Antimicrobial surfaces for craniofacial implants: state of the art

Zoledronic Acid Implant Coating Results in Local Medullary Bone Growth

Osteoarthritis (OA) can necessitate surgical interventions to restore the function of the joint in severe cases. Joint replacement surgery is one of the procedures implemented to replace the damaged joint with prosthetic implants in severe cases of OA. However, after successful implantation, a fraction of OA patients still require revision surgery due to aseptic prosthetic loosening. Insufficient osseointegration is one of the factors that contribute to such loosening of the bone implant, which is commonly made from titanium-based materials. Zoledronic acid (ZA), a potent bisphosphonate agent, has been previously shown to enhance osseointegration of titanium implants. Herein, we fabricated ZA/Ca composites using a reverse microemulsion method and coated them with 1,2-dioleoyl-sn-glycero-3-phosphate monosodium salt (DOPA) to form ZA/Ca/DOPA composites. Titanium alloy screws were subsequently dip-coated with a suspension of the ZA/Ca/DOPA composites and poly(lactic-co-glycolic) acid (PLGA) in chloroform to yield Za/PLGA-coated screws. The coated screws exhibited a biphasic in vitro release profile with an initial burst release within 48 h, followed by a sustained release over 1 month. To assess their performance in vivo, the Za/PLGA screws were then implanted into the tibiae of Sprague-Dawley rats. After 8 weeks, microCT imaging showed new bone growth along the medullary cavity around the implant site, supporting the local release of ZA to enhance bone growth around the implant. Histological staining further confirmed the presence of new mineralized medullary bone growth resembling the cortical bone. Such local medullary growth represents an opportunity for future studies with alternative coating methods to fine-tune the local release of ZA from the coating and enhance complete osseointegration of the implant.

Influences of Extrusion and Silver Content on the Degradation of Mg-Ag Alloys In Vitro and In Vivo

Binary magnesium-silver (Mg-Ag) alloys were designed as antibacterial materials for biomedical implant applications. In the present study, we focused on the effects of extrusion (extrusion ratio (ER): 1, 7.1, and 72.2) and Ag content (Ag = 0, 3, and 6 wt.%) on the degradation of Mg-Ag alloys in vitro and in vivo via microstructure characterization and corrosion/degradation measurements. The results showed that the Ag promoted a galvanic reaction with the Mg matrix to accelerate degradation or formed a protective oxide mesh texture to inhibit degradation, especially in vivo. Ag might also be beneficial for product crystallization, biomineralization, and organic matter deposition. For pure Mg, extrusion produced a more refined grain and decreased the degradation rate. For the Mg-Ag alloys, a low extrusion ratio (7.1) accelerated the degradation caused by the increase in the proportion of the precipitate. This promoted the release of Mg2+ and Ag+, which led to more deposition of organic matter and calcium phosphate, but also more H2 bubbles, which led to disturbance of product deposition in some local positions or even inflammatory reactions. Extrusion at a higher ratio (72.2) dissolved the precipitates. This resulted in moderate degradation rates and less gas production, which promoted osteogenesis without an obvious inflammation reaction.

Infections @ Trauma/Orthopedic Implants: Recent Advances on Materials, Methods, and Microbes-A Mini-Review

Implants and materials are indispensable in trauma and orthopedic surgery. The continuous improvements of implant design have resulted in an optimized mechanical function that supports tissue healing and restoration of function. One of the still unsolved problems with using implants and materials is infection. Trauma and material implantation change the local inflammatory situation and enable bacterial survival and material colonization. The main pathogen in orthopedic infections is Staphylococcus aureus. The research efforts to optimize antimicrobial surfaces and to develop new anti-infective strategies are enormous. This mini-review focuses on the publications from 2021 with the keywords S. aureus AND (surface modification OR drug delivery) AND (orthopedics OR trauma) AND (implants OR nails OR devices). The PubMed search yielded 16 original publications and two reviews. The original papers reported the development and testing of anti-infective surfaces and materials: five studies described an implant surface modification, three developed an implant coating for local antibiotic release, the combination of both is reported in three papers, while five publications are on antibacterial materials but not metallic implants. One review is a systematic review on the prevention of stainless-steel implant-associated infections, the other addressed the possibilities of mixed oxide nanotubes. The complexity of the approaches differs and six of them showed efficacy in animal studies.

Effect and mechanism of propranolol on promoting osteogenic differentiation and early implant osseointegration

The present study aimed to investigate the effect of β‑receptor blocker propranolol on early osseointegration of pure titanium implants and the underlying molecular regulatory mechanisms. An implant osseointegration model using the tibial metaphysis of New Zealand rabbits was established. The rabbits were divided into control and low‑, medium‑ and high‑dose propranolol groups. The formation of implant osseointegration was detected by X‑ray scanning. Mesenchymal stem cells (MSCs) and osteoblasts (OBs) were isolated and cultured in vitro, isoproterenol was supplemented to simulate sympathetic action and propranolol was subsequently administrated. The effect of propranolol on cell proliferation and osteogenic differentiation were assessed by EdU, flow cytometry, alizarin red staining and alkaline phosphatase (ALP) detection. The expression levels of bone morphogenetic protein (BMP)2, RUNX family transcription factor (RunX)2, collagen (COL)‑1, osteocalcin (OCN) and β2‑adrenergic receptor (AR) were detected by immunofluorescence, reverse transcription‑quantitative PCR and western blot assay. Propranolol effectively promoted implant osseointegration in vivo, facilitated proliferation of OBs, inhibited proliferation of MSCs and enhanced osteogenic differentiation of OBs and MSCs. The calcium content and ALP activity of cells treated with propranolol were markedly higher than in the control group. Propranolol also elevated mRNA and protein expression levels of BMP2, RunX2, COL‑1 and OCN in tissue and cells, and decreased the expression of β2‑AR. The present study demonstrated that the β‑receptor blocker propranolol promoted osteogenic differentiation of OBs and MSCs and enhanced implant osseointegration. The present study provided a novel insight into the application and regulatory mechanisms of propranolol.

Antimicrobial Potential of Strontium Hydroxide on Bacteria Associated with Peri-Implantitis

Background: Peri-implantitis due to infection of dental implants is a common complication that may cause significant patient morbidity. In this study, we investigated the antimicrobial potential of Sr(OH)₂ against different bacteria associated with peri-implantitis. Methods: The antimicrobial potential of five concentrations of Sr(OH)₂ (100, 10, 1, 0.1, and 0.01 mM) was assessed with agar diffusion test, minimal inhibitory concentration (MIC), and biofilm viability assays against six bacteria commonly associated with biomaterial infections: Streptococcus mitis, Staphylococcus epidermidis, Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Escherichia coli, and Fusobacterium nucleatum. Results: Zones of inhibition were only observed for, 0.01, 0.1, and 1 mM of Sr(OH)₂ tested against P. gingivalis, in the agar diffusion test. Growth inhibition in planktonic cultures was achieved at 10 mM for all species tested (p < 0.001). In biofilm viability assay, 10 and 100 mM Sr(OH)₂ showed potent bactericidal affect against S. mitis, S. epidermidis, A. actinomycetemcomitans, E. coli, and P. gingivalis. Conclusions: The findings of this study indicate that Sr(OH)₂ has antimicrobial properties against bacteria associated with peri-implantitis.

Structure, morphology, adhesion and in vitro biological evaluation of antibacterial multi-layer HA-Ag/SiO2/TiN/Ti coatings obtained by RF magnetron sputtering for biomedical applications

Biocompatible and antibacterial multi-layer coatings of hydroxyapatite (HA)-Ag/SiO2/TiN/Ti were obtained on the Ti-6Al-4V alloy, by means of the magnetron sputtering technique. During characterization of the coatings, the chemical composition was evaluated by energy dispersive X-ray spectroscopy and the phase analysis was carried out by X-ray diffraction. The morphology of the coatings was observed by field emission scanning electron microscopy, while transmission electron microscopy was used to appreciate their structure. The adhesion of the coatings to the substrate was evaluated by micro scratch test. The in vitro biological response was evaluated in terms of cytotoxicity, adhesion and differentiation of mouse mesenchymal stem cells, as well as adhesion and bacterial viability of Staphylococcus aureus strain. Through the compositional study carried out, the deposition of the HA phase was verified, with a Ca/P ratio close to 1.67 and the characteristic diffraction peaks of this compound. The structural study of the coatings evidenced the obtention of multi-layer architectures. The use of an intermediate SiO2/TiN/Ti trilayer was found to improve adhesion between HA-Ag and the substrate by 84%. Finally, the in vitro biological tests carried out indicated a potentially non-toxic character in the coatings. Additionally, an antibacterial effect was registered at low concentrations of Ag (<0.25 mg/L).

In vivo hydroxyapatite scaffold performance in infected bone defects

Critically sized bone defects are often compounded by infectious complications. The standard of care consists of bone autografts with systemic antibiotics. These injuries and treatments lead to donor site morbidity, antibiotic resistant strains of bacteria, and often end stage amputation. This study proposes an alternative to the autograft using a porous, hydroxyapatite (HA) scaffold evaluated with and without infection and antibiotics. Twenty-four New Zealand white rabbits received either our HA scaffold or a pulverized autograft (PBA) within a surgically created critical-sized defect in the femur. The two grafts were evaluated in either septic or aseptic defects and with or without antibiotic treatment. The HA scaffolds were characterized with micro computed tomography. Post-euthanasia, micro computed tomography, histology, and white blood cells component analysis were completed. The HA had significantly greater (p < .001) mineralization to total volume than the PBA groups with 27.56% and 14.88%, respectively, and the septic HA groups were significantly greater than the aseptic groups both with and without antibiotics (p = .016). The bone quality denoted by bone mineral density was also significantly greater (p < .001) in the HA groups (67.01 ± 0.38 mgHA/cm³ ) than the PBA groups (64.66 ± 0.85 mgHA/cm³ ). The HA scaffold is a viable alternative to the bone autograft in defects with and without infection as shown by the quality and quantity of bone.

The impact of proton pump inhibitors on bone regeneration and implant osseointegration

Proton pump inhibitors (PPIs) have become known for the treatment of gastric-acid related disorders. Similar to any other drugs, PPIs have possible adverse reactions, being associated with bone fractures, infections, kidney disease, mineral deficiency, dementia, and pneumonia. Multiple analyses have stated that PPIs therapy may affect bone regeneration and osseointegration process, causing an increased risk of bone fracture, deterioration of bone metabolism and impaired bone healing. In this review, we emphasized the current literature regarding the influence of proton pump inhibitors in the bone regeneration process. Results from the studies suggest a link between PPIs intake and bone regeneration, but several concerns are raised regarding inadequate recipient bone, surgical trauma, limitations on the titanium surface, comorbidities or interference with other pharmacological agents. Further studies are needed to determine whether the impaired bone regeneration process is due to PPI or coexisting factors.

An In Vitro Model for Candida albicans⁻Streptococcus gordonii Biofilms on Titanium Surfaces

The oral cavity serves as a nutrient-rich haven for over 600 species of microorganisms. Although many are essential to maintaining the oral microbiota, some can cause oral infections such as caries, periodontitis, mucositis, and endodontic infections, and this is further exacerbated with dental implants. Most of these infections are mixed species in nature and associated with a biofilm mode of growth. Here, after optimization of different parameters including cell density, growth media, and incubation conditions, we have developed an in vitro model of C. albicans–S. gordonii mixed-species biofilms on titanium discs that is relevant to infections of peri-implant diseases. Our results indicate a synergistic effect for the development of biofilms when both microorganisms were seeded together, confirming the existence of beneficial, mutualistic cross-kingdom interactions for biofilm formation. The morphological and architectural features of these dual-species biofilms formed on titanium were determined using scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). Mixed biofilms formed on titanium discs showed a high level of resistance to combination therapy with antifungal and antibacterial drugs. This model can serve as a platform for further analyses of complex fungal/bacterial biofilms and can also be applied to screening of new drug candidates against mixed-species biofilms.

Electrochemical testing of a novel alloy in natural and artificial body fluids

There is a recent trend in tissue engineering and regenerative medicine to use nanotechnology and bionanomaterials to obtain materials that mimic the surface properties of a natural tissue. From this perspective, nanolevel tissue engineering can be viewed as a novel anatomy of the future. In this paper, a novel titanium-based alloy is studied following this strategy. The alloy nanostructuration is proposed as an improved alternative for restorative prosthodontics or an implantable biomaterial. Tests in (i) standard solution of simulated body fluid (SBF) and (ii) natural saliva were performed to investigate the alloy's electrochemical stability. The results show that nanochannel growth on the alloy surface confers a higher stability than that of the untreated one in both natural and simulated environments.

The Impact of Incorporating Antimicrobials into Implant Surfaces

With the increase in numbers of joint replacements, spinal surgeries, and dental implantations, there is an urgent need to combat implant-associated infection. In addition to stringent sterile techniques, an efficacious way to prevent this destructive complication is to create new implants with antimicrobial properties. Specifically, these implants must be active in the dental implant environment where the implant is bathed in the glycoprotein-rich salivary fluids that enhance bacterial adhesion, and propagation, and biofilm formation. However, in designing an antimicrobial surface, a balance must be struck between antimicrobial activity and the need for the implant to interact with the bone environment. Three types of surfaces have been designed to combat biofilm formation, while attempting to maintain osseous interactions: 1) structured surfaces where topography, usually at the nanoscale, decreases bacterial adhesion sufficiently to retard establishment of infection; 2) surfaces that actively elute antimicrobials to avert bacterial adhesion and promote killing; and 3) surfaces containing permanently bonded agents that generate antimicrobial surfaces that prevent long-term bacterial adhesion. Both topographical and elution surfaces exhibit varying, albeit limited, antimicrobial activity in vitro. With respect to covalent coupling, we present studies on the ability of the permanent antimicrobial surfaces to kill organisms while fostering osseointegration. All approaches have significant drawbacks with respect to stability and efficacy, but the permanent surfaces may have an edge in creating a long-term antibacterial environment.

Influence of the Microstructure and Silver Content on Degradation, Cytocompatibility, and Antibacterial Properties of Magnesium-Silver Alloys In Vitro

Implantation is a frequent procedure in orthopedic surgery, particularly in the aging population. However, it possesses the risk of infection and biofilm formation at the surgical site. This can cause unnecessary suffering to patients and burden on the healthcare system. Pure Mg, as a promising metal for biodegradable orthopedic implants, exhibits some antibacterial effects due to the alkaline pH produced during degradation. However, this antibacterial effect may not be sufficient in a dynamic environment, for example, the human body. The aim of this study was to increase the antibacterial properties under harsh and dynamic conditions by alloying silver metal with pure Mg as much as possible. Meanwhile, the Mg-Ag alloys should not show obvious cytotoxicity to human primary osteoblasts. Therefore, we studied the influence of the microstructure and the silver content on the degradation behavior, cytocompatibility, and antibacterial properties of Mg-Ag alloys in vitro. The results indicated that a higher silver content can increase the degradation rate of Mg-Ag alloys. However, the degradation rate could be reduced by eliminating the precipitates in the Mg-Ag alloys via T4 treatment. By controlling the microstructure and increasing the silver content, Mg-Ag alloys obtained good antibacterial properties in harsh and dynamic conditions but had almost equivalent cytocompatibility to human primary osteoblasts as pure Mg.

A decomposable silica-based antibacterial coating for percutaneous titanium implant

Although percutaneous titanium implants have become one of the best choices as retainers in the facial defects, peri-implantitis still occurs at a significant rate. This unwanted complication occurs due to adhesion of bacteria and subsequent biofilm formation. To solve this problem, we have developed a novel antibiotic nanodelivery system based on self-decomposable silica nanoparticles. In this study, silica-gentamycin (SG) nanoparticles were successfully fabricated using an innovative one-pot solution. The nanoparticles were incorporated within a gelatin matrix and cross-linked on microarc-oxidized titanium. To characterize the SG nanoparticles, their particle size, zeta potential, surface morphology, in vitro drug release, and decomposition process were sequentially evaluated. The antibacterial properties against the gram-positive Staphylococcus aureus, including bacterial viability, antibacterial rate, and bacteria morphology, were analyzed using SG-loaded titanium specimens. Any possible influence of released gentamycin on the viability of human fibroblasts, which are the main component of soft tissues, was investigated. SG nanoparticles from the antibacterial titanium coating continuously released gentamycin and inhibited S. aureus growth. In vitro investigation showed that the obtained nanodelivery system has good biocompatibility. Therefore, this design can be further investigated as a method to prevent infection around percutaneous implants.

Bacterial and mammalian cells adhesion to tantalum-decorated micro-/nano-structured titanium

Microorganisms are frequently introduced to dental implants during surgery and start the race for the surface with host cells before osseointegration occurs. The aim of the study was to endow implant surfaces with biological functions that reliably select cells over microbes. Nano-structured tantalum (Ta) has exhibited excellent compatibility. Thus, nano-structured Ta films were deposited on the sand-blasted, large grit, and acid-etched (SLA) titanium by the magnetron sputtering method, thus forming hierarchical micro-/nano-structured surfaces. No obvious Ta release confirmed the robustness of the deposited layer probably arising from the stable Ta₂ O₅ . Moreover, Ta-modified surfaces not only improved the initial adhesion and spreading of rat bone mesenchymal stem cells (rBMSCs), but also exhibited good antibacterial activities towards Streptococcus mutans and Porphyromonas gingivalis. The satisfactory cell-surface interactions on Ta-modified surfaces depended largely on the up-regulation of adhesion-related genes and activation of focal adhesion kinase (FAK), as confirmed by real-time PCR and Western blot. Here, the coculture model was also forwarded to mimic the perioperative bacterial contamination. We found that the adherent cell number and the cell-surface coverage were hampered by bacteria presence on both surfaces. Yet, rBMSCs still attached and spread more readily on Ta-modified surfaces than on SLA titanium surfaces even in coculture with adhering oral pathogens. Our results revealed that Ta-modified micro-/nano-structured surfaces would selectively promote cell-surface rather than bacteria-surface interactions, boding well for the applications for dental implants in possibly infected environments. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 871-878, 2017.

Increased Mesenchymal Stem Cell Response and Decreased Staphylococcus aureus Adhesion on Titania Nanotubes without Pharmaceuticals

Titanium (Ti) implants with enhanced biocompatibility and antibacterial property are highly desirable and characterized by improved success rates. In this study, titania nanotubes (TNTs) with various tube diameters were fabricated on Ti surfaces through electrochemical anodization at 10, 30, and 60 V (denoted as NT10, NT30, and NT60, resp.). Ti was also investigated and used as a control. NT10 with a diameter of 30 nm could promote the adhesion and proliferation of bone marrow mesenchymal stem cells (BMSCs) without noticeable differentiation. NT30 with a diameter of 100 nm could support the adhesion and proliferation of BMSCs and induce osteogenesis. NT60 with a diameter of 200 nm demonstrated the best ability to promote cell spreading and osteogenic differentiation; however, it clearly impaired cell adhesion and proliferation. As the tube diameter increased, bacterial adhesion on the TNTs decreased and reached the lowest value on NT60. Therefore, NT30 without pharmaceuticals could be used to increase mesenchymal stem cell response and decrease Staphylococcus aureus adhesion and thus should be further studied for improving the efficacy of Ti-based orthopedic implants.

Antibacterial Effects and Biocompatibility of Titania Nanotubes with Octenidine Dihydrochloride/Poly(lactic-co-glycolic acid)

Titanium (Ti) implants with long-term antibacterial ability and good biocompatibility are highly desirable materials that can be used to prevent implant-associated infections. In this study, titania nanotubes (TNTs) were synthesized on Ti surfaces through electrochemical anodization. Octenidine dihydrochloride (OCT)/poly(lactic-co-glycolic acid) (PLGA) was infiltrated into TNTs using a simple solvent-casting technique. OCT/PLGA-TNTs demonstrated sustained drug release and maintained the characteristic hollow structures of TNTs. TNTs (200 nm in diameter) alone exhibited slight antibacterial effect and good osteogenic activity but also evidently impaired adhesion and proliferation of bone marrow mesenchymal stem cells (BMSCs). OCT/PLGA-TNTs (100 nm in diameter) supported BMSC adhesion and proliferation and showed good osteogenesis-inducing ability. OCT/PLGA-TNTs also exhibited good long-term antibacterial ability within the observation period of 7 d. The synthesized drug carrier with relatively long-term antibacterial ability and enhanced excellent biocompatibility demonstrated significant potential in bone implant applications.

Titanium Implant Osseointegration Problems with Alternate Solutions Using Epoxy/Carbon-Fiber-Reinforced Composite

The aim of the article is to present recent developments in material research with bisphenyl-polymer/carbon-fiber-reinforced composite that have produced highly influential results toward improving upon current titanium bone implant clinical osseointegration success. Titanium is now the standard intra-oral tooth root/bone implant material with biocompatible interface relationships that confer potential osseointegration. Titanium produces a TiO₂ oxide surface layer reactively that can provide chemical bonding through various electron interactions as a possible explanation for biocompatibility. Nevertheless, titanium alloy implants produce corrosion particles and fail by mechanisms generally related to surface interaction on bone to promote an inflammation with fibrous aseptic loosening or infection that can require implant removal. Further, lowered oxygen concentrations from poor vasculature at a foreign metal surface interface promote a build-up of host-cell-related electrons as free radicals and proton acid that can encourage infection and inflammation to greatly influence implant failure. To provide improved osseointegration many different coating processes and alternate polymer matrix composite (PMC) solutions have been considered that supply new designing potential to possibly overcome problems with titanium bone implants. Now for important consideration, PMCs have decisive biofunctional fabrication possibilities while maintaining mechanical properties from addition of high-strengthening varied fiber-reinforcement and complex fillers/additives to include hydroxyapatite or antimicrobial incorporation through thermoset polymers that cure at low temperatures. Topics/issues reviewed in this manuscript include titanium corrosion, implant infection, coatings and the new epoxy/carbon-fiber implant results discussing osseointegration with biocompatibility related to nonpolar molecular attractions with secondary bonding, carbon fiber in vivo properties, electrical semiconductors, stress transfer, additives with low thermal PMC processing and new coating possibilities.