Sulfated Chitosan-Modified CuS Nanocluster: A Versatile Nanoformulation for Simultaneous Antibacterial and Bone Regenerative Therapy in Periodontitis.

Periodontitis, a prevalent chronic inflammatory disease worldwide, is triggered by periodontopathogenic bacteria, resulting in the progressive destruction of periodontal tissue, particularly the alveolar bone. To effectively address periodontitis, this study proposed a nanoformulation known as CuS@MSN-SCS. This formulation involves coating citrate-grafted copper sulfide (CuS) nanoparticles with mesoporous silica (MSNs), followed by surface modification using amino groups and sulfated chitosan (SCS) through electrostatic interactions. The objective of this formulation is to achieve efficient bacteria removal by inducing ROS signaling pathways mediated by Cu2+ ions. Additionally, it aims to promote alveolar bone regeneration through Cu2+-induced pro-angiogenesis and SCS-mediated bone regeneration. As anticipated, by regulating the surface charges, the negatively charged CuS nanoparticles capped with sodium citrate were successfully coated with MSNs, and the subsequent introduction of amine groups using (3-aminopropyl)triethoxysilane was followed by the incorporation of SCS through electrostatic interactions, resulting in the formation of CuS@MSN-SCS. The developed nanoformulation was verified to not only significantly exacerbate the oxidative stress of Fusobacterium nucleatum, thereby suppressing bacteria growth and biofilm formation in vitro, but also effectively alleviate the inflammatory response and promote alveolar bone regeneration without evident biotoxicity in an in vivo rat periodontitis model. These findings contribute to the therapeutic effect on periodontitis. Overall, this study successfully developed a nanoformulation for combating bacteria and facilitating alveolar bone regeneration, demonstrating the promising potential for clinical treatment of periodontitis.

Modulation of Interfacial Characteristics of Copper Electrode by Electrodeposited Cu@Ti for High-Performance Anode-Free Zinc Ion Batteries.

Preparation of the NC-Cu@Ti electrode involved electrochemical deposition of nanocrystalline copper on the surface of titanium foil using a constant potential method, intended for high stability anode-free zinc ion battery (ZIB) anode material applications. This paper examines the effect of Cu2+ concentration in the electrodeposition solution on the structure and morphology of copper crystals on the NC-Cu@Ti electrode surface. The study also assesses how the interfacial properties of the NC-Cu@Ti electrode affect the process of anodic zinc deposition without anodic ZIBs. Our data suggest that with a voltage setting of -0.95 V and a copper ion concentration of 0.5 M in the solution, the deposition rate of copper crystals on the NC-Cu@Ti-0.5 electrode remains consistent. The resultant crystal phase surface appears smooth with a fine grain size. The NC-Cu@Ti-0.5 electrodes have increased hydrogen potentials and superior corrosion resistance; noting zinc nucleation sites at a mere 21.4 mV, it can provide stable electrochemical conditions for the zinc deposition interface of ZIBs and accelerate the process of zinc desolvation and nucleation. The constructed Zn//NC-Cu@Ti-0.5 asymmetric cell displays swift zinc deposition/stripping kinetics, elevated Coulombic efficiency, and prolonged stability (maintaining nearly 99% after 200 cycles). This performance significantly extends the service life relative to the Zn//Zn symmetric cell, which operates stably for 400 h at 1 mA/cm2. Moreover, the NC-Cu@Ti-0.5//MnO2 ZIBs offer enhanced conductivity and magnification performance to the pure zinc anode ZIBs. This study presents a novel approach for the low-cost and rapid preparation of anode materials for high-performance free-anode ZIBs.

Probiotic-loaded calcium alginate/fucoidan hydrogels for promoting oral ulcer healing.

Probiotics are beneficial bacteria located in the oral cavity which exhibit antimicrobial properties and contribute to the regulation of immune function and the modulation of tissue repair. Fucoidan (FD), a marine prebiotic, may further enhance the ability of probiotics to promote ulcer healing. However, neither FD nor probiotics are attached to the oral cavity and neither are well-suited for oral ulcer healing owing to the wet and highly dynamic environment. In this study, probiotic-loaded calcium alginate/fucoidan composite hydrogels were developed for use as bioactive oral ulcer patches. The well-shaped hydrogels exhibited remarkable wet-tissue adhesion, suitable swelling and mechanical properties, sustained probiotic release, and excellent storage durability. Moreover, in vitro biological assays demonstrated that the composite hydrogel exhibited excellent cyto/hemocompatibility and antimicrobial effects. Importantly, compared to commercial oral ulcer patches, bioactive hydrogels show superior therapeutic capability for promoting ulcer healing in vivo by enhancing cell migration, inducing epithelial formation and orderly collagen fiber deposition, as well as facilitating neovascularization. These results demonstrate that this novel composite hydrogel patch demonstrates great potential for the treatment of oral ulcerations.

Modulation of T Cell Responses by Fucoidan to Inhibit Osteogenesis.

Fucoidan has sparked considerable interest in biomedical applications because of its inherent (bio)physicochemical characteristics, particularly immunomodulatory effects on macrophages, neutrophils, and natural killer cells. However, the effect of fucoidan on T cells and the following regulatory interaction on cellular function has not been reported. In this work, the effect of sterile fucoidan on the T-cell response and the subsequent modulation of osteogenesis is investigated. The physicochemical features of fucoidan treated by high-temperature autoclave sterilization are characterized by UV-visible spectroscopy, X-ray diffraction, Fourier transform infrared and nuclear magnetic resonance analysis. It is demonstrated that high-temperature autoclave treatment resulted in fucoidan depolymerization, with no change in its key bioactive groups. Further, sterile fucoidan promotes T cells proliferation and the proportion of differentiated T cells decreases with increasing concentration of fucoidan. In addition, the supernatant of T cells co-cultured with fucoidan greatly suppresses the osteogenic differentiation of MC3T3-E1 by downregulating the formation of alkaline phosphatase and calcium nodule compared with fucoidan. Therefore, our work offers new insight into the fucoidan-mediated T cell and osteoblast interplay.

Regulation of T Cell Responses by Nano-Hydroxyapatite to Mediate the Osteogenesis.

Nano-hydroxyapatite (nHA) has been widely applied as a tissue-engineering biomaterial and interacted with osteoblasts/stem cells to repair bone defects. In addition, T cells that coexist with osteoblasts/stem cells in the bone modulate the regulation of osteoimmunology by cytokine formation. However, the effects of nHA on T cells and the following regulatory interplay on osteogenic differentiation have been rarely examined. In this work, the physicochemical properties of needle-like nHA are characterized by field emission scanning electron microscopy, zeta potential, Fourier transform-infrared and X-ray diffraction. It is found that as the concentration of nHA increases, the proliferation of T cells gradually increases, and the proportion of apoptotic T cells decreases. The percentage of CD4+ T cells is higher than that of CD8+ T cells under the regulation of needle-like nHA. Furthermore, the supernatant of T cells co-cultured with nHA significantly inhibits the osteogenic differentiation of MC3T3-E1 by downregulating the formation of alkaline phosphatase and calcium nodule compared with the supernatant of nHA. Thus, our findings provide new insight into the nHA-mediated T cell and osteoblast interactions.

Injectable Self-Healing First-Aid Tissue Adhesives with Outstanding Hemostatic and Antibacterial Performances for Trauma Emergency Care.

Soft-tissue trauma emergency caused by natural disasters and traffic accidents is highly prevalent, which can result in massive bleeding, pathogen infection, and even death. Although numerous tissue adhesives can bind to tissue surfaces and cover wounds, most of them still have several deficiencies, including long gelation time, poor adhesive strength, and anti-infection, making them inappropriate for use as first-aid bandages. Herein, injectable and self-healing four-arm-PEG-CHO/polyethyleneimine (PEI) tissue adhesives as liquid first-aid supplies are developed via the dynamic Schiff base reaction for trauma emergency. It is found that the prepared hydrogel adhesives exhibit short and controlled gelation time (9∼88 s), strong adhesive strength, and excellent antibacterial ability. Their hemostatic and antimicrobial performances can be tailored by the mass ratio of four-arm-PEG-CHO/PEI. Moreover, in vitro biological assays display that the developed tissue adhesives possess satisfactory cyto/hemocompatibility. Importantly, in vivo the designed adhesives show fast hemostatic capacity and excellent anti-infection as compared to commercial Prontosan gel. Thus, this work indicates that the four-arm-PEG-CHO/PEI first-aid tissue adhesives display great potential for wound emergency management.

Antibacterial quaternary ammonium chitosan/carboxymethyl starch/alginate sponges with enhanced hemostatic property for the prevention of dry socket.

Tooth extraction commonly leads to postoperative wound bleeding, bacterial infection, and even the occurrence of dry socket. Therefore, developing a biomedical material with favorable antibacterial and excellent hemostatic properties to prevent the post-extraction dry socket is necessary. Herein, quaternary ammonium chitosan/ carboxymethyl starch/alginate (ACQ) sponges are developed via Ca2+ cross-linking, electrostatic interaction, and lyophilization methods. The results show that the bio-multifunctional sponges exhibit interconnected porous structures with significant fluid absorption rates and suitable water vapor transmission rates. In vitro cellular and hemolysis experiments indicate that the developed sponges have acceptable biocompatibility. Notably, the constructed sponges effectively inhibit the growth of E. coli, S. aureus, and C. albicans, as well as achieve rapid hemostasis in the mouse liver injury and mini-pig tooth extraction models by absorbing blood and promoting red blood cell adhesion. Thus, the created bio-multifunctional sponges show tremendous promise as a hemostatic material for wound management after tooth extraction.

Nanomedicine for the Diagnosis and Therapy of COVID-19.

The coronavirus disease-2019 (COVID-19) pandemics caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been spreading around the world due to its high infection rate, long incubation period, as well as lack of effective diagnosis and therapy or vaccines, which is tearing global health systems apart. It is an urgent demand for point-of-care diagnosis and effective treatment to prevent the spread of COVID-19. Currently, based on the rapid development of functional materials with unique physicochemical features through advanced fabrication and chemical modification, nanomaterials provide an emerging tool to detect SARS-CoV-2, inhibit the interplay in the virus and host cell interface, and enhance host immune response. In our manuscript, we summarized recent advances of nanomaterials for the diagnosis and therapy of COVID-19. The limitation, current challenges, and perspectives for the nano-diagnosis and nano-therapy of COVID-19 are proposed. The review is expected to enable researchers to understand the effect of nanomaterials for the diagnosis and therapy of COVID-19 and may catalyze breakthroughs in this area.

Extracellular Vesicles as Natural Delivery Carriers Regulate Oxidative Stress Under Pathological Conditions.

Extracellular vesicles are cellular secretory particles that can be used as natural drug delivery carriers. They have successfully delivered drugs including chemotherapeutics, proteins, and genes to treat various diseases. Oxidative stress is an abnormal physiological phenomenon, and it is associated with nearly all diseases. In this short review, we summarize the regulation of EVs on oxidative stress. There are direct effects and indirect effects on the regulation of oxidative stress through EVs. On the one hand, they can deliver antioxidant substances or oxides to recipient cells, directly relieving or aggravating oxidative stress. On the other hand, regulate factors of oxidative stress-related signaling pathways can be delivered to recipient cells by the mediation of EVs, realizing the indirect regulation of oxidative stress. To the best of our knowledge, however, only endogenous drugs have been delivered by EVs to regulate oxidative stress till now. And the heterogeneity of EVs may complicate the regulation of oxidative stress. Therefore, this short review aims to draw more attention to the EVs-based regulation of oxidative stress, and we hope excellent EVs-based delivery carriers that can deliver exogenous drugs to regulate oxidative stress can be exploited.

Preparation of triamcinolone acetonide-loaded chitosan/fucoidan hydrogel and its potential application as an oral mucosa patch.

Oral inflammatory diseases (OIDs) are among the most common lesions in the oral cavity, affecting the quality of human life and even causing oral cancer. However, most of the current oral mucosa patches still have some limitations, particularly instant, poor mechanical strength and conformability, low adhesion to tissue, and foreign body sensation. Herein, triamcinolone acetonide (TA)-loaded chitosan/fucoidan (CF) composite hydrogels were prepared via chemical crosslinking. The macro/microscopic morphologies and (bio)physicochemical properties of composite hydrogels were investigated. Incorporating fucoidan in chitosan hydrogels greatly enhanced their swelling behavior, mechanical strength, and adhesion properties. Further, the addition of TA in CF hydrogels improved their elastic feature, inhibited inflammatory response, and promoted the formation of mature and well-organized collagen fibers. The developed composite hydrogels displayed not only good antibacterial properties but also good cytocompatibility and histocompatibility. Thus, the designed hydrogels allow the development of oral mucosa patches as a potential treatment for OIDs.

Enhanced autophagy suppresses inflammation-mediated bone loss through ROCK1 signaling in bone marrow mesenchymal stem cells.

Bone marrow mesenchymal stem cells (BMSCs) have strong proliferative ability and multi-directional differentiation potential. Osteoarthritis is a degenerative joint disease that is closely related to the loss of osteogenic differentiation function of BMSCs. Autophagy, plays a crucial role in the maintenance of cellular functions, but its regulatory mechanism during the osteogenic differentiation of BMSCs remains unclear. In this study, we analyzed the differential gene networks and pathways during BMSC osteogenesis using bioinformatics, and further validated the regulatory roles of autophagy during the osteogenic differentiation of BMSCs in inflammatory condition in vitro. We found that Tumor necrosis factor alpha (TNF-α) treatment led to actin cytoskeleton rearrangements and inhibited osteogenic differentiation in BMSCs. In addition, TNF-α enhanced Rho-associated protein kinase 1 (ROCK1) expression and decreased autophagy activation. ROCK1 knockdown reduced Endoplasmic Reticulum stress (ER stress) and promoted autophagy, resulting reversion of osteogenic differentiation in BMSCs under inflammatory condition. Rapamycin reversed the TNF-α-induced decrease in osteogenesis of BMSCs, assessed by alkaline phosphatase (ALP) activity and Alizarin staining. Autophagy treated with inhibitor 3-Methyladenine (3-MA) further increased TNF-α-induced osteogenesis inhibition of BMSCs. Collectively, these results indicate that ER stress and dysfunction of autophagy promote inflammation-induced bone loss through the activation of ROCK1 signaling in BMSCs.

Nanoparticles for Oral Cancer Diagnosis and Therapy.

Oral cancer is the sixth most common malignant cancer, affecting the health of people with an unacceptably high mortality rate. Despite numerous clinical methods in the diagnosis and therapy of oral cancer (e.g., magnetic resonance imaging, computed tomography, surgery, and chemoradiotherapy), they still remain far from optimal. Therefore, an urgent need exists for effective and practical techniques of early diagnosis and effective therapy of oral cancer. Currently, various types of nanoparticles have aroused wide public concern, representing a promising tool for diagnostic probes and therapeutic devices. Their inherent physicochemical features, including ultrasmall size, high reactivity, and tunable surface modification, enable them to overcome some of the limitations and achieve the expected diagnostic and therapeutic effect. In this review, we introduce different types of nanoparticles that emerged for the diagnosis and therapy of oral cancers. Then, the challenges and future perspectives for nanoparticles applied in oral cancer diagnosis and therapy are presented. The objective of this review is to help researchers better understand the effect of nanoparticles on oral cancer diagnosis and therapy and may accelerate breakthroughs in this field.

Effect of gingival mesenchymal stem cell-derived exosomes on inflammatory macrophages in a high-lipid microenvironment.

OBJECTIVE: The aim of this study was to examine the effect of gingival mesenchymal stem cells derived exosomes (GMSC-Exos) on lipopolysaccharide/interferon-gamma (LPS/INF-γ)-induced inflammatory macrophages in a high-lipid microenvironment. MATERIALS AND METHODS: Exosomes were obtained by culturing gingival mesenchymal stem cells (GMSCs) in alpha-MEM with exosome-free fetal bovine serum for 48 h. The control group was produced in vitro by inducing human acute monocytic leukemia cells (THP-1 cells) into naïve macrophages (M0). Inflammatory macrophages (M1) were made by activating M0 macrophages with LPS/IFN-γ. These M1 macrophages were treated with oxidized low-density lipoprotein (ox-LDL) to create the high-lipid group, of which some macrophages were further treated with GMSC-Exos for 24 h to form the GMSC-Exos group. Supernatants were collected, and total RNA were extracted for downstream analysis. The expression of surface markers in macrophages were analyzed by flow cytometry. The lipid accumulation level was assessed by oil red O staining. RESULTS: Exosomes were successfully isolated from GMSC medium. The GMSC-Exos group showed lower Tumor Necrosis Factor-α (TNF-α), Interleukin-6 (IL-6), Interleukin-1ß (IL-1ß), and cluster of differentiation 86 (CD86) expression levels than the high-lipid group, and the highest levels of Interleukin-10 (IL-10) among all groups. The GMSC-Exos group showed significant reductions in TNF-α levels than the high-lipid group, and significant escalations in IL-10 levels than the other two groups. Oil red o Staining showed that lipid accumulation in macrophages was inhibited in the GMSC-Exos group. CONCLUSIONS: GMSC-Exos reduce the release level and expression of inflammatory factors, inhibit lipid accumulation, and promote the polarization of pro-inflammatory macrophages into anti-inflammatory phenotype in a high-lipid microenvironment.

A biodegradable antibacterial alginate/carboxymethyl chitosan/Kangfuxin sponges for promoting blood coagulation and full-thickness wound healing.

Conventional wound-dressing materials with structural and functional deficiencies are not effective in promoting wound healing. The development of multifunctional wound dressings is emerging as a promising strategy to accelerate blood coagulation, inhibit bacterial infection, and trigger full-thickness wound into a regenerative process. Herein, multifunctional composite sponges were developed by incorporation of traditional Chinese medicine Kangfuxin (KFX) into alginate (AG)/carboxymethyl chitosan (CMC) via green crosslinking, electrostatic interaction, and freeze-drying methods. It is demonstrated that the AG/CMC/KFX (ACK) sponges exhibit a highly interconnected and porous structure, suitable water vapor transmittance, excellent elastic properties, antibacterial behavior, cytocompatibility, and rapid hemostasis. Further, in a rat full-thickness wounds model, the ACK sponge containing 10% KFX (ACK-10) significantly facilitates wound closure compared to the AC group and ACK sponge containing 5% and 15% KFX. Thus, the multifunctional ACK-10 composite sponge has great promise for the application of full-thickness wound healing.

[Related factors of atrophic glossitis in 124 consecutive cases].

PURPOSE: To study the relationship between atrophic glossitis and anemia, anemia types and other related factors(oral candida infection, xerostomia) in 124 consecutive cases. METHODS: One hundred and twenty-four cases with atrophic glossitis and 53 healthy controls were collected from Qingdao local population. The main indexes including general status, oral examination findings, hemoglobin (Hb), mean red blood cell volume (MCV), vitamin B12, ferritin, folic acid, anemia and anemia type, xerostomia and candida infection were statistically analyzed using SPSS 20.0 software package for Student's t test. RESULTS: Among 124 cases of glossitis group, 48.39% were found with anemia, 41.94% with xerostomia, 79.03% with Candida infection, 29.03% with Vitamin B12 deficiency, 22.58% with ferritin deficiency, 11.29% with folic acid deficiency. The contents of hemoglobin, ferritin and vitamin B12 in glossitis group were significantly lower than those in the control group(P<0.05), and the number of glossitis patients with anemia, xerostomia and candida infection were significantly higher than those in the control group (P<0.05). There was no significant difference in folic acid content between the two groups(P<0.05). CONCLUSIONS: Occurrence of atrophic glossitis is closely related to anemia, vitamin B12 deficiency, ferritin deficiency, xerostomia, oral candida infection. There is no correlation with folic acid deficiency. Patients with atrophic glossitis accompanied by anemia have a higher proportion of macrocytic anemia.

PARIS induced defects in mitochondrial biogenesis drive dopamine neuron loss under conditions of parkin or PINK1 deficiency.

BACKGROUND: Mutations in PINK1 and parkin cause autosomal recessive Parkinson's disease (PD). Evidence placing PINK1 and parkin in common pathways regulating multiple aspects of mitochondrial quality control is burgeoning. However, compelling evidence to causatively link specific PINK1/parkin dependent mitochondrial pathways to dopamine neuron degeneration in PD is lacking. Although PINK1 and parkin are known to regulate mitophagy, emerging data suggest that defects in mitophagy are unlikely to be of pathological relevance. Mitochondrial functions of PINK1 and parkin are also tied to their proteasomal regulation of specific substrates. In this study, we examined how PINK1/parkin mediated regulation of the pathogenic substrate PARIS impacts dopaminergic mitochondrial network homeostasis and neuronal survival in Drosophila. METHODS: The UAS-Gal4 system was employed for cell-type specific expression of the various transgenes. Effects on dopamine neuronal survival and function were assessed by anti-TH immunostaining and negative geotaxis assays. Mitochondrial effects were probed by quantitative analysis of mito-GFP labeled dopaminergic mitochondria, assessment of mitochondrial abundance in dopamine neurons isolated by Fluorescence Activated Cell Sorting (FACS) and qRT-PCR analysis of dopaminergic factors that promote mitochondrial biogenesis. Statistical analyses employed two-tailed Student's T-test, one-way or two-way ANOVA as required and data considered significant when P < 0.05. RESULTS: We show that defects in mitochondrial biogenesis drive adult onset progressive loss of dopamine neurons and motor deficits in Drosophila models of PINK1 or parkin insufficiency. Such defects result from PARIS dependent repression of dopaminergic PGC-1α and its downstream transcription factors NRF1 and TFAM that cooperatively promote mitochondrial biogenesis. Dopaminergic accumulation of human or Drosophila PARIS recapitulates these neurodegenerative phenotypes that are effectively reversed by PINK1, parkin or PGC-1α overexpression in vivo. To our knowledge, PARIS is the only co-substrate of PINK1 and parkin to specifically accumulate in the DA neurons and cause neurodegeneration and locomotor defects stemming from disrupted dopamine signaling. CONCLUSIONS: Our findings identify a highly conserved role for PINK1 and parkin in regulating mitochondrial biogenesis and promoting mitochondrial health via the PARIS/ PGC-1α axis. The Drosophila models described here effectively recapitulate the cardinal PD phenotypes and thus will facilitate identification of novel regulators of mitochondrial biogenesis for physiologically relevant therapeutic interventions.

Parkin interacting substrate zinc finger protein 746 is a pathological mediator in Parkinson's disease.

α-Synuclein misfolding and aggregation plays a major role in the pathogenesis of Parkinson's disease. Although loss of function mutations in the ubiquitin ligase, parkin, cause autosomal recessive Parkinson's disease, there is evidence that parkin is inactivated in sporadic Parkinson's disease. Whether parkin inactivation is a driver of neurodegeneration in sporadic Parkinson's disease or a mere spectator is unknown. Here we show that parkin in inactivated through c-Abelson kinase phosphorylation of parkin in three α-synuclein-induced models of neurodegeneration. This results in the accumulation of parkin interacting substrate protein (zinc finger protein 746) and aminoacyl tRNA synthetase complex interacting multifunctional protein 2 with increased parkin interacting substrate protein levels playing a critical role in α-synuclein-induced neurodegeneration, since knockout of parkin interacting substrate protein attenuates the degenerative process. Thus, accumulation of parkin interacting substrate protein links parkin inactivation and α-synuclein in a common pathogenic neurodegenerative pathway relevant to both sporadic and familial forms Parkinson's disease. Thus, suppression of parkin interacting substrate protein could be a potential therapeutic strategy to halt the progression of Parkinson's disease and related α-synucleinopathies.

JAK2/STAT3 is associated with the inflammatory process in periapical granuloma.

OBJECTIVE: It has been shown that JAK2/STAT3 is involved in the occurrence of various inflammatory diseases. The purpose of this study was to associate the expression of Janus kinase 2 (JAK2) and its receptor signal transducer and activator of transcription 3 (STAT3) and suppressors of cytokine signaling 3 (SOCS3), to periapical granuloma. METHODS: Samples were collected from 40 patients who were divided into two groups, namely, healthy control (N=20) and periapical granuloma (N=20) groups in accordance with classified standards. The samples were prepared for histological analysis, immunohistochemistry, and double immunofluorescence staining. RESULTS: Only slight inflammatory cell infiltration was observed in the tissues from the healthy control group. Extensive infiltration of inflammatory cells was observed in patients with chronic periapical disease. The periapical granuloma group had higher levels of JAK2, STAT3, p-JAK2, p-STAT3 and SOCS3 (all P<0.05) than the control group. Double immunofluorescence staining results showed the presence of JAK2-positive and STAT3-positive cells in the periapical lesion areas. CONCLUSIONS: This study demonstrated that JAK2, STAT3, and SOCS3 can be observed and may be associated with the inflammatory process in periapical lesions. The results of this study will provide new insights into the pathological mechanisms of human periapical granuloma.