Dentin regeneration in vital pulp therapy: design principles

Erythropoietin induces odontoblastic differentiation of human-derived pulp stem cells via EphB4-Mediated MAPK signaling pathway

OBJECTIVES

Human-derived pulp stem cells play key roles during dentinogenesis. Erythropoietin is reportedly involved in osteoblastogenesis and facilitates bone formation. However, the mechanism is still unknown. This research was to study the potential of erythropoietin in enhancing odontoblastic differentiation of human-derived pulp stem cells and to determine the underlying mechanism.

METHODS

The human-derived pulp stem cells were treated with erythropoietin, EphB4 inhibitor, and MAPK inhibitors, and the odontoblastic differentiation was measured by ALP staining, ALP activity assay, alizarin red S staining, and their quantitative analysis, and RT-qPCR of DSPP, DMP1, OCN, and RUNX2. The direct pulp capping model was established to evaluate the formation of tertiary dentin after treatment with erythropoietin. Western blot assay was conducted to assess relevant protein expressions in the phosphorylated EphB4 and MAPK pathway.

RESULTS

The results showed that erythropoietin promoted odontoblastic differentiation of human-derived pulp stem cells at 20 U/ml. Erythropoietin induced tertiary dentin formation in vivo. The potential mechanism of this was upregulating phosphorylated EphB4 and phosphorylated MAPK; furthermore, this effect could be decreased by EphB4 inhibitors, which inhibited MAPK phosphorylation. Blockage of MAPK pathways attenuated human-derived pulp stem cells' odontoblastic differentiation, suggesting that MAPK pathways are involved.

CONCLUSION

Erythropoietin induced tertiary dentin formation in vivo. And erythropoietin enhanced human-derived pulp stem cells' odontoblastic differentiation via the EphB4-mediated MAPK signaling pathway.

Biopolymers and Their Application in Bioprinting Processes for Dental Tissue Engineering

Dental tissues are composed of multiple tissues with complex organization, such as dentin, gingiva, periodontal ligament, and alveolar bone. These tissues have different mechanical and biological properties that are essential for their functions. Therefore, dental diseases and injuries pose significant challenges for restorative dentistry, as they require innovative strategies to regenerate damaged or missing dental tissues. Biomimetic bioconstructs that can effectively integrate with native tissues and restore their functionalities are desirable for dental tissue regeneration. However, fabricating such bioconstructs is challenging due to the diversity and complexity of dental tissues. This review provides a comprehensive overview of the recent developments in polymer-based tissue engineering and three-dimensional (3D) printing technologies for dental tissue regeneration. It also discusses the current state-of-the-art, focusing on key techniques, such as polymeric biomaterials and 3D printing with or without cells, used in tissue engineering for dental tissues. Moreover, the final section of this paper identifies the challenges and future directions of this promising research field.

Vital Pulp Therapy of Permanent Teeth with Reversible or Irreversible Pulpitis: An Overview of the Literature

Vital pulp therapy (VPT) has been recently proposed as an alternative approach even in symptomatic mature permanent teeth with deep caries’ lesions, aiming to maintain the pulp vitality over time and/or to avoid non-surgical root canal therapy (NSRCT). However, to date, the diagnosis of reversible or irreversible pulpitis is only based on clinical pain quantity and quality, without precisely reflecting the pulp inflammation status. Therefore, the aim of the present study was to provide an overview based on the current scientific literature to demonstrate the clinical effectiveness of VPT on mature permanent teeth, validating the use of hydraulic calcium silicate-based cements and their role in pain management. VPT may be successfully applied not only in mature permanent teeth diagnosed with reversible pulpitis, but also in permanent dental elements with signs and symptoms of irreversible pulpitis. Hydraulic cements showed favorable outcomes in terms of decrease of pro-inflammatory mediators and of post-operative pain. Pain plays a central role in the chance to perform VPT in mature permanent teeth, since it may be considered as a pre-operative diagnostic criterion as well as a treatment success parameter. In addition, proper assessment of pulp inflammation and choice of appropriate materials are key factors in enhancing VPT success.

Local Drug Delivery Systems for Vital Pulp Therapy: A New Hope

Vital pulp therapy (VPT) is deliberated as an ultraconservative/minimally invasive approach for the conservation of vital pulpal tissues, preservation of dental structure, and maintenance of tooth function in the oral cavity. In VPT, following the exposure of the dental pulp, the environment is prepared for the possible healing and probable refunctionalisation of pulpal connective tissue. However, to succeed in VPT, specific biomaterials are used to cover and/or dress the exposed pulp, lower the inflammation, heal the dental pulp, provoke the remaining odontoblastic cells, and induce the formation of a hard tissue, i.e., the dentinal bridge. It can be assumed that if the employed biomaterial is transferred to the target site using a specially designed micro-/nanosized local drug delivery system (LDDS), the biomaterial would be placed in closer proximity to the connective tissue, may be released in a controlled and sustained pattern, could properly conserve the remaining dental pulp and might appropriately enhance hard-tissue formation. Furthermore, the loaded LDDS could help VPT modalities to be more ultraconservative and may minimise the manipulation of the tooth structure as well as pulpal tissue, which could, in turn, result in better VPT outcomes.

Epiregulin enhances odontoblastic differentiation of dental pulp stem cells via activating MAPK signalling pathway

Objectives

The odontoblastic differentiation of dental pulp stem cells (DPSCs) contributes to tertiary dentin formation. Our previous study indicated that epiregulin (EREG) enhanced odontogenesis potential of dental pulp. Here, we explored the effects of EREG during DPSC odontoblastic differentiation.

Methods

The changes in EREG were detected during tertiary dentin formation. DPSCs were treated with recombinant human EREG (rhEREG), EREG receptor inhibitor gefitinib and short hairpin RNAs. The odontoblastic differentiation was assessed with ALP staining, ALP activity assay, alizarin red S staining and real‐time RT‐PCR of DSPP, OCN, RUNX2 and OSX. Western blot was conducted to examine the levels of p38 mitogen‐activated protein kinase (p38 MAPK), c‐Jun N‐terminal kinase (JNK) and extracellular signal‐regulated kinase 1/2 (Erk1/2). The expression of EREG and odontoblastic differentiation‐related markers was investigated in human dental pulp from teeth with deep caries and healthy teeth.

Results

Epiregulin was upregulated during tertiary dentin formation. rhEREG enhanced the odontoblastic differentiation of DPSCs following upregulated p38 MAPK and Erk1/2 phosphorylation, but not JNK, whereas depletion of EREG suppressed DPSC differentiation. Gefitinib decreased odontoblastic differentiation with decreased phosphorylation of p38 MAPK and Erk1/2. And suppression of p38 MAPK and Erk1/2 pathways attenuated DPSC differentiation. In human dental pulp tissue, EREG upregulation in deep caries correlates with odontoblastic differentiation enhancement.

Conclusion

Epiregulin is released during tertiary dentin formation. And EREG enhanced DPSC odontoblastic differentiation via MAPK pathways.

Characterization of Odontoblast-like Cell Phenotype and Reparative Dentin Formation In Vivo: A Comprehensive Literature Review

INTRODUCTION

The primary aim was to explore the criteria used in characterization of reparative cells and mineralized matrices formed after treatment of pulp exposures, and the sequence of relative events. The secondary aim was to evaluate whether the reparative events depend on the experimental model species, age, and therapeutic intervention.

METHODS

A literature search of databases using different combinations of the key words was undertaken. Data analysis was based only on studies having histological or histochemical assessment of the pulp tissue responses. The search yielded 86 studies, 47 capping material-based and 39 bioactive application-based experiments, which provided data on morphological or functional characterization of the mineralized matrices and the associated cells.

RESULTS

In 64% of capping material-based and 72% of bioactive application-based experiments, a 2-zone mineralized matrix formation (atubular followed by tubular) was detected, whereas characterization of odontoblastic differentiation is provided in only 25.5% and 46.1% of the studies, respectively. In 93.3% of the studies showing odontoblast-like cells, differentiated cells were in association with tubular mineralized matrix formation. Analyses further showed that cell- and matrix-related outcomes do not depend on experimental model species, age, and therapeutic intervention.

CONCLUSIONS

The evidence of the reviewed scientific literature is that dental pulp cells secrete a dentin-like matrix of tubular morphology in relation to primitive forms of atubular or osteotypic mineralized matrix. Furthermore, data analysis showed that dental pulp cells express in vivo the odontoblastic phenotype, and secrete matrix in a predentin-like pattern, regardless of the model species, age, and therapeutic intervention used.

Chitosan Biomaterials for Current and Potential Dental Applications

Chitosan (CHS) is a very versatile natural biomaterial that has been explored for a range of bio-dental applications. CHS has numerous favourable properties such as biocompatibility, hydrophilicity, biodegradability, and a broad antibacterial spectrum (covering gram-negative and gram-positive bacteria as well as fungi). In addition, the molecular structure boasts reactive functional groups that provide numerous reaction sites and opportunities for forging electrochemical relationships at the cellular and molecular levels. The unique properties of CHS have attracted materials scientists around the globe to explore it for bio-dental applications. This review aims to highlight and discuss the hype around the development of novel chitosan biomaterials. Utilizing chitosan as a critical additive for the modification and improvement of existing dental materials has also been discussed.

Odontoblastic inductive potential of epithelial cells derived from human deciduous dental pulp

For the dentin regeneration, dental epithelial cells are indispensible and must possess odontoblastic induction capability. Epithelial cell-like stem cells were recently identified in human deciduous dental pulp (DPESCs). However, their cellular characteristics remain poorly defined. The purpose of this study was to characterize DPESCs compared to HAT-7 ameloblastic cells. Expression levels of ameloblast-specific markers [odontogenic ameloblast-associated protein (Odam), matrix metalloproteinase (Mmp)-20, amelogenin, and ameloblastin] were detected in DPESCs. Co-culturing odontoblastic MDPC-23 cells with DPESCs increased expression of odontoblast differentiation markers (Dmp1 and Dspp) from days 4 to 10, while the expression of bone sialoprotein rapidly decreased. MDPC-23 cells cultured in DPESC-conditioned medium (CM) showed increased Dspp promoter activity compared with control MDPC-23 cultures. Mineralization was first observed in the CM groups from day 4 and proceeded rapidly until day 14, whereas mineralized nodules were found from day 7 in control media-cultured cells. In conclusion, DPESCs in human deciduous pulp possess ameloblast-like characteristics and differentiation properties, and substances derived from DPESCs promote odontoblastic differentiation. Thus, our results indicate that DPESCs can be a realistic epithelial source for use in odontoblastic induction and dentin formation of dental mesenchymal cells.

Evaluation of reparative dentin formation of ProRoot MTA, Biodentine and BioAggregate using micro-CT and immunohistochemistry

Objectives

The purpose of this study was to assess the ability of two new calcium silicate-based pulp-capping materials (Biodentine and BioAggregate) to induce healing in a rat pulp injury model and to compare them with mineral trioxide aggregate (MTA).

Materials and Methods

Eighteen rats were anesthetized, cavities were prepared and the pulp was capped with either of ProRoot MTA, Biodentine, or BioAggregate. The specimens were scanned using a high-resolution micro-computed tomography (micro-CT) system and were prepared and evaluated histologically and immunohistochemically using dentin sialoprotein (DSP).

Results

On micro-CT analysis, the ProRoot MTA and Biodentine groups showed significantly thicker hard tissue formation (p < 0.05). On H&E staining, ProRoot MTA showed complete dentin bridge formation with normal pulpal histology. In the Biodentine and BioAggregate groups, a thick, homogeneous hard tissue barrier was observed. The ProRoot MTA specimens showed strong immunopositive reaction for DSP.

Conclusions

Our results suggest that calcium silicate-based pulp-capping materials induce favorable effects on reparative processes during vital pulp therapy and that both Biodentine and BioAggregate could be considered as alternatives to ProRoot MTA.

Dentinogenic Specificity in the Preclinical Evaluation of Vital Pulp Treatment Strategies: A Critical Review

Reviews on the clinical performance of vital pulp treatment strategies and capping materials repeatedly showed an insufficient grade of evidence concerning their therapeutic validity. The biological mechanisms underlying the regenerative potential of pulp-dentin complex have attracted much attention during the last two decades, since new pulp treatment modalities have been designed and tested at the preclinical level. It has been recognized that evaluation should be based on the specific ability of therapeutic interventions to signal recruitment and differentiation of odontoblast-like cells forming a matrix in a predentin-like pattern, rather than uncontrolled hard tissue deposition in a scar-like form. The aim of the present article was to critically review data from histological experimental studies on pulp capping, published during the last 7 decades. A comprehensive literature search covering the period from 1949 to 2015 was done using the Medline/Pubmed database. Inclusion of a study was dependent on having sufficient data regarding the type of capping material used and the unit of observation (human permanent tooth in vivo or animal permanent dentition; primary teeth were excluded). The post-operatively deposited matrix was categorized into three types: unspecified, osteotypic, or dentin-like matrix. One hundred fifty-two studies were included in the final evaluation. Data from the present systematic review have shown that only 30.2% of the 152 experimental histological pulp capping studies described the heterogenic nature of the hard tissue bridge formation, including osteotypic and tubular mineralized tissue. Structural characteristics of the new matrix and the associated formative cells were not provided by the remaining 106 studies. Analysis showed that more careful preclinical evaluation with emphasis on the evidence regarding the dentinogenic specificity of pulp therapies is required. It seems that selection of appropriate vital pulp treatment strategies and pulp capping materials would be further facilitated in terms of their therapeutic validity if international consensus could be reached on a select number of mandatory criteria for tissue-specific dentinogenic events.

Regeneration of the dentine-pulp complex with revitalization/revascularization therapy: challenges and hopes

The concept of regenerative endodontics has gained much attention in clinical endodontics in the past decade. One aspect of this discipline is the application of revitalization/revascularization therapies for infected and/or necrotic immature pulps in permanent teeth. Following the publication of a case report (Iwaya et al. ), investigators have been rigorously examining the types of tissues formed in the canals as well as exploring strategies to regenerate the pulp-dentine complex in revitalized teeth. This review will provide an update on the types of tissues generated in the canals after revitalization/revascularization therapy in both animal and human studies. The understanding of the role of stem cells and microenvironment in the process of wound healing resulting in either regeneration or repair will be thoroughly discussed. Stem cells and microenvironmental cues introduced into the canal during revitalization/revascularization procedures will be examined. In addition, requirement of a sterile microenvironment in the canal and vital tissue generation in revitalization/revascularization therapy will be emphasized. The challenges that we face and the hopes that we have in revitalization/revascularization therapy for regenerative endodontics will be presented.

Advances in regeneration of dental pulp--a literature review

This review summarizes the biological response of dentin-pulp complexes to a variety of stimuli and responses to current treatment therapies and reviews the role of tissue engineering and its application in regenerative endodontics. An electronic search was undertaken based on keywords using Medline/PubMed, Embase, Web of Science and Ovid database resources up to March 2012 to identify appropriate articles, supplemented by a manual search using reference lists from relevant articles. Inclusion criteria were mainly based on different combinations of keywords and restricted to articles published in English language only. Biological approaches based on tissue engineering principles were found to offer the possibility of restoring natural tooth vitality, with distinct evidence that regeneration of lost dental tissues is possible. Studies to formulate an ideal restorative material with regenerative properties, however, are still under way. Further research with supporting clinical studies is required to identify the most effective and safe treatment therapy.

Pulpal and periradicular response to caries: current management and regenerative options

The pulp-dentin complex is a strategic and dynamic barrier to various insults that plague the dentition. Researchers have yet to understand the complete potential of this shifting junction and its components. The most common cause of injury to the pulp-dentin complex is carious breakdown of enamel and dentin. In recent years, there has been a change in restorative management of caries. The emphasis is on strategies to preserve dentin and protect the pulp. This article provides a brief review of the effect of caries on the pulp, of subsequent events on the periradicular tissues, and of current understanding of treatment modalities.

Future dentistry: cell therapy meets tooth and periodontal repair and regeneration

Cell-based tissue repair of the tooth and – tooth-supporting – periodontal ligament (PDL) is a new attractive approach that complements traditional restorative or surgical techniques for replacement of injured or pathologically damaged tissues. In such therapeutic approaches, stem cells and/or progenitor cells are manipulated in vitro and administered to patients as living and dynamic biological agents. In this review, we discuss the clonogenic potential of human dental and periodontal tissues such as the dental pulp and the PDL and their potential for tooth and periodontal repair and/or regeneration. We propose novel therapeutic approaches using stem cells or progenitor cells, which are targeted to regenerate the lost dental or periodontal tissue.

Mineral trioxide aggregate promotes odontoblastic differentiation via mitogen-activated protein kinase pathway in human dental pulp stem cells

Mitogen-activated protein kinase (MAPK) pathways are involved in stem cell differentiation. However, the odontoblastic differentiation-inducing effects by mineral trioxide aggregate (MTA) via MAPK pathways have not been clarified in human dental pulp stem cells (DPSCs). In this study we investigated the effects of MTA on cell viability and production of differentiation markers, and the involvement of MAPK signaling pathways in cultured human DPSCs. Cells were cultured with MTA, and the viability and differentiation productions of the cells were determined using the MTT assay and real-time PCR analysis, respectively. MAPK activation was measured by western blotting. MTA at concentrations of 20 and 10 mg/ml was toxic for human DPSCs. MTA significantly increased the expression of alkaline phosphatase (ALP), dentin sialophosphoprotein (DSPP), type I collagen (COLI), osteocalcin (OCN) and bone sialoprotein (BSP) mRNAs and induced the phosphorylation of p42 and p44 (p42/44), p38 and c-Jun N-terminal kinases 1 and 2 (JNK1/2) MAPK. Furthermore, the inhibitor of p42/44 MAPK attenuated the MTA-induced odontoblastic differentiation. These data indicated that MTA-induced odontoblastic differentiation of human DPSCs was via MAPK pathways, which may play a key role in the repair responses of dentin-pulp-like complexes.

Self-etching adhesives: possible new pulp capping agents to vital pulp therapy

Pulp capping is one of the solving for keeping vital pulp in the case of dentin caries, reversible pulpitis or traumatic pulp exposure. The presence of bacteria on the cavity walls or in the pulp was the major factor that leads to the failure of pulp capping. Traditional pulp capping agent, calcium hydroxide, may not prevent microleakage. Selfetching system is a newly developed adhesive system, which could provide less microleakage and would not break down or dissolve, preventing the oral fluids and bacteria from the pulp along the cavity wall. This may reduce such clinical problems as postoperative sensitivity, secondary caries and marginal discoloration. Researches showed that some kinds of self-etching adhesives induced the mild to moderate inflammatory pulp response, with negative bacterial staining. Inclusion of antibacterial components into self-etching system, such as 12-methacryloyloxydodecylpyridinium bromide (MDPB) may inhibit bacteria and provide better clinical effects. It is speculated that using the self-etching adhesive system containing the antibacterial agent, such as MDPB, to the dental pulp directly or indirectly, may inhibit bacteria after the placement of restoration as well as residual bacteria in the cavity.

Differentiation potential of dental papilla, dental pulp, and apical papilla progenitor cells

INTRODUCTION

Regenerative endodontic procedures use the differentiation potential of embryonic and adult pulp progenitor cell populations to reconstitute dental structures.

METHODS

An in-depth search of the literature was accomplished to review biologic knowledge from basic research on tooth morphogenesis and differentiation, root development, dentin-pulp regeneration, pulp revascularization and apexification, experimental and clinical studies on the dentinogenic differentiation potential of progenitor cells in the embryonic dental papilla, dental pulp, and associated mesenchymal tissues of the developing root.

RESULTS

Odontogenic potential is determined during early tooth morphogenesis in the odontogenic mesenchyme. Progenitor cells from the odontogenic mesenchyme give rise to primary dentin-forming cells (odontoblasts) in the presence of stage-specific enamel epithelium and/or basement membrane and tertiary dentin-forming cells (odontoblast-like cells) in experimental conditions. The specificity of odontogenic mesenchymal cells to form tertiary dentin might be related to the repertoire of signaling pathways operated by the temporospatial pattern of epithelial-mesenchymal interactions during tooth formation. Dental papilla cells isolated from tooth germs before the onset of odontoblast differentiation have not shown any competence to become odontoblasts in the absence of enamel epithelium. On the other hand, the specificity of progenitor cells in the mesenchymal cell populations of the developing root apex remains to be determined.

CONCLUSIONS

It seems evident that the dental pulp might be only used as a source of progenitor cells with dentinogenic competence for the regeneration of the dentin-pulp complex. The nature of dental or apical papilla progenitor cells in terms of their specificity for dentin regeneration has to be first characterized.

Regeneration of dentine/pulp-like tissue using a dental pulp stem cell/poly(lactic-co-glycolic) acid scaffold construct in New Zealand white rabbits

With the expanding knowledge of tooth regeneration and biological mechanisms of functional dental tissue repair, current treatment strategies are beginning to give way to evolving fields such as tissue engineering and biomimetics. Dental pulp stem cells were isolated from rabbit teeth and seeded onto scaffolds prepared from 50/50 poly(lactic-co-glycolic acid) polymers using two different porogen particle sizes. These cell/scaffold constructs were then transplanted subcutaneously in the rabbits. The expanded rabbit dental pulp stem cells showed high proliferative and clonogenic capacities as well as the ability to give rise to mineralised-like tissues in vitro in culture flasks and after seeding them onto the scaffolds for 12 days. Histological evaluation of transplanted samples revealed the formation of osteodentine-like structures as well as tubular bilayered structures of vertically aligned parallel tubules resembling tubular-like dentine. Using a tissue engineering approach yielded tissues quite similar to normal dentine/pulp-like tissues that can perhaps be used later on for regenerative endodontic or operative procedures.

The formation of tertiary dentin after pulp capping with a calcium phosphate cement, loaded with PLGA microparticles containing TGF-β1

The aim of the current study was to evaluate the effect of a calcium phosphate material equipped with poly (lactic-co-glycolic acid) microspheres for pulp capping, and to measure the dentin bridge formation, when using various concentrations of transforming growth factor (TGF) beta1. Preset samples were made (2 mm diameter; 2 mm height), containing 0 (controls), 20, or 400 ng TGF-beta1. These were placed in goat incisors. Incisors capped with glass-ionomer cement only were used as negative controls. Twelve weeks after pulp capping, the incisors were retrieved, processed for histology, and graded on basis of tertiary dentin formation. The results showed that new dentin formation was seen in all samples, except the negative controls. The histological grading indicated significant differences between the samples loaded with high amount of TGF-beta1 versus the three other groups (p < 0.05). In conclusion, our study demonstrated that the composite with 400 ng TGF-beta1 was able to trigger resident stem cells in the pulp to differentiate into odontoblast-like cells and to induce the formation of tertiary dentin. The material might be a good candidate for vital pulp therapy. Production and manipulation methods could be improved for follow-up studies.

[Stem cells of dental pulp]

Any clinician dreams to obtain the regeneration of the destroyed organ for his patient. In the human being, the regeneration of complex structures is not possible, except the liver and the bone marrow, which can be regenerated because of the presence of adult stem cells in these tissues. The stem cells have two principal properties: they ensure their self-renewal and they have the ability to differentiate into several cellular types. Using specific markers allowing the identification of the stem cells in bone marrow, stem cells were observed in dental pulp tissues. Although the origin, the identification, and the localization of these stem cells of dental pulp remain under consideration, the optimism in research on stem cells permits to believe that the knowledge on dental stem cells will lead to their use in therapeutics.

Human pulp-derived cells immortalized with Simian Virus 40 T-antigen

Primary cells in culture have a limited capacity to divide and soon reach a non-proliferative state. This cellular senescence limits the investigation of cells derived from human pulp concerning cellular pathways, gene regulation, mechanisms of dentin formation, or responses to material exposure. To overcome this problem, primary human pulp-derived cells were established and transfected with a plasmid containing coding sequences of Simian Virus 40 (SV40) large T-antigen. This resulted in the establishment of several cell clones showing an extension of life span. Expression of T-antigen transcripts and protein was verified by reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. Primary human pulp cells were cultured until senescence (i.e. up to passage 7) and transfected cells could be cultured to passage 18 after transfection, when a cellular crisis with massive cell death occurred. One clone escaped from crisis and has been maintained in culture for 55 wk. Experiments were performed to characterize transfected cells in comparison to primary cells. Cell morphology and proliferation were analyzed, and expression of cell-specific gene transcripts and proteins (including collagen types I and III, alkaline phosphatase, bone sialoprotein, osteocalcin, and dentin sialophosphoprotein and dentin matrix protein I) was detected by RT-PCR and immunohistochemistry. Transfection of human pulp-derived cells resulted in an immortalized cell line retaining many of the phenotypic characteristics observed in primary cells.

Gene-enhanced tissue engineering for dental hard tissue regeneration: (2) dentin-pulp and periodontal regeneration

Potential applications for gene-based tissue engineering therapies in the oral and maxillofacial complex include the delivery of growth factors for periodontal regeneration, pulp capping/dentin regeneration, and bone grafting of large osseous defects in dental and craniofacial reconstruction. Part 1 reviewed the principals of gene-enhanced tissue engineering and the techniques of introducing DNA into cells. This manuscript will review recent advances in gene-based therapies for dental hard tissue regeneration, specifically as it pertains to dentin regeneration/pulp capping and periodontal regeneration.

Experimental dentin-based approaches to tissue regeneration in vital pulp therapy

The potential direct induction of odontoblastlike cell differentiation at the surface of implanted dentin matrix has been tested in a series of capping experiments. Pieces of Teflon (control) or autogenous dentin matrix were placed in contact with the wound surface at a conventional capping situation, or at the dentinal base of the cavity at a distance from the exposed pulp periphery. Tissue responses were studied by light microscopy after periods of 2 and 4 weeks. Partial degradation of the dentin matrix implants was seen. Formation of a tubular calcified matrix, occasionally followed by tubular reparative dentin, was consistently detected in association with dentinal particles. The area between the traumatized dental pulp periphery and the capping material had been occupied by a well-vascularized tissue, regardless of the capping material and postoperative time period. Traces of calcified matrix were detected along the cut dentinal walls. The present data indicate that dentin matrix is limited in its ability to directly induce odontoblastlike cell differentiation and reparative dentin formation at the surface of mechanically exposed pulp of mature teeth. Furthermore, it seems that the traumatized mature pulp maintains the ability to grow, while a calcifying potential could be expressed by this growing part of the pulp core.

Enamel knots as signaling centers linking tooth morphogenesis and odontoblast differentiation

Odontoblasts differentiate from the cells of the dental papilla, and it has been well-established that their differentiation in developing teeth is induced by the dental epithelium. In experimental studies, no other mesenchymal cells have been shown to have the capacity to differentiate into odontoblasts, indicating that the dental papilla cells have been committed to odontoblast cell lineage during earlier developmental stages. We propose that the advancing differentiation within the odontoblast cell lineage is regulated by sequential epithelial signals. The first epithelial signals from the early oral ectoderm induce the odontogenic potential in the cranial neural crest cells. The next step in the determination of the odontogenic cell lineage is the development of the dental papilla from odontogenic mesenchyme. The formation of the dental papilla starts at the onset of the transition from the bud to the cap stage of tooth morphogenesis, and this is regulated by epithelial signals from the primary enamel knot. The primary enamel knot is a signaling center which forms at the tip of the epithelial tooth bud. It becomes fully developed and morphologically discernible in the cap-stage dental epithelium and expresses at least ten different signaling molecules belonging to the BMP, FGF, Hh, and Wnt families. In molar teeth, secondary enamel knots appear in the enamel epithelium at the sites of the future cusps. They also express several signaling molecules, and their formation precedes the folding and growth of the epithelium. The differentiation of odontoblasts always starts from the tips of the cusps, and therefore, it is conceivable that some of the signals expressed in the enamel knots may act as inducers of odontoblast differentiation. The functions of the different signals in enamel knots are not precisely known. We have shown that FGFs stimulate the proliferation of mesenchymal as well as epithelial cells, and they may also regulate the growth of the cusps. We have proposed that the enamel knot signals also have important roles, together with mesenchymal signals, in regulating the patterning of the cusps and hence the shape of the tooth crown. We suggest that the enamel knots are central regulators of tooth development, since they link cell differentiation to morphogenesis.