Subgingival microbiota and immune response modulation of osseointegrable implants

SILVA, Nicole Serqueira da; ALMEIDA, Ana Carolina Rosa de; NASCIMENTO, Marvin do; SOUZA, Bruno Martins de; LOURENÇO, Talita Gomes Baeta; POSCH, Aline Tany

doi:10.1590/1981-86372023004820220070

Nicole Serqueira da SILVA

data interpretation

manuscript preparation

Universidade Federal do Rio de Janeiro, Faculdade de Odontologia, Departamento de Prótese e Materiais Dentário. Rio de Janeiro, RJ, Brasil.

http://orcid.org/0000-0001-6882-2922

Ana Carolina Rosa de ALMEIDA

data interpretation

manuscript preparation

Universidade Federal do Rio de Janeiro, Faculdade de Odontologia, Departamento de Prótese e Materiais Dentário. Rio de Janeiro, RJ, Brasil.

http://orcid.org/0000-0001-7894-5635

Marvin do NASCIMENTO Correspondence to: M Nascimento. E-mail: mvnascimento@ime.eb.br.

guidance

supervision

critical review

final approval

Instituto Militar de Engenharia, Programa de Pós-Graduação em Ciência dos Materiais. Praça Gen, Tibúrcio, 80, Urca, 22290-270, Rio de Janeiro, RJ, Brasil.

http://orcid.org/0000-0001-8010-7382

Bruno Martins de SOUZA

guidance

supervision

critical review

final approval

Instituto Militar de Engenharia, Programa de Pós-Graduação em Ciência dos Materiais. Praça Gen, Tibúrcio, 80, Urca, 22290-270, Rio de Janeiro, RJ, Brasil.

http://orcid.org/0000-0002-1075-0441

Talita Gomes Baeta LOURENÇO

guidance

supervision

critical review

final approval

Universidade Federal do Rio de Janeiro, Instituto de Microbiologia Paulo de Góes, Departamento de Microbiologia Médica. Rio de Janeiro, RJ, Brasil.

http://orcid.org/0000-0003-0966-3620

Aline Tany POSCH

guidance

supervision

critical review

final approval

Universidade Federal do Rio de Janeiro, Faculdade de Odontologia, Departamento de Prótese e Materiais Dentário. Rio de Janeiro, RJ, Brasil.

http://orcid.org/0000-0002-4501-4161

Correspondence to: M Nascimento. E-mail: mvnascimento@ime.eb.br.

Assistant editor: Fabiana Mantovani Gomes França

	Features	Reference
Bone Tissue Interaction with Ti Implant	After dental implants are anchored, a sequence of immune-inflammatory responses, followed by angiogenesis and osteogenesis, occur to achieve osseointegration. These events play a key role in the initial homeostasis as they release cytokines and growth factors that stimulate deposition of the collagenous matrix around the titanium oxide layer, leading to newly formed bone tissue (usually occurs 5 days later). Osteoclasts drive the process of bone resorption and remodeling and replacement by lamellar bone with a higher degree of mineralization. Titanium induces bioactivity favoring bone remodeling over resorption. The osteoblasts attach themselves to the mineralized collagenous matrix, forming a sealing zone, depositing bone directly on the implant surface (micro scale). In 8 to 12 weeks, the lamellar bone begins biological stability, meaning osseointegration.	Lee & Bance [¹²12 Lee JWY, Bance ML. Physiology of Osseointegration. Otolaryngol Clin North Am. 2019;52(2):231-242. http://dx.doi.org/10.1016/j.otc.2018.11.004. https://doi.org/10.1016/j.otc.2018.11.00... ] Insua et al. [¹³13 Insua A, Monje A, Wang HL, Miron RJ. Basis of bone metabolism around dental implants during osseointegration and peri-implant bone loss. J Biomed Mater Res A. 2017;105(7):2075-2089. http://dx.doi.org/10.1002/jbm.a.36060 https://doi.org/10.1002/jbm.a.36060... ] Terheyden et al. [¹⁴14 Terheyden H, Lang NP, Bierbaum S, Stadlinger B. Osseointegration: communication of cells. Clin Oral Implants Res. 2011;23(10):1127-1135. http://dx.doi.org/10.1111/j.1600-0501.2011.02327.x https://doi.org/10.1111/j.1600-0501.2011... ]
Surface Topography	The topography of the dental implant can be classified into macro-, micro- and nanoscale. It is crucial for adhesion and differentiation of osteoblasts during the initial phase of osseointegration, as well as in long-term bone remodeling. It can be modified at various levels, from the macroscopic design or shape of the implant to the introduction of microscopic, or nanoscopic topographies superimposed on each other, in order to alter growth, metabolism and migration, as well as cytokine and osteogenic cell growth factor production.	Smeets et al. [²2 Smeets R, Stadlinger B, Schwarz F, Beck-Broichsitter B, Jung O, et al. Impact of dental implant surface modifications on osseointegration. Biomed Res Int. 2016;2016:6285620. https://doi.org//10.1155/2016/6285619 https://doi.org/10.1155/2016/6285619... ]
Roughness	Surface roughness is a parameter that affects the osteoconduction rate, mainly influencing the establishment of primary stability. Rougher surfaces are directly proportional with a higher microbial colonization while smoother surfaces tend to aggregate a lower colonization. In addition, immune system cells such as neutrophils, monocytes, dendritic cells, and macrophages are affected and modulate their response depending on the surface roughness.	Elias et al. [¹⁵15 Elias CN, Oshida Y, Lima JH, Muller CA. Relationship between surface properties (roughness, wettability and morphology) of titanium and dental implant removal torque. J Mech Behav Biomed Mater. 2008;1(3):234-42. http://dx.doi.org/10.1016/j.jmbbm.2007.12.002. Epub 2007 Dec 31. https://doi.org/10.1016/j.jmbbm.2007.12.... ] Rohr et al. [¹⁶16 Rohr N, Bergemann C, Nebe JB, Fischer J. Crystal structure of zirconia affects osteoblast behavior. Dent Mater. 2020;36(7):905-913. http://dx.doi.org/10.1016/j.dental.2020.04.017 https://doi.org/10.1016/j.dental.2020.04... ] Leite et al. [¹⁷17 Leite GB, Fonseca YR, Gomes AV, Elias CN. Relação entre os parâmetros de rugosidade 3D e a molhabilidade do titânio com grãos micrométricos e sub-micrométricos. Matéria (Rio J.). 2020;25(2):e-12655. http://dx.doi.org/10.1590/s1517-707620200002.1055 https://doi.org/10.1590/s1517-7076202000... ] Brito et al. [¹⁸18 Brito TO, Nascimento M, Rocha AML, Nattrodt AKR, Marques AA, Netto MCB, Lima MPS, Souza BMS, Morales LMM, Elias CN. A influência da rugosidade nos mecanismos da osseointegração de implantes: uma revisão de literatura. In: CB Fadel, organizadora. Odontologia: Pesquisa e Práticas Contemporâneas. Brasil: Editora Científica; 2021. v.2, p.44-58 http://dx.doi.org/10.37885/211106833 https://doi.org/10.37885/211106833... ]
Wettability	Wettability is expressed by the water contact angle that ranges from 0° to 90° on hydrophilic surfaces to greater than 90° on hydrophobic surfaces. Perhaps the most influential surface property in modulating the activation of anti-inflammatory macrophages is surface energy (usually calculated, indirectly, by means of wettability). Increasing surface energy greatly elevates the anti-inflammatory macrophage polarization in various applications. Hydrophilic surfaces significantly decrease pro-inflammatory leukocyte activation compared to hydrophobic, cationic, or anionic surfaces.	Zhou et al. [⁴4 Zhou P, Long S, Mao F, Huang H, Li H, et al. Controlling cell viability and bacterial attachment through fabricating extracellular matrix-like micro/nanostructured surface on titanium implant. Biomed Mater. 2020;15(3):035002. http://dx.doi.org/10.1088/1748-605X/ab70ee https://doi.org/10.1088/1748-605X/ab70ee... ]
Primary Stability	Primary implant stability is an indirect indication of osseointegration and can be assessed, clinically, by: clinical mobility testing, radiological imaging, resonance frequency analysis. With implant insertion, a dental implant gains primary stability. The implant is passively stabilized in the surgical wound by mechanical friction with the primary bone contacts. The denser the host bone, the more primary bone contacts are available and the greater the primary stability. Primary stability implies that the friction holding the implant in place is greater than the higher dynamic loading forces applied.	Khan et al. [⁵5 Khan SN, Ramachandran M, Senthil SK, Krishnan V, Sundaram R. Osseointegration and more: a review of literature. Indian J Dentistry. 2012;3(2):72-76. http://dx.doi.org/10.1016/j.ijd.2012.03.011 https://doi.org/10.1016/j.ijd.2012.03.01... ]
Microbiota-Inmune System-Host Interaction	The microorganisms indigenous to the oral microbiome live in a symbiotic state with the host, adhering to any biotic or abiotic surfaces present in this ecosystem. Microbial accumulation and biofilm formation on implanted materials can trigger various biological and chemical processes, such as polymicrobial infections and biomaterial deterioration. The Ti particles released by microbial corrosion, increase the release of pro-inflammatory cytokines, infiltration of immune-inflammatory cells and activation of osteoclastic activity, generating unfavorable results. Therefore, the presence of Ti products around dental implants may contribute to peri-implant bone resorption, microbial dysbiosis, and consequently increase the risk of developing peri-implantitis of osseointegration failure. The different conditions that the subgingival microbiota may find itself in, whether in symbiosis or dysbiosis, together with the surface characteristics of Ti implants, will influence the polarization of different immune cell profiles, generating immune cascades with different cellular responses, ultimately causing a positive or negative modulation of the osseointegration process.	Costa et al. [³3 Costa RC, Abdo VL, Mendes PHC, Mota-Veloso I, Bertolini M, et al. Correction to: microbial corrosion in titanium based dental implants: how tiny bacteria can create a big problem? J Bio Tribo Corros. 2021;7:136. https://doi.org/10.1007/s40735-021-00575-8 https://doi.org/10.1007/s40735-021-00575... ] Albrektsson et al. [⁹9 Albrektsson T, Jemt T, Mölne J, Tengvall P, Wennerberg A. On inflammation-immunological balance theory-A critical apprehension of disease concepts around implants: Mucositis and marginal bone loss may represent normal conditions and not necessarily a state of disease. Clin Implant Dent Relat Res. 2019;21(1):183-189. http://dx.doi.org/10.1111/cid.12711. Epub 2018 Dec 28. https://doi.org/10.1111/cid.12711... ] Belibasakis & Manoil [¹⁹19 Belibasakis GN, Manoil D. Microbial community-driven etiopathogenesis of peri-implantitis. J Dent Res. 2021;100(1):21-28. http://dx.doi.org/10.1177/0022034520949851. Epub 2020 Aug 12. https://doi.org/10.1177/0022034520949851... ] Albrektsson et al. [²⁰20 Albrektsson T, Dahlin C, Reinedahl D, Tengvall P, Trindade R, Wennerberg A. An imbalance of the immune system instead of a disease behind marginal bone loss around oral implants: position paper. Int J Oral Maxillofac Implants. 2020;35(3):495-502. http://dx.doi.org/10.11607/jomi.8218 https://doi.org/10.11607/jomi.8218... ]
Peri-implantitis	It is a polymicrobial infection around dental implants in prosthetic function, causing inflammation of the peri-implant tissue (release of inflammatory mediators of periodontal disease), which may lead to progressive damage to the supporting bone tissue and occasionally to implant loss. In other words, biofilm formation on the surfaces of dental implants is one of the main causes of the etiopathogenesis of peri-implantitis, and the main reason for implant failure. The resulting changes in the implant microenvironment cause dysbiotic changes that exacerbate inflammatory progression, and it has been shown that the peri-implant microbiota gradually gains complexity as the infection progresses.	Charalampakis & Belibasakis [¹1 Charalampakis G, Belibasakis GN. Microbiome of peri-implant infections: lessons from conventional, molecular and metagenomic analyses. Virulence. 2015;6(3):183-187. http://dx.doi.org/10.4161/21505594.2014.980661. https://doi.org/10.4161/21505594.2014.98... ] Faveri et al. [⁷7 Faveri M, Figueiredo LC, Shibli JA, Pérez-Chaparro PJ, Feres M. Microbiological diversity of peri-implantitis biofilms. Adv Exp Med Biol. 2015;830:85-96. http://dx.doi.org/10.1007/978-3-319-11038-7_5 https://doi.org/10.1007/978-3-319-11038-... ] Zheng et al. [⁸8 Zheng H, Xu L, Wang Z, Li L, Zhang J, et al. Subgingival microbiome in patients with healthy and ailing dental implants. Sci Rep. 2015;5:10948. http://dx.doi.org/10.1038/srep10948 https://doi.org/10.1038/srep10948... ] Pérez-Chaparro et al. [²¹21 Pérez-Chaparro PJ, Duarte PM, Shibli JA, Montenegro S, Lacerda SH, et al. The current weight of evidence of the microbiologic profile associated with peri-implantitis: a systematic review. J Periodontol. 2016;87(11):1295-1304. http://dx.doi.org/10.1902/jop.2016.160184 https://doi.org/10.1902/jop.2016.160184... ]
Peri-implantitis	It is a polymicrobial infection around dental implants in prosthetic function, causing inflammation of the peri-implant tissue (release of inflammatory mediators of periodontal disease), which may lead to progressive damage to the supporting bone tissue and occasionally to implant loss. In other words, biofilm formation on the surfaces of dental implants is one of the main causes of the etiopathogenesis of peri-implantitis, and the main reason for implant failure. The resulting changes in the implant microenvironment cause dysbiotic changes that exacerbate inflammatory progression, and it has been shown that the peri-implant microbiota gradually gains complexity as the infection progresses.	Charalampakis & Belibasakis [¹1 Charalampakis G, Belibasakis GN. Microbiome of peri-implant infections: lessons from conventional, molecular and metagenomic analyses. Virulence. 2015;6(3):183-187. http://dx.doi.org/10.4161/21505594.2014.980661. https://doi.org/10.4161/21505594.2014.98... ] Faveri et al. [⁷7 Faveri M, Figueiredo LC, Shibli JA, Pérez-Chaparro PJ, Feres M. Microbiological diversity of peri-implantitis biofilms. Adv Exp Med Biol. 2015;830:85-96. http://dx.doi.org/10.1007/978-3-319-11038-7_5 https://doi.org/10.1007/978-3-319-11038-... ] Zheng et al. [⁸8 Zheng H, Xu L, Wang Z, Li L, Zhang J, et al. Subgingival microbiome in patients with healthy and ailing dental implants. Sci Rep. 2015;5:10948. http://dx.doi.org/10.1038/srep10948 https://doi.org/10.1038/srep10948... ] Pérez-Chaparro et al. [²¹21 Pérez-Chaparro PJ, Duarte PM, Shibli JA, Montenegro S, Lacerda SH, et al. The current weight of evidence of the microbiologic profile associated with peri-implantitis: a systematic review. J Periodontol. 2016;87(11):1295-1304. http://dx.doi.org/10.1902/jop.2016.160184 https://doi.org/10.1902/jop.2016.160184... ]
Innate Immune Response	It is the first response to harmful stimuli. It counts on the action of neutrophils, monocytes, and macrophages. Neutrophils and macrophages have phagocytic and signaling functions, especially at the beginning of the inflammatory phase of biomaterial implantation. Ultimately, these cell types determine the outcome of implants as inflammation, foreign body response, fibrointegration or osseointegration. Neutrophils exhibit distinct phenotypes along a pro-anti-inflammatory spectrum, although these phenotypes are not as well characterized as those of macrophages. M1 macrophages are considered harmful to tissue repair. In contrast, M2 macrophages have pro-regenerative capabilities.	Zhang et al. [¹⁰10 Zhang B, Su Y, Zhou J, Zheng Y, Zhu D. Toward a Better Regeneration through Implant-Mediated Immunomodulation: Harnessing the Immune Responses. Adv Sci (Weinh). 2021;8(16):e2100446. http://dx.doi.org/10.1002/advs.202100446 https://doi.org/10.1002/advs.202100446... ]
Adaptive Immune Response	When innate immune cells fail to defeat the threat of invasion, mobilization of adaptive immunity occurs from B and T cells, which can specifically eliminate the threat encountered. There are several subsets of T cells with distinct functionalities triggered by different chemokines and cytokines. Dendritic cells play roles similar to macrophages, promoting early inflammation and resolving late inflammation. B cells have as their main role during the immune response to present antigens and produce antibodies.	Abaricia et al. [¹¹11 Abaricia JO, Farzad N, Heath TJ, Simmons J, Morandini L, Olivares-Navarrete R. Control of innate immune response by biomaterial surface topography, energy, and stiffness. Acta Biomater. 2021;133:58-73. http://dx.doi.org/10.1016/j.actbio.2021.04.021 https://doi.org/10.1016/j.actbio.2021.04... ]
Innate Immune Response	It is the first response to harmful stimuli. It counts on the action of neutrophils, monocytes, and macrophages. Neutrophils and macrophages have phagocytic and signaling functions, especially at the beginning of the inflammatory phase of biomaterial implantation. Ultimately, these cell types determine the outcome of implants as inflammation, foreign body response, fibrointegration or osseointegration. Neutrophils exhibit distinct phenotypes along a pro-anti-inflammatory spectrum, although these phenotypes are not as well characterized as those of macrophages. M1 macrophages are considered harmful to tissue repair. In contrast, M2 macrophages have pro-regenerative capabilities.	Zhang et al. [¹⁰10 Zhang B, Su Y, Zhou J, Zheng Y, Zhu D. Toward a Better Regeneration through Implant-Mediated Immunomodulation: Harnessing the Immune Responses. Adv Sci (Weinh). 2021;8(16):e2100446. http://dx.doi.org/10.1002/advs.202100446 https://doi.org/10.1002/advs.202100446... ]
Adaptive Immune Response	When innate immune cells fail to defeat the threat of invasion, mobilization of adaptive immunity occurs from B and T cells, which can specifically eliminate the threat encountered. There are several subsets of T cells with distinct functionalities triggered by different chemokines and cytokines. Dendritic cells play roles similar to macrophages, promoting early inflammation and resolving late inflammation. B cells have as their main role during the immune response to present antigens and produce antibodies.	Abaricia et al. [¹¹11 Abaricia JO, Farzad N, Heath TJ, Simmons J, Morandini L, Olivares-Navarrete R. Control of innate immune response by biomaterial surface topography, energy, and stiffness. Acta Biomater. 2021;133:58-73. http://dx.doi.org/10.1016/j.actbio.2021.04.021 https://doi.org/10.1016/j.actbio.2021.04... ]

Immune Cells	Features
Neutrophils	Innate immune cells that have the function of secreting bactericidal content and proteases that exhibit the ability to destroy pathogens or produce neutrophil extracellular traps (NETs) with bacterial phagocytic ability. In addition, the surface properties of biomaterials can modulate neutrophil activation.
Macrophages	Cells that are related to the process of tissue regeneration and repair. Pro-inflammatory macrophages (M1) secrete reactive chemicals, phagocytize apoptotic neutrophils, necrotic tissue fragments, and pathogens. Anti-inflammatory macrophages (M2) help in tissue homeostasis, being involved in matrix remodeling and collagen and connective tissue formation. Regarding biomaterials, macrophage activation and phenotype can be altered by their physicochemical characteristics, such as surface topography, wettability and hardness.
Dendritic Cells	Phagocytic mononuclear cells that act as guardians of the inflammatory response, performing more tolerogenic functions during homeostasis, promoting early inflammation and resolving late inflammation. They may also be related to osteoclastogenesis and bone renewal. In addition, dendritic cells can detect biomaterials through toll-like receptors.
Monocytes	They participate in inflammation and the subsequent tissue repair process by providing matrix shaping, angiogenesis, and prevention of fibrosis, through the secretion of cytokines such as TGF-B and IL-10.
Mast cells	Granulocytic cells play an important role in allergic reactions, wound repair through cell recruitment, angiogenesis, and extracellular matrix deposition, as well as in fibrosis and foreign body response to implanted biomaterials.
Lymphocytes	These cells are related to the body’s adaptive immune responses. Pro- or anti-inflammatory effects, usually associated with other innate or adaptive immune cells in response to physical or chemical properties in biomaterials, such as increases in pro-inflammatory cytokines IL-1?, IL-17 and TNF-? or release of anti-inflammatory cytokines, may in part be the result of activation of lymphoid cells.

[1] Correspondence to: M Nascimento. E-mail: mvnascimento@ime.eb.br.

Brasil

Brasil

Subgingival microbiota and immune response modulation of osseointegrable implants

Modulação da microbiota subgengival e resposta imune dos implantes osseointegráveis

ABSTRACT