The race for the optimal antimicrobial surface: perspectives and challenges related to plasma electrolytic oxidation coating for titanium-based implants

A review of the advances in implant technology: accomplishments and challenges for the design of functionalized surface structures

Biomedical implants are extensively utilized to replace hard-tissue defects owing to their biocompatibility and remarkable tissue-affinity. The materials and functional design are selected based on the resultant osseointegration level and resistance to infection, and these considerations constitute the dominant research topic in this field. However, high rates of implantation failure and peri-implantitis have been reported. Current research on biomedical-implant design encompasses enhancement of the implant surface properties, such as the roughness, nano/micro topography, and hydrophilicity, along with the realization of advanced features including antibacterial properties and cell and immunomodulation regulation. This review considers the two achievements of contemporary implant manufacturing; namely, osseointegration and the realization of antibacterial properties. Present mainstream surface modifications and coatings are discussed, along with functional design technologies and achievements. The impacts of direct surface-treatment techniques and osteogenic functional coatings on osseointegration performance and antibacterial surface structures are elucidated, considering inorganic and organic coatings with antibacterial properties as well as antibiotic-releasing coatings. Furthermore, this review highlights recent advancements in physically driven antimicrobial strategies. Expanding upon existing research, future directions for implant studies are proposed, including the realization of comprehensive functionality that integrates osseointegration and antibacterial properties, as well as patient-specific design. Our study presents a comprehensive review and offers a novel perspective on the design of biomedical implants for enhanced versatility. An in-depth exploration of future research directions will also stimulate subsequent investigations.

Plasma-electrolytic oxidation: A rapid single step post processing approach for additively manufactured biomedical implants

Laser-powder bed fusion (PBF-LB) has enabled production of customised skeletal implants that incorporate porous lattices structures to enable bone ingrowth. However, the inherent surface roughness of PBF-LB, characterised by partially adhered particles and undulating sub-topography, remains a barrier to adoption. As such PBF-LB surfaces require several time-consuming post-processing steps, nevertheless, conventional finishing techniques are often limited by geometrical part complexity, making them unsuitable for porous PBF-LB parts. Herein we explore the possibility to utilise plasma-electrolytic oxidation (PEO) as a rapid, single step surface finishing method not constrained by implant design. Specifically, PEO treatment was performed in a phosphate-based electrolyte on as-printed and polished Ti-6Al-4V PBF-LB samples with complete surface coverage and chemical functionalisation, as observed by optical profilometry, SEM-EDX, XRD and XRF, achieved after only 20 min. To test the lack of geometric constraints brought by PEO, clinically relevant BCC porous lattices were also successfully PEO treated accomplishing a coating that either masked or removed surface adhered particles throughout the structure. Promisingly for medical application, no cytotoxicity was noted for MC3T3-E1 murine osteoblasts over 7 days and significantly more (p < 0.05) mineralisation was observed after 21 days compared with as-printed and polished PBF-LB controls. Still, an enhanced pro-inflammatory response, iNOS and TNF-α, was observed in murine RAW261 macrophages seeded on PEO surfaces, indicating further optimisation is required to guide the inflammatory process. Overall, these findings showcase the widespread opportunity to robustly ensure PBF-LB implant safety by using PEO to tackle partially adhered particles while also offering new avenues to enhance functionality through variations in coating chemistry.

Zinc-Doped Antibacterial Coating as a Single Approach to Unlock Multifunctional and Highly Resistant Titanium Implant Surfaces

Failures of dental and orthopedic implants due to microbial colonization, corrosion, and insufficient osseointegration remain persistent clinical challenges. Current implant surface coatings often lack the mechanical robustness needed for long-term success. Therefore, this study developed zinc (Zn)-doped coatings on titanium implants via plasma electrolytic oxidation (PEO), achieving 11 at % Zn incorporation primarily as zinc oxide (ZnO). The Zn-doped coatings were primarily composed of zinc, calcium, phosphorus, and oxygen, displaying moderate roughness (∼1 μm), hydrophilic behavior, and high crystallinity with anatase and rutile phases. Tribological tests demonstrated over a 50% reduction in mass loss, while electrochemical tests confirmed significantly enhanced corrosion resistance of Zn-doped coating with higher open circuit potential values, larger Nyquist plot semicircles, and higher impedance values at low frequencies compared to controls (p < 0.05). The Zn-doped coatings also showed superior antimicrobial efficacy, reducing Streptococcus sanguinis viability, completely inhibiting Escherichia coli growth, and reducing biofilm biomass by over 60%, which may be related to the sustained Zn release (∼6 μg/cm2) over 7 days. Enhanced bioactivity was evidenced by greater protein adsorption, increased hydroxyapatite formation, and improved preosteoblastic cell metabolism and morphology. Ex vivo analyses confirmed coating mechanical stability, without morphological or chemical impairment, during implant insertion and removal from bovine rib bone, with increased implant stability quotient (ISQ) values, indicating benefits in poor bone quality. These findings highlight the significant promise of Zn-doped plasma electrolytic oxidation coatings for advancing dental and orthopedic implant technology, offering enhanced longevity, antimicrobial defense, and improved bioactivity to optimize clinical outcomes.

Microbiome modulation of implant-related infection by a novel miniaturized pulsed electromagnetic field device

Dental implant-related infections, which lack effective therapeutic strategies, are considered the primary cause for treatment failure. Pulsed electromagnetic field (PEMF) technology has been introduced as a safe and effective modality for enhancing biological responses. However, the PEMF effect on modulating microbial diversity has not been explored. Thus, we tested a miniaturized PEMF biomedical device as a healing component for dental implants. PEMF activation did not alter the chemical composition, surface roughness, wettability, and electrochemical performance. PEMF effectively controlled chronic in vitro polymicrobial microbial accumulation. The in vivo study where devices were inserted in the patients' oral cavities and 16S RNA sequencing analysis evidenced a fivefold or more reduction in 23 bacterial species for PEMF group and the absence of some species for this group, including pathogens associated with implant-related infections. PEMF altered bacterial interactions and promoted specific bacterial pathways. PEMF has emerged as an effective strategy for controlling implant-related infections.

Tailoring magnesium-doped coatings for improving surface and biological properties of titanium-based dental implants

Physicochemical modifications of biomaterials have been proposed to overcome bone integration impairment and microbial infections. The magnesium (Mg) incorporation on dental implant surfaces has shown positive results in bone-to-implant contact and in the reduction of microbial colonization. Here, we explored the potential of using different Mg precursors to synthesize coatings via plasma electrolytic oxidation (PEO) on commercially pure titanium (cpTi), aiming to optimize the surface and biological properties. For this, we investigated Mg acetate and Mg nitrate precursors in different concentrations (0.04 M and 0.12 M), using calcium (Ca) and phosphorus (P) as the base electrolyte for all groups. Coatings with only the CaP base electrolyte were used as the control group. The surfaces were characterized by confocal laser scanning microscopy, scanning electron microscopy, film thickness measurement, profilometry, wettability, X-ray diffraction, energy dispersive spectroscopy, X-ray photoelectron spectroscopy, electrochemical behavior, and ion release. For biological analyses, the adhesion (2 h) of Streptococcus sanguinis was evaluated, as well as MC3T3-E1 osteoblastic cells proliferation at 1 and 3 days, and mineralization of calcium phosphates after 28 days. PEO treatment using different Mg precursors promoted physicochemical modifications of cpTi. The experimental groups MgN 0.04 and MgN 0.12 exhibited higher surface roughness and wettability compared to the other surfaces. Regardless of the Mg precursor, the higher the ion concentration in the electrolyte solution, the higher the Mg atomic concentration on the surfaces. Concerning the electrochemical behavior, the results indicated that the incorporation of Mg in the coatings may enhance the electrochemical performance. Mg treated surfaces did not promote greater bacterial adherence when compared to the control. MgAc 0.04 and MgAc 0.12 coatings displayed improved MC3T3-E1 pre-osteoblastic cells proliferation at day 3 compared to other groups. The hydroxyapatite formation on MgAc 0.12 surfaces was higher than in the other groups. Our data indicate that Mg precursor selection positively influences physicochemical and biological properties of coatings. Specifically, MgAc 0.12 surfaces showed the most promising surface features with greater cell proliferation, without affecting microbial colonization, being an excellent candidate for surface treatment of titanium-based dental implants.

Efficacy of pH-Responsive Surface Functionalized Titanium Screws in Treating Implant-associated S. aureus Osteomyelitis with Biofilms Formation

Implant-associated Staphylococcus aureus (S. aureus) osteomyelitis (IASO) leads to high orthopedic implant failure rates due to the formation of Staphylococcal abscess community within the bone marrow and bacterial colonization in the osteocyte lacuno-canalicular network (OLCN). To address this, antimicrobial peptides (HHC36)-loaded titania nanotubes (NTs) are developed on titanium screws (Ti-NTs-P-A), which integrate pH-responsive polymethacrylic acid to control HHC36 release for eradicating bacteria in IASO. Colony-forming unit assay confirmed that Ti-NTs-P-A screws maintained sustainable antibacterial effectiveness, killing over 65% of S. aureus even after multiple bacterial solution replacements. Notably, Ti-NTs-P-A screws exhibit significant pH-responsive HHC36 release behavior and bactericidal activity, consistent with the phenotype of peptides-killed bacteria from scanning electron microscopy. Transcriptome sequencing results reveal that Ti-NTs-P-A screws interfered with ribosome formation and disrupted the arginine biosynthesis, which is crucial for bacterial survival in acidic environments. In the non-infected implant model, the bone-implant contact ratio of the Ti-NTs-P-A screw is 2.3 times that of the clinically used titanium screw. In an IASO model, Ti-NTs-P-A screws effectively eradicated bacteria within the OLCN, achieving an 80% infection control rate and desirable osteointegration. Collectively, Ti-NTs-P-A screws with pH-responsive antibacterial properties exhibit great potential for eradicating bacteria and achieving osseointegration in IASO.

The Application Progress of Nonthermal Plasma Technology in the Modification of Bone Implant Materials

With the accelerating trend of global aging, bone damage caused by orthopedic diseases, such as osteoporosis and fractures, has become a shared international event. Traffic accidents, high-altitude falls, and other incidents are increasing daily, and the demand for bone implant treatment is also growing. Although extensive research has been conducted in the past decade to develop medical implants for bone regeneration and healing of body tissues, due to their low biocompatibility, weak bone integration ability, and high postoperative infection rates, pure titanium alloys, such as Ti-6A1-4V and Ti-6A1-7Nb, although widely used in clinical practice, have poor induction of phosphate deposition and wear resistance, and Ti-Zr alloy exhibits a lack of mechanical stability and processing complexity. In contrast, the Ti-Ni alloy exhibits toxicity and low thermal conductivity. Nonthermal plasma (NTP) has aroused widespread interest in synthesizing and modifying implanted materials. More and more researchers are using plasma to modify target catalysts such as changing the dispersion of active sites, adjusting electronic properties, enhancing metal carrier interactions, and changing their morphology. NTP provides an alternative option for catalysts in the modification processes of oxidation, reduction, etching, coating, and doping, especially for materials that cannot tolerate thermodynamic or thermosensitive reactions. This review will focus on applying NTP technology in bone implant material modification and analyze the overall performance of three common types of bone implant materials, including metals, ceramics, and polymers. The challenges faced by NTP material modification are also discussed.

Recent Advances and Prospects in β-type Titanium Alloys for Dental Implants Applications

Titanium and its alloys, especially Ti-6Al-4V, are widely studied in implantology for their favorable characteristics. However, challenges remain, such as the high modulus of elasticity and concerns about cytotoxicity. To resolve these issues, research focuses on β-type titanium alloys that incorporate elements such as Mo, Nb, Sn, and Ta to improve corrosion resistance and obtain a lower modulus of elasticity compatible with bone. This review comprehensively examines current β titanium alloys, evaluating their mechanical properties, in particular the modulus of elasticity, and corrosion resistance. To this end, a systematic literature search was carried out, where 81 articles were found to evaluate these outcomes. In addition, this review also covers the formation of the alloy, processing methods such as arc melting, and its physical, mechanical, electrochemical, tribological, and biological characteristics. Because β-Ti alloys have a modulus of elasticity closer to that of human bone compared to other metal alloys, they help reduce stress shielding. This is important because the alloy allows for a more even distribution of forces by having a modulus of elasticity more similar to that of bone. In addition, these alloys show good corrosion resistance due to the formation of a noble titanium oxide layer, facilitated by the incorporation of β stabilizers. These alloys also show significant improvements in mechanical strength and hardness. Finally, they also have lower cytotoxicity and bacterial adhesion, depending on the β stabilizer used. However, there are persistent challenges that require detailed research in critical areas, such as optimizing the composition of the alloy to achieve optimal properties in different clinical applications. In addition, it is crucial to study the long-term effects of implants on the human body and to advance the development of cutting-edge manufacturing techniques to guarantee the quality and biocompatibility of implants.

Copper tannate nanosheets-embedded multifunctional coating for antifouling and photothermal bactericidal applications

Implant-associated infections (IAIs), triggered by pathogenic bacteria, are a leading cause of implant failure. The design of functionalized coatings on biomedical materials is crucial to address IAIs. Herein, a multifunctional coating with good antifouling effect and antibacterial photothermal therapy (aPTT) performance was developed. The copper tannate nanosheets (CuTA NSs) were formed via coordination bonding of Cu2+ ions and tannic acid (TA). The CuTA NSs were then integrated into the TA and poly(ethylene glycol) (PEG) network to form the TCP coating for deposition on the titanium (Ti) substrates via surface adhesion of TA and gravitational effect. The resulting Ti-TCP substrate exhibited good antifouling property, reactive oxygen species (ROS) scavenging capability and cytocompatibility. The TCP coating exhibited antifouling efficacy in conjunction with aPTT, curtailing the surface adhesion and biofilm formation of pathogens, such as Staphylococcus aureus and Escherichia coli. Notably, the Ti-TCP substrate also exhibited the ability to prevent bacterial infection in vivo in a subcutaneous implantation model. The present work demonstrated a promising approach in designing high-performance antifouling and photothermal bactericidal coatings to combat IAIs.

Titanium Implants Coated with Hydroxyapatite Used in Orbital Wall Reconstruction-A Literature Review

With the increasing incidences of orbital wall injuries, effective reconstruction materials and techniques are imperative for optimal clinical outcomes. In this literature review, we delve into the efficacy and potential advantages of using titanium implants coated with nanostructured hydroxyapatite for the reconstruction of the orbital wall. Titanium implants, recognized for their durability and mechanical strength, when combined with the osteoconductive properties of hydroxyapatite, present a potentially synergistic solution. The purpose of this review was to critically analyze the recent literature and present the state of the art in orbital wall reconstruction using titanium implants coated with nanostructured hydroxyapatite. This review offers clinicians detailed insight into the benefits and potential drawbacks of using titanium implants coated with nanostructured hydroxyapatite for orbital wall reconstruction. The highlighted results advocate for its benefits in terms of osseointegration and provide a novel strategy for orbital reconstruction, though further studies are essential to establish long-term efficacy and address concerns.

Surface (bio)-functionalization of metallic materials: How to cope with real interfaces?

Metallic materials are an important class of biomaterials used in various medical devices, owing to a suitable combination of their mechanical properties. The (bio)-functionalization of their surfaces is frequently performed for biocompatibility requirements, as it offers a powerful way to control their interaction with biological systems. This is particularly important when physicochemical processes and biological events, mainly involving proteins and cells, are initiated at the host-material interface. This review addresses the state of "real interfaces" in the context of (bio)-functionalization of metallic materials, and the necessity to cope with it to avoid frequent improper evaluation of the procedure used. This issue is, indeed, well-recognized but often neglected and emerges from three main issues: (i) ubiquity of surface contamination with organic compounds, (ii) reactivity of metallic surfaces in biological medium, and (iii) discrepancy in (bio)-functionalization procedures between expectations and reality. These disturb the assessment of the strategies adopted for surface modifications and limit the possibilities to provide guidelines for their improvements. For this purpose, X-ray photoelectrons spectroscopy (XPS) comes to the rescue. Based on significant progresses made in methodological developments, and through a large amount of data compiled to generate statistically meaningful information, and to insure selectivity, precision and accuracy, the state of "real interfaces" is explored in depth, while looking after the two main constituents: (i) the bio-organic adlayer, in which the discrimination between the compounds of interest (anchoring molecules, coupling agents, proteins, etc) and organic contaminants can be made, and (ii) the metallic surface, which undergoes dynamic processes due to their reactivity. Moreover, through one of the widespread (bio)-functionalization strategy, given as a case study, a particular attention is devoted to describe the state of the interface at different stages (composition, depth distribution of contaminants and (bio)compounds of interest) and the mode of protein retention. It is highlighted, in particular, that the occurrence or improvement of bioactivity does not demonstrate that the chemical schemes worked in reality. These aspects are particularly essential to make progress on the way to choose the suitable (bio)-functionalization strategy and to provide guidelines to improve its efficiency.

Advances in reparative materials for infectious bone defects and their applications in maxillofacial regions

Infectious bone defects are characterized by the partial loss or destruction of bone tissue resulting from bacterial contaminations subsequent to diseases or external injuries. Traditional bone transplantation and clinical methods are insufficient in meeting the treatment demands for such diseases. As a result, researchers have increasingly focused on the development of more sophisticated biomaterials for improved therapeutic outcomes in recent years. This review endeavors to investigate specific reparative materials utilized for the treatment of infectious bone defects, particularly those present in the maxillofacial region, with a focus on biomaterials capable of releasing therapeutic substances, functional contact biomaterials, and novel physical therapy materials. These biomaterials operate via heightened antibacterial or osteogenic properties in order to eliminate bacteria and/or stimulate bone cells regeneration in the defect, ultimately fostering the reconstitution of maxillofacial bone tissue. Based upon some successful applications of new concept materials in bone repair of other parts, we also explore their future prospects and potential uses in maxillofacial bone repair later in this review. We highlight that the exploration of advanced biomaterials holds promise in establishing a solid foundation for the development of more biocompatible, effective, and personalized treatments for reconstructing infectious maxillofacial defects.

A Dual-Antioxidative Coating on Transmucosal Component of Implant to Repair Connective Tissue Barrier for Treatment of Peri-Implantitis

Since the microgap between implant and surrounding connective tissue creates the pass for pathogen invasion, sustained pathological stimuli can accelerate macrophage-mediated inflammation, therefore affecting peri-implant tissue regeneration and aggravate peri-implantitis. As the transmucosal component of implant, the abutment therefore needs to be biofunctionalized to repair the gingival barrier. Here, a mussel-bioinspired implant abutment coating containing tannic acid (TA), cerium and minocycline (TA-Ce-Mino) is reported. TA provides pyrogallol and catechol groups to promote cell adherence. Besides, Ce3+ /Ce4+  conversion exhibits enzyme-mimetic activity to remove reactive oxygen species while generating O2 , therefore promoting anti-inflammatory M2 macrophage polarization to help create a regenerative environment. Minocycline is involved on the TA surface to create local drug storage for responsive antibiosis. Moreover, the underlying therapeutic mechanism is revealed whereby the coating exhibits exogenous antioxidation from the inherent properties of Ce and TA and endogenous antioxidation through mitochondrial homeostasis maintenance and antioxidases promotion. In addition, it stimulates integrin to activate PI3K/Akt and RhoA/ROCK pathways to enhance VEGF-mediated angiogenesis and tissue regeneration. Combining the antibiosis and multidimensional orchestration, TA-Ce-Mino repairs soft tissue barriers and effector cell differentiation, thereby isolating the immune microenvironment from pathogen invasion. Consequently, this study provides critical insight into the design and biological mechanism of abutment surface modification to prevent peri-implantitis.

In Vivo Prevention of Implant-Associated Infections Caused by Antibiotic-Resistant Bacteria through Biofunctionalization of Additively Manufactured Porous Titanium

Additively manufactured (AM) porous titanium implants may have an increased risk of implant-associated infection (IAI) due to their huge internal surfaces. However, the same surface, when biofunctionalized, can be used to prevent IAI. Here, we used a rat implant infection model to evaluate the biocompatibility and infection prevention performance of AM porous titanium against bioluminescent methicillin-resistant Staphylococcus aureus (MRSA). The specimens were biofunctionalized with Ag nanoparticles (NPs) using plasma electrolytic oxidation (PEO). Infection was initiated using either intramedullary injection in vivo or with in vitro inoculation of the implant prior to implantation. Nontreated (NT) implants were compared with PEO-treated implants with Ag NPs (PT-Ag), without Ag NPs (PT) and infection without an implant. After 7 days, the bacterial load and bone morphological changes were evaluated. When infection was initiated through in vivo injection, the presence of the implant did not enhance the infection, indicating that this technique may not assess the prevention but rather the treatment of IAIs. Following in vitro inoculation, the bacterial load on the implant and in the peri-implant bony tissue was reduced by over 90% for the PT-Ag implants compared to the PT and NT implants. All infected groups had enhanced osteomyelitis scores compared to the noninfected controls.

Cold atmospheric plasma mediated cell membrane permeation and gene delivery-empirical interventions and pertinence

Delivery of genetic material to cells is an integral tool to analyze and reveal the genetic interventions in normal cellular processes and differentiation, disease development and for gene therapy. It has profound applications in pharmaceutical, agricultural, environmental and biotechnological sectors. The major methods relied for gene delivery or transfection requires either viral vectors or xenogenic carrier molecules, which renders probabilistic carcinogenic, immunogenic and toxic effects. A newly evolved physical method, Cold atmospheric plasma induced transfection neither needs vector nor carriers. The 4th state of matter 'Plasma' is a quasineutral ionized gas-containing ions, neutral atoms, electrons and reactive radical molecules; and possess electric and magnetic field, along with emanating photons and UV radiations. Plasma produced at atmospheric pressure conditions, and having room temperature is conferred as Low temperature plasma or Cold atmospheric plasma. Selective and controlled application of cold atmospheric plasma on tissues creates temporary, restorable pores on cell membranes that could be diligently manipulated for gene delivery. Research in this regard attained pace since 2016. Cold atmospheric plasma induces transfection by lipid peroxidation, electroporation, and clathrin dependent endocytosis in cell membranes, by virtue of its reactive radicals and electric field. Plasma formed reactive radicals, especially 'OH' penetrates to the cell membrane and cleaves the phosphate head group of membrane lipids, peroxidize and detaches fatty acid tails. This decreases membrane thickness, increases membrane fluidity and permeability. Simultaneously plasma formed ions, electrons and reactive radicals accumulate over cells, generating local electric field and neutralize the negative charge of cell membrane. This induces stress on cell membrane and disrupts its structural integrity, by infringing the dynamic equilibrium between surface tension, spatial repulsion and linear tension between the head groups of phospholipids, generating minute pores. Neutralization of membrane charge promote foreign, external plasmid and gene movement towards cells and its enhanced binding with ligands and receptors on cell membrane, instigating clathrin dependent endocytosis. In vitro and in vivo studies have successfully delivered plasmids, linear DNA, siRNA and miRNA to several established cell lines like, HeLa, PC12, CHL, HUVEC, Jurkat, MCF, SH-SY5Y, HT, B16F10, HaCaT, LP-1, etc., and live C57BL/6 and BALB/c mice, using cold atmospheric plasma. This review delineates the cell surface mechanism of plasma-induced transfection, critically summarizes the research progress in this context, plasma devices used, and the inimitable features of this method. Metabolic activity, cell function, and viability are not adversely affected by this process; moreover, the cell permeating plasma-formed reactive radicals are effectively defended by cellular antioxidant mechanisms like superoxide dismutase, glutathione reductase and cytokines, alleviating its toxicity. A deeper understanding on mechanism of plasma action on cells, its aftermath, and the research status in this field would provide a better insight on future avenues of research.

Advanced surface engineering of titanium materials for biomedical applications: From static modification to dynamic responsive regulation

Titanium (Ti) and its alloys have been widely used as orthopedic implants, because of their favorable mechanical properties, corrosion resistance and biocompatibility. Despite their significant success in various clinical applications, the probability of failure, degradation and revision is undesirably high, especially for the patients with low bone density, insufficient quantity of bone or osteoporosis, which renders the studies on surface modification of Ti still active to further improve clinical results. It is discerned that surface physicochemical properties directly influence and even control the dynamic interaction that subsequently determines the success or rejection of orthopedic implants. Therefore, it is crucial to endow bulk materials with specific surface properties of high bioactivity that can be performed by surface modification to realize the osseointegration. This article first reviews surface characteristics of Ti materials and various conventional surface modification techniques involving mechanical, physical and chemical treatments based on the formation mechanism of the modified coatings. Such conventional methods are able to improve bioactivity of Ti implants, but the surfaces with static state cannot respond to the dynamic biological cascades from the living cells and tissues. Hence, beyond traditional static design, dynamic responsive avenues are then emerging. The dynamic stimuli sources for surface functionalization can originate from environmental triggers or physiological triggers. In short, this review surveys recent developments in the surface engineering of Ti materials, with a specific emphasis on advances in static to dynamic functionality, which provides perspectives for improving bioactivity and biocompatibility of Ti implants.

Surface Modification and Functionalities for Titanium Dental Implants

Dental implants have become the mainstream strategy for oral restoration, and implant materials are the most important research hot spot in this field. So far, Ti implants dominate all kinds of implants. The surface properties of the Ti implant play decisive roles in osseointegration and antibacterial performance. Surface modifications can significantly change the surface micro/nanotopography and composition of Ti implants, which will effectively improve their hydrophilicity, mechanical properties, osseointegration performance, antibacterial performance, etc. These optimizations will thus improve implant success and service life. In this paper, the latest surface modification techniques of Ti dental implants are systematically and comprehensively reviewed. The various biomedical functionalities of surface modifications are discussed in-depth. Finally, a profound comment on the challenges and opportunities of this frontier is proposed, and the most promising directions for the future were explored.

Unraveling the effectiveness of antibiotics for peri-implantitis treatment: A scoping review

BACKGROUND

Antibiotics are the most effective adjuncts in the treatment of periodontitis. However, the benefits of these agents in treating peri-implantitis are still debatable and demand further analysis.

PURPOSE

The aim of this review was to critically appraise the literature on the use of antibiotics to treat peri-implantitis, with the ultimate goal of supporting evidence-based clinical recommendations, defining gaps in knowledge and guiding future studies on this topic.

METHODS

A systematized literature search was conducted in MEDLINE/PubMed and Cochrane Library databases for randomized clinical trials (RCTs) on patients with peri-implantitis treated by mechanical debridement-only or with adjunctive use of local or systemic antibiotics. Clinical and microbiological data were extracted from the RCTs included. The findings were critically reviewed, interpreted, and discussed. An overview of antibiotic-loaded dental implant materials in peri-implantitis treatment was also provided.

RESULTS

Twelve RCTs testing local/systemic antibiotics were included. Although not always statistically significant, all antibiotic-treated groups had greater reductions in mean PD than those treated by mechanical debridement-only. The only clinically relevant antibiotic protocol supported by one RCT with low risk of bias and long-lasting benefits was systemic metronidazole (MTZ). Studies using ultrasonic debridement reported better outcomes. No RCTs to date have tested MTZ-only or with amoxicillin (AMX) as adjuncts to open-flap implant debridement. In vitro/animal studies suggested that biomaterials with antimicrobial properties are promising to treat peri-implantitis.

CONCLUSION

There are insufficient data to support a particular evidence-based antibiotic protocol to treat peri-implantitis using surgical or nonsurgical therapy, but some conclusions may be drawn. Systemic MTZ adjunct to ultrasonic debridement is an effective protocol to improve the outcomes of nonsurgical treatment. Future studies should assess the clinical and microbiological effects of MTZ and MTZ + AMX as adjuncts to optimal nonsurgical implant decontamination protocols or open-flap debridement. In addition, new locally delivered drugs and antibiotic-loaded surfaces should be assessed by RCTs.

Biomaterial engineering surface to control polymicrobial dental implant-related infections: focusing on disease modulating factors and coatings development

INTRODUCTION

Peri-implantitis is the leading cause of dental implant loss and is initiated by a polymicrobial dysbiotic biofilm formation on the implant surface. The destruction of peri-implant tissue by the host immune response and the low effectiveness of surgical or non-surgical treatments highlight the need for new strategies to prevent, modulate and/or eliminate biofilm formation on the implant surface. Currently, several surface modifications have been proposed using biomolecules, ions, antimicrobial agents, and topography alterations.

AREAS COVERED

Initially, this review provides an overview of the etiopathogenesis and host- and material-dependent modulating factors of peri-implant disease. In addition, a critical discussion about the antimicrobial surface modification mechanisms and techniques employed to modify the titanium implant material is provided. Finally, we also considered the future perspectives on the development of antimicrobial surfaces to narrow the bridge between idea and product and favor the clinical application possibility.

EXPERT OPINION

Antimicrobial surface modifications have demonstrated effective results; however, there is no consensus about the best modification strategy and in-depth information on the safety and longevity of the antimicrobial effect. Modified surfaces display recurring challenges such as short-term effectiveness, the burst release of drugs, cytotoxicity, and lack of reusability. Stimulus-responsive surfaces seem to be a promising strategy for a controlled and precise antimicrobial effect, and future research should focus on this technology and study it from models that better mimic clinical conditions.