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Titanium release in peri-implantitis
Umeå University, Faculty of Medicine, Department of Odontology.ORCID iD: 0000-0001-5992-8135
Department of Chemistry - BMC, Analytical Chemistry, Uppsala, University. (Pettersson/Andersson group)ORCID iD: 0000-0003-4764-1246
Umeå University, Faculty of Medicine, Department of Odontology.ORCID iD: 0000-0002-8069-8263
Umeå University, Faculty of Medicine, Department of Odontology.ORCID iD: 0000-0002-4915-6845
2019 (English)In: Journal of Oral Rehabilitation, ISSN 0305-182X, E-ISSN 1365-2842, Vol. 46, no 2, p. 179-188Article in journal (Refereed) Published
Abstract [en]

Objectives: The aim of this study was to investigate the titanium (Ti) content of biopsies from patients with severe peri-implantitis or periodontitis and to examine whether Ti particles can be identified in samples from peri-implantitis lesions.

Background: Long-term follow-up studies show that implant usage to replace missing or lost teeth is a safe and predictable treatment. However, inflammation and loss of supporting bone around an implant (peri-implantitis) lead to patient suffering and costs. Peri-implantitis is considered to be an infectious disease, but recent studies have shown that Ti can aggravate inflammation in combination with bacterial products. The Ti content of peri-implantitis and periodontitis tissue is unknown.

Methods: Thirteen patients referred for peri-implantitis and eleven for periodontitis treatment were included in the study. Disease severity was obtained from dental records. Biopsies were taken from both groups and chemically analyzed with inductively coupled plasma mass spectrometry (ICP-MS) for Ti content. Additionally, two patients with peri-implantitis and two with periodontitis were recruited and their biopsies were analyzed microscopically with light microscopy (LM), transmission electron microscopy (TEM), and scanning electron microscopy (SEM) with element analysis to investigate the presence of particulate Ti.

Results: All patients lost one or more implants despite undergoing peri-implant or periodontal treatment. Peri-implantitis tissue contained significantly higher concentrations of Ti than periodontitis tissue with a mean ± SDof 98.7 ± 85.6 μg/g and 1.2 ± 0.9 μg/g, respectively. Particulate metal was identified in peri-implantitis and periodontitis biopsies, but element analyses could confirm only the presence of Ti in peri-implantitis tissue. The mean size ± SDof the visible particles with LM was 10.9 ± 35.7 μm2 (mean of three repeated measurements) (95% CI, 6.5-15.3).

Conclusion: We showed that high contents of particulate and submicron Ti were present in peri-implantitis tissue. These high Ti contents in peri-implant mucosa can potentially aggravate inflammation, which might reduce the prognosis of treatment interventions.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019. Vol. 46, no 2, p. 179-188
Keywords [en]
energy dispersive X-ray spectroscopy, inductively coupled plasma mass spectrometry, light microscopy, peri-implantitis, scanning electron microscopy, titanium
National Category
Dentistry
Research subject
Odontology
Identifiers
URN: urn:nbn:se:umu:diva-147118DOI: 10.1111/joor.12735ISI: 000455483300010PubMedID: 30325523OAI: oai:DiVA.org:umu-147118DiVA, id: diva2:1202376
Funder
Västerbotten County Council, VLL 1147-2014
Note

Originally included in thesis in manuscript form.

Available from: 2018-04-27 Created: 2018-04-27 Last updated: 2019-02-08Bibliographically approved
In thesis
1. On titanium release from dental implants and the inflammatory response
Open this publication in new window or tab >>On titanium release from dental implants and the inflammatory response
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In dentistry, dental implants have become a standard treatment for single tooth loss and partial and total edentulism since their introduction by P-I Brånemark in the 1960s. Long-term follow-up studies have shown that dental implantation is a predictable treatment, with an overall implant survival over ninety-five percent. Mucositis and peri-implantitis are types of inflammation in the peri-implant soft tissue, and the latter occurs with the simultaneous loss of supporting bone. The pathogenesis of mucositis and peri-implantitis is considered a microbial infection in the peri-implant tissue that causes bone loss induced by inflammation. Immune and resident cells are activated by bacterial products and toxins, which induce the release of a cascade of proinflammatory cytokines and chemokines that can activate osteoclasts and cause further bone resorption. Noninfection-induced inflammatory reactions caused by wear particles from an orthopedic implant leading to loss of the prosthesis is a well-known condition in orthopedics. This immune response induced by metal particles has been shown to act by the assembly of a protein complex, i.e., an inflammasome, in macrophages, leading to the release of proinflammatory cytokines, e.g., interleukin 1 beta (IL-1β). Whether metal particles from a dental implant are associated in the pathogenesis of peri-implantitis has not yet been investigated thoroughly. Although titanium dioxide (TiO2) nanoparticles are known to induce a proinflammatory response, the relation between titanium (Ti) and peri-implantitis is not known.

The overall aim of this thesis was to gain knowledge of the proinflammatory capacity of Ti and its potential association with the pathogenesis of peri-implantitis. The null hypothesis in this thesis is that Ti has no proinflammatory effect.

To investigate the proinflammatory capacity of Ti, we exposed macrophages derived from a human cell line and monocytes isolated from human blood to Ti. We identified the activation and release of the proinflammatory cytokine IL-1β after the exposure of human macrophages to Ti ions, indicating activation of the inflammasome complex. A five-fold increase in the release of IL-β was found when cells were primed with bacterial products, e.g., Escherichia coli lipopolysaccharide (E. coli LPS) prior to exposure to Ti in culture medium. The proinflammatory effect of Ti was shown to be mediated by metal-protein aggregates formed in the medium and phagocytosed by macrophages. 

The exposure of macrophages to E. coli LPS mediates the production of intracellular pro-IL-1β, and a second stimulus is needed to cleave the proform of the cytokine, resulting in active IL-1β. Caspase-1, an intracellular protein, is activated through the assembly of the inflammasome complex and is needed for the activation of pro-IL-1β into its active form. Our findings indicate that the Ti-induced activation and release of IL-1β is mediated through the inflammasome complex, as the effect was reduced in the presence of a caspase-1 inhibitor. Peri-implantitis and periodontitis soft tissue samples were investigated chemically and microscopically, and a high content of Ti could be identified in the peri-implantitis tissue samples. The Ti particles identified in the peri-implantitis soft tissue might aggravate the inflammatory response and jeopardize the peri-implant treatment outcome. Transmission electron microscopy (TEM) was used to visualize the formed Ti-protein aggregates, and we discovered that the morphology of the aggregates differed in the presence of cobalt (Co). By microscopy, we could show the uptake of Ti-protein aggregates into macrophage phagolysosomes and that the location of these aggregates differed when Co was present. The origin of the Ti particles found in peri-implantitis soft tissue is unknown, but we could show that Ti is abraded from the implant during insertion into the bone. This abrasion of Ti from the implant surface into the bone is more prominent from an implant with a rough surface than with a smooth surface. 

We can conclude that Ti can act as a secondary stimulus to macrophages and activate the release of active IL-1β via inflammasome complex assembly. Additionally, Ti forms metal-protein aggregates with a proinflammatory effect that can be inhibited by the presence of Co. Peri-implantitis soft tissue samples contained high concentrations of Ti and metal fragments. Lastly, Ti particles are abraded from the implant during insertion into the bone in amounts that could be proinflammatory. The proinflammatory effect induced by Ti can act in synergy with infection-induced inflammation and cause an imbalance in the host response, leading to the progression of peri-implantitis. The null hypothesis could be rejected.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2018. p. 82
Series
Umeå University odontological dissertations, ISSN 0345-7532 ; 139
Keywords
titanium, inflammation, dental implants, peri-implantitis
National Category
Dentistry
Research subject
Odontology
Identifiers
urn:nbn:se:umu:diva-147119 (URN)978-91-7601-859-0 (ISBN)
Public defence
2018-06-01, Sal B, 9 tr., byggnad 1D, målpunkt T, Institutionen för odontologi, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Funder
Västerbotten County Council, VLL 1147-2014
Available from: 2018-05-04 Created: 2018-04-27 Last updated: 2018-06-09Bibliographically approved

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Pettersson, MattiasPettersson, JeanJohansson, AndersMolin Thorén, Margareta

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