Clinical effectiveness of anorganic bovine-derived hydroxyapatite matrix/cell-binding peptide grafts for regeneration of periodontal defects: a systematic review and meta-analysis

Evolution of Biological Hydroxyapatite Modification Strategy: Anti-Inflammation Approach Rescues the Calcium-NOD-Like Receptor-Inflammation Axis-Mediated Periodontal Redevelopment Failure

Periodontal regenerative medicine is currently undergoing a paradigm shift from dissecting the healing process toward utilization of the developmental program. Biological hydroxyapatite (BHA), a major component of guided tissue regeneration, has long been optimized for inducing multidirectional differentiation of periodontal ligament cells (PDLCs). However, this approach runs counter to the redevelopment strategy. Thus, the conventional BHA should evolve to induce the redevelopment process of periodontal tissue. In this study, histopathological changes and immune microenvironment characteristics of the periodontal developmental process, natural healing process (Blank group), and BHA-mediated healing process (BHA group) were compared to evaluate the main manifestations of BHA-mediated periodontal "developmental engineering" outcome. Our results suggested that neither the Blank nor BHA group could recur key events in periodontal development. The implantation of BHA led to pro-inflammatory immune microenvironment and an unstable blood fibrin clot structure, which facilitated the invasion of outer gingival fibroblasts, consequently disrupting redevelopmental events. High-throughput chip technology was further used to explore the underlying mechanism of immune activation, revealing that the calcium-NOD-like receptor-inflammation axis signaling axis promoted the activation of pro-inflammatory immune response that contributed to redevelopment failure. An immunomodulatory cytokine interleukin 4 (IL4)-modified BHA was used to further validate the efficacy of developmental engineering strategy. IL4 could partially rescued the redevelopment failure through immunosuppression. This study presented an innovative strategy for the development of advanced periodontal regenerative materials and offered a potential approach for the application of development-inspired periodontal tissue engineering strategies. It represented a marked advancement in the development of regenerative medicine and propelled the clinical organ restoration forward.

Clinical efficacy and safety of P-15 peptide enhanced bone graft substitute in surgical bone regenerative procedures in adult maxillofacial, spine, and trauma patients : a systematic literature review

Aims

Autologous bone graft (ABG) is considered the 'gold standard' among graft materials for bone regeneration. However, complications including limited availability, donor site morbidity, and deterioration of regenerative capacity over time have been reported. P-15 is a synthetic peptide that mimics the cell binding domain of Type-I collagen. This peptide stimulates new bone formation by enhancing osteogenic cell attachment, proliferation, and differentiation. The objective of this study was to conduct a systematic literature review to determine the clinical efficacy and safety of P-15 peptide in bone regeneration throughout the skeletal system.

Methods

PubMed, Embase, Web of Science, and Cochrane Library were searched for relevant articles on 13 May 2023. The systematic review was reported according to the PRISMA guidelines. Two reviewers independently screened and assessed the identified articles. Quality assessment was conducted using the methodological index for non-randomized studies and the risk of bias assessment tool for randomized controlled trials.

Results

After screening, 28 articles were included and grouped by surgical indication, e.g. maxillofacial procedures (n = 18), spine (n = 9), and trauma (n = 1). Published results showed that P-15 peptide was effective in spinal fusion (n = 7) and maxillofacial (n = 11), with very few clinically relevant adverse events related to P-15 peptide.

Conclusion

This systematic literature review concluded that moderate- (risk of bias, some concern: 50%) to high-quality (risk of bias, low: 46%) clinical evidence exists showing equivalent safety and efficacy in bone regeneration using a P-15 peptide enhanced bone graft substitute compared to ABG. P-15 peptide is safe and effective, resulting in rapid bone formation with a low probability of minor complications.

Systematic Review Regarding the Clinical Implications of Allograft and Alloplastic Bone Substituents Used for Periodontal Regenerative Therapy

Background/Objectives: Regenerative periodontal therapy is a treatment method that focuses on restoring the periodontium affected by chronic inflammatory disease or injury. It involves using different biomaterials and techniques to completely restore the periodontal structures. The main objective was to identify and critically evaluate relevant studies comparing the clinical efficacy of allograft and alloplastic materials in regenerative periodontal therapy. Methods: For evaluation, a systematic review based on PRISMA guidelines was conducted. Data were extracted using only specific types of study designs, which included randomized controlled trials, cohort studies, and case-control studies. Target patients with periodontal disease or periodontal lesions undergoing periodontal therapy using allograft or alloplastic materials were selected. Periodontal parameters such as clinical attachment level, probing pocket depth, radiographic bone fill, or patient-reported outcomes were analyzed. Results: The results showed that allograft and alloplastic materials offered reduced pocket depth, a gain in clinical attachment, and bone repairment. The variation observed indicated that allografts showed a slightly more significant clinical attachment gain and a superior bone fill than alloplastic ones, suggesting that allografts enhance osteogenesis and provide a greater capacity for repair in periodontal defects. Conclusions: The results of the present study suggest that allograft and alloplastic materials offered reduced pocket depth, a gain in clinical attachment, and bone repairment, with both methods having similar clinical efficacy.

Compressive Strength of Newly Developed Nonsintered Hydroxyapatite Blocks for Bone Graft Applications

OBJECTIVE

 This study aimed to fabricate and evaluate the phase purity and compressive strength of the nonsintered hydroxyapatite (HA) block obtained via phase transformation of set calcium sulfate dihydrate (CSD) block under hydrothermal conditions at different temperatures.

MATERIALS AND METHODS

 Nonsintered HA block was prepared by immersion CSD block (4 mm in diameter and 8 mm in height) in a 1 mol/L sodium phosphate (Na3PO4) solution under hydrothermal conditions at 100°C, 140°C, and 180°C for 48 hours. X-ray diffraction was used to determine the crystalline phase of the obtained blocks. The mechanical strength of the blocks was measured using a compressive strength test.

RESULTS

 The result shows that the CSD block could be fully transformed into a HA block at 180°C for 48 hours without changing its macroscopic shape. The compressive strength of the obtained blocks was lower compared with the CSD block.

CONCLUSION

 The current method has successfully produced a nonsintered HA block at 180°C for 48 hours. The compressive strength of the HA block decreased compared with the gypsum block used as a precursor. However, the compressive strength of the HA block that was produced still falls within the range of cancellous bone.

3D Bioprinting of a Bioactive Composite Scaffold for Cell Delivery in Periodontal Tissue Regeneration

Hydrogels have been widely applied to the fabrication of tissue engineering scaffolds via three-dimensional (3D) bioprinting because of their extracellular matrix-like properties, capacity for living cell encapsulation, and shapeable customization depending on the defect shape. However, the current hydrogel scaffolds show limited regeneration activity, especially in the application of periodontal tissue regeneration. In this study, we attempted to develop a novel multi-component hydrogel that possesses good biological activity, can wrap living cells for 3D bioprinting and can regenerate periodontal soft and hard tissue. The multi-component hydrogel consisted of gelatin methacryloyl (GelMA), sodium alginate (SA) and bioactive glass microsphere (BGM), which was first processed into hydrogel scaffolds by cell-free 3D printing to evaluate its printability and in vitro biological performances. The cell-free 3D-printed scaffolds showed uniform porous structures and good swelling capability. The BGM-loaded scaffold exhibited good biocompatibility, enhanced osteogenic differentiation, apatite formation abilities and desired mechanical strength. The composite hydrogel was further applied as a bio-ink to load with mouse bone marrow mesenchymal stem cells (mBMSCs) and growth factors (BMP2 and PDGF) for the fabrication of a scaffold for periodontal tissue regeneration. The cell wrapped in the hydrogel still maintained good cellular vitality after 3D bioprinting and showed enhanced osteogenic differentiation and soft tissue repair capabilities in BMP2- and PDGF-loaded scaffolds. It was noted that after transplantation of the cell- and growth factor-laden scaffolds in Beagle dog periodontal defects, significant regeneration of gingival tissue, periodontal ligament, and alveolar bone was detected. Importantly, a reconstructed periodontal structure was established in the treatment group eight weeks post-transplantation of the scaffolds containing the cell and growth factors. In conclusion, we developed a bioactive composite bio-ink for the fabrication of scaffolds applicable for the reconstruction and regeneration of periodontal tissue defects.

Antimicrobial effects of hydroxyapatite mosaicked polyvinyl alcohol-alginate semi-interpenetrating hydrogel-loaded with ethanolic extract of Glycyrrhiza glabra against oral pathogens

Glycyrrhiza glabra (GG) elicits protective effects against periodontal diseases. However, the sustained bioavailability of GG extract at therapeutic concentration warrants ideal delivery vehicles. Present study has focused on the design, fabrication, and evaluations of ethanolic-crude extract of GG-loaded semi-interpenetrating network (semi-IPN) hydrogel (HAAPS-GG) using alginic acid and polyvinyl alcohol (PVA) hydrogel mosaicked with HA for periodontal regeneration. The study has examined the performance of the hydrogel against the selected oral pathogens S. mutans, E. faecalis, L. acidophilus and C. albicans. HAAPS-GG was successfully fabricated and the surface functional groups were confirmed by attenuated total reflectance-infrared (ATR-IR) spectroscopy. HAAPS-GG displayed interconnecting pores, hydrophilicity and excellent water profile contributing to the biocompatibility as evident from direct contact and MTT assay in L929 fibroblasts. The hydrogel was mechanically stable and was immunocompatible owing to the relatively decreased levels of pro-inflammatory mediators COX2, 5LPO, iNOS and MPO in RAW 264.7 macrophages. In addition, the transcript analysis on RAW 264.7 revealed the down-regulation of inflammatory transcription factor NF-κβ and the pro-inflammatory cytokine TNF-α. Importantly, HAAPS-GG arrested the progression of periodontal pathogens predominantly S. mutans, and C. albicans as evident by disc diffusion assay, MTT assay and confocal microscopy. Overall, the HAAPS-GG system offers promising translational avenues in periodontal regeneration.

Human Umbilical Cord Mesenchymal Stem Cells: Current Literature and Role in Periodontal Regeneration

Periodontal disease can cause irreversible damage to tooth-supporting tissues such as the root cementum, periodontal ligament, and alveolar bone, eventually leading to tooth loss. While standard periodontal treatments are usually helpful in reducing disease progression, they cannot repair or replace lost periodontal tissue. Periodontal regeneration has been demonstrated to be beneficial in treating intraosseous and furcation defects to varied degrees. Cell-based treatment for periodontal regeneration will become more efficient and predictable as tissue engineering and progenitor cell biology advance, surpassing the limitations of present therapeutic techniques. Stem cells are undifferentiated cells with the ability to self-renew and differentiate into several cell types when stimulated. Mesenchymal stem cells (MSCs) have been tested for periodontal regeneration in vitro and in humans, with promising results. Human umbilical cord mesenchymal stem cells (UC-MSCs) possess a great regenerative and therapeutic potential. Their added benefits comprise ease of collection, endless source of stem cells, less immunorejection, and affordability. Further, their collection does not include the concerns associated with human embryonic stem cells. The purpose of this review is to address the most recent findings about periodontal regenerative mechanisms, different stem cells accessible for periodontal regeneration, and UC-MSCs and their involvement in periodontal regeneration.

Autogenous Tooth Bone Grafts for Repair and Regeneration of Maxillofacial Defects: A Narrative Review

Autogenous tooth graft is an innovative and ingenious technique that employs a stepwise approach and utilizes human teeth as an autogenous source of bone graft. The structure of teeth closely resembles bone, both physically and biochemically, and can be efficiently used for the process as it depicts properties of osteoinduction and osteoconduction. Autogenous tooth bone has characteristics similar to bone grafts in terms of healing potential, physical properties, and clinical outcome. Autogenous tooth graft has shown reasonable promise as a graft material for the regeneration of maxillary and mandibular defects. Autogenous tooth bone graft finds its principal application in sinus and ridge augmentations and for socket preservation before implant placement. Additionally, it can be used successfully for alveolar cleft patients and patients with limited periodontal defects. The overall complication rates reported for autogenous tooth grafts are comparable to other graft sources. However, although long-term results are still underway, it is still recommended as a grafting option for limited defects in the cranio-facial region.

Nanocrystalline hydroxyapatite in regeneration of periodontal intrabony defects: A systematic review and meta-analysis

BACKGROUND

Alveolar bone loss and mobility of teeth is commonly observed in periodontitis patients. Regeneration of periodontal intrabony defects is indicated to restore the lost bone and periodontal tissues. The aim of the present study was to evaluate the clinical outcomes of periodontal intrabony lesions by using nanocrystalline hydroxyapatite (NHA) graft and comparing it with open flap debridement (OFD) alone.

MATERIALS AND METHODS

The eligibility criteria encompassed randomized (RCTs) and controlled clinical trials (CCTs). Weighted mean differences were calculated for clinical attachment level (CAL) gain, probing pocket depth (PPD) reduction and gingival recession (REC) change, demonstrated as forest plots. The revised Cochrane Risk of Bias tool for randomized trials (RoB2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool were used for quality assessment of RCTs and non-randomized trials respectively.

RESULTS

From 22 full-text articles identified, three RCTs, one CCT and one retrospective follow-up of RCT were included. All the five papers comprised the quantitative evaluation. The use of NHA graft provided additional CAL gain of 0.96 mm (p = 0.0009) and PPD reduction of 0.97 mm (p < 0.00001) when compared to OFD alone. However, in terms of REC changes, no considerable benefits of NHA graft were demonstrated than OFD alone (p = 0.48).

CONCLUSIONS

The bioactive NHA graft showed promising results clinically in regenerative periodontology and can be considered for the management of periodontal intrabony defects. The use of NHA graft considerably provided better clinical outcomes in intrabony defects compared to using the OFD alone. Future research investigating NHA graft against other regenerative materials including specific BGs, at longer follow-up periods and bigger sample sizes and in furcation defects warranted.

Potential of Bone-Marrow-Derived Mesenchymal Stem Cells for Maxillofacial and Periodontal Regeneration: A Narrative Review

Bone-marrow-derived mesenchymal stem cells (BM-MSCs) are one of the most widely studied postnatal stem cell populations and are considered to utilize more frequently in cell-based therapy and cancer. These types of stem cells can undergo multilineage differentiation including blood cells, cardiac cells, and osteogenic cells differentiation, thus providing an alternative source of mesenchymal stem cells (MSCs) for tissue engineering and personalized medicine. Despite the ability to reprogram human adult somatic cells to induced pluripotent stem cells (iPSCs) in culture which provided a great opportunity and opened the new door for establishing the in vitro disease modeling and generating an unlimited source for cell base therapy, using MSCs for regeneration purposes still have a great chance to cure diseases. In this review, we discuss the important issues in MSCs biology including the origin and functions of MSCs and their application for craniofacial and periodontal tissue regeneration, discuss the potential and clinical applications of this type of stem cells in differentiation to maxillofacial bone and cartilage in vitro, and address important future hopes and challenges in this field.

Comparing Nanohydroxyapatite Graft and Other Bone Grafts in the Repair of Periodontal Infrabony Lesions: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the results of periodontal infrabony lesions treated using nanohydroxyapatite (NcHA) graft with other bone grafts (BGs).

METHODS

Four electronic databases were searched including PubMed (NLM), Embase (Ovid), Medline, and Dentistry and Oral Sciences (EBSCO). The inclusion criteria included randomised controlled clinical trials (RCTs) and controlled clinical trials (CCTs). The clinical results of NcHA were compared with other BGs. For clinical attachment level (CAL) gain, probing pocket depth (PPD) decrease, and gingival recession (REC) change, weighted averages and forest plots were computed.

RESULTS

Seven RCTs fulfilled the selection criteria that were included. When NcHA was compared to other BGs, no clinically significant differences were found in terms of each outcome assessed, except the REC change for synthetic BGs as compared to NcHA.

CONCLUSIONS

The use of an NcHA graft showed equivalent results compared to other types of BGs. To further validate these findings, future studies are required to compare the NcHA and various BGs over longer time periods and in furcation deficiencies.

Synthesis and characterization of lysozyme-conjugated Ag.ZnO@HA nanocomposite: A redox and pH-responsive antimicrobial agent with photocatalytic activity

Hydroxyapatite (HA) is extensively used for implantable device coating; however, it lacks antibacterial property, leading to potential bacterial infection during orthopedic implantation surgery. Herein, to enhance the antibacterial activity of HA, a redox- and pH-responsive HA nanocomposite with photocatalytic activity was designed. A photosensitive heterostructure, zinc oxide/hydroxyapatite (ZnO.HA), was coated with Ag nanoparticles (AgNPs) with assisted gallic acid using the UV-irradiation method. An antibacterial enzyme, lysozyme, was then conjugated on the surface of the nanocomposite by a cleavable disulfide linker, resulting in a redox-sensitive nanoplatform. In comparison with bare HA, the designed nanocomposites as Lyso.CAGZ@HA displayed much higher antibacterial activity (> 5-fold) toward Escherichia coli (E. coli) owing to the synergistic antibacterial effects of ZnONPs, AgNPs, gallic acid, and lysozyme on the surface of the nanocomposite. However, antibacterial and antifouling effects are much more enhanced in Lyso.CAGZ@HA-treated bacteria as they were subjected to UVA irradiation. Moreover, the cellular uptake of nanocomposite and intracellular glutathione depletion enhanced in the presence of UVA light, resulting in reactive oxygen specious generation enhancement. Further, in vitro cytotoxicity experiments on mammalian cells (human foreskin fibroblast) revealed that nanocomposite has no cytotoxic effects. Hence, this study demonstrated that Lyso.CAGZ@HA could be considered as a potential therapeutic approach against bacterial infectious diseases.

Zn-Containing Membranes for Guided Bone Regeneration in Dentistry

Barrier membranes are employed in guided bone regeneration (GBR) to facilitate bone in-growth. A bioactive and biomimetic Zn-doped membrane with the ability to participate in bone healing and regeneration is necessary. The aim of the present study is to state the effect of doping the membranes for GBR with zinc compounds in the improvement of bone regeneration. A literature search was conducted using electronic databases, such as PubMed, MEDLINE, DIMDI, Embase, Scopus and Web of Science. A narrative exploratory review was undertaken, focusing on the antibacterial effects, physicochemical and biological properties of Zn-loaded membranes. Bioactivity, bone formation and cytotoxicity were analyzed. Microstructure and mechanical properties of these membranes were also determined. Zn-doped membranes have inhibited in vivo and in vitro bacterial colonization. Zn-alloy and Zn-doped membranes attained good biocompatibility and were found to be non-toxic to cells. The Zn-doped matrices showed feasible mechanical properties, such as flexibility, strength, complex modulus and tan delta. Zn incorporation in polymeric membranes provided the highest regenerative efficiency for bone healing in experimental animals, potentiating osteogenesis, angiogenesis, biological activity and a balanced remodeling. Zn-loaded membranes doped with SiO₂ nanoparticles have performed as bioactive modulators provoking an M2 macrophage increase and are a potential biomaterial for promoting bone repair. Zn-doped membranes have promoted pro-healing phenotypes.

Critical features of periodontal flaps with regard to blood clot stability: A review

BACKGROUND

Wound healing is a multifactorial procedure involving different cell types and biological mediators. The principles of wound healing are also applicable to periodontal tissues. The formation and stability of blood clots play a vital role in successful healing of wounds in periodontal tissues. The aim of the present review was to highlight the vital factors of periodontal flaps associated with blood clot stability.

HIGHLIGHT

The data on periodontal regeneration and wound healing have evolved greatly in light of several factors, including space for blood clots and blood clot stabilization. In periodontal osseous defects, the stability of blood clots seems critical to wound healing. If mechanical forces can be managed by wound stabilization, the gingival flap-tooth root interface may show connective tissue repair. However, compromised adhesion is susceptible to mechanical forces and can cause wound breakage and epithelialization.

CONCLUSION

The presence of a thick blood clot may hinder the plasmatic circulation between the recipient bed and graft during the initial stage of healing, which is critical in cases of mucogingival surgery. Root conditioning can also determine the healing consequence by enhancing blood clot adhesion.