Antimicrobial activity of endodontic sealers and medications containing chitosan and silver nanoparticles against Enterococcus faecalis

A Comparison of Conventional Root Canal Sealers With Ones That Use Green Synthesized Nanoparticles for Antimicrobial Activity: Protocol for a Systematic Review

BACKGROUND

Root canal failure and secondary endodontic infection are frequent clinical scenarios in dentistry. The main microorganisms implicated in root canal therapy failure are persistent Enterococcus faecalis, Candida albicans, and Staphylococcus aureus. To combat the impact of disease resistance, scientists are concentrating on alternative antimicrobial root canal sealers. Nanomaterials are a recent development in endodontic materials that exhibit great antimicrobial properties, making them an ideal material choice for root canal sealers.

OBJECTIVE

This systematic review aims to compare the antimicrobial properties of conventional root canal sealers to those incorporating green synthesized nanoparticles between 2010 and 2024.

METHODS

A well-constructed protocol was established and registered with PROSPERO (CRD42021286373). Ethics approval was obtained from the Biomedical Research and Ethics Committee from the University of the Western Cape (UWC; BM22/1/4). PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) reporting guidelines were followed. The included criteria demonstrate the green synthesized nanoparticles studies where the nanoparticles (NPs) are incorporated in root canal sealers. MeSH (Medical Subject Headings) terms were used for the search strategy of the systematic electronic databases for articles published in English between 2010 and 2024. The selected databases included Scopus, PubMed, Web of Science, Science Direct, EBSCOhost, SpringerLink, and Wiley Online. A quality assessment tool for laboratory studies will be used to critically appraise the included studies. If applicable, statistical measures (mean, SD, etc) will be used for data analysis and presentation of the results.

RESULTS

The protocol is registered with PROSPERO. A preliminary search was conducted using a determined search strategy across 8 electronic databases, and the review is now complete.

CONCLUSIONS

It is anticipated that the results of this systematic review may reveal the increased interest and application for nanoparticle-enhanced root canal sealers. This will aid in the future development of root canal sealants and mitigate the risk of endodontic failure.

TRIAL REGISTRATION

PROSPERO CRD42021286373; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=286373.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51351.

Chitosan nanoparticle applications in dentistry: a sustainable biopolymer

The epoch of Nano-biomaterials and their application in the field of medicine and dentistry has been long-lived. The application of nanotechnology is extensively used in diagnosis and treatment aspects of oral diseases. The nanomaterials and its structures are being widely involved in the production of medicines and drugs used for the treatment of oral diseases like periodontitis, oral carcinoma, etc. and helps in maintaining the longevity of oral health. Chitosan is a naturally occurring biopolymer derived from chitin which is seen commonly in arthropods. Chitosan nanoparticles are the latest in the trend of nanoparticles used in dentistry and are becoming the most wanted biopolymer for use toward therapeutic interventions. Literature search has also shown that chitosan nanoparticles have anti-tumor effects. This review highlights the various aspects of chitosan nanoparticles and their implications in dentistry.

Evaluation of the effect of graphene oxide-based nanocomposites on smear layer by a scanning electron microscope: Laboratory investigation

This study is to examine the effect of graphene oxide (GO) and GO-based nanocomposites (GO_EDTA, GO_CHIT) on the smear layer by scanning electron microscopy (SEM). Sixty human single-rooted anterior teeth were used. Samples were randomly categorised into six groups. Distilled water in group 1, 17% EDTA in group 2, chitosan (CHIT) solution in group 3, GO solution in group 4, GO_EDTA solution in group 5 and GO_CHIT in group 6 were used as irrigation solutions. Photomicrographs were acquired from the coronal, middle and apical parts of the samples by SEM. Statistical analyses were performed using Kruskal-Wallis, Mann-Whitney U and Wilcoxon tests. There was a statistically significant difference among the groups (p < 0.003). Adding GO to CHIT and EDTA did not affect removing the smear layer in all segments (p < 0.003). Incorporating GO into EDTA and CHIT solutions did not change their interaction with the smear layer.

Applications of Chitosan Nanoparticles in Dentistry: A Review

Recently, nanotechnology has garnered significant interest across various fields due to its emerging and diverse applications. Numerous investigators have proposed that chitosan nanoparticles (CSNPs) stand out as some of the most promising nanomaterials for facilitating various activities. Chitosan, a natural biopolymer established through the deacetylation of chitin, has been extensively studied using interdisciplinary approaches for a wide range of applications. Chitosan biomaterials exhibit distinctive attributes, including biodegradability, muco-adhesion, and biocompatibility, as well as a broad spectrum of antibacterial and antifungal properties. Furthermore, chitosan stands as the sole naturally occurring cationic polysaccharide, and it can be chemically tailored into various derivatives, depending on the intended role and utilization. The potential applications of chitosan are vast and intriguing, with many yet to be fully explored and understood. The unique characteristics of chitosan have sparked growing attentiveness in pharmaceutical industries and biomedical areas around the globe. The characteristics of chitosan like its biocompatibility, and anti-inflammatory effects hold the potential to yield promising outcomes in wound healing and periodontal care following tooth extractions. The objective of this study is to provide an overview of potential applications of chitosan in the field of dentistry.

Enhancement of Antimicrobial Effect of Endodontic Sealers Using Nanoparticles: A Systematic Review

INTRODUCTION

The elimination of biofilms during root canal therapy continues to pose a challenge due to complex anatomies and uninstrumented portions of the root canal system. The incorporation of nanoparticles in endodontic sealers is an area of interest for potentially enhancing antimicrobial activity and improving treatment outcomes. This systematic review evaluated the antimicrobial effects of various nanoparticles in endodontic sealers.

METHODS

Comprehensive literature review was conducted using the electronic Embase, Web of Science, and PubMed databases followed by citation searching for articles eligible per the inclusion criteria.

RESULTS

A total of 1845 citations were screened, of which 13 articles met the inclusion criteria and were included in this review. All included articles were in vitro studies with low-to-moderate quality assessment scores. The incorporation of select nanoparticles was associated with significant enhancement of antibacterial effects in planktonic and/or biofilm forms, whereas other nanoparticles were not.

CONCLUSIONS

The incorporation of certain types and concentrations of nanoparticles into endodontic sealers displayed antimicrobial effects in vitro. The need for well-designed clinical studies translating in vitro findings into clinical practice is warranted. The incorporation of nanoparticles may enhance the antimicrobial properties of endodontic sealers and may improve treatment outcomes.

Synthesis of silver core-shell nanoparticles and their influence on an experimental resin endodontic sealer: An in vitro analysis

AIM

To avoid root canal recontamination and endodontic treatment failure, endodontic sealers with antibacterial activity could be an alternative. Silver nanoparticles have antibacterial activity and this study aimed to synthesize Ag@SiO₂ nanoparticles, incorporate them into an experimental endodontic resin sealer and evaluate their influence on physicochemical and biological properties.

METHODOLOGY

Ag@SiO₂ nanoparticles were produced using the sol-gel process, based on the Stöber method. The particles were characterized in terms of their chemical structure by Fourier transform-infrared spectroscopy (FTIR), X-ray diffraction (XRD), thermogravimetric analysis (TGA), UV-Vis spectral analysis, scanning electron microscopy, and transmission electron microscopy, where the particle morphology and diameter were analysed. A dual-cured experimental endodontic resin sealer was formulated using 70 wt% UDMA, 15 wt% GDMA, and 15 wt% BisEMA. The photoinitiators were added separately in two pastes. The Ag@SiO₂ nanoparticles were incorporated into the endodontic sealer at the concentrations of 2.5 wt%, 5 wt%, and 10 wt%, and a control group without nanoparticles was also formulated. The endodontic sealers were evaluated for their flow, film thickness, degree of conversion, softening in solvent, radiopacity, cytotoxicity and antibacterial activity immediately and after 9 months in water storage.

RESULTS

Silver was detected in the chemical characterization of Ag@SiO₂ that presented a spheric regular shape and average 683.51 nm ± 93.58 diameter. Sealers presented adequate flow and film thickness while radiopacity values were below the ones required by ISO 6876. All groups underwent softening after immersion in a solvent. The 10 wt% groups showed a higher loss of subsurface hardness (∆KHN%). No reduction in cell viability was observed. Enterococcus faecalis viability in biofilm was reduced in 10 wt% groups after 24 h and 9 months.

CONCLUSION

The addition of 10 wt% Ag@SiO₂ reduced E. faecalis viability at immediate and longitudinal analysis while maintaining the physicochemical properties of developed sealers.

Nanomaterials-Based Combinatorial Therapy as a Strategy to Combat Antibiotic Resistance

Since the discovery of antibiotics, humanity has been able to cope with the battle against bacterial infections. However, the inappropriate use of antibiotics, the lack of innovation in therapeutic agents, and other factors have allowed the emergence of new bacterial strains resistant to multiple antibiotic treatments, causing a crisis in the health sector. Furthermore, the World Health Organization has listed a series of pathogens (ESKAPE group) that have acquired new and varied resistance to different antibiotics families. Therefore, the scientific community has prioritized designing and developing novel treatments to combat these ESKAPE pathogens and other emergent multidrug-resistant bacteria. One of the solutions is the use of combinatorial therapies. Combinatorial therapies seek to enhance the effects of individual treatments at lower doses, bringing the advantage of being, in most cases, much less harmful to patients. Among the new developments in combinatorial therapies, nanomaterials have gained significant interest. Some of the most promising nanotherapeutics include polymers, inorganic nanoparticles, and antimicrobial peptides due to their bactericidal and nanocarrier properties. Therefore, this review focuses on discussing the state-of-the-art of the most significant advances and concludes with a perspective on the future developments of nanotherapeutic combinatorial treatments that target bacterial infections.

Emergence of Nano-Dentistry as a Reality of Contemporary Dentistry

(1) Background. Nanotechnology offers significant alternative ways to solve scientific, medical, and human health issues. Dental biomaterials were improved by nanotechnology. It manufactures better materials or improves the existing ones and forms the basis of novel methods for disease diagnosis and prevention. Modern nanotechnology makes oral health care services more acceptable for patients. Nanotechnology is now important area of research, covering a broad range of applications in dentistry. (2) Methods. Relevant literature from Scopus published in English was selected using the keywords “nanoparticle” and “dentistry”. To the selected articles we applied the inclusion and exclusion criteria to choose the relevant ones. (3) Results. Based on the relevant articles, a literature review was prepared. This review provides an insight into the applications of nanotechnology in various branches of dentistry. We applied several regression models to fit number of papers versus time and chose the best one. We used it to construct the forecast and its 95%-confidence interval for the number of publications in 2022–2026. (4) Conclusions. It shows that a significant rise in papers is expected. This review familiarizes dentists with properties and benefits of nanomaterials and nanotechnology. Additionally, it can help scientists to consider the direction of their research and to plan prospective research projects.

Antimicrobial potential of AH Plus supplemented with bismuth lipophilic nanoparticles on E. faecalis isolated from clinical isolates

The objective of this study was to determine the antimicrobial potential of AH plus supplemented with bismuth lipophilic nanoparticles (BisBAL NPs) on the growth of Enterococcus faecalis isolated from patients with endodontic infections. BisBAL NPs, synthesized with the colloidal method, were characterized, in its pure form or AH Plus-absorbed, by energy-dispersive X-ray spectroscopy and scanning electron microscopy (EDS-SEM). Antimicrobial activity was evaluated with disc diffusion assays, and antibiofilm activity with fluorescence microscopy. BisBAL NP-supplemented AH Plus had a 4.9 times higher antimicrobial activity than AH Plus alone (p = 0.0001). In contrast to AH Plus alone, AH Plus supplemented with BisBAL NP inhibited E. faecalis biofilm formation. The sealing properties of AH plus were not modified by the incorporation of BisBAL NPs, which was demonstrated by a 12-day split-chamber leakage assay with daily inoculation, which was used to evaluate the possible filtration of E. faecalis. Finally, BisBAL NP-supplemented AH plus-BisBAL NPs was not cytotoxic for cultured human gingival fibroblasts. Their viability was 83.7% to 89.9% after a 24-h exposure to AH Plus containing 50 and 10 µM BisBAL NP, respectively. In conclusion, BisBAL NP-supplemented AH Plus constitutes an innovative nanomaterial to prevent re-infection in endodontic patients without cytotoxic effects.

Therapeutic Applications of Antimicrobial Silver-Based Biomaterials in Dentistry

Microbial infection accounts for many dental diseases and treatment failure. Therefore, the antibacterial properties of dental biomaterials are of great importance to the long-term results of treatment. Silver-based biomaterials (AgBMs) have been widely researched as antimicrobial materials with high efficiency and relatively low toxicity. AgBMs have a broad spectrum of antimicrobial properties, including penetration of microbial cell membranes, damage to genetic material, contact killing, and dysfunction of bacterial proteins and enzymes. In particular, advances in nanotechnology have improved the application value of AgBMs. Hence, in many subspecialties of dentistry, AgBMs have been researched and employed, such as caries arresting or prevention, root canal sterilization, periodontal plaque inhibition, additives in dentures, coating of implants and anti-inflammatory material in oral and maxillofacial surgery. This paper aims to provide an overview of the application approaches of AgBMs in dentistry and present better guidance for oral antimicrobial therapy via the development of AgBMs.

General Characteristics, Biomedical and Dental Application, and Usage of Chitosan in the Treatment of Temporomandibular Joint Disorders: A Narrative Review

The aim of this narrative review was to present research investigating chitosan, including its general characteristics, properties, and medical and dental applications, and finally to present the current state of knowledge regarding the efficacy of chitosan in the treatment of temporomandibular disorders (TMDs) based on the literature. The PICO approach was used for the literature search strategy. The PubMed database was analyzed with the following keywords: (“chitosan”[MeSH Terms] OR “chitosan”[All Fields] OR “chitosans”[All Fields] OR “chitosan s”[All Fields] OR “chitosane”[All Fields]) AND (“temporomandibular joint”[MeSH Terms] OR (“tem-poromandibular”[All Fields] AND “joint”[All Fields]) OR “temporomandibular joint”[All Fields] OR (“temporomandibular”[All Fields] AND “joints”[All Fields]) OR “temporo-mandibular joints”[All Fields]). After screening 8 results, 5 studies were included in this review. Chitosan presents many biological properties and therefore it can be widely used in several branches of medicine and dentistry. Chitosan promotes wound healing, helps to control bleeding, and is used in wound dressings, such as sutures and artificial skin. Apart from its antibacterial property, chitosan has many other properties, such as antifungal, mucoadhesive, anti-inflammatory, analgesic, antioxidant, antihyperglycemic, and antitumoral properties. Further clinical studies assessing the efficacy of chitosan in the treatment of TMD are required. According to only one clinical study, chitosan was effective in the treatment of TMD; however, better clinical results were obtained with platelet-rich plasma.

Bacterial leakage assessment in root canals sealed with AH Plus sealer modified with silver nanoparticles

BACKGROUND

Successful endodontic therapy requires prevention of bacterial leakage between the root canal filing and root-canal walls. Sealing quality of a root canal filling depends strongly on the sealing ability of the sealer used. The present study aimed to evaluate the bacterial leakage resistance of AH Plus sealer modified with silver nanoparticles.

METHODS

Forty sound teeth were obturated using lateral compaction technique except for five teeth as the negative controls. After considering five teeth as the positive controls (filled without sealer), the remaining teeth were assigned to two groups (n = 15) in terms of the sealer used (AH Plus sealer and silver nanoparticle-modified AH Plus). Bacterial leakage was evaluated in saliva using the two-chamber technique in every 24 h. When all the samples in the test groups were contaminated, the study was terminated. The data were analyzed with log-rank statistical test.

RESULTS

All samples in both experimental groups were contaminated during the 3-months period of observation. There was no significant difference in contamination time between study groups (P > 0.05).

CONCLUSIONS

Silver nanoparticles used in tested concentration did not improve the bacterial leakage resistance of AH Plus sealer.

Nanomaterials Application in Endodontics

In recent years, nanomaterials have become increasingly present in medicine, especially in dentistry. Their characteristics are proving to be very useful in clinical cases. Due to the intense research in the field of biomaterials and nanotechnology, the efficacy and possibilities of dental procedures have immensely expanded over the years. The nano size of materials allows them to exhibit properties not present in their larger-in-scale counterparts. The medical procedures in endodontics are time-consuming and mostly require several visits to be able to achieve the proper result. In this field of dentistry, there are still major issues about the removal of the mostly bacterial infection from the dental root canals. It has been confirmed that nanoparticles are much more efficient than traditional materials and appear to have superior properties when it comes to surface chemistry and bonding. Their unique antibacterial properties are also promising features in every medical procedure, especially in endodontics. High versatility of use of nanomaterials makes them a powerful tool in dental clinics, in a plethora of endodontic procedures, including pulp regeneration, drug delivery, root repair, disinfection, obturation and canal filling. This study focuses on summing up the current knowledge about the utility of nanomaterials in endodontics, their characteristics, advantages, disadvantages, and provides a number of reasons why research in this field should be continued.

Antimicrobial Activity of Calcium Silicate-Based Dental Materials: A Literature Review

Endodontic biomaterials have significantly improved dental treatment techniques in several aspects now that they can be used for vital pulp treatments, as temporary intracanal medication, in definitive fillings, in apical surgeries, and for regenerative procedures. Calcium silicate-based cement is a class of dental material that is used in endodontics in direct contact with the dental structures, connective tissue, and bone. Because the material interacts with biological tissues and stimulates biomineralization processes, its properties are of major importance. The main challenge in endodontic treatments is the elimination of biofilms that are present in the root canal system anatomical complexities, as it remains even after chemical-mechanical preparation and disinfection procedures. Thus, an additional challenge for these biomaterials is to exert antimicrobial activity while maintaining their biological properties in parallel. This article reviews the literature for studies considering the antimicrobial properties of calcium silicate-based dental biomaterials used in endodontic practice. Considering the reviewed studies, it can be affirmed that the reduced antimicrobial effect exhibited by calcium silicate-based endodontic materials clearly emphasizes that all clinical procedures prior to their use must be carefully performed. Future studies for the evaluation of these materials, and especially newly proposed materials, under poly-microbial biofilms associated with endodontic diseases will be necessary.

One-pot biosynthesis of silver nanoparticles with potential antimicrobial and antibiofilm efficiency against otitis media-causing pathogens

There are increasing demands for biogenic synthesis of silver nanoparticles (AgNPs) due to their unique properties and their numerous applications especially in biomedical field. Direct sunlight irradiation on aqueous garlic extract (AGE) represent fast, applicable, non-toxic, cheap, and ecofriendly method for (AgNPs) synthesis, with potentials to compete multi-drug-resistant (MDR) and biofilm-forming pathogens causing otitis media (OM). The aim of this study was to establish an eco-friendly method for synthesis of AgNPs, using aqueous garlic extract and sunlight, and moreover, detect its potential to inhibit MDR OM microbes. Obtained AgNPs were characterized by UV-visible spectral analysis, TEM, DLS, XRD, and FTIR. The effect of biosynthesized AgNPs on microbial growth, as well as biofilm productivity, was assessed against five resistant OM-causing strains, namely Bacillus cereus, Pseudomonas aeruginosa, Penicillium chrysogenum, Aspergillus niger, and Aspergillus flavus. Kirby-Bauer disc diffusion method was used to assess the inhibitory effect of 100, 50, 25, 12.5, and 6.25 μg/ml of AgNPs compared with tetracycline or nystatin and AGE. Additionally, the effect of 25 μg/ml of AgNPs on biofilm productivity of such strains was qualitatively assessed using Congo red agar (CRA) and TEM used to capture the changes inside the selected strains. The obtained AgNPs showed a highly significant (p value < 0.001) antimicrobial and antibiofilm activities against tested strains. TEM images of Pseudomonas aeruginosa and Aspergillus flavus treated with 25 μg/ml AgNPs showed shrinkage in the cytoplasmic materials and rupture of cell walls.

Egyptian Propolis-Loaded Nanoparticles as a Root Canal Nanosealer: Sealing Ability and in vivo Biocompatibility

Background

Successful endodontic therapy is mainly governed by the satisfactory sealing ability of the applied root canal sealer. Also, tolerability of root canal structure to accommodate the presence of a sealer participates in the efficiency of the treatment. Hence, this study was aimed to extrapolate our previous one that was concerned with the preparation and evaluation of novel nature-based root canal sealers. Our current work is focused on the evaluation of sealing ability and in vivo biocompatibility.

Materials and Methods

Egyptian propolis was extracted (ProE) and encapsulated in polymeric nanoparticles (ProE-loaded NPs). Two root sealers, PE sealer and PE nanosealer, were fabricated by incorporating ProE and ProE-loaded NPs, respectively. The sealing ability of the developed sealers was tested by a dye extraction method. An in vivo biocompatibility study was conducted using a subcutaneous implantation method for two and four weeks. At the same time, a model sealer (AH Plus®) was subjected to the same procedures to enable accurate and equitable results.

Results

The teeth treated with PE sealer exhibited weak sealing ability which did not differ from that of unfilled teeth. PE nanosealer enhanced the sealing ability similarly to the model sealer with minimal apical microleakage. Studying in vivo biocompatibility indicated the capability of the three tested sealers to induce cell proliferation and tissue healing. However, PE nanosealer had superior biocompatibility, with higher potential for cell regeneration and tissue proliferation.

Conclusion

PE nanosealer can be presented as an innovative root canal sealer, with enhanced sealing ability as well as in vivo biocompatibility. It can be applied as a substitute for the currently available sealers that demonstrate hazardous effects.

Antibacterial effect of chitosan and its derivative on Enterococcus faecalis associated with endodontic infection

Chitosan and its derivatives have been increasingly used for bacteriostasis. To date, the effect of chitosan and N-(2-hydroxyl) propyl-3-trimethyl ammonium chitosan chloride (HTCC) on Enterococcus faecalis (E. faecalis) associated with endodontic infection has remained to be determined. Chitosan and HTCC were serially diluted with double-distilled water (DDW) or PBS at concentrations of 20-2,500 µg/ml. Various strains of E. faecalis (American Type Tissue Collection no. 29212, as well as isolated strains P25RC and P52Sa) in plankton were adjusted to an optical density at 600 nm of 0.10 and treated with chitosan or HTCC. A colony-forming unit assay was used to determine the concentration of residual bacteria after treatment. Furthermore, E. faecalis biofilms were cultured on coverslips and treated with chitosan or HTCC. The coverslips were rinsed, stained using Live/dead^® BacLight™ bacterial viability kit and observed under an inverted fluorescence microscope. In addition, biofilms on dentine blocks were prepared and observed under a scanning electron microscope. MC3T3-E1 pre-osteoblasts were seeded on 96-well plates and treated with chitosan or HTCC at various concentrations. The cytotoxicity of chitosan and HTCC on MC3T3-E1 pre-osteoblasts was detected using a Cell Counting Kit-8 assay after 24, 48 and 72 h of treatment. The results revealed that the final minimum bactericidal concentrations (MBC) of chitosan and HTCC dissolved in DDW were 70 and 140 µg/ml, respectively. Chitosan and HTCC in DDW exerted a significantly greater antibacterial effect as compared with that in PBS (P<0.05). At the MBC, chitosan and HTCC in DDW, but particularly chitosan, had a significant antibacterial effect on E. faecalis biofilm. Chitosan exhibited no cytotoxicity to MC3T3-E1 pre-osteoblasts at a concentration of <625 µg/ml, while HTCC inhibited the proliferation of the cells in the concentration range of 39-10,000 µg/ml. In conclusion, chitosan and HTCC exhibited prominent antibacterial properties on E. faecalis in the planktonic state and as a biofilm via charge interaction, indicating their potential for application in root canal disinfection and fillings.

Application of Chitosan in Bone and Dental Engineering

Chitosan is a deacetylated polysaccharide from chitin, the natural biopolymer primarily found in shells of marine crustaceans and fungi cell walls. Upon deacetylation, the protonation of free amino groups of the d-glucosamine residues of chitosan turns it into a polycation, which can easily interact with DNA, proteins, lipids, or negatively charged synthetic polymers. This positive-charged characteristic of chitosan not only increases its solubility, biodegradability, and biocompatibility, but also directly contributes to the muco-adhesion, hemostasis, and antimicrobial properties of chitosan. Combined with its low-cost and economic nature, chitosan has been extensively studied and widely used in biopharmaceutical and biomedical applications for several decades. In this review, we summarize the current chitosan-based applications for bone and dental engineering. Combining chitosan-based scaffolds with other nature or synthetic polymers and biomaterials induces their mechanical properties and bioactivities, as well as promoting osteogenesis. Incorporating the bioactive molecules into these biocomposite scaffolds accelerates new bone regeneration and enhances neovascularization in vivo.