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Xu K, Zhang Q, Zhu D, Jiang Z. Hydrogels in Gene Delivery Techniques for Regenerative Medicine and Tissue Engineering. Macromol Biosci 2024; 24:e2300577. [PMID: 38265144 DOI: 10.1002/mabi.202300577] [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: 12/16/2023] [Revised: 01/16/2024] [Indexed: 01/25/2024]
Abstract
Hydrogels are 3D networks swollen with water. They are biocompatible, strong, and moldable and are emerging as a promising biomedical material for regenerative medicine and tissue engineering to deliver therapeutic genes. The excellent natural extracellular matrix simulation properties of hydrogels enable them to be co-cultured with cells or enhance the expression of viral or non-viral vectors. Its biocompatibility, high strength, and degradation performance also make the action process of carriers in tissues more ideal, making it an ideal biomedical material. It has been shown that hydrogel-based gene delivery technologies have the potential to play therapy-relevant roles in organs such as bone, cartilage, nerve, skin, reproductive organs, and liver in animal experiments and preclinical trials. This paper reviews recent articles on hydrogels in gene delivery and explains the manufacture, applications, developmental timeline, limitations, and future directions of hydrogel-based gene delivery techniques.
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Affiliation(s)
- Kexing Xu
- Zhejiang University School of Medicine, Hangzhou, China
| | - Qinmeng Zhang
- Zhejiang University School of Medicine, Hangzhou, China
- Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, 310000, China
| | - Danji Zhu
- Zhejiang University School of Medicine, Hangzhou, China
- Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, 310000, China
| | - Zhiwei Jiang
- Zhejiang University School of Medicine, Hangzhou, China
- Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, 310000, China
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Gholap AD, Rojekar S, Kapare HS, Vishwakarma N, Raikwar S, Garkal A, Mehta TA, Jadhav H, Prajapati MK, Annapure U. Chitosan scaffolds: Expanding horizons in biomedical applications. Carbohydr Polym 2024; 323:121394. [PMID: 37940287 DOI: 10.1016/j.carbpol.2023.121394] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 11/10/2023]
Abstract
Chitosan, a natural polysaccharide from chitin, shows promise as a biomaterial for various biomedical applications due to its biocompatibility, biodegradability, antibacterial activity, and ease of modification. This review overviews "chitosan scaffolds" use in diverse biomedical applications. It emphasizes chitosan's structural and biological properties and explores fabrication methods like gelation, electrospinning, and 3D printing, which influence scaffold architecture and mechanical properties. The review focuses on chitosan scaffolds in tissue engineering and regenerative medicine, highlighting their role in bone, cartilage, skin, nerve, and vascular tissue regeneration, supporting cell adhesion, proliferation, and differentiation. Investigations into incorporating bioactive compounds, growth factors, and nanoparticles for improved therapeutic effects are discussed. The review also examines chitosan scaffolds in drug delivery systems, leveraging their prolonged release capabilities and ability to encapsulate medicines for targeted and controlled drug delivery. Moreover, it explores chitosan's antibacterial activity and potential for wound healing and infection management in biomedical contexts. Lastly, the review discusses challenges and future objectives, emphasizing the need for improved scaffold design, mechanical qualities, and understanding of interactions with host tissues. In summary, chitosan scaffolds hold significant potential in various biological applications, and this review underscores their promising role in advancing biomedical science.
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Affiliation(s)
- Amol D Gholap
- Department of Pharmaceutics, St. John Institute of Pharmacy and Research, Palghar 401404, Maharashtra, India
| | - Satish Rojekar
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Harshad S Kapare
- Department of Pharmaceutics, Dr. D. Y. Patil Institute of Pharmaceutical Sciences and Research, Pune 411018, Maharashtra, India
| | - Nikhar Vishwakarma
- Department of Pharmacy, Gyan Ganga Institute of Technology and Sciences, Jabalpur 482003, Madhya Pradesh, India
| | - Sarjana Raikwar
- Department of Pharmaceutical Sciences, Dr. Harisingh Gour Central University, Sagar 470003, Madhya Pradesh, India
| | - Atul Garkal
- Department of Pharmaceutics, Institute of Pharmacy, Nirma University, Ahmedabad 382481, Gujrat, India
| | - Tejal A Mehta
- Department of Pharmaceutics, Institute of Pharmacy, Nirma University, Ahmedabad 382481, Gujrat, India
| | - Harsh Jadhav
- Department of Food Engineering and Technology, Institute of Chemical Technology (ICT), Mumbai 400 019, Maharashtra, India
| | - Mahendra Kumar Prajapati
- Department of Pharmaceutics, School of Pharmacy and Technology Management, SVKM's NMIMS, Shirpur 425405, Maharashtra, India.
| | - Uday Annapure
- Institute of Chemical Technology, Marathwada Campus, Jalna 431203, Maharashtra, India; Department of Food Engineering and Technology, Institute of Chemical Technology (ICT), Mumbai 400 019, Maharashtra, India.
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Hu B, Gao J, Lu Y, Wang Y. Applications of Degradable Hydrogels in Novel Approaches to Disease Treatment and New Modes of Drug Delivery. Pharmaceutics 2023; 15:2370. [PMID: 37896132 PMCID: PMC10610366 DOI: 10.3390/pharmaceutics15102370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/03/2023] [Accepted: 09/07/2023] [Indexed: 10/29/2023] Open
Abstract
Hydrogels are particularly suitable materials for loading drug delivery agents; their high water content provides a biocompatible environment for most biomolecules, and their cross-linked nature protects the loaded agents from damage. During delivery, the delivered substance usually needs to be released gradually over time, which can be achieved by degradable cross-linked chains. In recent years, biodegradable hydrogels have become a promising technology in new methods of disease treatment and drug delivery methods due to their many advantageous properties. This review briefly discusses the degradation mechanisms of different types of biodegradable hydrogel systems and introduces the specific applications of degradable hydrogels in several new methods of disease treatment and drug delivery methods.
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Affiliation(s)
- Bo Hu
- Department of Medicinal Chemistry, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China; (B.H.); (J.G.)
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Engineering Research Center of Endogenous Prophylactic, Ministry of Education of China, Beijing Laboratory of Biomedical Materials, Beijing 100069, China
| | - Jinyuan Gao
- Department of Medicinal Chemistry, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China; (B.H.); (J.G.)
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Engineering Research Center of Endogenous Prophylactic, Ministry of Education of China, Beijing Laboratory of Biomedical Materials, Beijing 100069, China
| | - Yu Lu
- Department of Medicinal Chemistry, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China; (B.H.); (J.G.)
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Engineering Research Center of Endogenous Prophylactic, Ministry of Education of China, Beijing Laboratory of Biomedical Materials, Beijing 100069, China
- Laboratory for Clinical Medicine, Capital Medical University, Beijing 100069, China
| | - Yuji Wang
- Department of Medicinal Chemistry, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China; (B.H.); (J.G.)
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Engineering Research Center of Endogenous Prophylactic, Ministry of Education of China, Beijing Laboratory of Biomedical Materials, Beijing 100069, China
- Laboratory for Clinical Medicine, Capital Medical University, Beijing 100069, China
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Ortega MA, De Leon-Oliva D, Boaru DL, Fraile-Martinez O, García-Montero C, Diaz R, Coca S, Barrena-Blázquez S, Bujan J, García-Honduvilla N, Saez MA, Álvarez-Mon M, Saz JV. Unraveling the New Perspectives on Antimicrobial Hydrogels: State-of-the-Art and Translational Applications. Gels 2023; 9:617. [PMID: 37623072 PMCID: PMC10453485 DOI: 10.3390/gels9080617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
The growing impact of infections and the rapid emergence of antibiotic resistance represent a public health concern worldwide. The exponential development in the field of biomaterials and its multiple applications can offer a solution to the problems that derive from these situations. In this sense, antimicrobial hydrogels represent a promising opportunity with multiple translational expectations in the medical management of infectious diseases due to their unique physicochemical and biological properties as well as for drug delivery in specific areas. Hydrogels are three-dimensional cross-linked networks of hydrophilic polymers that can absorb and retain large amounts of water or biological fluids. Moreover, antimicrobial hydrogels (AMH) present good biocompatibility, low toxicity, availability, viscoelasticity, biodegradability, and antimicrobial properties. In the present review, we collect and discuss the most promising strategies in the development of AMH, which are divided into hydrogels with inherent antimicrobial activity and antimicrobial agent-loaded hydrogels based on their composition. Then, we present an overview of the main translational applications: wound healing, tissue engineering and regeneration, drug delivery systems, contact lenses, 3D printing, biosensing, and water purification.
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Affiliation(s)
- Miguel A. Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
| | - Diego De Leon-Oliva
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
| | - Diego Liviu Boaru
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
| | - Oscar Fraile-Martinez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
| | - Cielo García-Montero
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
| | - Raul Diaz
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain
| | - Santiago Coca
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
| | - Silvestra Barrena-Blázquez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
- Department of Nursing and Physiotherapy, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Julia Bujan
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
| | - Miguel A. Saez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
- Pathological Anatomy Service, Central University Hospital of Defence-UAH Madrid, 28801 Alcala de Henares, Spain
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (M.A.O.); (D.D.L.-O.); (D.L.B.); (O.F.-M.); (C.G.-M.); (S.C.); (J.B.); (N.G.-H.); (M.A.S.); (M.Á.-M.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
- Immune System Diseases-Rheumatology Service, Central University Hospital of Defence-UAH Madrid, 28801 Alcala de Henares, Spain
| | - Jose V. Saz
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain; (R.D.); (J.V.S.)
- Department of Biomedicine and Biotechnology, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain
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Zhang L, Yuan Z, Shafiq M, Cai Y, Wang Z, Nie P, Mo X, Xu Y. An Injectable Integration of Autologous Bioactive Concentrated Growth Factor and Gelatin Methacrylate Hydrogel with Efficient Growth Factor Release and 3D Spatial Structure for Accelerated Wound Healing. Macromol Biosci 2023; 23:e2200500. [PMID: 36788664 DOI: 10.1002/mabi.202200500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/06/2023] [Indexed: 02/16/2023]
Abstract
Growth factors are essential for wound healing owing to their multiple reparative effects. Concentrated growth factor (CGF) is a third-generation platelet extract containing various endogenous growth factors. Here, a CGF extract solution is combined with gelatin methacrylate (GM) by physical blending to produce GM@CGF hydrogels for wound repair. The GM@CGF hydrogels show no immune rejection during autologous transplantation. Compared to CGF, GM@CGF hydrogels not only exhibit excellent plasticity and adhesivity but also prevent rapid release and degradation of growth factors. The GM@CGF hydrogels display good injectability, self-healing, swelling, and degradability along with outstanding cytocompatibility, angiogenic functions, chemotactic functions, and cell migration-promoting capabilities in vitro. The GM@CGF hydrogel can release various effective molecules to rapidly initiate wound repair, stimulate the expressions of type I collagen, transform growth factor β1, epidermal growth factor, and vascular endothelial growth factor, promote the production of granulation tissues, vascular regeneration and reconstruction, collagen deposition, and epidermal cell migration, as well as prevent excessive scar formation. In conclusion, the injectable GM@CGF hydrogel can release various growth factors and provide a 3D spatial structure to accelerate wound repair, thereby providing a foundation for the clinical application and translation of CGF.
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Affiliation(s)
- Lixiang Zhang
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, No. 183, Xinqiao Street, Shapingba District, Chongqing, 400037, China
| | - Zhengchao Yuan
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai, 201620, China
| | - Muhammad Shafiq
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai, 201620, China.,Department of Chemical Engineering, Faculty of Engineering, Graduate School, Kyushu University, 744 Motooka, Nishi-ku, Fukuoka-shi, Fukuoka, 819-0385, Japan
| | - Youjun Cai
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, No. 183, Xinqiao Street, Shapingba District, Chongqing, 400037, China
| | - Zewen Wang
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, No. 183, Xinqiao Street, Shapingba District, Chongqing, 400037, China
| | - Piming Nie
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, No. 183, Xinqiao Street, Shapingba District, Chongqing, 400037, China
| | - Xiumei Mo
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai, 201620, China
| | - Yuan Xu
- Department of Orthopaedics, Xinqiao Hospital, Army Military Medical University, No. 183, Xinqiao Street, Shapingba District, Chongqing, 400037, China
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de Jesus G, Marques L, Vale N, Mendes RA. The Effects of Chitosan on the Healing Process of Oral Mucosa: An Observational Cohort Feasibility Split-Mouth Study. NANOMATERIALS (BASEL, SWITZERLAND) 2023; 13:706. [PMID: 36839074 PMCID: PMC9963900 DOI: 10.3390/nano13040706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 06/18/2023]
Abstract
The healing process is a dynamic process accompanied by some classical symptoms of inflammation such as redness, swelling, pain, and loss of function. Chitosan is a natural polymer with properties that contribute to tissue healing, with properties that could be applied in periodontal therapy, such as the wound healing of oral mucosa. This experimental split-mouth study aims to assess the possibilities of chitosan influencing the healing process of oral mucosa in eight patients, where the studied group was subjected to two oral surgeries: one with chitosan hydrogel into the socket and other without the biomaterial. A semi-quantitative analysis of the data was performed. Some classic signs of inflammation in a short period of time were observed where chitosan acted, compared to the control. An absence of bleeding was observed in the chitosan cases. According to the literature, chitosan recruits and activates neutrophils and macrophages and stimulates angiogenesis. Hemostatic and antimicrobial activity of chitosan also play an important role in wound healing. Chitosan seems to improve the postoperative quality of patients, allowing rapid wound healing with less complications.
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Affiliation(s)
- Gonçalo de Jesus
- Centro Regional das Beiras, Universidade Católica Portuguesa, Estrada da Circunvalação, 3504-505 Viseu, Portugal
| | - Lara Marques
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
| | - Rui Amaral Mendes
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- Department of Oral and Maxillofacial Medicine and Diagnostic Sciences, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-7401, USA
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