Application of Enamel Matrix Derivative (Emdogain) in Endodontic Therapy: A Comprehensive Literature Review

New Insights in Hydrogels for Periodontal Regeneration

Periodontitis is a destructive inflammatory disease characterized by microbial infection that damages the tissues supporting the tooth (alveolar bone, gingiva, periodontal ligament, and cementum), ultimately resulting in the loss of teeth. The ultimate goal of periodontal therapy is to achieve the regeneration of all of the periodontal tissues. Thus, tissue engineering approaches have been evolving from simple membranes or grafts to more complex constructs. Hydrogels are highly hydrophilic polymeric networks with the ability to simulate the natural microenvironment of cells. In particular, hydrogels offer several advantages when compared to other forms of scaffolds, such as tissue mimicry and sustained drug delivery. Moreover, hydrogels can maintain a moist environment similar to the oral cavity. Hydrogels allow for precise placement and retention of regenerative materials at the defect site, minimizing the potential for off-target effects and ensuring that the treatment is focused on the specific defect site. As a mechanism of action, the sustained release of drugs presented by hydrogels allows for control of the disease by reducing the inflammation and attracting host cells to the defect site. Several therapeutic agents, such as antibiotics, anti-inflammatory and osteogenic drugs, have been loaded into hydrogels, presenting effective benefits in periodontal health and allowing for sustained drug release. This review discusses the causes and consequences of periodontal disease, as well as the advantages and limitations of current treatments applied in clinics. The main components of hydrogels for periodontal regeneration are discussed focusing on their different characteristics, outcomes, and strategies for drug delivery. Novel methods for the fabrication of hydrogels are highlighted, and clinical studies regarding the periodontal applications of hydrogels are reviewed. Finally, limitations in current research are discussed, and potential future directions are proposed.

Comparative evaluation of treatment outcome of partial pulpotomy using different agents in permanent teeth-a randomized controlled trial

AIM

To compare and evaluate the clinical and radiographic performance, post-operative pain, and anti-inflammatory intake after partial pulpotomy (PP) with calcium hydroxide (CH), mineral trioxide aggregate (MTA), Biodentine (BD), and Emdogain (EMD) as pulp capping agents in mature permanent molars with definitive diagnosis of reversible pulpitis.

MATERIALS AND METHODS

As part of this prospective, randomized clinical trial with four parallel arms (CTRI Registration No.: CTRI/2020/11/029329 dated 24/11/2020), hundred and ten permanent molars with a clinical diagnosis of reversible pulpitis and normal apical tissues, from patients between the ages of 15 and 45 years, were recruited and randomly assigned to four groups-CH, MTA, BD, and EMD. Operative procedure was performed under local anesthesia and dental dam isolation. After carious pulpal exposure, 2 mm of superficially inflamed coronal pulp tissue was amputated and either of the four pulp capping materials was placed. The outcome assessment was carried out at 1, 3, 6, and 12 month(s) and was categorized as success (asymptomatic patients with PAI score = 1) or failure (symptomatic patients or PAI score > 1).

RESULTS

There was a significant difference in post-operative pain and anti-inflammatory medication intake after partial pulpotomy with Emdogain vis-à-vis other three capping agents. No difference in both clinical and radiographic performances was observed among the four capping agents.

CONCLUSION

Partial pulpotomy when performed following evidence-based guidelines results in high success rates regardless of capping agent employed. EMD can be considered a valid and suitable pulp capping agent in PP.

CLINICAL RELEVANCE

Meticulous examination and removal of superficially inflamed pulp under magnification and complete asepsis lead to successful pulpal healing regardless of capping agent employed.

Effect of an enamel matrix derivative (Emdogain) on the microhardness and chemical composition of human root dentin: an in vitro study

The advantage of using an Enamel matrix derivative EMD Emdogain as an intracanal medication could be a manner to strength the tooth structure, improving the physical and chemical properties of dentin. We tested, in vitro, the effect of Emdogain on the surface microhardness and chemical composition of root dentin. Ten human teeth were used to produce dentin specimens originated from the canal walls (n = 30) that remained in contact to Emdogain gel for 90 days. Baseline and 90-days after Emdogain treatment measurements were performed using Fourier Transform Infrared Spectroscopy (ATR/FTIR), Scanning Electron Microscopy/Energy Dispersive Spectroscopy (SEM/EDS) and Knoop indenters. The use of EMD (Emdogain) for 90 days in contact with human root canal dentin specimens did not alter the microhardness and morphology of dentin. The elemental structure of dentin was altered because there was a reduction in carbonate content.

Biocompatibility and Osteogenic Potential of Calcium Silicate-Based Cement Combined with Enamel Matrix Derivative: Effects on Human Bone Marrow-Derived Stem Cells

The characteristics of retrograde filling material are important factors that can affect the long-term success of apical microsurgery. Various calcium silicate-based cements (CSC) were introduced to overcome drawbacks of mineral trioxide aggregate (MTA), while Emdogain is known to be effective in the regeneration of periodontal tissues. The aim of this study is to evaluate the biocompatibility and osteogenic potential of various CSCs combined with Emdogain on human bone marrow-derived mesenchymal stem cells. Experimental groups were classified into eight groups depending on the material and the presence of Emdogain. In the cell-counting kit test, all experimental groups combined with Emdogain showed higher cell viability compared with those without Emdogain at days 1 and 2. In the wound-healing assay, cell migration increased significantly over time, with or without Emdogain. In the alkaline phosphatase assay, all groups treated with Emdogain showed higher activity compared with those without Emdogain at day 3 (p < 0.05). Using alizarin red S staining, all groups treated with Emdogain showed greater calcium nodule formation compared with those without Emdogain at days 7 and 14 (p < 0.05). In conclusion, using CSCs as retrograde filling materials and the application of additional Emdogain will increase bone regeneration and improve the prognosis of apical microsurgery.

Enamel Matrix Derivative in Diffusion Chamber Implanted Subcutaneously in Rat Induces Formation of Fibrous Connective Tissue Containing Abundant Blood Vessels

BACKGROUND

Enamel matrix derivative (EMD) is widely used for regeneration therapy in dental clinical situations, but the mechanism of EMD bioactivity remains obscure. To clarify this mechanism, we focused on the formation of connective tissue and blood vessels. The aim of this study was to confirm whether EMD induces the formation of connective tissue and blood vessels by using the diffusion chamber (DC) technique.

MATERIALS AND METHODS

Individual DCs containing EMD (DC-EMD) or propylene glycol alginate (PGA) were implanted subcutaneously in rat dorsum. At 4 weeks after the implantation, histological analysis of DCs was performed using azan staining.

RESULTS

DC-EMD induced the formation of much larger amounts of connective tissue containing abundant blood vessels than did DC-PGA.

CONCLUSION

The results indicated that EMD can induce the formation of both connective tissue and blood vessels. This bioactivity may contribute to the mechanism whereby EMD induces tissue regeneration.

The Effect of Transforming Growth Factor Beta 1 on the Mineralization of Human Cementoblasts

INTRODUCTION

Transforming growth factor beta 1 (TGF-β1) plays an important role in bone mineralization and has been reported to promote osteoblast proliferation and differentiation. However, there is no report about the effects of TGF-β1 on human cementoblasts. The purpose of this study was to clarify the effect of TGF-β1 on the proliferation and differentiation of the human cementoblast cell line (HCEM) in vitro.

METHODS

HCEM cells were stimulated with TGF-β1 at concentrations of 0.05, 0.5, 5, and 10 ng/mL. A proliferation assay was performed from 24-72 hours. The effect of TGF-β1 on mineralization was analyzed by quantifying the area stained with alizarin red on days 7 and 14. Real-time polymerase chain reaction was used to assess the effect of TGF-β1 on the mineralization-related genes alkaline phosphatase, bone sialoprotein, and type I collagen on days 3, 7, and 14.

RESULTS

TGF-β1 did not affect cell proliferation. TGF-β1 together with the mineralization medium (consisting of ascorbic acid, dexamethasone, and β-glycerophosphate) increased the alizarin red-stained area on days 7 and 14. Real-time polymerase chain reaction revealed that alkaline phosphatase messenger RNA expression was increased in TGF-β1-stimulated HCEM cells in mineralization medium on days 3 and 7, whereas bone sialoprotein and type I collagen messenger RNA expression was increased on day 7.

CONCLUSIONS

Although TGF-β1 does not affect cell proliferation, it does promote cell differentiation and mineralization of HCEM cells.

The use of enamel matrix derivative in the treatment of class II furcation defects: systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of enamel matrix derivative (EMD) in the regeneration of class II furcation defects, used alone or in conjunction with biomaterials.

METHODS

Electronic database searches and hand searches were carried out and double-blind randomized controlled trials evaluating the use of EMD in class II furcation therapy were included, and a meta-analysis comparing the effect of open flap debridement (OFD) + βTCP/HA with and without EMD was carried out.

RESULTS

The initial search resulted in a total of 298 articles, after removing the duplicates and exclusions after analysing the titles, abstracts and full text, five studies were included for the qualitative synthesis and two for the quantitative analysis. The meta-analysis showed no statistical difference when comparing OFD + βTCP/ HA with or without EMD in the treatment of furcation defects in any of the evaluated parameters. According to GRADE, the certainty of the evidence for the variables evaluated was moderate.

CONCLUSION

The therapeutic modalities studied improved the periodontal clinical parameters of class II furcations, but the use of EMD in the treatment of these defects did not contribute to a clinical improvement that justified its use associated with the therapies/biomaterials. It is important to emphasize the need for more studies with larger samples to increase the certainty of the evidence reported in this review.

Potential Application of Human β-Defensin 4 in Dental Pulp Repair

When pulp tissue is damaged by caries or trauma, vital pulp therapy (VPT) can help preserve the pulp tissue for long-term retention of teeth. However, the choice of pulp capping agent used in VPT is important for the successful preservation of the pulp tissue. Here we investigated the expression and biological function of human β-defensin 4 (HBD4) in dental pulp stem cells (DPSC) and explored its potential as a pulp capping agent. We examined the expression of HBD4 in DPSC in vitro using qPCR and immunofluorescence staining. We also looked at the effect of HBD4 on inflammatory factors in lipopolysaccharide (LPS)-stimulated DPSC, and its effects on mineralizing cell phenotype differentiation, via qPCR and western blot. Finally, we examined the ability of HBD4 to promote the restoration of the pulp-dentin complex in vivo, using male Wistar rats with reversible pulpitis. We found HBD4 was highly expressed in DPSC stimulated by TNF-α and IL-1α. HBD4 down-regulated the expression of inflammatory mediators (i.e., IL-1α, IL-1β, IL-6, TNF-α) in LPS-stimulated DPSC, and suppressed MAPK activity and the NF-κB pathway. HBD4 also enhanced the differentiation of DPSC into osteoblasts or odontoblasts, potentially by modulating the Notch pathway. Furthermore, HBD4 controlled the degree of pulp inflammation in a rat model of reversible pulpitis and induced the formation of restorative dentin. Together our findings indicate HBD4 may be a useful pulp capping agent for use in VPT.

A long-term treatment outcome of intentional replantation in Taiwanese population

BACKGROUND/PURPOSE

Intentional replantation was a conventional treatment option in surgical endodontics but usually be seen as a last resort. Therefore, the purpose of this study was to evaluate the long-term treatment outcome of intentional replantation in Taiwanese population, including the survival rates and the related prognostic factors.

METHODS

Subjects included 215 teeth from 199 patients who had received intentional replantation in a Taiwan medical center. Patients at age under 20 years and those follow-up periods less than 6 months were excluded. The replanted teeth were followed up for a period of 6 months-120 months. Post-treatment assessments, including tooth survival and functional status, were evaluated using both clinical and radiographic examinations.

RESULTS

Kaplan-Meier survival analysis revealed the overall tooth survival rate at 4 years was 82.8%. In bivariate analysis, both root-end filling material and enamel matrix derivative (EMD) applications were found to be significant (P < 0.05). The multivariate analysis revealed that age and the presence of a sinus tract or abscess might be the predictors of treatment outcome in intentional replantation.

CONCLUSION

Intentional replantation, operated with improved modern technique, is a reliable and viable treatment with a high long-term survival rate (82.8%). If replanted teeth are diagnosed as acute or chronic apical abscess at the pre-operative examination, the risk of failure is measured 2.7 times higher than those diagnosed with other conditions. Application of EMD on the root surface of a replanted tooth may promote the formation and regeneration of periodontal apparatus, therefore increasing the functioning rate and improving the treatment outcome.

Development and application of a 3D periodontal in vitro model for the evaluation of fibrillar biomaterials

Background

Periodontitis is a chronic inflammation of the tooth supporting structures that finally can lead to tooth loss. As chronic periodontitis is associated with systemic diseases multiple approaches have been followed to support regeneration of the destructed tissue. But very few materials are actually used in the clinic. A new and promising group of biomaterials with advantageous biomechanical properties that have the ability to support periodontal regeneration are self-assembling peptides (SAP). However, there is still a lack of 3D periodontal models that can evaluate the migration potential of such novel materials.

Methods

All experiments were performed with primary human periodontal ligament fibroblasts (HPLF). Migration capacity was assessed in a three-dimensional model of the human periodontal ligament by measuring the migration distance of viable cells on coated (Enamel Matrix Protein (EMP), P11–4, collagen I) or uncoated human dentin. Cellular metabolic activity on P11–4 hydrogels was assessed by a metabolic activity assay. Deposition of ECM molecules in a P11–4 hydrogel was visualized by immunostaining of collagen I and III and fibrillin I.

Results

The 3D periodontal model was feasible to show the positive effect of EMP for periodontal regeneration. Subsequently, self-assembling peptide P11–4 was used to evaluate its capacity to support regenerative processes in the 3D periodontal model. HPLF coverage of the dentin surface coated with P11–4 increased significantly over time, even though delayed compared to EMP. Cell viability increased and inclusion of ECM proteins into the biomaterial was shown.

Conclusion

The presented results indicate that the 3D periodontal model is feasible to assess periodontal defect coverage and that P11–4 serves as an efficient supporter of regenerative processes in the periodontal ligament.

Clinical relevance

The establishment of building-block synthetic polymers offers new opportunities for clinical application in dentistry. Self-assembling peptides represent a new generation of biomaterials as they are able to respond dynamically to the changing environment of the biological surrounding. Especially in the context of peri-implant disease prevention and treatment they enable the implementation of new concepts.

Response of stem cells from human exfoliated deciduous teeth (SHED) to three bioinductive materials - An in vitro experimental study

Introduction

Stem cells have unmatched capacity and potential for regeneration and when used alone or in combination with scaffolds to replace or repair damaged cells, can differentiate into any mature cell.

Aim

To evaluate the functional differentiation potential of EMD (Enamel Matrix Derivative), MTA (Mineral Trioxide Aggregate) and Biodentine on Stem Cells from Human Exfoliated Deciduous teeth (SHED).

Objective

To determine functional differentiation potential (osteogenic/odontogenic) of various biomaterials on SHED.

Material and method

SHED derived from 5^th linear passage after sub-culturing were treated with EMD, MTA and Biodentine individually and their effect on cell viability was compared and evaluated by MTT (3-4,5-dimethylthiazol-2-yl-2,5-diphenyltetrazolium bromide) assay for 7 days. Alizarin red S staining was used to assess mineralization potential of these materials by the staining calcium deposits for 14 days. The results were analyzed using One-way ANOVA, Post hoc Tukey’s test for multiple comparisons.

Results

It was observed that EMD imparted the highest cell viability at the end of 7 days (p < 0.001) followed by Biodentine and MTA. Likewise EMD showed highest potential to enhanced mineralization and expression of dentine sialoprotein (p < 0.001) followed by Biodentine and MTA at the end of 14 days (p<0.001).

Conclusion

It can be concluded that all the tested materials are bioinductive to SHED. EMD can be used for various vital pulp therapies as that of Biodentine and MTA with predictable as well as enhanced success rate.

Oroactive dental biomaterials and their use in endodontic therapy

Dental biomaterials have revolutionized modern therapies. Untreated dental caries remains the major etiological factor for endodontic treatment, and together with a decreasing rate of tooth loss escalates the importance of continuously improving the materials used for endodontic therapies. Endodontic biomaterials are used for vital pulp therapies, irrigation, intracanal medicaments, obturation and regenerative procedures. These materials offer several functions including: antimicrobial activity, mechanical reinforcement, aesthetics, and therapeutic effects. Vital pulp therapies have seen an improvement in clinical results with an incremental approach to build on the strengths of past materials such as calcium hydroxide and calcium silicates. While sodium hypochlorite remains the gold standard for canal irrigation, numerous nanoparticle formulations have been developed to promote sustained antimicrobial action. Gutta-percha based bulk fillers remain the most common materials for root filling. However, while multiple studies focus on the development of novel formulations containing drugs, glass derivatives or ionic-, polymeric-, or drug- loaded nanoparticles, a lack of reliable and long-term clinical evidence obligates further study as experienced clinicians prefer to use what has worked for decades. This review delves in to the biochemistry of the materials to scrutinize their shortcomings, and where opportunity lies to further enhance their efficacy in endodontic practice. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 108B:201-212, 2020.

Manejo endodôntico de dentes reimplantados: revisão de literatura

O reimplante dentário destaca-se como um procedimento conservador, sendo a conduta não-protética que pode ser realizada em casos de avulsão, evitando sequelas estéticas, funcionais e psicológicas junto ao paciente. Para controlar os processos reabsortivos que se desencadeiam devido a lesão no ligamento periodontal, o tratamento endodôntico se faz necessário. Objetivo: apresentar uma revisão de literatura sobre o manejo endodôntico de dentes reimplantados, elucidando os aspectos clínicos, radiográficos e fisiológicos envolvidos no processo e, também, confeccionar um guia de consulta para prática clínica. Conclusão: O reimplante dentário auxilia no aspecto psicológico decorrente da perda dentária, sendo a endodontia uma etapa fundamental no processo. Ao final do tratamento Endodôntico de um dente re-implantado, com uso da medicação intracanal adeaquada, a saber hidróxido de cálcio,  espera-se um dente clinicamente assintomático e radiograficamente ausência de sinais de reabsorção e lesão apical. Contudo, o  acompanhamento clínico e radiográfico do paciente deve ser feito por pelo menos cinco anos.