Influence of extracellular matrix scaffolds on histological outcomes of regenerative endodontics in experimental animal models: a systematic review

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).

Applications of graphene oxide and reduced graphene oxide in advanced dental materials and therapies

The graphene family of nanomaterials acquired significant attention in the field of dentistry due to a range of interesting properties. Graphene oxide (GO) and reduced graphene oxide (rGO) are the major graphene derivatives that are widely used in dental applications. These derivatives exhibit excellent mechanical properties, superior biocompatibility, good antibacterial properties, extreme chemical stability, and favorable tribological characteristics, thus representing highly materials for dentistry. The amphiphilic nature of GO allows covalent and noncovalent modifications that are favorable for biomedical applications. Graphene can influence the differentiation of dental pulp stem cells (DPSCs) and enhance the properties of other biomaterials. Here, we review the dental applications of GO or rGO with regards to antimicrobial activity, therapeutic drug delivery, restorative dentistry, implants, pulp regeneration, bone regeneration, periodontal tissue regeneration, biosensors, and tooth whitening.

Does the use of different scaffolds have an impact on the therapeutic efficacy of regenerative endodontic procedures? A systematic evaluation and meta-analysis

BACKGROUND

In the regenerative endodontic procedures, scaffolds could influence the prognosis of affected teeth. Currently, there is controversy regarding the postoperative evaluation of various scaffolds for pulp regeneration. The objective of this study was to access whether other scaffolds, used alone or in combination with blood clot (BC), are more effective than BC in regenerative endodontic procedures.

METHODS

We systematically search the PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Google Scholar databases. Randomized controlled trials examining the use of BC and other scaffold materials in the regenerative endodontic procedures were included. A random effects model was used for the meta-analysis. The GRADE method was used to determine the quality of the evidence.

RESULTS

We screened 168 RCTs related to young permanent tooth pulp necrosis through electronic and manual retrieval. A total of 28 RCTs were related to regenerative endodontic procedures. Ultimately, 12 articles met the inclusion criteria and were included in the relevant meta-analysis. Only 2 studies were assessed to have a low risk of bias. High quality evidence indicated that there was no statistically significant difference in the success rate between the two groups (RR=0.99, 95% CI=0.96 to 1.03; 434 participants, 12 studies); low-quality evidence indicated that there was no statistically significant difference in the increase in root length or root canal wall thickness between the two groups. Medium quality evidence indicated that there was no statistically significant difference in pulp vitality testing between the two groups.

CONCLUSIONS

For clinical regenerative endodontic procedures, the most commonly used scaffolds include BC, PRP, and PRF. All the different scaffolds had fairly high clinical success rates, and the difference was not significant. For regenerative endodontic procedures involving young permanent teeth with pulp necrosis, clinical practitioners could choose a reasonable scaffold considering the conditions of the equipment and patients.

Inhibition of soluble epoxide hydrolase enhances the dentin-pulp complex regeneration mediated by crosstalk between vascular endothelial cells and dental pulp stem cells

BACKGROUND

Revascularization and restoration of normal pulp-dentin complex are important for tissue-engineered pulp regeneration. Recently, a unique periodontal tip-like endothelial cells subtype (POTCs) specialized to dentinogenesis was identified. We have confirmed that TPPU, a soluble epoxide hydrolase (sEH) inhibitor targeting epoxyeicosatrienoic acids (EETs) metabolism, promotes bone growth and regeneration by angiogenesis and osteogenesis coupling. We hypothesized that TPPU could also promote revascularization and induce POTCs to contribute to pulp-dentin complex regeneration. Here, we in vitro and in vivo characterized the potential effect of TPPU on the coupling of angiogenesis and odontogenesis and investigated the relevant mechanism, providing new ideas for pulp-dentin regeneration by targeting sEH.

METHODS

In vitro effects of TPPU on the proliferation, migration, and angiogenesis of dental pulp stem cells (DPSCs), human umbilical vein endothelial cells (HUVECs) and cocultured DPSCs and HUVECs were detected using cell counting kit 8 (CCK8) assay, wound healing, transwell, tube formation and RT-qPCR. In vivo, Matrigel plug assay was performed to outline the roles of TPPU in revascularization and survival of grafts. Then we characterized the VEGFR2 + POTCs around odontoblast layer in the molar of pups from C57BL/6 female mice gavaged with TPPU. Finally, the root segments with DPSCs mixed with Matrigel were implanted subcutaneously in BALB/c nude mice treated with TPPU and the root grafts were isolated for histological staining.

RESULTS

In vitro, TPPU significantly promoted the migration and tube formation capability of cocultured DPSCs and HUVECs. ALP and ARS staining and RT-qPCR showed that TPPU promoted the osteogenic and odontogenic differentiation of cultured cells, treatment with an anti-TGF-β blocking antibody abrogated this effect. Knockdown of HIF-1α in HUVECs significantly reversed the effect of TPPU on the expression of angiogenesis, osteogenesis and odontogenesis-related genes in cocultured cells. Matrigel plug assay showed that TPPU increased VEGF/VEGFR2-expressed cells in transplanted grafts. TPPU contributed to angiogenic-odontogenic coupling featured by increased VEGFR2 + POTCs and odontoblast maturation during early dentinogenesis in molar of newborn pups from C57BL/6 female mice gavaged with TPPU. TPPU induced more dental pulp-like tissue with more vessels and collagen fibers in transplanted root segment.

CONCLUSIONS

TPPU promotes revascularization of dental pulp regeneration by enhancing migration and angiogenesis of HUVECs, and improves odontogenic differentiation of DPSCs by TGF-β. TPPU boosts the angiogenic-odontogenic coupling by enhancing VEGFR2 + POTCs meditated odontoblast maturation partly via upregulating HIF-1α, which contributes to increasing pulp-dentin complex for tissue-engineered pulp regeneration.

Crucial Factors Influencing the Involvement of Odontogenic Exosomes in Dental Pulp Regeneration

Recent progress in exosome based studies has revealed that they possess several advantages over cells, including "cell-free" properties, low immunogenicity and ethical controversy, high biological safety and effective action. These characteristics confer exosomes significant advantages that allow them to overcome the limitations associated with traditional "cell therapy" by circumventing the issues of immune rejection, scarcity of donor cells, heterogeneity, and ethical concerns. Identification of a complete and effective radical treatment for irreversible pulpal disease, a common clinical problem, continues to pose challenges. Although traditional root canal therapy remains the primary clinical treatment, it does not fully restore the physiological functions of pulp. Although stem cell transplantation appears to be a relatively viable treatment strategy for pulp disease, issues such as cell heterogeneity and poor regeneration effects remain problematic. Dental pulp regeneration strategies based on "cell-free" exosome therapies explored by numerous studies appear to have shown significant advantages. In particular, exosomes derived from odontogenic stem cells have demonstrated considerable potential in tooth tissue regeneration engineering, and continue to exhibit superior therapeutic effects compared to non-odontogenic stem cell-derived exosomes. However, only a few studies have comprehensively summarised their research results, particularly regarding the critical factors involved in the process. Therefore, in this study, our purpose was to review the effects exerted by odontogenic exosomes on pulp regeneration and to analyse and discus crucial factors related to this process, thereby providing scholars with a feasible and manageable new concept with respect to regeneration schemes.

Fabrication and characterization of a novel injectable human amniotic membrane hydrogel for dentin-pulp complex regeneration

OBJECTIVE

Injectable biomaterials that can completely fill the root canals and provide an appropriate environment will have potential application for pulp regeneration in endodontics. This study aimed to fabricate and characterize a novel injectable human amniotic membrane (HAM) hydrogel scaffold crosslinked with genipin, enabling the proliferation of Dental Pulp Stem Cells (DPSCs) and optimizing pulp regeneration.

METHODS

HAM extracellular matrix (ECM) hydrogels (15, 22.5, and 30 mg/ml) crosslinked with different genipin concentrations (0, 0.1, 0.5, 1, 5, and 10 mM) were evaluated for mechanical properties, tooth discoloration, cell viability, and proliferation of DPSCs. The hydrogels were subcutaneously injected in rats to assess their immunogenicity. The hydrogels were applied in a root canal model and subcutaneously implanted in rats to determine their regenerative potential for eight weeks, and histological and immunostaining analyses were performed.

RESULTS

Hydrogels crosslinked with low genipin concentration demonstrated low tooth discoloration, but 0.1 mM genipin crosslinked hydrogels were excluded due to their unfavourable mechanical properties. The degradation ratio was lower in hydrogels crosslinked with 0.5 mM genipin. The 30 mg/ml-0.5 mM crosslinked hydrogel exhibited a microporous structure, and the modulus of elasticity was 1200 PA. In vitro, cell culture showed maximum viability and proliferation in 30 mg/ml-0.5 mM crosslinked hydrogel. All groups elicited minimum immunological responses, and highly vascularized pulp-like tissue was formed in human tooth roots in both groups with/without DPSCs.

SIGNIFICANCE

Genipin crosslinking improved the biodegradability of injectable HAM hydrogels and conferred higher biocompatibility. Hydrogels encapsulated with DPSCs can support stem cell viability and proliferation. In addition, highly vascularized pulp-like tissue formation by this biomaterial displayed potential for pulp regeneration.

Dentin extracellular matrix loaded bioactive glass/GelMA support rapid bone mineralization for potential pulp regeneration

The study aims to develop a novel dentin extracellular matrix (dECM) loaded gelatin methacrylate (GelMA)-5 wt% bioactive glass (BG) (Gel-BG) hydrogel for dental pulp regeneration. We investigate the role of dECM content (2.5, 5, and 10 wt%) on the physicochemical characteristics and biological responses of Gel-BG hydrogel in contact with stem cells isolated from human exfoliated deciduous teeth (SHED). Results showed that the compressive strength of Gel-BG/dECM hydrogel significantly enhanced from 18.9 ± 0.5 kPa (at Gel-BG) to 79.8 ± 3.0 kPa after incorporation of 10 wt% dECM. Moreover, we found that in vitro bioactivity of Gel-BG improved and the degradation rate and swelling ratio reduced with increasing dECM content. The hybrid hydrogels also revealed effectual biocompatibility, >138 % cell viability after 7 days of culture; where Gel-BG/5%dECM was most suitable. In addition, the incorporation of 5 wt% dECM within Gel-BG considerably improved alkaline phosphatase (ALP) activity and osteogenic differentiation of SHED cells. Taken together, the novel bioengineered Gel-BG/dECM hydrogels having appropriate bioactivity, degradation rate, osteoconductive and mechanical properties represent the potential applications for clinical practice in the future.

Biological characteristics and pulp regeneration potential of stem cells from canine deciduous teeth compared with those of permanent teeth

BACKGROUND

Clinical studies have demonstrated that dental pulp stem cells isolated from permanent teeth (PT-DPSCs) are safe and efficacious for complete pulp regeneration in mature pulpectomized permanent teeth with complete apical closure. Moreover, dental pulp stem cells from deciduous teeth (DT-DPSCs) have also been shown to be useful for pulp regenerative cell therapy of injured immature permanent teeth. However, direct comparisons of the pulp regenerative potential of DT-DPSCs and PT-DPSCs from the same individual have not been performed. This study aimed to compare the differences in stem cell properties and pulp regenerative potential of DT-DPSCs and PT-DPSCs of identical origin.

METHODS

DT-DPSCs and PT-DPSCs were isolated from the same individual dogs at 4 months and 9 months of age, respectively. The expression of cell surface antigen markers, proliferation and migration activities, and gene expression of stem cell markers, angiogenic/neurotrophic factors and senescence markers were compared. The effects of conditioned medium (CM) derived from these cells on cellular proliferation, migration, angiogenesis, neurite outgrowth and immunosuppression were also compared. Autologous transplantation of DT-DPSCs or PT-DPSCs together with G-CSF was performed to treat pulpectomized teeth in individual dogs. The vascularization and reinnervation of the regenerated pulp tissues were qualitatively and quantitatively compared between groups by histomorphometric analyses.

RESULTS

The rates of positive CXCR4 and G-CSFR expression in DT-DPSCs were significantly higher than those in PT-DPSCs. DT-DPSCs migrated at a higher rate with/without G-CSF and exhibited increased expression of the stem cell markers Oct3/4 and CXCR4 and the angiogenic factor VEGF and decreased expression of the senescence marker p16 than PT-DPSCs. DT-DPSC-derived CM promoted increased cell proliferation, migration with G-CSF, and angiogenesis compared with PT-DPSC-derived CM; however, no difference was observed in neurite outgrowth or immunosuppression. The regenerated pulp tissues in the pulpectomized teeth were quantitatively and qualitatively similar between the DT-DPSCs and PT-DPSCs transplant groups.

CONCLUSIONS

These results demonstrated that DT-DPSCs could be a potential clinical alternative to PT-DPSCs for pulp regenerative therapy. DT-DPSCs can be preserved in an individual cell bank and used for potential future pulp regenerative therapy before the supply of an individual's own sound discarded teeth has been exhausted.

Photocross-linked silk fibroin/hyaluronic acid hydrogel loaded with hDPSC for pulp regeneration

The construction of suitable biomaterials for pulp regeneration has always been a major challenge in the field of stomatology. Considering the complex and irregular anatomy of the root canal system, injectable hydrogels have received extensive attention as cell carriers in dental pulp regeneration. Here, we developed an injectable photocrosslinked methacrylylated silk fibroin (RSFMA)/methacrylylated hyaluronic acid (MeHA) composite hydrogel and characterized its physicochemical properties. The biocompatibility of encapsulated human dental pulp stem cells (hDPSCs) was subsequently investigated. With the addition of RSFMA, the pore size of the scaffolds became more regular with negligible change in porosity and exhibited excellent mechanical properties. Furthermore, the low concentration of RSFMA hydrogel in the composite hydrogel had higher cross-linking efficiency. In contrast to MeHA hydrogels, hDPSCs were encapsulated in hydrogels either in the absence or presence of high concentrations of RSFMA. The results indicated that cells in low-concentration RSFMA composite gel presented better growth ability, proliferation ability and osteogenic differentiation ability. This injectable photocrosslinked silk fibroin/hyaluronic acid hydrogel shows great potential in the field of dental pulp tissue engineering.

Outcomes of root canal therapy or full pulpotomy using two endodontic biomaterials in mature permanent teeth: a randomized controlled trial

OBJECTIVE

The concept of minimally invasive endodontics recommends less-invasive vital pulp therapy (VPT) modalities over more aggressive traditional endodontic approaches in mature permanent teeth with carious pulp exposure, including irreversible pulpitis (IP) cases. Consequently, VPT needs to be compared with root canal therapy (RCT) in terms of treatment outcomes. This randomized clinical trial compares the results of full pulpotomy using two calcium-silicate cements, i.e., mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement, with RCT in mature permanent teeth.

MATERIALS AND METHODS

A total of 157 carious pulp exposure cases in two academic centers with/without established IP were selected/included/randomly appointed to three study arms; (i) RCT (n = 51) as the reference treatment, (ii) pulpotomy with ProRoot MTA (PMTA; n = 55), and (iii) pulpotomy with CEM cement (PCEM; n = 51) as two alternative VPT treatments. Two-year clinical/radiographic results were the outcomes of interest. Data were statistically analyzed through the analysis of variance, chi-square, Fisher exact test, and Kruskal-Wallis.

RESULTS

At 2-year recall, 147 teeth were examined (6.4% dropout). All molars, except for one, were clinically functional/symptom-free, and there was no statistical difference between the three study arms (p = 0.653). The radiographic success rates in RCT, PMTA, and PCEM arms were 98%, 100%, and 97.9%, respectively, without statistically significant differences (p = 0.544).

CONCLUSION

In the management of mature permanent teeth with/without established IP, all experimental groups exhibited equivalent/comparable results.

CLINICAL RELEVANCE

Simple VPT using MTA/CEM can be suggested/recommended as a viable advantageous alternative to RCT for the management of carious pulp exposures with/without sign/symptoms of IP.

Efficacy of i-PRF in regenerative endodontics therapy for mature permanent teeth with pulp necrosis: study protocol for a multicentre randomised controlled trial

BACKGROUND

Dental pulp necrosis, a common health problem, is traditionally treated with root canal therapy; however, it fails in restoring the vitality of damaged pulp. Most studies regarding regenerative endodontic therapy (RET) are limited to the treatment of immature necrotic teeth. Given that injectable platelet-rich fibrin (i-PRF) has shown great potential in regenerative medicine as a novel platelet concentration, this study is designed to explore whether i-PRF can serve as a biological scaffold, extending the indications for RET and improving the clinical feasibility of RET in mature permanent teeth with pulp necrosis.

METHODS

This is a randomised, double-blind, controlled, multicentre clinical trial designed to evaluate the clinical feasibility of RET for mature permanent teeth with pulp necrosis and to compare the efficacy of i-PRF and blood clots as scaffolds in RET. A total of 346 patients will be recruited from three centres and randomised at an allocation ratio of 1:1 to receive RET with either a blood clot or i-PRF. The changes in subjective symptoms, clinical examinations, and imaging examinations will be tracked longitudinally for a period of 24 months. The primary outcome is the success rate of RET after 24 months. The secondary outcome is the change in pulp vitality measured via thermal and electric pulp tests. In addition, the incidence of adverse events such as discolouration, reinfection, and root resorption will be recorded for a safety evaluation.

DISCUSSION

This study will evaluate the clinical feasibility of RET in mature permanent teeth with pulp necrosis, providing information regarding the efficacy, benefits, and safety of RET with i-PRF. These results may contribute to changes in the treatment of pulp necrosis in mature permanent teeth and reveal the potential of i-PRF as a novel biological scaffold for RET.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04313010 . Registered on 19 March 2020.

Characterization of stable hypoxia-preconditioned dental pulp stem cells compared with mobilized dental pulp stem cells for application for pulp regenerative therapy

Background

Dental pulp stem cells (DPSCs) have been developed as a potential source of mesenchymal stem cells (MSCs) for regeneration of dental pulp and other tissues. However, further strategies to isolate highly functional DPSCs beyond the colony-forming methods are required. We have demonstrated the safety and efficacy of DPSCs isolated by G-CSF-induced mobilization and cultured under normoxia (mobilized DPSCs, MDPSCs) for pulp regeneration. The device for isolation of MDPSCs, however, is not cost-effective and requires a prolonged cell culture period. It is well known that MSCs cultured under hypoxic-preconditions improved MSC proliferation activity and stemness. Therefore, in this investigation, we attempted to improve the clinical utility of DPSCs by hypoxia-preconditioned DPSCs (hpDPSCs) compared with MDPSCs to improve the potential clinical utility for pulp regeneration in endodontic dentistry.

Methods

Colony-forming DPSCs were isolated and preconditioned with hypoxia in a stable closed cultured system and compared with MDPSCs isolated from the individual dog teeth. We examined the proliferation rate, migration potential, anti-apoptotic activity, and gene expression of the stem cell markers and angiogenic/neurotrophic factors. Trophic effects of the conditioned medium (CM) were also evaluated. In addition, the expression of immunomodulatory molecules upon stimulation with IFN-γ was investigated. The pulp regenerative potential and transplantation safety of hpDPSCs were further assessed in pulpectomized teeth in dogs by histological and immunohistochemical analyses and by chemistry of the blood and urine tests.

Results

hpDPSCs demonstrated higher proliferation rate and expression of a major regulator of oxygen homeostasis, HIF-1α, and a stem cell marker, CXCR-4. The direct migratory activity of hpDPSCs in response to G-CSF was significantly higher than MDPSCs. The CM of hpDPSCs stimulated neurite extension. However, there were no changes in angiogenic, migration, and anti-apoptotic activities compared with the CM of MDPSCs. The expression of immunomodulatory gene, PTGE was significantly upregulated by IFN gamma in hpDPSCs compared with MDPSCs. However, no difference in nitric oxide was observed. The regenerated pulp tissue was quantitatively and qualitatively similar in hpDPSC transplants compared with MDPSC transplants in dog teeth. There was no evidence of toxicity or adverse events of the hpDPSC transplantation.

Conclusions

These results demonstrated that the efficacy of hpDPSCs for pulp regeneration was identical, although hpDPSCs improved stem cell properties compared to MDPSCs, suggesting their potential clinical utility for pulp regeneration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02240-w.

Resolvin E1 accelerates pulp repair by regulating inflammation and stimulating dentin regeneration in dental pulp stem cells

Background

Unresolved inflammation and tissue destruction are considered to underlie the failure of dental pulp repair. As key mediators of the injury response, dental pulp stem cells (DPSCs) play a critical role in pulp tissue repair and regeneration. Resolvin E1 (RvE1), a major dietary omega-3 polyunsaturated fatty-acid metabolite, is effective in resolving inflammation and activating wound healing. However, whether RvE1 facilitates injured pulp-tissue repair and regeneration through timely resolution of inflammation and rapid mobilization of DPSCs is unknown. Therefore, we established a pulp injury model and investigated the effects of RvE1 on DPSC-mediated inflammation resolution and injured pulp repair.

Methods

A pulp injury model was established using 8-week-old Sprague-Dawley rats. Animals were sacrificed on days 1, 3, 7, 14, 21, and 28 after pulp capping with a collagen sponge immersed in PBS with RvE1 or PBS. Hematoxylin-eosin and Masson’s trichrome staining, immunohistochemistry, and immunohistofluorescence were used to evaluate the prohealing properties of RvE1. hDPSCs were incubated with lipopolysaccharide (LPS) to induce an inflammatory response, and the expression of inflammatory factors after RvE1 application was measured. Effects of RvE1 on hDPSC proliferation, chemotaxis, and odontogenic differentiation were evaluated by CCK-8 assay, transwell assay, alkaline phosphatase (ALP) staining, alizarin red staining, and quantitative PCR, and possible signaling pathways were explored using western blotting.

Results

In vivo, RvE1 reduced the necrosis rate of damaged pulp and preserved more vital pulps, and promoted injured pulp repair and reparative dentin formation. Further, it enhanced dentin matrix protein 1 and dentin sialoprotein expression and accelerated pulp inflammation resolution by suppressing TNF-α and IL-1β expression. RvE1 enhanced the recruitment of CD146⁺ and CD105⁺ DPSCs to the damaged molar pulp mesenchyme. Isolated primary cells exhibited the mesenchymal stem cell immunophenotype and differentiation. RvE1 promoted hDPSC proliferation and chemotaxis. RvE1 significantly attenuated pro-inflammatory cytokine (TNF-α, IL-1β, and IL-6) release and enhanced ALP activity, nodule mineralization, and especially, expression of the odontogenesis-related genes DMP1, DSPP, and BSP in LPS-stimulated DPSCs. RvE1 regulated AKT, ERK, and rS6 phosphorylation in LPS-stimulated DPSCs.

Conclusions

RvE1 promotes pulp inflammation resolution and dentin regeneration and positively influences the proliferation, chemotaxis, and differentiation of LPS-stimulated hDPSCs. This response is, at least partially, dependent on AKT, ERK, and rS6-associated signaling in the inflammatory microenvironment. RvE1 has promising application potential in regenerative endodontics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02141-y.

What is the best long-term treatment modality for immature permanent teeth with pulp necrosis and apical periodontitis?

PURPOSE

To evaluate and assess the current knowledge about apexification and regenerative techniques as a meaningful treatment modality and to map the scientific evidence for the efficacy of both methods for the management of traumatised immature teeth with pulp necrosis and apical periodontitis.

METHODS

This systematic review searched five databases: PubMed, Web of Science, Cochrane Library, Ovid (Medline), and Embase. Published articles written in English were considered for inclusion. The following keywords were used: Regenerative endodontic treatment OR regenerat* OR revital* OR endodontic regeneration OR regenerative endodontics OR pulp revascularization OR revasculari* OR 'traumatized immature teeth'. Only peer-reviewed studies with a study size of at least 20 cases followed up for 24 months were included. Eligibility assessment was performed independently in a blinded manner by three reviewers and disagreements were resolved by consensus. Subgroup analyses were performed on three clinical outcomes: survival, success, and continued root development.

RESULTS

Seven full texts out of 1359 citations were included and conventional content analysis was performed. Most of the identified citations were case reports and case series.

CONCLUSIONS

In the present systematic review, the qualitative analysis revealed that both regenerative and apexification techniques had equal rates of success and survival and proved to be effective in the treatment of immature necrotic permanent teeth. Endodontic regenerative techniques appear to be superior to apexification techniques in terms of stimulation of root maturation, i.e. root wall thickening and root lengthening. Knowledge gaps were identified regarding the treatment and follow-up protocols for both techniques.

The combined application of rat bone marrow mesenchymal stem cells and bioceramic materials in the regeneration of dental pulp-like tissues

This study aims to observe the effects of the combined application of rat bone marrow mesenchymal stem cells (rBMSCs) and a bioceramic material on pulp-like tissue formation. Rat incisor root fragments without pulp tissues were prepared and filled with a collagen scaffold seeded with rBMSCs, while one side of the root segment was covered by a bioceramic material (iRoot BP). After they were cultured for 12 hours, the root fragments were implanted subcutaneously for 3 months. Hematoxylin and eosin (HE) staining was applied to observe the biocompatibility and the formation of pulp-like tissues. The incisor root fragments were divided into three parts (BP1/3, M1/3, and D1/3) to analyze the areas and the number of new vessels. Immunohistochemical staining of the neuroendocrine marker PGP9.5, the dentin sialophosphoprotein (DSPP), and the vascular endothelial growth factor (VEGF) was applied to observe the formation of the pulp-like tissues. Root fragments filled with only the collagen scaffold were used as a control. Three months after the implantation, the root fragments were collected, and they were surrounded by a transparent tissue membrane with a good blood supply. The root fragment cavity was filled with pink vascularized pulp-like tissue. According to the HE results, iRoot BP had good biocompatibility with the new pulp-like tissues and a few infiltrating inflammatory cells. Increases in the number and area of the new blood vessels were observed in BP1/3 compared with the other two parts. The PGP9.5 and DSPP expressions showed that the newly formed tissues were similar to normal pulp tissues. iRoot BP has good biocompatibility and increases the number and area of new blood vessels. The combined application of stem cells and bioceramic materials may be a better method for pulp revascularization.

Cotransplantation of human umbilical cord mesenchymal stem cells and endothelial cells for angiogenesis and pulp regeneration in vivo

AIMS

To explored the potential of human umbilical cord mesenchymal stem cells (hUCMSCs) as seed cells for dental pulp regeneration and the possibility of cotransplantation hUCMSCs and endothelial cells (ECs) for angiogenesis and pulp regeneration in vivo.

MATERIALS AND METHODS

hUCMSCs and human umbilical vein endothelial cells (HUVECs) were cocultured for matrigel angiogenesis assay in vitro and Matrigel plug assay in vivo. Next, we used the transwell coculture system to coculture hUCMSCs and HUVECs in vitro for RNA- sequencing (RNA-seq). Last, encapsulated hUCMSCs and HUVECs in scaffolds were injected into the root segments, and transplanted into immunodeficient mice for dental pulp regeneration.

KEY FINDINGS

In vitro Matrigel angiogenesis assay and in vivo Matrigel plug assay indicated that cocultured hUCMSCs and HUVECs promote vascular formation of HUVECs, especially in 1:5 (hUCMSCs:HUVECs) coculture group. The RNA-seq result indicated that cocultured HUVECs exhibited high Hif-1 signaling pathway activity. We performed the cell transfection assay to knock down HIF1A-AS2 in HUVECs and then coculture with hUCMSCs, and the expression of VEGFA, HIF1A and PECAM1 were reduced. In pulp regeneration assay, Cotransplantation of hUCMSCs and HUVECs (1,5) group showed pulp-like tissue regeneration.

SIGNIFICANCE

Cocultured hUCMSCs and HUVECs can promote vascular formation of HUVECs, and the optimal coculture ration is 1:5 (hUCMSCs:HUVECs). hUCMSCs promote angiogenesis of HUVECs through the long noncoding RNA HIF1A-AS2-activation of the Hif-1 signaling pathway. Cotransplantation of hUCMSCs and HUVECs can regenerate dental pulp-like tissue in vivo.

Dental pulp stem cells from human teeth with deep caries displayed an enhanced angiogenesis potential in vitro

Background/purpose

Dental pulp stem cells can be isolated from human teeth with deep caries (cDPSCs), but their biological characteristics are still unclear. The aim of this study was to investigate the angiogenic potential of cDPSCs and compare them to dental pulp stem cells from human normal teeth (nDPSCs).

Materials and methods

Cells were isolated from human pulp tissue of normal and infected teeth with deep caries. Basic mesenchymal stem cell (MSC) characterization was conducted. Colony forming units and proliferation ability were evaluated in nDPSCs and cDPSCs. Expression of VEGF in both tissues and cells was examined by immunohistochemical staining. After stimulating nDPSCs and cDPSCs with an angiogenic medium, angiogenic markers were evaluated by qRT-PCR and western blotting. Finally, tube formation assays were used to evaluate the in vitro angiogenesis potential of both cell populations.

Results

Both nDPSCs and cDPSCs possessed typical MSC characteristics. cDPSCs had enhanced colony formation and proliferation capacities than nDPSCs did. The expression of VEGF was higher in pulp tissue from teeth with deep caries and cDPSCs than in normal tissue and nDPSCs. When both cell types were grown in vitro under angiogenic conditions, cDPSCs expressed a higher level of angiogenic markers and showed a stronger angiogenesis potential than nDPSCs did.

Conclusion

cDPSCs maintained MSC traits and presented a higher angiogenesis potential than nDPSCs.

[Clinical management and prognosis evaluation of pulp regeneration therapy]

Pulp regeneration in a tooth with pulp necrosis is the research hotspot in current clinical treatment of endodontic diseases. Up to now, the revascularization therapy, which is one of the regenerative endodontic treatment, and the most extensive and effective method in clinical practice, can partially achieve the goal of pulp regeneration and root development in young permanent immature teeth. In order to standardize the technique and improve the curative effect, this atticle discusses the indications, pre-treatment preparation, treatment procedure and the rapeutic evaluation of pulp revascularization therapy.

Contraction dynamics of dental pulp cell rod microtissues

OBJECTIVES

The factors that contribute to the morphological changes of dental pulp cell-derived microtissues are unknown. Here, we investigated the contraction dynamics of rod-shaped microtissues derived from dental pulp cells and examined the underlying cell signaling pathways.

METHODS

Human dental pulp cells were seeded into agarose molds to assemble into rod-shaped microtissues. Resazurin- and tetrazolium-based cytotoxicity assays, Live/Dead staining, and hematoxylin and eosin staining for histological evaluation of rods were performed. Rod contraction was evaluated and measured for a period of 10 days. The role of TGF-β, phosphoinositide 3-kinase (PI3K)/AKT, and mitogen-activated protein kinase (MAPK) signaling pathway was analyzed.

RESULTS

Dental pulp cells readily assembled into rods, maintaining the geometric shape for 48 h. Following this period, they condensed to form stable spheroidal structures that remained vital for 10 days from seeding. Inhibition of phosphoinositide 3-kinase signaling pathway by LY294002 significantly prolonged the diminution in the length of rods formed by dental pulp cells. TGF-β and pharmacological inhibition of TGF-β signaling did not show pronounced effects.

CONCLUSION

Overall, dental pulp cells readily formed rod-shaped patterns of microtissues which, over a period of time, condensed into more stable spheroidal structures. Hence, technologies like bioprinting, using direct fabrication of microtissues need to consider the contraction dynamics.

CLINICAL RELEVANCE

The field of regenerative endodontology will benefit from our findings as it can be applied as a novel platform to test the impact of pharmacological agents, biomaterials, and regenerative approaches including bioprinting.

Dental pulp stem cells overexpressing stromal-derived factor-1α and vascular endothelial growth factor in dental pulp regeneration

OBJECTIVES

The current study aimed to investigate the effects of vascular endothelial growth factor (VEGF) and stromal cell-derived factor-1α (SDF-1α) overexpressing dental pulp stem cells (DPSCs) in vascularized dental pulp regeneration in vivo.

MATERIALS AND METHODS

Human DPSCs were transfected with VEGF or SDF-1α using premade lentiviral particles. Overexpression was verified by quantitative polymerase chain reaction (q-PCR), enzyme-linked immunosorbent assay (ELISA), and western blot analysis. Effects of SDF-1α and VEGF overexpressing DPSCs on their proliferation (CCK-8 and MTT assays) and endothelial vascular-tube formation (Matrigel assay) were investigated in vitro. Human tooth roots sectioned into 6-mm segments were injected with gene-modified DPSCs encapsulated in PuraMatrix hydrogel and implanted in the dorsum of severe-combined-immunodeficient (SCID) mice. Implants were retrieved after 4 weeks and examined for regenerated pulp-like tissue and vascularization using histology and immunohistochemistry. p < 0.05 was considered statistically significant.

RESULTS

Gene-modified DPSCs expressed significantly high levels (p < 0.05) of SDF-1α and VEGF mRNA and proteins, respectively. Transfected DPSCs showed a significantly higher cell proliferation compared to that of wild-type DPSCs. Furthermore, they enhanced endothelial cell migration and vascular-tube formation on Matrigel in vitro. When injected into tooth root canals and implanted in vivo, DPSCs/SDF-1α + DPSCs/VEGF-mixed group resulted in significantly increased length of regenerated pulp-like tissue within the root canals compared to that of wild-type DPSCs/VEGF and DPSCs/SDF-1α groups. Vessel area density was significantly higher in DPSCs/SDF-1α and mixed DPSCs/SDF-1α + DPSCs/VEGF groups than in DPSCs-VEGF alone or wild-type DPSCs groups.

CONCLUSION

A combination of VEGF-overexpressing and SDF-1α-overexpressing DPSCs could enhance the area of vascularized dental pulp regeneration in vivo.

CLINICAL RELEVANCE

Enhancing vascularization in pulp regeneration is crucial to overcome the clinical limitation of the limited blood supply to the root canals via a small apical foramen enclosed by hard dentin.

[Vascular endothelial growth factor-loaded microspheres promote dental pulp regeneration and vascularization]

Objective: To evaluate the effect of vascular endothelial growth factor (VEGF)-loaded microspheres on dental pulp tissue regeneration and vascularization in vivo. Methods:In vitro release experiment and human umbilical vein endothelial cell migration experiment were conducted with VEGF loaded microspheres. The dental pulp stem cells (DPSC) were co-cultured with VEGF microspheres to observe the compatibility between the cells and the microspheres. DPSC and VEGF loaded microspheres were injected into the root lumen through the apical foramen, which were then transplanted subcutaneously into nude mice. Histological and immunohistochemical features were observed after nine weeks. Results: DPSCs attached and spread on the surface of the microspheres. HE staining showed that the regenerated pulp-like tissue fulfilled the whole apex and middle third of the root. Differentiated odontoblast-like cells aligned with the existing tubular root dentin. Conclusions: VEGF-loaded microspheres promoted the regeneration of pulp-like tissues and formation of blood vessels.

Triple antibiotic paste: momentous roles and applications in endodontics: a review

This study investigated the latest findings and notions regarding ‘triple antibiotic paste’ (TAP) and its applications in dentistry, particularly endodontics. TAP is a combination of 3 antibiotics, ciprofloxacin, metronidazole, and minocycline. Despite the problems and pitfalls research pertaining to this paste has unveiled, it has been vastly used in endodontic treatments. The paste's applications vary, from vital pulp therapy to the recently introduced regeneration and revascularisation protocol. Studies have shown that the paste can eliminate the root canal microorganisms and prepare an appropriate matrix for further treatments. This combination is able to remove diverse groups of obligate and facultative gram-positive and gram-negative bacteria, providing an environment for healing. In regeneration protocol cases, this allows the development, disinfection, and possible sterilization of the root canal system, so that new tissue can infiltrate and grow into the radicular area. Moreover, TAP is capable of creating a discipline in which other wanted and needed treatments can be successfully performed. In conclusion, TAP, as an antibacterial intracanal medication, has diverse uses. Nevertheless, despite its positive effects, the paste has shown drawbacks. Further research concerning the combined paste and other intracanal medications to control microbiota is a must.

Allogeneic transplantation of mobilized dental pulp stem cells with the mismatched dog leukocyte antigen type is safe and efficacious for total pulp regeneration

Background

We recently demonstrated that autologous transplantation of mobilized dental pulp stem cells (MDPSCs) was a safe and efficacious potential therapy for total pulp regeneration in a clinical study. The autologous MDPSCs, however, have some limitations to overcome, such as limited availability of discarded teeth from older patients. In the present study, we investigated whether MDPSCs can be used for allogeneic applications to expand their therapeutic use.

Methods

Analysis of dog leukocyte antigen (DLA) was performed using polymerase chain reaction from blood. Canine allogeneic MDPSCs with the matched and mismatched DLA were transplanted with granulocyte-colony stimulating factor in collagen into pulpectomized teeth respectively (n = 7, each). Results were evaluated by hematoxylin and eosin staining, Masson trichrome staining, PGP9.5 immunostaining, and BS-1 lectin immunostaining performed 12 weeks after transplantation. The MDPSCs of the same DLA used in the first transplantation were further transplanted into another pulpectomized tooth and evaluated 12 weeks after transplantation.

Results

There was no evidence of toxicity or adverse events of the allogeneic transplantation of the MDPSCs with the mismatched DLA. No adverse event of dual transplantation of the MDPSCs with the matched and mismatched DLA was observed. Regenerated pulp tissues including neovascularization and neuronal extension were quantitatively and qualitatively similar at 12 weeks in both matched and mismatched DLA transplants. Regenerated pulp tissue was similarly observed in the dual transplantation as in the single transplantation of MDPSCs both with the matched and mismatched DLA.

Conclusions

Dual allogeneic transplantation of MDPSCs with the mismatched DLA is a safe and efficacious method for total pulp regeneration.

Electronic supplementary material

The online version of this article (10.1186/s13287-018-0855-8) contains supplementary material, which is available to authorized users.

Odontoblast-like differentiation and mineral formation of pulpsphere derived cells on human root canal dentin in vitro

BACKGROUND

The revitalization or regeneration of the dental pulp is a preferable goal in current endodontic research. In this study, human dental pulp cell (DPC) spheres were applied to human root canal samples to evaluate their potential adoption for physiological tissue-like regeneration of the dental root canal by odontoblastic differentiation as well as cell-induced mineral formation.

METHODS

DPC were cultivated into three-dimensional cell spheres and seeded on human root canal specimens. The evaluation of sphere formation, tissue-like behavior and differentiation as well as mineral formation of the cells was carried out with the aid of optical light microscopy, immunohistochemical staining and scanning electron microscopy (SEM).

RESULTS

Spheres and cells migrated out of the spheres showed an intense cell-cell- and cell-dentin-contact with the formation of extra cellular matrix. In addition, the ingrowth of cell processes into dentinal tubules and the interaction of cell processes with the tubule walls were detected by SEM-imaging. Immunohistochemical staining of the odontoblast specific matrix proteins, dentin matrix protein-1, and dentin sialoprotein revealed an odontoblast-like cell differentiation in contact with the dentin surface. This differentiation was confirmed by SEM-imaging of cells with an odontoblast specific phenotype and cell induced mineral formation.

CONCLUSIONS

The results of the present study reveal the high potential of pulp cells organized in spheres for dental tissue engineering. The odontoblast-like differentiation and the cell induced mineral formation display the possibility of a complete or partial "dentinal filling" of the root canal and the opportunity to combine this method with other current strategies.

Pulp regeneration by transplantation of dental pulp stem cells in pulpitis: a pilot clinical study

Background

Experiments have previously demonstrated the therapeutic potential of mobilized dental pulp stem cells (MDPSCs) for complete pulp regeneration. The aim of the present pilot clinical study is to assess the safety, potential efficacy, and feasibility of autologous transplantation of MDPSCs in pulpectomized teeth.

Methods

Five patients with irreversible pulpitis were enrolled and monitored for up to 24 weeks following MDPSC transplantation. The MDPSCs were isolated from discarded teeth and expanded based on good manufacturing practice (GMP). The quality of the MDPSCs at passages 9 or 10 was ascertained by karyotype analyses. The MDPSCs were transplanted with granulocyte colony-stimulating factor (G-CSF) in atelocollagen into pulpectomized teeth.

Results

The clinical and laboratory evaluations demonstrated no adverse events or toxicity. The electric pulp test (EPT) of the pulp at 4 weeks demonstrated a robust positive response. The signal intensity of magnetic resonance imaging (MRI) of the regenerated tissue in the root canal after 24 weeks was similar to that of normal dental pulp in the untreated control. Finally, cone beam computed tomography demonstrated functional dentin formation in three of the five patients.

Conclusions

Human MDPSCs are safe and efficacious for complete pulp regeneration in humans in this pilot clinical study.

PDGFRβ+/c-kit+ pulp cells are odontoblastic progenitors capable of producing dentin-like structure in vitro and in vivo

Background

Successful pulp regeneration depends on identification of pulp stem cells capable of differentiation under odontoblastic lineage and producing pulp-dentinal like structure. Recent studies demonstrate that platelet-derived growth factor (PDGF) plays an important role in damage repair and tissue regeneration. The aim of this study was to identify a subpopulation of dental pulp cells responsive to PDGF and with dentin regeneration potential.

Methods

Pulp tissues were isolated from 12 freshly extracted human impacted third molars. Pulp cells were sorted by their expression of PDGFRβ and stem cell marker genes via flow cytometry. For the selected cells, proliferation was analyzed by a colorimetric cell proliferation assay, differentiation was assessed by real time PCR detection the expression of odontoblast marker genes, and mineralization was evaluated by Alizarin Red S staining. GFP marked PDGFRβ⁺/c-kit⁺ pulp cells were transplanted into emptied root canals of nude rat lower left incisors. Pulp-dentinal regeneration was examined by immunohistochemistry.

Results

PDGFRβ⁺/c-kit⁺ pulp cells proliferated significantly faster than whole pulp cells. In mineralization media, PDGFRβ⁺/c-kit⁺ pulp cells were able to develop under odontoblastic linage as demonstrated by a progressively increased expression of DMP1, DSPP, and osteocalcin. BMP2 seemed to enhance whereas PDGF-BB seemed to inhibit odontoblastic differentiation and mineralization of PDGFRβ⁺/c-kit⁺ pulp cells. In vivo root canal transplantation study revealed globular dentin and pulp-like tissue formation by PDGFRβ⁺/c-kit⁺ cells.

Conclusions

PDGFRβ⁺/c-kit⁺ pulp cells appear to have pulp stem cell potential capable of producing dentinal like structure in vitro and in vivo.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-016-0307-8) contains supplementary material, which is available to authorized users.

Pulp development, repair, and regeneration: challenges of the transition from traditional dentistry to biologically based therapies

The traditional concept of replacing diseased tooth/pulp tissues by inert materials (restoration) is being challenged by recent advances in pulp biology leading to regenerative strategies aiming at the generation of new vital tissue. New tissue formation in the pulp chamber can be observed after adequate infection control and the formation of a blood clot. However, differentiation of true odontoblasts is still more speculative, and the approach is largely limited to immature teeth with open apices. A more systematic approach may be provided by the adoption of the tissue engineering concepts of using matrices, suitable (stem) cells, and signaling molecules to direct tissue events. With these tools, pulplike constructs have already been generated in experimental animals. However, a number of challenges still remain for clinical translation of pulp regeneration (eg, the cell source [resident vs nonresident stem cells, the latter associated with cell-free approaches], mechanisms of odontoblast differentiation, the pulp environment, the role of infection and inflammation, dentin pretreatment to release fossilized signaling molecules from dentin, and the provision of suitable matrices). Transition as a process, defined by moving from one form of "normal" to another, is based not only on the progress of science but also on achieving change to established treatment concepts in daily practice. However, it is clear that the significant recent achievements in pulp biology are providing an exciting platform from which clinical translation of dental pulp regeneration can advance.

Pulp regeneration in a full-length human tooth root using a hierarchical nanofibrous microsphere system

While pulp regeneration using tissue engineering strategy has been explored for over a decade, successful regeneration of pulp tissues in a full-length human root with a one-end seal that truly simulates clinical endodontic treatment has not been achieved. To address this challenge, we designed and synthesized a unique hierarchical growth factor-loaded nanofibrous microsphere scaffolding system. In this system, vascular endothelial growth factor (VEGF) binds with heparin and is encapsulated in heparin-conjugated gelatin nanospheres, which are further immobilized in the nanofibers of an injectable poly(l-lactic acid) (PLLA) microsphere. This hierarchical microsphere system not only protects the VEGF from denaturation and degradation, but also provides excellent control of its sustained release. In addition, the nanofibrous PLLA microsphere integrates the extracellular matrix-mimicking architecture with a highly porous injectable form, efficiently accommodating dental pulp stem cells (DPSCs) and supporting their proliferation and pulp tissue formation. Our in vivo study showed the successful regeneration of pulp-like tissues that fulfilled the entire apical and middle thirds and reached the coronal third of the full-length root canal. In addition, a large number of blood vessels were regenerated throughout the canal. For the first time, our work demonstrates the success of pulp tissue regeneration in a full-length root canal, making it a significant step toward regenerative endodontics.

STATEMENT OF SIGNIFICANCE

The regeneration of pulp tissues in a full-length tooth root canal has been one of the greatest challenges in the field of regenerative endodontics, and one of the biggest barriers for its clinical application. In this study, we developed a unique approach to tackle this challenge, and for the first time, we successfully regenerated living pulp tissues in a full-length root canal, making it a significant step toward regenerative endodontics. This study will make positive scientific impact and interest the broad and multidisciplinary readership in the dental biomaterials and craniofacial tissue engineering community.

Systemic BMSC homing in the regeneration of pulp-like tissue and the enhancing effect of stromal cell-derived factor-1 on BMSC homing

Pulp regeneration caused by endogenous cells homing has become the new research spot in endodontics. However, the source of functional cells that are involved in and contributed to the reconstituting process has not been identified. In this study, the possible role of systemical BMSC in pulp regeneration and the effect of stromal cell-derived factor-1 (SDF-1) on stem cell recruitment and angiogenesis were evaluated. 54 mice were divided into three groups: SDF-1 group (subcutaneous pockets containing roots with SDF-1 absorbed neutralized collagen gel and the green fluorescent protein (GFP) positive BMSCs transplantation via the tail vein), SDF-1-free group (pockets containing roots with gel alone and GFP + BMSCs transplantation) and Control group (pockets containing roots with gel alone). The animals were sacrificed after the roots were implanted into subcutaneous pockets for 3 weeks. Histomorphometric analysis was performed to evaluate the regenerated tissue in the canal by hematoxylin and eosin (HE) staining. The homing of the transplanted BMSCs was monitored with a fluorescence microscope and immunohistochemical analysis. The expression of ALP in new formed tissue was detected immunohistochemically. Dental-pulp-like tissue and new vessels were regenerated and GFP-positive BMSCs and expression of ALP could be observed in both SDF-1 group and SDF-1-free group. Furthermore, more GFP+ cells, stronger expression of ALP and stronger angiogenesis were found in the SDF-1 group than in the SDF-1-free group. To conclude, systemic BMSC can home to the root canal and participate in dental-pulp-like tissue regeneration. Intracanal application of SDF-1 may enhance BMSC homing efficiency and angiogenesis.

Dental pulp tissue engineering with bFGF-incorporated silk fibroin scaffolds

The clinical translation of regenerative endodontics demands further development of suitable scaffolds. Here, we assessed the possibility of using silk fibroin scaffold for pulp regeneration with dental pulp stem cells (DPSCs) and basic fibroblast growth factor (bFGF) in ectopic root canal transplantation model. Porous silk fibroin scaffolds were fabricated using freeze-drying technique (with or without bFGF incorporation), and characterized by scanning electron microscopy (SEM) and Fourier transform infrared spectroscopy. DPSCs were isolated, characterized, seeded onto scaffolds, and inserted into the tooth root fragments. Cell viability and morphology were tested in the 3D model in vitro using CCK8 assay and SEM. Furthermore, the ectopic transplantation model was used to verify the generation of pulp-like tissue in DPSCs seeded silk fibroin scaffold with bFGF, as examined by histological analysis. DPSCs seeded in silk fibroin scaffold survived, exhibited cytoplasmic elongation in scaffolds at least 4 weeks in culture. bFGF promoted DPSCs viability in tooth fragments/scaffolds (TSS) between 7 and 28 days. Pulp-like tissue was generated in the bFGF-incorporated TSS with DPSCs. Histologically, the generated tissue was shown to be with well vascularity, have new matrix deposition and dentin-like tissue formation, and consist of both the transplanted and host-derived cells. Collectively, these data support the use of bFGF-incorporated silk fibroin scaffold as a highly promising scaffold candidate for future treatment concepts in regenerative endodontics to save teeth.

Autophagy in SDF-1α-mediated DPSC migration and pulp regeneration

Critical morphological requirements for pulp regeneration are tissues replete with vascularisation, neuron formation, and dentin deposition. Autophagy was recently shown to be related to angiogenesis, neural differentiation, and osteogenesis. The present study aimed to investigate the involvement of autophagy in stromal cell-derived factor-1α (SDF-1α)-mediated dental pulp stem cell (DPSC) migration and pulp regeneration, and identify its presence during pulp revascularisation of pulpectomised dog teeth with complete apical closure. In vitro studies showed that SDF-1α enhanced DPSCs migration and optimised focal adhesion formation and stress fibre assembly, which were accompanied by autophagy. Moreover, autophagy inhibitors significantly suppressed, whereas autophagy activator substantially augmented SDF-1α-stimulated DPSCs migration. Furthermore, after ectopic transplantation of tooth fragment/silk fibroin scaffold with DPSCs into nude mice, pulp-like tissues with vascularity, well-organised fibrous matrix formation, and new dentin deposition along the dentinal wall were generated in SDF-1α-loaded samples accompanied by autophagy. More importantly, in a pulp revascularisation model in situ, SDF-1α-loaded silk fibroin scaffolds improved the de novo ingrowth of pulp-like tissues in pulpectomised mature dog teeth, which correlated with the punctuated LC3 and Atg5 expressions, indicating autophagy. Our findings provide novel insights into the pulp regeneration mechanism, and SDF-1α shows promise for future clinical application in pulp revascularisation.

Multidisciplinary treatment options of tooth avulsion considering different therapy concepts

BACKGROUND

Avulsion of permanent front teeth is a rare accident, mostly affecting children between seven and nine years of age. Replanted and splinted, these teeth often develop inflammation, severe resorption or ankylosis affecting alveolar bone development and have to be extracted sooner or later.

OBJECTIVES

The purpose of this study was to evaluate different therapy concepts to create a structured concept for the treatment of avulsions.

RESULTS

Based on existing therapy concepts, a concept for different initial conditions (dry time, age, growth, tooth, hard and soft tissues) was developed and is presented here.

CONCLUSION

A great deal of research has been performed during recent years and guidelines for the management of avulsions have been published. With the help of this literature it is possible to identify the best treatment procedure for each tooth.

CLINICAL RELEVANCE

The prognosis of avulsed teeth can be improved by considering evidence-based therapy concepts. Resorption, ankylosis and tooth loss could be minimized.

The use of granulocyte-colony stimulating factor induced mobilization for isolation of dental pulp stem cells with high regenerative potential

Human dental pulp stem cells (DPSCs) contain subsets of progenitor/stem cells with high angiogenic, neurogenic and regenerative potential useful for cell therapy. It is essential to develop a safe and efficacious method to isolate the clinical-grade DPSCs subsets from a small amount of pulp tissue without using conventional flow cytometry. Thus, a method for isolation of DPSCs subsets based on their migratory response to optimized concentration of 100 ng/ml of granulocyte-colony stimulating factor (G-CSF) was determined in this study. The DPSCs mobilized by G-CSF (MDPSCs) were enriched for CD105, C-X-C chemokine receptor type 4 (CXCR-4) and G-CSF receptor (G-CSFR) positive cells, demonstrating stem cell properties including high proliferation rate and stability. The absence of abnormalities/aberrations in karyotype and lack of tumor formation after transplantation in an immunodeficient mouse were demonstrated. The conditioned medium of MDPSCs exhibited anti-apoptotic activity, enhanced migration and immunomodulatory properties. Furthermore, transplantation of MDPSCs accelerated vasculogenesis in an ischemic hindlimb model and augmented regenerated pulp tissue in an ectopic tooth root model compared to that of colony-derived DPSCs, indicating higher regenerative potential of MDPSCs. In conclusion, this isolation method for DPSCs subsets is safe and efficacious, having utility for potential clinical applications to autologous cell transplantation.