Transplantation of dental pulp stem cells and platelet-rich plasma for pulp regeneration

Autologous Platelet Concentrates for Pulp and Dentin Regeneration: A Literature Review of Animal Studies

INTRODUCTION

The purpose of this study was to evaluate the effectiveness of autologous platelet concentrates (APCs) in promoting pulp and dentin regeneration in animal models.

METHODS

An electronic search was performed on MEDLINE, Embase, Scopus, SciELO, LILACS, and CENTRAL. Animal studies using APC as a root filling material after pulpectomy in mature or immature teeth were included. Articles underwent risk of bias assessment. Histologic evaluation of intracanal neoformed tissue was the primary outcome; root development, root wall thickening, apical closure, and periapical healing in apical periodontitis were the secondary outcomes.

RESULTS

Seven articles were included. Platelet-rich plasma (PRP) was used as root filling material during regenerative procedures in the experimental group in either mature or immature teeth. After revascularization with PRP alone or in conjunction with stem cells of a different source, the histologic analyses revealed that, in addition to an odontoblastic cell layer or dentinlike structure, the neoformed intracanal tissues were mainly cementumlike, bonelike, and connective tissues.

CONCLUSIONS

True regeneration of necrotic pulp may not be achieved with current techniques using PRP, all of which stimulated tissue repair. Benefits of PRP adjunct for pulp tissue regeneration in preclinical studies remain unclear. Further studies with standardized protocols are necessary to assess the actual contribution of PRP in endodontic regenerative therapies.

In Vivo Experiments with Dental Pulp Stem Cells for Pulp-Dentin Complex Regeneration

In recent years, many studies have examined the pulp-dentin complex regeneration with DPSCs. While it is important to perform research on cells, scaffolds, and growth factors, it is also critical to develop animal models for preclinical trials. The development of a reproducible animal model of transplantation is essential for obtaining precise and accurate data in vivo. The efficacy of pulp regeneration should be assessed qualitatively and quantitatively using animal models. This review article sought to introduce in vivo experiments that have evaluated the potential of dental pulp stem cells for pulp-dentin complex regeneration. According to a review of various researches about DPSCs, the majority of studies have used subcutaneous mouse and dog teeth for animal models. There is no way to know which animal model will reproduce the clinical environment. If an animal model is developed which is easier to use and is useful in more situations than the currently popular models, it will be a substantial aid to studies examining pulp-dentin complex regeneration.

Histologic Analysis of the Influence of a Gelatin-based Scaffold in the Repair of Immature Dog Teeth Subjected to Regenerative Endodontic Treatment

INTRODUCTION

Regenerative endodontic treatment is a new and promising approach to manage immature teeth with necrotic pulps and apical periodontitis. The use of scaffolds is essential to treatment success, but many materials are difficult to acquire and have a high cost. This study assessed tissue repair in immature dog teeth with necrotic pulps and apical periodontitis after using a gelatin-based scaffold (Gelfoam; Pharmacia & Upjohn Co, Kalamazoo, MI).

METHODS

Apical periodontitis was induced in 20 immature dog teeth. After disinfection with triple antibiotic paste for 2 weeks, canals were irrigated, dried, and filled with a blood clot alone (10 teeth) or combined with Gelfoam (10 teeth). Another 10 teeth were used as negative controls (no intervention). After 7 months, the dogs were euthanized. Histologic sections were stained with hematoxylin-eosin and analyzed in relation to tissue repair. Categoric data were analyzed using the Fisher exact test (P < .05), numeric data (histomorphometric analysis), and the Mann-Whitney U test.

RESULTS

Histologic analysis revealed a higher percentage of roots with new cementumlike mineralized tissue and connective tissue inside the canal in the blood clot + Gelfoam group (P < .001). Histomorphometric analysis showed a higher area of mineralized tissue in the same group (P = .029). Apical extension of root and inflammation were similar between the experimental groups. The new tissue formed onto canal walls and in the root canal space showed characteristics of cementum and periodontal ligament, respectively.

CONCLUSIONS

The use of a gelatin-based scaffold (Gelfoam) combined with a blood clot improved repair in immature dog teeth with apical periodontitis subjected to regenerative endodontic treatment.

Pulp Revascularization on Permanent Teeth with Open Apices in a Middle-aged Patient

Pulp revascularization is a promising procedure for the treatment of adolescents' immature permanent teeth with necrotic pulp and/or apical periodontitis. However, the ability to successfully perform pulp revascularization in a middle-aged patient remains unclear. A 39-year-old woman was referred for treatment of teeth #20 and #29 with necrotic pulp, extensive periapical radiolucencies, and incomplete apices. Pulp revascularization procedures were attempted, including root canal debridement, triple antibiotic paste medication, and platelet-rich plasma transplantation to act as a scaffold. Periapical radiographic and cone-beam computed tomographic examinations were used to review the changes in the apical lesions and root apex configuration. The patient remained asymptomatic throughout the 30-month follow-up. Periapical radiographic examination revealed no change in the apical lesions of either tooth at 8 months. The periapical radiolucency disappeared on tooth #20 and significantly decreased on tooth #29 by the 30-month follow-up, findings that were also confirmed by cone-beam computed tomographic imaging. No evidence of root lengthening or thickening was observed. Successful revascularization was achieved in a middle-aged patient's teeth.

Modulation of Dental Pulp Stem Cell Odontogenesis in a Tunable PEG-Fibrinogen Hydrogel System

Injectable hydrogels have the great potential for clinical translation of dental pulp regeneration. A recently developed PEG-fibrinogen (PF) hydrogel, which comprises a bioactive fibrinogen backbone conjugated to polyethylene glycol (PEG) side chains, can be cross-linked after injection by photopolymerization. The objective of this study was to investigate the use of this hydrogel, which allows tuning of its mechanical properties, as a scaffold for dental pulp tissue engineering. The cross-linking degree of PF hydrogels could be controlled by varying the amounts of PEG-diacrylate (PEG-DA) cross-linker. PF hydrogels are generally cytocompatible with the encapsulated dental pulp stem cells (DPSCs), yielding >85% cell viability in all hydrogels. It was found that the cell morphology of encapsulated DPSCs, odontogenic gene expression, and mineralization were strongly modulated by the hydrogel cross-linking degree and matrix stiffness. Notably, DPSCs cultured within the highest cross-linked hydrogel remained mostly rounded in aggregates and demonstrated the greatest enhancement in odontogenic gene expression. Consistently, the highest degree of mineralization was observed in the highest cross-linked hydrogel. Collectively, our results indicate that PF hydrogels can be used as a scaffold for DPSCs and offers the possibility of influencing DPSCs in ways that may be beneficial for applications in regenerative endodontics.

Dental Stem Cells in Pulp Regeneration: Near Future or Long Road Ahead?

Although regenerative endodontic procedures have yielded an impressive body of favorable outcomes, the treatment of necrotic immature permanent teeth in particular remains to be a challenge. Recent advances in dental stem cell (DSC) research have gained increasing insight in their regenerative potential and prospective use in the formation of viable dental tissues. Numerous studies have already reported successful dental pulp regeneration following application of dental pulp stem cells, stem cells from the apical papilla, or dental follicle precursor cells in different in vivo models. Next to responsive cells, dental tissue engineering also requires the support of an appropriate scaffold material, ranging from naturally occurring polymers to treated dentin matrix components. However, the routine use and banking of DSCs still holds some major challenges, such as culture-associated differences, patient-related variability, and the effects of culture medium additives. Only in-depth evaluation of these problems and the implementation of standardized models and protocols will effectively lead to better alternatives for patients who no longer benefit from current treatment protocols.

Tumor Necrosis Factor Alpha Stimulates Proliferation of Dental Pulp Stem Cells via Akt/Glycogen Synthase Kinase-3β/Cyclin D1 Signaling Pathway

INTRODUCTION

It has been widely accepted that dental pulp stem cells (DPSCs), which are a class of self-renewal and differentiation potential of adult stem cells, play an important role in the repair procession of pulp's inflammation. We investigated whether tumor necrosis factor alpha (TNF-α) could induce the proliferation of DPSCs and clarified the potential mechanism of this proliferation.

METHODS

Cell Counting Kit-8 assay (Dojindo Laboratories, Mashiki-machi, Kumamoto, Japan) and 5-ethynyl-2'-deoxyuridine-based proliferation assays were determined to investigate various concentrations or hours of TNF-α inducing a cell number change of DPSCs. Next, flow cytometry analysis was performed to investigate the main cell cycle phase process of DPSCs. Furthermore, the signaling pathway of TNF-α-induced proliferation of DPSCs was analyzed using Western blot analysis. Then, inhibitors were added to confirm the mechanism of this signaling pathway.

RESULTS

TNF-α induced the proliferation of DPSCs in a dose- and time-dependent manner. Cyclin D1, which controlled the cell cycle process from the G1 to the S phase, was up-regulated by TNF-α in a time-dependent manner, whereas its overexpression alone increased DPSC proliferation. Furthermore, TNF-α was capable of inducing Akt/GSK-3β signaling pathway activation. Blockage of phosphoinositide 3-kinase/Akt by their kinase or genetic inhibitors could significantly reduce TNF-α-induced proliferation of DPSCs.

CONCLUSIONS

This study confirmed that TNF-α induced the proliferation of DPSCs by regulating the Akt/GSK-3β/cyclin D1 signaling pathway and then provided a suitable number for the requirements of cell differentiation.

Complete pulpodentin complex regeneration by modulating the stiffness of biomimetic matrix

Dental caries is one of the most prevalent chronic diseases in all populations. The regeneration of dentin-pulp tissues (pulpodentin) using a scaffold-based tissue engineering strategy is a promising approach to replacing damaged dental structures and restoring their biological functions. However, the current scaffolding design for pulpodentin regeneration does not take into account the distinct difference between pulp and dentin, therefore, is incapable of regenerating a complete tooth-like pulpodentin complex. In this study, we determined that scaffolding stiffness is a crucial biophysical cue to modulate dental pulp stem cell (DPSC) differentiation. The DPSCs on a high-stiffness three-dimensional (3D) nanofibrous gelatin (NF-gelatin) scaffold had more organized cytoskeletons and a larger spreading area than on a low-stiffness NF-gelatin scaffold. In the same differentiation medium, a high-stiffness NF-gelatin facilitated DPSC differentiation to form a mineralized tissue, while a low-stiffness NF-gelatin promoted a soft pulp-like tissue formation from the DPSCs. A facile method was then developed to integrate the low- and high-stiffness gelatin matrices into a single scaffold (S-scaffold) for pulpodentin complex regeneration. A 4-week in vitro experiment showed that biomineralization took place only in the high-stiffness peripheral area and formed a ring-like structure surrounding the non-mineralized central area of the DPSC/S-scaffold construct. A complete pulpodentin complex similar to natural pulpodentin was successfully regenerated after subcutaneous implantation of the DPSC/S-scaffold in nude mice for 4weeks. Histological staining showed a significant amount of extracellular matrix (ECM) formation in the newly formed pulpodentin complex, and a number of blood vessels were observed in the pulp tissue. Taken together, this work shows that modulating the stiffness of the NF-gelatin scaffold is a successful approach to regenerating a complete tooth-like pulpodentin complex.

Coculture of stem cells from apical papilla and human umbilical vein endothelial cell under hypoxia increases the formation of three-dimensional vessel-like structures in vitro

The success of bioengineered dental pulp depends on two principles, (1) whether the transplanted tissue can develop its own vascular endothelial tubule network and (2) whether the host vasculature can be induced to penetrate the bioengineered pulp replacement and conjoin. Major inductive molecules that participate in laying down blood vessels include vascular endothelial growth factor (VEGF), ephrinB2, and hypoxia-inducible factor 1α (HIF-1α). Being able to modulate the genes encoding these angiogenic molecules is a therapeutic target in pulp regeneration for endogenous blood vessel formation, prevention of graft rejection, and exclusion of infection. Once implanted inside the root canal, bioengineered pulp is subjected to severe hypoxia that causes tissue degeneration. However, short-term hypoxia is known to stimulate angiogenesis. Thus, it may be feasible to prime dental cells for angiogenic activity before implantation. Stem cells from apical papilla (SCAP) are arguably one of the most potent and versatile dental stem cell populations for bioengineering pulp in vitro. Our study aimed to investigate whether coculture of SCAP and human umbilical vein endothelial cells (HUVECs) under hypoxia promotes the formation of endothelial tubules and a blood vessel network. In addition, we clarified the interplay between the genes that orchestrate these important angiogenic molecules in SCAP under hypoxic conditions. We found that SCAP cocultured with HUVEC at a 1:5 ratio increased the number of endothelial tubules, tubule lengths, and branching points. Fluorescence staining showed that HUVEC formed the trunk of tubular structures, whereas SCAP located adjacent to the endothelial cell line, resembling the pericyte location. When we used CoCl2 (0.5 mM) to induce hypoxic environment, the expression of proteins, HIF-1α and VEGF, and transcript of ephrinB2 in SCAP was upregulated. However, minimal VEGF levels in supernatants of HUVEC and coculture Petri dishes were detected, suggesting that VEGF secreted by SCAP might be used by HUVEC to accelerate the formation of vessel-like structures. Taken together, we revealed that artificial hypoxia stimulates angiogenic responses in SCAP for possible use in engineering dental pulp replacements. Our results may help to delineate the optimal therapeutic target to promote angiogenesis so that future bioengineered pulp replacements integrate faster and permanently within the host.

Immunohistochemical and histochemical analysis of newly formed tissues in root canal space transplanted with dental pulp stem cells plus platelet-rich plasma

INTRODUCTION

Tissue regeneration in root canals after pulpectomy can be achieved by transplantation of autologous dental pulp stem cells and/or platelet-rich plasma. However, the identity of the newly formed tissue in the pulp space has been only examined by histologic analysis. This study aimed to apply immunohistochemistry and histochemistry to detect specific markers in the newly generated tissues after root canal regenerative treatment.

METHODS

In our previous study, 32 root canals in 4 mature dogs were treated with a pulp regeneration procedure after pulpectomy using either blood clot, transplantation of dental pulp stem cells, platelet-rich plasma, or a combination of cells and plasma. In the present study, the tissues were examined for the expression of periostin to detect periodontal ligament tissue, nestin and dentin sialoprotein for odontoblasts, and bone sialoprotein and osteocalcin for bone tissues. Samples were also stained for tartrate-resistant acid phosphatase (TRAP) as a marker for osteoclastic lineages.

RESULTS

Continuous periostin-positive tissue was observed extending from the periodontal ligament into the inner canal surface in which the mineral islands were surrounded by weak periostin staining. There was also positive staining for TRAP, bone sialoprotein, and osteocalcin in the canal space, suggesting the presence of bone tissue. A layer of mineralized tissue along the inner surface of the root canal was negative for TRAP, suggesting the tissue likely to be cementum. In all samples, no nestin-positive reaction was observed, whereas dentin sialoprotein was detected in PDL, dentinal tubules, and intracanal fibrous tissues. There was no difference between any of the 4 groups.

CONCLUSIONS

The tissues formed in the dog mature root canals after regenerative endodontic procedures are not pulp tissues but mainly periodontal tissues.

In vitro and in vivo characteristics of stem cells from human exfoliated deciduous teeth obtained by enzymatic disaggregation and outgrowth

OBJECTIVE

Stem cells from human exfoliated deciduous teeth (SHED) are a good source of dental tissue for regeneration therapy, and can be obtained using different primary culture methods. The aim of this study was to determine the differences in the in vitro and in vivo characteristics between SHED isolated via enzymatic disaggregation (e-SHED) and outgrowth (o-SHED) primary culture methods.

DESIGN

Dental pulp stem cells were isolated from 14 exfoliated deciduous teeth by enzymatic disaggregation (n=7) and outgrowth (n=7). Their proliferation potential and colony-forming ability were evaluated in vitro, as was their mesenchymal stem-cell-marker expression (using flow cytometry), and their differentiation was verified using quantitative real-time PCR (qPCR) and histochemical staining. In addition, the qualitative and quantitative characteristics of the hard tissue that was generated after in vivo transplantation were compared using haematoxylin and eosin staining, immunohistochemical staining, qPCR, and quantitative alkaline phosphatase analysis.

RESULTS

The cell-proliferation potential, colony-forming ability, and Stro-1 and CD146 expression were higher in e-SHED than in o-SHED. While the in vitro adipogenic differentiation potential was greater in e-SHED than in o-SHED, the in vitro osteogenic differentiation did not differ significantly between the two cell types. Although in vivo hard tissue formation was greater following transplantation of o-SHED into mice, there was no difference in the quality of hard tissue generated by e-SHED and o-SHED.

CONCLUSION

The findings of this study indicate that e-SHED exhibit stronger stemness characteristics, but that o-SHED are more suitable for hard-tissue regeneration therapy in teeth.

Histologic comparison between platelet-rich plasma and blood clot in regenerative endodontic treatment: an animal study

INTRODUCTION

In regenerative endodontic treatment (RET) for immature permanent tooth, better treatment results could be obtained by applying platelet-rich plasma (PRP) as the scaffold rather than the blood clot. The goal of this study was to compare the histologic differences between using PRP and blood clot in RET.

METHODS

Three 6-month-old beagles each carrying 9 premolars with double root canals were randomly assigned to the PRP group, blood clot group, or negative control group. All experimental teeth suffered apical periodontitis, and RET was performed. In the blood clot group, bleeding was induced from the periapical tissues to fill the canal space. In the PRP group, autologous PRP was injected into each root canal. The animals were sacrificed 3 months later. Histologic sections were stained with hematoxylin-eosin. Statistical analysis was performed by the Fisher exact test, with the significance set at 0.05.

RESULTS

With the ingrowth of cellular cementumlike tissues, the canal wall was thickened, and the apical apex was closed in both the PRP and blood clot groups. Cementocytelike cells were present in the newly formed tissues. Meanwhile, no statistical difference was found in both experimental groups for the average percentage of apical closure, new tissue formation, and pulplike tissue formation. Noticeably, a large number of inflammatory cells were present in some root canals in both groups although the postoperative radiograph revealed the disappearance of periapical radiolucency.

CONCLUSIONS

PRP application could be an option for clinical cases in which little or no bleeding were found when irritating the apical tissue during RET.