Small blood stem cells for enhancing early osseointegration formation on dental implants: a human phase I safety study

Sheng-Wei Feng, Yi-Han Su, Yen-Kuang Lin, Yu-Chih Wu, Yen-Hua Huang, Fu-Hung Yang, Hsi-Jen Chiang, Yun Yen, Peter Da-Yen Wang, Sheng-Wei Feng, Yi-Han Su, Yen-Kuang Lin, Yu-Chih Wu, Yen-Hua Huang, Fu-Hung Yang, Hsi-Jen Chiang, Yun Yen, Peter Da-Yen Wang

Abstract

Background: Small blood stem cells (SB cells), isolated from human peripheral blood, demonstrated the ability to benefit bone regeneration and osseointegration. The primary goal of our study is to examine the safety and tolerability of SB cells in dental implantation for human patients with severe bone defects.

Methods: Nine patients were enrolled and divided into three groups with SB cell treatment doses of 1 × 105, 1 × 106, and 1 × 107 SB cells, and then evaluated by computed tomography (CT) scans to assess bone mineral density (BMD) by Hounsfield units (HU) scoring. Testing was conducted before treatment and on weeks 4, 6, 8, and 12 post dental implantation. Blood and comprehensive chemistry panel testing were also performed.

Results: No severe adverse effects were observed for up to 6-month trial. Grade 1 leukocytosis, anemia, and elevated liver function were observed, but related with the patient's condition or the implant treatment itself and not the transplantation of SB cells. The levels of cytokines and chemokines were detected by a multiplex immunological assay. Elevated levels of eotaxin, FGF2, MCP-1, MDC, and IL17a were found among patients who received SB cell treatment. This observation suggested SB cells triggered cytokines and chemokines for local tissue repair. To ensure the efficacy of SB cells in dental implantation, the BMD and maximum stresses via stress analysis model were measured through CT scanning. All patients who suffered from severe bone defect showed improvement from D3 level to D1 or D2 level. The HU score acceleration can be observed by week 2 after guided bone regeneration (GBR) and prior to dental implantation.

Conclusions: This phase I study shows that treatment of SB cells for dental implantation is well tolerated with no major adverse effects. The use of SB cells for accelerating the osseointegration in high-risk dental implant patients warrants further phase II studies.

Trial registration: Taiwan Clinical Trial Registry ( SB-GBR001 ) and clinical trial registry of the United States ( NCT04451486 ).

Keywords: Dental implantation; Guided bone regeneration; Osseointegration; SB cell therapy; Stem cells.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Purification and characterization of SB cells from human peripheral blood. A SB cells were presented using the DAPI positive staining (red arrow). WBC, yellow arrow. Bar = 10 μm. B The ratio of CD61−Lin− cells in the SB mixture was analyzed by a flow cytometer. C The ratio of Lgr5+ cells in SB mixture or CD61−Lin− fraction was analyzed by a flow cytometer. D SB cell morphology was analyzed by TEM. Red dotted line, nucleus; Red arrow, mitochondria. Bar = 2 μm
Fig. 2
Fig. 2
Mean bone mineral density (BMD) measurements. Patients were screened and stratified into three treatment dose groups: low (n = 3), middle (n = 3), and high (n = 3). The course of study spanned 24 weeks. Data points represent BMD measurements given as Hounsfield units (HU). “↓” indicates start of treatment and GBR. Dental implantation was done on week 12. The increase in BMD between dose groups were not statistically significant
Fig. 3
Fig. 3
Temporal profiling of selected cytokines for individual patients based on dose groups (low, middle, and high). Blood was drawn from patients on week 4, immediately prior to the dental implant procedure on week 12 and during follow-up visits on weeks 16 and 24. Chemokine level was regressed over time using ordinary linear regression to estimate changes over time. Regression testing was done to estimate the profiles of Fractalkine (Fracktalk), interleukin-17A (IL-17A), fibroblast growth factor 2 (FGF2), eotaxin, macrophage-derived chemokine (MDC), and monocyte chemoattractant protein-1 (MCP-1). Results are given as concentration levels (pg/mL) on y-axis over time x-axis. Bolded red line represents β from generalized estimating equation
Fig. 4
Fig. 4
Bone mineral density (BMD) measurements during a standard dental implantation treatment for 9 patients with SB cell treatment compared to a reference set from 5 real-world patient data for the same treatment without SB cells. BMD measurements were taken at the start of dental implantation treatment, and after 1 month and 3 months on follow-up visits. For both data sets, a rapid increase in BMD was observed within the first month compared to the subsequent 2-month period. Data was provided by Dr Chiang, TMUH. Abbreviation: HU – Hounsfield units

References

    1. Parsa A, Ibrahim N, Hassan B, van der Stelt P, Wismeijer D. Bone quality evaluation at dental implant site using multislice CT, micro-CT, and cone beam CT. Clin Oral Implants Res. 2015;26(1):e1–e7. doi: 10.1111/clr.12315.
    1. Huang HM, Chee TJ, Lew WZ, Feng SW. Modified surgical drilling protocols influence osseointegration performance and predict value of implant stability parameters during implant healing process. Clin Oral Investig. 2020;24(10):3445–3455. doi: 10.1007/s00784-020-03215-6.
    1. Moraschini V, Poubel LA d C, Ferreira VF, Barboza E d SP. Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review. Int J Oral Maxillofac Surg. 2015;44(3):377–388. doi: 10.1016/j.ijom.2014.10.023.
    1. Song YD, Jun SH, Kwon JJ. Correlation between bone quality evaluated by cone-beam computerized tomography and implant primary stability. Int J Oral Maxillofac Implants. 2009;24(1):59–64.
    1. Retzepi M, Donos N. Guided Bone Regeneration: biological principle and therapeutic applications. Clin Oral Implants Res. 2010;21(6):567–576. doi: 10.1111/j.1600-0501.2010.01922.x.
    1. Liu J, Kerns DG. Mechanisms of guided bone regeneration: a review. Open Dent J. 2014;8:56–65. doi: 10.2174/1874210601408010056.
    1. Wang HL, Boyapati L. ‘PASS’ principles for predictable bone regeneration. Implant Dent. 2006;15(1):8–17. doi: 10.1097/01.id.0000204762.39826.0f.
    1. Zheng C, Chen J, Liu S, Jin Y. Stem cell-based bone and dental regeneration: a view of microenvironmental modulation. Int J Oral Sci. 2019;11(3):23. doi: 10.1038/s41368-019-0060-3.
    1. Miguita L, Mantesso A, Pannuti CM, Deboni MCZ. Can stem cells enhance bone formation in the human edentulous alveolar ridge? A systematic review and meta-analysis. Cell Tissue Bank. 2017;18(2):217–228. doi: 10.1007/s10561-017-9612-y.
    1. Gronthos S, Mankani M, Brahim J, Robey PG, Shi S. Postnatal human dental pulp stem cells (DPSCs) in vitro and in vivo. Proc Natl Acad Sci U S A. 2000;97(25):13625–13630. doi: 10.1073/pnas.240309797.
    1. Lee YC, Chan YH, Hsieh SC, Lew WZ, Feng SW. Comparing the Osteogenic Potentials and Bone Regeneration Capacities of Bone Marrow and Dental Pulp Mesenchymal Stem Cells in a Rabbit Calvarial Bone Defect Model. Int J Mol Sci. 2019;20(20):5015. doi: 10.3390/ijms20205015.
    1. Wang J, Guo X, Lui M, Chu P, Yoo J, Chang M, et al. Identification of a distinct small cell population from human bone marrow reveals its multipotency in vivo and in vitro. PLoS One. 2014;9(1):e85112. doi: 10.1371/journal.pone.0085112.
    1. Sovalat H, Scrofani M, Eidenschenk A, Pasquet S, Rimelen V, Hénon P. Identification and isolation from either adult human bone marrow or G-CSF-mobilized peripheral blood of CD34(+)/CD133(+)/CXCR4(+)/ Lin(-)CD45(-) cells, featuring morphological, molecular, and phenotypic characteristics of very small embryonic-like (VSEL) stem cells. Exp Hematol. 2011;39(4):495–505.
    1. Ning H, Lin G, Lue TF, Lin CS. Mesenchymal Stem Cell Marker Stro-1 is a 75kd Endothelial Antigen. Biochem Biophys Res Commun. 2011;413(2):353–357. doi: 10.1016/j.bbrc.2011.08.104.
    1. Young HE, Lochner F, Lochner D, et al. Primitive Stem Cells in Adult Human Peripheral Blood. Stem Cells Regen Med. 2017;1(1):1–8.
    1. Ou KL, Weng CC, Wu CC, Lin YU, Chiang HJ, Yang TS, et al. Research of StemBios Cell Therapy on Dental Implants Containing Nanostructured Surfaces: Biomechanical Behaviors, Microstructural Characteristics, and Clinical Trial. Implant Dent. 2016;25(1):63–73. doi: 10.1097/ID.0000000000000337.
    1. Weng CC, Ou KL, Wu CY, Huang YH, Wang J, Yen Y, et al. Mechanism and Clinical Properties of StemBios Cell Therapy: Induction of Early Osseointegration in Novel Dental Implants. Int J Oral Maxillofac Implants. 2017;32(1):e47–e54. doi: 10.11607/jomi.4460.
    1. Le Tourneau C, Lee JJ, Siu LL. Dose escalation methods in phase I cancer clinical trials. J Natl Cancer Inst. 2009;101(10):708–720. doi: 10.1093/jnci/djp079.
    1. Kumar H, Ha DH, Lee EJ, Park JH, Shim JH, Ahn TK, Kim KT, Ropper AE, Sohn S, Kim CH, Thakor DK, Lee SH, Han IB. Safety and tolerability of intradiscal implantation of combined autologous adipose-derived mesenchymal stem cells and hyaluronic acid in patients with chronic discogenic low back pain: 1-year follow-up of a phase I study. Stem Cell Res Ther. 2017;8(1):262. doi: 10.1186/s13287-017-0710-3.
    1. Ahn SY, Chang YS, Sung SI, Park WS. Mesenchymal Stem Cells for Severe Intraventricular Hemorrhage in Preterm Infants: Phase I Dose-Escalation Clinical Trial. Stem Cells Transl Med. 2018;7(12):847–856. doi: 10.1002/sctm.17-0219.
    1. Schlosser K, Wang JP, Dos Santos C, Walley KR, Marshall J, Fergusson DA, Winston BW, Granton J, Watpool I, Stewart DJ, McIntyre LA, Mei SHJ. Effects of mesenchymal stem cell treatment on systemic cytokine levels in a phase 1 dose escalation safety trial of septic shock patients. Crit Care Med. 2019;47(7):918–925. doi: 10.1097/CCM.0000000000003657.
    1. Soder RP, Dawn B, Weiss ML, Dunavin N, Weir S, Mitchell J, Li M, Shune L, Singh AK, Ganguly S, Morrison M, Abdelhakim H, Godwin AK, Abhyankar S, McGuirk J. A phase I study to evaluate two doses of Wharton’s jelly-derived mesenchymal stromal cells for the treatment of de novo high-risk or steroid-refractory acute graft versus host disease. Stem Cell Rev Rep. 2020;16(5):979–991. doi: 10.1007/s12015-020-10015-8.
    1. Fraisse J, Dinart D, Tosi D, Bellera C, Mollevi C. Optimal biological dose: a systematic review in cancer phase I clinical trials. BMC Cancer. 2021;21(1):60. doi: 10.1186/s12885-021-07782-z.
    1. Al-Ekrish AA, Widmann G, Alfadda SA. Revised, Computed tomography-based Lekholm and Zarb Jawbone Quality Classification. Int J Prosthodont. 2018;31(4):342–345. doi: 10.11607/ijp.5714.
    1. Turkyilmaz I, Tözüm TF, Tumer C. Bone density assessments of oral implant sites using computerized tomography. J Oral Rehabil. 2007;34(4):267–272. doi: 10.1111/j.1365-2842.2006.01689.x.
    1. Su YH, Peng BY, Wang PD, Feng SW. Evaluation of the implant stability and the marginal bone level changes during the first three months of dental implant healing process: a prospective clinical study. J Mech Behav Biomed Mater. 2020;110:103899. doi: 10.1016/j.jmbbm.2020.103899.
    1. Rokn A, Rasouli Ghahroudi AA, Daneshmonfared M, Menasheof R, Shamshiri AR. Tactile sense of the surgeon in determining bone density when placing dental implant. Implant Dent. 2014;23(6):697–703.
    1. Yoon BH, Esquivies L, Ahn C, Gray PC, Ye SK, Kwiatkowski W, Choe S. An activin A/BMP2 chimera, AB204, displays bone-healing properties superior to those of BMP2. J Bone Miner Res. 2014;29(9):1950–1959. doi: 10.1002/jbmr.2238.
    1. Rico-Llanos GA, Becerra J, Visser R. Insulin-like growth factor-1 (IGF-1) enhances the osteogenic activity of bone morphogenetic protein-6 (BMP-6) in vitro and in vivo, and together have a stronger osteogenic effect than when IGF-1 is combined with BMP-2. J Biomed Mater Res A. 2017;105(7):1867–1875. doi: 10.1002/jbm.a.36051.
    1. Whetton AD, Graham GJ. Homing and mobilization in the stem cell niche. Trends Cell Biol. 1999;9(6):233–238. doi: 10.1016/S0962-8924(99)01559-7.
    1. Andreas K, Sittinger M, Ringe J. Toward in situ tissue engineering: chemokine-guided stem cell recruitment. Trends Biotechnol. 2014;32:483–492. doi: 10.1016/j.tibtech.2014.06.008.
    1. Brylka LJ, Schinke T. Chemokines in Physiological and Pathological Bone Remodeling. Front Immunol. 2019;10:2182. doi: 10.3389/fimmu.2019.02182.
    1. Fawzy El-Sayed KM, Elahmady M, Adawi Z, Aboushadi N, Elnaggar A, Eid M, Hamdy N, Sanaa D, Dörfer CE. The periodontal stem/progenitor cell inflammatory-regenerative cross talk: a new perspective. J Periodontal Res. 2019;54:81–94. doi: 10.1111/jre.12616.
    1. Rundle CH, Mohan S, Edderkaoui B. Duffy antigen receptor for chemokines regulates post-fracture inflammation. PLoS One. 2013;8(10):e77362. doi: 10.1371/journal.pone.0077362.
    1. Yoshimura T. The chemokine MCP-1 (CCL2) in the host interaction with cancer: a foe or ally? Cell Mol Immunol. 2018;15(4):335–345. doi: 10.1038/cmi.2017.135.
    1. Graves DT. The potential role of chemokines and inflammatory cytokines in periodontal disease progression. Clin Infect Dis. 1999;28(3):482–490. doi: 10.1086/515178.
    1. Deshmane SL, Kremlev S, Amini S, Sawaya BE. Monocyte chemoattractant protein-1 (MCP-1): an overview. J Interferon Cytokine Res. 2009;29(6):313–326. doi: 10.1089/jir.2008.0027.
    1. Edderkaoui B. Potential role of chemokines in fracture repair. Front Endocrinol (Lausanne) 2017;8:39. doi: 10.3389/fendo.2017.00039.
    1. Mulholland BS, Forwood MR, Morrison NA. Monocyte chemoattractant protein-1 (MCP-1/CCL2) drives activation of bone remodelling and skeletal metastasis. Curr Osteoporos Rep. 2019;17(6):538–547. doi: 10.1007/s11914-019-00545-7.
    1. Li X, Qin L, Bergenstock M, Bevelock LM, Novack DV, Partridge NC, et al. Parathyroid hormone stimulates osteoblastic expression of MCP-1 to recruit and increase the fusion of pre/osteoclasts. J Biol Chem. 2007;282(45):33098–33106. doi: 10.1074/jbc.M611781200.
    1. Kim MS, Day CJ, Morrison NA. MCP-1 is induced by receptor activator of nuclear factor-κB ligand, promotes human osteoclast fusion, and rescues granulocyte macrophage colony-stimulating factor suppression of osteoclast formation. J Biol Chem. 2005;280(16):16163–16169. doi: 10.1074/jbc.M412713200.
    1. Ishikawa M, Ito H, Kitaori T, Murata K, Shibuya H, Furu M, et al. MCP/CCR2 signaling is essential for recruitment of mesenchymal progenitor cells during the early phase of fracture healing. PLoS One. 2014;9(8):e104954. doi: 10.1371/journal.pone.0104954.
    1. Volejnikova S, Laskari M, Marks SC, Graves DT. Monocyte recruitment and expression of monocyte chemoattractant protein-1 are developmentally regulated in remodeling bone in the mouse. Am J Pathol. 1997;150(5):1711–1721.
    1. Merino JJ, Cabaña-Muñoz ME, Toledano Gasca A, Garcimartín A, Benedí J, Camacho-Alonso F, Parmigiani-Izquierdo JM. Elevated systemic L-kynurenine/l-tryptophan ratio and increased il-1 beta and chemokine (CX3CL1, MCP-1) proinflammatory mediators in patients with long-term titanium dental implants. J Clin Med. 2019;8(9):1368. doi: 10.3390/jcm8091368.
    1. Galler KM, D’Souza RN. Tissue engineering approaches for regenerative dentistry. Regen Med. 2011;6(1):111–124. doi: 10.2217/rme.10.86.
    1. Huang CF, Chiang HJ, Lin HJ, Hosseinkhani H, Ou KL, Pengaz PW. Comparison of cell response and surface characteristics on titanium implant with SLA and SLAffinity functionalization. J Electrochem Soc. 2014;161:G15. doi: 10.1149/2.084403jes.
    1. Meng W, Zhou Y, Zhang Y, Cai Q, Yang L, Wang B. Effects of hierarchical micro/nano-textured titanium surface features on osteoblast-specific gene expression. Implant Dent. 2013;22(6):656–661. doi: 10.1097/01.id.0000434273.22605.78.
    1. Sbricoli L, Guazzo R, Annunziata M, Gobbato L, Bressan E, Nastri L. Selection of collagen membranes for bone regeneration: a literature review. Materials (Basel). 2020;13(3):786. doi: 10.3390/ma13030786.
    1. Bollman M, Malbrue R, Li C, Yao H, Guo S, Yao S. Improvement of osseointegration by recruiting stem cells to titanium implants fabricated with 3D printing. Ann N Y Acad Sci. 2020;1463(1):37–44. doi: 10.1111/nyas.14251.
    1. Agarwal R, García AJ. Biomaterial strategies for engineering implants for enhanced osseointegration and bone repair. Adv Drug Deliv Rev. 2015;94:53–62. doi: 10.1016/j.addr.2015.03.013.
    1. Amrollahi P, Shah B, Seifi A, Tayebi L. Recent advancements in regenerative dentistry: a review. Mater Sci Eng C Mater Biol Appl. 2016;69:1383–1390. doi: 10.1016/j.msec.2016.08.045.
    1. Huangfu D, Maehr R, Guo W, Eijkelenboom A, Snitow M, Chen AE, et al. Induction of pluripotent stem cells by defined factors is greatly improved by small-molecule compounds. Nat Biotechnol. 2008;26(7):795–797. doi: 10.1038/nbt1418.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere