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Farimani Z, Shamshiri AR, Asl Roosta H, Akbari S, Bohlouli M. Regenerative benefits of using growth factors in treatment of periodontal defects: A systematic review and meta-analysis with Trial Sequential Analysis on preclinical studies. J Tissue Eng Regen Med 2021; 15:964-997. [PMID: 34480421 DOI: 10.1002/term.3241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/13/2021] [Accepted: 08/28/2021] [Indexed: 02/06/2023]
Abstract
The ultimate goal in periodontal treatments is to achieve a functional and anatomical regeneration of the lost tissues. Numerous studies have in some way illustrated the beneficial effects of biologic modifiers in this process, yet they are subject to a rather large degree of diversity in their results. Thanks to the promising outcomes of bioengineering techniques in the field of periodontal regeneration, this systematic review aims to evaluate the effect of various biologic modifiers used in periodontal defects of animal models. Electronic databases (Medline, Scopus, Embase, Web of Science, and Google Scholar) were searched (March 2010-December 2020) for every study that used biomolecules for regeneration of periodontal osseous defects in animal models. Regenerated bone height or area, new cementum, new connective tissues, new regenerated periodontal ligament and the dimensions of epithelial attachment (either in mm/mm2 or percentage) were the investigated outcomes. The risk of bias of the included studies was assessed using the SYRCLE tool. In closing, there was a meta-analysis carried out on the outcomes of interest. Trial Sequential Analysis was also carried out to figure out the power of meta-analytic outcomes. From 1995 studies which were found in the initial search, 34 studies were included in this review, and 20 of them were selected for the meta-analysis. The eligible studies were categorized according to the morphology of the experimental periodontal defects as one-, two-, and three-wall intrabony defects; furcation defects, and recession-type defects. The most studied biomolecules were rhFGF-2, rhGDF-5, platelet-derived growth factor, bone morphogenetic protein-2, and enamel matrix derivative (EMD). Based on the meta-analysis findings, combined application of biomolecules with regenerative treatments could improve new bone and cementum formation near 1 mm when compared to the control groups in one, two and three-wall intrabony defect models (p < 0.001). In furcation grade II defect, the addition of biomolecules was observed to enhance bone area gain and cementum height regeneration up to almost 2 mm (p < 0.001). Trial Sequential Analysis results confirmed the significant effect in the aforementioned meta-analyses. In cases of the buccal recession model, the application of rhFGF-2 and rhGDF-5 decreased the dimension of epithelial attachments besides regenerative advantages on bone and cementum formation, but EMD deposition exerted no inhibitory effect on epithelial down-growth. Application of biologic modifiers especially FGF-2 and GDF-5, could positively improve the regeneration of periodontal tissues, particularly cementum and bone in animal models. Trial Sequential Analysis confirmed the results but the power of the evidences was high just in some subgroup meta-analyses, like bone and cementum regeneration in furcation grade II model and cementum regeneration in one-wall intrabony defects. The outcomes of this study can potentially endow clinicians with guidelines for the appropriate application of growth factors in periodontal regenerative therapies.
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Affiliation(s)
- Zeinab Farimani
- Department of Periodontics, School of Dentistry, Alborz University of Medical Sciences, Karaj, Iran
| | - Ahmad Reza Shamshiri
- Department of Community Oral Health, School of Dentistry, Research Center for Caries Prevention, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoori Asl Roosta
- Department of Periodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Solmaz Akbari
- Department of Periodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboubeh Bohlouli
- Department of Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ikawa T, Akizuki T, Ono W, Maruyama K, Okada M, Stavropoulos A, Izumi Y, Iwata T. Ridge reconstruction in damaged extraction sockets using tunnel β-tricalcium phosphate blocks: A 6-month histological study in beagle dogs. J Periodontal Res 2020; 55:496-502. [PMID: 31985082 DOI: 10.1111/jre.12735] [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: 08/29/2019] [Revised: 12/17/2019] [Accepted: 01/05/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The present study aimed to evaluate the histological outcome of tunnel β-TCP blocks grafting in extraction sockets missing the buccal bone wall, after 6 months of healing. BACKGROUND Tunnel β-tricalcium phosphate (β-TCP) blocks made of randomly organized tunnel-shaped β-TCP ceramics appeared promising for alveolar ridge preservation in tooth extraction sockets missing the buccal bone, in a previous study in dogs, with a 2-month healing time. METHODS In six beagle dogs, the maxillary first premolars were extracted and the buccal bone was surgically removed to create bone defects of 4 mm (mesio-distal) × 5 mm (apico-coronal) × 4 mm (bucco-palatal). Thus, extraction sockets missing the buccal bone plate were grated with tunnel β-TCP blocks (test) or left empty for spontaneous healing (control). Histology/histomorphometry was performed after 6 months of healing. RESULTS The horizontal bucco-palatal width of the alveolar ridge was significantly greater at test sites than at control sites. The amount of mineralized tissue was greater at test sites (57.8% ± 11.1%) than at control sites (28.9% ± 8.5%), while the amount of connective tissue was significantly greater at control sites (41.7% ± 6.4%) than at test sites (19.6% ± 9.2%). No significant difference was found between sites in terms of basic multicellular units and bone marrow. Residual β-TCP at test sites was 5.8% ± 3.2%. CONCLUSION Grafting with tunnel β-TCP block significantly limited the resorption of the alveolar ridge at extraction sockets missing the buccal bone compared with sites left to heal spontaneously, even after 6-month follow-up.
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Affiliation(s)
- Takahiro Ikawa
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Periodontology, Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Tatsuya Akizuki
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Wataru Ono
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kiichi Maruyama
- Oral Diagnosis and General Dentistry, University Hospital of Dentistry, Tokyo Medical and Dental University, Tokyo, Japan
| | - Munehiro Okada
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Andreas Stavropoulos
- Department of Periodontology, Faculty of Odontology, Malmö University, Malmö, Sweden.,Division of Conservative Dentistry and Periodontology, University Clinic of Dentistry, Medical University of Vienna, Vienna, Austria
| | - Yuichi Izumi
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Oral Care Perio Center, Southern TOHOKU General Hospital, Southern TOHOKU Research Institute for Neuroscience, Koriyama, Japan
| | - Takanori Iwata
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Histologic evidence of periodontal regeneration in furcation defects: a systematic review. Clin Oral Investig 2019; 23:2861-2906. [PMID: 31165313 DOI: 10.1007/s00784-019-02964-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 05/16/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To systematically review the available histologic evidence on periodontal regeneration in class II and III furcations in animals and humans. MATERIALS AND METHODS A protocol including all aspects of a systematic review methodology was developed including definition of the focused question, defined search strategy, study inclusion criteria, determination of outcome measures, screening methods, data extraction and analysis, and data synthesis. The focused question was defined as follows: "What is the regenerative effect obtained by using or not several biomaterials as adjuncts to open flap surgery in the treatment of periodontal furcation defects as evaluated in animal and human histological studies?" SEARCH STRATEGY Using the MEDLINE database, the literature was searched for articles published up to and including September 2018: combinations of several search terms were applied to identify appropriate studies. Reference lists of review articles and of the included articles in the present review were screened. A hand search of the most important dental journals was also performed. CRITERIA FOR STUDY SELECTION AND INCLUSION Only articles published in English describing animal and human histological studies evaluating the effect of surgical treatment, with or without the adjunctive use of potentially regenerative materials (i.e., barrier membranes, grafting materials, growth factors/proteins, and combinations thereof) for the treatment of periodontal furcation defects were considered. Only studies reporting a minimum of 8 weeks healing following reconstructive surgery were included. The primary outcome variable was formation of periodontal supporting tissues [e.g., periodontal ligament, root cementum, and alveolar bone, given as linear measurements (in mm) or as a percentage of the instrumented root length (%)] following surgical treatment with or without regenerative materials, as determined histologically/histomorphometrically. Healing type and defect resolution (i.e., complete regeneration, long junctional epithelium, connective tissue attachment, connective tissue adhesion, or osseous repair) were also recorded. RESULTS In animals, periodontal regeneration was reported in class II and III defects with open flap debridement alone or combined with various types of bone grafts/bone substitues, biological factors, guided tissue regeneration, and different combinations thereof. The use of biological factors and combination approaches provided the best outcomes for class II defects whereas in class III defects, the combination approaches seem to offer the highest regenerative outcomes. In human class II furcations, the best outcomes were obtained with DFDBA combined with rhPDGF-BB and with GTR. In class III furcations, evidence from two case reports indicated very limited to no periodontal regeneration. CONCLUSIONS Within their limits, the present results suggest that (a) in animals, complete periodontal regeneration has been demonstrated in class II and class III furcation defects, and (b) in humans, the evidence for substantial periodontal regeneration is limited to class II furcations. CLINICAL RELEVANCE At present, regenerative periodontal surgery represents a valuable treatment option only for human class II furcation defects but not for class III furcations.
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Sigusch BW, Dietsch S, Berg A, Voelpel A, Guellmar A, Rabe U, Schnabelrauch M, Steen D, Gitter B, Albrecht V, Watts DC, Kranz S. Antimicrobial photodynamic active biomaterials for periodontal regeneration. Dent Mater 2018; 34:1542-1554. [PMID: 29970234 DOI: 10.1016/j.dental.2018.06.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/18/2018] [Accepted: 06/18/2018] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Biomaterials for periodontal regeneration may have insufficient mechanical and antimicrobial properties or are difficult to apply under clinical conditions. The aim of the present study was to develop a polymeric bone grafting material of suitable physical appearance and antimicrobial photodynamic activity. METHODS Two light curable biomaterials based on urethane dimethacrylate (BioM1) and a tri-armed oligoester-urethane methacrylate (BioM2) that additionally contained a mixture of β-tricalcium phosphate microparticles and 20wt% photosensitizer mTHPC (PS) were fabricated and analyzed by their compressive strength, flexural strength and modulus of elasticity. Cytotoxicity was observed by incubating eluates and in direct-contact to MC3T3-E1 cells. Antimicrobial activity was ascertained on Porphyromonas gingivalis and Enterococcus faecalis upon illumination with laser light (652nm, 1×100J/cm2, 2×100J/cm2). RESULTS The compressive strength, flexural strength and elastic modulus were, respectively, 311.73MPa, 22.81MPa and 318.85MPa for BioM1+PS and 742.37MPa, 7.58MPa and 406.23MPa for BioM2+PS. Both materials did not show any cytotoxic behavior. Single laser-illumination (652nm) caused total suppression of P. gingivalis (BioM2+PS), while repeated irradiation reduced E. faecalis by 3.7 (BioM1+PS) and 3.1 (BioM2+PS) log-counts. SIGNIFICANCE Both materials show excellent mechanical and cytocompatible properties. In addition, irradiation with 652nm induced significant bacterial suppression. The manufactured biomaterials might enable a more efficient cure of periodontal bone lesions. Due to the mechanical properties functional stability might be increased. Further, the materials are antimicrobial upon illumination with light that enables a trans-mucosal eradication of residual pathogens.
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Affiliation(s)
- B W Sigusch
- Department of Conservative Dentistry and Periodontology, University Hospitals Jena, An der alten Post 4, 07743 Jena, Germany
| | - S Dietsch
- Department of Conservative Dentistry and Periodontology, University Hospitals Jena, An der alten Post 4, 07743 Jena, Germany
| | - A Berg
- Biomaterials Department, INNOVENT e.V. Pruessingstrasse 27 B, 07745 Jena, Germany
| | - A Voelpel
- Department of Conservative Dentistry and Periodontology, University Hospitals Jena, An der alten Post 4, 07743 Jena, Germany
| | - A Guellmar
- Department of Conservative Dentistry and Periodontology, University Hospitals Jena, An der alten Post 4, 07743 Jena, Germany
| | - U Rabe
- Department of Conservative Dentistry and Periodontology, University Hospitals Jena, An der alten Post 4, 07743 Jena, Germany
| | - M Schnabelrauch
- Biomaterials Department, INNOVENT e.V. Pruessingstrasse 27 B, 07745 Jena, Germany
| | - D Steen
- biolitec research GmbH, Otto-Schott-Str. 15, 07745 Jena, Germany
| | - B Gitter
- biolitec research GmbH, Otto-Schott-Str. 15, 07745 Jena, Germany
| | - V Albrecht
- biolitec research GmbH, Otto-Schott-Str. 15, 07745 Jena, Germany
| | - D C Watts
- University of Manchester, School of Medical Sciences,Oxford Road, M13 9PL Manchester, UK
| | - S Kranz
- Department of Conservative Dentistry and Periodontology, University Hospitals Jena, An der alten Post 4, 07743 Jena, Germany.
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Shujaa Addin A, Akizuki T, Hoshi S, Matsuura T, Ikawa T, Fukuba S, Matsui M, Tabata Y, Izumi Y. Biodegradable gelatin/beta-tricalcium phosphate sponges incorporating recombinant human fibroblast growth factor-2 for treatment of recession-type defects: A split-mouth study in dogs. J Periodontal Res 2017; 52:863-871. [PMID: 28345758 DOI: 10.1111/jre.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Tissue engineering by using recombinant human (rh) growth factor technology may offer a promising therapeutic approach for treatment of gingival recession. Fibroblast growth factor-2 (FGF-2) has shown the ability to promote periodontal regeneration. Gelatin/beta-tricalcium phosphate (gelatin/β-TCP) sponges have been developed to control the release of growth factors. The present study evaluated the periodontal regenerative efficacy of rhFGF-2 by comparing gelatin/β-TCP sponges incorporated with rhFGF-2 to the scaffolds alone in artificially created recession-type defects in dogs. MATERIAL AND METHODS Critically sized buccal gingival recession defects were surgically created on maxillary canine teeth of five dogs. In each animal, defects were randomized to receive either a gelatin/β-TCP sponge soaked with rhFGF-2 (gelatin/β-TCP/rhFGF-2) or phosphate-buffered saline (gelatin/β-TCP). Eight weeks after surgery, biopsy specimens were obtained and subjected to microcomputed tomography and histological analyses. RESULTS Complete root coverage was achieved in both groups. Microcomputed tomography revealed significantly greater new bone volume in the gelatin/β-TCP/rhFGF-2 group. Histologically, both groups achieved periodontal regeneration; however, gelatin/β-TCP/rhFGF-2 sites exhibited more tissue regeneration, characterized by significantly larger amounts of new cementum and new bone. Gelatin/β-TCP sites featured increased long junctional epithelium and connective tissue attachment. In the gelatin/β-TCP/rhFGF-2 sites, new bone exhibited many haversian canals and circumferential lamellae as well as remarkably thick periosteum with blood vascularization and hypercellularity. CONCLUSION Within the limitations of this study, rhFGF-2 in gelatin/β-TCP sponges exhibits an increased potential to support periodontal wound healing/regeneration in canine recession-type defects.
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Affiliation(s)
- A Shujaa Addin
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - T Akizuki
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - S Hoshi
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - T Matsuura
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - T Ikawa
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - S Fukuba
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - M Matsui
- Polymer Chemistry Division, Chemical Resources Laboratory, Tokyo Institute of Technology, Kanagawa, Japan
| | - Y Tabata
- Department of Biomaterials, Field of Tissue Engineering, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
| | - Y Izumi
- Department of Periodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Saito E, Saito A, Kato H, Shibukawa Y, Inoue S, Yuge F, Nakajima T, Takahashi T, Kawanami M. A Novel Regenerative Technique Combining Bone Morphogenetic Protein-2 With Fibroblast Growth Factor-2 for Circumferential Defects in Dog Incisors. J Periodontol 2016; 87:1067-74. [PMID: 27240475 DOI: 10.1902/jop.2016.150746] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Periodontal regeneration of incisors is necessary for esthetic recovery. A novel regenerative method combining bone morphogenetic protein (BMP)-2 and fibroblast growth factor (FGF)-2 was developed. The purpose of this study is to evaluate periodontal healing, including root coverage, in circumferential defects of incisors. METHODS Fifty incisors in five beagles were used. After circumferential defects were surgically created, each group, consisting of ten recipient sites, received: 1) a double layer with FGF-2 (2 μg)/collagen as inner layer and BMP-2 (4 μg)/collagen as outer layer (FB-DL group); 2) collagen impregnated with both FGF-2 (2 μg) and BMP-2 (4 μg) (FB-M group); 3) BMP-2 (4 μg)/collagen (B group); 4) FGF-2 (4 μg)/collagen (F group); or 5) collagen (C group). Dogs were sacrificed 8 weeks post-surgery, and healing was evaluated histologically. RESULTS The three groups treated with BMP-2 showed enhanced new bone formation compared with control and F groups (P < 0.05). Furthermore, connective tissue attachment with cementum regeneration in the FB-DL group was significantly greater than in FB-M and B groups (P <0.05). Ankylosis in the FB-DL group was significantly less than in FB-M and B groups (P <0.05). Gingival recession was inhibited significantly better in FB-DL and FB-M groups compared with control and B groups. CONCLUSION These data support development of a double-layer method combining BMP-2 and FGF-2 as a therapeutic approach to periodontal regeneration at incisors with horizontal circumferential defects.
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Affiliation(s)
- Emiko Saito
- Department of Periodontology and Endodontology, Hokkaido University Graduate School of Dental Medicine, Sapporo, Japan
| | - Akira Saito
- Department of Crown and Bridge Prosthodontics, Hokkaido University Graduate School of Dental Medicine
| | | | | | - Satoshi Inoue
- Division of Clinical Education, Hokkaido University Graduate School of Dental Medicine
| | - Fumihiko Yuge
- Department of Crown and Bridge Prosthodontics, Hokkaido University Graduate School of Dental Medicine
| | - Toshinori Nakajima
- Department of Crown and Bridge Prosthodontics, Hokkaido University Graduate School of Dental Medicine
| | - Tomomi Takahashi
- Support Section for Education and Research, Hokkaido University Graduate School of Dental Medicine
| | - Masamitsu Kawanami
- Department of Periodontology and Endodontology, Hokkaido University Graduate School of Dental Medicine, Sapporo, Japan
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Sanz M, Jepsen K, Eickholz P, Jepsen S. Clinical concepts for regenerative therapy in furcations. Periodontol 2000 2015; 68:308-32. [DOI: 10.1111/prd.12081] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 11/26/2022]
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Muzio G, Martinasso G, Baino F, Frairia R, Vitale-Brovarone C, Canuto RA. Key role of the expression of bone morphogenetic proteins in increasing the osteogenic activity of osteoblast-like cells exposed to shock waves and seeded on bioactive glass-ceramic scaffolds for bone tissue engineering. J Biomater Appl 2014; 29:728-36. [DOI: 10.1177/0885328214541974] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this work, the role of shock wave-induced increase of bone morphogenetic proteins in modulating the osteogenic properties of osteoblast-like cells seeded on a bioactive scaffold was investigated using gremlin as a bone morphogenetic protein antagonist. Bone-like glass-ceramic scaffolds, based on a silicate experimental bioactive glass developed at the Politecnico di Torino, were produced by the sponge replication method and used as porous substrates for cell culture. Human MG-63 cells, exposed to shock waves and seeded on the scaffolds, were treated with gremlin every two days and analysed after 20 days for the expression of osteoblast differentiation markers. Shock waves have been shown to induce osteogenic activity mediated by increased expression of alkaline phosphatase, osteocalcin, type I collagen, BMP-4 and BMP-7. Cells exposed to shock waves plus gremlin showed increased growth in comparison with cells treated with shock waves alone and, conversely, mRNA contents of alkaline phosphatase and osteocalcin were significantly lower. Therefore, the shock wave-mediated increased expression of bone morphogenetic protein in MG-63 cells seeded on the scaffolds is essential in improving osteogenic activity; blocking bone morphogenetic protein via gremlin completely prevents the increase of alkaline phosphatase and osteocalcin. The results confirmed that the combination of glass-ceramic scaffolds and shock waves exposure could be used to significantly improve osteogenesis opening new perspectives for bone regenerative medicine.
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Affiliation(s)
- Giuliana Muzio
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Germana Martinasso
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Francesco Baino
- Institute of Materials Physics and Engineering, Department of Applied Science and Technology, Politecnico di Torino, Turin, Italy
| | - Roberto Frairia
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Chiara Vitale-Brovarone
- Institute of Materials Physics and Engineering, Department of Applied Science and Technology, Politecnico di Torino, Turin, Italy
| | - Rosa A Canuto
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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