Histologic examinations of teeth treated with 2 scaffolds: a pilot animal investigation

Histologic and Electron Microscopic Characterization of a Human Immature Permanent Premolar with Chronic Apical Abscess 16 years after Regenerative Endodontic Procedures

Previous studies have reported successful clinical outcomes after regenerative endodontic procedures (REPs) for immature permanent teeth with pulpal infection. However, it remains unclear whether the procedures promote true regeneration or repair. This case report describes the histologic and electron microscopic characteristics of a human immature permanent premolar with a chronic apical abscess that was treated with an REP. Tooth #20 of a 9-year-old girl underwent an REP. At the 6-year follow-up, the patient was asymptomatic, and closure of the apex and thickening of the dentinal walls were observed. However, 16 years after the procedure, apical periodontitis recurred, necessitating apical surgery. The resected root fragments were obtained during the surgery and analyzed using micro-computed tomography, light microscopy, and scanning electron microscopy. Distinct dentinal tubules and interglobular dentin were observed in the regenerated hard tissue. Cementum-like tissue and a root canal were also observed in the apical fragment. The regenerated root tissue in this case exhibited a structure similar to the native root structure. Therefore, we believe that cell-free REPs possess regenerative potential for teeth diagnosed with pulp necrosis and chronic apical abscess.

Effect of Intracoronal Sealing Biomaterials on the Histological Outcome of Endodontic Revitalisation in Immature Sheep Teeth-A Pilot Study

The influence of intracoronal sealing biomaterials on the newly formed regenerative tissue after endodontic revitalisation therapy remains unexplored. The objective of this study was to compare the gene expression profiles of two different tricalcium silicate-based biomaterials alongside the histological outcomes of endodontic revitalisation therapy in immature sheep teeth. The messenger RNA expression of TGF-β, BMP2, BGLAP, VEGFA, WNT5A, MMP1, TNF-α and SMAD6 was evaluated after 1 day with qRT-PCR. For evaluation of histological outcomes, revitalisation therapy was performed using Biodentine (n = 4) or ProRoot white mineral trioxide aggregate (WMTA) (n = 4) in immature sheep according to the European Society of Endodontology position statement. After 6 months' follow-up, one tooth in the Biodentine group was lost to avulsion. Histologically, extent of inflammation, presence or absence of tissue with cellularity and vascularity inside the pulp space, area of tissue with cellularity and vascularity, length of odontoblast lining attached to the dentinal wall, number and area of blood vessels and area of empty root canal space were measured by two independent investigators. All continuous data were subjected to statistical analysis using Wilcoxon matched-pairs signed rank test at a significance level of p < 0.05. Biodentine and ProRoot WMTA upregulated the genes responsible for odontoblast differentiation, mineralisation and angiogenesis. Biodentine induced the formation of a significantly larger area of neoformed tissue with cellularity, vascularity and increased length of odontoblast lining attached to the dentinal walls compared to ProRoot WMTA (p < 0.05), but future studies with larger sample size and adequate power as estimated by the results of this pilot study would confirm the effect of intracoronal sealing biomaterials on the histological outcome of endodontic revitalisation.

Cytotoxicity and Biomineralization Potential of Flavonoids Incorporated into PNVCL Hydrogels

This study aimed to evaluate the effects of flavonoids incorporated into poly(N-vinylcaprolactam) (PNVCL) hydrogel on cell viability and mineralization markers of odontoblast-like cells. MDPC-23 cells were exposed to ampelopsin (AMP), isoquercitrin (ISO), rutin (RUT) and control calcium hydroxide (CH) for evaluation of cell viability, total protein (TP) production, alkaline phosphatase (ALP) activity and mineralized nodule deposition by colorimetric assays. Based on an initial screening, AMP and CH were loaded into PNVCL hydrogels and had their cytotoxicity and effect on mineralization markers determined. Cell viability was above 70% when MDPC-23 cells were treated with AMP, ISO and RUT. AMP showed the highest ALP activity and mineralized nodule deposition. Extracts of PNVCL+AMP and PNVCL+CH in culture medium (at the dilutions of 1/16 and 1/32) did not affect cell viability and stimulated ALP activity and mineralized nodules’ deposition, which were statistically higher than the control in osteogenic medium. In conclusion, AMP and AMP-loaded PNVCL hydrogels were cytocompatible and able to induce bio-mineralization markers in odontoblast-cells.

Tissue Characteristics in Endodontic Regeneration: A Systematic Review

The regenerative endodontic procedure (REP) represents a treatment option for immature necrotic teeth with a periapical lesion. Currently, this therapy has a wide field of pre-clinical and clinical applications, but no standardization exists regarding successful criteria. Thus, by analysis of animal and human studies, the aim of this systematic review was to highlight the main characteristics of the tissue generated by REP. A customized search of PubMed, EMBASE, Scopus, and Web of Science databases from January 2000 to January 2022 was conducted. Seventy-five human and forty-nine animal studies were selected. In humans, the evaluation criteria were clinical 2D and 3D radiographic examinations. Most of the studies identified a successful REP with an asymptomatic tooth, apical lesion healing, and increased root thickness and length. In animals, histological and radiological criteria were considered. Newly formed tissues in the canals were fibrous, cementum, or bone-like tissues along the dentine walls depending on the area of the root. REP assured tooth development and viability. However, further studies are needed to identify procedures to successfully reproduce the physiological structure and function of the dentin–pulp complex.

lncRNA SNHG1 regulates odontogenic differentiation of human dental pulp stem cells via miR-328-3p/Wnt/β-catenin pathway

Background

Elucidating the mechanism of odontogenic differentiation of human dental pulp stem cells (hDPSCs) is the key to in-depth mastery and development of regenerative endodontic procedures (REPs). In odontogenic differentiation, lncRNAs have a regulatory role. The goal of this research is to determine the involvement of short nucleolar RNA host gene 1 (SNHG1) in hDPSCs’ odontogenic differentiation and the mechanism that underpins it.

Methods

hDPSCs were isolated from the dental pulp tissue of healthy immature permanent teeth. Follow-up experiments were performed when the third generation of primary cells were transfected. The proliferation ability was measured by CCK-8. The biological effects of SNHG1 and miR-328-3p were determined by real-time quantitative polymerase chain reaction (qRT-PCR), western blot (WB), alkaline phosphatase (ALP) staining and activity, alizarin red S staining (ARS) and quantification, and immunofluorescence staining. The binding of SNHG1 and miR-328-3p was confirmed using a dual-luciferase reporter assay. qRT-PCR and WB were used to determine whether the canonical Wnt/β-catenin pathway was activated.

Results

On the 0th, 3rd, and 7th days of odontogenic differentiation of hDPSCs, SNHG1 showed a gradual up-regulation trend. SNHG1 overexpression enhanced the mRNA and protein expression of dentin sialophosphoprotein (DSPP), dentine matrix protein 1 (DMP-1) and ALP. We found that SNHG1 could bind to miR-328-3p. miR-328-3p inhibited the odontogenic differentiation of hDPSCs. Therefore, miR-328-3p mimics rescued the effect of SNHG1 overexpression on promoting odontogenic differentiation. In addition, SNHG1 inhibited Wnt/β-catenin pathway via miR-328-3p in odontogenic differentiation of hDPSCs.

Conclusion

lncRNA SNHG1 inhibits Wnt/β-catenin pathway through miR-328-3p and then promotes the odontogenic differentiation of hDPSCs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-022-02979-w.

Influencing factors of pulp-dentin complex regeneration and related biological strategies

Regenerative endodontic therapy (RET) utilizing tissue engineering approach can promote the regeneration of pulp-dentin complex to restore pulp vascularization, neuralization, immune function and tubular dentin, therefore the regenerated pulp-dentin complex will have normal function. Multiple factors may significantly affect the efficacy of RET, including stem cells, biosignaling molecules and biomaterial scaffolds. Stem cells derived from dental tissues (such as dental pulp stem cells) exhibit certain advantages in RET. Combined application of multiple signaling molecules and activation of signal transduction pathways such as Wnt/β-catenin and BMP/Smad play pivotal roles in enhancing the potential of stem cell migration, proliferation, odontoblastic differentiation, and nerve and blood vessel regeneration. Biomaterials suitable for RET include naturally-derived materials and artificially synthetic materials. Artificially synthetic materials should imitate natural tissues for biomimetic modification in order to realize the temporal and spatial regulation of pulp-dentin complex regeneration. The realization of pulp-dentin complex regeneration depends on two strategies: stem cell transplantation and stem cell homing. Stem cell homing strategy does not require the isolation and culture of stem cells in vitro, so is better for clinical application. However, in order to achieve the true regeneration of pulp-dentin complex, problems related to improving the success rate of stem cell homing and promoting their proliferation and differentiation need to be solved. This article reviews the influencing factors of pulp-dentin complex regeneration and related biological strategies, and discusses the future research direction of RET, to provide reference for clinical translation and application of RET.

Revitalizing previously treated teeth with open apices: A case report and a literature review

Revitalizing the root canals of previously treated teeth with open apices is appealing to clinicians and patients. However, there are fundamental differences in the microbiome and the microenvironment between a canal with a primary endodontic infection and a canal with a persistent endodontic infection. The aims of this report are to report a case where a previously treated tooth with an open apex and a large apical radiolucency was treated successfully using regenerative endodontic treatment (RET) and to review and critically appraise the literature on procedures and outcomes of RET that result in revitalization of canal(s) in previously treated teeth with open apices. A maxillary central incisor with poor-quality root filling, a large apical radiolucency and an open apex was retreated using RET using platelet-rich fibrin as the scaffold. After 24 months, there was complete healing of the periapical lesion and obvious radiographic signs of apical root closure. Electronic searches were performed in MEDLINE, Scopus and Embase, and the baseline, procedural and outcome data of qualified articles were collected. An assessment tool was developed to rate the quality of evidence reported in these case report/series. Nine articles, three case series and six case reports, with a total of 17 teeth of all types, were included in the reports identified. The age of patients ranged from 7 to 48 years (mean: 19.4 years). The recall period ranged from 12 to 72 months (mean: 29 months). All 17 teeth survived and were functional with healing/healed outcomes. "Apical closure" was the most common radiographic finding regarding root development. The quality of evidence using the new assessment tool was rated "Excellent" in three case reports but only "Fair" in the other six articles. The present case report, as well as the review of the literature, suggests that revitalizing the root canal system of teeth with open apices and post-treatment disease using RET is a potentially valid treatment option. However, more clinical studies with higher levels of evidence and higher quality of evidence are required to confirm the viability of this treatment approach.

Regenerating the Pulp-Dentine Complex Using Autologous Platelet Concentrates: A Critical Appraisal of the Current Histological Evidence

Background:

Autologous platelet concentrates such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) have gained overwhelming popularity in regenerative endodontics. Clinical evidence reveals the lack of a particular advantage of using PRP or PRF over an evoked blood clot in promoting canal wall thickening and/or continued root development in immature necrotic teeth. Moreover, despite stimulating tissue repair and repopulating the root canals of immature and mature permanent teeth, the new vital tissue may not possess the functional activity of the native pulp tissue.

Methods:

To better understand the origin, nature, and long-term fate of the tissue types found within the pulp space, we critically examine all available histo-/morphological evidence for pulp–dentine complex regeneration using PRP and/or PRF, alone or together with an evoked blood clot, specialised or unspecialised primary cells, and other biomaterials.

Results:

Histological data from clinical studies is scant. Reportedly, the inner dentinal surface supports cementum-like tissue formation, but this interface likely deviates in structure and function from the native cementodentinal junction. Presence of bone-like tissue within the pulp space is intriguing since de novo osteogenesis requires closely coordinated recruitment and differentiation of osteoprogenitor cells. Compared to untreated necrotic teeth, an evoked blood clot (with/without PRF) improves fracture resistance. Tooth regeneration using PRF and dental bud cells is unreliable and the constituent neoformed tissues are poorly organised.

Conclusion:

PRP/PRF fail to demonstrate a significant advantage over an induced blood clot, alone. The true nature of neoformed tissues remains poorly characterised while their response to subsequent insult/injury is unexplored.

In vivo Biocompatibility and Bioactivity of Calcium Silicate-Based Bioceramics in Endodontics

Endodontic therapy aims to preserve or repair the activity and function of pulp and periapical tissues. Due to their excellent biological features, a substantial number of calcium silicate-based bioceramics have been introduced into endodontics and simultaneously increased the success rate of endodontic treatment. The present manuscript describes the in vivo biocompatibility and bioactivity of four types of calcium silicate-based bioceramics in endodontics.

Trigeminal Sensory Neurons and Pulp Regeneration

The pulp-dentin complex is innervated by a high density of trigeminal neurons free nerve endings. These neuronal fibers are highly specialized to sense noxious stimuli such as thermal, mechanical, chemical, and biological cues. This robust alert system provides immediate feedback of potential or actual injury triggering reflex responses that protect the teeth from further injury. In the case of patients, pain is the most important experience that leads them to seek oral health care. The adequate removal of the etiology, such as caries, provides ample opportunity for the robust reparative and regenerative potential of the pulp-dentin complex to restore homeostasis. In addition to this elaborated surveillance system, evidence has accumulated that sensory neuronal fibers can potentially modulate various steps of the reparative and regenerative process through cellular communication processes. These include modulation of immunologic, angiogenic, and mineralization responses. Despite these orchestrated cellular events, the defense of the pulp-dentin complex may be overwhelmed, resulting in pulp necrosis and apical periodontitis. Regenerative endodontic procedures have evolved to restore the once lost function of the pulp-dentin complex. After these procedures, a large subset of successful cases demonstrates a positive response to sensitivity testing, suggesting reinnervation of the canal space. This process is likely mediated through cellular and noncellular release of neurotrophic factors such as brain-derived nerve growth factor. In addition, these newly recruited nerve fibers appear equipped to sense thermal stimuli through nonhydrodynamic mechanisms. Collectively, the significance of innervation in the normal physiology of the pulp-dentin complex and its role in regeneration need to be better appreciated to promote further research in this area that could potentially bring new therapeutic opportunities.

Regenerative Endodontics: A Paradigm Shift in Clinical Endodontics

Preserving the natural dentition in its normal form and function is one of the major goals of endodontic treatment. Re-establishing the lost vitality and development of root maturation in immature permanent teeth with pulp necrosis/apical periodontitis is quiet challenging clinically. The very basis of regenerative endodontics relies on the concept of tissue engineering using stem cells, biomimetic scaffold, and bioactive growth factors to regenerate the pulp tissue damaged by microbial infection, injury, or developmental defects. In clinical endodontics, this approach is referred to as a “paradigm shift.” Even though repair instead of true regeneration is achieved with current protocols, it is hoped that further research in the area of stem-cell-based tissue engineering will allow for true regeneration and improved treatment outcomes. The aim of this review is to discuss about the various aspects of regenerative endodontics, current clinical protocols, and the future of pulp regeneration techniques.

Improving pulp revascularization outcomes with buccal fat autotransplantation

Several techniques have been introduced to improve the pulp revascularization outcomes. The use of the tissue graft can create more practical tissue regeneration, provide vascular supply, and enhance tissue healing. The aim of the present study was to investigate the histologic and molecular outcomes of pulp revascularization with buccal fat autotransplantation. Fifty-six open apex roots from four dogs aged 4-6 months were randomly allocated to five groups of endodontic regeneration models: Group 1 (negative control, n = 4); Group 2 (control and without intervention, n = 4); Group 3 (blood clot, n = 16); Group 4 (buccal fat autotransplantation, n = 16); and Group 5 (blood clot plus buccal fat autotransplantation, n = 16). After 3 months, the extracted dog teeth were analyzed by histological and immunohistochemical techniques. Furthermore, real-time quantitative polymerase chain reactions were implemented to assess the gene expression profiles of dentin sialophosphoprotein (DSPP), dentin matrix protein (DMP), collagen I (COL1), and alkaline phosphatase (ALP) on regenerated tissue in the root canals. There were no significant differences in the severity of inflammation and necrosis between intervention groups. Immunohistochemical analysis showed significant differences among the study groups in expression level of extracellular glycoproteins such as fibronectin, laminin, and tenascin C. Group 5 showed an increase in the expression of DMP1 and COL1 genes. The expression of DSPP gene increased significantly in Group 4. The expression of ALP gene increased significantly in Group 3. Using this procedure may open new fields of research for regenerative endodontic procedure in which tissue autotransplant, particularly adipose tissue, may improve the outcomes of pulp revascularization.

Enterococcus faecalis and Staphylococcus aureus stimulate nitric oxide production in macrophages and fibroblasts in vitro

Aim: Nitric oxide (NO) is an important mediator related to damage of the pulp tissue and at the same time to regenerative pulp processes. However, it is not clear how common endodontic microorganisms can regulate this mediator. This study aimed to investigate NO production by macrophages and fibroblasts against Enterococcus faecalis- and Staphylococcus aureus-antigens. Methods: RAW 264.7 macrophages and L929 fibroblast cell lines were stimulated with different heat-killed (HK) antigen concentrations (105-108 colony forming units - CFU) from E. faecalis and S. aureus with or without interferon-gamma (IFN-γ). Cell viability by MTT colorimetric assay and NO production from the culture supernatants were evaluated after 72 h. Results: Data here reported demonstrated that none of the antigen concentrations decreased cell viability in macrophages and fibroblasts. The presence of HK-S. aureus and HK-E. faecalis antigen- stimulated NO production with or without IFN-γ on RAW 264.7. The HK-S. aureus antigen stimulated NO production in L929 fibroblasts with or without IFN-γ, and the highest concentration of HK-E. faecalis with IFN-γ also stimulated NO production by these cells. Conclusion: The amount of NO produced by macrophages and fibroblasts may be involved in the concentration and type of prevalent endodontic microorganisms, generating new answers for the understanding of pulpal revascularization/regeneration processes.

Autologous platelet-rich-fibrin-induced revascularization sequelae: Two case reports

BACKGROUND

A key requirement for biomimetic regeneration of tissues is a 3D scaffold. The gold standard scaffold for revascularization is the blood clot, however, an adequate blood clot cannot always be achieved in narrow canals or mature roots. Hereby, we document the effects of platelet-rich fibrin (PRF) for the regenerative endodontic treatment (RET) of two immature permanent teeth with necrotic pulps for up to 48 mo.

CASES SUMMARY

The first patient was a 22-year-old female with history of trauma in tooth #9 with a sinus tract and a large periapical lesion. The second was a 9-year-old male presenting with a badly decayed tooth #14. Both cases were treated with RET and PRF prepared from the patients’ blood. PRF and its extract were used as a scaffold for RET. Patients were followed-up to 9 and 48 mo (4 years), respectively. Both patients, were asymptomatic after treatment. At the 9-mo-follow-up of case #1, there was radiographic evidence of periapical bone healing, however, the root apex was still open. In case #2, the roots exhibited apical closure and normal periapical bone architecture at 12-mo follow-up, while no root lengthening was observed. After 48 mo, case #2 showed extensive intracanal calcification in all root canals that complicated conventional root canal treatment.

CONCLUSION

RET with PRF and its extract could be used in revascularization of immature permanent teeth. However, proper case selection to comply with long-term follow-up is necessary and adverse events such as calcification and canal obliteration should be planned for.

Topographic cues of a novel bilayered scaffold modulate dental pulp stem cells differentiation by regulating YAP signalling through cytoskeleton adjustments

Objectives

Topographic cues can modulate morphology and differentiation of mesenchymal stem cells. This study aimed to determine how topographic cues of a novel bilayered poly (lactic‐co‐glycolic acid) (PLGA) scaffold affect osteogenic/odontogenic differentiation of dental pulp stem cells (DPSCs).

Methods

The surface morphology of the scaffolds was visualized by scanning electron microscope, and the surface roughness was measured by profilometry. DPSCs were cultured on each side of the scaffolds. Cell morphology, expression of Yes‐associated protein (YAP) and osteogenic/odontogenic differentiation were analysed by immunohistochemistry, real‐time polymerase chain reaction, and Alizarin Red S staining. In addition, cytochalasin D (CytoD), an F‐actin disruptor, was used to examine the effects of F‐actin on intracellular YAP localisation. Verteporfin, a YAP transcriptional inhibitor, was used to explore the effects of YAP signalling on osteogenic/odontogenic differentiation of DPSCs.

Results

The closed side of our scaffold showed smaller pores and less roughness than the open side. On the closed side, DPSCs exhibited enhanced F‐actin stress fibre alignment, larger spreading area, more elongated appearance, predominant nuclear YAP localization and spontaneous osteogenic differentiation. Inhibition of F‐actin alignments was correlated with nuclear YAP exclusion of DPSCs. Verteporfin restricted YAP localisation to the cytoplasm, down‐regulated expression of early osteogenic/odontogenic markers and inhibited mineralization of DPSCs cultures.

Conclusions

The surface topographic cues changed F‐actin alignment and morphology of DPSCs, which in turn regulated YAP signalling to control osteogenic/odontogenic differentiation.

Animal Models for Stem Cell-Based Pulp Regeneration: Foundation for Human Clinical Applications

IMPACT STATEMENT

Animal models are essential for tissue regeneration studies. This review summarizes and discusses the small and large animal models, including mouse, ferret, dog, and miniswine that have been utilized to experiment and to demonstrate stem cell-mediated dental pulp tissue regeneration. We describe the models based on the location where the tissue regeneration is tested-either ectopic, semiorthotopic, or orthotopic. Developing and utilizing optimal animal models for both mechanistic and translational studies of pulp regeneration are of critical importance to advance this field.

Comprehensive Characterization of 2 Immature Teeth Treated with Regenerative Endodontic Procedures

INTRODUCTION

Regeneration of the pulp-dentin complex is the penultimate goal of regenerative endodontic procedures (REPs). Histological outcomes have demonstrated reparative tissue formation in human teeth extracted post-REPs. However, lack of accurate characterization has precluded identification of the true nature of tissues formed post-REP.

METHODS

Here, we present 2 case reports of tooth #29 and #9 treated with REPs and demonstrate their clinical, radiographic, and histological outcomes.

RESULTS

Clinical outcomes revealed healing of apical periodontitis in both teeth and re-establishment of vitality responses in tooth #29. Moreover, radiographic assessments using 2D and 3D-volumetric analyses demonstrate considerable increase in root development for both teeth. Further, histological outcomes evaluated using Hematoxylin and Eosin and immunohistochemical staining demonstrates presence of vascular and lymphatic structures as well as immune cell markers indicative of regeneration of an immunocompetent pulp. Lastly, examination of hard tissue deposition shows dentin-like tissue in parts of tooth #29 demonstrating for the first time, regeneration of a pulp-dentin complex post-REP.

CONCLUSIONS

Collectively, this is the first study demonstrating recapitulation of several tissues commonly found as part of a pulp-dentin complex in teeth treated with REPs.

Regenerative Endodontic Procedures Using Contemporary Endodontic Materials

Calcium hydroxide apexification and Mineral Trioxide Aggregate (MTA) apexification are classical treatments for necrotic immature permanent teeth. The first tend to fail for lack of compliance given the high number of sessions needed; the second has technical difficulties such as material manipulation and overfilling. With both techniques, the root development is interrupted leaving the tooth with a fragile root structure, a poor crown-to-root ratio, periodontal breakdown, and high risk of fracture, compromising long-term prognosis of the tooth. New scientific literature has described a procedure that allows complete root development of these specific teeth. This regenerative endodontic procedure (REP) proposes the use of a combination of antimicrobials and irrigants, no canal walls instrumentation, induced apical bleeding to form a blood clot and a tight seal into the root canal to promote healing. MTA is the most used material to perform this seal, but updated guidelines advise the use of other bioactive endodontic cements that incorporate calcium and silicate in their compositions. They share most of their characteristics with MTA but claim to have fewer drawbacks with regards to manipulation and aesthetics. The purpose of the present article is to review pertinent literature and to describe the clinical procedures protocol with its variations, and their clinical application.

Pulp-dentin regeneration: current approaches and challenges

Regenerative endodontic procedures for immature permanent teeth with apical periodontitis confer biological advantages such as tooth homeostasis, enhanced immune defense system, and a functional pulp-dentin complex, in addition to clinical advantages such as the facilitation of root development. Currently, this procedure is recognized as a paradigm shift from restoration using materials to regenerate pulp-dentin tissues. Many studies have been conducted with regard to stem/progenitor cells, scaffolds, and biomolecules, associated with pulp tissue engineering. However, preclinical and clinical studies have evidently revealed several drawbacks in the current clinical approach to revascularization that may lead to unfavorable outcomes. Therefore, our review examines the challenges encountered under clinical conditions and summarizes current research findings in an attempt to provide direction for transition from basic research to clinical practice.

A Bilayered Poly (Lactic-Co-Glycolic Acid) Scaffold Provides Differential Cues for the Differentiation of Dental Pulp Stem Cells

IMPACT STATEMENT

In this article we used an FDA-approved biodegradable biomaterial, poly (lactic-co-glycolic acid) (PLGA 75:25) to generate a bilayered scaffold with the capacity to induce differential, layer-specific dentinogenic differentiation of dental pulp stem cells (DPSCs) in vitro. We surmise that such a scaffold can be used in conjunction with current regenerative endodontic procedures to help regenerating a physiologic dentin-pulp complex in vivo. We hypothesize that our scaffold in conjunction with DPSCs will advance current regenerative endodontics by restoring dentin and initiating the innervation and revascularization of the pulp.

Regenerative Endodontics for Adult Patients

The goal of endodontics is to save teeth. Since inception, endodontic treatments are performed to obturate disinfected root canals with inert materials such as gutta-percha. Although teeth can be saved after successful endodontic treatments, they are devitalized and therefore susceptible to reinfections and fractures. The American Association of Endodontists (AAE) has made a tremendous effort to revitalize disinfected immature permanent teeth in children and adolescents with diagnoses including pulp necrosis or apical periodontitis. The American Dental Association (ADA) in 2011 issued several clinical codes for regenerative endodontic procedures or apical revascularization in necrotic immature permanent teeth in children and adolescents. These AAE and ADA initiatives have stimulated robust interest in devising a multitude of tissue engineering approaches for dental pulp and dentin regeneration. Can the concept of regenerative endodontics be extended to revitalize mature permanent teeth with diagnoses including irreversible pulpitis and/or pulp necrosis in adults? The present article was written not only to summarize emerging findings to revitalize mature permanent teeth in adult patients but also to identify challenges and strategies that focus on realizing the goal of regenerative endodontics in adults. We further present clinical cases and describe the biological basis of potential regenerative endodontic procedures in adults. This article explores the frequently asked question if regenerative endodontic therapies should be developed for dental pulp and/or dentin regeneration in adults, who consist of the great majority of endodontic patients.

Regenerative endodontics: a comprehensive review

The European Society of Endodontology and the American Association for Endodontists have released position statements and clinical considerations for regenerative endodontics. There is increasing literature on this field since the initial reports of Iwaya et al. (Dental Traumatology, 17, 2001, 185) and Banchs & Trope (Journal of Endodontics, 30, 2004, 196). Endogenous stem cells from an induced periapical bleeding and scaffolds using blood clot, platelet rich plasma or platelet-rich fibrin have been utilized in regenerative endodontics. This approach has been described as a 'paradigm shift' and considered the first treatment option for immature teeth with pulp necrosis. There are three treatment outcomes of regenerative endodontics; (i) resolution of clinical signs and symptoms; (ii) further root maturation; and (iii) return of neurogenesis. It is known that results are variable for these objectives, and true regeneration of the pulp/dentine complex is not achieved. Repair derived primarily from the periodontal and osseous tissues has been shown histologically. It is hoped that with the concept of tissue engineering, namely stem cells, scaffolds and signalling molecules, that true pulp regeneration is an achievable goal. This review discusses current knowledge as well as future directions for regenerative endodontics. Patient-centred outcomes such as tooth discolouration and possibly more appointments with the potential for adverse effects needs to be discussed with patients and parents. Based on the classification of Cvek (Endodontics and Dental Traumatology, 8, 1992, 45), it is proposed that regenerative endodontics should be considered for teeth with incomplete root formation although teeth with near or complete root formation may be more suited for conventional endodontic therapy or MTA barrier techniques. However, much is still not known about clinical and biological aspects of regenerative endodontics.

Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part II: other clinical applications and complications

Mineral trioxide aggregate (MTA) is a dental material used extensively for vital pulp therapies (VPT), protecting scaffolds during regenerative endodontic procedures, apical barriers in teeth with necrotic pulps and open apices, perforation repairs as well as root canal filling and root-end filling during surgical endodontics. A number of bioactive endodontic cements (BECs) have recently been introduced to the market. Most of these materials have calcium and silicate in their compositions; however, bioactivity is a common property of these cements. These materials include the following: BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, Neo MTA Plus, Ortho MTA, Quick-Set, Retro MTA, Tech Biosealer, and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA but without the drawbacks. In Part I of this review, the available information on the chemical composition of the materials listed above was reviewed and their applications for VPT was discussed. In this article, the clinical applications of MTA and other BECs will be reviewed for apexification, regenerative endodontics, perforation repair, root canal filling, root-end filling, restorative procedures, periodontal defects and treatment of vertical and horizontal root fractures. In addition, the literature regarding the possible drawbacks of these materials following their clinical applications is reviewed. These drawbacks include their discolouration potential, systemic effects and retreatability following use as a root filling material. Based on selected keywords, all publications were searched regarding the use of MTA as well as BECs for the relevant clinical applications. Numerous publications were found regarding the use of BECs for various endodontic applications. The majority of these investigations compared BECs with MTA. Despite promising results for some materials, the number of publications using BECs for various clinical applications was limited. Furthermore, most studies had several methodological shortcomings and low levels of evidence.

Regenerative Endodontics

Regenerative endodontics has been defined as “biologically based procedure designed to replace damaged structures, including dentin and root structures, as well as cells of the pulp–dentin complex.” This is an exciting and rapidly evolving field of human endodontics for the treatment of immature permanent teeth with infected root canal systems. These procedures have shown to be able not only to resolve pain and apical periodontitis but continued root development, thus increasing the thickness and strength of the previously thin and fracture-prone roots. In the last decade, over 80 case reports, numerous animal studies, and series of regenerative endodontic cases have been published. However, even with multiple successful case reports, there are still some remaining questions regarding terminology, patient selection, and procedural details. Regenerative endodontics provides the hope of converting a nonvital tooth into vital one once again.

Regenerative Endodontic Treatment versus Apical Plug in Immature Teeth: Three-Year Follow-Up

This report compares and evaluates the treatment outcomes of regenerative endodontic treatment and apical plug as two accepted treatment protocols in a pair of necrotic immature maxillary central incisors of a 12-year old female. The patient was referred complaining of a dull pain and swelling in her upper lip area. She had a history of trauma to the anterior maxilla two years earlier. Both teeth were clinically diagnosed with pulp necrosis and periapical radiographs revealed that separate periapical radiolucent lesions surrounded the immature apices of both teeth. The left and right incisors were treated with apical plug and regenerative endodontic treatment, respectively, using calcium-enriched mixture (CEM) cement. The patient was followed-up for three years. During this period, both teeth were clinically asymptomatic and showed complete radiographic healing of the periapical lesions. The right central incisor showed root development. No tooth discoloration was evident. Apexification by apical plug placement and pulp regeneration are both reliable treatments for immature non-vital teeth. In order to choose the right treatment the advantages of either technique should be weighed against its drawbacks. CEM cement can be successfully applied for both purposes. This biomaterial causes less discoloration of the tooth.

Regenerative Endodontic Therapy in a Single Visit Using Platelet-rich Plasma and Biodentine in Necrotic and Asymptomatic Immature Molar Teeth: A Report of 3 Cases

This report describes 3 successful single-visit regenerative endodontic therapy cases using platelet-rich plasma (PRP) and Biodentine (Septodont, Saint Maurdes Fossés, France) for 3 immature mandibular molar teeth, all with necrotic pulp, in 2 children aged 8 years and 1 aged 9 years. Three teeth were separately diagnosed as having a necrotic pulp. After preparation of the access cavity under rubber dam isolation, the necrotic pulp was removed, and each canal was irrigated with 2.5% sodium hypochlorite, sterile saline, and 17% EDTA solutions. Freshly prepared PRP was injected into each canal up to the cementoenamel junction, and Biodentine was placed directly over the PRP clot. Each access cavity was then restored with composite resin. Follow-up clinical examinations revealed negative responses to cold and electric pulp tests. None of the treated teeth were sensitive to percussion or palpation. Radiographic examination showed continued thickening of root canal walls and apical closure of the root apex of each tooth. Single-visit regenerative endodontic therapy can be considered in necrotic and asymptomatic immature permanent teeth. PRP and Biodentine may serve as scaffold and barrier materials in regenerative endodontic procedures.

Management of incompletely developed teeth requiring root canal treatment

Endodontic management of the permanent immature tooth continues to be a challenge for both clinicians and researchers. Clinical concerns are primarily related to achieving adequate levels of disinfection as 'aggressive' instrumentation is contraindicated and hence there exists a much greater reliance on endodontic irrigants and medicaments. The open apex has also presented obturation difficulties, notably in controlling length. Long-term apexification procedures with calcium hydroxide have proven to be successful in retaining many of these immature infected teeth but due to their thin dentinal walls and perceived problems associated with long-term placement of calcium hydroxide, they have been found to be prone to cervical fracture and subsequent tooth loss. In recent years there has developed an increasing interest in the possibility of 'regenerating' pulp tissue in an infected immature tooth. It is apparent that although the philosophy and hope of 'regeneration' is commendable, recent histologic studies appear to suggest that the calcified material deposited on the canal wall is bone/cementum rather than dentine, hence the absence of pulp tissue with or without an odontoblast layer.

Isolation, Characterization, and Differentiation of Dental Pulp Stem Cells in Ferrets

INTRODUCTION

The ferret canine tooth has been introduced as a suitable model for studying dental pulp regeneration. The aim of this study was to isolate and characterize ferret dental pulp stem cells (fDPSCs) and their differentiation potential.

METHODS

Dental pulp stem cells were isolated from freshly extracted ferret canine teeth. The cells were examined for the expression of stem cell markers STRO-1, CD90, CD105, and CD146. The osteo/odontogenic and adipogenic differentiation potential of fDPSCs was evaluated. Osteogenic and odontogenic marker genes were evaluated using quantitative real-time polymerase chain reaction (qRT-PCR) on days 1, 4, and 8 after osteo/odontogenic induction of fDPSCs including dentin sialophosphoprotein (DSPP), dentin matrix protein-1, osteopontin, and alkaline phosphatase. Human dental pulp cells were used as the control. The results were analyzed using 3-way analysis of variance.

RESULTS

fDPSCs were positive for STRO1, CD90, and CD105 and negative for CD146 markers with immunohistochemistry. fDPSCs showed strong osteogenic and weak adipogenic potential. The overall expression of DSPP was not significantly different between fDPSCs and human dental pulp cells. The expression of DSPP in osteo/odontogenic media was significantly higher in fDPSCs on day 4 (P < .01). The overall expression of dentin matrix protein-1, osteopontin, and alkaline phosphatase was significantly higher in fDPSCs (P = .0005).

CONCLUSIONS

fDPSCs were positive for several markers of dental pulp stem cells resembling human DPSCs and appeared to show a stronger potential to differentiate to osteoblastic rather than odontoblastic lineage.

Autologous Platelet Concentrates for Pulp and Dentin Regeneration: A Literature Review of Animal Studies

INTRODUCTION

The purpose of this study was to evaluate the effectiveness of autologous platelet concentrates (APCs) in promoting pulp and dentin regeneration in animal models.

METHODS

An electronic search was performed on MEDLINE, Embase, Scopus, SciELO, LILACS, and CENTRAL. Animal studies using APC as a root filling material after pulpectomy in mature or immature teeth were included. Articles underwent risk of bias assessment. Histologic evaluation of intracanal neoformed tissue was the primary outcome; root development, root wall thickening, apical closure, and periapical healing in apical periodontitis were the secondary outcomes.

RESULTS

Seven articles were included. Platelet-rich plasma (PRP) was used as root filling material during regenerative procedures in the experimental group in either mature or immature teeth. After revascularization with PRP alone or in conjunction with stem cells of a different source, the histologic analyses revealed that, in addition to an odontoblastic cell layer or dentinlike structure, the neoformed intracanal tissues were mainly cementumlike, bonelike, and connective tissues.

CONCLUSIONS

True regeneration of necrotic pulp may not be achieved with current techniques using PRP, all of which stimulated tissue repair. Benefits of PRP adjunct for pulp tissue regeneration in preclinical studies remain unclear. Further studies with standardized protocols are necessary to assess the actual contribution of PRP in endodontic regenerative therapies.

In Vivo Experiments with Dental Pulp Stem Cells for Pulp-Dentin Complex Regeneration

In recent years, many studies have examined the pulp-dentin complex regeneration with DPSCs. While it is important to perform research on cells, scaffolds, and growth factors, it is also critical to develop animal models for preclinical trials. The development of a reproducible animal model of transplantation is essential for obtaining precise and accurate data in vivo. The efficacy of pulp regeneration should be assessed qualitatively and quantitatively using animal models. This review article sought to introduce in vivo experiments that have evaluated the potential of dental pulp stem cells for pulp-dentin complex regeneration. According to a review of various researches about DPSCs, the majority of studies have used subcutaneous mouse and dog teeth for animal models. There is no way to know which animal model will reproduce the clinical environment. If an animal model is developed which is easier to use and is useful in more situations than the currently popular models, it will be a substantial aid to studies examining pulp-dentin complex regeneration.

Efficacy of platelet-rich plasma as a scaffold in regenerative endodontic treatment

INTRODUCTION

Current research is concerned with discovering better scaffolds for use in regenerative endodontic treatment. This study aimed to clinically and radiographically evaluate the efficacy of platelet-rich plasma (PRP) used as a scaffold in regenerative endodontic treatment and compare it with that of a conventional blood clot (BC) scaffold.

METHODS

A total of 20 necrotic, single-rooted immature teeth were randomly distributed into 2 groups. After disinfecting the root canal space with triple antibiotic paste (1:1:1 ciprofloxacin, metronidazole, and cefaclor), a tissue scaffold was created by using either PRP or BC and covered with white mineral trioxide aggregate. Clinical and radiographic follow-up examinations were performed once every 3 months during an 18-month period. Differences in root area were calculated from preoperative and postoperative radiographs. Fisher exact and Mann-Whitney U tests were used to evaluate differences between groups, with P value <.05 considered to be statistically significant.

RESULTS

All 20 teeth were clinically asymptomatic during 18-month follow-up period; however, 1 tooth in the BC group exhibited periapical pathosis and was judged radiographically unsuccessful. Complete apical closure was observed in a mean of 8.1 months in the PRP group compared with 9 months in the BC group. The PRP group exhibited 9.86% increase in root area, compared with 12.6% increase in the BC group. The difference in success rates between the groups was not statistically significant (P > .05).

CONCLUSIONS

PRP successfully created a scaffold for regenerative endodontic treatment; however, treatment outcomes did not differ significantly between PRP and conventional BC scaffold.