INTRODUCTION:

Hyperglycemia is the pathognomonic feature in diabetes mellitus (DM)¹. Hyperglycemia can generate numerous adverse effects in the oral cavity, one of which is the inhibition of wound healing. This condition reduces the availability of growth factors, one of which is the fibroblast growth factor (FGF)². One type of FGF is fibroblast growth factor-2 (FGF-2), which forms new blood vessels (angiogenesis) in the wound healing process. Hyperglycemia is directly associated with a significant reduction in FGF-2-induced angiogenesis in vivo³.

Oral wounds are damage to the epithelium of the soft tissues of the oral cavity that can affect the quality of life because it can interfere with eating and drinking⁴. Disruption of the wound healing phase due to various factors such as hyperglycemia can cause chronic wounds⁵. If it does not heal due to systemic factors such as hyperglycemia and is not quickly treated can lead to bacteremia⁶.

Antiseptics and corticosteroids are the most common medication used in wound treatment^2,7. Though antiseptic and corticosteroid are considered to be ineffective for wound treatment in diabetic patients. The administration of both drugs does not ameliorate oral wound healing process². Moreover, triamcinolone acetonide has anti-angiogenic effects that would indirectly impede the proliferation of endothelial cells⁸.

Out of the 22 different molluscs, Anadara granosa has the highest potential as a pro-angiogenic biomaterial. Hydroxyapatite nanoparticles formed from Anadara granosa shells directly affect tissue regeneration and induce growth factors production^9,10. Another study reported that the Anadara granosa shell could accelerate angiogenesis in the mandible by increasing FGF-2¹¹. This paper will review the potential of Anadara granosa shell nanoparticles in increasing FGF-2 in chronic wounds affected by hyperglycemia.

DISCUSSION:

The wound healing phase comprises four stages: haemostasis, inflammation, proliferation, and remodeling^12,13. A chronic wound is a wound that fails to go through the normal stages of healing and cannot be repaired regularly and in a timely manner¹². Several causative factors are infection, tissue hypoxia, necrosis, level of exudate, and excess of inflammatory cytokines⁵. In wound healing, angiogenesis supports and intersects with other ongoing proliferative activities and with the remodelling phase¹⁵. Studies have shown that hyperglycaemia is directly associated with a significant reduction in FGF-2-induced angiogenesis in vivo³. FGF-2 helps the proliferation of endothelial cells and the arrangement of endothelial cells to form a tube to support the process of angiogenesis¹⁶. The mRNA expression of endogenous FGF-2 was first detected in immature granulation tissue three days after periodontal surgery and increased up to 7 days¹⁷. Increased glycation and accumulation of glycated plasma proteins have significant roles in the pathogenesis of various diseases. Under conditions of hyperglycaemia, the formation of advanced glycation end-products (AGE) increases. The resulting group of chemical compounds appears to activate intracellular signalling pathways and generate pro-inflammatory and pro-sclerotic cytokines, leading to the development and progression of diabetic complications¹⁴.

Anadara granosa is an infauna shellfish commonly found in sloping beach topography to a depth of 20 meters¹⁸. These shells are called blood clams because they have red blood pigment or hemoglobin¹⁹. The shell of Anadara granosa is a mineral and biopolymer composite consisting of 95% to 99% by weight of calcium carbonate (CaCO₃) in the form of aragonite crystals20. Biogenic CaCO₃ nanoparticles have shown promising potential as drug carrier targets against cancer cells and can meet cellular needs so that the process of cell mitosis becomes better through the pathway of increasing calcium influx into the cytoplasm^21,22.

The high calcium content of the Anadara granosa shell can increase FGF-2 by activating NF-κB signalling and induce cyclooxygenase-2 (COX-2) and Ep4 expression levels at the transcriptional level, leading to sequential activation of prostaglandin E2 (PGE2)/EP4 signalling and increased FGF-2 expression²³. CaCO3 stimulates the activity of resident macrophages in the area of the wound. Macrophages, along with other inflammatory cells, strengthen the process of angiogenesis²⁴. Other studies have shown that PGE2 and FGF-2 work synergistically for tissue healing, collateralization, revascularization, and inflammatory reactions. The PGE2 receptor, namely EP3, facilitates this function. PGE2, in turn, will increase the production of FGF-2²⁵.

Chronic hyperglycaemia leads to the accelerated formation of advanced glycation end-products (AGE). When AGE binds to receptor-advanced glycation end-products (RAGE), it can cause defects in angiogenesis^26,27. In addition, it can cause apoptosis of the fibroblast cells before they can migrate to the wound tissue, proliferate, and form a new extracellular matrix. Thus, the normal healing process is inadequate and the wound does not heal²⁸. Fibroblast cell metabolism and angiogenesis are influenced by growth factors, one of which is FGF-2. Hypoxic conditions of injured tissue trigger production of FGF-2²⁹. Hypoxic conditions will cause hypoxia-inducible factor-1a (HIF-1a) accumulation, which performs angiogenic functions such as increased vascular permeability, proliferation, migration, adhesion, tube formation of endothelial cells, and regulating pro-angiogenic factor genes such as FGF-2³⁰. Endothelial cells will produce FGF-2 and produce microvascular growth, which will begin producing mature endothelial cells to synthesize new blood vessels further²⁹.

Hyperglycaemia conditions in diabetics can cause growth factor deficiency, one of which is FGF-2. Hyperglycaemia conditions can cause macromolecular (fibrinogen, macroglobulin, and albumin) leakage in blood vessels and can bind growth factors so that FGF-2 in wound tissue is not available enough for the normal healing process, and chronic wounds are formed¹². Another research concludes that the hyperglycaemia-induced defect in endothelial cell proliferation was caused by an increase in endothelial cell apoptosis rather than a decrease in the number of growth factors³. Upregulation of FGF-2 has a high potential to enhance the process of angiogenesis³¹. Administration of Anadara granosa shell nanoparticles can be a treatment option to enhance the FGF-2-induced angiogenesis process. This study used the Anadara granosa shell as a bone graft aimed at increasing FGF-2-induced angiogenesis. The results showed that FGF-2 increased dramatically on day seven compared to the positive control group using xenograft and the negative control group¹¹. Other studies have shown that the shell of Anadara granosa acts as a growth factor carrier and enables cell attachment, cell growth, cell proliferation, and cell differentiation. Giving Anadara granosa shell can increase the number of osteoblasts but has a drawback because it has pro-inflammatory properties characterized by an increase in the number of osteoclasts. The addition of anti-inflammatory ingredients such as Sardinella longiceps can be a solution to this problem²⁴. Other studies have shown the same thing when Anadara granosa shell combined with Stichopus hermanni as an anti-inflammatory agent showed a greater degree of defect closure, indicating a more optimal healing process²⁹.

Anadara granosa shells can be formed into hydroxyapatite nanoparticles because they consist of about 98% calcium carbon elements and pure CaCO₃ crystals in the form of pure aragonite polymorphs and have great potential in the field of tissue engineering and regenerative medicine^32,33. A study applied Anadara granosa shell hydroxyapatite nanoparticles to skin wounds by administration both topically and intravenously. Administration of Anadara granosa shell hydroxyapatite nanoparticles intravenously showed more significant wound healing results than topical administration. The increase in the healing process was obtained due to the role of calcium content in Anadara granosa shell hydroxyapatite nanoparticles³⁴.

Hypothetically, applying Anadara granosa shell hydroxyapatite nanoparticles on skin wounds and oral mucosa has the same therapeutic effect because skin wounds and oral mucosa go through the same phases. However, it has been shown that the oral mucosa is a unique environment that exhibits an increased speed of wound healing compared to normal skin. In addition to healing quickly, the result of oral healing is minimal scarring^35,36. The high calcium content in Anadara granosa shell nanoparticles has an important role in increasing FGF-2. Calcium can activate NF- κB signalling and induce COX-2 and EP4 expression levels at the transcriptional level, leading to sequential PGE2/EP4 signalling activation, which will further develop increase FGF-2 expression levels²³. This statement is in line with research showing that PGE2 and FGF-2 work synergistically for tissue healing, collateralization, revascularization, and inflammatory reactions. PGE2 acts as a primer for angiogenic function by promoting FGF-2/FGFR1 interactions through increased FGF-2 expression and mobilization of the extracellular matrix²⁵.

Based on these studies, no studies directly show that applying Anadara granosa shell nanoparticles on chronic oral wounds can increase FGF-2 in hyperglycemic conditions. However, the Administration of Anadara granosa shell on bone defects increases FGF-2 and angiogenesis processes. Research also shows that the application of Anadara granosa shell hydroxyapatite nanoparticles can accelerate the healing process of skin wounds by increasing calcium in wound tissue.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

There are no acknowledgments

REFERENCES:

1. Kharroubi AT. Diabetes mellitus: The Epidemic of The Century. World Journal of Diabetes. 2015 Jun; 6(6): 850-867. doi:10.4239/wjd.v6.i6.850.

2. Tripathi R, Tripathi K. Management of Non-Healing Oral Ulcer in Diabetic Patient Using Topical Application of Epidermal Growth Factor: A Case Report. Scholars Academic Journal of Biosciences. 2015; 3(8): 640–643.

3. Larger E, Marre M, Corvol P, Gasc J-M. Hyperglycemia-Induced Defects in Angiogenesis in the Chicken Chorioallantoic Membrane Model. Methods in Molecular Biology. 2004; 53(3): 752–61. doi:10.2337/diabetes.53.3.752.

4. Lewis M, Wilson N. Oral ulceration: causes and management. The Pharmaceutical Journal. 2019 Mar; 302: 1–13.doi:10.1211/PJ.2019.20205786.

5. Velnar T, Bailey T, Smrkolj V. The wound healing process: An overview of the cellular and molecular mechanisms. Journal of International Medical Research. 2009; 37(5): 1528-42. doi:10.1177/147323000903700531.

6. Iqbal A, Jan A, Wajid MA, Tariq S. Management of Chronic Non-healing Wounds by Hirudotherapy. World Journal of Plastic Surgery. 2017; 6(1):9–17.

7. Mortazavi H, Safi Y, Baharvand M, Rahmani S. Diagnostic Features of Common Oral Ulcerative Lesions: An Updated Decision Tree. International Journal of Dentistry. 2016; 2016. doi:10.1155/2016/7278925.

8. Veritti D, Perissin L, Zorzet S, Lanzetta P. The effect of triamcinolone acetonide, sodium hyaluronate, and chondroitin sulfate on human endothelial cells: An in vitro study. European Journal of Ophthalmology. 2011; 21Suppl 6: S75–9. doi:10.5301/EJO.2010.6060.

9. Chu C et al. Nanoparticles combined with growth factors: Recent progress and applications. RSC Advances. 2016; 6(93): 90856–72. doi:10.1039/C6RA13636B

10. Fianza Rezkita, Kadek G. P. Wibawa, Alexander P. Nugraha. Curcumin loaded Chitosan Nanoparticle for Accelerating the Post Extraction Wound Healing in Diabetes Mellitus Patient: A Review. Research Journal of Pharmacy and Technology. 2020; 13(2):1039-1042. doi: 10.5958/0974-360X.2020.00191.2

11. Widyastuti W, Rubianto M, Soetjipto. Induction of Angiogenesis Process in Mandible Using Anadara granosa Shell Graft (Experimental Laboratory Study on Rattus norvegicus). IOP Conference Series Earth Environmental Science. 2019; 217(1): 012033.doi:10.1088/1755-1315/217/1/012033.

12. Robson MC, Steed DL, Franz MG. Wound healing: biologic features and approaches to maximum healing trajectories. Current Problem in Surgery. 2001; 38(2): 72–141. doi:10.1067/msg.2001.111167.

13. Broughton G, Janis JE, Attinger CE. Wound healing: An overview. Plastic Reconstructive Surgery. 2006; 117 (7 SUPPL.): 1–32. doi:10.1097/01.prs.0000222562.60260.f9.

14. Singh VP, Bali A, Singh N, Jaggi AS. Advanced glycation end products and diabetic complications. Korean Journal of Physiology and Pharmacology. 2014; 18(1): 1–14.doi:10.4196/kjpp.2014.18.1.1.

15. Gurtner GC, Werner S, Barrandon Y, Longaker MT. Wound repair and regeneration. Nature. 2008; 453(7193): 314–21. doi:10.1038/nature07039.

16. Yun YR et al. Fibroblast growth factors: Biology, function, and application for tissue regeneration. Journal of Tissue Engineering. 2010;1(1):1–18. doi:10.4061/2010/218142.

17. Nagayasu-Tanaka T et al. Action mechanism of fibroblast growth factor-2 (FGF-2) in the promotion of periodontal regeneration in beagle dogs. PLoS One. 2015; 10(6): 1–19. doi:10.1371/journal.pone.0131870.

18. Praja F, Rusliadi, Mulyadi. Growth rates of shellfish blood (Anadara granosa) at different stocking density. Student Fishery and Marine Science Faculty Riau University. 2014;1(1):821–2.

19. Nurjanah, Zulhamsyah, Kustiyariyah. Kandungan mineral dan proksimat kerang darah (Anadara granosa) yang Diambil dari Kabupaten Boalemo, Gorontalo. 2005;VIII(2):15–24.

20. Saryati, Sukaryo SG, Handayani A, Untoro P, Sugeng B. Hidrosiapatit berpori dari kulit kerang. J Sains Mater Indones. 2012;13(4):31–5.doi: 10.17146/jsmi.2012.13.4.4753

21. Kamba AS, Ismail M, Azmi Tengku Ibrahim T, Zakaria ZAB. Biocompatibility of bio based calcium carbonate nanocrystals aragonite polymorph on nih 3T3 fibroblast cell line. African J Tradit Complement Altern Med. 2014;11(4):31–8.

22. Orrenius S, Zhivotovsky B, Nicotera P. Regulation of cell death: The calcium-apoptosis link. Nat Rev Mol Cell Biol. 2003;4(7):552–65.

23. Kanaya S, Nemoto E, Sakisaka Y, Shimauchi H. Calcium-mediated increased expression of fibroblast growth factor-2 acts through NF-κB and PGE2/EP4 receptor signaling pathways in cementoblasts. Bone. 2013;56(2):398–405. Available from: http://dx.doi.org/10.1016/j.bone.2013.06.031

24. Hermanto E, Sari RP, Imaniar ACD, Anggoro K. Grafting effectiveness of Anadara granosa shell combined with sardinella longiseps gel on the number of osteoblast-osteoclast cells. Dent J (Majalah Kedokt Gigi). 2018;50(3):138.

25. Finetti F, Donnini S, Giachetti A, Morbidelli L, Ziche M. Prostaglandin E2 primes the angiogenic switch via a synergic interaction with the fibroblast growth factor-2 pathway. Circ Res. 2009;105(7):657–66.

26. Chilelli NC, Burlina S, Lapolla A. AGEs, rather than hyperglycemia, are responsible formicrovascular complications in diabetes: A"glycoxidation-centric" point of view. Nutr Metab Cardiovasc Dis [Internet]. 2013;23(10):913–9. Available from: http://dx.doi.org/10.1016/j.numecd.2013.04.004

27. Puddu A, Sanguineti R, Maggi D, Nicolò M, Traverso CE, Cordera R, et al. Advanced Glycation End-Products and Hyperglycemia Increase Angiopoietin-2 Production by Impairing Angiopoietin-1-Tie-2 System. J Diabetes Res. 2019;2019.

28. Van Putte L, De Schrijver S, Moortgat P. The effects of advanced glycation end products (AGEs) on dermal wound healing and scar formation: a systematic review. Scars, Burn Heal. 2016; 2: 205951311667682.

29. Sari RP, Sudjarwo SA, Rahayu RP, Prananingrum W, Revianti S, Kurniawan H, et al. The effects of Anadara granosa shell-Stichopus hermanni on bFGF expressions and blood vessel counts in the bone defect healing process of Wistar rats. Dent J (Majalah Kedokt Gigi). 2017;50(4):194.

30. Krock BL, Skuli N, Simon MC. Hypoxia-Induced Angiogenesis: Good and Evil. Genes and Cancer. 2011;2(12):1117–33.

31. Seo HR, Jeong HE, Joo HJ, Choi SC, Park CY, Kim JH, et al. Intrinsic FGF2 and FGF5 promotes angiogenesis of human aortic endothelial cells in 3D microfluidic angiogenesis system. Sci Rep. 2016;6(6):1–11. Available from: http://dx.doi.org/10.1038/srep28832

32. Mailafiya MM, Abubakar K, Danmaigoro A, Chiroma SM, Rahim EBA, Moklas MAM, et al. Cockle shell-derived calcium carbonate (aragonite) nanoparticles: A dynamite to nanomedicine. Appl Sci. 2019;9(14):1–25.

33. Biradar S, Ravichandran P, Gopikrishnan R, Goornavar V, Hall JC, Ramesh V, et al. Calcium carbonate nanoparticles: Synthesis, characterization and biocompatibility. J Nanosci Nanotechnol. 2011;11(8):6868–74.

34. Kawai K, Larson BJ, Ishise H, Carre AL, Nishimoto S, Longaker M, et al. Calcium-based nanoparticles accelerate skin wound healing. PLoS One. 2011;6(11).

35. Johnson A, Francis M, DiPietro LA. Differential Apoptosis in Mucosal and Dermal Wound Healing. Adv Wound Care. 2014; 3(12): 751–61.

36. DiPietro LA, Schrementi M. Oral Mucosal Healing. Wound Heal Stem Cells Repair Restorations, Basic Clin Asp. 2018; 125–32.

Received on 31.08.2021 Modified on 27.01.2022

Research J. Pharm. and Tech 2022; 15(12):5757-5760.

DOI: 10.52711/0974-360X.2022.00971