The Impact of Candida albicans in the Development, Kinetics, Structure, and Cell Viability of Biofilms on Implant Surfaces—An In Vitro Study with a Validated Multispecies Biofilm Model

This study aimed to evaluate the impact of Candida albicans on subgingival biofilm formation on dental implant surfaces. Scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM) were used to compare biofilm structure and microbial biomass in the presence and absence of the fungus after periods of 24, 48, and 72 h. Quantitative polymerase chain reaction (qPCR) was used to quantify the number of viable and total micro-organisms for each of the biofilm-forming strains. A general linear model was applied to compare CLSM and qPCR results between the control and test conditions. The biofilm developed with C. albicans at 72 h had a higher bacterial biomass and a significantly higher cell viability (p < 0.05). After both 48 and 72 h of incubation, in the presence of C. albicans, there was a significant increase in counts of Fusobacterium nucleatum and Porphyromonas gingivalis and in the cell viability of Streptococcus oralis, Aggregatibacter actinomycetemcomitans, F. nucleatum, and P. gingivalis. Using a dynamic in vitro multispecies biofilm model, C. albicans exacerbated the development of the biofilm grown on dental implant surfaces, significantly increasing the number and cell viability of periodontal bacteria.


Introduction
The use of dental implants is currently the most widespread strategy for the rehabilitation of total or partial edentulism, resulting in long-term satisfactory success rates [1][2][3].However, these implant-supported restorations are susceptible to complications during their function, both mechanical and biological.At the last World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions (2017), peri-implant diseases were classified as peri-implant mucositis and peri-implantitis [4], with estimated prevalence ranges between 43% and 47% for peri-implant mucositis and 20% and 22% for peri-implantitis [5].The primary etiological factor of peri-implantitis is the biofilm formed on dental implants and their restorative component surfaces, triggering a chronic inflammatory response, eventually leading to bone destruction and progressive loss of implant osseointegration [4,[6][7][8][9].Submarginal biofilms are structurally and functionally organized complex microbial communities, consisting mainly of bacteria but also viruses, protozoa, and, to a greater extent, fungi, that synthesize an extracellular polymeric matrix, which binds cells together and anchors them to biotic or abiotic surfaces susceptible to colonization [10][11][12][13][14].The development of dysbiotic biofilms, with changes in the relative proportions of the bacterial communities, has been associated with the etiology and pathogenesis of periodontal and peri-implant diseases and the decreasing efficacy of antimicrobial treatments [15].
The most frequent fungal pathogen in the oral cavity is Candida albicans, a dimorphic facultative anaerobic fungus that is usually present as a yeast under favorable environments, although it usually presents as a filamentous fungus under unfavorable conditions [16].These differential conditions are related to nutrient availability, environmental atmospheric composition, or the presence of antifungal agents [17].
The presence of C. albicans in subgingival pockets has been reported at higher rates in subjects with periodontitis compared with periodontally healthy individuals [18], although there is a high heterogeneity in the reported prevalence of C. albicans in the subgingival microbiota of periodontitis patients, ranging from 14.6% to 87.5% [19,20].Similarly, in peri-implantitis, the presence of C. albicans is higher than around implants with healthy peri-implant tissues or in peri-implant mucositis sites [21].In different studies, C. albicans was detected in 27%, 15.8%, 77.6%, and 76.2% of patients with peri-implantitis, versus 0%, 10%, 12.2%, and 9.8% in patients with peri-implant health [7,[22][23][24].This high variability could be due to the different identification methods used in the different studies.
The pathogenicity of C. albicans is mediated by its adhesion to the implant surface in a process favored by salivary mucin and albumin [25].Once adhered, its growth generates hyphae and secretes hydrolytic enzymes, basically proteases, lipases, and hemolysins, which may activate the inflammatory response of the host soft tissues [26][27][28].The inflammatory response to C. albicans-infected epithelial cells is mediated by proinflammatory cytokines, which further contribute to the chronic inflammatory response characteristic of peri-implant disease lesions and, eventually, to the tissue destruction and alveolar bone resorption characteristic of peri-implantitis [29][30][31].
Validated biofilm models have been used to study the interactions between microorganisms and test in vitro antimicrobial therapies [32][33][34][35].The pathogenic mechanisms of the potential interactions between C. albicans and the bacteria present in subgingival/submarginal biofilms have been mostly studied in vitro, using culturing or static biofilm models [36][37][38].These studies have demonstrated that C. albicans influences biofilm architecture and favors the presence and virulence of certain periodontal pathogenic bacterial strains [39][40][41].However, the overall effect of C. albicans on a multispecies biofilm or on biofilm formation on dental implant surfaces has not yet been studied.It was, therefore, the aim of this in vitro study to evaluate the impact of C. albicans on the development, kinetics, structure, and viability of biofilm formation on dental implant surfaces in a validated multispecies dynamic model.Further knowledge about these interactions may help in the development of new therapies aimed at the control of periodontal and peri-implant diseases.

Scanning Electron Microscopy (SEM) Analysis
Figure 1 depicts the SEM images of biofilms grown on the implant surfaces after 24, 48, and 72 h in the presence (test) and absence (control) of the fungus Candida albicans, clearly showing a differential biofilm morphology.
After 24 h of incubation, C. albicans presented as yeast (Figure 1G) and did not affect the structure of the biofilm, composed at this first stage by cocci (Streptococcus oralis and Veillonella parvula), and rods and spindle-shaped bacteria, corresponding to Actinomyces naeslundii and Fusobacterium nucleatum (Figure 1A,D).After 24 h of incubation, C. albicans presented as yeast (Figure 1G) and did not affect the structure of the biofilm, composed at this first stage by cocci (Streptococcus oralis and Veillonella parvula), and rods and spindle-shaped bacteria, corresponding to Actinomyces naeslundii and Fusobacterium nucleatum (Figures 1A,D).
At 48 h, C. albicans started to manifest as filaments, forming pseudohyphae to which F. nucleatum and cocci bacteria were anchored (Figure 1H).Compared to the 24-h biofilm, there was a higher density of spindle-shaped bacteria and cocci, corresponding to F. nucleatum and Aggregatibacter actinomycetemcomitans, respectively.In the test biofilms (with C. albicans) (Figure 2E), the presence of coccobacillary forms of Porphyromonas gingivalis was more frequent than in the control biofilms (Figure 2B).At 48 h, C. albicans started to manifest as filaments, forming pseudohyphae to which F. nucleatum and cocci bacteria were anchored (Figure 1H).Compared to the 24-h biofilm, there was a higher density of spindle-shaped bacteria and cocci, corresponding to F. nucleatum and Aggregatibacter actinomycetemcomitans, respectively.In the test biofilms (with C. albicans) (Figure 2E), the presence of coccobacillary forms of Porphyromonas gingivalis was more frequent than in the control biofilms (Figure 2B).
At 72 h, cellular aggregates formed by spindles, cocci, and coccobacilli (F.nucleatum, A. actinomycetemcomitans and P. gingivalis, respectively) were deposited on the pseudohyphae of C. albicans, presenting as a mixed mature biofilm with a higher biomass than in the previous time intervals (Figure 1I).The test biofilms demonstrated a higher bacterial density, as shown in Figure 1F,C.In fact, control biofilms at 72 h presented a lower bacterial density than the test biofilms at 48 h.At 72 h, cellular aggregates formed by spindles, cocci, and coccobacilli (F.nucleatum A. actinomycetemcomitans and P. gingivalis, respectively) were deposited on the pseudohyphae of C. albicans, presenting as a mixed mature biofilm with a higher biomass than in the previous time intervals (Figure 1I).The test biofilms demonstrated a higher bacterial density, as shown in Figures 1F,C.In fact, control biofilms at 72 h presented a lower bacterial density than the test biofilms at 48 h.

Confocal Laser Scanning Microscopy (CLSM) Analysis
C. albicans increased its size on the implant surface as the biofilm was maturing after 24, 48, and 72 h of incubation (Figures 2 and 3).

Quantitative Polymerase Chain Reaction (qPCR) Analysis
Figure 4 shows counts of total and viable cells in biofilms develop h, expressed as colony-forming units (CFU)/mL for each bacterial spe in test biofilms, together with cell viability and the percentage of live Biofilms formed after 48 h also did not show differences between test and control biofilms.Control biofilms had a bacterial biomass of 10.02 µm 3 /µm 2 (SD = 6.21) and test ones of 9.69 µm 3 /µm 2 (SD = 2.14) (Figure 2B,E).There were also no differences between the cell viability of the two biofilms, 52.47% (SD = 5.00%) for control biofilms and 58.50% (SD = 18.07%) for test biofilms (Figure 3).C. albicans had a biomass of 8.86 µm 3 /µm 2 (SD = 2.78) (Figure 2H).

Quantitative Polymerase Chain Reaction (qPCR) Analysis
Figure 4 shows counts of total and viable cells in biofilms developed at 24, 48, and 72 h, expressed as colony-forming units (CFU)/mL for each bacterial species and C. albicans in test biofilms, together with cell viability and the percentage of live cells to total counts.
At 24 h of incubation, the growth and viability of C. albicans were limited.There were no statistically significant differences in counts for any of the six biofilm-forming bacterial species when comparing test and control biofilms.
At 48 h, the development of C. albicans increased, and in the test biofilms, the counts and viability of F. nucleatum and P. gingivalis were significantly higher.The same pattern was observed for A. naeslundii.Cell viability of A. actinomycetemcomitans was also significantly higher in test biofilms.
At 72 h, a similar pattern occurred, with higher growth of C. albicans, when compared to previous intervals, and larger counts of F. nucleatum, P. gingivalis, and A. naeslundii in test biofilms when compared to control biofilms.At this stage, also the number of viable cells of S. oralis, F. nucleatum, P. gingivalis, and A. actinomycetemcomitans were significantly higher compared to the controls.which was 18.91 µm 3 /µm 2 (SD = 6.31).

Quantitative Polymerase Chain Reaction (qPCR) Analysis
Figure 4 shows counts of total and viable cells in biofilms developed at 24, 48, and 72 h, expressed as colony-forming units (CFU)/mL for each bacterial species and C. albicans in test biofilms, together with cell viability and the percentage of live cells to total counts.S1.
At 24 h of incubation, the growth and viability of C. albicans were limited.There were no statistically significant differences in counts for any of the six biofilm-forming bacterial species when comparing test and control biofilms.
At 48 h, the development of C. albicans increased, and in the test biofilms, the counts and viability of F. nucleatum and P. gingivalis were significantly higher.The same pattern was observed for A. naeslundii.Cell viability of A. actinomycetemcomitans was also significantly higher in test biofilms.
At 72 h, a similar pattern occurred, with higher growth of C. albicans, when compared to previous intervals, and larger counts of F. nucleatum, P. gingivalis, and A. naeslundii in test biofilms when compared to control biofilms.At this stage, also the number of viable cells of S. oralis, F. nucleatum, P. gingivalis, and A. actinomycetemcomitans were significantly higher compared to the controls.S1.

Discussion
In the present study, a validated in vitro multispecies dynamic biofilm model was used to assess the influence of C. albicans on biofilms developed on dental implant surfaces.The selection of species for the biofilm model was based on selecting a representative sample of the diversity of the subgingival biofilm including early, intermediate, and late colonizers.This selection included gram-positive and gram-negative bacterial strains as well as bacteria of different nutritional and environmental requirements.Bacterial counts determined by qPCR analysis indicated that, after 48 and 72 h of growth, the number and cell viability of F. nucleatum and P. gingivalis were significantly higher in biofilms developed in the presence of the fungus.Similarly, the proportion of live cells of A. actinomycetemcomitans and S. oralis also increased significantly in the presence of C. albicans in mature biofilms (72 h) (Figure 4 and Table S1).Similar results were obtained by CLSM analyses, depicting a significantly higher overall size and cell viability in mature biofilms (72 h) in the presence of C. albicans (Figures 2 and 3).
The progressive filamentation of C. albicans cells observed in the SEM analysis (Figure 1) may have been favored by the experimental conditions of the biofilm model used, since they simulate oral cavity conditions (pH 7, 37 • C, anaerobic environment) and the presence of gram-negative bacteria (V.parvula, F. nucleatum, P. gingivalis, and A. actinomycetemcomitans) [17].The filamentation process is mediated by the ROB1 946S allele [42].In the maturation of C. albicans-associated biofilms, the filamentation process led to the attachment to implant surfaces of hyphae and yeast-like (sessile) cells, associated with microcolonies of rods and spindle-shaped bacteria, embedded in an extracellular matrix.This morphology coincides with other previous descriptions of C. albicans-associated biofilms [43].The impact of C. albicans on biofilm formation shown in the present study, demonstrating significantly higher biofilm biomass and higher percentages/counts of total and viable bacterial strains, may be exacerbated by the demonstrated activation in the expression of hydrolytic enzymes by C. albicans in the presence of periodontal bacteria, which may further compromise the host immune response and enhance the resistance of the resulting biofilm to antifungal agents [36,44].
One of the possible relevant findings of the present study is the specific impact of C. albicans on the percentage of viable cells in P. gingivalis (Figure 4 and Table S1).This effect may be due to the enhanced anaerobic environment generated by the fungal hyphae due to oxygen consumption [45], clearly depicted within the biofilm architecture shown by SEM.Additionally, Interlin InlJ has been involved in the expression of P. gingivalis genes responsible for the interaction with C. albicans hyphae [46].It has also been reported that adhesins Als3 and the proteases Sap6 and Sap9 of C. albicans, together with the gingipains of P. gingivalis, may favor the invasion of these micro-organisms in epithelial cells and fibroblasts [39,47].Along the same lines, citrullination, mediated by peptidyl arginine deiminase (PPAD) secreted by P. gingivalis, may favor the adhesion of this bacterial species to the cell wall of C. albicans, thus increasing its viability under aerobic conditions [48].The competition for iron sources that may occur between P. gingivalis and C. albicans under conditions such as those of the present study, where this nutrient is limited, may also explain the increased viability of the bacteria in the mixed biofilm.Furthermore, this competition may also favor the resistance of P. gingivalis to antimicrobial substances by increasing the expression of virulence genes [49].Thus, the beneficial effect of C. albicans on P. gingivalis could increase the pathogenic capacity of this periodontal pathogen.In contrast to the results from the present investigation, Cavalcanti et al. (2016) reported that P. gingivalis exerted an opposite influence on C. albicans by inhibiting its hyphal production.In the model used in the present investigation, the concomitant presence of Streptococcus and Actinomyces species may have reverted to this inhibition [36,37].In fact, other authors have argued that the effect of this interaction is dependent on the fungal strain, the composition of the medium, and the streptococcal population present [50].
C. albicans also significantly increased the vitality of F. nucleatum in the multispecies biofilm (Figure 4 and Table S1).This could be due to the interaction between the bacterial adhesin radD and the fungal cell wall mannoprotein FLO9, thus facilitating a specific dual aggregation and enhanced growth of F. nucleatum [51,52].This increased growth may enhance the bridging role of F. nucleatum between primary colonizers and the late colonizers P. gingivalis and A. actinomycetemcomitans, an effect that has already been attributed to C. albicans [41].Conversely, another in vitro study indicated that F. nucleatum could inhibit the filamentation process of C. albicans by limiting its ability to kill macrophages and, thus, attenuating its pathogenic potential [53].Similarly, the presence of A. actinomycetemcomitans through its autoinducer Quorum Sensing-2 (AI-2) molecule inhibits fungal hyphal formation and C. albicans aggregation [38].However, the quantitative results from the present study indicated that C. albicans increased the survival rate of A. actinomycetemcomitans in mature biofilms.This phenomenon may suggest that the protective anaerobic environment generated by the hyphae and the consequent increased development of F. nucleatum spindles would favor the survival of A. actinomycetemcomitans in mature biofilms.Further studies are needed to elucidate this specific dual interaction.
The increase in live cells of the initial colonizer, S. oralis, in the mature biofilm was also favored by C. albicans.This effect can be explained by the binding of the cocci to the gtfR glucan-binding domain, the main component of the cell wall of C. albicans [54].S. oralis is also supposed to induce filamentation of C. albicans, which may enhance the invasiveness of fungal and bacterial cells into host epithelial cells [55,56].
Based on the above interactions, Figure 5 shows a comparison of biofilms developed in the presence and absence of C. albicans.The presence of the fungus stimulates a more robust and compact mature biofilm, where anaerobic environments are enhanced, which may stimulate the proliferation and growth of more pathogenic bacteria.
the filamentation process of C. albicans by limiting its ability to kill macrophages and, thus, attenuating its pathogenic potential [53].Similarly, the presence of A. actinomycetemcomitans through its autoinducer Quorum Sensing-2 (AI-2) molecule inhibits fungal hyphal formation and C. albicans aggregation [38].However, the quantitative results from the present study indicated that C. albicans increased the survival rate of A. actinomycetemcomitans in mature biofilms.This phenomenon may suggest that the protective anaerobic environment generated by the hyphae and the consequent increased development of F. nucleatum spindles would favor the survival of A. actinomycetemcomitans in mature biofilms.Further studies are needed to elucidate this specific dual interaction.
The increase in live cells of the initial colonizer, S. oralis, in the mature biofilm was also favored by C. albicans.This effect can be explained by the binding of the cocci to the gtfR glucan-binding domain, the main component of the cell wall of C. albicans [54].S. oralis is also supposed to induce filamentation of C. albicans, which may enhance the invasiveness of fungal and bacterial cells into host epithelial cells [55,56].
Based on the above interactions, Figure 5 shows a comparison of biofilms developed in the presence and absence of C. albicans.The presence of the fungus stimulates a more robust and compact mature biofilm, where anaerobic environments are enhanced, which may stimulate the proliferation and growth of more pathogenic bacteria.Consistent with the results from the present investigation, in vivo studies have also reported that C. albicans may exert an important pathogenic effect in the later stages of peri-implantitis, when the biofilm is already established [36].In fact, case-control studies have demonstrated a higher presence of C. albicans in the peri-implant sulcus of patients with peri-implantitis compared with those with healthy peri-implant tissues [57].Similarly, the presence of hyphae in connective tissue specimens of peri-implantitis has been demonstrated in association with P. gingivalis, A. actinomycetemcomitams and P. intermedia [58], as well as with V. parvula, Tannerella forsythia and Parvimonas micra [59].A deeper understanding of the interactions of C. albicans with the virulence of the different individual bacterial species within the subgingival/submarginal biofilms may help to better understand its pathogenicity and its resistance to antimicrobial strategies.For example, the β,1-3 glucan in the cell wall of C. albicans has been shown to modulate the tolerance of periodontal bacterial anaerobes to different antibiotics [60].This knowledge may also help to design more effective preventive strategies, such as those based on the use of pre-or probiotics [37] or agents aimed at preventing this dysbiotic effect.
The experimental procedures used for the development of the present study are not free of limitations that should be acknowledged.First, although the biofilm model Consistent with the results from the present investigation, in vivo studies have also reported that C. albicans may exert an important pathogenic effect in the later stages of peri-implantitis, when the biofilm is already established [36].In fact, case-control studies have demonstrated a higher presence of C. albicans in the peri-implant sulcus of patients with peri-implantitis compared with those with healthy peri-implant tissues [57].Similarly, the presence of hyphae in connective tissue specimens of peri-implantitis has been demonstrated in association with P. gingivalis, A. actinomycetemcomitams and P. intermedia [58], as well as with V. parvula, Tannerella forsythia and Parvimonas micra [59].A deeper understanding of the interactions of C. albicans with the virulence of the different individual bacterial species within the subgingival/submarginal biofilms may help to better understand its pathogenicity and its resistance to antimicrobial strategies.For example, the β,1-3 glucan in the cell wall of C. albicans has been shown to modulate the tolerance of periodontal bacterial anaerobes to different antibiotics [60].This knowledge may also help to design more effective preventive strategies, such as those based on the use of pre-or probiotics [37] or agents aimed at preventing this dysbiotic effect.
The experimental procedures used for the development of the present study are not free of limitations that should be acknowledged.First, although the biofilm model attempts to mimic the conditions of the oral cavity, there are specific individual variables that cannot be reproduced.In addition, natural subgingival/submarginal biofilms may be composed of hundreds of species, whereas the model used is composed of six bacterial species that are intended to be representative of different types of colonizers.Finally, the accuracy of the data obtained is limited due to the high experimental variability linked to in vitro work with live micro-organisms.
Considering the acknowledged limitations, the statistical evaluation of the obtained results allows us to conclude that C. albicans has a significant impact on the growth, dynamics, structure, and viability of subgingival/submarginal biofilms formed on implant surfaces, favoring an increase in the development of P. gingivalis, F. nucleatum, A. actinomycetemcomitans, and S. oralis.In conclusion, the effect on the biofilm and on the periodontal pathogens P. gingivalis and A. actinomycetemcomitans exerted by C. albicans may impact the initiation and progression of periodontal and peri-implant diseases.

In Vitro Dynamic Multispecies Biofilm Model
An in vitro multispecies dynamic biofilm model was used [61,62], which has been validated on biofilms growing on implant surfaces [35,63].Basically, the system consists of a sterile vessel where the liquid culture medium, namely the previously described protein-enriched BHI medium, is pumped into the bioreactor by a peristaltic pump at constant pressure.The bioreactor (Lambda Minifor © bioreactor, LAMBDA Laboratory Instruments, Sihlbruggstrasse, Switzerland) maintains the culture medium under stable conditions at 37 • C, pH 7.2, and an anaerobic atmosphere (10% H 2 , 10% CO 2 , and N 2 balance) during the whole incubation process.These conditions are maintained by directly pumping an anaerobic gas mixture (10% H 2 , 10% CO 2 , and equilibrium N 2 ) through a filter into the incubation vessel, keeping the pressure constant.The system is inoculated with 5 mL of the previously described microbial suspension and maintained for 12 h under the described conditions.Subsequently, once the mixed culture reached the exponential growth phase, the continuous culture was activated through a second peristaltic pump with a flow rate of 30 mL/h to transfer the culture to Robbins devices placed in series that carry the sterile dental implant units on which the biofilm was developed (Straumann ® Tissue Level Standard, 8 mm in length and 3.3 mm in diameter, with the patented moderately rough sandblasted and acid-etched surface [Straumann Institute AG, Basel, Switzerland]).
Inside the Robbins device, anaerobic conditions and a constant temperature (37 • C) are maintained during each experimental interval to allow biofilm development.

Experimental Groups
To evaluate the effect of C. albicans on the dynamics of subgingival biofilm formation on implant surfaces, three time intervals were analyzed: 24, 48, and 72 h.For each time interval, the developed biofilms were incubated under two different conditions, the test biofilms included a mixed culture composed of the bacterial strains S. oralis, A. naeslundii, V. parvula, F. nucleatum, P. gingivalis, A. actinomycetemcomitans, and the fungus C. albicans, while the control biofilms included only the six bacterial strains.At each time and in each condition, three implants were analyzed by confocal microscopy (CLSM) (n = 3), three by scanning electron microscopy (SEM) (n = 3), and nine by real-time polymerase chain reaction (qPCR) (n = 9).

Scanning Electron Microscopy (SEM)
After removal of the implants from the Robbins device, the implants were sequentially washed three times with 2 mL of phosphate-buffered saline (PBS) (immersion time per rinse, 10 s) to remove unattached bacteria.The implants were then fixed in a solution of 4% paraformaldehyde (Panreac Química, Barcelona, Spain) and 2.5% glutaraldehyde (Panreac Química) for 4 h at 4 • C.They were then washed in PBS and sterile water (immersion time per wash: 10 min) and dehydrated through a series of graded ethanol solutions (30%, 50%, 70%, 80%, 90%, and 100%; immersion time per series: 10 min).Then the specimens were dried, coated with gold, and analyzed using a JSM 6400 electron microscope (JSM6400, JEOL, Tokyo, Japan), with a backscatter electron detector and an image resolution of 25 kV.
This analysis was carried out at the National Centre of Electron Microscopy (Instalación Científico-Técnico singular; ICTS) at the Moncloa Campus of the Complutense University of Madrid (Madrid, Spain).
Prior to the microscopic analysis, the Robbins device was taken from the bioreactor and carefully removed the implants, which were then washed three times with 2 mL of PBS (immersion time per rinse, 10 s) to remove unattached bacteria.
For observing and quantifying the biofilm bacteria, the samples were stained with the LIVE/DEAD ® BacLightTM bacterial viability kit solution (Molecular Probes, The Netherlands), which contains propidium iodide (PI) and SYTO9 nucleic acid dyes.With this method, dead cells or those with compromised viability are stained in red (PI), while cells with an intact membrane are stained in green (SYTO9).Implants were then coated with fluorochromes in a 1:1 ratio and incubated for 9 ± 1 min to obtain the optimal fluorescence signal at the corresponding wavelengths (SYTO9: 515-530 nm; PI: >600 nm).To observe and quantify C. albicans, implants were stained for 10 min with 3% Calcofluor White (CFW), thus obtaining an optimal signal using a wavelength of 405 nm.
Representative implant surface locations involving both the peak of a thread and the bottom of the valley were selected for the CLSM analyses.
The analysis was performed at the Biological Research Centre Margarita Salas (Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas-CIB-CSIC), located at the Moncloa Campus of the Complutense University of Madrid (Madrid, Spain).

Figure 1 .
Figure 1.Images obtained by scanning electron microscopy (SEM) with 2500× magnification of control biofilms (in the absence of Candida albicans) developed at 24, 48, and 72 h ((A-C), respectively) and of test biofilms (in the presence of C. albicans) developed at the same intervals ((D-F), respectively).Images (G-I) show test biofilms with 5000× magnification after 24, 48, and 72 h of incubation, respectively (n = 6).

Figure 1 .
Figure 1.Images obtained by scanning electron microscopy (SEM) with 2500× magnification of control biofilms (in the absence of Candida albicans) developed at 24, 48, and 72 h ((A-C), respectively) and of test biofilms (in the presence of C. albicans) developed at the same intervals ((D-F), respectively).Images (G-I) show test biofilms with 5000× magnification after 24, 48, and 72 h of incubation, respectively (n = 6).
Figure 2A-F depict CLSM images representative of control and test biofilms, respectively, clearly showing the impact of C. albicans on the biomass of the test biofilms.
Figure 2G-I show C. albicans in the test biofilms The kinetics of the development of both biofilms are shown in Figure 3.
Figure 2A-F depict CLSM images representative of control and test biofilms, respectively, clearly showing the impact of C. albicans on the biomass of the test biofilms.Figure 2G-I show C. albicans in the test biofilms.The kinetics of the development of both biofilms are shown in Figure 3.

Figure 3 .
Figure 3. Kinetics of control and test biofilms and Candida albicans [expressed of biofilm (µm 3 /µm 2 )] obtained by quantification of images of confocal laser (CLSM).Percentages show the proportion of viable cells at each interval of statistically significant differences when comparing test and control biofilms a

Figure 3 .
Figure 3. Kinetics of control and test biofilms and Candida albicans [expressed as microbial biomass of biofilm (µm 3 /µm 2 )] obtained by quantification of images of confocal laser scanning microscopy (CLSM).Percentages show the proportion of viable cells at each interval of incubation.* p < 0.05, statistically significant differences when comparing test and control biofilms at each time interval.

Figure 4 .
Figure 4. Kinetics (expressed as mean and standard deviation (SD)) of total and live microbial species (colony-forming units (CFUs)/mL) determined by quantitative polymerase chain reaction (qPCR) in 24, 48, and 72 h biofilms on dental implants in the presence (T, test) and absence (C, control) of Candida albicans (n = 9), using specific primers and probes directed to the 16S rRNA gene.* p < 0.05, statistically significant differences when comparing CFU/mL between test and control biofilms at each time interval.Comparisons between groups were performed considering viable cells and total cells.Figure corresponding to Supplementary TableS1.

Figure 4 .
Figure 4. Kinetics (expressed as mean and standard deviation (SD)) of total and live microbial species (colony-forming units (CFUs)/mL) determined by quantitative polymerase chain reaction (qPCR) in 24, 48, and 72 h biofilms on dental implants in the presence (T, test) and absence (C, control) of Candida albicans (n = 9), using specific primers and probes directed to the 16S rRNA gene.* p < 0.05, statistically significant differences when comparing CFU/mL between test and control biofilms at each time interval.Comparisons between groups were performed considering viable cells and total cells.Figure corresponding to Supplementary TableS1.

Figure 5 .
Figure 5. Graphical representation of the control biofilm, without Candida albicans, and the biofilm test developed in the presence of the fungus.Image was created on BioRender.com(accessed on 4 March 2024).

Figure 5 .
Figure 5. Graphical representation of the control biofilm, without Candida albicans, and the biofilm test developed in the presence of the fungus.Image was created on BioRender.com(accessed on 4 March 2024).