Estimation of L-carnitine levels in diabetic completely edentulous patients for implant diagnosis: A cross-sectional study

Rinki George; Subhabrata Maiti; Dhanraj M Ganapathy

doi:10.4103/1735-3327.384367

ORIGINAL ARTICLE

Year : 2023 | Volume : 20 | Issue : 1 | Page : 96

Estimation of L-carnitine levels in diabetic completely edentulous patients for implant diagnosis: A cross-sectional study

Rinki George, Subhabrata Maiti, Dhanraj M Ganapathy
Departments of Prosthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India

Date of Submission	08-Dec-2022
Date of Acceptance	26-May-2023
Date of Web Publication	28-Aug-2023

Correspondence Address:
Dr. Subhabrata Maiti
Department of Prosthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai - 600 077, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1735-3327.384367

Abstract

Background: Carnitine is effective in preventing the accumulation of end products related to lipid peroxidation due to its anti-inflammatory and antioxidant effects. Carnitine also exerts a significant anti-inflammatory role through the downregulation of the nuclear factor kappa beta pathway, which leads to a decrease in the expression of pro-inflammatory cytokines.The aim of the study was to estimate the L-carnitine (L-C) levels in diabetic completely edentulous patients.
Materials and Methods: A cross-sectional study was conducted after the selection of 60 samples based on the inclusion and exclusion criteria. The collected saliva samples were utilized to measure the levels of L-C using the sandwich enzyme-linked immunosorbent assay (ELISA) method. One hundred microliters of sample was applied to a particular row of wells and incubated for an hour as part of the sandwich ELISA procedure. After the wells had been cleaned, a second batch of monoclonal L-C was added, and they were once more incubated for an hour. The horseradish peroxidase substrate was then applied after washing the second batch as well. To allow the blue-to-yellow color transition, the wells were kept steady. Following the observation of the color shift, the OD was measured, and the concentration was determined using the sandwich ELISA kit's standard curve as an intercept. The data were statistically analyzed using the independent t-test (significant level P < 0.05) and were tabulated.
Results: The L-C levels have higher levels in nondiabetic patients than in diabetic patients. The difference in the baseline mean value between the groups was statistically significant (P = 0.00). Although it is statistically significant (P = 0.00), the mean value for diabetic individuals is 0.19 as opposed to 0.29 for nondiabetic patients.
Conclusion: Based on the findings, it can be concluded that L-C improves insulin sensitivity and glucose disposal in diabetic completely edentulous patients.

Keywords: Adult-onset diabetes mellitus, dental implant, edentulous jaw, enzyme-linked immunosorbent assay, levocarnitine

How to cite this article:
George R, Maiti S, Ganapathy DM. Estimation of L-carnitine levels in diabetic completely edentulous patients for implant diagnosis: A cross-sectional study. Dent Res J 2023;20:96

How to cite this URL:
George R, Maiti S, Ganapathy DM. Estimation of L-carnitine levels in diabetic completely edentulous patients for implant diagnosis: A cross-sectional study. Dent Res J [serial online] 2023 [cited 2023 Sep 28];20:96. Available from: https://www.drjjournal.net/text.asp?2023/20/1/96/384367

Introduction

Inflammation is a complex biological process where there are elevated levels of free radicals and reactive oxygen species (ROS), which may cause structural damage to the cells. Inflammation and oxidative stress are associated with numerous range of chronic diseases, including atherosclerosis, diabetes mellitus, neurological disorders, pulmonary diseases, cancer, and rheumatoid arthritis.^[1] Carnitine is widely effective in preventing the accumulation of end products related to lipid peroxidation due to its anti-inflammatory and antioxidant effects. The major physiologic role of carnitine is transporting long-chain fatty acids through the mitochondrial membrane and contributing to the oxidative release of energy.^[2] It not only helps with long-chain fatty acids but also helps to remove the short- and medium-chain fatty acids from mitochondria.^[3] Any differences in carnitine homeostasis will have an impact on the metabolism and function of lipids, red blood cells, and cardiac muscle cells.^[4]

L-carnitine (L-C) constant infusion improves insulin sensitivity in insulin-resistant diabetic patients; a significant effect on whole-body insulin-mediated glucose uptake is also observed in normal subjects. In diabetics, glucose, taken up by the tissues, appears to be promptly utilized as fuel since glucose oxidation is increased during L-C administration.^[5] L-C, a shuttle for the acetyl groups through the mitochondrial membrane and a cofactor in the oxidation of fatty acids, has been shown to stimulate human osteoblast functions and intracellular calcium signaling. Increased mitochondrial performance, particularly from L-C, may have favorable effects on high-energy-demanding organs such as muscle and bone. It is noteworthy that L-C has a direct impact on human osteoblasts, causing them to proliferate and operate more actively, as well as express collagen Type I, bone sialoproteins (BSPs), and osteopontin (OPN).

L-C has recently demonstrated antioxidant action that prevents age-related mitochondrial dysfunction and maintains the equilibrium of ROS generation in several types of cells.^[6] The development of myotubes and their hypertrophy were seen to speed the differentiation of C2C12 myoblasts,^[7] counteract mitochondrial malfunction, and reduce oxidative stress. Glycemia depicts the level of sugar in the blood, which plays a vital role in the consequences of osseointegration,^[8] as a correlation between glycemic control and the development of microvascular and macrovascular complications was observed specifically during implant placement.^[9] Tight and intensive glycemic control in diabetic patients can delay the onset and the progression of many microvascular-related complications associated with the condition.^[10]

Our team has extensive knowledge and research experience that have translated into high-quality publications.^{[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26]} The aim of the study was to estimate the L-C levels in diabetic completely edentulous patients, where the null hypothesis stated that there is no difference in the level of L-C patients completely edentulous patients when compared to healthy individuals.

Materials and Methods

Study design

This was a cross-sectional study.

Sample size calculation

In the prosthodontics department of a well-known university hospital, a clinical trial was conducted. The G*Power software (Version 3.1.9.4) Mac OS X and windows XP/ vista/7/8 was used to estimate the sample size, and the sample included 60 patients (30 diabetics and 30 nondiabetics). All of the chosen patients were told of the study and provided with voluntarily informed written permission.

Method of sampling

Patients with chief complaints of the replacement of completely edentulous teeth participated in the study. The study was on patients who were undergoing implant-supported complete denture treatment which included 30 diabetic and 30 nondiabetic participants with ages ranging between 40 and 65 years. A simple random sampling method was followed [Figure 1].

Figure 1: Flow chart of the study population selection including patient recruitment, exclusion criteria, and refusals. CD = Complete denture.

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Ethical approval

Ethical approval was obtained from the Institutional Ethics Committee. Number: IHEC/SDC/UG-1873/22/PROSTHO/625.

Selection criteria

Inclusion

Completely edentulous diabetic and nondiabetic patients, time of edentulism within 1 year, and patient not wearing any denture were considered inclusion criteria.

Exclusion

Partial edentulous patients, patients wearing dentures for more than a year, patients with systemic disease, and patients needing preprosthetic surgery were considered exclusion criteria.

Procedure

Patients at the dental hospital provided 1.5 ml of unstimulated saliva samples. 50–90 years old is the age range. In uricol containers, the samples were gathered, and they were thereafter kept in the cold room. Following that, the samples were utilized to measure the levels of L-C using the sandwich enzyme-linked immunosorbent assay (ELISA) method. One hundred microliters of sample was applied to a particular row of wells and incubated for an hour as part of the sandwich ELISA procedure. After the wells had been cleaned, a second batch of monoclonal L-C was added, and they were once more incubated for an hour. The horseradish peroxidase substrate was then applied after washing the second batch as well. To allow the blue-to-yellow color transition, the wells were kept steady. Following the observation of the color shift, the Optical density (OD) was measured, and the concentration in ng/mL was determined using the sandwich ELISA kit's standard curve as an intercept.

Data collection

A total sample of 70 patients for 1 month with complete edentulism was taken; out of which only 60 patients met the inclusion criteria. Two diabetic patients were eliminated from the data collection sheet as they did not report back after selection. Data were reviewed by an external reviewer. The result from the laboratory testing was tabulated.

Statistical analysis

Data were recorded in Microsoft Excel 2016 (Microsoft Office 10) and later exported to SPSS (Statistical Package for the Social Sciences for Windows versions, 20.0), SPSS Inc., (Chicago, IL, USA), and subjected to statistical analysis. The data were statistically analyzed using the independent t-test (P < 0.05) and were tabulated.

Results

The L-C levels have higher levels in nondiabetic patients than in diabetic patients [Table 1]. The difference in the mean value between the groups was statistically significant (P = 0.00).

Table 1: Comparison between the diabetic and nondiabetic groups based on L-carnitine concentration

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Discussion

The goal of the current study was to measure the L-C levels of diabetic patients with no remaining teeth. The current investigation demonstrated that there was a statistically significant difference between the groups in the mean value at the baseline (P = 0.00). Although it is statistically significant (P = 0.00), the mean value for diabetic individuals is 0.19 when compared to 0.29 for nondiabetic patients. Studies done in the past found that diabetic patients had dental implant chances of success that were similar to those of healthy individuals. The fact that diabetics under control are virtually always included in research could be the cause. The development of microvascular complications and subsequent early or late implant failure is brought on by continuous hyperglycemia.

Osseointegration is the process by which an alloplastic substance is rigidly fixed in bone and retained therein under functional loads while exhibiting no clinical symptoms. Dental implants undergo osseointegration during the healing process, resulting in a functioning unit that may restore one or more lost teeth and support dental prostheses. The immune and nutritional state of the host should be considered in addition to important aspects that influence osseointegration, such as surgical technique, bone quality and quantity, postoperative inflammation or infection, smoking habits, and implant material and surface.^[27]

L-C improves the mitochondria's overall functionality and guards against oxidative stress. In addition, L-C stimulates the CaMKII and ERK/AKT signaling pathways, favoring the activation of genes related to bone growth.^[28] Reduced energy supply for altered mitochondrial biogenesis and activity could be blamed, at least in part, for the age-related structural degradation of bone caused by dysregulation of bone remodeling. Studies have shown that L-C improves the mitochondria's overall performance, which suggests that L-C might help meet the high metabolic demand of osteoblasts during bone production. L-C, a coenzyme in fatty acid oxidation, has been shown to promote the actions of human osteoblasts. The expression of collagen Type I, BSPs, and OPN are also all greatly increased, as are osteoblast activity and proliferation. L-C can prevent oxidative damage and support maintaining bone quality.^[29]

A flaw in the regulation of mitochondrial ROS concentration leads to an imbalance between superoxide radical production and destruction, which is greater than the capacity of osteoblasts to detoxify them, and suppresses the expression of osteogenic genes and matrix mineralization. The ability of L-C to boost mitochondrial superoxide dismutase-2 production and lower osteoblast ROS concentration indicates that L-C therapy improves the mitochondrial-mediated equilibrium between ROS production and catabolism. Through the ERK pathway, L-C increases the expression of the RUNX2 and OSX genes, supporting a role for L-C in promoting osteogenic cell activities.^[30]

Based on all these findings as well as the results from the present study, carnitine supplementation can be an effective intervention for the improvement of oxidative stress and promotes osteogenic activity when associated with implant placement; however, these findings need to be confirmed by more research and have to be performed for clinical significance. The null hypothesis was removed as there were increased levels of L-C in diabetically edentulous patients.

Conclusion

The present study demonstrated that L-C potentiates the anti-osteoporotic effect by suppressing the overexpressed inflammatory cytokines and ameliorates bone osteoporotic histopathological changes. L-C can be considered a new therapeutic regimen to maintain bone health and limit the worsening of osteoporotic bony changes in diabetic completely edentulous patients associated with implant placements.

Acknowledgment

This study was supported by saveetha dental college and hospital. Lab support was from Dr. Selvaraj J and his team, saveetha institute of medical and technical sciences.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.

References

1.	Sun X, Xu M, Ding L, Yang G, Kong J, Zhu Y, et al. The amino acid and carnitine concentration changes in bronchoalveolar lavage fluid from lung cancer patients. World J Surg Oncol 2022;20:380.
2.	Huguenard CJ, Cseresznye A, Evans JE, Darcey T, Nkiliza A, Keegan AP, et al. APOE ε4 and Alzheimer's disease diagnosis associated differences in L-carnitine, GBB, TMAO, and acylcarnitines in blood and brain. Curr Res Transl Med 2023;71:103362.
3.	Bain SD, Gross TS. Structural aspects of bone resorption. In: Bronner F, Farach-Carson MC, Rubin J, editors. Bone Resorption. Topics in Bone Biology. Vol. 2. London: Springer; 2005.
4.	Sørensen MG, Karsdal MA, Dziegiel MH, Boutin JA, Nosjean O, Henriksen K. Screening of protein kinase inhibitors identifies PKC inhibitors as inhibitors of osteoclastic acid secretion and bone resorption. BMC Musculoskelet Disord 2010;11:250.
5.	Morales-Gonzalez JA, editor. Oxidative Stress and Chronic Degenerative Diseases: A Role for Antioxidants. Mexico: InTech; 2013.
6.	Pekala J, Patkowska-Sokoła B, Bodkowski R, Jamroz D, Nowakowski P, Lochyński S, et al. L-carnitine – Metabolic functions and meaning in humans life. Curr Drug Metab 2011;12:667-78.
7.	Longo N, Frigeni M, Pasquali M. Carnitine transport and fatty acid oxidation. Biochim Biophys Acta 2016;1863:2422-35.
8.	Terruzzi I, Montesano A, Senesi P, Villa I, Ferraretto A, Bottani M, et al. L-Carnitine reduces oxidative stress and promotes cells differentiation and bone matrix proteins expression in human osteoblast-like cells. Biomed Res Int 2019;2019:5678548.
9.	Hoppel CL. Carnitine and carnitine palmitoyltransferase in fatty acid oxidation and ketosis. Fed Proc 1982;41:2853-7.
10.	Ulinski T, Cirulli M, Virmani MA. The role of L-Carnitine in kidney disease and related metabolic dysfunctions. Kidney Dial 2023;3:178-91.
11.	Jayaraj G, Sherlin HJ, Ramani P, Premkumar P, Natesan A. Stromal myofibroblasts in oral squamous cell carcinoma and potentially malignant disorders. Indian J Cancer 2015;52:87-92. [PUBMED] [Full text]
12.	Sekhar CH, Narayanan V, Baig MF. Role of antimicrobials in third molar surgery: Prospective, double blind, randomized, placebo-controlled clinical study. Br J Oral Maxillofac Surg 2001;39:134-7.
13.	Khalid W, Varghese SS, Sankari M, Jayakumar ND. Comparison of serum levels of endothelin-1 in chronic periodontitis patients before and after treatment. J Clin Diagn Res 2017;11:C78-81.
14.	Khalid W, Vargheese SS, Lakshmanan R, Sankari M, Jayakumar ND. Role of endothelin-1 in periodontal diseases: A structured review. Indian J Dent Res 2016;27:323-33. [PUBMED] [Full text]
15.	Putchala MC, Ramani P, Sherlin HJ, Premkumar P, Natesan A. Ascorbic acid and its pro-oxidant activity as a therapy for tumours of oral cavity – A systematic review. Arch Oral Biol 2013;58:563-74.
16.	Ramesh A, Ravi S, Kaarthikeyan G. Comprehensive rehabilitation using dental implants in generalized aggressive periodontitis. J Indian Soc Periodontol 2017;21:160-3. [PUBMED] [Full text]
17.	Padavala S, Sukumaran G. Molar Incisor hypomineralization and its prevalence. Contemp Clin Dent 2018;9:S246-50.
18.	Keerthana B, Thenmozhi MS. Occurrence of foramen of Huschke and its clinical significance. Res J Pharm Technol 2016;9:1835-6.
19.	Patturaja K, Pradeep D. Awareness of basic dental procedure among general population. J Adv Pharm Technol Res 2016;9:1349.
20.	Krishnan V, Lakshmi T. Bioglass: A novel biocompatible innovation. J Adv Pharm Technol Res 2013;4:78-83. [PUBMED] [Full text]
21.	Ponnanna AA, Maiti S, Rai N, Jessy P. Three-dimensional-printed Malo Bridge: Digital fixed prosthesis for the partially edentulous maxilla. Contemp Clin Dent 2021;12:451-3. [Full text]
22.	Merchant A, Ganapathy DM, Maiti S. Effectiveness of local and topical anesthesia during gingival retraction. Braz Dent Sci 2022;25:e2591.
23.	Aparna J, Maiti S, Jessy P. Polyether ether ketone – As an alternative biomaterial for metal Richmond crown-3-dimensional finite element analysis. J Conserv Dent 2021;24:553-7. [Full text]
24.	Agarwal S, Ashok V, Maiti S. Open- or closed-tray impression technique in implant prosthesis: A dentist's perspective. J Long Term Eff Med Implants 2020;30:193-8.
25.	Agarwal S, Maiti S, Ashok V. Correlation of soft tissue biotype with pink aesthetic score in single full veneer crown. Bioinformation 2020;16:1139-44.
26.	Kasabwala H, Maiti S, Ashok V, Sashank K. Data on dental bite materials with stability and displacement under load. Bioinformation 2020;16:1145-51.
27.	Ge C, Cawthorn WP, Li Y, Zhao G, Macdougald OA, Franceschi RT. Reciprocal control of osteogenic and Adipogenic differentiation by ERK/MAP kinase phosphorylation of Runx2 and PPARγ transcription factors. J Cell Physiol 2016;231:587-96.
28.	Niu Q, Gao J, Wang L, Liu J, Zhang L. Regulation of differentiation and generation of osteoclasts in rheumatoid arthritis. Front Immunol 2022;13:01-17.
29.	Zhang JJ, Wu ZB, Cai YJ, Ke B, Huang YJ, Qiu CP, et al. L-carnitine ameliorated fasting-induced fatigue, hunger, and metabolic abnormalities in patients with metabolic syndrome: A randomized controlled study. Nutr J 2014;13:110.
30.	Samimi M, Jamilian M, Ebrahimi FA, Rahimi M, Tajbakhsh B, Asemi Z. Oral carnitine supplementation reduces body weight and insulin resistance in women with polycystic ovary syndrome: A randomized, double-blind, placebo-controlled trial. Clin Endocrinol (Oxf) 2016;84:851-7.