Abstract
Background/Aim: Autologous platelet-derived growth factors such as platelet rich fibrin (PRF) are receiving increasing attention in the context of different medical situations such as soft-tissue wound healing or bone regeneration in patients with cancer suffering from therapy-associated osteonecrosis. PRF has been observed to support the colonization and differentiation of osteoblasts, thereby improving the wound healing process. In the recent past, fruit extracts from the tropical plant Morinda citrifolia have been associated with improved intestinal health and anti-inflammatory therapeutic effects. The aim of this study was to investigate the influence of Morinda citrifolia-derived noni juice on clinical blood parameters and the composition of human PRF.
Materials and Methods: Forty healthy volunteers participated in a prospective, single-blinded, placebo-controlled, cross-over study. Participants consumed either noni juice (2 ml/kg/day) or placebo for four weeks, separated by a four-week washout. Blood samples were collected, and PRF was prepared by centrifugation. Clinical blood values were analyzed, and PRF samples were examined for growth factors, structural proteins, and cytokines using ELISA and cytokine arrays.
Results: Noni juice consumption led to significant changes in blood calcium, ALAT, and γ-GT levels. PRF analysis revealed elevated interleukin-11 (IL-11), macrophage colony-stimulating factor (M-CSF), and chemokine CCL7, indicating that noni juice alters the molecular profile of PRF.
Conclusion: Regular intake of noni juice influences PRF composition and modulates hepatic enzymes. These findings highlight the potential of dietary factors to impact regenerative biomaterials and warrant further targeted investigations.
Introduction
The use of autologous platelets-derived growth factors such as platelet rich plasma (PRP) and platelet rich fibrin (PRF) has recently drawn interest in many medical conditions, including soft-tissue wound healing (1) and bone regeneration (2) in patients with cancer suffering from bisphosphonate-associated osteonecrosis of the jaw (BRONJ) as a side effect of the oncological therapy (3-5).
Several studies have shown that PRF promotes the colonization, adhesion, proliferation, and differentiation of osteoblasts as well as the osteoblastic differentiation of bone marrow-derived mesenchymal stem cells due to high concentrations of osteogenic and endothelial growth factors (6-9). Alternative production protocols for PRF have recently been postulated to increase the expression of certain proteins and growth factors and improve its regenerative features (10). It is widely accepted that changes in platelet concentration and the use of anti-coagulative drugs have significant impact on the quality of autologous PRF (11).
Furthermore, nutritional habits may influence the composition of PRF as well, thus contributing to their potential regenerative features. Recently, excessive research has been carried out on the tropical plant Morinda citrifolia, the so-called Noni fruit. The latter grows in the tropical belt and is widely used in India and the southern Pacific regions in many medical conditions and is believed to play an anti-oxidative role (12).
The fruits and leaves of the tree, which grows to a height of two to six meters, have been used for more than 3000 years in traditional medicine. In 2003, noni juice was approved as a novel food in the European Union (13). Recently, scientific interest in the potential physical and psychological effects of noni juice aroused and several studies provided reliable findings regarding its health-promoting and therapeutic effects. Three main effects of noni juice have been postulated: antibacterial activity (14-16), anti-inflammatory effect (17, 18), and immune stimulation (19).
To investigate the potential effect of noni juice consumption on the PRF contents and composition, we conducted a prospective, single-blinded, placebo-controlled clinical study with a cross-over design. We especially measured crucial osteogenic growth factors and relevant structural proteins as well as a wide range of different cytokines and chemokines.
Materials and Methods
Ethics statement. All volunteers were recruited at the Department of Oral and Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Luebeck, and gave written informed consent for the following examinations. The study was approved by the local ethics committee of the University of Luebeck (approval number 20-175) and was conducted in accordance with the ethical principles for medical research as formulated in the World Medical association (WMA) Declaration of Helsinki.
Patients and study design. A total of 40 healthy volunteers (24 females/16 males; mean age 31.3 years) were randomized and divided into two groups of n=20 each. The 20 participants in group A received 2 ml/kg BW of noni juice (100%) once daily for four weeks. Maximum dose was set at 160 ml. After 30 days, the intake was discontinued for four weeks (washout period) and then replaced with a placebo juice (100% blueberry nectar, Kelterei Walther, Arnsdorf, Germany) at the same dose for a further four weeks. A second group of 20 participants (group B) received the juices in the opposite order. Regular medication was an exclusion criterion. Figure 1 shows the flowchart of the study design and the blood sampling procedure.
Flowchart of (A) the study design and (B) the processing procedure of blood samples. Forty healthy volunteers were randomly assigned to two groups of 20. Group A consumed 2 ml /kg BW of 100% noni juice daily (up to 160 ml) for 28 days, followed by a 28-day break, then a placebo in the same dosage for another 28 days. Group B followed the reverse order. Four blood samples were taken per person. First, the following parameters were measured: platelets, potassium, calcium, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase and gamma-glutamyltransferase. Additionally, four 10 ml whole blood samples were taken for PRF preparation, centrifuged and processed according to the manufacturer’s protocol. The fibrin layer was separated, transferred to a sterile monovette, pooled in both groups and stored at −80°C for ELISA analysis.
Blood samples and preparation of PRF. Through a standard vein puncture (median basilica vein, median cubital vein or median cephalic vein), blood samples were taken from the participants four times during the 12-week study for analysis in the central laboratory of the study site. Platelets count, concentration of potassium, calcium, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase and gamma-glutamyltransferase were measured. In addition, 4×10 ml whole blood samples were collected for PRF preparation, filled into sample tubes from Mectron® (mectron Deutschland Vertriebs GmbH, Cologne Dellbrück, Germany), centrifuged and immediately processed according to the manufacturer’s application protocol (19). The centrifugation of the samples was carried out for 8 min at 200g. The resulting fibrin layer was separated from the erythrocyte clot and transferred to an empty sterile monovette before being aliquoted into four portions per group and frozen at −80°C until further examination, as shown in Figure 1.
Growth factor quantification using ELISA assays. For the immunologic analysis of the different proteins and growth factors in PRF, four different ELISA assays were performed on the available sample material: tumor necrosis factor α (TNFα), bone morphogenetic protein-2 (BMP-2), alkaline phosphatase (ALP), collagen type I alpha 1 (Col1α1). Measurements were carried out according to the manufacturer’s instructions (CLOUD-CLONE CORP; Wuhan, China and CUSABIO; Houston, TX, USA). Measurements were performed using a microplate spectrophotometer set at 540 nm (Clariostar, BMG-Labtech, Ortenberg, Germany).
Cytokine analysis. Cell culture supernatants were collected and instantly frozen with liquid nitrogen and preserved at −80°C. Analyses of cytokines and chemokines were performed using membrane-based Proteome Profiler™ Human XL cytokine arrays (R&D Systems, Minneapolis, MN, USA) as recommended by the supplier. Expression was visualized using an enhanced chemiluminescence detection kit (R&D Systems). Quantification was performed by measuring the density of the dots using an iBright CL 1000 biomolecular imager (Invitrogen, Carlsbad, CA, USA).
Statistical evaluation. A statistical analysis was performed using Wolfram Mathematica (version 14.0; 2024; Champaign, IL, USA) and GraphPad Prism Version 7.0f (GraphPad Software, Inc., San Diego, CA, USA). Five dropouts were not included. As part of a single-factor, univariate analysis of variance (ANOVA), the data of the laboratory parameters were checked for normal distribution using the Kolmogorov-Smirnov test and then for equality of variance using the Levene test. The Bonferroni correction, used to adjust significance levels, considered all ANOVA tests. Data are expressed as mean±standard deviation. p<0.05 (*), p<0.01 (**), and p<0.001 (***).
Results
Clinical blood values upon noni juice consumption. Clinical blood values for platelets, potassium, calcium, lactate dehydrogenase (LDH), aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT) and gamma glutamyl transferase (γ-GT) were then measured in blood samples taken before and after noni juice administration and compared with placebo controls (Table I and Table II).
Statistical analysis of the measured blood parameters (platelets, potassium, calcium, lactate dehydrogenase (LDH), aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT) and gamma glutamyl transferase (γ-GT) of all study participants before and after taking noni juice.
Statistical analysis of the measured blood parameters (platelets, potassium, calcium, lactate dehydrogenase (LDH), aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT) and gamma glutamyl transferase (γ-GT) of all study participants before and after taking placebo juice.
Data revealed significantly lower calcium concentrations (p=0.012; 2.4±0.11 mmol/l) after noni juice intake compared to the initial situation (2.41±0.07 mmol/l). The concentration of ALAT was significantly higher after noni juice ingestion (p=0.010; 22.54±11.68 U/l) than before (21.43±9.28 U/l). The concentration of γ-GT also increased significantly (p<0.001; before noni juice intake: 21.06±9.31 U/l; after noni juice intake: 22.49±13.36 U/l). No significant differences were found for platelet counts and blood concentrations of potassium, LDH, and ASAT (Figure 2).
Clinical blood values for thrombocytes, potassium, calcium, lactate dehydrogenase (LDH), aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT) and gamma glutamyl transferase (γ-GT) were measured in blood samples before and after noni juice administration and compared to placebo controls. *p<0.05; **p<0.01; ***p<0.001.
Growth factor and cytokine levels upon noni juice consumption. First, the influence of noni juice administration on the expression levels of selected proteins including TNFα, BMP-2, ALP and Col1α1 was analyzed using ELISA. Data revealed no significant difference among the analyzed proteins in response to noni juice consumption in our cohort (data not shown).
Next, comprehensive analysis of secretion patterns of 105 different cytokines and chemokines were analyzed using membrane-based human cytokine arrays to further elucidate the potential influence of noni juice consumption on the molecular composition of PRF. Data revealed significantly elevated abundances of interleukin-11 (IL-11), chemokine (C-C motif) ligand 7 (CCL7), and macrophage colony-stimulating factor (M-CSF) in the analyzed cohort of healthy volunteers in response to noni juice consumption compared to the initial (pre-noni) situation (Figure 3).
Noni-juice-associated cytokine secretion pattern. (A) Example image of a membrane-based cytokine array of PRF illustrating the membrane organisation of positive and negative controls and cytokine dots. (B) Quantitative analysis was conducted by measuring the density of the membrane dots and revealed elevated levels of cytokines interleukin-11 (IL-11), chemokine (C-C motif) ligand 7 (CCL7), and macrophage colony-stimulating factor (M-CSF) upon noni-juice consumption (post) compared to the initial situation (pre). *p<0.05.
Discussion
Due to its high concentration of growth factors, PRF can be used to promote bone and soft-tissue regeneration as well as in the treatment of some related medical conditions such as bisphosphonate or medication related osteonecrosis of the jaw in patients with cancer (7-9, 20). There are different hypotheses and processing approaches to enhance the amount and quality of growth factors in PRF, so that wound healing can occur more effectively.
Therefore, this study investigated whether daily consumption of noni juice correlates with a change in the expression profile of growth factors in PRF and thus has an effect on osteogenesis and wound healing.
Natural plant-derived Morinda citrifolia fruit juice (noni juice) is supposed to have antioxidant (6), antibacterial (14-16), anti-inflammatory (17, 18) as well as immune activating (19) properties. It has been suggested as an alternative treatment option to inhibit the progression of inflammatory diseases, such as inflammatory bowel disease (IBD). In this context, reduced levels of intestinal pro-inflammatory cytokines such as TNFα, interferon-γ (IFN-γ), IL-17, and an improved intestinal architecture have been observed following noni juice administration (21). TNFα in particular, is an important regulatory cytokine in intestinal inflammatory diseases and has been shown to be elevated in the intestinal mucosa of patients with IBD (22, 23).
In vitro studies on the influence of noni juice incubation revealed reduced secretion levels of TNFα, IL-1β, and IL-4, but an increased production of the anti-inflammatory cytokine IL-10 in human monocytes, which are a major source of both pro- and anti-inflammatory cytokines (24-26). Furthermore, monotropein isolated from the roots of Morinda officinalis, a member of the Rubiaceae family like M. citrifolia, has been shown to down-regulate the production of inflammation-associated nitric oxide in human macrophages (27).
Our investigation revealed three significant changes in the measured blood components: calcium, ALAT and γ-GT. Calcium, the most abundant mineral in the human body, is mainly found bound in the bones as calcium phosphate. Its balance is regulated by parathyroid hormone, calcitriol and calcitonin. Calcium serves as an intracellular second messenger, increases the presynaptic release of transmitters at chemical synapses, plays an important role in muscle contraction, stabilizes membrane potential and acts as coagulation factor (28). These diverse effects demonstrate the relevance of the electrolyte and suggest that even small changes in its concentration have an impact on the human organism, as in our study: the comparison of the calcium values (before noni juice intake: 2.41±0.07 mmol/l; after noni juice intake: 2.4±0.11 mmol/l) shows a statistically significant decrease.
Examining the ALAT concentration (before noni juice intake: 21.43±9.28 U/l; after noni juice intake: 22.54±11.68 U/l), a significant increase is apparent. ALAT, an enzyme involved in gluconeogenesis and urea formation, is mainly found in the cytoplasm of liver cells. In general, the detection of an increased serum concentration serves as a diagnostic indication of liver cell damage and as a risk factor for essential hypertension as well as for type 2 diabetes (29). In this study, we only see a light increase in ALAT, which could indicate that the liver is slightly stressed by the metabolism of the noni juice.
The concentration of γ-GT (before noni juice intake: 21.06±9.31 U/l; after noni juice intake: 22.49±13.36 U/l) shows a significant increase. As a membrane-bound enzyme of glutathione metabolism and amino acid transport, γ-GT is the most sensitive parameter for a disease of the liver and bile ducts. Furthermore, various studies indicate that, within its normal range, the serum γ-GT level may be an early marker of oxidative stress (30). Noni juice appears to have an influence on the intestinal architecture and the composition of the peripheral blood.
The decrease of blood calcium, as observed in the present study, leads to a change in the macroscopic structure of PRF, inhibits the formation of the buffy coat, and keeps its fluid consistency enabling application within a scaffold as a regenerative filler (10, 31, 32).
The significant increase in the ALAT and γ-GT following consumption of noni-juice indicates however an impact on hepatic function. This effect has previously been reported with controversial results and considered relatively harmless or either protective (6, 33), or was deemed maximally toxic with crucial consequences (34).
Furthermore, membrane-based analysis of a wide range of different cytokines and chemokines revealed significantly elevated abundances of IL-11, CCL7 and M-CSF in PRF upon noni juice consumption.
Particularly IL-11, a member of the IL-6 family of cytokines, has emerged as an important protein for the regulation of osteoclasts (bone resorption), osteoblasts (bone formation), and osteocytes (cells that form a syncytial network within the bone) (35). However, the PRF preparation procedure could also be responsible for increased IL-11 levels. It has recently been shown in gingival fibroblasts, that blood centrifugation leads to a stimulation of TGF-β signaling and elevated expression levels of IL-11, NADPH oxidase 4 (NOX-4) and proteoglycan 4 (PRG4) (36).
The chemotactic myokine CCL7 has been shown to be highly expressed in MLO-Y4 osteocyte-like cells, where its major function may be the protection of these cells against glucocorticoid-induced cell death (37). Similarly, M-CSF is required for the survival and activity of bone-resorbing osteoclasts via mammalian target of rapamycin (mTOR) (38). In summary, our data underline a significant influence of noni juice administration on an improved molecular composition of PRF. These findings should be further investigated in larger cohorts of patients with cancer suffering from bisphosphonate-associated osteonecrosis or similar medical situations.
Acknowledgements
The Authors are grateful to all members of the involved Departments for supporting sample collection and helpful discussions.
Footnotes
Authors’ Contributions
D. Steller, S.G. Hakim and R. Pries designed the study. R. Hoppermann, C. Firle, K. Plötze-Martin and R. Pries performed and evaluated the experiments and designed the figures. R. Hoppermann, S.G. Hakim, J. Fleckner, K. L. Bruchhage and R. Pries wrote the manuscript. All Authors read and approved of the final manuscript.
Conflicts of Interest
The Authors declare no conflicts of interest in relation to this study.
Funding
This study received no funding.
Artificial Intelligence (AI) Disclosure
No artificial intelligence (AI) tools, including large language models or machine learning software, were used in the preparation, analysis, or presentation of this manuscript.
- Received August 4, 2025.
- Revision received September 8, 2025.
- Accepted September 10, 2025.
- Copyright © 2026 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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