications. Currently, targeting drug delivery is emerging as an effective approach for oral delivery of different therapeutics. Herein we provide a state-of-the-art review on the current progress of targeting drug delivery for oral cancer therapy. Variously oral delivery systems including polymeric/inorganic nanoparticles, liposomes, cyclodextrins, nanolipids, and hydrogels-based forms are emphasized and discussed, and biomimetic systems with respect to oral delivery like therapeutic vitamin, exosomes, proteins, and virus-like particles are also described with emphasis on the cancer treatment. A future perspective is also provided to highlight the existing challenges and possible resolution toward clinical translation of current oral cancer therapies.
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Affiliation(s)
- Mingming Zhang
- Strategic Support Force Characteristic Medical Center of Chinese People's Liberation Army, Beijing, China
| | - Jianqin Liang
- The 8th Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Yanyu Yang
- College of Materials Science and Engineering, Zhengzhou University, Zhengzhou, China
| | - Huize Liang
- Strategic Support Force Characteristic Medical Center of Chinese People's Liberation Army, Beijing, China
| | - Huaping Jia
- Strategic Support Force Characteristic Medical Center of Chinese People's Liberation Army, Beijing, China
| | - Dawei Li
- The 4th Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
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Zhao L, Liu M, Ouyang J, Zhu Z, Geng W, Dong J, Xiong Y, Wang S, Zhang X, Qiao Y, Ding H, Sun H, Liang G, Shang H, Han X. The Per-1 Short Isoform Inhibits de novo HIV-1 Transcription in Resting CD4+ T-cells. Curr HIV Res 2019; 16:384-395. [PMID: 30774045 PMCID: PMC6446521 DOI: 10.2174/1570162x17666190218145048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/02/2019] [Accepted: 02/11/2019] [Indexed: 12/24/2022]
Abstract
Background: Understanding of the restriction of HIV-1 transcription in resting CD4+ T-cells is critical to find a cure for AIDS. Although many negative factors causing HIV-1 transcription blockage in resting CD4+ T-cells have been found, there are still unknown mechanisms to explore. Objective: To explore the mechanism for the suppression of de novo HIV-1 transcription in resting CD4+ T-cells. Methods: In this study, a short isoform of Per-1 expression plasmid was transfected into 293T cells with or without Tat's presence to identify Per-1 as a negative regulator for HIV-1 transcription. Silenc-ing of Per-1 was conducted in resting CD4+ T-cells or monocyte-derived macrophages (MDMs) to evaluate the antiviral activity of Per-1. Additionally, we analyzed the correlation between Per-1 expres-sion and viral loads in vivo, and silenced Per-1 by siRNA technology to investigate the potential anti-HIV-1 roles of Per-1 in vivo in untreated HIV-1-infected individuals. Results: We found that short isoform Per-1 can restrict HIV-1 replication and Tat ameliorates this in-hibitory effect. Silencing of Per-1 could upregulate HIV-1 transcription both in resting CD4+ T-cells and MDMs. Moreover, Per-1 expression is inversely correlated with viral loads in Rapid progressors (RPs) in vivo. Conclusion: These data together suggest that Per-1 is a novel negative regulator of HIV-1 transcrip-tion. This restrictive activity of Per-1 to HIV-1 replication may contribute to HIV-1 latency in resting CD4+ T-cells.
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Affiliation(s)
- Li Zhao
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Mei Liu
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Jiayue Ouyang
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Zheming Zhu
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Wenqing Geng
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Jinxiu Dong
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Ying Xiong
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Shumei Wang
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Xiaowei Zhang
- The Core Laboratory for Public Health Science and Practice, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Ying Qiao
- The Core Laboratory for Public Health Science and Practice, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Haibo Ding
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Hong Sun
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Guoxin Liang
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Hong Shang
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
| | - Xiaoxu Han
- Key Laboratory of AIDS Immunology of National Health and Family Planning Commission, Department of Laboratory Medicine, Shenyang, China
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Ketabat F, Pundir M, Mohabatpour F, Lobanova L, Koutsopoulos S, Hadjiiski L, Chen X, Papagerakis P, Papagerakis S. Controlled Drug Delivery Systems for Oral Cancer Treatment-Current Status and Future Perspectives. Pharmaceutics 2019; 11:E302. [PMID: 31262096 PMCID: PMC6680655 DOI: 10.3390/pharmaceutics11070302] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 12/18/2022] Open
Abstract
Oral squamous cell carcinoma (OSCC), which encompasses the oral cavity-derived malignancies, is a devastating disease causing substantial morbidity and mortality in both men and women. It is the most common subtype of the head and neck squamous cell carcinoma (HNSCC), which is ranked the sixth most common malignancy worldwide. Despite promising advancements in the conventional therapeutic approaches currently available for patients with oral cancer, many drawbacks are still to be addressed; surgical resection leads to permanent disfigurement, altered sense of self and debilitating physiological consequences, while chemo- and radio-therapies result in significant toxicities, all affecting patient wellbeing and quality of life. Thus, the development of novel therapeutic approaches or modifications of current strategies is paramount to improve individual health outcomes and survival, while early tumour detection remains a priority and significant challenge. In recent years, drug delivery systems and chronotherapy have been developed as alternative methods aiming to enhance the benefits of the current anticancer therapies, while minimizing their undesirable toxic effects on the healthy non-cancerous cells. Targeted drug delivery systems have the potential to increase drug bioavailability and bio-distribution at the site of the primary tumour. This review confers current knowledge on the diverse drug delivery methods, potential carriers (e.g., polymeric, inorganic, and combinational nanoparticles; nanolipids; hydrogels; exosomes) and anticancer targeted approaches for oral squamous cell carcinoma treatment, with an emphasis on their clinical relevance in the era of precision medicine, circadian chronobiology and patient-centred health care.
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Affiliation(s)
- Farinaz Ketabat
- Laboratory of Oral, Head and Neck Cancer - Personalized Diagnostics and Therapeutics, Department of Surgery - Division of Head and Neck Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Meenakshi Pundir
- Laboratory of Oral, Head and Neck Cancer - Personalized Diagnostics and Therapeutics, Department of Surgery - Division of Head and Neck Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Fatemeh Mohabatpour
- Laboratory of Oral, Head and Neck Cancer - Personalized Diagnostics and Therapeutics, Department of Surgery - Division of Head and Neck Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Liubov Lobanova
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
| | - Sotirios Koutsopoulos
- Center for Biomedical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Lubomir Hadjiiski
- Departmnet of Radiology, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Xiongbiao Chen
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
- Department of Mechanical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Petros Papagerakis
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Silvana Papagerakis
- Laboratory of Oral, Head and Neck Cancer - Personalized Diagnostics and Therapeutics, Department of Surgery - Division of Head and Neck Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada.
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada.
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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Rahman S, Kraljević Pavelić S, Markova-Car E. Circadian (De)regulation in Head and Neck Squamous Cell Carcinoma. Int J Mol Sci 2019; 20:ijms20112662. [PMID: 31151182 PMCID: PMC6600143 DOI: 10.3390/ijms20112662] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/26/2019] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
Head and neck cancer encompass different malignancies that develop in and around the throat, larynx, nose, sinuses and mouth. Most head and neck cancers are squamous cell carcinomas (HNSCC) that arise in the flat squamous cells that makeup the thin layer of tissue on the surface of anatomical structures in the head and neck. Each year, HNSCC is diagnosed in more than 600,000 people worldwide, with about 50,000 new cases. HNSCC is considered extremely curable if detected early. But the problem remains in treatment of inoperable cases, residues or late stages. Circadian rhythm regulation has a big role in developing various carcinomas, and head and neck tumors are no exception. A number of studies have reported that alteration in clock gene expression is associated with several cancers, including HNSCC. Analyses on circadian clock genes and their association with HNSCC have shown that expression of PER1, PER2, PER3, CRY1, CRY2,CKIε, TIM, and BMAL1 are deregulated in HNSCC tissues. This review paper comprehensively presents data on deregulation of circadian genes in HNSCC and critically evaluates their potential diagnostics and prognostics role in this type of pathology.
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Affiliation(s)
- Sadia Rahman
- University of Rijeka, Department of Biotechnology, Centre for High-Throughput Technologies, 51000 Rijeka, Croatia.
| | - Sandra Kraljević Pavelić
- University of Rijeka, Department of Biotechnology, Centre for High-Throughput Technologies, 51000 Rijeka, Croatia.
| | - Elitza Markova-Car
- University of Rijeka, Department of Biotechnology, Centre for High-Throughput Technologies, 51000 Rijeka, Croatia.
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Adeola HA, Papagerakis S, Papagerakis P. Systems Biology Approaches and Precision Oral Health: A Circadian Clock Perspective. Front Physiol 2019; 10:399. [PMID: 31040792 PMCID: PMC6476986 DOI: 10.3389/fphys.2019.00399] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/22/2019] [Indexed: 12/20/2022] Open
Abstract
A vast majority of the pathophysiological and metabolic processes in humans are temporally controlled by a master circadian clock located centrally in the hypothalamic suprachiasmatic nucleus of the brain, as well as by specialized peripheral oscillators located in other body tissues. This circadian clock system generates a rhythmical diurnal transcriptional-translational cycle in clock genes and protein expression and activities regulating numerous downstream target genes. Clock genes as key regulators of physiological function and dysfunction of the circadian clock have been linked to various diseases and multiple morbidities. Emerging omics technologies permits largescale multi-dimensional investigations of the molecular landscape of a given disease and the comprehensive characterization of its underlying cellular components (e.g., proteins, genes, lipids, metabolites), their mechanism of actions, functional networks and regulatory systems. Ultimately, they can be used to better understand disease and interpatient heterogeneity, individual profile, identify personalized targetable key molecules and pathways, discover novel biomarkers and genetic alterations, which collectively can allow for a better patient stratification into clinically relevant subgroups to improve disease prediction and prevention, early diagnostic, clinical outcomes, therapeutic benefits, patient's quality of life and survival. The use of “omics” technologies has allowed for recent breakthroughs in several scientific domains, including in the field of circadian clock biology. Although studies have explored the role of clock genes using circadiOmics (which integrates circadian omics, such as genomics, transcriptomics, proteomics and metabolomics) in human disease, no such studies have investigated the implications of circadian disruption in oral, head and neck pathologies using multi-omics approaches and linking the omics data to patient-specific circadian profiles. There is a burgeoning body of evidence that circadian clock controls the development and homeostasis of oral and maxillofacial structures, such as salivary glands, teeth and oral epithelium. Hence, in the current era of precision medicine and dentistry and patient-centered health care, it is becoming evident that a multi-omics approach is needed to improve our understanding of the role of circadian clock-controlled key players in the regulation of head and neck pathologies. This review discusses current knowledge on the role of the circadian clock and the contribution of omics-based approaches toward a novel precision health era for diagnosing and treating head and neck pathologies, with an emphasis on oral, head and neck cancer and Sjögren's syndrome.
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Affiliation(s)
- Henry A Adeola
- Hair and Skin Research Laboratory, Division of Dermatology, Department of Medicine, Faculty of Health Sciences and Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,Department of Oral and Maxillofacial Pathology, Faculty of Dentistry, University of the Western Cape and Tygerberg Hospital, Cape Town, South Africa
| | - Silvana Papagerakis
- Laboratory of Oral, Head & Neck Cancer-Personalized Diagnostics and Therapeutics, Division of Head and Neck Surgery, Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada
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