A New Calcium Silicate–based Bioceramic Material Promotes Human Osteo- and Odontogenic Stem Cell Proliferation and Survival via the Extracellular Signal-regulated Kinase Signaling Pathway

The impact of root end filling material type and the application of bone graft on healing of periapical tissues after endodontic microsurgery (a clinical randomized controlled trial)

To evaluate the effect of combining different bioactive root-end filling materials with composite bone graft (xenogeneic mixed with autogenous bone fragments) on the healing process of periapical tissues after endodontic micro-surgery procedure. In this triple-blinded clinical trial, 56 patients were divided into 2 main groups (28 each) according to the root-end filling material and 2 subgroups according to the presence or absence of the composite bone graft material. Group I: MTA root-end filling (n = 28) in which there are Sub-group A: without bone graft (n = 14) and Sub-group B: with composite bone graft (n = 14). Group II: TotalFill root-end filling (n = 28) in which there are Sub-group A: without bone graft (n = 14) and Sub-group B: with composite bone graft (n = 14). Healthy patients whose ages range from 20 to 50 years with small-to-medium size radiolucency in CBCT related to single-rooted maxillary teeth were included in this study. Patients were assigned a number starting from 1 to 56 and were randomly allocated to four test groups (2 main groups and 2 sub-groups) following simple randomization procedure guidelines described by IBM SPSS V23 (IBM USA) statistical analysis software. This trial was triple-blind where the patient, the outcome assessors, and the main operator were blinded to the applied intervention. Every patient was evaluated clinically and by CBCT at two main observation periods: presurgical and 12-month post-operative. They were also examined and evaluated clinically and radiographically through periapical x-rays after one week, three, and six months. Statistical analysis was performed with IBM SPSS Statistics for Windows Version 23.0. Armonk, NY: IBM Corp. Of the 56 patients enrolled in the study, 49 patients were available for the final analysis. All groups showed no statistically significant differences with regard to healing or success rates at the 12-month follow-up mark. No adverse effects were encountered. Results showed that high success rates were achieved using MTA and TotalFill in the healing of periapical lesions after endodontic surgery. The addition of bone graft in small-to-medium size lesions did not affect the success rate of endodontic surgeries.

The Influence of Bioceramic Cements on the Activity of Macrophages of Different Lineages: A Laboratory Study

INTRODUCTION

The repair process of periradicular tissues depends, among other factors, on the properties of endodontic cements. Macrophages are among the main cells involved in this process.

MATERIALS AND METHODS

Murine peritoneal macrophages obtained from C57BL/6 (MBL6) and BALB/c (MBalb) mice, respectively, were cultured with capillaries containing or not Endosequence BC Sealer (BC), Sealer Plus BC (MK), Bio-C Sealer (Ang), and mineral trioxide aggregate (MTA). Cell viability was measured by Trypan blue and MTT methods at 24, 48, and 72 hours. Cell adhesion, phagocytosis of Saccharomyces boulardii, production of reactive oxygen species (ROS), nitric oxide (NO), and the cytokines tumor necrosis factor-α and transforming growth factor (TGF)-β were also evaluated. The data were analyzed using the analysis of variance test (P < .05).

RESULTS

Cell viability was similar between bioceramic sealers and MTA (P > .05). There was no statistical difference between both macrophages when adherence and phagocytose were assayed. The presence of inflammation stimulus significantly altered the production of ROS by MBL6 macrophages in contact with the cements. The production of TGF-β was similar for both lineages of macrophages.

CONCLUSIONS

This study shows that the evaluated bioceramic cements do not interfere with MBL6 and MBalb macrophage adhesion, phagocytic capacity, or TGF-β production. The cements stimulated the production of ROS by MBL6 macrophages in response to induced inflammation, potentially favoring the elimination of residual pathogens.

Biocompatibility and pro-mineralization effects of premixed calcium silicate-based materials on human dental pulp stem cells: An in vitro and in vivo study

Premixed calcium silicate-based materials have recently been developed and are recommended for a wide range of endodontic procedures, including vital pulp therapy. This study investigated the in vitro biocompatibility and pro-mineralization effect and in vivo reparative dentin formation of EndoSequence Root Repair Material, EndoSequence BCRRM, Bio-C Repair, and Well-pulp PT. Both fresh and set extracts had no detrimental effect on the growth of human dental pulp stem cells. The fresh extracts had a higher calcium concentration than the set extracts and induced considerably greater mineralized nodule formation. EndoSequence Root Repair Material had the longest setting time, whereas Bio-C Repair had the shortest. When these materials were applied to exposed rat molar pulps, mineralized tissue deposition was found at the exposure sites after 2 weeks. These results indicate that the premixed calcium silicate-based materials tested could have positive benefits for direct pulp capping procedures.

A comparative study of biological properties of three root canal sealers

OBJECTIVES

The aim of this study was to evaluate the effects of Hiflow with other two kinds of root canal sealers on the biological behavior of stem cells from the apical papilla (SCAP), the influence on inflammatory cytokines release and its antibacterial effects.

MATERIALS AND METHODS

Material extracts of Hiflow, iRoot SP, and AH Plus were prepared. Then, SCAP was incubated with extracts. The effects were evaluated by CCK-8, wound healing assay, ALP staining, alizarin red staining, and qRT-PCR. Meanwhile, polymorphonuclears (PMNs) and monocytes were isolated and treated with extracts for 4 h and 24 h respectively. Cell viability was analyzed by Annexin-V/PI double staining flow cytometry. The effects on the release of cytokines were observed by ELISA. The antibacterial effects of different sealers were tested against three kinds of bacteria found in chronic apical periodontitis.

RESULTS

A series of results of SCAP showed that Hiflow and iRoot SP could promote cell proliferation, migration, and osteogenesis (p < 0.05). Although Hiflow was associated with greater cell apoptosis and necrosis when incubated with PMNs and monocytes (p < 0.05), it had an approximate release of anti-inflammatory cytokines with iRoot SP, which was higher than AH plus (p < 0.05). The co-culture showed that Hiflow and iRoot SP inhibited the colony formation of F. nucleatum (p < 0.05). However, both sealers had no obvious antibacterial effect on E. faecalis and P. gingivalis (p > 0.05).

CONCLUSIONS

In summary, Hiflow and iRoot SP both had positive biological stimulus on SCAP. Meanwhile, Hiflow showed a better induction on anti-inflammatory cytokines over the others. All the properties mentioned above and its antibacterial effect of F. nucleatum promise Hiflow a bright application prospect in endodontic uses.

CLINICAL RELEVANCE

References for clinical work to use BC Sealer Hiflow as a good biological root canal sealer.

Evaluation of the Impact of Calcium Silicate-Based Sealer Insertion Technique on Root Canal Obturation Quality: A Micro-Computed Tomography Study

BACKGROUND

Calcium silicate-based sealers have gained in popularity over time due to their physicochemical/biological properties and their possible use with single-cone obturation. The single cone technique is a sealer-based obturation and there is still a knowledge gap regarding the potential impact of the sealer insertion method on the root canal-filling quality. Therefore, the aim of this micro-CT study was to assess the impact of the calcium silicate-based sealer insertion technique on void occurrence and on the sealer extrusion following single-cone obturation.

METHODS

Thirty-six single-rooted mandibular premolars with one canal were shaped with Reciproc® R25 (VDW, Munich, Germany) then divided randomly into four groups of nine canals, each depending on the TotalFill® BC Sealer insertion technique used with single cone obturation: injection in the coronal two-thirds (group A); injection in the coronal two-thirds followed by direct sonic activation (group B); injection in the coronal two-thirds followed by indirect ultrasonic activation on tweezers (group C); sealer applied only on the master-cone (control group D). Samples were then scanned using micro-CT for voids and sealer extrusion calculation. Data were statistically analyzed using v.26 IBM; Results: No statistically significant differences were noted between the four groups in terms of voids; nevertheless, sonic activation (group B) followed by ultrasonic activation on the tweezers (group C) showed the best results (p = 0.066). Group D showed significantly less sealer extrusion when compared with group C (p = 0.044), with no statistically significant differences between groups D, A and B (p > 0.05).

CONCLUSIONS

Despite no significant differences observed between the different sealer placement techniques, the use of sonic and ultrasonic activation might be promising to reduce void occurrence. Further investigations are needed to demonstrate the potential benefit of calcium silicate-based sealer activation especially in wide and oval root canals in order to improve the quality of the single-cone obturation.

Assessment of pH Value and Release of Calcium Ions in Calcium Silicate Cements: An In Vitro Comparative Study

The goal of this study was to evaluate the pH and the release of calcium from four calcium-silicate-based cements.

METHODS

Four materials were tested (ProClinic MTA; Angelus MTA; ProRoot MTA; Biodentine). The palatal canal root of acrylic upper molars was filled with each cement. Afterwards, they were set in phosphate-buffered saline. Measurements were taken by atomic adsorption spectroscopy (AAS) at 3, 24, 72, 168, 336, 672, and 1008 h. The pH was measured at the same timepoints. Kruskal-Wallis tests were carried out in each period, as the Kolmogorov-Smirnov and Shapiro-Wilk tests showed no parametric results.

RESULTS

Significant differences (p < 0.05) in calcium release were found at the 3-, 24-, and 72-hour evaluations. All of the analyzed groups presented a release of calcium ions up to 168 h, and the general tendency was to increase up to 672 h, with a maximum release of 25.45 mg/g in the ProRoot group. We could only observe significant differences (p < 0.05) in pH value over 168 h between the Biodentine (7.93) and Angelus MTA (7.31) groups.

CONCLUSIONS

There were significant differences (p < 0.05) in calcium release. Nevertheless, no significant differences (p > 0.05) in the pH values were found at the studied timepoints, except for the values at 168 h.

Comparative Biocompatibility and Odonto-/Osteogenesis Effects of Hydraulic Calcium Silicate-Based Cements in Simulated Direct and Indirect Approaches for Regenerative Endodontic Treatments: A Systematic Review

BACKGROUND

Regenerative dentistry is the operation of restoring dental, oral and maxillofacial tissues. Currently, there are no guidelines for the ideal cement/material in regenerative endodontic treatments (RET). Hydraulic calcium silicate-based cements (hCSCs) are currently the material of choice for RET.

OBJECTIVES

This systematic review was conducted to gather all of the different direct and indirect approaches of using hCSCs in RET in vitro and in vivo, and to ascertain if there are any superiorities to indirect approaches.

METHODS AND MATERIALS

This systematic review was conducted according to the 2020 PRISMA guidelines. The study question according to the PICO format was as follows: Comparison of the biological behavior (O) of stem cells (P) exposed to hCSCs through direct and indirect methods (I) with untreated stem cells (C). An electronic search was executed in Scopus, Google Scholar, and PubMed.

RESULTS

A total of 78 studies were included. Studies were published between 2010 and 2022. Twenty-eight commercially available and eighteen modified hCSCs were used. Seven exposure methods (four direct and three indirect contacts) were assessed. ProRoot MTA and Biodentine were the most used hCSCs and had the most desirable results. hCSCs were either freshly mixed or set before application. Most studies allowed hCSCs to set in incubation for 24 h before application, which resulted in the most desirable biological outcomes. Freshly mixed hCSCs had the worst outcomes. Indirect methods had significantly better viability/proliferation and odonto-/osteogenesis outcomes.

CONCLUSION

Biodentine and ProRoot MTA used in indirect exposure methods result in desirable biological outcomes.

Osteogenesis of bone marrow mesenchymal stem cell in hyperglycemia

Diabetes mellitus (DM) has been shown to be a clinical risk factor for bone diseases including osteoporosis and fragility. Bone metabolism is a complicated process that requires coordinated differentiation and proliferation of bone marrow mesenchymal stem cells (BMSCs). Owing to the regenerative properties, BMSCs have laid a robust foundation for their clinical application in various diseases. However, mounting evidence indicates that the osteogenic capability of BMSCs is impaired under high glucose conditions, which is responsible for diabetic bone diseases and greatly reduces the therapeutic efficiency of BMSCs. With the rapidly increasing incidence of DM, a better understanding of the impacts of hyperglycemia on BMSCs osteogenesis and the underlying mechanisms is needed. In this review, we aim to summarize the current knowledge of the osteogenesis of BMSCs in hyperglycemia, the underlying mechanisms, and the strategies to rescue the impaired BMSCs osteogenesis.

Effect of cleaning materials on microtensile bond strength of resin composite to primary dentin contaminated with root canal sealers

BACKGROUND

There have been no studies on the bond strength of adhesives with dentin surfaces contaminated with root canal sealers in primary teeth without underlying permanent teeth germs. This study investigated the cleaning materials used for primary tooth dentin contaminated with root canal sealers. The aim was to increase the success rate of root canal treatment in pedodontics clinics and retain the teeth for longer.

METHODS

The occlusal enamel layer was removed, followed by the application of root canal sealers (AH Plus or MTA Fillapex) to the dentin and cleaning using different irrigation solutions (saline, NaOCl, and ethanol). The specimens were restored using a self-etch adhesive and composite. Sticks with a thickness of approximately 1 mm were obtained from each sample, and the bond strengths were measured using a microtensile testing device. The interfacial morphology of the bonded space was evaluated using scanning electron microscopy.

RESULTS

The control and AH Plus saline groups had the highest bond strengths. The groups cleaned using ethanol had the lowest bond strengths (p < 0.01).

CONCLUSION

Cleaning the dentin with saline-soaked cotton pellets provided the best bond strengths. Therefore, saline is the most effective material for removing both epoxy resin- and calcium silicate-based root canal sealers from the access cavity.

Cytotoxicity and genotoxicity of Bio-C Repair, Endosequence BC Root Repair, MTA Angelus and MTA Repair HP

The aim was to evaluate in vitro cytotoxicity and genotoxicity of Bio-C Repair (BCR), compared to Endosequence BC Root Repair (ERRM), MTA Angelus (MTA-Ang), and MTA Repair HP (MTA-HP). MC3T3 osteoblastic cells were exposed to extracts of the repairing bioceramic cements. After 1, 3, and 7 days, cytotoxicity and genotoxicity were evaluated by MTT and Micronucleus tests, respectively. Cells not exposed to biomaterials were used as a negative control. Data were compared using ANOVA two-way, followed by the Tukey Test (α=5%). MTA-Ang and MTA-HP showed no difference in relation to control regarding cytotoxicity in any experimental times. BCR and ERRM reduced cell viability after 3 and 7 days (p<0.05); however, the reduction caused by BCR was less than that caused by ERRM. Considering the micronucleus formation, all biomaterials caused an increase after 3 and 7 days (p<0.05), being greater for the BCR and ERRM groups. It can be concluded that BCR is non-cytotoxic in osteoblastic cells, as well as MTA-Ang e MTA Repair HP. BCR and ERRM showed greater genotoxicity than others tested biomaterials.

Fracture Resistance of Molars With Simulated Strip Perforation Repaired With Different Calcium Silicate-Based Cements

Background and aims A root perforation is a connection between the root canal system and the external supportive tissues. Strip perforation (SP), occurring within root canals in a strip, can worsen the prognosis of a treated tooth, reduce its mechanical resistance, and impair the tooth structure. One of the suggested methods to treat SP is to seal it with a bio-material such as calcium silicate cement. Therefore, this in vitro study aimed to assess the molar structure impairment due to SP, which requires studying the fracture resistance, and the ability of mineral trioxide aggregate (MTA), bioceramic, and calcium-enriched mixture (CEM) to repair this perforation. Materials and methods Seventy-five molars were instrumented to size #25 and taper 4%, irrigated with sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA), dried, and then divided randomly into five groups (G1-G5): in G1, root canals were filled with gutta-percha and sealer (negative control sample), whereas the rest of the groups (G2-G5) had a manual simulated SP made with Gates Glidden drill at the mesial root of the extracted molar, and filled with gutta-percha and sealer up to their perforation area; in G2, SP was filled with gutta-percha and sealer (positive control sample); G3 used MTA to repair the SP; G4 used bioceramic putty; and G5 used CEM. Fracture resistance tests of the molars were conducted in the crown-apical direction using a universal testing machine. One-way ANOVA test and Bonferroni test were used to study the significance of the differences in the mean values of the tooth fracture resistance, where statistical significance was set at 0.05. Results The ANOVA test showed that there were statistically significant differences between the fracture resistance (in newtons) values among groups (p = 0.000). The Bonferroni test showed that G2 had a smaller fracture resistance mean than the other four study groups (656.53 N; p = 0.000), and that of G5 was smaller than G1, G3, and G4 (794.40 N, 1083.73 N, 1025.20 N, and 1034.20 N, respectively; p = 0.000 in each pairwise comparison). Conclusion SP reduced the fracture resistance of endodontically treated molars. SP restored using MTA and bioceramic putty was better than that treated with CEM and similar to molars without SP. Moreover, MTA and bioceramic putty enhanced the fracture resistance of endodontically treated teeth to levels similar to molars without SP.

Biocompatible Properties and Mineralization Potential of Premixed Calcium Silicate-Based Cements and Fast-Set Calcium Silicate-Based Cements on Human Bone Marrow-Derived Mesenchymal Stem Cells

Premixed calcium silicate-based cements (CSCs) and fast-set CSCs were developed for the convenience of retrograde filling during endodontic microsurgery. The aim of this study was to analyze the biocompatible properties and mineralization potential of premixed CSCs, such as Endocem MTA Premixed (EM Premixed) and EndoSequence BC RRM putty (EndoSequence), and fast-set RetroMTA on human bone marrow-derived mesenchymal stem cells (BMSCs) compared to ProRoot MTA. Using CCK-8, a significantly higher proliferation of BMSCs occurred only in the EM Premixed group on days 2 and 4 (p < 0.05). On day 6, the ProRoot MTA group had significantly higher cell proliferation than the control group (p < 0.05). Regardless of the experimental materials, all groups had complete cell migration by day 4. Alizarin Red-S staining and alkaline phosphatase assay demonstrated higher mineralization potential of all CSCs similar to ProRoot MTA (p < 0.05). The EndoSequence group showed more upregulation of SMAD1 and OSX gene expression than the other experimental groups (p < 0.05), and all experimental cements upregulated osteogenic gene expression more than the control group (p < 0.05). Therefore, using premixed CSCs and fast-set CSCs as retrograde filling cements may facilitate satisfactory biological responses and comparable osteogenic potential to ProRoot MTA.

Trends of calcium silicate biomaterials in medical research and applications: A bibliometric analysis from 1990 to 2020

Background: Calcium silicate biomaterials (CSB) have witnessed rapid development in the past 30 years. This study aimed to accomplish a comprehensive bibliometric analysis of the published research literature on CSB for biomedical applications and explore the research hotspot and current status.

Methods: Articles related to CSB published in the last three decades (1990–2020) were retrieved from Web of Science Core Collection. The R bibliometrix package and VOSviewer were used to construct publication outputs and collaborative networking among authors, their institutes, countries, journals’ matrices and keywords plus.

Results: A total of 872 publications fulfilling the search criteria were included. CSB is mainly reported for bone tissues and dental applications. Among researchers, Chang J from Chinese Academy of Sciences and Gandolfi MG from the University of Bologna are the most productive author in these two fields, respectively. China was the leading contributor to the research on CSB in the medical field. A total of 130 keywords appeared more ten or more times were identified. The term “mineral trioxide aggregate” ranked first with 268 occurrences. The co-occurrence analysis identified three major clusters: CSB in dentistry, bone tissue and vitro bioactivity.

Conclusion: Calcium silicate biomaterials have a promising scope for various biomedical applications ranging from regeneration of hard tissues (bone and teeth) to skin, tumor, cardiac muscle and other soft tissues. This study may help researchers further understand the frontiers of the field.

Present Status and Future Directions - Surgical Endodontics

Endodontic surgery encompasses several procedures for the treatment of teeth with a history of failed root canal treatment, such as root-end surgery, crown- and root resections, surgical perforation repair, and intentional replantation. Endodontic microsurgery is the evolution of the traditional apicoectomy techniques and incorporates high magnification, ultrasonic root-end preparation and root-end filling with biocompatible filling materials. Modern endodontic surgery uses the dental operating microscope, incorporates cone-beam computed tomography (CBCT) for preoperative diagnosis and treatment planning, and has adopted piezoelectric approaches to osteotomy and root manipulation. Crown- and root resection techniques have benefitted from the same technological advances. This review focuses on the current state of root-end surgery by comparing the techniques and materials applied during endodontic microsurgery to the most widely used earlier methods and materials. The most recent additions to the clinical protocol and technical improvements are discussed, and an outlook on future directions is given. While non-surgical retreatment remains the first choice to address most cases with a history of endodontic failure, modern endodontic microsurgery has become a predictable and minimally invasive alternative for the retention of natural teeth.

Dicalcium silicate-induced mitochondrial dysfunction and autophagy-mediated macrophagic inflammation promotes osteogenic differentiation of BMSCs

Dicalcium silicate (Ca2SiO4, C2S) has osteogenic potential but induces macrophagic inflammation. Mitochondrial function plays a vital role in macrophage polarization and macrophagic inflammation. The mitochondrial function of C2S-treated macrophages is still unclear. This study hypothesized: (i) the C2S modulates mitochondrial function and autophagy in macrophages to regulate macrophagic inflammation, and (ii) C2S-induced macrophagic inflammation regulates osteogenesis. We used RAW264.7 cells as a model of macrophage. The C2S (75-150 μg/ml) extract was used to analyze the macrophagic mitochondrial function and macrophage-mediated effect on osteogenic differentiation of mouse bone marrow-derived mesenchymal stem cells (BMSCs). The results showed that C2S extract (150 μg/ml) induced TNF-α, IL-1β and IL-6 production in macrophages. C2S extract (150 μg/ml) enhanced reactive oxygen species level and intracellular calcium level but reduced mitochondrial membrane potential and ATP production. TEM images showed reduced mitochondrial abundance and altered the mitochondrial morphology in C2S (150 μg/ml)-treated macrophages. Protein level expression of PINK1, Parkin, Beclin1 and LC3 was upregulated but TOMM20 was downregulated. mRNA sequencing and KEGG analysis showed that C2S-induced differentially expressed mRNAs in macrophages were mainly distributed in the essential signaling pathways involved in mitochondrial function and autophagy. The conditioned medium from C2S-treated macrophage robustly promoted osteogenic differentiation in BMSCs. In conclusion, our results indicate mitochondrial dysfunction and autophagy as the possible mechanism of C2S-induced macrophagic inflammation. The promotion of osteogenic differentiation of BMSCs by the C2S-induced macrophagic inflammation suggests the potential application of C2S in developing immunomodulatory bone grafts.

Biomaterials in periapical regeneration after microsurgical endodontics: A narrative review

Background

The objective of this narrative review was to analyze the available scientific evidence regarding the application of biomaterials in endodontic microsurgery and its influence in post-surgical tissue repair.

Material and Methods

The review question was Do biomaterials used in endodontic microsurgery influence post-surgical tissue repair and regeneration? Systematic MEDLINE/PubMed review was used to evaluate and present the results.

Results

The search yielded 131 references, 82 of which were selected for full text review after reading the abstracts. After a manual search in the references of the articles selected, 52 references were eliminated. Finally, 30 articles were selected.

Conclusions

Bone grafts, membranes and bioceramics, especially MTA, are biomaterials with the ability to stimulate periapical tissue regeneration. This is one of many reason why bioceramics are the best choice as retrograde sealing materials. However, microsurgically treated periapical lesions can heal completely without the need to use bone grafts or membranes. Those techniques are indicated in endodontic microsurgery when additional stimulation of tissue regeneration is required, or when bone collapse needs to be prevented.

Key words:Bioactive endodontic cements, endodontic surgery, periapical repair.

Nell-1 attenuates lipopolysaccharide-induced inflammation in human dental pulp cells

Nel-like molecule type 1 (Nell-1) is a secreted protein that plays an important role in osteoinduction in multiple animal models. A previous study has suggested the anti-inflammatory effect of Nell-1 on bone inflammation inhibition. However, its role in pulpitis has not been investigated. The present study aims to explore the effect of human recombinant Nell-1 (Nell-1) on rat pulp inflammation response, and its effect on lipopolysaccharide-induced inflammation in human dental pulp cells and its related intracellular signaling pathways. 30 Wistar rats with healthy non-carious maxillary first molars were chosen, Nell-1 was absorbed onto a sterile collagen sponge and capped onto exposed pulps. The expression of IL-6 and IL-8 were detected by immunohistochemical staining. Human dental pulp cells (hDPCs) were isolated from healthy extracted premolars and third molars. hDPCs were co-cultured with Escherichia coli lipopolysaccharide (LPS), Nell-1 protein, and mitogen-activated protein kinase (MAPK) inhibitors. The expression of pro-inflammatory cytokines and chemokines, such as IL-6 and IL-8, was examined via quantitative real-time PCR and enzyme-linked immunosorbent assay. The results showed that Nell-1 inhibited the inflammatory response of rat pulp. LPS treatment contributed to the expression of inflammatory factors in hDPCs, whereas Nell-1 obviously suppressed the LPS-induced inflammation. p38 MAPK and extracellular signal-regulated kinase (ERK) MAPK inhibitors attenuated the anti-inflammatory effect of hrNell-1, whereas the c-Jun N-terminal kinases (JNK) MAPK inhibitor exerted minimal effect. Therefore Nell-1 could inhibit LPS-induced inflammation in human dental pulp cells, and this effect may be mediated by p38 and ERK MAPK signaling pathways, but not JNK MAPK signaling pathway.

In vitro biocompatibility and bioactivity of calcium silicate‑based bioceramics in endodontics (Review)

Calcium silicate-based bioceramics have been applied in endodontics as advantageous materials for years. In addition to excellent physical and chemical properties, the biocompatibility and bioactivity of calcium silicate-based bioceramics also serve an important role in endodontics according to previous research reports. Firstly, bioceramics affect cellular behavior of cells such as stem cells, osteoblasts, osteoclasts, fibroblasts and immune cells. On the other hand, cell reaction to bioceramics determines the effect of wound healing and tissue repair following bioceramics implantation. The aim of the present review was to provide an overview of calcium silicate-based bioceramics currently applied in endodontics, including mineral trioxide aggregate, Bioaggregate, Biodentine and iRoot, focusing on their in vitro biocompatibility and bioactivity. Understanding their underlying mechanism may help to ensure these materials are applied appropriately in endodontics.

Premixed bioceramics: A novel pulp capping agent

The main aim of restorative dentistry is to protect the vitality of the Pulp tissue. The pin point carious expoure and iatrogenic errors warrant the need for various pulp capping procedures like Indirect Pulp Capping and Direct Pulp Capping. Pulp Capping is dressing of the dental pulp exposed due to mechanical procedure, carious lesion or traumatic injury to preserve its vitality and function. There has been constant evolution and research on materials used to cap the Pulp tissue. The different kind of chemical and biological materials has been used with varying degree of success. The prognosis based on the pulp capping material has dramatically improved with the introduction of bioactive cement. Though MTA and biodentine have shown a high success rate, their properties can be adversely affected with error in powder/liquid ratio and may present with difficulty in the handling characteristic. Premixed bioceramics have been introduced in the market and present with desirable properties as a pulp capping agent. Owing to good handling characteristics, biocompatibility, odontogenic property, and antibacterial action it is a potent pulp capping agent for clinical application. This review is aimed to discuss the introduction of premixed bioceramics, forms of premixed bioceramics available, and its physical, chemical, and biocompatible properties.

Solubility of bioceramic- and epoxy resin-based root canal sealers: A systematic review and meta-analysis

This systematic review and meta-analysis evaluated whether epoxy resin-based root canal sealers present an increased solubility than calcium silicate-based root canal sealers. A systematic search was performed in the following databases: PubMed, Science Direct, Scopus, Web of Science and Open Grey. The inclusion criteria consisted of in vitro studies that compared the solubility of epoxy resin-based and calcium silicate-based sealers. The quality assessment and data extraction of the selected articles were performed. The meta-analysis of the pooled data and the subgroups according to the root thirds were carried out using the RevMan software (P < 0.05). After the duplicate removal and eligibility criteria assessment, a total of 22 studies were included all of them were considered as having a low risk of bias. The meta-analysis demonstrated overall lower solubility of AH Plus. AH Plus presented lower solubility than Bio-C Sealer, BioRoot RCS, MTA Fillapex, Sealer Plus and Total Fill BC Sealer.

The effects of mineral trioxide aggregate on osteo/odontogenic potential of mesenchymal stem cells: a comprehensive and systematic literature review

The significance of dental materials in dentin-pulp complex tissue engineering is undeniable. The mechanical properties and bioactivity of mineral trioxide aggregate (MTA) make it a promising biomaterial for future stem cell-based endodontic therapies. There are numerous in vitro studies suggesting the low cytotoxicity of MTA towards various types of cells. Moreover, it has been shown that MTA can enhance mesenchymal stem cells' (MSCs) osteo/odontogenic ability. According to the preferred reporting items for systematic reviews and meta-analyses (PRISMA), a literature review was conducted in the Medline, PubMed, and Scopus databases. Among the identified records, the cytotoxicity and osteo/odontoblastic potential of MTA or its extract on stem cells were investigated. Previous studies have discovered the differentiation-inducing potential of MTA on MSCs, providing a background for dentin-pulp complex cell therapies using the MTA, however, animal trials are needed before moving into clinical trials. In conclusion, MTA can be a promising candidate dental biomaterial for futuristic stem cell-based endodontic therapies.

Analysis of the physicochemical properties, cytotoxicity and volumetric changes of AH Plus, MTA Fillapex and TotalFill BC Sealer

Background

To evaluate the physicochemical properties and cytotoxicity of AH Plus, MTA Fillapex and TotalFill BC Sealer. Volumetric changes were also evaluating using micro-computed tomography (micro-CT).

Material and Methods

Radiopacity and flow were evaluated in accordance with the ISO 6876, while setting time was evaluated in accordance with the ASTM- C266-08 specifications. The release of Ca2+ ions and pH were measured with spectrophotometer and pH meter, respectively, after different time intervals (1h, 3h, 24h, 72h, 168h, and 360h). Cytotoxicity was evaluated by MTT reduction assay to check 3T3 cells viability at 24, 48 and 72 hours. Volumetric change was evaluated by micro-CT, by using 30 acrylic teeth, filled with gutta-percha cones and the tested root canal sealer. The samples were evaluated after 168h, 360h and 720h of immersion in distilled water. Data were statistically analyzed by one-way ANOVA and Tukey test or by Kruskal-Wallis and Dunn tests (P<0.05).

Results

MTA Fillapex and TotalFill BC Sealer showed lower radiopacity than AH Plus (P<0.05). The MTA Fillapex showed the highest flow, while AH Plus showed the lowest flow (P<0.05). The initial and final setting time of AH Plus were lower than MTA Fillapex and TotalFill BC Sealer (P<0.05). In general, TotalFill BC Sealer presented higher Ca2+ ion release and pH than the other tested sealers. TotalFill BC Sealer also showed overall lower cytotoxicity when compared to the other sealers. Volumetric change of AH Plus and TotalFill BC Sealer was lower than MTA Fillapex (P<0.05).

Conclusions

AH Plus, MTA Fillapex and TotalFill BC Sealer showed slight differences in the physicochemical properties and cytotoxicity, but all suitable for an endodontic sealer. However, AH Plus and TotalFill BC Sealer showed low volumetric changes when compared to MTA Fillapex.

Key words:Calcium silicate, cytotoxicity, physicochemical properties, micro computed tomography.

Strontium-substituted sub-micron bioactive glasses inhibit ostoclastogenesis through suppression of RANKL-induced signaling pathway

Strontium-substituted bioactive glass (Sr-BG) has shown superior performance in bone regeneration. Sr-BG-induced osteogenesis has been extensively studied; however, Sr-BG-mediated osteoclastogenesis and the underlying molecular mechanism remain unclear. It is recognized that the balance of osteogenesis and osteoclastogenesis is closely related to bone repair, and the receptor activators of nuclear factor kappaB ligand (RANKL) signaling pathway plays a key role of in the regulation of osteoclastogenesis. Herein, we studied the potential impact and underling mechanism of strontium-substituted sub-micron bioactive glass (Sr-SBG) on RANKL-induced osteoclast activation and differentiation in vitro. As expected, Sr-SBG inhibited RANKL-mediated osteoclastogenesis significantly with the experimental performance of decreased mature osteoclasts formation and downregulation of osteoclastogenesis-related gene expression. Furthermore, it was found that Sr-SBG might suppress osteoclastogenesis by the combined effect of strontium and silicon released through inhibition of RANKL-induced activation of p38 and NF-κB pathway. These results elaborated the effect of Sr-SBG-based materials on osteoclastogenesis through RANKL-induced downstream pathway and might represent a significant guidance for designing better bone repair materials.

The Response of the Pulp-Dentine Complex, PDL, and Bone to Three Calcium Silicate-Based Cements: A Histological Study in an Animal Rat Model

Objective

The aim of this study was to histologically examine the tissue reaction of three different calcium silicate cements in the closure of perforations in rat incisor teeth. Material and Methods. An experimental lateral root perforation with pulp exposure was performed in 32 lower incisors of 16 male Wistar albino rats. They were randomly assigned into three test groups (each including eight teeth) that were filled either by Biodentine (BD) or MicroMega mineral trioxide aggregate (MM-MTA) or EndoSequence root repair material putty (ESRRM putty), besides eight unperforated incisors from the other four rats (control group). The inflammatory response and healing process were evaluated histologically and scored after one and four weeks. Differences among groups were tested by Kruskal-Wallis tests at P ≤ 0.05.

Results

In the first week, BD produced more inflammatory response in the pulpal (score 3) than other materials (score 2). Only ESRRM putty showed odontoblast-like cells in 50%, 25% dentine-like deposit, 25% evidence of bone deposition in the drilling site (score 2), and minimum periodontal ligament (PDL) necrosis and disorganization (25%, score 2). After one month, all groups had healthy pulpal tissue, but 25% of ESRRM putty retained score 1 inflammatory response, and 50% of the BD case had an incomplete palisading odontoblast layer (score 3). A thick and regular dentine bridge deposition was seen in the ESRRM putty group in comparison with MM-MTA and BD cases. The cortical plate healing in all ESRRM putty samples was complete (score 3), while an incomplete closure was seen in MM-MTA and BD groups (score 2). Both the MM-MTA and ESRRM putty groups had fully organized PDL (score 2), while in 50% of BD cases, a necrotizing area and disorganized PDL with inflammatory cells infiltration were still present. Statistically significant differences in the scores of any histologic parameters among the three tested materials were observed neither in the 1st nor in the 4th weeks of the experimental period.

Conclusion

Better tissue compatibility and repair of pulpal and periodontal tissue have been detected after lateral perforation in the root of rat incisors when treated with ESRRM putty than MM-MTA and BD. However, the difference was not significant.

Cytocompatibility and cell proliferation evaluation of calcium phosphate-based root canal sealers

Objectives

This study aimed to evaluate the cell viability and migration of Endosequence Bioceramic Root Canal Sealer (BC Sealer) compared to MTA Fillapex and AH Plus.

Materials and Methods

BC Sealer, MTA Fillapex, and AH Plus were placed in contact with culture medium to obtain sealers extracts in dilution 1:1, 1:2 and 1:4. 3T3 cells were plated and exposed to the extracts. Cell viability and migration were assessed by 3-(4,5-dimethyl-thiazoyl)-2,5-diphenyl-tetrazolium bromide (MTT) and Scratch assay, respectively. Data were analyzed by Kruskal-Wallis and Dunn's test (p < 0.05).

Results

The MTT assay revealed greater cytotoxicity for AH Plus and MTA Fillapex at 1:1 dilution when compared to control (p < 0.05). At 1:2 and 1:4 dilutions, all sealers were similar to control (p > 0.05) and MTA Fillapex was more cytotoxic than BC Sealer (p < 0.05). Scratch assay demonstrated the continuous closure of the wound according to time. At 30 hours, the control group presented closure of the wound (p < 0.05). At 36 hours, only BC Sealer presented the closure when compared to AH Plus and MTA Fillapex (p < 0.05). At 42 hours, AH Plus and MTA Fillapex showed a wound healing (p > 0.05).

Conclusions

All tested sealers demonstrated cell viability highlighting BC Sealer, which showed increased cell migration capacity suggesting that this sealer may achieve better tissue repair when compared to other tested sealers.

Comparison between iRoot BP Plus (EndoSequence Root Repair Material) and Mineral Trioxide Aggregate as Pulp-capping Agents: A Systematic Review

INTRODUCTION

iRoot BP Plus, also known as EndoSequence root repair material (EERM) is a premixed bioceramic thick/putty. According to its instruction manual, iRoot BP Plus is composed of tricalcium silicate, zirconium oxide, tantalum pentoxide, dicalcium silicate, calcium sulfate, calcium phosphate monobasic, and filler agents. This systematic review was carried out to evaluate and present the iRoot BP Plus material as a pulp-capping agent.

MATERIALS AND METHODS

A systematic search for articles with the scope of the selection criteria undergoing for data extraction was conducted through electronic databases. Studies on evaluation of the cytotoxicity, bioactivity, and dentinal bridge formation of iRoot BP, iRoot BP Plus, ERRM putty, or ERRM paste (ERRM) on variant human cells were selected for in vitro models, and dentinal bridge formation on human and animals teeth for in vivo models were selected.

RESULTS

A total of 22 articles were discussed in the review, 14 in vitro studies, five in vivo studies, and three articles with both studies. Methyl thiazol tetrazolium was the most used method for evaluating cytotoxicity. As for dentinal bridge formation, histological assessment and micro-Computed tomography were used. Human dental pulp cells (hDPCs) were the most investigated for in vitro models and rats for in vivo models. Except for one study, all studies involved in this review were primarily examining the material and comparing it to different types of mineral trioxide aggregate.

CONCLUSION

iRoot BP, iRoot BP Plus, and ERRM are biocompatible materials that enhance hDPCs and other variant human cells proliferation, migration, attachment adhesion, mineralization, and dentinal bridge formation.

Comparison of the biocompatibility of calcium silicate-based materials to mineral trioxide aggregate: Systematic review

The objective of this systematic review was to evaluate the biocompatibility and interaction of bioceramic materials with animal and human mesenchymal cells in vitro and in vivo and to compare them with mineral trioxide aggregate (MTA). Two independent researchers conducted PubMed/Medline, Web of Science, and Scopus searches to identify studies published in English, without restrictions on year of publication using the following keywords: “root canal sealer,” “root repair material,” “cytotoxicity,” and “bioceramics.” The articles were selected following the PRISMA statement. A total of 1486 titles were identified in the initial search. However, only 18 studies met the inclusion and exclusion criteria. The results showed that bioceramic materials have biological properties similar to those of MTA, including low cytotoxicity as well as promoting cell proliferation and adhesion, low expression of inflammatory cytokines, and reduced pulp inflammation. This systematic review therefore suggests that the choice of repair bioceramic materials or MTA based on biocompatibility should be the professional's decision.

Induction of Osteogenic Differentiation of Mesenchymal Stem Cells by Bioceramic Root Repair Material

This study aimed to evaluate the osteogenic activity of Endosequence Root Repair Material (ERRM) putty using rat mesenchymal stem cells (MSCs). The extract of set ERRM and ProRoot-mineral trioxide aggregate (MTA) (control) was cocultured with rat MSCs and incubated for one, three, and seven days. The cell viability and proliferation were assessed. A quantitative real-time polymerase chain reaction for bone morphogenetic protein-2 (BMP-2), alkaline phosphatase, bone sialoprotein, and osteocalcin gene expression was performed. Both materials enhanced cell viability and proliferation, which increased over time. On day seven, the cells treated with either material exhibited significantly greater cell viability compared with control untreated cells. MSCs treated with either material showed deeper alkaline phosphatase staining after three days compared to control untreated cells. Treated MSCs also exhibited upregulation of the gene expression of bone morphogenetic protein-2, alkaline phosphatase, bone sialoprotein, and osteocalcin. Both ERRM and ProRoot-MTA enhance the osteogenic differentiation of MSCs.

Tricalcium silicate cements: osteogenic and angiogenic responses of human bone marrow stem cells

Tricalcium silicate cements (TSCs) are used in endodontic procedures to promote wound healing and hard tissue formation. The aim of this study was to evaluate and compare the effect of commonly used TSCs [mineral trioxide aggregate (MTA), Biodentine, and TotalFill] on cellular metabolism and osteogenic/angiogenic differentiation of human bone marrow mesenchymal stem cells (hBMSCs) in vitro. We tested the null hypothesis of no difference between MTA, Biodentine, and TotalFill in stem cell responses. Cells were subjected to eluates of the tested materials for up to 14 d. Cell viability was evaluated using the 3-(4,5-dimethyl-thiazoyl)-2,5-diphenyl-tetrazolium bromide (MTT) assay. Real-time PCR was used to determine the levels of expression of the osteogenic factors alkaline phosphatase (ALP), osteoprotegerin (OPG), osteocalcin (OC), and collagen 1A (COL1A1), and the angiogenic factors vascular endothelial growth factor A (VEGFA) and fibroblast growth factor 1 (FGF1). ELISAs were used to measure the levels of VEGFA and ALP in culture supernatants. Mineralization in vitro of hBMSCs was assessed using Alizarin Red staining. The hBMSCs tolerated exposure to TSCs well, with Biodentine showing the most favorable effect on cell viability. Expression of ALP, COL1A1, OPG, and VEGFA were differentially affected by the materials, with Biodentine and TotalFill inducing earlier changes at gene level. Increased mineralization was observed with time, after exposure to all TSCs tested, with MTA showing the greatest effect. The results revealed different responses of hBMSCs to TSCs in vitro.

Mineral Trioxide Aggregate Mixed with 5-Aminolevulinic Acid for the Photodynamic Antimicrobial Strategy in Hard Tissue Regeneration

Aminolevulinic acid (ALA) based photodynamic antimicrobial strategy can provide good antimicrobial effects and be used for medical applications. The aim of this study was to apply this strategy to Mineral Trioxide Aggregate (MTA), which is commonly used as a filling material for root endings and by doing so, to increase the bactericidal capability of MTA, as well as to investigate its characterization, cytocompatibility, and odontogenic differentiation potential. MTA is known to be a derivative of calcium silicate (CS). In this study, MTA specimens with or without ALA and light treatment were prepared. Diametral tensile strength values (DTS), setting durations, X-ray diffraction (XRD) spectra, apatite-mineralization, and antimicrobial abilities of the MTA, were also analyzed. Human dental pulp cells (hDPCs) can proliferate into the newly formed matrix and differentiate into odontoblasts to reinforce and strengthen the root. Levels of hDPCs proliferation and its odontogenic capabilities when cultured on MTA with ALA and light treatment, and the percentages of cells existing in the various cell cycle stages, were further evaluated in this study. The results indicated that MTA added ALA with light treatment had greater antibacterial ability and cytocompatibility, compared to MTA alone. A higher percentage S phase of the cells cultured on MTA added ALA with light treatment was observed. Furthermore, hDPCs cultured on MTA added ALA with light treatment had the highest expression levels of the odontoblastic differentiation markers. ALA has great antimicrobial efficiency and is a potential material for future medical applications. ALA-based photodynamic antibacterial strategy applied in the MTA has great antibacterial ability, cytocompatibility, and odontoblastic differentiation potential, and can facilitate the development of root canal treatment.

Progress in the use of dental pulp stem cells in regenerative medicine

The field of tissue engineering is emerging as a multidisciplinary area with promising potential for regenerating new tissues and organs. This approach requires the involvement of three essential components: stem cells, scaffolds and growth factors. To date, dental pulp stem cells have received special attention because they represent a readily accessible source of stem cells. Their high plasticity and multipotential capacity to differentiate into a large array of tissues can be explained by its neural crest origin, which supports applications beyond the scope of oral tissues. Many isolation, culture and cryopreservation protocols have been proposed that are known to affect cell phenotype, proliferation rate and differentiation capacity. The clinical applications of therapies based on dental pulp stem cells demand the development of new biomaterials suitable for regenerative purposes that can act as scaffolds to handle, carry and implant stem cells into patients. Currently, the development of xeno-free culture media is emerging as a means of standardization to improve safe and reproducibility. The present review aims to describe the current knowledge of dental pulp stem cells, considering in depth the key aspects related to the characterization, establishment, maintenance and cryopreservation of primary cultures and their involvement in the multilineage differentiation potential. The main clinical applications for these stem cells and their combination with several biomaterials is also covered.

The effect of delta-like 1 homologue on the proliferation and odontoblastic differentiation in human dental pulp stem cells

INTRODUCTION

This study aimed to investigate the functions of delta-like homologue 1 (DLK1) in the proliferation and differentiation of human dental pulp stem cells (hDPSCs).

METHODS

Immunohistochemical analysis was used to determine the expression of alkaline phosphatase (ALP), dentin sialophosphoprotein (DSPP), DLK1, NOTCH1 and p-ERK1/2 in the mouse first maxillary molar. Recombinant lentivirus was constructed to overexpress DLK1 stably in hDPSCs. The cell viability and proliferation of hDPSCs were examined by CCK8 and EdU incorporation assay respectively. The odontoblastic differentiation of hDPSCs was determined by detection of ALPase activity assay, ALP and alizarin red staining and the expression of mineralization-related genes including ALP, DSPP and dental matrix protein. The mRNA and protein levels of DLK1 and p-ERK1/2 protein expression were detected. ERK inhibitor was used to test the differentiation effect of DLK1 on hDPSCs.

RESULTS

Delta-like homologue 1 was highly expressed on the odontoblasts and dental pulp cells on the first maxillary molar; the expression of p-ERK1/2 is similar with the DLK1 in the same process. The expression level of DLK1 increased significantly after the odontoblastic induction of hDPSCs. DLK1 overexpression increased the proliferation ability of hDPSCs and inhibited odontoblastic differentiation of hDPSCs. The protein level of p-ERK1/2 significantly increased in hDPSCs/dlk1-oe group. ERK signalling pathway inhibitor reversed the odontoblastic differentiation effects of DLK1 on hDPSCs.

CONCLUSIONS

The proliferation of hDPSCs was promoted after DLK1 overexpression. DLK1 inhibited the odontoblastic differentiation of hDPSCs, which maybe through ERK signalling pathway.

Effect of an Experimental Direct Pulp-capping Material on the Properties and Osteogenic Differentiation of Human Dental Pulp Stem Cells

Effective pulp-capping materials must have antibacterial properties and induce dentin bridge formation; however, many current materials do not satisfy clinical requirements. Accordingly, the effects of an experiment pulp-capping material (Exp) composed of an antibacterial resin monomer (MAE-DB) and Portland cement (PC) on the viability, adhesion, migration, and differentiation of human dental pulp stem cells (hDPSCs) were examined. Based on a Cell Counting Kit-8 assay, hDPSCs exposed to Exp extracts showed limited viability at 24 and 48 h, but displayed comparable viability to the control at 72 h. hDPSC treatment with Exp extracts enhanced cellular adhesion and migration according to in vitro scratch wound healing and Transwell migration assays. Exp significantly upregulated the expression of osteogenesis-related genes. The hDPSCs cultured with Exp exhibited higher ALP activity and calcium deposition in vitro compared with the control group. The novel material showed comparable cytocompatibility to control cells and promoted the adhesion, migration, and osteogenic differentiation of hDPSCs, indicating excellent biocompatibility. This new direct pulp-capping material containing MAE-DB and PC shows promise as a potential alternative to conventional materials for direct pulp capping.