Biological mediators for periodontal regeneration

Plasma rich in growth factors promote gingival tissue regeneration by stimulating fibroblast proliferation and migration and by blocking transforming growth factor-β1-induced myodifferentiation

BACKGROUND

Periodontitis involves inflammation and infection of the ligaments and bones that support the teeth. Gingival fibroblasts are the most abundant cells in periodontal tissue, and they play a role in maintaining the structural integrity of the tissue. Plasma rich in growth factors contain a pool of proteins and growth factors that promote wound healing and tissue regeneration. In the present study, we evaluate the potential of different formulations obtained with this approach to stimulate several biologic processes involved in wound healing, including fibroblast proliferation, migration, adhesion, and the autocrine release of some angiogenic factors and extracellular matrix components. Furthermore, the ability of this technology to prevent and inhibit transforming growth factor β1-induced myodifferentiation was also determined.

METHODS

Cell proliferation was evaluated through a colorimetric assay, cell migration was performed on culture inserts, and cell adhesion was studied through a fluorescence-based method. Enzyme-linked immunosorbent assay was used to determine some of the biomolecules released by gingival fibroblasts. Smooth muscle actin expression was assessed through immunofluorescence microscopy.

RESULTS

Results showed that plasma rich in growth factors significantly increased gingival fibroblast proliferation, migration, and cell adhesion on type I collagen matrix. In addition, it stimulated the autocrine expression of vascular endothelial growth factor, hepatocyte growth factor, and hyaluronic acid. The myofibroblast phenotype, which is characterized by expressing α-smooth muscle actin, was inhibited and reverted by treating with this technology.

CONCLUSION

These findings suggest that plasma rich in growth factors is capable of promoting regeneration of gingival connective tissue by stimulating some of the main processes involved in wound regeneration.

Treatment of endodontically induced periapical lesions using hydroxyapatite, platelet-rich plasma, and a combination of both: An in vivo study

Aim and Objectives:

To evaluate bone regeneration in endodontically induced periapical lesions using Hydroxyapatite, Platelet-Rich Plasma (PRP), and a combination of Hydroxyapatite and Platelet-Rich Plasma for a period of one year.

Materials and Methods:

Twenty systemically healthy patients of both genders between the ages 20 and 40 years were included. To qualify, the patient had to have a tooth where non-surgical root canal therapy had failed, periapical radiolucency was present, and periapical root end surgery was required. The bony defect had to be confined to the apical area, with the bone covering the entire root surface coronally, with an intact lingual cortical plate. Patients were randomly divided into four groups, with five patients each, as follows: Group I — Replacement with Hydroxyapatite, Group II — Replacement with PRP, Group III — Replacement with PRP and Hydroxyapatite, and Group IV — Control group with no substitutes. The patients were evaluated both clinically and radiographically.

Results:

The radiographic evaluation revealed that Group I patients showed complete bone regeneration with evidence of a trabecular pattern, at the end of one year, Group II patients showed complete bone regeneration at the end of nine months, Group III patients showed complete bone regeneration at the end of six months, and Group IV patients showed bone regeneration, which was not satisfactory even after one year.

Conclusions:

The PRP and Hydroxyapatite combination facilitated better and faster bone regeneration when compared to PRP alone.

A finite element method approach for the mechanobiological modeling of the osseointegration of a dental implant

The aim of this paper is to introduce a new mathematical model using a mechanobiological approach describing the process of osseointegration at the bone-dental implant interface in terms of biological and mechanical factors and the implant surface. The model has been computationally implemented by using the finite element method. The results show the spatial-temporal patterns distribution at the bone-dental implant interface and demonstrate the ability of the model to reproduce features of the wound healing process such as blood clotting, osteogenic cell migration, granulation tissue formation, collagen-like matrix displacements and new osteoid formation. The model might be used as a methodological basis for designing a dental tool useful to predict the degree of osseointegration of dental implants and subsequent formulation of mathematical models associated with different types of bone injuries and different types of implantable devices.

Effect of rhTGF-β1 combined with bone grafts on human periodontal cell differentiation

Various techniques and materials have been proposed for the treatment of periodontal defects. In periodontal regeneration, periodontal ligament (PDL) cell differentiation as well as certain growth factors and their delivery system applied are critical. The purpose of this study was to evaluate the in vitro effect of recombinant human transforming growth factor-beta 1 (rhTGF-β1) combined with two different bone grafts on human PDL (hPDL) cell differentiation. The hPDL cells were treated with TGF-β1 alone or in combination with a calcified freeze-dried bone allograft (FDBA) and a porous biphasic calcium phosphate (BC) bone graft. Cell differentiation effect was estimated by measuring alkaline phosphatase (ALPase) activity and osteocalcin secretion. Results demonstrated that rhTGF-β1 alone or in combination with FDBA and BC provoked a significant (p<0.05) increase in ALPase activity as compared with controls. The findings of this study confirmed the beneficial role of rhTGF-β1 combined with FDBA and BC as carriers in periodontal regeneration.

Influence of antiplatelet drugs in the pathogenesis of experimental periodontitis and periodontal repair in rats

BACKGROUND

Platelets contain an array of biologic mediators that can modulate inflammation and repair processes including proinflammatory mediators and growth factors. Previous studies have shown that periodontitis and periodontal repair are associated with platelet activation. We hypothesized that drug-induced platelet inactivation may interfere in the processes of inflammation and repair in experimental periodontitis in rats by suppressing the release of biologic mediators from platelets to the site of injury.

METHODS

To measure the effects on periodontitis, ligatures were placed around first molars, and aspirin (Asp, 30 mg/kg) or clopidogrel (Clo, 75 mg/kg) was given intragastrically once daily for 15 days. Interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and thromboxane A(2) levels were measured by enzyme-linked immunosorbent assay. To evaluate the effects of antiplatelet drugs on periodontal repair, ligatures were removed after 15 days of periodontitis induction, and Asp or Clo were administered beginning the following day for 15 days. Periodontal repair was assessed by microcomputed tomography.

RESULTS

On periodontitis phase, Asp and Clo significantly reduced levels of TNF-α and Il-6 (P <0.05), but only Asp decreased thromboxane A(2) (P <0.05). Asp and Clo decreased inflammatory infiltration; however, this reduction was more pronounced with Clo treatment (P <0.05). Histometric analysis showed that Asp and Clo impaired alveolar bone resorption. During the repair phase and after removal of the ligatures, microcomputed tomography analysis demonstrated that treatment with Asp and Clo did not impair alveolar bone repair.

CONCLUSION

Systemic administration of Asp and Clo attenuates the inflammation associated with periodontitis without affecting the repair process when stimulus is removed.

Cyclooxygenase 2 plays a role in Emdogain-induced proliferation

BACKGROUND AND OBJECTIVE

Enamel matrix proteins are involved in the development and regeneration of root cementum and in its attachment to dentin; however, the mechanisms through which this occurs have yet to be elucidated. The present study was therefore carried out to evaluate the mitogenic and proliferative responses of human periodontal fibroblast (HPLF) cells to Emdogain (EMD), and the potential role of cyclooxygenase 2 (COX-2) in this process.

MATERIAL AND METHODS

We investigated the effects of EMD on 5-bromo-2'-deoxyuridine (BrdU) incorporation, colchicine freezing of mitosis, XTT [2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide] reduction and Trypan Blue dye exclusion, with or without celecoxibe, a selective cyclooxygenase-2 (COX-2) inhibitor; we also evaluated the expression of COX-2 mRNA and COX-2 protein in response to EMD.

RESULTS

EMD significantly enhanced mitosis in, and proliferation of, human periodontal ligament fibroblasts in a dose-dependent manner; however, there was a small increase of DNA synthesis only in response to a high dose of EMD (200 μg/mL). EMD (100 and 200 μg/mL) elicited an increase in COX-2 expression (p ≤ 0.05). Celecoxibe (20 μm) diminished the EMD-induced mitosis and proliferation of HPLF cells (p ≤ 0.05).

CONCLUSION

Celecoxibe hampered EMD-induced mitosis and proliferation, which, in association with EMD-increased COX-2 expression, indicates that COX-2 may be involved in the proliferative response of HPLF cells to EMD.

Review paper: DNA delivery strategies to promote periodontal regeneration

Periodontal diseases are caused by bacteria with an inflammatory component that result in the loss of bone and soft tissue around the neck of the teeth. Recent therapies allow clinicians to regenerate some of the lost structures of the periodontium. Regeneration of these lost supporting structures is a highly orchestrated process, involving various cellular and molecular players, leading to the complete restoration of the periodontium (the tooth-supporting apparatus). The introduction of growth factors has positively influenced the clinical outcome of the existing regenerative procedures but the supra-physiological doses and the high cost associated with these growth factors can be drawbacks. Gene therapy may offer some interesting advantages to current therapies. In the field of periodontology, several studies have been conducted to explore the efficacy of delivering the DNA of key growth factors using viral vectors in both periodontal and peri-implant bone regeneration. Relatively few studies have explored the application of nonviral gene therapy in periodontal regeneration. This article is aimed at reviewing the studies conducted so far using viral and nonviral gene delivery approaches to achieve periodontal and peri-implant bone regeneration.

Novel regenerative strategies to enhance periodontal therapy outcome

BACKGROUND

Chronic periodontitis is a widely prevalent inflammatory condition of the supporting tissues of the teeth and is characterized by loss of teeth with an associated risk of systemic complications. Regenerative therapies such as guided tissue and bone regeneration form an important armamentarium in periodontics with a high degree of outcome predictability in certain ideal clinical scenarios.

OBJECTIVE/METHODS

This review elaborates novel tissue regenerative treatment modalities based on sound understanding of developmental biology, tissue engineering, inflammation and wound healing. We focus on the role of biological mediators such as growth factors, gene-based therapy, cell therapy and pro-resolution lipid mediators in the regeneration of lost bone or periodontium.

RESULTS/CONCLUSIONS

These therapies have the potential to regenerate both periodontium and bone, aiding in the treatment of even clinically challenging cases.

Endoglin is involved in BMP-2-induced osteogenic differentiation of periodontal ligament cells through a pathway independent of Smad-1/5/8 phosphorylation

The periodontal ligament (PDL), a connective tissue located between the cementum of teeth and the alveolar bone of mandibula, plays a crucial role in the maintenance and regeneration of periodontal tissues. The PDL contains fibroblastic cells of a heterogeneous cell population, from which we have established several cell lines previously. To analyze characteristics unique for PDL at a molecular level, we performed cDNA microarray analysis of the PDL cells versus MC3T3-E1 osteoblastic cells. The analysis followed by validation by reverse transcription-polymerase chain reaction and immunochemical staining revealed that endoglin, which had been shown to associate with transforming growth factor (TGF)-beta and bone morphogenetic proteins (BMPs) as signaling modulators, was abundantly expressed in PDL cells but absent in osteoblastic cells. The knockdown of endoglin greatly suppressed the BMP-2-induced osteoblastic differentiation of PDL cells and subsequent mineralization. Interestingly, the endoglin knockdown did not alter the level of Smad-1/5/8 phosphorylation induced by BMP-2, while it suppressed the BMP-2-induced expression of Id1, a representative BMP-responsive gene. Therefore, it is conceivable that endoglin regulates the expression of BMP-2-responsive genes in PDL cells at some site downstream of Smad-1/5/8 phosphorylation. Alternatively, we found that Smad-2 as well as Smad-1/5/8 was phosphorylated by BMP-2 in the PDL cells, and that the BMP-2-induced Smad-2 phosphorylation was suppressed by the endoglin knockdown. These results, taken together, raise a possibility that PDL cells respond to BMP-2 via a unique signaling pathway dependent on endoglin, which is involved in the osteoblastic differentiation and mineralization of the cells.

Loss of proliferation and differentiation capacity of aged human periodontal ligament stem cells and rejuvenation by exposure to the young extrinsic environment

The application of periodontal ligament stem cells (PDLSCs) may be effective for periodontal regenerative therapy. As tissue regenerative potential may be negatively regulated by aging, whether aging and its microenvironment modify human PDLSCs remains a question. In this study, we compared the proliferation and differentiation capacity of PDLSCs obtained from young and aged donors. Then, we exposed aged PDLSCs to young periodontal ligament cell-conditioned medium (PLC-CM), and young PDLSCs were exposed to aged PLC-CM. Morphological appearance, colony-forming assay, cell cycle analysis, osteogenic and adipogenic induction media, gene expression of cementoblast phenotype, and in vivo differentiation capacities of PDLSCs were evaluated. PDLSCs obtained from aged donors exhibited decreased proliferation and differentiation capacity when compared with those from young donors. Young PLC-CM enhanced the proliferation and differentiation capacity of PDLSCs from aged donors. Aged PDLSCs induced by young PLC-CM showed enhanced tissue-regenerative capacity to produce cementum/periodontal ligament-like structures, whereas young PDLSCs induced by aged PLC-CM transplants mainly formed connective tissues. To our knowledge, this is the first study to mimic the developmental microenvironment of PDLSCs in vitro, and our data suggest that age influences the proliferation and differentiation potential of human PDLSCs, and that the activity of human PDLSCs can be modulated by the extrinsic microenvironment.

Regulation of matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases by basic fibroblast growth factor and dexamethasone in periodontal ligament cells

BACKGROUND AND OBJECTIVES

In this study, we investigated the effect of basic fibroblast growth factor (bFGF) and dexamethasone (Dex) on mRNA expressions of collagen (COL) type I, III and X, matrix metalloproteinases (MMP)-1, -2, -3 and -9 and tissue inhibitors of metalloproteinases (TIMP)-1 and -2, and also on mineralization and morphology of periodontal ligament (PDL) cells.

MATERIAL AND METHODS

Periodontal ligament cells were obtained from premolar teeth extracted for orthodontic reasons. Periodontal ligament cells were cultured with Dulbecco's modified Eagle's medium containing: (1) 5% fetal bovine serum (FBS); (2) 5% FBS + ascorbic acid (AA, 50 microg/mL); (3) 5% FBS + Dex (10(-7) m) + AA; (4) 5% FBS + bFGF (10 ng/mL) + AA; or (5) 5% FBS + Dex (10(-7) m) + bFGF + AA. Cells within each group were evaluated for gene expression profile using semi-quantitative reverse transcriptase-polymerase chain reaction for COL I, III and X, MMP-1, -2, -3 and -9 and TIMP-1 and -2 on days 14 and 21 and for biomineralization by von Kossa stain in vitro on day 21. Images of PDL cells were examined using a phase contrast microscope.

RESULTS

Basic fibroblast growth factor stimulated MMP-1, MMP-3 and MMP-9 mRNA expressions and inhibited TIMP-2 mRNA expression. Treatment of cells with Dex + bFGF led to downregulation of MMP-1, MMP-3 and MMP-9 transcripts. Whilst AA alone and Dex alone induced biomineralization of PDL cells, bFGF blocked the mineralization activity of the cells. In the Dex + bFGF group, more mineral nodules were noted when compared to AA alone and Dex alone groups.

CONCLUSION

The addition of Dex to culture reversed bFGF-mediated inhibition of mineralization. Use of combined bFGF and Dex to regulate PDL cell function may be a good therapeutic option to obtain periodontal regeneration.

Periodontal and endodontic regeneration

Guided tissue regeneration (GTR) is effective in halting tissue and bone destruction and promoting new tissue and bone formation. Although the goal of complete and predictable regeneration still remains elusive, many techniques and materials have been developed that show good clinical and histologic outcomes. The most commonly used materials in GTR include bone replacement grafts from numerous sources, nonresorbable and bioabsorbable membranes, and recently growth hormones/cytokines and other host modulating factors. This article reviews the biologic rationale behind current techniques used for tissue/bone regeneration, reviews the most common materials and techniques, and attempts to explain the factors that influence the outcomes of these therapies.

Periodontal regeneration in experimentally-induced alveolar bone dehiscence by an improved porous biphasic calcium phosphate ceramic in beagle dogs

Regeneration of lost periodontium is the focus of periodontal therapy. To achieve the effective regeneration, a number of bone graft substitute materials have been developed. This study aimed to investigate the histological response in alveolar bone dehiscences which were filled with an improved biphasic calcium phosphate (BCP) ceramic with more reasonable pore diameter, pore wall thickness and porosity. Twenty-four alveolar bone dehiscences were made surgically in twelve beagle dogs by reflecting mucoperiosteal flaps on the buccal aspect of bilateral lower second premolars and removing alveolar bone. The left dehiscences were treated with BCP ceramic and the contralaterals were cured with the open flap debridement (OFD) as controls. Three dogs were used at week 4, 12, and 24 respectively. Histological observations were processed through three-dimensional micro-computed tomographic imaging, fluorescence and light microscopy. The histological study indicated that the biphasic ceramic was biocompatible, and regeneration was achieved more effectively through the BCP treatment. There were also arrest of epithelial migration apically and formation of new bone and cementum, as well as proliferation of fibrous connective tissues that became attached to the newly formed cementum at week 24, while there was no significant periodontal regeneration in the OFD group only with epithelial tissue migrating into the dehiscence regions. Clinically speaking, though the surgical location formed a limitation to the application of the improved BCP on the periodontal regeneration, the actual result was positive. It proved that the BCP had biocompatibility and was able to act as a stable scaffold to induce periodontal regeneration effectively.

Guided tissue regeneration may modulate gene expression in periodontal intrabony defects: a human study

BACKGROUND AND OBJECTIVE

Guided tissue regeneration has been shown to lead to periodontal regeneration, however, the mechanisms involved remain to be clarified. The present study was carried out to assess the expression of genes involved in the healing process of periodontal tissues in membrane-protected vs. nonprotected intrabony defects in humans.

MATERIAL AND METHODS

Thirty patients with deep intrabony defects (> or = 5 mm, two or three walls) around teeth that were scheduled for extraction were selected and randomly assigned to receive one of the following treatments: flap surgery alone (control group) or flap surgery plus guided tissue regeneration (expanded polytetrafluorethylene (e-PTFE) membrane) (test group). Twenty-one days later, the newly formed tissue was harvested and quantitatively assessed using the polymerase chain reaction assay for the expression of the following genes: alkaline phosphatase, receptor activator of nuclear factor-kappa B ligand, osteoprotegerin, osteopontin, osteocalcin, bone sialoprotein, basic fibroblast growth factor, interleukin-1, interleukin-4, interleukin-6, matrix metalloproteinase-2 and matrix metalloproteinase-9.

RESULTS

Data analysis demonstrated that mRNA levels for alkaline phosphatase, receptor activator of nuclear factor-kappa B ligand, osteoprotegerin, osteopontin, bone sialoprotein, basic fibroblast growth factor, interleukin-1, interleukin-6, matrix metalloproteinase-2 and matrix metalloproteinase -9 were higher in the sites where guided tissue regeneration was applied compared with the control sites (p < 0.05), whereas osteocalcin mRNA levels were lower (p < 0.05). No difference was observed in interleukin-4 mRNA levels between control and test groups.

CONCLUSION

Within the limits of this study, it can be concluded that genes are differentially expressed in membrane barrier-led periodontal healing when compared with flap surgery alone, and this may account for the clinical outcome achieved by guided tissue regeneration.

Induction of cementogenesis and periodontal ligament regeneration by recombinant human transforming growth factor-beta3 in Matrigel with rectus abdominis responding cells

BACKGROUND AND OBJECTIVE

In primates and in primates only, the transforming growth factor-b proteins induce endochondral bone formation. Transforming growth factor-b3 also induces periodontal tissue regeneration. Two regenerative treatments using human recombinant transforming growth factor-b3 were examined after implantation in mandibular furcation defects of the nonhuman primate, Papio ursinus.

MATERIAL AND METHODS

Class III furcation defects were surgically created bilaterally in the mandibular first and second molars of two adult Chacma baboons (P. ursinus). Different doses of recombinant transforming growth factor-beta3 reconstituted with Matrigel matrix were implanted in the rectus abdominis muscle to induce heterotopic ossicles for subsequent transplantation to selected furcation defects. Twenty days after heterotopic implantation, periodontal defects were re-exposed, further debrided and implanted with minced fragments of induced heterotopic ossicles. Contralateral class III furcation defects were implanted directly with recombinant transforming growth factor-beta3 in Matrigel matrix with the addition of minced fragments of autogenous rectus abdominis muscle. Treated quadrants were not subjected to oral hygiene procedures so as to study the effect of the direct application of the recombinant morphogen in Matrigel on periodontal healing. Histomorphometric analyses on undecalcified sections cut from specimen blocks harvested on day 60 measured the area of newly formed alveolar bone and the coronal extension of the newly formed cementum along the exposed root surfaces.

RESULTS

Morphometric analyses showed greater alveolar bone regeneration and cementogenesis in furcation defects implanted directly with 75 microg of transforming growth factor-beta3 in Matrigel matrix with the addition of minced muscle tissue.

CONCLUSION

Matrigel matrix is an optimal delivery system for the osteogenic proteins of the transforming growth factor-beta superfamily, including the mammalian transforming growth factor-beta3 isoform. The addition of minced fragments of rectus abdominis muscle provides responding stem cells for further tissue induction and morphogenesis by the transforming growth factor-beta3 protein.

Putative stem cells in regenerating human periodontium

BACKGROUND AND OBJECTIVE

Human postnatal stem cells have been identified in periodontal ligament, with the potential to regenerate the periodontium in vivo. However, it is unclear if periodontal ligament stem cells are present in regenerating periodontal tissues. The aim of this study was to identify and localize putative stem cells in block biopsies and explant cultures of regenerating human periodontal tissues.

MATERIAL AND METHODS

Guided tissue regeneration was carried out on the molars of three human volunteers. After 6 wk, the teeth with the surrounding regenerating tissues and bone were surgically removed and processed for immunohistochemistry. The mesenchymal stem cell-associated markers STRO-1, CD146 and CD44 were used to identify putative stem cells. Cell cultures established from regenerating tissue explants were analysed by flow cytometry to assess the expression of these markers. Mineralization, calcium concentration and adipogenic potential of regenerating tissue cells were assessed and compared with periodontal ligament stem cells, bone marrow stromal stem cells and gingival fibroblasts.

RESULTS

STRO-1(+), CD44(+) and CD146(+) cells were identified in the regenerating tissues. They were found mainly in the paravascular and extravascular regions. Flow cytometry revealed that cultured regenerating tissue cells expressed all three mesenchymal stem cell associated markers. The regenerating tissue cells were able to form mineral deposits and lipid-containing adipocytes. However, the level of mineralization in these cells was lower than that of periodontal ligament stem cells and bone marrow stromal stem cells.

CONCLUSION

Cells with characteristics of putative mesenchymal stem cells were found in regenerating periodontal tissues, implying their involvement in periodontal regeneration.

Treatment of periodontal intrabony defects with demineralized freeze-dried bone allograft in combination with platelet-rich plasma: a comparative clinical trial

BACKGROUND

The aim of the present randomized, double-masked, clinical trial was to compare platelet-rich plasma (PRP) combined with a demineralized freeze-dried bone allograft (DFDBA) to DFDBA mixed with a saline solution in the treatment of human intrabony defects.

METHODS

Sixty interproximal intrabony osseous defects in 60 healthy, non-smoking subjects diagnosed with chronic periodontitis were treated in this study. Thirty subjects each were randomly assigned to the test group (PRP + DFDBA) or the control group (DFDBA + saline). Clinical and radiographic measurements were made at baseline and at the 12-month evaluation.

RESULTS

Compared to baseline, the 12-month results indicated that both treatment modalities resulted in significant changes in all clinical parameters (gingival index, bleeding on probing, probing depth, clinical attachment level, and gingival recession; P <0.001) and radiographic parameters (hard tissue fill and bone depth reduction; P <0.001). However, the test group exhibited statistically significantly greater changes compared to the control group in probing depth reduction (4.3 +/- 1.7 mm versus 2.6 +/- 2.2 mm; P <0.05) and clinical attachment gain (3.5 +/- 2.1 mm versus 2.3 +/- 2.4 mm; P <0.001).

CONCLUSIONS

Treatment with a combination of PRP and DFDBA led to a significantly greater clinical improvement in intrabony periodontal defects compared to DFDBA with saline. No statistically significant differences were observed in the hard tissue response between the two treatment groups, which confirmed that PRP had no effect on hard tissue fill or gain in new hard tissue formation.

Apical tooth germ cell-conditioned medium enhances the differentiation of periodontal ligament stem cells into cementum/periodontal ligament-like tissues

BACKGROUND AND OBJECTIVE

Limitations of current periodontal regeneration modalities in both predictability and extent of healing response, especially on new cementum and attachment formation, underscore the importance of restoring or providing a microenvironment that is capable of promoting the differentiation of periodontal ligament stem cells (PDLSCs) towards cementoblast-like cells and the formation of cementum/periodontal ligament-like tissues. The aim of this study was to investigate the biological effect of conditioned medium from developing apical tooth germ cells (APTG-CM) on the differentiation and cementogenesis of PDLSCs both in vitro and in vivo.

MATERIAL AND METHODS

Using the limiting dilution technique, single-colony-derived human PDLSCs were isolated and expanded to obtain homogeneous populations of PDLSCs. Morphological appearance, cell cycle analysis, bromodeoxyuridine incorporation, alkaline phosphatase (ALP) activity, mineralization behavior, gene expression of cementoblast phenotype and in vivo differentiation capacities of PDLSCs co-cultured with APTG-CM were evaluated.

RESULTS

The induced PDLSCs exhibited several characteristics of cementoblast lineages, as indicated by the morphological changes, increased proliferation, high ALP activity, and the expression of cementum-related genes and calcified nodule formation in vitro. When transplanted into immunocompromised mice, the induced PDLSCs showed tissue-regenerative capacity to produce cementum/periodontal ligament-like structures, characterized by a layer of cementum-like mineralized tissues and associated periodontal ligament-like collagen fibers connecting with the newly formed cementum-like deposits, whereas control, untreated PDLSCs transplants mainly formed connective tissues.

CONCLUSION

Our findings suggest that APTG-CM is able to provide a cementogenic microenvironment and induce differentiation of PDLSCs along the cementoblastic lineage. This has important implications for periodontal engineering.

Extracellular matrix expression and periodontal wound-healing dynamics following guided tissue regeneration therapy in canine furcation defects

AIM

Temporal and spatial expression pattern of extracellular matrix (ECM) components in furcation defects following guided tissue regeneration (GTR) compared with open-flap debridement (OFD).

MATERIAL AND METHODS

In 21 dogs, mandibular second and fourth pre-molars were treated with one non-resorbable and three different resorbable membranes. Third pre-molars were treated by OFD. After 2, 4, 8 weeks and 3, 6, and 12 months, tissues were analysed by immunohistochemistry for collagen I (Col-I) and III (Col-III), fibronectin (FN), bone sialoprotein (BSP), and osteopontin (OPN).

RESULTS

At 2 weeks, the defect was mainly occupied by FN+ granulation tissue (GT), which was sequentially replaced by new connective tissue expressing FN, Col-I, and increasingly Col-III. Following superficial resorptions by OPN+ osteoclasts and odontoclasts, cementum and bone formation ensued with strong expression of BSP and OPN along bone and tooth surfaces. Deposition of Col-I, FN, BSP and OPN+ cementoid and osteoid became evident after 4 weeks. Extrinsic fibres of cementum and bone stained intensely for Col-III. The newly formed periodontal ligament expressed FN, Col-I, and Col-III, but no BSP or OPN.

CONCLUSIONS

The spatial ECM expression was similar for OFD and the different GTR methods, although the timing and quantity of ECM expression were influenced by wound stabilization and inflammatory reactions.

Lysophosphatidic acid modulates the healing responses of human periodontal ligament fibroblasts and enhances the actions of platelet-derived growth factor

BACKGROUND

Platelet-derived growth factor (PDGF) has been used to promote healing in many in vitro and in vivo models of periodontal regeneration. PDGF interacts extensively with lysophosphatidic acid (LPA). We recently showed that LPA modulates the responses of human gingival fibroblasts to PDGF. The objectives of this study were as follows: 1) to evaluate the basic interactions of LPA with primary human periodontal ligament fibroblasts (PDLFs) alone and with PDGF-BB for promoting PDLF growth and migration; 2) to determine the effects in an in vitro oral wound-healing model; and 3) to identify the LPA receptors (LPARs) expressed by PDLF.

METHODS

PDLF regenerative responses were measured using 1 and 10 microM LPA in the absence or presence of 1 or 10 ng/ml PDGF. Cell proliferation was determined by 5-bromo-2'-deoxyuridine (BrdU) immunohistochemistry and by cell counting. Migration responses were measured using a microchemotaxis chamber. PDLFs were grown to confluence on glass slides, a 3-mm-wide wound was mechanically inflicted, and wound fill on days 4, 6, and 9 was reported. PDLF LPAR expression was determined using Western blotting.

RESULTS

PDLFs exhibited proliferative and chemotactic responses to LPA; these responses were enhanced when LPA and PDGF were present together. LPA plus PDGF elicited complete wound fill. PDLFs express the LPARs LPA(1), LPA(2), and LPA(3).

CONCLUSIONS

To our knowledge, this study provides the first evidence that LPA stimulates human PDLF wound healing responses and interacts positively with PDGF to regulate these actions. These results suggest that LPA and its receptors play important modulatory roles in PDLF regenerative biology.

The effect of different platelet-rich plasma concentrations on proliferation and differentiation of human periodontal ligament cells in vitro

OBJECTIVES

The use of platelets and platelet products has become increasingly popular clinically as a means of accelerating endosseous wound healing. It is likely that growth factors released by activated platelets at the site of injury play a role in periodontal regeneration by regulating cellular activity. The purpose of this study was to evaluate the biological effects of platelet-rich plasma (PRP) on human periodontal ligament cells (hPDLCs) in vitro.

MATERIALS AND METHODS

Primary cultures of hPDLCs were obtained from healthy premolars. PRP was isolated by two-step centrifugation. Two main growth factors present in the thrombin-activated PRP (platelet-derived growth factor [PDGF-AB] and transforming growth factor-beta1 [TGF-beta1]) were evaluated using ELISA assay. Activated PRP or the combination of recombined human TGF-beta1 (rhTGF-beta1) and PDGF-AB (rhPDGF-AB) were added to hPDLCs in different concentrations to assess cell proliferation and osteogenic differentiation.

RESULTS

PRP contained high levels of TGF-beta1 and PDGF-AB. Cell attachment, proliferation and ALP activity were enhanced by addition of PRP or rhTGF-beta1 and rhPDGF-AB combination to the cell cultures, while the stimulatory potency of PRP was much greater than the latter. These stimulatory effects presented in a dose-dependant manner, it seemed that PRP with 50~100 ng/ml TGF-beta1 was an ideal concentration.

CONCLUSIONS

PRP can enhance hPDLC adhesion, proliferation and induce the differentiation of hPDLC into mineralized tissue formation cell; thereby contribute to the main processes of periodontal tissue regeneration. For economical and biological reasons, PRP has more clinical beneficial than analogous growth factors.

Favorable Periodontal Healing of 1-Wall Infrabony Defects After Application of Calcium Phosphate Cement Wall Alone or in Combination With Enamel Matrix Derivative: A Pilot Study With Canine Mandibles

BACKGROUND

Although various periodontal regenerative therapies are used, their effects on non-contained infrabony defects are unpredictable. Our previous studies showed that injectable, moldable, fast-setting calcium phosphate cement (CPC) promoted histocompatible periodontal healing in 3-wall intrabony defects. The present study evaluated healing patterns after surgical application of CPC walls with and without an enamel matrix derivative (EMD) in 1-wall infrabony defects in dogs.

METHODS

One-wall infrabony defects (5 x 5 x 4 mm) were created surgically on the mesial and distal sides of bilateral mandibular fourth premolars in four beagle dogs. After elevating a full-thickness flap, exposed root surfaces were planed thoroughly. The 16 defects were assigned randomly to one of the following experimental conditions: CPC, CPC+EMD, EMD, and open flap debridement (OFD). Ten weeks post-surgery, the animals were sacrificed, and histologic specimens were prepared for histomorphometric evaluation.

RESULTS

Defect sites treated with EMD only exhibited varying degrees of new cementum and new bone formation, whereas the OFD group presented only limited new cementum and bone formation. Defect sites where a CPC wall was implanted (CPC and CPC+EMD groups) revealed significantly greater regeneration of new bone and new cementum than in the EMD and OFD groups. No significant differences were observed between the CPC and CPC+EMD groups.

CONCLUSIONS

CPC walls with and without EMD promoted regeneration of alveolar bone and cementum in 1-wall infrabony defects. Space and stable wound healing are believed to be crucial for periodontal regeneration in non-contained infrabony defects.

In vitro effects of enamel matrix derivative on microvascular cells

BACKGROUND

Periodontal regeneration requires a coordinated series of events that includes not only the recruitment of periodontal ligament (PDL)-specific cells, but vascular cells as well. The mechanisms of action of enamel matrix derivative (EMD) are poorly understood, and its effects on vascular cells are unknown. The objective of this study was to examine the extent to which EMD affects angiogenesis and PDL cell recruitment.

METHODS

The effects of EMD on human microvascular endothelial cells (HMVECs) were determined by examining proliferation, chemotaxis, angiogenesis, and migration. Proliferation was determined using water-soluble tetrazolium salt (WST)-1 reagent. Chemotaxis was determined using microporous-culture well inserts. Angiogenesis was assessed on plates containing matrigel. The effects of HMVECs on the migration of PDL cells were assessed by evaluating PDL cell outgrowth from collagen gels cultured in the presence of HMVECs on fibrin matrix and surrounded by fibronectin-containing fibrin clots at 24 hours. Effects of EMD on PDL expression of vascular endothelial cell (VEGF) types (A, B, C, and D) and isoforms were determined using reverse transcription-polymerase chain reaction (RT-PCR). Production of VEGF, platelet-derived growth factor (PDGF)-AA, PDGF-BB, PDGF-AB, and transforming growth factor (TGF)-beta1 by EMD-stimulated PDL cells was assessed quantitatively in conditioned media using specific enzyme-linked immunosorbent assays (ELISAs).

RESULTS

EMD at concentrations <50 microg/ml resulted in significant (P <0.05) stimulation of HMVEC proliferation. Compared to baseline, EMD also stimulated a 100% increase in HMVEC chemotaxis when PDL cells were present (P <0.05). All doses of EMD tested (25, 50, and 100 microg/ml) increased angiogenesis in vitro. HMVECs, in combination with EMD at a concentration of 100 microg/ml, stimulated a 750% increase in migration of PDL cells from collagen gels into fibrin clots compared to controls when neither was present. RT-PCR results indicated that PDL cells expressed VEGF-A, -B, and -C and multiple isoforms of VEGF-A, including VEGF(121), VEGF(165), and VEGF(189), whether or not EMD was present in the culture media. ELISAs determined a 400% increase in VEGF concentration by PDL C cells in EMD-stimulated conditioned media and a similar increase in TGF-beta(1)-stimulated media.

CONCLUSIONS

It is likely that EMD stimulates angiogenesis directly by stimulating endothelial cells and indirectly by stimulating the production of angiogenic factors (VEGF) by PDL cells. Importantly, the data are consistent with the concept that EMD enhances bidirectional communication between HMVEC and PDL cells during angiogenesis associated with healing.

Anabolic agents and the bone morphogenetic protein pathway

A major unmet need in the medical field today is the availability of suitable treatments for the ever-increasing incidence of osteoporosis and the treatment of bone deficit conditions. Although therapies exist which prevent bone loss, the options are extremely limited for patients once a substantial loss of skeletal bone mass has occurred. Patients who have reduced bone mass are predisposed to fractures and further morbidity. The FDA recently approved PTH (1-34) (Teriparatide) for the treatment of postmenopausal osteoporosis after both preclinical animal and clinical human studies indicated it induces bone formation. This is the only approved bone anabolic agent available but unfortunately it has limited use, it is relatively expensive and difficult to administer. Consequently, the discovery of low cost orally available bone anabolic agents is critical for the future treatment of bone loss conditions. The intricate process of bone formation is co-ordinated by the action of many different bone growth factors, some stored in bone matrix and others released into the bone microenvironment from surrounding cells. Although all these factors play important roles, the bone morphogenetic proteins (BMPs) clearly play a central role in both bone cartilage formation and repair. Recent research into the regulation of the BMP pathway has led to the discovery of a number of small molecular weight compounds as candidate bone anabolic agents. These agents may usher in a new wave of more innovative and versatile treatments for osteoporosis as well as orthopedic and dental indications.

Recapitulating Development: A Template for Periodontal Tissue Engineering

The induction of bone formation by the soluble osteogenic molecular signals of the transforming growth factor-beta (TGF-beta) superfamily is a critical issue to periodontologists, molecular biologists, and tissue engineers alike, because preclinical studies in primates and clinical trials have demonstrated the bone induction capacity of bone morphogenetic and osteogenic proteins (BMPs/OPs) in clinical context. BMPs/OPs, pleiotropic members of the TGF-beta superfamily, induce de novo endochondral bone formation as a recapitulation of embryonic development and act as soluble signals for tissue morphogenesis sculpting the multicellular mineralized structures of the periodontal tissues with functionally oriented periodontal ligament fibers inserting into newly formed cementum. This paper reviews the induction of the complex tissue morphologies of the periodontal tissues in the nonhuman primate Papio ursinus with furcation defects treated with doses of naturally derived and recombinantly produced human BMPs/OPs. Periodontal tissue regeneration develops as a mosaic structure in which the OPs of the TGF-beta superfamily singly, synergistically, and synchronously initiate and maintain tissue induction and morphogenesis.

Influence of autologous platelet concentrate on healing in intra-bony defects following guided tissue regeneration therapy: a randomized prospective clinical split-mouth study

OBJECTIVES

To investigate the influence of autologous platelet concentrate (APC) on early wound healing and regeneration outcomes following guided tissue regeneration (GTR) therapy.

MATERIAL AND METHODS

In 25 patients, two contralateral deep intra-bony defects were treated with beta-TCP and a bioresorbable GTR membrane. They were randomly assigned to test and control procedure. In test defects, APC was additionally applied. After 3, 6, and 12 months, healing results were assessed by clinical parameters and quantitative digital subtraction radiography.

RESULTS

Post-operative membrane exposures occurred in 48% of the test sites and 80% of the control sites. Both groups revealed a significant clinical attachment level (CAL) gain of 5 mm after 12 months. Eighty-eight per cent of test and control sites showed a CAL gain of > or =4 mm. No clinical parameter revealed significant differences between test and control sites. A significant bone density gain was found in both groups after 3, 6, and 12 months. Only after 6 months, the bone density gain was significantly greater in the test defects.

CONCLUSION

Within the limits of this study, autologous platelet concentrate did not seem to have a noticeable influence on the clinical and most of the radiographic outcomes following GTR. However, APC might reduce the occurrence of post-operative membrane exposures and accelerate bone density gain.

Role of growth factors on periodontal repair

Regeneration of periodontal structures lost during periodontal diseases constitutes a complex biological process regulated among others by interactions between cells and growth factors. Growth factors are biologically active polypeptides affecting the proliferation, chemotaxis and differentiation of cells from epithelium, bone and connective tissue. They express their action by binding to specific cell-surface receptors present on various target cells including osteoblasts, cementoblasts and periodontal ligament fibroblasts. The observation that growth factors participate in all cell functions led to exogenous application during periodontal tissue repair aiming to their use as an alternative therapeutic approach to periodontal therapy. Cell types and cultures conditions, dose, carrier materials, application requirements are of critical importance in the outcome of periodontal repair. The purpose of this article is to review the literature with respect to the biological actions of PDGF, TGF, FGF, IGF and EGF on periodontal cells and tissues, which are involved in periodontal regeneration.

Growth factors and cytokines in autologous platelet concentrate and their correlation to periodontal regeneration outcomes

AIM

To determine the concentration of naturally available biologic mediators in autologous platelet concentrates and their correlation with periodontal regeneration outcomes.

MATERIAL AND METHODS

In 25 patients with two intra-bony defects each, an autologous platelet concentrate (APC) was prepared by a laboratory thrombocyte apheresis technique pre-operatively. Both defects were treated using a bioresorbable guided tissue regeneration-membrane in combination with tricalciumphosphate (TCP). In the test defect, APC was additionally applied. In the APC, platelets were counted and the levels of growth factors and cytokines were determined by ELISA. Correlations between the platelet counts or the growth factor/cytokine levels and the potential clinical and radiographic regeneration outcomes due to APC were calculated after 3, 6, and 12 months.

RESULTS

The APC contained 2.2 x 10(6) platelets/mul, which was 7.9 times more than in the venous blood. Transforming growth factor-beta1 (TGF-beta1), insulin-like growth factor-I (IGF-I), platelet-derived growth factor-AB (PDGF-AB), PDGF-BB, vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF) were found in the APC, whereas interleukin-1beta (IL-1beta), IL-6, tumor necrosis factor alpha (TNFalpha), IL-4, and IL-10 were not detectable. The regression analysis showed a weak correlation between the platelet counts or the growth factor levels and the clinical and radiographic regeneration outcomes (r2<or=0.4).

CONCLUSION

Autologous platelet concentrate contains relatively high concentrations of PDGF-AB, PDGF-BB, TGF-beta1, and IGF-I, but their potential influence on periodontal regeneration remains unclear.

Insulin-like growth factor system components in the periodontium during tooth root resorption and early repair processes in the rat

There is evidence that growth factors, such as the insulin-like growth factors (IGFs), are involved in biological and pathological processes in oro-dento-facial tissues. To investigate their roles in tooth movement, root resorption, and repair, the occurrence of components of the IGF system, including the ligands IGF-I and -II, the IGF receptor 1 (IGF1R) and six IGF-binding proteins (IGFBP-1 to -6), was investigated by immunohistochemistry on sections from rat maxillae where the first molar had been moved mesially by means of an orthodontic appliance for 9 d to induce root resorption. After force deactivation on day 0, early repair was studied after a further 5, 7, 10, 12, 14, and 17 d. The immunostaining pattern in the periodontal ligament, cementum, and bone of control animals showed similarities known from studies in human teeth. Increased immunostaining for nearly all components in pressure sides and resorption lacunae indicated an involvement in resorption processes and clastic activities. During early stages of repair, the occurrence of several components (e.g. IGF-II, IGFBP-5 or -6) within lacunae and in cementoblasts showed an involvement in the resorption-repair sequence, which is considered to be a coupling process as known from bone.

The epithelial cell rests of Malassez--a role in periodontal regeneration?

This article reviews general aspects about the epithelial cell rests of Malassez (ERM). The historical and general morphological features of the ERM are briefly described. The embryological derivation of the ERM is presented as an important consideration in understanding the events associated with their origin and possible functional roles within the periodontal ligament. The ultrastructural description of the ERM is also included to complement the morphological characteristics which distinguish these cells as the unique epithelial element of the periodontal ligament. The unique ability of these cells to synthesize and secrete a number of proteins usually associated with cells of mesenchymal origin, rather than ectodermal origin, is discussed in light of their role in cementum repair and regeneration. Such considerations lead to our hypothesis that one of the functional roles of the ERM may lie not only their role in maintaining and contributing to the normal periodontal cellular elements and function but also contributing, in a significant manner, to periodontal regeneration.