Pulp development, repair, and regeneration: challenges of the transition from traditional dentistry to biologically based therapies

Biomimetic microenvironments for regenerative endodontics

Regenerative endodontics has been proposed to replace damaged and underdeveloped tooth structures with normal pulp-dentin tissue by providing a natural extracellular matrix (ECM) mimicking environment; stem cells, signaling molecules, and scaffolds. In addition, clinical success of the regenerative endodontic treatments can be evidenced by absence of signs and symptoms; no bony pathology, a disinfected pulp, and the maturation of root dentin in length and thickness. In spite of the various approaches of regenerative endodontics, there are several major challenges that remain to be improved: a) the endodontic root canal is a strong harbor of the endodontic bacterial biofilm and the fundamental etiologic factors of recurrent endodontic diseases, (b) tooth discolorations are caused by antibiotics and filling materials, (c) cervical root fractures are caused by endodontic medicaments, (d) pulp tissue is not vascularized nor innervated, and (e) the dentin matrix is not developed with adequate root thickness and length. Generally, current clinical protocols and recent studies have shown a limited success of the pulp-dentin tissue regeneration. Throughout the various approaches, the construction of biomimetic microenvironments of pulp-dentin tissue is a key concept of the tissue engineering based regenerative endodontics. The biomimetic microenvironments are composed of a synthetic nano-scaled polymeric fiber structure that mimics native pulp ECM and functions as a scaffold of the pulp-dentin tissue complex. They will provide a framework of the pulp ECM, can deliver selective bioactive molecules, and may recruit pluripotent stem cells from the vicinity of the pulp apex. The polymeric nanofibers are produced by methods of self-assembly, electrospinning, and phase separation. In order to be applied to biomedical use, the polymeric nanofibers require biocompatibility, stability, and biodegradability. Therefore, this review focuses on the development and application of the biomimetic microenvironments of pulp-dentin tissue among the current regenerative endodontics.

Antioxidant therapy enhances pulpal healing in bleached teeth

Objectives

The purpose of this study was to evaluate the histopathological effects of an antioxidant therapy on the pulp tissue of rat teeth exposed to a bleaching gel with 35% hydrogen peroxide.

Materials and Methods

Forty rats were subjected to oral ingestion by gavage of distilled water (DW) or ascorbic acid (AA) 90 min before the bleaching therapy. For the bleaching treatment, the agent was applied twice for 5 min each to buccal surfaces of the first right mandibular molars. Then, the animals were sacrificed at 6 hr, 24 hr, 3 day, or 7 day post-bleaching, and the teeth were processed for microscopic evaluation of the pulp tissue.

Results

At 6 hr, the pulp tissue showed moderate inflammatory reactions in all teeth of both groups. In the DW and AA groups, 100% and 80% of teeth exhibited pulp tissue with significant necrosis and intense tissue disorganization, respectively. At 24 hr, the AA-treated group demonstrated a greater regenerative capability than the DW group, with less intense inflammatory reaction and new odontoblast layer formation in 60% of the teeth. For up to the 7 day period, the areas of pulpal necrosis were replaced by viable connective tissue, and the dentin was underlined by differentiated odontoblast-like cells in most teeth of both groups.

Conclusions

A slight reduction in initial pulpal damage during post-bleaching was promoted by AA therapy. However, the pulp tissue of AA-treated animals featured faster regenerative potential over time.

Dental Stem Cells in Pulp Regeneration: Near Future or Long Road Ahead?

Although regenerative endodontic procedures have yielded an impressive body of favorable outcomes, the treatment of necrotic immature permanent teeth in particular remains to be a challenge. Recent advances in dental stem cell (DSC) research have gained increasing insight in their regenerative potential and prospective use in the formation of viable dental tissues. Numerous studies have already reported successful dental pulp regeneration following application of dental pulp stem cells, stem cells from the apical papilla, or dental follicle precursor cells in different in vivo models. Next to responsive cells, dental tissue engineering also requires the support of an appropriate scaffold material, ranging from naturally occurring polymers to treated dentin matrix components. However, the routine use and banking of DSCs still holds some major challenges, such as culture-associated differences, patient-related variability, and the effects of culture medium additives. Only in-depth evaluation of these problems and the implementation of standardized models and protocols will effectively lead to better alternatives for patients who no longer benefit from current treatment protocols.

Indirect cytocompatibility of a low-concentration hydrogen peroxide bleaching gel to odontoblast-like cells

AIM

To assess the initial cytotoxicity and the late phenotype marker expression of odontoblast-like cells (MDPC-23) subjected to less aggressive in-office bleaching therapies.

METHODOLOGY

A 17.5% hydrogen peroxide (H2O2) gel was applied for 45, 15 or 5 min to enamel/dentine discs adapted to trans-wells positioned over cultured MDPC-23 cells. No treatment was performed on the negative control. Immediately after bleaching, the cell viability, gene expression of inflammatory mediators and quantification of H2O2 diffusion were evaluated. The ALP activity, DSPP and DMP-1 gene expression and mineralized nodule deposition (MND) were assessed at 7, 14 or 21 days post-bleaching and analysed statistically with Mann-Whitney U-tests (α = 5%).

RESULTS

H2O2 diffusion, proportional to treatment time, was observed in all bleached groups. Reductions of approximately 31%, 21% and 13% in cell viability were observed for the 45-, 15- and 5-min groups, respectively. This reduction was significant (P < 0.05) for the 45- and 15-min groups, which also presented significant (P < 0.05) over-expression of inflammatory mediators. The 45-min group was associated with significant (P < 0.05) reductions in DMP-1/DSPP expression at all periods, relative to control. The ALP activity and MND were reduced only in initial periods. The 15-min group had less intense reduction of all markers, with no difference to control at 21 days.

CONCLUSIONS

The 17.5% H2O2 applied to tooth specimens for 5 min caused no alteration in the odontoblast-like cells. When this gel was applied for 45 or 15 min, a slight cytotoxicity, associated with alterations in phenotypic markers, was observed. However, cells were able to recover their functions up to 21 days post-bleaching.

Regeneration of dentin–pulp-like tissue using an injectable tissue engineering technique

An injectable tissue engineering technique to regenerate dentin–pulp complex.

Effect of intracanal medicaments used in endodontic regeneration procedures on microhardness and chemical structure of dentin

Objectives

This study was performed to investigate the effects of different intracanal medicaments on chemical structure and microhardness of dentin.

Materials and Methods

Fifty human dentin discs were obtained from intact third molars and randomly assigned into two control groups and three treatment groups. The first control group received no treatment. The second control group (no medicament group) was irrigated with sodium hypochlorite (NaOCl), stored in humid environment for four weeks and then irrigated with ethylenediaminetetraacetic acid (EDTA). The three treatment groups were irrigated with NaOCl, treated for four weeks with either 1 g/mL triple antibiotic paste (TAP), 1 mg/mL methylcellulose-based triple antibiotic paste (DTAP), or calcium hydroxide [Ca(OH)₂] and finally irrigated with EDTA. After treatment, one half of each dentin disc was subjected to Vickers microhardness (n = 10 per group) and the other half was used to evaluate the chemical structure (phosphate/amide I ratio) of treated dentin utilizing attenuated total reflection Fourier transform infrared spectroscopy (n = 5 per group). One-way ANOVA followed by Fisher's least significant difference were used for statistical analyses.

Results

Dentin discs treated with different intracanal medicaments and those treated with NaOCl + EDTA showed significant reduction in microhardness (p < 0.0001) and phosphate/amide I ratio (p < 0.05) compared to no treatment control dentin. Furthermore, dentin discs treated with TAP had significantly lower microhardness (p < 0.0001) and phosphate/amide I ratio (p < 0.0001) compared to all other groups.

Conclusions

The use of DTAP or Ca(OH)₂ medicaments during endodontic regeneration may cause significantly less microhardness reduction and superficial demineralization of dentin compared to the use of TAP.

Effect of tricalcium aluminate on the physicochemical properties, bioactivity, and biocompatibility of partially stabilized cements

Background/Purpose

Mineral Trioxide Aggregate (MTA) was widely used as a root-end filling material and for vital pulp therapy. A significant disadvantage to MTA is the prolonged setting time has limited the application in endodontic treatments. This study examined the physicochemical properties and biological performance of novel partially stabilized cements (PSCs) prepared to address some of the drawbacks of MTA, without causing any change in biological properties. PSC has a great potential as the vital pulp therapy material in dentistry.

Methods

This study examined three experimental groups consisting of samples that were fabricated using sol-gel processes in C3S/C3A molar ratios of 9/1, 7/3, and 5/5 (denoted as PSC-91, PSC-73, and PSC-55, respectively). The comparison group consisted of MTA samples. The setting times, pH variation, compressive strength, morphology, and phase composition of hydration products and ex vivo bioactivity were evaluated. Moreover, biocompatibility was assessed by using lactate dehydrogenase to determine the cytotoxicity and a cell proliferation (WST-1) assay kit to determine cell viability. Mineralization was evaluated using Alizarin Red S staining.

Results

Crystalline phases, which were determined using X-ray diffraction analysis, confirmed that the C3A contents of the material powder differed. The initial setting times of PSC-73 and PSC-55 ranged between 15 and 25 min; these values are significantly (p<0.05, ANOVA and post-hoc test) lower than those obtained for MTA (165 min) and PSC-91 (80.5 min). All of the PSCs exhibited ex vivo bioactivity when immersed in simulated body fluid. The biocompatibility results for all of the tested cements were as favorable as those of the negative control, except for PSC-55, which exhibited mild cytotoxicity.

Conclusion

PSC-91 is a favorable material for vital pulp therapy because it exhibits optimal compressive strength, a short setting time, and high biocompatibility and bioactivity.