Regenerative endodontic therapy: From laboratory bench to clinical practice

BACKGROUND

Maintaining the vitality and functionality of dental pulp is paramount for tooth integrity, longevity, and homeostasis. Aiming to treat irreversible pulpitis and necrosis, there has been a paradigm shift from conventional root canal treatment towards regenerative endodontic therapy.

AIM OF REVIEW

This extensive and multipart review presents crucial laboratory and practical issues related to pulp-dentin complex regeneration aimed towards advancing clinical translation of regenerative endodontic therapy and enhancing human life quality.

KEY SCIENTIFIC CONCEPTS OF REVIEW

In this multipart review paper, we first present a panorama of emerging potential tissue engineering strategies for pulp-dentin complex regeneration from cell transplantation and cell homing perspectives, emphasizing the critical regenerative components of stem cells, biomaterials, and conducive microenvironments. Then, this review provides details about current clinically practiced pulp regenerative/reparative approaches, including direct pulp capping and root revascularization, with a specific focus on the remaining hurdles and bright prospects in developing such therapies. Next, special attention was devoted to discussing the innovative biomimetic perspectives opened in establishing functional tissues by employing exosomes and cell aggregates, which will benefit the clinical translation of dental pulp engineering protocols. Finally, we summarize careful consideration that should be given to basic research and clinical applications of regenerative endodontics. In particular, this review article highlights significant challenges associated with residual infection and inflammation and identifies future insightful directions in creating antibacterial and immunomodulatory microenvironments so that clinicians and researchers can comprehensively understand crucial clinical aspects of regenerative endodontic procedures.

An examination of the effect of exercise and creatine monohydrate on oral tissues

Although physical exercise is extremely important for health and a good lifestyle, it can trigger oxidative stress, inflammation, and muscle fatigue. The aim of this study was to determine changes in dental tissues and the mandible created by creatines monohydrate (CrM) supplementation together with low and high-intensity exercise (HIE). The study material comprised Balb/c male mices, which were separated into two groups for the application of low and HIE on a running band. CrM supplement was administered together with the exercise. At the end of the experiment period, dental tissue samples were surgically removed and examined histopathologically and immunohistochemically (TNF-α and lL-1β).As a result of the histopathological examinations, in the pulp, oedema, vascular congestion, and capillary dilatation were seen to be statistically significantly increased in the Group 3 mices that performed HIE compared to the control group (p = 0.001, p = 0.003, p = 0.001, respectively). A statistically significant increase was observed in periodontal ligament (PDL) degeneration, and disruption of the continuity and separation of collagen fibers in Group 3 compared to the control group (p = 0.001). In the immunohistochemical examination, TNF-α and IL-1β positivity was observed in Group 3, and this was significantly increased compared to the control group (p = 0.001, p = 0.000).Exposure of the mices to low and HIE caused histological and immunohistochemical changes in dental pulp and PDL, and it was determined that the use of CrM could have a protective effect against these changes. RESEARCH HIGHLIGHTS: The results of this study showed negative effects of HIE in the dental pulp and PDL, which play an important role in dental health. CrM was seen to be effective in preventing these negative effects.

Cav1.2 regulated odontogenic differentiation of NG2+ pericytes during pulp injury

NG2⁺ pericytes, as the possible precursor cells of mesenchymal stem cells (MSCs), have drawn attention due to their ability to differentiate into odontoblasts. Ca_v1.2 is involved in the differentiation process of stem cells, but its role in the differentiation of NG2⁺ pericytes is not clear. The aim of the present study was to examine the role of Ca_v1.2 in the differentiation of NG2⁺ pericytes into odontoblasts. NG2⁺ pericytes were obtained from human dental pulp cells by magnetic-activated cell sorting. During the odontogenic differentiation of NG2⁺ pericytes, the effects of the Ca_v1.2 inhibitors, nimodipine and Ca_v1.2 knockdown shRNA, were analyzed by real-time polymerase chain reaction and alizarin red staining. NG2CreERT2/Rosa26-GFP lineage-tracing mice were established to further investigate the roles of NG2⁺ pericytes and Ca_v1.2 in incisor self-repair after injury in vivo. At 10 min, 1 day, and 3 days after pulp injuries in transgenic mice, NG2-GFP⁺ and Ca_v1.2 immunofluorescence co-staining was performed on the incisors. Nimodipine treatment and Ca_v1.2 knockdown showed similar inhibition of calcium nodule formation and mRNA levels of osteogenic markers (DSPP, DMP1, and Runx2, p < 0.05). NG2⁺ pericytes migrated from their inherent perivascular location to the odontoblast layers after pulp injury. Ca_v1.2 showed a similar response pattern as NG2⁺ pericytes and gradually returned to normal levels. In addition, many co-stained areas of Ca_v1.2 and NG2⁺ pericytes, both near the perivascular and odontoblast layers, were observed. These results indicate that Ca_v1.2 played a vital role in the odontogenic differentiation of NG2⁺ pericytes, and that it might be closely linked to the NG2⁺ pericytes-mediated repair of dental pulp injury in vivo.

The 5-HT and PLC Signaling Pathways Regulate the Secretion of IL-1β, TNF-α and BDNF from NG2 Cells

The present study was clarified the relationship between NG2 glial cells and 5-hydroxytryptamine (5-HT) to further revealed a role in the regulation of cortical excitability. The co-localization of NG2 cells and 5-HT in rat prefrontal cortex was determined using immunofluorescence. Different concentrations of 5-HT were applied to cultured NG2 cells. Real-time PCR measured the expression of interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α) and brain-derived neurotrophic factor (BDNF). Changes in the expression of IL-1β, TNF-α, and BDNF in NG2 cells were detected after the addition of 5-HT receptor specific blockers and phospholipase C (PLC) specific activators and inhibitors. The results confirmed that the NG2 protein and 5-HT co-localized in the prefrontal cortex. 5-HT treatment of NG2 cells significantly reduced the expression of IL-1β and BDNF mRNA and increased the expression of TNF-α. The 5-HT receptor specific inhibitors alverine citrate, ketanserin, ondansetron and SB-399885 blocked the regulatory effects of 5-HT on NG2 cells. The PLC signal was linked to the secretion of IL-1β, TNF-α and BDNF in NG2 cells. These results indicated that 5-HT affected IL-1β, TNF-α, and BDNF secretion from NG2 cells via the 5-HT1A, 5-HT2A, 5-HT3, 5-HT6 receptors and the PLC signaling pathway.

Role of Lipopolysaccharide, Derived from Various Bacterial Species, in Pulpitis—A Systematic Review

Lipopolysaccharide (LPS) is widely used for induction of inflammation in various human tissues, including dental pulp. The purpose of this study was to summarize current medical literature focusing on (1) cell types used by researchers to simulate dental pulp inflammation, (2) LPS variants utilized in experimental settings and how these choices affect the findings. Our study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched for studies reporting outcomes of lipopolysaccharide application on dental pulp cells in vitro using electronic databases: MEDLINE, Web of Science and Scopus. Having gathered data from 115 papers, we aimed to present all known effects LPS has on different cell types present in dental pulp. We focused on specific receptors and particles that are involved in molecular pathways. Our review provides an essential foundation for further research using in vitro models of pulpitis.

Relevance of Cellular Redox Homeostasis for Vital Functions of Human Dental Pulp Cells

Odontogenic MSCs are vulnerable to LPS-triggered bacterial infections, and they respond by secreting inflammatory mediators, such as IL-6, and with mineralization. Since both processes might be prone to a disturbance of the redox homeostasis, the oxidative stress influence on vital functions of human dental pulp cells (HPCs) was investigated. With these aims, a model of LPS-stimulated primary HPCs was established, and anti- and pro-oxidant substances were administered up to 21 days to measure inflammation and mineralization parameters. LPS-stimulated HPCs retained mineralization potential, which was decreased with the antioxidants NAC and fisetin and the pro-oxidant BSO. The expression of surface markers related to odontogenic commitment was influenced accordingly but counteracted by the enhanced expression of BMP2 and ALP at the transcriptional level. LPS triggers an early IL-6 production in non-odontogenic conditions, while it can be measured only after 15 days in the presence of the differentiation medium. The present study shows that HPCs functions causally depend on a tightly regulated cellular redox balance. Our data demonstrate a redox control of pulp MSC odontogenic commitment along with a potential association between an IL-6 late secretion and mineralization. These findings lay the groundwork for investigations on the molecular role of IL-6 in dental hard tissue metabolism.

Efficacy of Photobiomodulation and Vitamin D on Odontogenic Activity of Human Dental Pulp Stem Cells

Introduction: The regeneration of dental pulp tissue using human dental pulp stem cells (HDPSCs) has attracted increasing attention in recent years. Recent studies have suggested that several factors such as photobiomodulation (PBM) and vitamin D affect the proliferation and differentiation of HDPSCs. Therefore, the present study evaluated the effects of PBM and vitamin D on odontogenic differentiation of HDPSCs for dentin -like tissue formation. Methods: HDPSCs were collected, isolated, and characterized and then divided into six groups: group I, control; group II, vitamin D (10^-7 Mol); group III, irradiation at 1 J/cm² of 810 nm diode laser; group IV, irradiation at 1 J/cm² and culture with vitamin D; group V, irradiation at 2 J/cm², and group VI, irradiation at 2 J/cm² and culture with vitamin D, cell viability assay was measured through MTT. Alkaline phosphatase (ALP) enzyme activity and mRNA levels of vascular endothelial growth factor (VEGF), bone morphogenic protein-2 (BMP-2), and dentin sialophosphoprotein (DSPP) were also assessed. Results: PBM at 1 and 2 J/cm² combined with vitamin D significantly promoted HDPSCs proliferation through MTT assay and odontogenic differentiation through gene expression of VEGF, BMP-2, and DSPP levels (P < 0.0001). Conclusion: PBM at 2 J/cm² combined with vitamin D enhanced the HDPSCs proliferation and odontogenic differentiation and thus could be a novel strategy for dentin regeneration in dentistry.

The Role of Small Extracellular Vesicles Derived from Lipopolysaccharide-preconditioned Human Dental Pulp Stem Cells in Dental Pulp Regeneration

INTRODUCTION

Regenerative endodontics has created a desirable shift in the treatment paradigm despite current limitations of regenerative outcomes. Mesenchymal stem cells (MSCs) facilitate tissue regeneration and repair in a mild inflammatory environment. Small extracellular vesicles (sEVs) derived from MSCs play an imperative role in the paracrine modulation of regenerative responses modulated by MSCs. However, it remains unknown whether MSCs enhance dental pulp regeneration or whether this enhancement is mediated by sEVs in a mild inflammatory environment. The present study aimed to elucidate the effects of sEVs originated from lipopolysaccharide (LPS)-preconditioned human dental pulp stem cells (hDPSCs) on dental pulp regeneration.

METHODS

All sEVs were isolated from hDPSCs cultured with or without LPS (ie, N-sEVs and L-sEVs, respectively). The effect of N-sEVs and L-sEVs on proliferation, migration, angiogenesis, and differentiation of rat bone marrow MSCs was identified in vitro. Moreover, N-sEVs or L-sEVs were implanted into rat pulpless root canal models, and the regenerated tissue in root canals was assessed via hematoxylin-eosin staining, Masson staining, and immunohistochemistry after 30 days of transplantation.

RESULTS

Both N-sEVs and L-sEVs could modulate BMSC proliferation, migration, angiogenesis, and differentiation. Both kinds of sEVs enhanced the structure of the regenerated tissue closer to that of a normal dental pulp in vivo. L-sEVs had a more significant effect than N-sEVs.

CONCLUSIONS

sEVs released by hDPSCs in a mild inflammatory microenvironment are capable of facilitating the regeneration of dental pulp through functional healing instead of scar healing, which has potential applications in regenerative endodontics.

[Role of autophagy in lipopolysaccharide-induced apoptosis of odontoblasts]

OBJECTIVE

To investigate the role of autophagy in lipopolysaccharide (LPS)-induced apoptosis of murine odontoblasts.

METHODS

Murine odontoblasts (mDPC-23 cells) were treated with 5 μg/mL LPS for 6, 12 and 24 h, and the changes in cell viability was examined using CCK8 kit and cell apoptosis was detected by TUNEL staining. The changes in the protein levels of LC3, Beclin1, Atg5, AKT, p-AKT, mTOR and p-mTOR were detected using Western blotting. The effect of 3-MA treatment for 24 h on LPS-induced apoptosis of mDPC-23 cells was evaluated by detecting the expressions of apoptosis-related proteins caspase-3 and Bax using Western blotting.

RESULTS

Stimulation with LPS for 6 and 12 h did not cause significant changes in the proliferation or apoptosis of mDPC-23 cells, but LPS treatment for 24 h significantly suppressed cell proliferation (P < 0.05) and promoted cell apoptosis as shown by TUNEL assay (P < 0.05). Stimulation with LPS for 24 significantly increased the expression levels of LC3, Beclin1 and Atg5, decreased the expressions of p-AKT and p-mTOR (P < 0.05), and obviously upregulated the expressions of caspase-3 and Bax (P < 0.05). Treatment with 3-MA markedly lowered caspase-3 and Bax protein expressions in LPS-stimulated cells (P < 0.05).

CONCLUSIONS

LPS stimulation induces autophagy to promote apoptosis of mDPC-23 cells, and suppression of autophagy attenuates LPS-induced apoptosis. Autophagy may play an important role in the injury of inflamed pulp tissues.