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Liang Z, Li J, Lin H, Zhang S, Liu F, Rao Z, Chen J, Feng Y, Zhang K, Quan D, Lin Z, Bai Y, Huang Q. Understanding the multi-functionality and tissue-specificity of decellularized dental pulp matrix hydrogels for endodontic regeneration. Acta Biomater 2024; 181:202-221. [PMID: 38692468 DOI: 10.1016/j.actbio.2024.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/06/2024] [Accepted: 04/25/2024] [Indexed: 05/03/2024]
Abstract
Dental pulp is the only soft tissue in the tooth which plays a crucial role in maintaining intrinsic multi-functional behaviors of the dentin-pulp complex. Nevertheless, the restoration of fully functional pulps after pulpitis or pulp necrosis, termed endodontic regeneration, remained a major challenge for decades. Therefore, a bioactive and in-situ injectable biomaterial is highly desired for tissue-engineered pulp regeneration. Herein, a decellularized matrix hydrogel derived from porcine dental pulps (pDDPM-G) was prepared and characterized through systematic comparison against the porcine decellularized nerve matrix hydrogel (pDNM-G). The pDDPM-G not only exhibited superior capabilities in facilitating multi-directional differentiation of dental pulp stem cells (DPSCs) during 3D culture, but also promoted regeneration of pulp-like tissues after DPSCs encapsulation and transplantation. Further comparative proteomic and transcriptome analyses revealed the differential compositions and potential mechanisms that endow the pDDPM-G with highly tissue-specific properties. Finally, it was realized that the abundant tenascin C (TNC) in pDDPM served as key factor responsible for the activation of Notch signaling cascades and promoted DPSCs odontoblastic differentiation. Overall, it is believed that pDDPM-G is a sort of multi-functional and tissue-specific hydrogel-based material that holds great promise in endodontic regeneration and clinical translation. STATEMENT OF SIGNIFICANCE: Functional hydrogel-based biomaterials are highly desirable for endodontic regeneration treatments. Decellularized extracellular matrix (dECM) preserves most extracellular matrix components of its native tissue, exhibiting unique advantages in promoting tissue regeneration and functional restoration. In this study, we prepared a porcine dental pulp-derived dECM hydrogel (pDDPM-G), which exhibited superior performance in promoting odontogenesis, angiogenesis, and neurogenesis of the regenerating pulp-like tissue, further showed its tissue-specificity compared to the peripheral nerve-derived dECM hydrogel. In-depth proteomic and transcriptomic analyses revealed that the activation of tenascin C-Notch axis played an important role in facilitating odontogenic regeneration. This biomaterial-based study validated the great potential of the dental pulp-specific pDDPM-G for clinical applications, and provides a springboard for research strategies in ECM-related regenerative medicine.
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Affiliation(s)
- Zelin Liang
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Junda Li
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Hongkun Lin
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Sien Zhang
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Fan Liu
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Zilong Rao
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, PCFM Lab, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510006, China
| | - Jiaxin Chen
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, PCFM Lab, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510006, China
| | - Yuwen Feng
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
| | - Kexin Zhang
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, PCFM Lab, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510006, China
| | - Daping Quan
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, PCFM Lab, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510006, China
| | - Zhengmei Lin
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China.
| | - Ying Bai
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, PCFM Lab, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou 510006, China.
| | - Qiting Huang
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China.
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Elnawam H, Abdallah A, Nouh S, Khalil NM, Elbackly R. Influence of extracellular matrix scaffolds on histological outcomes of regenerative endodontics in experimental animal models: a systematic review. BMC Oral Health 2024; 24:511. [PMID: 38689279 PMCID: PMC11061952 DOI: 10.1186/s12903-024-04266-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Decellularized extracellular matrix (dECM) from several tissue sources has been proposed as a promising alternative to conventional scaffolds used in regenerative endodontic procedures (REPs). This systematic review aimed to evaluate the histological outcomes of studies utilizing dECM-derived scaffolds for REPs and to analyse the contributing factors that might influence the nature of regenerated tissues. METHODS The PRISMA 2020 guidelines were used. A search of articles published until April 2024 was conducted in Google Scholar, Scopus, PubMed and Web of Science databases. Additional records were manually searched in major endodontic journals. Original articles including histological results of dECM in REPs and in-vivo studies were included while reviews, in-vitro studies and clinical trials were excluded. The quality assessment of the included studies was analysed using the ARRIVE guidelines. Risk of Bias assessment was done using the (SYRCLE) risk of bias tool. RESULTS Out of the 387 studies obtained, 17 studies were included for analysis. In most studies, when used as scaffolds with or without exogenous cells, dECM showed the potential to enhance angiogenesis, dentinogenesis and to regenerate pulp-like and dentin-like tissues. However, the included studies showed heterogeneity of decellularization methods, animal models, scaffold source, form and delivery, as well as high risk of bias and average quality of evidence. DISCUSSION Decellularized ECM-derived scaffolds could offer a potential off-the-shelf scaffold for dentin-pulp regeneration in REPs. However, due to the methodological heterogeneity and the average quality of the studies included in this review, the overall effectiveness of decellularized ECM-derived scaffolds is still unclear. More standardized preclinical research is needed as well as well-constructed clinical trials to prove the efficacy of these scaffolds for clinical translation. OTHER The protocol was registered in PROSPERO database #CRD42023433026. This review was funded by the Science, Technology and Innovation Funding Authority (STDF) under grant number (44426).
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Affiliation(s)
- Hisham Elnawam
- Endodontics, Conservative Dentistry Department, Faculty of Dentistry, Alexandria University, Champollion Street, Azarita, Alexandria, Egypt.
- Tissue Engineering Laboratories, Faculty of Dentistry, Alexandria University, Alexandria, Egypt.
| | - Amr Abdallah
- Endodontics, Conservative Dentistry Department, Faculty of Dentistry, Alexandria University, Champollion Street, Azarita, Alexandria, Egypt
| | - Samir Nouh
- Tissue Engineering Laboratories, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
- Surgery Department, Faculty of Veterinary Medicine, Alexandria University, Alexandria, Egypt
| | - Nesma Mohamed Khalil
- Oral Biology Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Rania Elbackly
- Endodontics, Conservative Dentistry Department, Faculty of Dentistry, Alexandria University, Champollion Street, Azarita, Alexandria, Egypt
- Tissue Engineering Laboratories, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
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Hazrati P, Mirtaleb MH, Boroojeni HSH, Koma AAY, Nokhbatolfoghahaei H. Current Trends, Advances, and Challenges of Tissue Engineering-Based Approaches of Tooth Regeneration: A Review of the Literature. Curr Stem Cell Res Ther 2024; 19:473-496. [PMID: 35984017 DOI: 10.2174/1574888x17666220818103228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/17/2022] [Accepted: 06/01/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Tooth loss is a significant health issue. Currently, this situation is often treated with the use of synthetic materials such as implants and prostheses. However, these treatment modalities do not fully meet patients' biological and mechanical needs and have limited longevity. Regenerative medicine focuses on the restoration of patients' natural tissues via tissue engineering techniques instead of rehabilitating with artificial appliances. Therefore, a tissue-engineered tooth regeneration strategy seems like a promising option to treat tooth loss. OBJECTIVE This review aims to demonstrate recent advances in tooth regeneration strategies and discoveries about underlying mechanisms and pathways of tooth formation. RESULTS AND DISCUSSION Whole tooth regeneration, tooth root formation, and dentin-pulp organoid generation have been achieved by using different seed cells and various materials for scaffold production. Bioactive agents are critical elements for the induction of cells into odontoblast or ameloblast lineage. Some substantial pathways enrolled in tooth development have been figured out, helping researchers design their experiments more effectively and aligned with the natural process of tooth formation. CONCLUSION According to current knowledge, tooth regeneration is possible in case of proper selection of stem cells, appropriate design and manufacturing of a biocompatible scaffold, and meticulous application of bioactive agents for odontogenic induction. Understanding innate odontogenesis pathways play a crucial role in accurately planning regenerative therapeutic interventions in order to reproduce teeth.
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Affiliation(s)
- Parham Hazrati
- School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Helia Sadat Haeri Boroojeni
- Oral and Maxillofacial Surgery Department, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Hanieh Nokhbatolfoghahaei
- Dental Research Center, Research Institute of Dental Sciences, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Liang C, Liao L, Tian W. Advances Focusing on the Application of Decellularized Extracellular Matrix in Periodontal Regeneration. Biomolecules 2023; 13:673. [PMID: 37189420 PMCID: PMC10136219 DOI: 10.3390/biom13040673] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/01/2023] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
The decellularized extracellular matrix (dECM) is capable of promoting stem cell proliferation, migration, adhesion, and differentiation. It is a promising biomaterial for application and clinical translation in the field of periodontal tissue engineering as it most effectively preserves the complex array of ECM components as they are in native tissue, providing ideal cues for regeneration and repair of damaged periodontal tissue. dECMs of different origins have different advantages and characteristics in promoting the regeneration of periodontal tissue. dECM can be used directly or dissolved in liquid for better flowability. Multiple ways were developed to improve the mechanical strength of dECM, such as functionalized scaffolds with cells that harvest scaffold-supported dECM through decellularization or crosslinked soluble dECM that can form injectable hydrogels for periodontal tissue repair. dECM has found recent success in many periodontal regeneration and repair therapies. This review focuses on the repairing effect of dECM in periodontal tissue engineering, with variations in cell/tissue sources, and specifically discusses the future trend of periodontal regeneration and the future role of soluble dECM in entire periodontal tissue regeneration.
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Affiliation(s)
| | - Li Liao
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Engineering Research Center of Oral Translational Medicine, Ministry of Education and National Engineering Laboratory for Oral Regenerative Medicine, West China Hospital of Stomatology, Sichuan University, Sichuan 610041, China
| | - Weidong Tian
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Engineering Research Center of Oral Translational Medicine, Ministry of Education and National Engineering Laboratory for Oral Regenerative Medicine, West China Hospital of Stomatology, Sichuan University, Sichuan 610041, China
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Abuarqoub D, Theeb LS, Omari MB, Hamadneh YI, Alrawabdeh JA, Aslam N, Jafar H, Awidi A. The Osteogenic Role of Biomaterials Combined with Human-Derived Dental Stem Cells in Bone Tissue Regeneration. Tissue Eng Regen Med 2023; 20:251-270. [PMID: 36808303 PMCID: PMC10070593 DOI: 10.1007/s13770-022-00514-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 02/23/2023] Open
Abstract
The use of stem cells in regenerative medicine had great potential for clinical applications. However, cell delivery strategies have critical importance in stimulating the differentiation of stem cells and enhancing their potential to regenerate damaged tissues. Different strategies have been used to investigate the osteogenic potential of dental stem cells in conjunction with biomaterials through in vitro and in vivo studies. Osteogenesis has a broad implication in regenerative medicine, particularly for maxillofacial defects. This review summarizes some of the most recent developments in the field of tissue engineering using dental stem cells.
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Affiliation(s)
- Duaa Abuarqoub
- Department of Pharmacology and Biomedical Sciences, Faculty of Pharmacy and Medical Sciences, University of Petra, Amman, Jordan.
- Cell Therapy Center, The University of Jordan, Amman, Jordan.
| | - Laith S Theeb
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Mohammad B Omari
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Yazan I Hamadneh
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | | | - Nazneen Aslam
- Cell Therapy Center, The University of Jordan, Amman, Jordan
| | - Hanan Jafar
- Cell Therapy Center, The University of Jordan, Amman, Jordan
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Abdalla Awidi
- Cell Therapy Center, The University of Jordan, Amman, Jordan.
- School of Medicine, The University of Jordan, Amman, 11942, Jordan.
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Sugiaman VK, Jeffrey, Naliani S, Pranata N, Djuanda R, Saputri RI. Polymeric Scaffolds Used in Dental Pulp Regeneration by Tissue Engineering Approach. Polymers (Basel) 2023; 15:1082. [PMID: 36904323 PMCID: PMC10007583 DOI: 10.3390/polym15051082] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/24/2023] Open
Abstract
Currently, the challenge in dentistry is to revitalize dental pulp by utilizing tissue engineering technology; thus, a biomaterial is needed to facilitate the process. One of the three essential elements in tissue engineering technology is a scaffold. A scaffold acts as a three-dimensional (3D) framework that provides structural and biological support and creates a good environment for cell activation, communication between cells, and inducing cell organization. Therefore, the selection of a scaffold represents a challenge in regenerative endodontics. A scaffold must be safe, biodegradable, and biocompatible, with low immunogenicity, and must be able to support cell growth. Moreover, it must be supported by adequate scaffold characteristics, which include the level of porosity, pore size, and interconnectivity; these factors ultimately play an essential role in cell behavior and tissue formation. The use of natural or synthetic polymer scaffolds with excellent mechanical properties, such as small pore size and a high surface-to-volume ratio, as a matrix in dental tissue engineering has recently received a lot of attention because it shows great potential with good biological characteristics for cell regeneration. This review describes the latest developments regarding the usage of natural or synthetic scaffold polymers that have the ideal biomaterial properties to facilitate tissue regeneration when combined with stem cells and growth factors in revitalizing dental pulp tissue. The utilization of polymer scaffolds in tissue engineering can help the pulp tissue regeneration process.
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Affiliation(s)
- Vinna K. Sugiaman
- Department of Oral Biology, Faculty of Dentistry, Maranatha Christian University, Bandung 40164, West Java, Indonesia
| | - Jeffrey
- Department of Pediatric Dentistry, Faculty of Dentistry, Jenderal Achmad Yani University, Cimahi 40531, West Java, Indonesia
| | - Silvia Naliani
- Department of Prosthodontics, Faculty of Dentistry, Maranatha Christian University, Bandung 40164, West Java, Indonesia
| | - Natallia Pranata
- Department of Oral Biology, Faculty of Dentistry, Maranatha Christian University, Bandung 40164, West Java, Indonesia
| | - Rudy Djuanda
- Department of Conservative Dentistry and Endodontic, Faculty of Dentistry, Maranatha Christian University, Bandung 40164, West Java, Indonesia
| | - Rosalina Intan Saputri
- College of Medicine, Veterinary, and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK
- Faculty of Dentistry, Maranatha Christian University, Bandung 40164, West Java, Indonesia
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Hu N, Li W, Jiang W, Wen J, Gu S. Creating a Microenvironment to Give Wings to Dental Pulp Regeneration-Bioactive Scaffolds. Pharmaceutics 2023; 15:158. [PMID: 36678787 PMCID: PMC9861529 DOI: 10.3390/pharmaceutics15010158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023] Open
Abstract
Dental pulp and periapical diseases make patients suffer from acute pain and economic loss. Although root canal therapies, as demonstrated through evidence-based medicine, can relieve symptoms and are commonly employed by dentists, it is still difficult to fully restore a dental pulp's nutrition, sensory, and immune-regulation functions. In recent years, researchers have made significant progress in tissue engineering to regenerate dental pulp in a desired microenvironment. With breakthroughs in regenerative medicine and material science, bioactive scaffolds play a pivotal role in creating a suitable microenvironment for cell survival, proliferation, and differentiation, following dental restoration and regeneration. This article focuses on current challenges and novel perspectives about bioactive scaffolds in creating a microenvironment to promote dental pulp regeneration. We hope our readers will gain a deeper understanding and new inspiration of dental pulp regeneration through our summary.
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Affiliation(s)
- Nan Hu
- Department of Endodontics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai 200011, China
| | - Weiping Li
- National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai 200011, China
- Department of Oral and Maxillofacial Head & Neck Oncology, Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
| | - Wentao Jiang
- Department of Endodontics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai 200011, China
| | - Jin Wen
- National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai 200011, China
- Department of Prosthodontics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai 200125, China
| | - Shensheng Gu
- Department of Endodontics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai 200011, China
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Adanir N, Khurshid Z, Ratnayake J. The Regenerative Potential of Decellularized Dental Pulp Extracellular Matrix: A Systematic Review. MATERIALS (BASEL, SWITZERLAND) 2022; 15:6386. [PMID: 36143698 PMCID: PMC9505725 DOI: 10.3390/ma15186386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The regeneration of dental pulp remains a challenge. Although several treatment modalities have been proposed to promote pulpal regeneration, these treatments have several drawbacks. More recently, decellularized dental pulp extracellular matrix (DP-ECM) has been proposed to regenerate dental pulp. However, to date, no systematic review has summarized the overall outcome and assessed the available literature focusing on the endodontic use of DP-ECM. The aim of this systematic review is to critically appraise the literature, summarize the overall outcomes, and provide clinical recommendations about DP-ECM. METHODOLOGY Following the Participants Intervention Control and Outcomes (PICO) principle, a focused question was constructed before conducting a search of the literature and of electronic research databases and registers. The focused question was: 'Compared to controls, does decellularized dental pulp extracellular matrix (DP-ECM) stimulate the regeneration of dental pulp cells and tissue?' Quality assessment of the studies was carried out using Guidelines for Reporting Pre-Clinical in Vitro Studies on Dental Materials and ARRIVE guidelines. RESULTS 12 studies were included in this review. Data from five in vitro experiments and eight in vivo experiments were extracted and the quality of the experiments was assessed. In majority of the studies, DP-ECM appeared to have stimulated pulpal regeneration. However, several sources of bias and methodological deficiencies were found during the quality assessment. CONCLUSION Within the limitations of this review and the included studies, it may be concluded that there is insufficient evidence to deduce the overall efficacy of DP-ECM for pulpal regeneration. More research, clinical and pre-clinical, is required for more conclusive evidence.
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Affiliation(s)
- Necdet Adanir
- Department of Restorative Dentistry, College of Dentistry, King Faisal University, Al-Ahsa 31982, Saudi Arabia
| | - Zohaib Khurshid
- Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, Al-Ahsa 31982, Saudi Arabia
| | - Jithendra Ratnayake
- Faculty of Dentistry, Sir John Walsh Research Institute, University of Otago, P.O. Box 56, Dunedin 9054, New Zealand
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