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Mustakim KR, Eo MY, Seo MH, Yang HC, Kim MK, Myoung H, Kim SM. Ultrastructural and immunohistochemical evaluation of hyperplastic soft tissues surrounding dental implants in fibular jaws. Sci Rep 2024; 14:10717. [PMID: 38730018 PMCID: PMC11087521 DOI: 10.1038/s41598-024-60474-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
In reconstructive surgery, complications post-fibula free flap (FFF) reconstruction, notably peri-implant hyperplasia, are significant yet understudied. This study analyzed peri-implant hyperplastic tissue surrounding FFF, alongside peri-implantitis and foreign body granulation (FBG) tissues from patients treated at the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital. Using light microscopy, pseudoepitheliomatous hyperplasia, anucleate and pyknotic prickle cells, and excessive collagen deposition were observed in FFF hyperplastic tissue. Ultrastructural analyses revealed abnormal structures, including hemidesmosome dilation, bacterial invasion, and endoplasmic reticulum (ER) swelling. In immunohistochemical analysis, unfolded protein-response markers ATF6, PERK, XBP1, inflammatory marker NFκB, necroptosis marker MLKL, apoptosis marker GADD153, autophagy marker LC3, epithelial-mesenchymal transition, and angiogenesis markers were expressed variably in hyperplastic tissue surrounding FFF implants, peri-implantitis, and FBG tissues. NFκB expression was higher in peri-implantitis and FBG tissues compared to hyperplastic tissue surrounding FFF implants. PERK expression exceeded XBP1 significantly in FFF hyperplastic tissue, while expression levels of PERK, XBP1, and ATF6 were not significantly different in peri-implantitis and FBG tissues. These findings provide valuable insights into the interconnected roles of ER stress, necroptosis, apoptosis, and angiogenesis in the pathogenesis of oral pathologies, offering a foundation for innovative strategies in dental implant rehabilitation management and prevention.
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Affiliation(s)
- Kezia Rachellea Mustakim
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Mi Young Eo
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Mi Hyun Seo
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Hyeong-Cheol Yang
- Department of Dental Biomaterials Science, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea
| | - Min-Keun Kim
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea
| | - Hoon Myoung
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Soung Min Kim
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
- Oral and Maxillofacial Microvascular Reconstruction LAB, Brong Ahafo Regional Hospital, P.O.Box 27, Sunyani, Ghana.
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Cao N, Wan Z, Chen D, Tang L. Deciphering peri-implantitis: Unraveling signature genes and immune cell associations through bioinformatics and machine learning. Medicine (Baltimore) 2024; 103:e37862. [PMID: 38640305 PMCID: PMC11030017 DOI: 10.1097/md.0000000000037862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/16/2024] [Accepted: 03/20/2024] [Indexed: 04/21/2024] Open
Abstract
Early diagnosis of peri-implantitis (PI) is crucial to understand its pathological progression and prevention. This study is committed to investigating the signature genes, relevant signaling pathways and their associations with immune cells in PI. We analyzed differentially expressed genes (DEGs) from a PI dataset in the gene expression omnibus database. Functional enrichment analysis was conducted for these DEGs. Weighted Gene Co-expression Network Analysis was used to identify specific modules. Least absolute shrinkage and selection operator and support vector machine recursive feature elimination were ultimately applied to identify the signature genes. These genes were subsequently validated in an external dataset. And the immune cells infiltration was classified using CIBERSORT. A total of 180 DEGs were screened from GSE33774. Weighted Gene Co-expression Network Analysis revealed a significant association between the MEturquoise module and PI (cor = 0.6, P < .0001). Least absolute shrinkage and selection operator and support vector machine recursive feature elimination algorithms were applied to select the signature genes, containing myeloid-epithelial-reproductive tyrosine kinase, microfibrillar-associated protein 5, membrane-spanning 4A 4A, tribbles homolog 1. In the validation on the external dataset GSE106090, all these genes achieved area under curve values exceeding 0.95. GSEA analysis showed that these genes were correlated with the NOD-like receptor signaling pathway, metabolism of xenobiotics by cytochrome P450, and arachidonic acid metabolism. CIBERSORT revealed elevated levels of macrophage M2 and activated mast cells in PI. This study provides novel insights into understanding the molecular mechanisms of PI and contributes to advancements in its early diagnosis and prevention.
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Affiliation(s)
- Ning Cao
- Department of Implant Dentistry, College & Hospital of Stomatology, Guangxi Medical University, Nanning, Guangxi, China
- Guangxi Key Laboratory of the Rehabilitation and Reconstruction of Oral and Maxillofacial Research, Nanning, China
- Key Laboratory of Research and Application of Stomatological Equipment (College of Stomatology, Hospital of Stomatology, Guangxi Medical University), Education Department of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, China
| | - Ziwei Wan
- Guangxi Key Laboratory of the Rehabilitation and Reconstruction of Oral and Maxillofacial Research, Nanning, China
- Key Laboratory of Research and Application of Stomatological Equipment (College of Stomatology, Hospital of Stomatology, Guangxi Medical University), Education Department of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, China
| | - Donghui Chen
- Department of Implant Dentistry, College & Hospital of Stomatology, Guangxi Medical University, Nanning, Guangxi, China
- Guangxi Key Laboratory of the Rehabilitation and Reconstruction of Oral and Maxillofacial Research, Nanning, China
- Key Laboratory of Research and Application of Stomatological Equipment (College of Stomatology, Hospital of Stomatology, Guangxi Medical University), Education Department of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, China
| | - Li Tang
- Department of Implant Dentistry, College & Hospital of Stomatology, Guangxi Medical University, Nanning, Guangxi, China
- Guangxi Key Laboratory of the Rehabilitation and Reconstruction of Oral and Maxillofacial Research, Nanning, China
- Key Laboratory of Research and Application of Stomatological Equipment (College of Stomatology, Hospital of Stomatology, Guangxi Medical University), Education Department of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, China
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3
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Sinjab K, Sawant S, Ou A, Fenno JC, Wang HL, Kumar P. Impact of surface characteristics on the peri-implant microbiome in health and disease. J Periodontol 2024; 95:244-255. [PMID: 37665015 PMCID: PMC10909931 DOI: 10.1002/jper.23-0205] [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: 03/26/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Because little is known about the impact of implant surface modifications on the peri-implant microbiome, we aimed to examine peri-implant communities in various surface types in order to better understand the impact of these surfaces on the development of peri-implantitis (PI). METHODS One hundred and six systemically healthy individuals with anodized (AN), hydroxyapatite-coated (HA), or sandblasted acid-etched (SLA) implants that were >6 months in function were recruited and categorized into health (H) or PI. Peri-implant biofilm was analyzed using 16S rRNA gene sequencing and compared between health/disease and HA/SLA/AN using community-level and taxa-level metrics. RESULTS Healthy implants did not demonstrate significant differences in clustering, alpha- or beta-diversity based on surface modification. AN and HA surfaces displayed significant differences between health and PI (p < 0.05); however, such a clustering was not evident with SLA (p > 0.05). AN and HA surfaces also differed in the magnitude and diversity of differences between health and PI. Six species belonging to the genera Shuttleworthia, Scardovia, and Prevotella demonstrated lower abundances in AN implants with PI, and 18 species belonging to the genera Fretibacterium, Tannerella, Treponema, and Fusobacterium were elevated, while in HA implants with PI, 20 species belonging to the genera Streptococcus, Lactobacillus, Veillonella, Rothia, and family Ruminococcaceae were depleted and Peptostreptococcaceae, Atopobiaceae, Veillonellaceae, Porphyromonadaceae, Desulfobulbaceae, and order Synergistales were enriched. CONCLUSIONS Within the limitations of this study, we demonstrate that implant surface can differentially modify the disease-associated microbiome, suggesting that surface topography must be considered in the multi-factorial etiology of peri-implant diseases.
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Affiliation(s)
- Khaled Sinjab
- Department of Periodontics and Oral Medicine, School of Dentistry University of Michigan 1011 N University Ave Ann Arbor, Michigan 48109
| | - Shriya Sawant
- Department of Periodontics and Oral Medicine, School of Dentistry University of Michigan 1011 N University Ave Ann Arbor, Michigan 48109
| | - Alice Ou
- Department of Periodontics and Oral Medicine, School of Dentistry University of Michigan 1011 N University Ave Ann Arbor, Michigan 48109
| | - J. Christopher Fenno
- Department of Biological and Material Sciences and Prosthodontics, School of Dentistry University of Michigan 1011 N University Ave Ann Arbor, Michigan 48109
| | - Hom-Lay Wang
- Department of Periodontics and Oral Medicine, School of Dentistry University of Michigan 1011 N University Ave Ann Arbor, Michigan 48109
| | - Purnima Kumar
- Department of Periodontics and Oral Medicine, School of Dentistry University of Michigan 1011 N University Ave Ann Arbor, Michigan 48109
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Ng E, Tay JRH, Mattheos N, Bostanci N, Belibasakis GN, Seneviratne CJ. A Mapping Review of the Pathogenesis of Peri-Implantitis: The Biofilm-Mediated Inflammation and Bone Dysregulation (BIND) Hypothesis. Cells 2024; 13:315. [PMID: 38391928 PMCID: PMC10886485 DOI: 10.3390/cells13040315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
This mapping review highlights the need for a new paradigm in the understanding of peri-implantitis pathogenesis. The biofilm-mediated inflammation and bone dysregulation (BIND) hypothesis is proposed, focusing on the relationship between biofilm, inflammation, and bone biology. The close interactions between immune and bone cells are discussed, with multiple stable states likely existing between clinically observable definitions of peri-implant health and peri-implantitis. The framework presented aims to explain the transition from health to disease as a staged and incremental process, where multiple factors contribute to distinct steps towards a tipping point where disease is manifested clinically. These steps might be reached in different ways in different patients and may constitute highly individualised paths. Notably, factors affecting the underlying biology are identified in the pathogenesis of peri-implantitis, highlighting that disruptions to the host-microbe homeostasis at the implant-mucosa interface may not be the sole factor. An improved understanding of disease pathogenesis will allow for intervention on multiple levels and a personalised treatment approach. Further research areas are identified, such as the use of novel biomarkers to detect changes in macrophage polarisation and activation status, and bone turnover.
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Affiliation(s)
- Ethan Ng
- Department of Restorative Dentistry, National Dental Centre Singapore, Singapore 168938, Singapore;
| | - John Rong Hao Tay
- Department of Restorative Dentistry, National Dental Centre Singapore, Singapore 168938, Singapore;
| | - Nikos Mattheos
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok 10330, Thailand;
- Division of Oral Health and Periodontology, Department of Dental Medicine, Karolinska Institute, 14152 Stockholm, Sweden; (N.B.); (G.N.B.)
| | - Nagihan Bostanci
- Division of Oral Health and Periodontology, Department of Dental Medicine, Karolinska Institute, 14152 Stockholm, Sweden; (N.B.); (G.N.B.)
| | - Georgios N. Belibasakis
- Division of Oral Health and Periodontology, Department of Dental Medicine, Karolinska Institute, 14152 Stockholm, Sweden; (N.B.); (G.N.B.)
| | - Chaminda Jayampath Seneviratne
- School of Dentistry, The University of Queensland, Brisbane, QLD 4006, Australia
- School of Dentistry, Center for Oral-Facial Regeneration, Rehabilitation and Reconstruction (COR3), The University of Queensland, Brisbane, QLD 4072, Australia
- National Dental Research Institute Singapore, National Dental Centre Singapore, Singapore 168938, Singapore
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5
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Atieh MA, Alsabeeha NHM. Peri-implantitis Through the Looking Glass. Int Dent J 2024; 74:42-45. [PMID: 37891059 PMCID: PMC10829342 DOI: 10.1016/j.identj.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/18/2023] [Accepted: 09/05/2023] [Indexed: 10/29/2023] Open
Affiliation(s)
- Momen A Atieh
- Mohammed Bin Rashid University of Medicine and Health Sciences, Hamdan Bin Mohammed College of Dental Medicine, Dubai Healthcare City, Dubai, United Arab Emirates; Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand.
| | - Nabeel H M Alsabeeha
- Department of Dental Services, Emirates Health Services, Dubai, United Arab Emirates
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Padial-Molina M, Montalvo-Acosta S, Martín-Morales N, Pérez-Carrasco V, Magan-Fernandez A, Mesa F, O’Valle F, Garcia-Salcedo JA, Galindo-Moreno P. Correlation between Inflammasomes and Microbiota in Peri-Implantitis. Int J Mol Sci 2024; 25:961. [PMID: 38256037 PMCID: PMC10815557 DOI: 10.3390/ijms25020961] [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: 12/07/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
The activation of inflammasomes is thought to induce the inflammatory process around dental implants. No information is available on the correlation between microbiota and inflammasomes in clinical samples from patients suffering peri-implantitis. For this cross-sectional study, 30 biofilm samples were obtained from 19 patients undergoing surgical treatment for peri-implantitis because of the presence of bleeding on probing, probing depth higher than 6 mm, and radiographic bone loss higher than 3 mm. Then, soft tissue samples from around the implant were also collected. The relative abundance of bacteria and alpha-diversity indexes were calculated after analyzing the 16S rRNA gene using next-generation sequencing. The soft-tissue samples were processed for evaluation of the inflammasomes NLRP3 and AIM2 as well as caspase-1 and IL-1β. The relative abundance (mean (SD)) of specific species indicated that the most abundant species were Porphyromonas gingivalis (10.95 (14.17)%), Fusobacterium vincentii (10.93 (13.18)%), Porphyromonas endodontalis (5.89 (7.23)%), Prevotella oris (3.88 (4.94)%), Treponema denticola (2.91 (3.19)%), and Tannerella forsythia (2.84 (4.15)%). Several correlations were found between the species and the immunohistochemical detection of the inflammasomes NLRP3 and AIM2 as well as caspase-1 and IL-1β, both in the epithelium and the lamina propria. A network analysis found an important cluster of variables formed by NLRP3 in the lamina propria and AIM2, caspase-1, and IL-1β in the lamina propria and the epithelium with Prevotella dentalis, Prevotella tannerae, Tannerella forsythia, or Selenomonas timonae. Thus, it could be concluded that inflammasomes NLRP3 and AIM2 and their downstream effectors caspase-1 and interleukin-1β can be significantly associated with specific bacteria.
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Affiliation(s)
- Miguel Padial-Molina
- Department of Oral Surgery and Implant Dentistry, School of Dentistry, University of Granada, 18071 Granada, Spain;
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
| | - Saray Montalvo-Acosta
- PhD Program in Clinical Medicine and Public Health, University of Granada, 18071 Granada, Spain
| | - Natividad Martín-Morales
- PhD Program in Biomedicine, University of Granada, 18071 Granada, Spain
- Department of Pathology, School of Medicine, University of Granada, 18071 Granada, Spain
| | - Virginia Pérez-Carrasco
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
- Centre for Genomics and Oncological Research, Pfizer–University of Granada–Andalusian Regional Government (GENYO), PTS Granada, 18016 Granada, Spain
- Microbiology Unit, University Hospital Virgen de las Nieves, 18014 Granada, Spain
| | - Antonio Magan-Fernandez
- Department of Periodontics, School of Dentistry, University of Granada, 18071 Granada, Spain (F.M.)
| | - Francisco Mesa
- Department of Periodontics, School of Dentistry, University of Granada, 18071 Granada, Spain (F.M.)
| | - Francisco O’Valle
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
- Institute of Biopathology and Regenerative Medicine (IBIMER, CIBM), University of Granada, 18071 Granada, Spain
| | - Jose Antonio Garcia-Salcedo
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
- Centre for Genomics and Oncological Research, Pfizer–University of Granada–Andalusian Regional Government (GENYO), PTS Granada, 18016 Granada, Spain
- Microbiology Unit, University Hospital Virgen de las Nieves, 18014 Granada, Spain
| | - Pablo Galindo-Moreno
- Department of Oral Surgery and Implant Dentistry, School of Dentistry, University of Granada, 18071 Granada, Spain;
- Instituto de Investigación Biosanitaria ibs.GRANADA, 18012 Granada, Spain
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Galindo-Moreno P, Montalvo-Acosta S, Martín-Morales N, Carrillo-Gálvez AB, González-Rey E, O'Valle F, Padial-Molina M. Inflammasomes NLRP3 and AIM2 in peri-implantitis: A cross-sectional study. Clin Oral Implants Res 2023; 34:1342-1353. [PMID: 37642257 DOI: 10.1111/clr.14174] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/18/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Inflammasome components NLRP3 and AIM2 contribute to inflammation development by the activation of caspase-1 and IL-1β. They have not been yet evaluated in samples from patients with active peri-implantitis. Thus, the aim of the present study is to analyze the expression of inflammasomes NLRP3 and AIM2 and subsequent caspase 1 and IL-1β assessing the microenvironment of leukocyte subsets in samples from patients with active peri-implantitis. METHODS Biopsies were collected from 33 implants in 21 patients being treated for peri-implantitis. Biopsies from gingival tissues from 15 patients with healthy periodontium were also collected for control. These tissues were evaluated through conventional histological stainings. Then, immunohistochemical detection was performed to analyze NLRP3, AIM2, caspase-1, and IL-1β and markers of different leukocyte subsets. PCR for inflammasomes and related genes was also done. RESULTS This manuscript reveals a high immunohistochemical and mRNA expression of NLRP3 and AIM2 inflammasomes, caspase-1, and IL-1β in biopsies collected from human peri-implantitis. The expression of the tested markers was significantly correlated with the increase in inflammatory infiltrate, probing depth, presence of biofilm, and bleeding on probing. In these peri-implantitis lesions, the area of biopsy tissue occupied by inflammatory infiltrate was intense while the area occupied by collagen was significantly lower. In comparison with periodontal healthy tissues, the inflammatory infiltrate was statistically significantly higher in the peri-implantitis biopsies and was mainly composed of plasma cells, followed by T and B lymphocytes. CONCLUSION In human peri-implantitis, chronic inflammation can be explained in part by the action of IL-1β/caspase 1 induced through NLRP3 and AIM2 inflammasome activation.
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Affiliation(s)
- Pablo Galindo-Moreno
- Department of Oral Surgery and Implant Dentistry, School of Dentistry, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
| | - Saray Montalvo-Acosta
- PhD Program in Clinical Medicine and Public Health, University of Granada, Granada, Spain
| | - Natividad Martín-Morales
- Department of Oral Surgery and Implant Dentistry, School of Dentistry, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
- PhD Program in Biomedicine, University of Granada, Granada, Spain
- Department of Pathology, School of Medicine, University of Granada, Granada, Spain
| | | | - Elena González-Rey
- Institute of Parasitology and Biomedicine Lopez-Neyra, IPBLN-CSIC, Parque Tecnologico de la Salud, Granada, Spain
| | - Francisco O'Valle
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
- Department of Pathology, School of Medicine, University of Granada, Granada, Spain
- Institute of Biopathology and Regenerative Medicine (IBIMER, CIBM), University of Granada, Granada, Spain
| | - Miguel Padial-Molina
- Department of Oral Surgery and Implant Dentistry, School of Dentistry, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Granada, Spain
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8
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Choi W, Mangal U, Park JY, Kim JY, Jun T, Jung JW, Choi M, Jung S, Lee M, Na JY, Ryu DY, Kim JM, Kwon JS, Koh WG, Lee S, Hwang PTJ, Lee KJ, Jung UW, Cha JK, Choi SH, Hong J. Occlusive membranes for guided regeneration of inflamed tissue defects. Nat Commun 2023; 14:7687. [PMID: 38001080 PMCID: PMC10673922 DOI: 10.1038/s41467-023-43428-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Guided bone regeneration aided by the application of occlusive membranes is a promising therapy for diverse inflammatory periodontal diseases. Symbiosis, homeostasis between the host microbiome and cells, occurs in the oral environment under normal, but not pathologic, conditions. Here, we develop a symbiotically integrating occlusive membrane by mimicking the tooth enamel growth or multiple nucleation biomineralization processes. We perform human saliva and in vivo canine experiments to confirm that the symbiotically integrating occlusive membrane induces a symbiotic healing environment. Moreover, we show that the membrane exhibits tractability and enzymatic stability, maintaining the healing space during the entire guided bone regeneration therapy period. We apply the symbiotically integrating occlusive membrane to treat inflammatory-challenged cases in vivo, namely, the open and closed healing of canine premolars with severe periodontitis. We find that the membrane promotes symbiosis, prevents negative inflammatory responses, and improves cellular integration. Finally, we show that guided bone regeneration therapy with the symbiotically integrating occlusive membrane achieves fast healing of gingival soft tissue and alveolar bone.
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Affiliation(s)
- Woojin Choi
- Department of Chemical and Biomolecular Engineering, College of Engineering, Yonsei University, Seoul, 03722, Republic of Korea
| | - Utkarsh Mangal
- Department of Orthodontics, Institute of Craniofacial Deformity, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
| | - Jin-Young Park
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
| | - Ji-Yeong Kim
- Department of Orthodontics, Institute of Craniofacial Deformity, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
| | - Taesuk Jun
- Department of Chemical and Biomolecular Engineering, College of Engineering, Yonsei University, Seoul, 03722, Republic of Korea
| | - Ju Won Jung
- Department of Oral Microbiology and Immunology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, 08826, Republic of Korea
| | - Moonhyun Choi
- Department of Chemical and Biomolecular Engineering, College of Engineering, Yonsei University, Seoul, 03722, Republic of Korea
| | - Sungwon Jung
- Department of Chemical and Biomolecular Engineering, College of Engineering, Yonsei University, Seoul, 03722, Republic of Korea
| | - Milae Lee
- Department of Chemical and Biomolecular Engineering, College of Engineering, Yonsei University, Seoul, 03722, Republic of Korea
| | - Ji-Yeong Na
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
| | - Du Yeol Ryu
- Department of Chemical and Biomolecular Engineering, College of Engineering, Yonsei University, Seoul, 03722, Republic of Korea
| | - Jin Man Kim
- Department of Oral Microbiology and Immunology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, 08826, Republic of Korea
| | - Jae-Sung Kwon
- Department and Research Institute of Dental Biomaterials and Bioengineering, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
| | - Won-Gun Koh
- Department of Chemical and Biomolecular Engineering, College of Engineering, Yonsei University, Seoul, 03722, Republic of Korea
| | - Sangmin Lee
- School of Mechanical Engineering, Chung-ang University, 84, Heukserok-ro, Dongjak-gu, Seoul, 06974, Republic of Korea
| | - Patrick T J Hwang
- Cardiovascular Institute, Rowan-Virtua School of Translational Biomedical Engineering & Sciences, Rowan University, 201 Mullica Hill Rd., Glassboro, NJ, 08028, USA
| | - Kee-Joon Lee
- Department of Orthodontics, Institute of Craniofacial Deformity, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
| | - Ui-Won Jung
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
| | - Jae-Kook Cha
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea.
| | - Sung-Hwan Choi
- Department of Orthodontics, Institute of Craniofacial Deformity, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea.
| | - Jinkee Hong
- Department of Chemical and Biomolecular Engineering, College of Engineering, Yonsei University, Seoul, 03722, Republic of Korea.
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Dini C, Costa RC, Bertolini M, Shibli JA, Feres M, Klein MI, de Avila ÉD, Souza JGS, Barão VAR. In-vitro polymicrobial oral biofilm model represents clinical microbial profile and disease progression during implant-related infections. J Appl Microbiol 2023; 134:lxad265. [PMID: 37951291 DOI: 10.1093/jambio/lxad265] [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: 08/21/2023] [Revised: 10/31/2023] [Accepted: 11/09/2023] [Indexed: 11/13/2023]
Abstract
AIM Clinically relevant in-vitro biofilm models are essential and valuable tools for mechanistically dissecting the etiopathogenesis of infectious diseases and test new antimicrobial therapies. Thus, the aim of this study was to develop and test a clinically relevant in-vitro oral polymicrobial biofilm model that mimics implant-related infections in terms of microbial profile. METHODS AND RESULTS For this purpose, 24-well plate system was used to model oral biofilms, using three different microbial inoculums to grow in-vitro biofilms: (1) human saliva from periodontally healthy patients; (2) saliva as in inoculum 1 + Porphyromonas gingivalis strain; and (3) supra and subgingival biofilm collected from peri-implant sites of patients diagnosed with peri-implantitis. Biofilms were grown to represent the dynamic transition from an aerobic to anaerobic community profile. Subsequently, biofilms were collected after each phase and evaluated for microbiological composition, microbial counts, biofilm biomass, structure, and susceptibility to chlorhexidine (CHX). Results showed higher live cell count (P < .05) for biofilms developed from patients' biofilm inoculum, but biomass volume, dry weight, and microbiological composition were similar among groups (P > .05). Interestingly, according to the checkerboard DNA-DNA hybridization results, the biofilm developed from stimulated human saliva exhibited a microbial composition more similar to the clinical subgingival biofilm of patients with peri-implantitis, with proportions of the main pathogens closer to those found in the disease. In addition, biofilm developed using saliva as inoculum was shown to be susceptible to CHX with significant reduction in bacteria compared with biofilms without exposure to CHX (P < .05). CONCLUSION The findings suggested that the in-vitro polymicrobial biofilm developed from human saliva as inoculum is a suitable model and clinically relevant tool for mimicking the microbial composition of implant-related infections.
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Affiliation(s)
- Caroline Dini
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, Universidade Estadual de Campinas (UNICAMP), Piracicaba, SP 13414-903, Brazil
| | - Raphael Cavalcante Costa
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, Universidade Estadual de Campinas (UNICAMP), Piracicaba, SP 13414-903, Brazil
| | - Martinna Bertolini
- Department of Periodontics and Preventive Dentistry, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15260, United States
| | - Jamil Awad Shibli
- Dental Research Division, Guarulhos University, Guarulhos, SP 07011-010, Brazil
| | - Magda Feres
- Dental Research Division, Guarulhos University, Guarulhos, SP 07011-010, Brazil
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA 02115, United States
| | - Marlise Inêz Klein
- Department of Oral Diagnosis, Piracicaba Dental School, Universidade Estadual de Campinas (UNICAMP), Piracicaba, SP 13414-903, Brazil
| | - Érica Dorigatti de Avila
- Department of Dental Materials and Prosthodontics, School of Dentistry at Araraquara, São Paulo State University (UNESP), Araraquara, SP 14801-385, Brazil
- Department of Dental Materials and Prosthodontics, School of Dentistry at Araçatuba, São Paulo State University (UNESP), Araçatuba, SP 16015-050, Brazil
| | | | - Valentim Adelino Ricardo Barão
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, Universidade Estadual de Campinas (UNICAMP), Piracicaba, SP 13414-903, Brazil
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Chen LW, Jin SH, Lu Q, Zhou JG, Liu JG, Guan XY, Xia HB, He H. Identification of immunological bioprocesses involved in peri-implantitis using weighted gene co-expression network analysis. J Periodontol 2023; 94:1078-1089. [PMID: 37032448 DOI: 10.1002/jper.22-0405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 01/04/2023] [Accepted: 03/18/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Peri-implantitis is an irreversible infectious disease that occurs with high incidence. Exploring the immune responses of peri-implantitis is key to developing targeted treatment strategies. However, there is limited research on the immune response of peri-implantitis. METHODS This study performed a weighted gene co-expression network analysis to identify the peri-implantitis related gene network and conducted a functional enrichment analysis of the gene network. Thereafter, the candidate hub genes were selected by constructing a protein-protein interaction network and drawing an upset plot. The hub genes were identified through their significant associations with disease condition and validated using quantitative reverse transcription-polymerase chain reaction (qRT-PCR) analysis. Using the gene set variation analysis, the hub genes were further used to explore infiltrating immunocytes and immune factors in peri-implantitis. Finally, the immunocytes and immune factor related hub genes were intersected to obtain the therapeutic target, which was validated using histological staining. RESULTS The peri-implantitis related gene network was enriched in innate and adaptive immune response. Subsequently, interleukin (IL)1B, IL10, ITGAM, ITGB1, STAT3, and TLR4 were identified as hub genes. Plasmacytoid dendritic cells, macrophages, myeloid-derived suppressor cells, natural killer T cells, and immature B cells were positively and significantly related to the hub genes IL1B, TLR4, ITGAM, and ITGB1 (correlation coefficient > 0.80). While immune factors CXCL10, IL6, and CXCL12 and hub genes IL10 and IL1B held the highest degree in the immune factors network. IL1B may be a promising therapeutic target. CONCLUSION This study provides new insights into the hub genes, immunocytes, and immune factors underlying peri-implantitis immunological bioprocess.
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Affiliation(s)
- Liang-Wen Chen
- Hubei-MOST KLOS & KLOBM, Department of Oral Implantology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Su-Han Jin
- Department of Orthodontics, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
- Department of Orthodontics, Affiliated Stomatological Hospital of Zunyi Medical University, Zunyi, China
| | - Qian Lu
- Hubei-MOST KLOS & KLOBM, Department of Oral Implantology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Jian-Guo Zhou
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jian-Guo Liu
- School of Stomatology, Special Key Laboratory of Oral Diseases Research, Higher Education Institution, Zunyi Medical University, Zunyi, China
| | - Xiao-Yan Guan
- Department of Orthodontics, Affiliated Stomatological Hospital of Zunyi Medical University, Zunyi, China
| | - Hai-Bin Xia
- Hubei-MOST KLOS & KLOBM, Department of Oral Implantology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Hong He
- Department of Orthodontics, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
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11
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Jung HJ, Lee W. Difference in microbiome compositions of healthy peri-implant sulcus and peri-implantitis sulcus from the same patient. Heliyon 2023; 9:e20303. [PMID: 37809828 PMCID: PMC10560055 DOI: 10.1016/j.heliyon.2023.e20303] [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: 03/05/2023] [Revised: 09/02/2023] [Accepted: 09/18/2023] [Indexed: 10/10/2023] Open
Abstract
Objective The objective of this study is to compare the microbiome of healthy peri-implant sulcus (C) and peri-implantitis sulcus (U) from the same patient and analyze the difference in the microbiome composition. Materials and methods DNA samples of subgingival biofilms from 10 C (control group) and 10 U (uncontrolled group) sites were sent to Microbiome Center in Korea Research Institute of Biomedical Science and analyzed using 16s rRNA gene amplification and sequencing (MiSeq, Illumina) and human oral microbiome database (HOMD). Results At the phylum level, Firmicutes and Proteobacteria were more abundant in group C, while Firmicutes and Bacteroidetes were dominant in group U. At the genus level, the core peri-implant microbiome was Streptococcus in group C. On the other hand, the core peri-implant microbiome was Porphyromonas, especially P. gingivalis in group U. Conclusion In this study, the microbiome composition of peri-implantitis sulcus was different from that of healthy peri-implant sulcus from the same patient. The peri-implantitis microbiome was pathogen-enriched and was similar to the microbiome associated with periodontitis.
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Affiliation(s)
- Hyun Jung Jung
- Department of Dentistry, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Won Lee
- Department of Dentistry, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea
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12
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Zhang Z, Ji C, Wang D, Wang M, Song D, Xu X, Zhang D. The burden of diabetes on the soft tissue seal surrounding the dental implants. Front Physiol 2023; 14:1136973. [PMID: 36875028 PMCID: PMC9978121 DOI: 10.3389/fphys.2023.1136973] [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: 01/03/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023] Open
Abstract
Soft tissue seal around implant prostheses is considered the primary barrier against adverse external stimuli and is a critical factor in maintaining dental implants' stability. Soft tissue seal is formed mainly by the adhesion of epithelial tissue and fibrous connective tissue to the transmembrane portion of the implant. Type 2 diabetes mellitus (T2DM) is one of the risk factors for peri-implant inflammation, and peri-implant disease may be triggered by dysfunction of the soft tissue barrier around dental implants. This is increasingly considered a promising target for disease treatment and management. However, many studies have demonstrated that pathogenic bacterial infestation, gingival immune inflammation, overactive matrix metalloproteinases (MMPs), impaired wound healing processes and excessive oxidative stress may trigger poor peri-implant soft tissue sealing, which may be more severe in the T2DM state. This article reviews the structure of peri-implant soft tissue seal, peri-implant disease and treatment, and moderating mechanisms of impaired soft tissue seal around implants due to T2DM to inform the development of treatment strategies for dental implants in patients with dental defects.
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Affiliation(s)
- Zhanwei Zhang
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Shandong Provincial Clinical Research Center for Oral, Shandong University , Jinan, China
| | - Chonghao Ji
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Shandong Provincial Clinical Research Center for Oral, Shandong University , Jinan, China
| | | | - Maoshan Wang
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Shandong Provincial Clinical Research Center for Oral, Shandong University , Jinan, China
| | - Dawei Song
- School of Stomatology, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Xin Xu
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Shandong Provincial Clinical Research Center for Oral, Shandong University , Jinan, China
| | - Dongjiao Zhang
- Department of Implantology, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration, Shandong Provincial Clinical Research Center for Oral, Shandong University , Jinan, China
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13
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Monje A, Kan JY, Borgnakke W. Impact of local predisposing/precipitating factors and systemic drivers on peri‐implant diseases. Clin Implant Dent Relat Res 2022. [PMID: 36533411 DOI: 10.1111/cid.13155] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/01/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Strong evidence suggests the infectious nature of peri-implant diseases occurring in susceptible hosts. Epidemiological reports, though, indicate that peri-implantitis is a site-specific entity. Hence, the significance of local factors that may predispose/precipitate plaque accumulation and the impact of systemic drivers that alter the immune response are relevant in the prevention and management of peri-implant disorders. PURPOSE The purpose of the present review is to shed light on the significance of local and systemic factors on peri-implant diseases, making special emphasis on the associations with peri-implantitis. METHODS The biologic plausibility and supporting evidence aiming at providing a concluding remark were explored in the recent scientific literature for local predisposing/precipitating factors and systemic drivers related to peri-implant diseases. RESULTS Local predisposing factors such as soft tissue characteristics, implant position and prosthetic design proved being strongly associated with the occurrence of peri-implant diseases. Hard tissue characteristics, however, failed to demonstrate having a direct association with peri-implant diseases. Robust data points toward the strong link between residual sub-mucosal cement and peri-implant diseases, while limited data suggests the impact of residual sub-mucosal floss and peri-implantitis. Systemic drivers/habits such as hyperglycemia and smoking showed a strong negative impact on peri-implantitis. However, there is insufficient evidence to claim for any link between metabolic syndrome, atherosclerotic cardiovascular disease, and obesity and peri-implant diseases. CONCLUSION Local predisposing/precipitating factors and systemic drivers may increase the risk of peri-implant diseases. Therefore, comprehensive anamnesis of the patients, educational/motivational programs and exhaustive prosthetically-driven treatment planning must be fostered aiming at reducing the rate of biological complications in implant dentistry.
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Affiliation(s)
- Alberto Monje
- Department of Periodontology and Oral Medicine University of Michigan Ann Arbor Michigan USA
- Department of Periodontology Universitat Internacional de Catalunya Barcelona Spain
- Department of Periodontology, ZMK University of Bern Bern CH Switzerland
| | - Joseph Y. Kan
- Department of Implantology Loma Linda University Loma Linda California USA
| | - Wenche Borgnakke
- Department of Periodontology and Oral Medicine University of Michigan Ann Arbor Michigan USA
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Quorum Sensing and Quorum Quenching with a Focus on Cariogenic and Periodontopathic Oral Biofilms. Microorganisms 2022; 10:microorganisms10091783. [PMID: 36144385 PMCID: PMC9503171 DOI: 10.3390/microorganisms10091783] [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: 08/06/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
Numerous in vitro studies highlight the role of quorum sensing in the pathogenicity and virulence of biofilms. This narrative review discusses general principles in quorum sensing, including Gram-positive and Gram-negative models and the influence of flow, before focusing on quorum sensing and quorum quenching in cariogenic and periodontopathic biofilms. In cariology, quorum sensing centres on the role of Streptococcus mutans, and to a lesser extent Candida albicans, while Fusobacterium nucleatum and the red complex pathogens form the basis of the majority of the quorum sensing research on periodontopathic biofilms. Recent research highlights developments in quorum quenching, also known as quorum sensing inhibition, as a potential antimicrobial tool to attenuate the pathogenicity of oral biofilms by the inhibition of bacterial signalling networks. Quorum quenchers may be synthetic or derived from plant or bacterial products, or human saliva. Furthermore, biofilm inhibition by coating quorum sensing inhibitors on dental implant surfaces provides another potential application of quorum quenching technologies in dentistry. While the body of predominantly in vitro research presented here is steadily growing, the clinical value of quorum sensing inhibitors against in vivo oral polymicrobial biofilms needs to be ascertained.
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Kajikawa T, Mastellos DC, Hasturk H, Kotsakis GA, Yancopoulou D, Lambris JD, Hajishengallis G. C3-targeted host-modulation approaches to oral inflammatory conditions. Semin Immunol 2022; 59:101608. [PMID: 35691883 DOI: 10.1016/j.smim.2022.101608] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Periodontitis is an inflammatory disease caused by biofilm accumulation and dysbiosis in subgingival areas surrounding the teeth. If not properly treated, this oral disease may result in tooth loss and consequently poor esthetics, deteriorated masticatory function and compromised quality of life. Epidemiological and clinical intervention studies indicate that periodontitis can potentially aggravate systemic diseases, such as, cardiovascular disease, type 2 diabetes mellitus, rheumatoid arthritis, and Alzheimer disease. Therefore, improvements in the treatment of periodontal disease may benefit not only oral health but also systemic health. The complement system is an ancient host defense system that plays pivotal roles in immunosurveillance and tissue homeostasis. However, complement has unwanted consequences if not controlled appropriately or excessively activated. Complement overactivation has been observed in patients with periodontitis and in animal models of periodontitis and drives periodontal inflammation and tissue destruction. This review places emphasis on a promising periodontal host-modulation therapy targeting the complement system, namely the complement C3-targeting drug, AMY-101. AMY-101 has shown safety and efficacy in reducing gingival inflammation in a recent Phase 2a clinical study. We also discuss the potential of AMY-101 to treat peri-implant inflammatory conditions, where complement also seems to be involved and there is an urgent unmet need for effective treatment.
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Affiliation(s)
- Tetsuhiro Kajikawa
- University of Pennsylvania, Penn Dental Medicine, Department of Basic and Translational Sciences, Philadelphia, PA, USA; Tohoku University Graduate School of Dentistry, Department of Periodontology and Endodontology, Sendai, Miyagi, Japan
| | - Dimitrios C Mastellos
- National Center for Scientific Research 'Demokritos', Division of Biodiagnostic Sciences and Technologies, INRASTES, Athens, Greece
| | - Hatice Hasturk
- The Forsyth Institute, Center for Clinical and Translational Research, Cambridge, MA, USA
| | - Georgios A Kotsakis
- University of Texas Health Science Center at San Antonio, School of Dentistry, Department of Periodontics, San Antonio, TX, USA
| | | | - John D Lambris
- University of Pennsylvania, Perelman School of Medicine, Department of Pathology and Laboratory Medicine, Philadelphia, PA, USA
| | - George Hajishengallis
- University of Pennsylvania, Penn Dental Medicine, Department of Basic and Translational Sciences, Philadelphia, PA, USA.
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