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Huang C, Chiang SYV, Gawkrodger DJ. The contribution of metal allergy to the failure of metal alloy implants, with special reference to titanium: Current knowledge and controversies. Contact Dermatitis 2024; 90:201-210. [PMID: 38148670 DOI: 10.1111/cod.14481] [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: 09/25/2023] [Revised: 11/26/2023] [Accepted: 11/29/2023] [Indexed: 12/28/2023]
Abstract
After almost three-quarters of a century during which contact dermatologists have often struggled to comprehend the relationship between metal allergy and failure of metal-alloy containing implant, it is possible to say that a relationship does exist, particularly for cobalt and chromium, but also for nickel. There is still debate as to whether allergy develops as a consequent of failure but thenceforth contributes to it, or whether sensitisation starts first and induces failure secondarily-opinion probably favours the first. Metal-on-polypropylene articulations were associated with few metal allergic problems but now are less favoured by orthopaedists due to plastic wear products causing osteolysis and pseudotumour formation through local inflammation. New metal alloys are regularly being introduced such that interested dermatologists need to stay on top of the situation. The jury is still out as to whether the recent favouring of titanium-containing alloys will confirm them to be more inert allergenically. Case reports do show some clinical reactions to titanium-containing implants and patch test series have inferred sometimes quite a high background rate of allergy, but interpretation must be tempered by the awareness that titanium salts on patch testing have a tendency to cause irritant reactions. Blood monitoring of metal ion values is now recommended in certain situations after joint replacement and increasing levels may be an indication that allergy with joint failure can develop, in which case patch testing is indicated, and suggested series are available. Predictive patch testing, whilst generally not recommended in the past, has been introduced into some protocols often by non-dermatologists, such that it is now needed for temporo-mandibular joint and Nuss bar insertion, and it can be anticipated that this may become more commonplace in the future. One of the major current deficits for patch testers is standardised guidance on which preparation or preparations to use for suspected titanium allergy. One suggestion is 0.5% titanium sulphate in petrolatum, though experience in at least one centre suggests the use of a battery of titanium salts might be desirable.
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Affiliation(s)
- Chenghao Huang
- Calderdale Royal Hospital, Calderdale and Huddersfield NHS Foundation Trust, Halifax, UK
| | - Shu Yu Vanessa Chiang
- Calderdale Royal Hospital, Calderdale and Huddersfield NHS Foundation Trust, Halifax, UK
| | - David J Gawkrodger
- Department of Dermatology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
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Hölken JM, Friedrich K, Merkel M, Blasius N, Engels U, Buhl T, Mewes KR, Vierkotten L, Teusch NE. A human 3D immune competent full-thickness skin model mimicking dermal dendritic cell activation. Front Immunol 2023; 14:1276151. [PMID: 38022577 PMCID: PMC10657825 DOI: 10.3389/fimmu.2023.1276151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
We have integrated dermal dendritic cell surrogates originally generated from the cell line THP-1 as central mediators of the immune reaction in a human full-thickness skin model. Accordingly, sensitizer treatment of THP-1-derived CD14-, CD11c+ immature dendritic cells (iDCs) resulted in the phosphorylation of p38 MAPK in the presence of 1-chloro-2,4-dinitrobenzene (DNCB) (2.6-fold) as well as in degradation of the inhibitor protein kappa B alpha (IκBα) upon incubation with NiSO4 (1.6-fold). Furthermore, NiSO4 led to an increase in mRNA levels of IL-6 (2.4-fold), TNF-α (2-fold) and of IL-8 (15-fold). These results were confirmed on the protein level, with even stronger effects on cytokine release in the presence of NiSO4: Cytokine secretion was significantly increased for IL-8 (147-fold), IL-6 (11.8-fold) and IL-1β (28.8-fold). Notably, DNCB treatment revealed an increase for IL-8 (28.6-fold) and IL-1β (5.6-fold). Importantly, NiSO4 treatment of isolated iDCs as well as of iDCs integrated as dermal dendritic cell surrogates into our full-thickness skin model (SM) induced the upregulation of the adhesion molecule clusters of differentiation (CD)54 (iDCs: 1.2-fold; SM: 1.3-fold) and the co-stimulatory molecule and DC maturation marker CD86 (iDCs ~1.4-fold; SM:~1.5-fold) surface marker expression. Noteworthy, the expression of CD54 and CD86 could be suppressed by dexamethasone treatment on isolated iDCs (CD54: 1.3-fold; CD86: 2.1-fold) as well as on the tissue-integrated iDCs (CD54: 1.4-fold; CD86: 1.6-fold). In conclusion, we were able to integrate THP-1-derived iDCs as functional dermal dendritic cell surrogates allowing the qualitative identification of potential sensitizers on the one hand, and drug candidates that potentially suppress sensitization on the other hand in a 3D human skin model corresponding to the 3R principles ("replace", "reduce" and "refine").
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Affiliation(s)
- Johanna Maria Hölken
- Institute of Pharmaceutical Biology and Biotechnology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Katja Friedrich
- Institute of Pharmaceutical Biology and Biotechnology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Marion Merkel
- Alternative Methods and Tissue Engineering, Henkel AG & Co. KGaA, Düsseldorf, Germany
| | - Nelli Blasius
- Alternative Methods and Tissue Engineering, Henkel AG & Co. KGaA, Düsseldorf, Germany
| | - Ursula Engels
- Alternative Methods and Tissue Engineering, Henkel AG & Co. KGaA, Düsseldorf, Germany
| | - Timo Buhl
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Karsten Rüdiger Mewes
- Alternative Methods and Tissue Engineering, Henkel AG & Co. KGaA, Düsseldorf, Germany
| | - Lars Vierkotten
- Alternative Methods and Tissue Engineering, Henkel AG & Co. KGaA, Düsseldorf, Germany
| | - Nicole Elisabeth Teusch
- Institute of Pharmaceutical Biology and Biotechnology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Metal Allergy: State-of-the-Art Mechanisms, Biomarkers, Hypersensitivity to Implants. J Clin Med 2022; 11:jcm11236971. [PMID: 36498546 PMCID: PMC9739320 DOI: 10.3390/jcm11236971] [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: 10/19/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Metal allergy is mainly an environmental disorder which can cause allergic contact dermatitis. Environmental metal exposures include jewelry, everyday metal items, mobile phones, leather, metal-rich food and implants, including stents or anchors. While consumer exposure is liable for the majority of metal hypersensitivity cases, the significance of occupational exposure to metals remains relevant. Although the most common metal allergens are nickel, chromium, and cobalt; however, lately, gold, palladium, titanium, and some others have also attracted attention. This review highlights advances in metal allergy mechanisms, biomarkers for potential patients' stratification as well as biological treatments. The most recent evidence of human exposure to metal for risk assessment is discussed, as well as the relationship between the occurrence of metal hypersensitivity and implanted devices, including non-characteristic symptoms. The latest data on the diagnosis of metal hypersensitivity are also reported.
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Yabit F, Hughes L, Sylvester B, Tiesenga F. Hypersensitivity Reaction Post Laparoscopic Cholecystectomy Due to Retained Titanium Clips. Cureus 2022; 14:e26167. [PMID: 35891858 PMCID: PMC9302919 DOI: 10.7759/cureus.26167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
Titanium is an inert metal that has many medical uses and applications because of its biocompatibility. However, titanium is not completely devoid of adverse reactions. This was the case of a 55-year-old female who presented following a laparoscopic cholecystectomy with right upper quadrant pain, diarrhea, nausea and eventual neuralgia in the right lower extremity. This led to a series of diagnostic procedures including an esophagogastroduodenoscopy (EGD), a colonoscopy, a CT scan, and an abdominal ultrasound, all of which proved to be futile. The patient was eventually formally diagnosed with hypersensitivity reaction due to titanium clips and underwent a diagnostic laparoscopy, adhesiolysis, and removal of foreign body under fluoroscopy. A total of four clips were identified and removed during the procedure. Repeat x-ray showed no evidence of further clips in the right upper quadrant nor throughout the abdomen. The patient was discharged the same day and showed improvement of symptoms one week later during the post-operative follow-up visit.
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Koning JJ, Rodrigues Neves CT, Schimek K, Thon M, Spiekstra SW, Waaijman T, de Gruijl TD, Gibbs S. A Multi-Organ-on-Chip Approach to Investigate How Oral Exposure to Metals Can Cause Systemic Toxicity Leading to Langerhans Cell Activation in Skin. FRONTIERS IN TOXICOLOGY 2022; 3:824825. [PMID: 35295125 PMCID: PMC8915798 DOI: 10.3389/ftox.2021.824825] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022] Open
Abstract
Investigating systemic toxicity in vitro is still a huge challenge. Here, a multi-organ-on-chip approach is presented as a typical case of topical exposure of oral mucosa to metals, which are known to activate the immune system and in turn may result in skin inflammation. Reconstructed human gingiva (RHG) and reconstructed human skin containing MUTZ-3–derived Langerhans cells (MUTZ-LC) in the epidermis (RHS-LC) were incorporated into a HUMIMIC Chip3plus, connected by dynamic flow and cultured for a total period of 72 h. Three independent experiments were performed each with an intra-experiment replicate in order to assess the donor and technical variations. After an initial culture period of 24 h to achieve stable dynamic culture conditions, nickel sulfate was applied topically to RHG for 24 h, and LC activation (maturation and migration) was determined in RHS-LC after an additional 24 h incubation time. A stable dynamic culture of RHG and RHS-LC was achieved as indicated by the assessment of glucose uptake, lactate production, and lactate dehydrogenase release into the microfluidics compartment. Nickel exposure resulted in no major histological changes within RHG or RHS-LC, or cytokine release into the microfluidics compartment, but did result in an increased activation of LC as observed by the increased mRNA levels of CD1a, CD207, HLA-DR, and CD86 in the dermal compartment (hydrogel of RHS-LC (PCR)). This is the first study to describe systemic toxicity and immune cell activation in a multi-organ setting and can provide a framework for studying other organoids in the future.
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Affiliation(s)
- Jasper J Koning
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Charlotte T Rodrigues Neves
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Maria Thon
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Sander W Spiekstra
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Taco Waaijman
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Tanja D de Gruijl
- Department of Medical Oncology, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Susan Gibbs
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Investigating the Immunomodulatory Potential of Dental Pulp Stem Cell Cultured on Decellularized Bladder Hydrogel towards Macrophage Response In Vitro. Gels 2022; 8:gels8030187. [PMID: 35323300 PMCID: PMC8954673 DOI: 10.3390/gels8030187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/25/2022] Open
Abstract
Mesenchymal stem cells (MSCs) possess immunomodulatory properties and capacity for endogenous regeneration. Therefore, MSC therapy is a promising treatment strategy for COVID-19. However, the cells cannot stay in the lung long enough to exert their function. The extracellular matrix from porcine bladders (B-ECM) has been shown not only to regulate cellular activities but also to possess immunoregulatory characteristics. Therefore, it can be hypothesized that B-ECM hydrogel could be an excellent scaffold for MSCs to grow and could anchor MSCs long enough in the lung so that they can exhibit their immunomodulatory functions. In this study, ECM degradation products and a co-culture system of MSCs and macrophages were developed to study the immunomodulatory properties of ECM and MSCs under septic conditions. The results showed that B-ECM degradation products could decrease pro-inflammatory and increase anti-inflammatory cytokines from macrophages. In an in vivo mimicking co-culture system, MSCs cultured on B-ECM hydrogel exhibited immunomodulatory properties at both gene and protein levels. Both B-ECM degradation products and MSC conditioned medium supported the wound healing of alveolar epithelial cells. The results from the study could offer a basis for investigation of immunomodulation by ECM and MSCs before conducting in vivo experiments, which could later be applied in regenerative medicine.
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Buonomo M, Ruggiero JL, Hylwa S. Titanium allergy as a likely cause of post-reconstruction dermatitis of the breast. Contact Dermatitis 2021; 86:142-143. [PMID: 34713461 DOI: 10.1111/cod.13997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Michele Buonomo
- Department of Dermatology, Park Nicollet Health Services, Minneapolis, Minnesota, USA.,University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jenna L Ruggiero
- Department of Dermatology, Park Nicollet Health Services, Minneapolis, Minnesota, USA.,University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Sara Hylwa
- Department of Dermatology, Park Nicollet Health Services, Minneapolis, Minnesota, USA
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Zhang Y, de Graaf NPJ, Roffel S, Spiekstra SW, Rustemeyer T, Kleverlaan CJ, Feilzer AJ, Bontkes H, Deng D, Gibbs S. Patch test-relevant concentrations of metal salts cause localized cytotoxicity, including apoptosis, in skin ex vivo. Contact Dermatitis 2021; 85:531-542. [PMID: 34268774 PMCID: PMC9291529 DOI: 10.1111/cod.13940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/30/2022]
Abstract
Background Metal alloys containing contact sensitizers (nickel, palladium, titanium) are extensively used in medical devices, in particular dentistry and orthopaedic surgery. The skin patch test is used to test for metal allergy. Objective To determine whether metal salts, when applied to freshly excised skin at patch test–relevant concentrations and using a method which mimics skin patch testing, cause in changes in the epidermis and dermis. Methods Tissue histology, apoptosis, metabolic activity, and inflammatory cytokine release were determined for two nickel salts, two palladium salts, and four titanium salts. Results Patch test–relevant concentrations of all metal salts caused localized cytotoxicity. This was observed as epidermis separation at the basement membrane zone, formation of vacuoles, apoptotic nuclei, decreased metabolic activity, and (pro)inflammatory cytokine release. Nickel(II) sulfate hexahydrate, nickel(II) chloride hexahydrate, titanium(IV) bis(ammonium lactato)dihydroxide, and calcium titanate were highly cytotoxic. Palladium(II) chloride, sodium tetrachloropalladate(II), titanium(IV) isopropoxide, and titanium(IV) dioxide showed mild cytotoxicity. Conclusion The patch test in itself may be damaging to the skin of the patient being tested. These results need further verification with biopsies obtained during clinical patch testing. The future challenge is to remain above the elicitation threshold at noncytotoxic metal concentrations.
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Affiliation(s)
- Yan Zhang
- Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - Niels P J de Graaf
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - Sanne Roffel
- Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sander W Spiekstra
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - Thomas Rustemeyer
- Department of Dermatology, Amsterdam University Medical Centre location AMC, Amsterdam, The Netherlands
| | - Cees J Kleverlaan
- Department of Dental Materials Science, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert J Feilzer
- Department of Dental Materials Science, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Hetty Bontkes
- Unit Medical Immunology, Department of Clinical Chemistry, VU University Medical Centre, Amsterdam, The Netherlands
| | - Dongmei Deng
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Susan Gibbs
- Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
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Rodrigues Neves CT, Spiekstra SW, de Graaf NPJ, Rustemeyer T, Feilzer AJ, Kleverlaan CJ, Gibbs S. Titanium salts tested in reconstructed human skin with integrated MUTZ-3-derived Langerhans cells show an irritant rather than a sensitizing potential. Contact Dermatitis 2020; 83:337-346. [PMID: 32677096 PMCID: PMC7689826 DOI: 10.1111/cod.13666] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 07/10/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The nature of clinically related adverse reactions to titanium is still unknown. OBJECTIVE To determine whether titanium salts have irritant or sensitizing potential in a reconstructed human skin (RHS) model with integrated Langerhans cells (LCs). METHODS RHS-LCs (ie, reconstructed epidermis) containing primary differentiated keratinocytes and CFSE+ CD1a+ -LCs generated from the MUTZ-3 cell line on a primary fibroblast-populated collagen hydrogel (dermis) were topically exposed to titanium(IV) bis(ammonium lactato)dihydroxide (TiALH). LC migration and plasticity were determined. RESULTS TiALH resulted in CFSE+ CD1a+ -LC migration out of the epidermis. Neutralizing antibodies to CCL5 and CXCL12 showed that LC migration was CCL5 and not CXCL12 mediated. LCs accumulating within the dermis after TiALH exposure were CFSE+ Lang+ CD68+ which is characteristic of a phenotypic switch of MUTZ-LC to a macrophage-like cell. Furthermore, TiALH did not result in increased interleukin (IL)-1β or CCR7 messenger RNA (mRNA) in the dermis, but did result in increased IL-10 mRNA. In addition, monocultures of MUTZ-LCs failed to increase LC maturation biomarkers CD83, CD86, and CXCL-8 when exposed to noncytotoxic concentrations of four different titanium salts. CONCLUSION These results classify titanium salts as irritants rather than sensitizers and indicate that titanium implant-related complaints could be due to localized irritant-mediated inflammation arising from leachable agents rather than a titanium metal allergy.
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Affiliation(s)
- Charlotte T Rodrigues Neves
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sander W Spiekstra
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Niels P J de Graaf
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Thomas Rustemeyer
- Department of Dermatology, Amsterdam University Medical Centre (location AMC), Amsterdam, The Netherlands
| | - Albert J Feilzer
- Department of Dental Materials Science, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Cees J Kleverlaan
- Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Susan Gibbs
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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