The Presence of Autophagy in Human Periapical Lesions

Association between apical periodontitis and brain inflammation: a systematic review from animals and human studies

Apical periodontitis (AP) is an oral inflammatory disease induced by dental pulp infection. It is characterized by inflammation, destruction, and resorption of mineralized tissues located around the dental apex. Although this is a local infection, pathogens and their products in the periapical area, as well as inflammatory cytokines, can reach other regions of the body and trigger a systemic immune/inflammatory response in the host. This condition has been associated with several types of systemic diseases. This systematic review aimed to explore the association between AP and neuroinflammation, providing insights into this relationship and discussing potential pathways used by AP microorganisms to reach the central nervous system. Extensive searches in electronic databases (PubMed, Embase, and Cochrane) and hand searches were conducted from January 2013 until May 2024, using the keywords apical periodontitis, endodontic infection, periapical abscess, periodontitis apical, brain inflammation, brain disorders, and neuroinflammation. Initially, 394 studies were selected. After exclusion and inclusion criteria were applied, 12 studies (7 case reports and 1 case series, 3 experimental studies using animal models, and 1 cohort study) were included in this systematic review. All studies showed the presence of AP in upper and/or lower teeth and brain disorders with neuroinflammation. It is important to mention that some cases reported the death of the patient. This systematic review indicates a significant relationship between AP and neuroinflammation based on animal and human studies. Moreover, this study suggests there may be pathways connecting upper and lower teeth with apical periodontitis to the brain, inducing neuroinflammation. Additionally, the oral cavity can become easily accessible when AP is present, allowing for the invasion of microorganisms that are usually non-invasive. This contributes to the development of systemic disorders and/or strengthens their effect, worsening brain pathologies by causing or enhancing neuroinflammation, potentially leading to death. Based on these inferences, periapex health care is essential to improve the health of the world population.Registration number: Prospero registration nº. CRD42023453543.

Autophagy regulates bone loss via the RANKL/RANK/OPG axis in an experimental rat apical periodontitis model

AIM

Autophagy is involved in human apical periodontitis (AP). However, it is not clear whether autophagy is protective or destructive in bone loss via the receptor activator of nuclear factor-κB ligand (RANKL)/RANK/osteoprotegerin (OPG) axis. This study aimed to investigate the involvement of autophagy via the RANKL/RANK/OPG axis during the development of AP in an experimental rat model.

METHODOLOGY

Twenty-four female Sprague-Dawley rats were divided into control, experimental AP (EAP) + saline, and EAP + 3-methyladenine (An autophagy inhibitor, 3-MA) groups. The control group did not receive any treatment. The EAP + saline group and the EAP + 3-MA group received intraperitoneal injections of saline and 3-MA, respectively, starting 1 week after the pulp was exposed. Specimens were collected for microcomputed tomography (micro-CT) scanning, histological processing, and immunostaining to examine the expression of light chain 3 beta (LC3B), RANK, RANKL, and OPG. Data were analysed using one-way analysis of variance (p < .05).

RESULTS

Micro-CT showed greater bone loss in the EAP + 3-MA group than in the EAP + saline group, indicated by an elevated trabecular space (Tb.Sp) (p < .05). Inflammatory cell infiltration was observed in the EAP + saline and EAP + 3-MA groups. Compared with EAP + saline group, the EAP + 3-MA group showed weaker expression of LC3B (p < .01) and OPG (p < .05), more intense expression of RANK (p < .01) and RANKL (p < .01), and a higher RANKL/OPG ratio (p < .05).

CONCLUSION

Autophagy may exert a protective effect against AP by regulating the RANKL/RANK/OPG axis, thereby inhibiting excessive bone loss.

BRF1 promotes the odontogenic differentiation of dental pulp stem cells in pulpitis by inducing autophagy

Objective

While post-transcriptional modifications play a pivotal role in the autophagy regulation, studies on dental pulp disease are limited. This study investigated the effect of BRF1 on autophagy in inflamed pulp tissue and human dental pulp stem cells (hDPSCs).

Methods

Immunohistochemical analysis was used to examine BRF1 expression, autophagy levels, and dentinogenic markers in normal and inflamed pulp. The presence of autophagosomes was observed by transmission electron microscopy. Primary hDPSCs were treated with 1 μg/mL lipopolysaccharide (LPS) for different lengths of time. The expression of BRF1 and autophagy makers was determined by Western blotting. BRF1 knockdown and 3 MA treatment were employed to assess changes in autophagy and dentinogenic differentiation. Double immunofluorescence staining was performed to co-localize BRF1 with LC3B in pulp tissue.

Results

The expressions of BRF1, LC3, DMP1, and DSP were significantly elevated in the inflamed pulp. LPS enhanced the protein production of IL-6, BRF1, LC3, and Beclin-1 from 6 h to 24 h after the treatment. BRF1 knockdown reduced the ratio of LC3-II/LC3-I and the differentiation ability of hDPSCs, while 3 MA inhibited LPS-mediated dentinogenic differentiation. Double-labeling revealed that BRF1 co-localized with LC3B in inflamed pulp.

Conclusion

This study demonstrated that BRF1 promoted autophagy activation and odontogenic differentiation in pulpitis.

Autophagy, a double-edged sword for oral tissue regeneration

BACKGROUND

Oral health is of fundamental importance to maintain systemic health in humans. Stem cell-based oral tissue regeneration is a promising strategy to achieve the recovery of impaired oral tissue. As a highly conserved process of lysosomal degradation, autophagy induction regulates stem cell function physiologically and pathologically. Autophagy activation can serve as a cytoprotective mechanism in stressful environments, while insufficient or over-activation may also lead to cell function dysregulation and cell death.

AIM OF REVIEW

This review focuses on the effects of autophagy on stem cell function and oral tissue regeneration, with particular emphasis on diverse roles of autophagy in different oral tissues, including periodontal tissue, bone tissue, dentin pulp tissue, oral mucosa, salivary gland, maxillofacial muscle, temporomandibular joint, etc. Additionally, this review introduces the molecular mechanisms involved in autophagy during the regeneration of different parts of oral tissue, and how autophagy can be regulated by small molecule drugs, biomaterials, exosomes/RNAs or other specific treatments. Finally, this review discusses new perspectives for autophagy manipulation and oral tissue regeneration.

KEY SCIENTIFIC CONCEPTS OF REVIEW

Overall, this review emphasizes the contribution of autophagy to oral tissue regeneration and highlights the possible approaches for regulating autophagy to promote the regeneration of human oral tissue.

The role of autophagy in odontogenesis, dental implant surgery, periapical and periodontal diseases

Autophagy is a cellular process that is evolutionarily conserved, involving the sequestration of damaged organelles and proteins into autophagic vesicles, which subsequently fuse with lysosomes for degradation. Autophagy controls the development of many diseases by influencing apoptosis, inflammation, the immune response and different cellular processes. Autophagy plays a significant role in the aetiology of disorders associated with dentistry. Autophagy controls odontogenesis. Furthermore, it is implicated in the pathophysiology of pulpitis and periapical disorders. It enhances the survival, penetration and colonization of periodontal pathogenic bacteria into the host periodontal tissues and facilitates their escape from host defences. Autophagy plays a crucial role in mitigating exaggerated inflammatory reactions within the host's system during instances of infection and inflammation. Autophagy also plays a role in the relationship between periodontal disease and systemic diseases. Autophagy promotes wound healing and may enhance implant osseointegration. This study reviews autophagy's dento-alveolar effects, focusing on its role in odontogenesis, periapical diseases, periodontal diseases and dental implant surgery, providing valuable insights for dentists on tooth development and dental applications. A thorough examination of autophagy has the potential to discover novel and efficacious treatment targets within the field of dentistry.

Role of Enterococcus faecalis in refractory apical periodontitis: from pathogenicity to host cell response

BACKGROUND

Refractory apical periodontitis (RAP) is an oral infectious disease characterised by persistent inflammation, progressive alveolar bone destruction, and delayed bone healing. RAP has received increasing attention, because it cannot be cured after repeated root canal therapies. The aetiology of RAP is related to the complex interplay between the pathogen and its host. However, the exact pathogenesis of RAP remains unclarified and includes several factors, such as microorganism immunogenicity, host immunity and inflammation, and tissue destruction and repair. Enterococcus faecalis is the dominant pathogen involved in RAP, and has evolved multiple strategies to ensure survival, which cause persistent intraradicular and extraradicular infections.

OBJECTIVE

To review the crucial role of E. faecalis in the pathogenesis of RAP, and open new avenues for prevention and treatment of RAP.

METHODS

The PubMed and Web of Science databases were searched for pertinent publications, employing the search terms "Enterococcus faecalis", "refractory apical periodontitis", "persistent periapical periodontitis", "pathogenicity", "virulence", "biofilm formation", "dentine tubule", "immune cell", "macrophage", and "osteoblast".

RESULTS AND CONCLUSION

Besides its high pathogenicity due to various virulence mechanisms, E. faecalis modulates the macrophage and osteoblast responses, including regulated cell death, cell polarisation, cell differentiation, and inflammatory response. An in-depth understanding of the multifaceted host cell responses modulated by E. faecalis will help to design potential future therapeutic strategies and overcome the challenges of sustained infection and delayed tissue healing in RAP.

Expression of PINK1 and Parkin in human apical periodontitis

AIM

PTEN-induced putative kinase 1 (PINK1) and Parkin E3 ubiquitin-protein ligase (Parkin) are critical for immune and inflammatory regulation in health and disease. PINK1 and Parkin have been confirmed to be involved in the progression of apical periodontitis by affecting mitophagy-related osteoblast apoptosis; however, the expression of PINK1 and Parkin in macrophages, one of the most important cells in apical periodontitis, remains unknown. This study aimed to investigate the expression of PINK1 and Parkin in human apical periodontitis lesions, as well as their possible localization in macrophages.

METHODOLOGY

Thirty-seven human periapical tissues, including periapical granulomas (PGs, n=12), radicular cysts (RCs, n=11), and healthy gingival tissues (n=14) were examined. The inflammatory infiltrates of lesions were evaluated by haemotoxylin staining, and the expression of PINK1 and Parkin was detected by immunohistochemistry. Double immunofluorescence was used to explore the colocalization of microtubule-associated protein 1 light chain 3 (LC3) and TOMM20, as well as the localization of PINK1 and Parkin, in macrophages of human apical periodontitis lesions. The ultrastructural morphology of mitochondria in human apical periodontitis lesions was visualized by transmission electron microscopy (TEM). Data were analyzed by one-way ANOVA with Student-Newman-Keul's test and Mann-Whitney test. P < 0.05 was considered statistically significant.

RESULTS

Immunohistochemistry demonstrated a significantly higher expression of PINK1 and Parkin proteins in human apical periodontitis lesions than in healthy gingival tissues (P < 0.0001), but no significant difference was demonstrated between PGs and RCs (P > 0.05). The higher expression of LC3 and the presence of more LC3-TOMM20 double-positive cells were also observed in human apical periodontitis. Double-labeling analysis of PINK1, Parkin, and LC3 with CD68 indicated that macrophage mitophagy might be present in the progression of human apical periodontitis. Finally, the results of TEM morphological analysis revealed the appearance of double-membraned mitophagosomes and vacuolated mitochondria in macrophage-like cells of apical periodontitis lesions.

CONCLUSIONS

Our findings indicated that PINK1 and Parkin proteins were highly expressed in clinical apical periodontitis lesions.

Autophagy in tooth: Physiology, disease and therapeutic implication

Autophagy is an evolutionarily conserved cellular process, in which damaged organelles and proteins are engulfed in autophagic vesicles and subsequently fuse with lysosomes for degradation. Autophagy is widely involved in different physiologic or pathologic processes in human. Accumulating evidence indicates that autophagy operates as a critical quality control mechanism to maintain pulp homeostasis and structural integrity of the dentin-pulp complex. Autophagy is activated during stresses and is involved in the pathogenesis of pulpitis and periapical infection. Recent discoveries have also provided intriguing insights into the roles of autophagy in tooth development, pulp aging and stress adaptation. In this review, we provide an update on the multifaceted functions of autophagy in physiology and pathophysiology of tooth. We also discuss the therapeutic implications of autophagy modulation in diseases and the regeneration of dentin-pulp complex.

Can Probiotics Emerge as Effective Therapeutic Agents in Apical Periodontitis? A Review

Apical periodontitis (AP) is a biofilm-associated disease initiated by the invasion of dental pulp by microorganisms from the oral cavity. Eradication of intracanal microbial infection is an important goal of endodontic treatment, and this is typically accomplished by mechanical instrumentation and application of sodium hypochlorite and chlorhexidine. However, these agents are tissue-irritating at higher concentrations and cytotoxic. Certain probiotics have been found effective in controlling marginal periodontitis, as evidenced by reduction of pathogenic bacterial loads, gains in clinical attachment levels, and reduced bleeding on probing. In vitro studies have shown inhibitory activity of some probiotics against endodontic pathogens. Similarly, in vivo studies in rats have demonstrated a positive immuno-modulatory role of probiotics in AP, as manifested by decreased levels of proinflammatory markers and increased levels of anti-inflammatory markers. A role for probiotics in effecting a reduction of bone resorption has also been reported. This review provides an outline of current research into the probiotic management of AP, with a focus on understanding the mechanisms of their direct antagonistic activity against target pathogens and of their beneficial modulation of the immune system.

Autophagy-mediated regulation of neutrophils and clinical applications

Autophagy, an adaptive catabolic process, plays a cytoprotective role in enabling cellular homeostasis in the innate and adaptive immune systems. Neutrophils, the most abundant immune cells in circulation, are professional killers that orchestrate a series of events during acute inflammation. The recent literature indicates that autophagy has important roles in regulating neutrophil functions, including differentiation, degranulation, metabolism and neutrophil extracellular trap formation, that dictate neutrophil fate. It is also becoming increasingly clear that autophagy regulation is critical for neutrophils to exert their immunological activity. However, evidence regarding the systematic communication between neutrophils and autophagy is insufficient. Here, we provide an updated overview of the function of autophagy as a regulator of neutrophils and discuss its clinical relevance to provide novel insight into potentially relevant treatment strategies.

Expression of autophagy‑associated proteins in rat dental irreversible pulpitis

Autophagy serves an important role in numerous diseases, as well as in infection and inflammation. Irreversible pulpitis (IP) is one of the most common inflammatory endodontic diseases, and autophagy has been reported to regulate IP in vitro. However, the level of autophagy in the IP pathogenic process in vivo remains unknown. The aim of the current study was, thus, to investigate the levels of autophagy-associated proteins in rats with IP in vivo. A rat dental IP model was successfully constructed, and five different time points (0, 1, 3, 5 and 7 days) were investigated. The levels of the autophagy-related 5 (ATG5), ATG7, light chain 3 (LC3) and Beclin-1 proteins exhibited a time-dependent increase in rats with IP, whereas the levels of mammalian target of rapamycin and p62/sequestosome 1 were decreased. In addition, the levels of ATG proteins were specifically increased in odontoblasts and microvascular endothelial cells in pulpitis tissue. Based on these findings, autophagy may serve an important role in IP, and the present study data provide a new insight into the IP pathogenesis and treatment.

Autophagy and its implication in human oral diseases

Macroautophagy/autophagy is a conserved lysosomal degradation process essential for cell physiology and human health. By regulating apoptosis, inflammation, pathogen clearance, immune response and other cellular processes, autophagy acts as a modulator of pathogenesis and is a potential therapeutic target in diverse diseases. With regard to oral disease, autophagy can be problematic either when it is activated or impaired, because this process is involved in diverse functions, depending on the specific disease and its level of progression. In particular, activated autophagy functions as a cytoprotective mechanism under environmental stress conditions, which regulates tumor growth and mediates resistance to anticancer treatment in established tumors. During infections and inflammation, activated autophagy selectively delivers microbial antigens to the immune systems, and is therefore connected to the elimination of intracellular pathogens. Impaired autophagy contributes to oxidative stress, genomic instability, chronic tissue damage, inflammation and tumorigenesis, and is involved in aberrant bacterial clearance and immune priming. Hence, substantial progress in the study of autophagy provides new insights into the pathogenesis of oral diseases. This review outlines the mechanisms of autophagy, and highlights the emerging roles of this process in oral cancer, periapical lesions, periodontal diseases, and oral candidiasis.

Autophagy-related gene 5 and Wnt5 signaling pathway requires differentiation of embryonic stem cells into odontoblast-like cells

We previously confirmed a unique and unanticipated role for an α2 integrin, extracellular matrix metalloproteinase inducer (Emmprin), and matrix metalloproteinase (MMP)-3-mediated signaling cascade, in driving the odontoblast-like differentiation of mouse embryonic stem (ES) cells in a collagen type-I scaffold (CS) combined with bone morphogenetic protein (BMP)-4 (CS/BMP-4). To explore the early signaling cascade for odontoblastic differentiation, we examined the upregulation of autophagy-related gene (Atg) and Wnt signaling by CS/BMP-4 mediated odontoblast differentiation. In a screening experiment, CS/BMP-4 increased the mRNA and protein levels of Atg5, Lrp5/Fzd9 (an Atg5 receptor), and Wnt5, but not microtubule-associated protein 1 light chain (LC3; a mammalian homolog of yeast Atg8), TFE3, Beclin1, and Atg12, together with the amount of autophagosomes and autophagy fluxes. Treatment with siRNAs against Atg5 and Wnt5 individually suppressed the CS/BMP-4-induced increase in odontoblast differentiation. The odontoblastic phenotype, involving dentin matrix protein-1 and dentin sialophosphoprotein expression, decreased when autophagy was inhibited by chloroquine, but increased after treatment with rapamycin (an autophagy enhancer). Taken together with our previous findings, we have revealed a unique sequential cascade involving Atg5, Wnt5a, α2 integrin, Emmprin, and MMP-3. This cascade results in a potent increase in odontoblastic cell differentiation, indicating the unique involvement of Atg5, autophagy and Wnt5 signaling in CS/BMP-4-induced differentiation of ES cells into odontoblast-like cells, at a relatively early stage.

Interleukin-1β-induced autophagy-related gene 5 regulates proliferation of embryonic stem cell-derived odontoblastic cells

We previously established a method for the differentiation of induced pluripotent stem cells and embryonic stem cells into α2 integrin-positive odontoblast-like cells. We also reported that Wnt5 in response to interleukin (IL)-1β induces matrix metalloproteinase (MMP)-3-regulated cell proliferation in these cells. Our findings suggest that MMP-3 plays a potentially unique physiological role in the generation of odontoblast-like cells under an inflammatory state. Here, we examined whether up-regulation of autophagy-related gene (Atg) 5 by IL-1β was mediated by Wnt5 signaling, thus leading to increased proliferation of odontoblast-like cells. IL-1β increased the mRNA and protein levels of Atg5, microtubule-associated protein 1 light chain (LC3, a mammalian homolog of yeast Atg8) and Atg12. Treatment with siRNAs against Atg5, but not LC3 and Atg12, suppressed the IL-1β-induced increase in MMP-3 expression and cell proliferation. Our siRNA analyses combined with western blot analysis revealed a unique sequential cascade involving Atg5, Wnt5a and MMP-3, which resulted in the potent increase in odontoblastic cell proliferation. These results demonstrate the unique involvement of Atg5 in IL-1β-induced proliferation of embryonic stem cell-derived odontoblast-like cells.