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Arhar A, Pavlič A, Hočevar L. Characteristics of oral health of patients with X-linked hypophosphatemia: case reports and literature review. BDJ Open 2024; 10:42. [PMID: 38821917 PMCID: PMC11143263 DOI: 10.1038/s41405-024-00223-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Oral health is impaired in X-linked hypophosphatemia (XLH), resulting in delayed dental development, malocclusion, and radiographic abnormalities. This study investigates the oral manifestations in Slovenian XLH patients, focusing on enamel and dentin abnormalities and a literature review of spontaneous periapical abscesses in XLH cases. OBJECTIVES To report XLH patients with specific oral signs and symptoms, histological analysis of affected teeth, and review of reported cases of XLH patients with spontaneous periapical abscesses. METHODS Case reports: Seven XLH patients from the National Registry of Patients with Rare Diseases underwent a detailed oral examination, including X-ray reviews. The patients who were expected to have tooth exfoliation or extraction were asked to donate their teeth for histological analysis by scanning electron microscopy. LITERATURE SEARCH A literature search of four electronic databases and a manual bibliography search aimed to identify documented cases of XLH with periapical abscesses up to January 21, 2024. Inclusion criteria were confirmed XLH patients with periapical abscesses in English peer-reviewed publications. RESULTS Tooth samples from three XLH patients showed reduced dentin mineralisation, affecting one-third to one-half of the outer dentin. Inadequate mineralisation, uneven dentin tubules, and cracks and chipping in the enamel were observed, indicating mineralisation deviations. Similar cracks extended into the dentin and were also present in the root of the examined tooth. Based on the content of the 75 items identified in the search, spontaneous abscesses are not uncommon in patients with XLH. CONCLUSIONS XLH significantly affects patients' lives and requires lifelong treatment. Dental examinations consistently revealed oral problems, including malocclusion. Histological analysis confirmed structural changes, especially in the dentin. Despite continued treatment, XLH patients may have an increased risk of oral pathologies. Further research is needed to understand the impact of XLH and its treatment on dental health.
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Affiliation(s)
- Ana Arhar
- Department of Paediatric and Preventive Dentistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
| | - Alenka Pavlič
- Department of Paediatric and Preventive Dentistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
- Department of Paediatric and Preventive Dentistry, University Medical Centre Ljubljana, Zaloška 2, Ljubljana, Slovenia
| | - Luka Hočevar
- Department of Paediatric and Preventive Dentistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia.
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Abdullah A, Wuersching SN, Kollmuss M, Poxleitner P, Dewenter I, Brandenburg LS, Steybe D, Fegg FN, Smolka W, Otto S, Obermeier KT. X-Linked Hypophosphatemia: Does Targeted Therapy Modify Dental Impairment? J Clin Med 2023; 12:7546. [PMID: 38137614 PMCID: PMC10744150 DOI: 10.3390/jcm12247546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/22/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
X-linked hypophosphatemia is a rare, hereditary disorder that significant influences teeth and alveolar bone. The first clinical sign leading to the diagnosis of X-linked hypophosphatemia is often dental impairment with dental abscesses and dentin mineralization defects. Genetic analysis helped find the responsible gene and therefore opened up new ways of therapeutically managing X-linked hypophosphatemia. The human monoclonal antibody Burosumab represents a milestone in the targeted therapy of this hereditary disease by directly addressing its pathophysiology. Targeted therapy has been shown to improve skeletal impairment, pain, and phosphate metabolism. However, the influence of this new therapy on dental impairment has only been addressed in a few recent studies with varying results. Therefore, in this review, we aim to summarize the dental phenotype and analyze the different treatment modalities with a focus on dental impairment.
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Affiliation(s)
- Anusha Abdullah
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, 80337 Munich, Germany
| | - Sabina Noreen Wuersching
- Department of Conservative Dentistry and Periodontology, University Hospital, LMU Munich, Goethestrasse 70, 80336 Munich, Germany
| | - Maximilian Kollmuss
- Department of Conservative Dentistry and Periodontology, University Hospital, LMU Munich, Goethestrasse 70, 80336 Munich, Germany
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, 80337 Munich, Germany
| | - Ina Dewenter
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, 80337 Munich, Germany
| | - Leonard Simon Brandenburg
- Medical Center—University of Freiburg, Center for Dental Medicine, Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - David Steybe
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, 80337 Munich, Germany
| | - Florian Nepomuk Fegg
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, 80337 Munich, Germany
| | - Wenko Smolka
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, 80337 Munich, Germany
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, 80337 Munich, Germany
| | - Katharina Theresa Obermeier
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, 80337 Munich, Germany
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Mohamed FF, de Oliveira FA, Kinoshita Y, Yalamanchili RR, Eltilib LA, Andras NL, Narisawa S, Tani T, Chu EY, Millán JL, Foster BL. Dentoalveolar Alterations in an Adenine-Induced Chronic Kidney Disease Mouse Model. J Bone Miner Res 2023; 38:1192-1207. [PMID: 37191192 PMCID: PMC10524958 DOI: 10.1002/jbmr.4829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/02/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023]
Abstract
Chronic kidney disease (CKD) is characterized by kidney damage and loss of renal function. CKD mineral and bone disorder (CKD-MBD) describes the dysregulation of mineral homeostasis, including hyperphosphatemia and elevated parathyroid hormone (PTH) secretion, skeletal abnormalities, and vascular calcification. CKD-MBD impacts the oral cavity, with effects including salivary gland dysfunction, enamel hypoplasia and damage, increased dentin formation, decreased pulp volume, pulp calcifications, and altered jaw bones, contributing to clinical manifestations of periodontal disease and tooth loss. Underlying mechanisms are not fully understood, and CKD mouse models commonly require invasive procedures with high rates of infection and mortality. We aimed to characterize the dentoalveolar effects of an adenine diet (AD)-induced CKD (AD-CKD) mouse model. Eight-week-old C57BL/6J mice were provided either a normal phosphorus diet control (CTR) or adenine and high-phosphorus diet CKD to induce kidney failure. Mice were euthanized at 15 weeks old, and mandibles were collected for micro-computed tomography and histology. CKD mice exhibited kidney failure, hyperphosphatemia, and hyperparathyroidism in association with porous cortical bone in femurs. CKD mice showed a 30% decrease in molar enamel volume compared to CTR mice. Enamel wear was associated with reduced ductal components, ectopic calcifications, and altered osteopontin (OPN) deposition in submandibular salivary glands of CKD mice. Molar cusps in CKD mice were flattened, exposing dentin. Molar dentin/cementum volume increased 7% in CKD mice and pulp volume decreased. Histology revealed excessive reactionary dentin and altered pulp-dentin extracellular matrix proteins, including increased OPN. Mandibular bone volume fraction decreased 12% and bone mineral density decreased 9% in CKD versus CTR mice. Alveolar bone in CKD mice exhibited increased tissue-nonspecific alkaline phosphatase localization, OPN deposition, and greater osteoclast numbers. AD-CKD recapitulated key aspects reported in CKD patients and revealed new insights into CKD-associated oral defects. This model has potential for studying mechanisms of dentoalveolar defects or therapeutic interventions. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Fatma F. Mohamed
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Flavia Amadeu de Oliveira
- Sanford Children’s Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Yuka Kinoshita
- Sanford Children’s Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Riti R. Yalamanchili
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Leena A. Eltilib
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Natalie L. Andras
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Sonoko Narisawa
- Sanford Children’s Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Takashi Tani
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Emily Y. Chu
- Department of General Dentistry, Operative Division, University of Maryland School of Dentistry, Baltimore, Maryland, USA
| | - José Luis Millán
- Sanford Children’s Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Brian L. Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
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Seefried L, Duplan MB, Briot K, Collins MT, Evans R, Florenzano P, Hawkins N, Javaid MK, Lachmann R, Ward LM. Anticipated effects of burosumab treatment on long-term clinical sequelae in XLH: expert perspectives. Front Endocrinol (Lausanne) 2023; 14:1211426. [PMID: 37547321 PMCID: PMC10400326 DOI: 10.3389/fendo.2023.1211426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/27/2023] [Indexed: 08/08/2023] Open
Abstract
X-linked hypophosphatemia (XLH) is a rare, progressive, genetic disease with multisystem impact that typically begins to manifest in early childhood. Two treatment options exist: oral phosphate in combination with active vitamin D ("conventional therapy") and a fully human monoclonal anti-FGF23 antibody, burosumab. The clinical benefit of conventional therapy in adults is limited, and poor tolerance and complications are common. Burosumab was first approved as a treatment for XLH in 2018 and its disease-modifying benefits in clinical trials in children suggest burosumab treatment could also alter the disease course in adults. Without long-term clinical data on multiple XLH-related sequelae available, the results of an elicitation exercise are reported, in which eight global experts in XLH posited how long-term treatment with burosumab is anticipated to impact the life course of clinical sequelae in adults with XLH. Based on their clinical experiences, the available evidence and their disease understanding, the experts agreed that some long-term benefits of using burosumab are likely in adults with XLH even if they have a misaligned skeleton from childhood. Burosumab treatment is anticipated to reduce the incidence of fractures and halt the progression of clinical sequelae associated with conventional therapy. While the trajectories for established dental abscesses are not expected to improve with burosumab treatment, dental abscess development may be prevented. Starting treatment with burosumab in childhood to increase the likelihood of an aligned skeleton and continuation into and throughout adulthood to maintain euphosphatemia may optimize patient outcomes, although future real-world investigation is required to support this hypothesis.
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Affiliation(s)
- Lothar Seefried
- Orthopedic Department, University of Würzburg, Würzburg, Germany
| | - Martin Biosse Duplan
- Service de Médecine Bucco-Dentaire, Hôpital Bretonneau, AP-HP, Paris, France
- UFR d’Odontologie, Université de Paris, Paris, France
- Institut Imagine, INSERM, Paris, France
| | - Karine Briot
- Department of Rheumatology, Hôpital Cochin, Université de Paris-Cité, Paris, France
| | - Michael T. Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
| | - Rachel Evans
- Health Economics, Visible Analytics, Oxford, United Kingdom
| | - Pablo Florenzano
- Department of Endocrinology, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Endocrinology, Centro Traslacional en Endocrinologia (CETREN-UC), Santiago, Chile
| | - Neil Hawkins
- Health Economics, Visible Analytics, Oxford, United Kingdom
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Leanne M. Ward
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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Wölfel EM, von Kroge S, Matthies L, Koehne T, Petz K, Beikler T, Schmid-Herrmann CU, Kahl-Nieke B, Tsiakas K, Santer R, Muschol NM, Herrmann J, Busse B, Amling M, Rolvien T, Jandl NM, Barvencik F. Effects of Infantile Hypophosphatasia on Human Dental Tissue. Calcif Tissue Int 2023; 112:308-319. [PMID: 36414794 PMCID: PMC9968273 DOI: 10.1007/s00223-022-01041-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022]
Abstract
Hypophosphatasia (HPP) is an inherited, systemic disorder, caused by loss-of-function variants of the ALPL gene encoding the enzyme tissue non-specific alkaline phosphatase (TNSALP). HPP is characterized by low serum TNSALP concentrations associated with defective bone mineralization and increased fracture risk. Dental manifestations have been reported as the exclusive feature (odontohypophosphatasia) and in combination with skeletal complications. Enzyme replacement therapy (asfotase alfa) has been shown to improve respiratory insufficiency and skeletal complications in HPP patients, while its effects on dental status have been understudied to date. In this study, quantitative backscattered electron imaging (qBEI) and histological analysis were performed on teeth from two patients with infantile HPP before and during asfotase alfa treatment and compared to matched healthy control teeth. qBEI and histological methods revealed varying mineralization patterns in cementum and dentin with lower mineralization in HPP. Furthermore, a significantly higher repair cementum thickness was observed in HPP compared to control teeth. Comparison before and during treatment showed minor improvements in mineralization and histological parameters in the patient when normalized to matched control teeth. HPP induces heterogeneous effects on mineralization and morphology of the dental status. Short treatment with asfotase alfa slightly affects mineralization in cementum and dentin. Despite HPP being a rare disease, its mild form occurs at higher prevalence. This study is of high clinical relevance as it expands our knowledge of HPP and dental involvement. Furthermore, it contributes to the understanding of dental tissue treatment, which has hardly been studied so far.
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Affiliation(s)
- Eva Maria Wölfel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
- Interdisciplinary Competence Center for Interface Research (ICCIR), Lottestr. 55A, Hamburg, Germany
| | - Simon von Kroge
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
| | - Levi Matthies
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Till Koehne
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
- Department of Orthodontics, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karin Petz
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Thomas Beikler
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carmen Ulrike Schmid-Herrmann
- Department of Orthodontics, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Bärbel Kahl-Nieke
- Department of Orthodontics, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Konstantinos Tsiakas
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nicole Maria Muschol
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Jochen Herrmann
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Section of Pediatric Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Björn Busse
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
- Interdisciplinary Competence Center for Interface Research (ICCIR), Lottestr. 55A, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
| | - Tim Rolvien
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nico Maximilian Jandl
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany.
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Abstract
Hypophosphatemic rickets typically presents in infancy or early childhood with skeletal deformities and growth plate abnormalities. The most common causes are genetic (such as X-linked hypophosphatemia), and these typically will result in lifelong hypophosphatemia and osteomalacia. Knowledge of phosphate metabolism, including the effects of fibroblast growth factor 23 (FGF23) (an osteocyte produced hormone that downregulates renal phosphate reabsorption and 1,25-dihydroxyvitamin-D (1,25(OH)2D) production), is critical to determining the underlying genetic or acquired causes of hypophosphatemia and to facilitate appropriate treatment. Serum phosphorus should be measured in any child or adult with musculoskeletal complaints suggesting rickets or osteomalacia. Clinical evaluation incudes thorough history, physical examination, laboratory investigations, genetic analysis (especially in the absence of a guiding family history), and imaging to establish etiology and to monitor severity and treatment course. The treatment depends on the underlying cause, but often includes active forms of vitamin D combined with phosphate salts, or anti-FGF23 antibody treatment (burosumab) for X-linked hypophosphatemia. The purpose of this article is to explore the approach to evaluating hypophosphatemic rickets and its treatment options.
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Affiliation(s)
- Sarah A Ackah
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Erik A Imel
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Dotta TC, Hayann L, de Padua Andrade Almeida L, Nogueira LFB, Arnez MM, Castelo R, Cassiano AFB, Faria G, Martelli-Tosi M, Bottini M, Ciancaglini P, Catirse ABCEB, Ramos AP. Strontium Carbonate and Strontium-Substituted Calcium Carbonate Nanoparticles Form Protective Deposits on Dentin Surface and Enhance Human Dental Pulp Stem Cells Mineralization. J Funct Biomater 2022; 13:jfb13040250. [PMID: 36412891 PMCID: PMC9680411 DOI: 10.3390/jfb13040250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Strontium acetate is applied for dental hypersensitivity treatment; however, the use of strontium carbonates for this purpose has not been described. The use of Sr-carbonate nanoparticles takes advantage of both the benefits of strontium on dentin mineralization and the abrasive properties of carbonates. Here in, we aimed to synthesize strontium carbonate and strontium-substituted calcium carbonate nanoparticles and test them as potential compounds in active dentifrices for treating dental hypersensitivity. For this, SrCO3, Sr0.5Ca0.5CO3, and CaCO3 nanoparticles were precipitated using Na2CO3, SrCl2, and/or CaCl2 as precursors. Their morphology and crystallinity were evaluated by electron microscopy (SEM) and X-ray diffraction, respectively. The nanoparticles were added to a poly (vinyl alcohol) gel and used to brush dentin surfaces isolated from human third molars. Dentin chemical composition before and after brushing was investigated by infrared spectroscopy (FTIR) and X-ray dispersive energy spectroscopy. Dentin tubule morphology, obliteration, and resistance of the coatings to acid attack were investigated by SEM and EDS. The cytotoxicity and ability of the particles to trigger the mineralization of hDPSCs in vitro were studied. Dentin brushed with the nanoparticles was coated by a mineral layer that was also able to penetrate the tubules, while CaCO3 remained as individual particles on the surface. FTIR bands related to carbonate groups were intensified after brushing with either SrCO3 or Sr0.5Ca0.5CO3. The shift of the phosphate-related FTIR band to a lower wavenumber indicated that strontium replaced calcium on the dentin structure after treatment. The coating promoted by SrCO3 or Sr0.5Ca0.5CO3 resisted the acid attack, while calcium and phosphorus were removed from the top of the dentin surface. The nanoparticles were not toxic to hDPSCs and elicited mineralization of the cells, as revealed by increased mineral nodule formation and enhanced expression of COL1, ALP, and RUNX2. Adding Sr0.5Ca0.5CO3 as an active ingredient in dentifrices formulations may be commercially advantageous since this compound combines the well-known abrasive properties of calcium carbonate with the mineralization ability of strontium, while the final cost remains between the cost of CaCO3 and SrCO3. The novel Sr0.5Ca0.5CO3 nanoparticles might emerge as an alternative for the treatment of dental hypersensitivity.
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Affiliation(s)
- Tatiane Cristina Dotta
- Department of Dental Materials and Prosthodontics, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto 14040-904, Brazil
| | - Larwsk Hayann
- Department of Chemistry, Ribeirão Preto Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto 14040-901, Brazil
| | - Leonardo de Padua Andrade Almeida
- Department of Dental Materials and Prosthodontics, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto 14040-904, Brazil
| | - Lucas Fabrício B. Nogueira
- Department of Chemistry, Ribeirão Preto Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto 14040-901, Brazil
| | - Mayara M. Arnez
- Department of Dental Materials and Prosthodontics, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto 14040-904, Brazil
| | - Raisa Castelo
- Department of Dental Materials and Prosthodontics, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto 14040-904, Brazil
| | - Ana Flávia B. Cassiano
- Department of Restorative Dentistry, School of Dentistry at Araraquara, Sao Paulo State University (UNESP), Araraquara 14801-385, Brazil
| | - Gisele Faria
- Department of Restorative Dentistry, School of Dentistry at Araraquara, Sao Paulo State University (UNESP), Araraquara 14801-385, Brazil
| | - Milena Martelli-Tosi
- Department of Chemistry, Ribeirão Preto Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto 14040-901, Brazil
- Department of Food Engineering, Faculty of Animal Science and Food Engineering, University of São Paulo, Pirassununga 13645-900, Brazil
| | - Massimo Bottini
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Pietro Ciancaglini
- Department of Chemistry, Ribeirão Preto Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto 14040-901, Brazil
| | - Alma B. C. E. B. Catirse
- Department of Dental Materials and Prosthodontics, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto 14040-904, Brazil
| | - Ana Paula Ramos
- Department of Chemistry, Ribeirão Preto Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo, Ribeirão Preto 14040-901, Brazil
- Correspondence:
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Mohamed FF, Chavez MB, Huggins S, Bertels J, Falck A, Suva LJ, Foster BL, Gaddy D. Dentoalveolar Defects of Hypophosphatasia are Recapitulated in a Sheep Knock-In Model. J Bone Miner Res 2022; 37:2005-2017. [PMID: 36053890 PMCID: PMC9613530 DOI: 10.1002/jbmr.4666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 06/17/2022] [Accepted: 07/27/2022] [Indexed: 11/11/2022]
Abstract
Hypophosphatasia (HPP) is the inherited error-of-metabolism caused by mutations in ALPL, reducing the function of tissue-nonspecific alkaline phosphatase (TNAP/TNALP/TNSALP). HPP is characterized by defective skeletal and dental mineralization and is categorized into several clinical subtypes based on age of onset and severity of manifestations, though premature tooth loss from acellular cementum defects is common across most HPP subtypes. Genotype-phenotype associations and mechanisms underlying musculoskeletal, dental, and other defects remain poorly characterized. Murine models that have provided significant insights into HPP pathophysiology also carry limitations including monophyodont dentition, lack of osteonal remodeling of cortical bone, and differing patterns of skeletal growth. To address this, we generated the first gene-edited large-animal model of HPP in sheep via CRISPR/Cas9-mediated knock-in of a missense mutation (c.1077C>G; p.I359M) associated with skeletal and dental manifestations in humans. We hypothesized that this HPP sheep model would recapitulate the human dentoalveolar manifestations of HPP. Compared to wild-type (WT), compound heterozygous (cHet) sheep with one null allele and the other with the targeted mutant allele exhibited the most severe alveolar bone, acellular cementum, and dentin hypomineralization defects. Sheep homozygous for the mutant allele (Hom) showed alveolar bone and hypomineralization effects and trends in dentin and cementum, whereas sheep heterozygous (Het) for the mutation did not exhibit significant effects. Important insights gained include existence of early alveolar bone defects that may contribute to tooth loss in HPP, observation of severe mantle dentin hypomineralization in an HPP animal model, association of cementum hypoplasia with genotype, and correlation of dentoalveolar defects with alkaline phosphatase (ALP) levels. The sheep model of HPP faithfully recapitulated dentoalveolar defects reported in individuals with HPP, providing a new translational model for studies into etiopathology and novel therapies of this disorder, as well as proof-of-principle that genetically engineered large sheep models can replicate human dentoalveolar disorders. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Fatma F Mohamed
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Michael B Chavez
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Shannon Huggins
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - Joshua Bertels
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - Alyssa Falck
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - Larry J Suva
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - Brian L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Dana Gaddy
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
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9
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Andras NL, Mohamed FF, Chu EY, Foster BL. Between a rock and a hard place: Regulation of mineralization in the periodontium. Genesis 2022; 60:e23474. [PMID: 35460154 PMCID: PMC9492628 DOI: 10.1002/dvg.23474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/08/2022] [Accepted: 04/09/2022] [Indexed: 12/30/2022]
Abstract
The periodontium supports and attaches teeth via mineralized and nonmineralized tissues. It consists of two, unique mineralized tissues, cementum and alveolar bone. In between these tissues, lies an unmineralized, fibrous periodontal ligament (PDL), which distributes occlusal forces, nourishes and invests teeth, and harbors progenitor cells for dentoalveolar repair. Many unanswered questions remain regarding periodontal biology. This review will focus on recent research providing insights into one enduring mystery: the precise regulation of the hard-soft tissue borders in the periodontium which define the interfaces of the cementum-PDL-alveolar bone structure. We will focus on advances in understanding the molecular mechanisms that maintain the unmineralized PDL "between a rock and a hard place" by regulating the mineralization of cementum and alveolar bone.
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Affiliation(s)
- Natalie L. Andras
- Biosciences Division, College of DentistryThe Ohio State UniversityColumbusOhioUSA
| | - Fatma F. Mohamed
- Biosciences Division, College of DentistryThe Ohio State UniversityColumbusOhioUSA
| | - Emily Y. Chu
- Division of Operative Dentistry, Department of General Dentistry, School of DentistryUniversity of MarylandBaltimoreMarylandUSA
| | - Brian L. Foster
- Biosciences Division, College of DentistryThe Ohio State UniversityColumbusOhioUSA
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10
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Mouradian W, Lee J, Wilentz J, Somerman M. A Perspective: Integrating Dental and Medical Research Improves Overall Health. FRONTIERS IN DENTAL MEDICINE 2021. [DOI: 10.3389/fdmed.2021.699575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The past decade has seen marked increases in research findings identifying oral-systemic links. Yet, much of dental research remains poorly integrated with mainstream biomedical research. The historic separation of dentistry from medicine has led to siloed approaches in education, research and practice, ultimately depriving patients, providers, and policy makers of findings that could benefit overall health and well-being. These omissions amount to lost opportunities for risk assessment, diagnosis, early intervention and prevention of disease, increasing cost and contributing to a fragmented and inefficient healthcare delivery system. This perspective provides examples where fostering interprofessional research collaborations has advanced scientific understanding and yielded clinical benefits. In contrast are examples where failure to include dental research findings has limited progress and led to adverse health outcomes. The impetus to overcome the dental-medical research divide gains further urgency today in light of the coronavirus pandemic where contributions that dental research can make to understanding the pathophysiology of the SARS-CoV-2 virus and in diagnosing and preventing infection are described. Eliminating the research divide will require collaborative and trans-disciplinary research to ensure incorporation of dental research findings in broad areas of biomedical research. Enhanced communication, including interoperable dental/medical electronic health records and educational efforts will be needed so that the public, health care providers, researchers, professional schools, organizations, and policymakers can fully utilize oral health scientific information to meet the overall health needs of the public.
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11
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Lira Dos Santos EJ, Chavez MB, Tan MH, Mohamed FF, Kolli TN, Foster BL, Liu ES. Effects of Active Vitamin D or FGF23 Antibody on Hyp Mice Dentoalveolar Tissues. J Dent Res 2021; 100:1482-1491. [PMID: 33906518 DOI: 10.1177/00220345211011041] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Mutations in the PHEX gene lead to X-linked hypophosphatemia (XLH), a form of inherited rickets featuring elevated fibroblast growth factor 23 (FGF23), reduced 1,25-dihydroxyvitamin D (1,25D), and hypophosphatemia. Hyp mutant mice replicate the XLH phenotype, including dentin, alveolar bone, and cementum defects. We aimed to compare effects of 1,25D versus FGF23-neutralizing antibody (FGF23Ab) monotherapies on Hyp mouse dentoalveolar mineralization. Male Hyp mice, either injected subcutaneously with daily 1,25D or thrice weekly with FGF23 blocking antibody from 2 to 35 d postnatal, were compared to wild-type (WT) controls and untreated Hyp mice. Mandibles were analyzed by high-resolution micro-computed tomography (micro-CT), histology, and immunohistochemistry. Both interventions maintained normocalcemia, increased serum phosphate levels, and improved dentoalveolar mineralization in treated versus untreated Hyp mice. 1,25D increased crown dentin volume and thickness and root dentin/cementum volume, whereas FGF23Ab effects were limited to crown dentin volume. 1,25D increased bone volume fraction, bone mineral density, and tissue mineral density in Hyp mice, whereas FGF23Ab failed to significantly affect these alveolar bone parameters. Neither treatment fully attenuated dentin and bone defects to WT levels, and pulp volumes remained elevated regardless of treatment. Both treatments reduced predentin thickness and improved periodontal ligament organization, while 1,25D promoted a more profound improvement in acellular cementum thickness. Altered cell densities and lacunocanalicular properties of alveolar and mandibular bone osteocytes and cementocytes in Hyp mice were partially corrected by either treatment. Neither treatment normalized the altered distributions of bone sialoprotein and osteopontin in Hyp mouse alveolar bone. Moderate improvements from both 1,25D and FGF23Ab treatment regimens support further studies and collection of oral health data from subjects receiving a newly approved anti-FGF23 therapy. The inability of either treatment to fully correct Hyp mouse dentin and bone prompts further experiments into underlying pathological mechanisms to identify new therapeutic approaches.
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Affiliation(s)
- E J Lira Dos Santos
- Biosciences Division, College of Dentistry, The Ohio State University, Columbus, OH, USA.,Campinas State University, School of Dentistry, Piracicaba, São Paulo, Brazil
| | - M B Chavez
- Biosciences Division, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - M H Tan
- Biosciences Division, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - F F Mohamed
- Biosciences Division, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - T N Kolli
- Biosciences Division, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - B L Foster
- Biosciences Division, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - E S Liu
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA.,Division of Endocrinology Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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12
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Clayton D, Chavez MB, Tan MH, Kolli TN, Giovani PA, Hammersmith KJ, Bowden SA, Foster BL. Mineralization Defects in the Primary Dentition Associated With X-Linked Hypophosphatemic Rickets. JBMR Plus 2021; 5:e10463. [PMID: 33869987 PMCID: PMC8046057 DOI: 10.1002/jbm4.10463] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/22/2020] [Accepted: 01/10/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Delaney Clayton
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
| | - Michael B Chavez
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
| | - Michelle H Tan
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
| | - Tamara N Kolli
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
| | - Priscila A Giovani
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA.,Department of Pediatric Dentistry, Piracicaba Dental School University of Campinas Campinas Brazil
| | - Kimberly J Hammersmith
- Division of Pediatric Dentistry, College of Dentistry The Ohio State University Columbus OH USA.,Department of Dentistry Nationwide Children's Hospital Columbus OH USA
| | - Sasigarn A Bowden
- Department of Pediatrics, Division of Endocrinology Nationwide Children's Hospital Columbus OH USA.,College of Medicine The Ohio State University Columbus OH USA
| | - Brian L Foster
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
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13
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Kramer K, Chavez MB, Tran AT, Farah F, Tan MH, Kolli TN, Dos Santos EJL, Wimer HF, Millán JL, Suva LJ, Gaddy D, Foster BL. Dental defects in the primary dentition associated with hypophosphatasia from biallelic ALPL mutations. Bone 2021; 143:115732. [PMID: 33160095 PMCID: PMC7769999 DOI: 10.1016/j.bone.2020.115732] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
ALPL encodes tissue-nonspecific alkaline phosphatase (TNAP), an enzyme expressed in bone, teeth, liver, and kidney. ALPL loss-of-function mutations cause hypophosphatasia (HPP), an inborn error-of-metabolism that produces skeletal and dental mineralization defects. Case reports describe widely varying dental phenotypes, making it unclear how HPP comparatively affects the three unique dental mineralized tissues: enamel, dentin, and cementum. We hypothesized that HPP affected all dental mineralized tissues and aimed to establish quantitative measurements of dental tissues in a subject with HPP. The female proband was diagnosed with HPP during childhood based on reduced alkaline phosphatase activity (ALP), mild rachitic skeletal effects, and premature primary tooth loss. The diagnosis was subsequently confirmed genetically by the presence of compound heterozygous ALPL mutations (exon 5: c.346G>A, p.A116T; exon 10: c.1077C>G, p.I359M). Dental defects in 8 prematurely exfoliated primary teeth were analyzed by high resolution micro-computed tomography (micro-CT) and histology. Similarities to the Alpl-/- mouse model of HPP were identified by additional analyses of murine dentoalveolar tissues. Primary teeth from the proband exhibited substantial remaining root structure compared to healthy control teeth. Enamel and dentin densities were not adversely affected in HPP vs. control teeth. However, analysis of discrete dentin regions revealed an approximate 10% reduction in the density of outer mantle dentin of HPP vs. control teeth. All 4 incisors and the molar lacked acellular cementum by micro-CT and histology, but surprisingly, 2 of 3 prematurely exfoliated canines exhibited apparently normal acellular cementum. Based on dentin findings in the proband's teeth, we examined dentoalveolar tissues in a mouse model of HPP, revealing that the delayed initiation of mineralization in the incisor mantle dentin was associated with a broader lack of circumpulpal dentin mineralization. This study describes a quantitative approach to measure effects of HPP on dental tissues. This approach has uncovered a previously unrecognized novel mantle dentin defect in HPP, as well as a surprising and variable cementum phenotype within the teeth from the same HPP subject.
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Affiliation(s)
- K Kramer
- Division of Orthodontics, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - M B Chavez
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - A T Tran
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - F Farah
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - M H Tan
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - T N Kolli
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - E J Lira Dos Santos
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA; Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas-UNICAMP, Piracicaba, SP, Brazil
| | - H F Wimer
- Department of Vertebrate Zoology, National Museum of Natural History, Smithsonian Institution, Washington, DC, USA; National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - J L Millán
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - L J Suva
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - D Gaddy
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - B L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA.
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14
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Nagasaki A, Nagasaki K, Chu EY, Kear BD, Tadesse WD, Ferebee SE, Li L, Foster BL, Somerman MJ. Ablation of Pyrophosphate Regulators Promotes Periodontal Regeneration. J Dent Res 2020; 100:639-647. [PMID: 33356859 DOI: 10.1177/0022034520981854] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Biomineralization is regulated by inorganic pyrophosphate (PPi), a potent physiological inhibitor of hydroxyapatite crystal growth. Progressive ankylosis protein (ANK) and ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) act to increase local extracellular levels of PPi, inhibiting mineralization. The periodontal complex includes 2 mineralized tissues, cementum and alveolar bone (AB), both essential for tooth attachment. Previous studies demonstrated that loss of function of ANK or ENPP1 (reducing PPi) resulted in increased cementum formation, suggesting PPi metabolism may be a target for periodontal regenerative therapies. To compare the effects of genetic ablation of Ank, Enpp1, and both factors concurrently on cementum and AB regeneration, mandibular fenestration defects were created in Ank knockout (Ank KO), Enpp1 mutant (Enpp1asj/asj), and double KO (dKO) mice. Genetic ablation of Ank, Enpp1, or both factors increased cementum regeneration compared to controls at postoperative days (PODs) 15 and 30 (Ank KO: 8-fold, 3-fold; Enpp1asj/asj: 7-fold, 3-fold; dKO: 11-fold, 4-fold, respectively) associated with increased fluorochrome labeling and expression of mineralized tissue markers, dentin matrix protein 1 (Dmp1/DMP1), osteopontin (Spp1/OPN), and bone sialoprotein (Ibsp/BSP). Furthermore, dKO mice featured increased cementum thickness compared to single KOs at POD15 and Ank KO at POD30. No differences were noted in AB volume between genotypes, but osteoblast/osteocyte markers were increased in all KOs, partially mineralized osteoid volume was increased in dKO versus controls at POD15 (3-fold), and mineral density was decreased in Enpp1asj/asj and dKOs at POD30 (6% and 9%, respectively). Increased numbers of osteoclasts were present in regenerated AB of all KOs versus controls. These preclinical studies suggest PPi modulation as a potential and novel approach for cementum regeneration, particularly targeting ENPP1 and/or ANK. Differences in cementum and AB regeneration in response to reduced PPi conditions highlight the need to consider tissue-specific responses in strategies targeting regeneration of the entire periodontal complex.
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Affiliation(s)
- A Nagasaki
- Laboratory of Oral Connective Tissue Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - K Nagasaki
- Laboratory of Oral Connective Tissue Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - E Y Chu
- Laboratory of Oral Connective Tissue Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - B D Kear
- Laboratory of Oral Connective Tissue Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - W D Tadesse
- Laboratory of Oral Connective Tissue Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - S E Ferebee
- Laboratory of Oral Connective Tissue Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - L Li
- Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - B L Foster
- Biosciences Division, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - M J Somerman
- Laboratory of Oral Connective Tissue Biology, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, MD, USA
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