Does the Use of Injectable Platelet-Rich Fibrin After Arthrocentesis for Disc Displacement Without Reduction Improve Clinical Outcomes?

PURPOSE: Many studies have reported the role of arthrocentesis to alleviate symptoms in patients with disc displacement without reduction (DDWoR). Nevertheless, the benefit of injectable platelet-rich fibrin (i-PRF) remains unclear. The aim of this study was to answer the following question: Among patients with DDWoR, do those treated with intra-articular injection of i-PRF after arthrocentesis, when compared to those treated with arthrocentesis only, have better clinical outcomes in terms of pain reduction and improvement of jaw movement? MATERIALS AND METHODS: This single-blind randomized, controlled study included patients with diagnosed DDWoR, in the Department of Oral and Maxillofacial Surgery at the School of Dentistry, Ege University, who had localized joint pain and limited range of motion. Patients were treated either with arthrocentesis (AC group) or arthrocentesis in combination with intra-articular i-PRF injection (AC + i-PRF group). The predictor variable was treatment (ie, arthrocentesis with or without i-PRF). The primary outcome variable was pain (visual analog scale). The secondary outcome variables were maximum mouth opening, lateral and protrusive movements. Outcome variables were recorded at pretreatment and at the postoperative 1st, 2nd, 3rd, 6th, and 12th months. Statistical analysis was performed using the Brunner-Langer model, with a significance level P < .05. RESULTS: This study comprised 76 patients (34 females/4 males, mean age 47.2 ± 9.1 for the AC + i-PRF group; 35 females/3 males, mean age 46.8 ± 10.2 for the AC group). The treatment success rate was 73.7% for the AC group and 100% for the AC + i-PRF group (P = .012). Pain levels in the AC + i-PRF group were found to decrease more than the AC group over 12 months postoperatively (palpation: -6.9 ± 1.2 vs -5.3 ± 1.3; chewing: -6.9 ± 1.5 vs -5.1 ± 1.7; jaw movements: -6.9 ± 1.1 vs -5.1 ± 1.4). This difference was statistically significant (P < .001). The degree of jaw movement in the AC + i-PRF group was found to increase more than the AC group over 12 months postoperatively (maximum mouth opening: 8.0 ± 2.1 vs 4.9 ± 2.0; contralateral: 1.8 ± 0.8 vs 0.2 ± 1.0; ipsilateral: 2.9 ± 1.3 vs 0.8 ± 1.5; protrusive: 2.6 ± 1.1 vs 0.8 ± 1.3). This difference was statistically significant (P < .001). CONCLUSION: Intra-articular injection of i-PRF after arthrocentesis produced greater improvements in pain reduction and jaw movement when compared to arthrocentesis only. These results indicate that i-PRF used in combination with arthrocentesis is an effective adjunctive treatment.

Injectable platelet-rich fibrin as treatment for temporomandibular joint osteoarthritis: A randomized controlled clinical trial.

The purpose of this study was to assess the treatment outcomes of intraarticular injection of injectable platelet-rich fibrin (i-PRF) after arthrocentesis in patients with temporomandibular joint osteoarthritis (TMJ-OA). Patients were randomly assigned to one of two treatment groups: those who received intraarticular injection of i-PRF after arthrocentesis procedure - the i-PRF group; and those who underwent the arthrocentesis procedure alone - the control group. The primary outcome variable was pain, the level of which was measured preoperatively and at 1, 2, 3, 6, and 12 months postoperatively. The secondary outcome variables included maximum mouth opening (MMO), and lateral and protrusive movements. Of the total of 36 patients, 18 were analyzed in the i-PRF group and 18 in the control group. There were significant differences between the groups in terms of pain levels and measurements of MMO, lateral movement, and protrusive movement over the 12 months of follow-up (p < 0.001). Significant increases in pain levels and decreases in measurements of MMO, lateral movement, and protrusive movement were observed in the control group from the 6th to 12th month postoperatively (p < 0.001). In contrast, no significant differences were found in both pain levels and measurements of MMO, lateral, and protrusive movements for the i-PRF group from the 2nd to the 12th month postoperatively. Within the limitations of the study it seems that intraarticular injection of i-PRF after arthrocentesis should be preferred whenever appropriate because when reducing pain intensity and improving functional jaw movement is the priority.

Convergent HIV-1 Evolution upon Targeted Destabilization of the gp120-gp41 Interface.

The HIV-1 envelope glycoprotein (Env) trimer is responsible for viral entry into target cells and is the sole target of neutralizing antibodies. The Env protein is therefore the focus of HIV-1 vaccine design. Env consists of two noncovalently linked subunits (gp120 and gp41) that form a trimer of heterodimers and this 6-subunit complex is metastable and conformationally flexible. Several approaches have been pursued to stabilize the Env trimer for vaccine purposes, which include structure-based design, high-throughput screening, and selection by mammalian cell display. Here, we employed directed virus evolution to improve Env trimer stability. Accordingly, we deliberately destabilized the Env gp120-gp41 interface by mutagenesis in the context of replicating HIV-1 LAI virus and virus evolution over time. We identified compensatory changes that pointed at convergent evolution, as they were largely restricted to specific Env regions, namely, the V1V2 domain of gp120 and the HR1 and HR2 domain of gp41. Specifically, S614G in V1V2 and Q567R in HR1 were frequently identified. Interestingly, the majority of the compensatory mutations were at distant locations from the original mutations and most likely strengthen intersubunit interactions. These results show how the virus can overcome Env instability and illuminate the regions that play a dominant role in Env stability. IMPORTANCE A successful HIV-1 vaccine most likely requires an envelope glycoprotein (Env) component, as Env is the only viral protein on the surface of the virus and the target for neutralizing antibodies. However, HIV Env is metastable and flexible because of the weak interactions between the Env subunits, complicating the generation of recombinant mimics of native Env. Here, we used directed viral evolution to study Env stability. We deliberately destabilized the interface between Env subunits and explored the capacity of the virus to repair trimer instability by evolution. We identified compensatory mutations that converged in specific Env locations: the apex and the trimer interface. Selected mutations enhanced the stability of recombinant soluble Env trimer proteins. These results provided clues on understanding the structural mechanisms involved in Env trimer stability, which can guide future immunogen design.

Guided bone regeneration simultaneous with implant placement using bovine-derived xenograft with and without liquid platelet-rich fibrin: a randomized controlled clinical trial.

OBJECTIVE: To assess augmentation success after guided bone regeneration (GBR) carried out simultaneously with implant placement using bovine-derived xenograft alone and in combination with liquid platelet-rich fibrin (liquid-PRF). METHODS: This randomized controlled clinical trial was conducted on patients with horizontal bone deficiency in the posterior regions of the mandible. After implant placement, GBR procedures were randomly performed using liquid-PRF-enriched bovine-derived xenograft (for the test group) and with bovine-derived xenograft alone (for the control group). To assess the change in augmentation thickness, the primary outcome of the study, cone beam computed tomography was carried out at the implant sites on completion and 6 months after surgery. The secondary outcomes were marginal bone level and implant survival rate at prosthetic delivery and at 6 months, 1 year, and 2 years follow-up after loading. The significance level was set at p<0.05 for all analysis. RESULTS: Twenty patients with 50 implants were analyzed for the test group and 20 patients with 48 implants for the control group. At 6 months postoperatively, the mean values of augmentation thickness were 1.63 ± 0.21 mm, 2.59 ± 0.34 mm, and 3.11 ± 0.36 mm for the test group and 1.34 ± 0.14 mm, 2.49 ± 0.24 mm, and 2.97 ± 0.24 mm for the control group at 2 mm, 4 mm, and 6 mm below to the implant shoulder (p < 0.001, p = 0.007, and p = 0.036, respectively). The mean marginal bone loss was found to be less than 1 mm for both study groups during the 2 years of follow-up after prosthetic loading. Implant survival rate was 100% for both study groups. CONCLUSION: Bovine-derived xenograft alone and in combination with liquid-PRF are both successful in achieving bone augmentation around the implants and produce a small change in marginal bone level and a high implant survival rate after loading. CLINICAL RELEVANCE: There is a lack of evidence in the literature regarding the augmentation success of liquid-PRF used in combination with bone graft substitutes. This study indicates that liquid-PRF could be used as a supportive material with bovine-derived xenograft in GBR procedures carried out simultaneously with implant placement.

The effect of concentrated growth factor (CGF) in the surgical treatment of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients: a randomized controlled study.

OBJECTIVES: The purpose of this present study was to evaluate the efficiency of the growth factors delivered by concentrated growth factor (CGF) on the healing process of osteoporotic patients with medication-related osteonecrosis of the jaws (MRONJ). METHODS: This randomized controlled study was composed of osteoporotic female patients who were treated with oral bisphosphonates (BPs) and diagnosed with MRONJ. For the CGF group, each patient was treated with a local application of CGF at the surgical site after removing the necrotic bone, while the surgical area was primarily closed as traditional surgical therapy for the control group. The patients underwent clinical examinations for 6 months postoperatively to check the presence of infection and dehiscence. RESULTS: Complete healing was achieved in 19 patients of 28 patients (mean age: CGF group, 73.57 ± 5.1; control group, 73.64 ± 5.49) diagnosed with MRONJ. There was no significant difference in post-op healing data between groups during healing periods (p > 0.05). In the CGF group (n = 14) in three cases, bone exposure without infection was detected, and one of them showed a recurrent infection. In the control group (n = 14) in six cases, bone exposure without infection was detected, and three of them also showed recurrent infection. CONCLUSION: Although our results were not statistically significant, our findings suggest that the local application of CGF appears to be an effective approach to the surgical treatment of MRONJ in osteoporosis patients by improving tissue regeneration. CLINICAL RELEVANCE: A specific treatment protocol to manage MRONJ is still controversial. This study justifies that CGF can be used in combination with surgical treatment.

Effect of concentrated growth factors on frequency of alveolar Osteitis following partially-erupted mandibular third molar surgery: a randomized controlled clinical study.

BACKGROUND: The aim of this prospective study was to assess the effectiveness of concentrated growth factors (CGF) in preventing the development of alveolar osteitis (AO) after the extraction of partially-erupted mandibular third molars. METHODS: Seventy patients (26 men and 44 women) 18 years or older (mean age 25.86; range 18-35) underwent 140 third molar extractions. All the patients presented with bilateral, partially-erupted mandibular third molars and underwent surgical extractions. In each case, one socket received CGF and the other served as a control. The predictor variable was the CGF application and the sides were categorized as 'CGF' and 'non-CGF'. The outcome variable was the development of AO during the first postoperative week. Other study variables included age and gender. Data were analyzed using Cochran's Q test with the significance level set at a P value less than 0.05. RESULTS: The overall frequency of AO was 11.4% for the control group. The frequency of AO in the CGF group was significantly lower than in the non-CGF group (p < 0.001). CONCLUSIONS: Based on the results of this study, application of CGF fibrin gel may decrease the risk of AO development after mandibular third molar surgery. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov database on November 1, 2019 (ID: NCT04151147 , retrospectively registered).

Bacterial vaginosis in association with spontaneous abortion and recurrent pregnancy losses.

CONTEXT: Bacterial vaginosis (BV) is related to the increased risk of miscarriage, preterm labor, and postpartum endometritis. AIMS: The aim of this study was to evaluate the association between BV and the history of spontaneous abortion and recurrent pregnancy losses. We also examined periods of gestation, including the first and second trimester miscarriages. MATERIALS AND METHODS: The study population consisted of 200 fertile women. Sixty one (30.5%) of 200 women had the history of a spontaneous abortion in the last six months (N = 30) and at least three recurrent pregnancy losses (N = 31). BV was diagnosed either by using Papanicolaou staining, Gram staining, or by culturing with BV-associated bacteria, Gardnerella vaginalis. RESULTS: The presence of BV was statistically associated with the history of a spontaneous abortion in the last 6 months (P < 0.05), whereas there was no significant relationship between BV and recurrent pregnancy losses (P > 0.05). These women were also evaluated in view of periods of gestation. Forty-seven (77%) of 61 women had first trimester miscarriage (≤12 weeks) and 14 (23%) of 61 women had second trimester miscarriage (>12 weeks). There was a statistically significant relationship between BV and second trimester miscarriage (P < 0.05). Positive BV findings were not associated with discharge, itching, and pain (P > 0.05). CONCLUSION: BV may contribute to spontaneous abortion and second trimester miscarriage.

HIV-1 VACCINES. HIV-1 neutralizing antibodies induced by native-like envelope trimers.

A challenge for HIV-1 immunogen design is the difficulty of inducing neutralizing antibodies (NAbs) against neutralization-resistant (tier 2) viruses that dominate human transmissions. We show that a soluble recombinant HIV-1 envelope glycoprotein trimer that adopts a native conformation, BG505 SOSIP.664, induced NAbs potently against the sequence-matched tier 2 virus in rabbits and similar but weaker responses in macaques. The trimer also consistently induced cross-reactive NAbs against more sensitive (tier 1) viruses. Tier 2 NAbs recognized conformational epitopes that differed between animals and in some cases overlapped with those recognized by broadly neutralizing antibodies (bNAbs), whereas tier 1 responses targeted linear V3 epitopes. A second trimer, B41 SOSIP.664, also induced a strong autologous tier 2 NAb response in rabbits. Thus, native-like trimers represent a promising starting point for the development of HIV-1 vaccines aimed at inducing bNAbs.

Immunosilencing a highly immunogenic protein trimerization domain.

Many therapeutic proteins and protein subunit vaccines contain heterologous trimerization domains, such as the widely used GCN4-based isoleucine zipper (IZ) and the T4 bacteriophage fibritin foldon (Fd) trimerization domains. We found that these domains induced potent anti-IZ or anti-Fd antibody responses in animals when fused to an HIV-1 envelope glycoprotein (Env) immunogen. To dampen IZ-induced responses, we constructed an IZ domain containing four N-linked glycans (IZN4) to shield the underlying protein surface. When fused to two different vaccine antigens, HIV-1 Env and influenza hemagglutinin (HA), IZN4 strongly reduced the antibody responses against the IZ, but did not affect the antibody titers against Env or HA. Silencing of immunogenic multimerization domains with glycans might be relevant for therapeutic proteins and protein vaccines.

Enhanced immunogenicity of HIV-1 envelope gp140 proteins fused to APRIL.

Current HIV-1 vaccines based on the HIV-1 envelope glycoprotein spike (Env), the only relevant target for broadly neutralizing antibodies, are unable to induce protective immunity. Env immunogenicity can be enhanced by fusion to costimulatory molecules involved in B cell activation, such as APRIL and CD40L. Here, we found that Env-APRIL signaled through the two receptors, BCMA and TACI. In rabbits, Env-APRIL induced significantly higher antibody responses against Env compared to unconjugated Env, while the antibody responses against the APRIL component were negligible. To extend this finding, we tested Env-APRIL in mice and found minimal antibody responses against APRIL. Furthermore, Env-CD40L did not induce significant anti-CD40L responses. Thus, in contrast to the 4-helix cytokines IL-21 and GM-CSF, the TNF-superfamily members CD40L and APRIL induced negligible autoantibodies. This study confirms and extends previous work and shows that fusion of Env-based immunogens to APRIL can improve Env immunogenicity and might help in designing HIV vaccines that induce protective humoral immunity.

Autoantibodies induced by chimeric cytokine-HIV envelope glycoprotein immunogens.

Cytokines are often used as adjuvants to increase the immunogenicity of vaccines because they can improve the immune response and/or direct it into a desired direction. As an alternative to codelivering Ags and cytokines separately, they can be fused into a composite protein, with the advantage that both moieties act on the same immune cells. The HIV-1 envelope glycoprotein (Env) spike, located on the outside of virus particles and the only relevant protein for the induction of neutralizing Abs, is poorly immunogenic. The induction of anti-Env Abs can be improved by coupling Env proteins to costimulatory molecules such as a proliferation inducing ligand (APRIL). In this study, we evaluated the immunogenicity of chimeric molecules containing uncleaved Env gp140 fused to the species-matched cytokines IL-21 or GM-CSF in rabbits and mice. Each cytokine was either fused to the C terminus of Env or embedded within Env at the position of the variable loops 1 and 2. The cytokine components of the chimeric Env-GM-CSF and Env-IL-21 molecules were functional in vitro, but none of the Env-cytokine fusion proteins resulted in improved Ab responses in vivo. Both the Env-GM-CSF and the Env-IL-21 molecules induced strong anticytokine Ab responses in both test species. These autoimmune responses were independent of the location of the cytokine in the chimeric Env molecules in that they were induced by cytokines inserted within the variable loops 1 and 2 of Env or fused to its C terminus. The induction of undesired autoimmune responses should be considered when using cytokines as costimulatory molecules in fusion proteins.

Functional analysis in mouse embryonic stem cells reveals wild-type activity for three MSH6 variants found in suspected Lynch syndrome patients.

Lynch syndrome confers an increased risk to various types of cancer, in particular early onset colorectal and endometrial cancer. Mutations in mismatch repair (MMR) genes underlie Lynch syndrome, with the majority of mutations found in MLH1 and MSH2. Mutations in MSH6 have also been found but these do not always cause a clear cancer predisposition phenotype and MSH6-defective tumors often do not show the standard characteristics of MMR deficiency, such as microsatellite instability. In particular, the consequences of MSH6 missense mutations are challenging to predict, which further complicates genetic counseling. We have previously developed a method for functional characterization of MSH2 missense mutations of unknown significance. This method is based on endogenous gene modification in mouse embryonic stem cells using oligonucleotide-directed gene targeting, followed by a series of functional assays addressing the MMR functions. Here we have adapted this method for the characterization of MSH6 missense mutations. We recreated three MSH6 variants found in suspected Lynch syndrome families, MSH6-P1087R, MSH6-R1095H and MSH6-L1354Q, and found all three to behave like wild type MSH6. Thus, despite suspicion for pathogenicity from clinical observations, our approach indicates these variants are not disease causing. This has important implications for counseling of mutation carriers.

An HIV-1 envelope glycoprotein trimer with an embedded IL-21 domain activates human B cells.

Broadly neutralizing antibodies (bNAbs) that target the HIV-1 envelope glycoproteins (Env) can prevent virus acquisition, but several Env properties limit its ability to induce an antibody response that is of sufficient quantity and quality. The immunogenicity of Env can be increased by fusion to co-stimulatory molecules and here we describe novel soluble Env trimers with embedded interleukin-4 (IL-4) or interleukin-21 (IL-21) domains, designed to activate B cells that recognize Env. In particular, the chimeric Env(IL-21) molecule activated B cells efficiently and induced the differentiation of antibody secreting plasmablast-like cells. We studied whether we could increase the activity of the embedded IL-21 by designing a chimeric IL-21/IL-4 (ChimIL-21/4) molecule and by introducing amino acid substitutions in the receptor binding domain of IL-21 that were predicted to enhance its binding. In addition, we incorporated IL-21 into a cleavable Env trimer and found that insertion of IL-21 did not impair Env cleavage, while Env cleavage did not impair IL-21 activity. These studies should guide the further design of chimeric proteins and Env(IL-21) may prove useful in improving antibody responses against HIV-1.

Chimeric HIV-1 envelope glycoproteins with potent intrinsic granulocyte-macrophage colony-stimulating factor (GM-CSF) activity.

HIV-1 acquisition can be prevented by broadly neutralizing antibodies (BrNAbs) that target the envelope glycoprotein complex (Env). An ideal vaccine should therefore be able to induce BrNAbs that can provide immunity over a prolonged period of time, but the low intrinsic immunogenicity of HIV-1 Env makes the elicitation of such BrNAbs challenging. Co-stimulatory molecules can increase the immunogenicity of Env and we have engineered a soluble chimeric Env trimer with an embedded granulocyte-macrophage colony-stimulating factor (GM-CSF) domain. This chimeric molecule induced enhanced B and helper T cell responses in mice compared to Env without GM-CSF. We studied whether we could optimize the activity of the embedded GM-CSF as well as the antigenic structure of the Env component of the chimeric molecule. We assessed the effect of truncating GM-CSF, removing glycosylation-sites in GM-CSF, and adjusting the linker length between GM-CSF and Env. One of our designed Env(GM-CSF) chimeras improved GM-CSF-dependent cell proliferation by 6-fold, reaching the same activity as soluble recombinant GM-CSF. In addition, we incorporated GM-CSF into a cleavable Env trimer and found that insertion of GM-CSF did not compromise Env cleavage, while Env cleavage did not compromise GM-CSF activity. Importantly, these optimized Env(GM-CSF) proteins were able to differentiate human monocytes into cells with a macrophage-like phenotype. Chimeric Env(GM-CSF) should be useful for improving humoral immunity against HIV-1 and these studies should inform the design of other chimeric proteins.

A chimeric HIV-1 envelope glycoprotein trimer with an embedded granulocyte-macrophage colony-stimulating factor (GM-CSF) domain induces enhanced antibody and T cell responses.

An effective HIV-1 vaccine should ideally induce strong humoral and cellular immune responses that provide sterilizing immunity over a prolonged period. Current HIV-1 vaccines have failed in inducing such immunity. The viral envelope glycoprotein complex (Env) can be targeted by neutralizing antibodies to block infection, but several Env properties limit the ability to induce an antibody response of sufficient quantity and quality. We hypothesized that Env immunogenicity could be improved by embedding an immunostimulatory protein domain within its sequence. A stabilized Env trimer was therefore engineered with the granulocyte-macrophage colony-stimulating factor (GM-CSF) inserted into the V1V2 domain of gp120. Probing with neutralizing antibodies showed that both the Env and GM-CSF components of the chimeric protein were folded correctly. Furthermore, the embedded GM-CSF domain was functional as a cytokine in vitro. Mouse immunization studies demonstrated that chimeric Env(GM-CSF) enhanced Env-specific antibody and T cell responses compared with wild-type Env. Collectively, these results show that targeting and activation of immune cells using engineered cytokine domains within the protein can improve the immunogenicity of Env subunit vaccines.