Effect of human dental pulp stem cell conditioned medium in the dentin-pulp complex regeneration: A pilot in vivo study

EFFICACY OF STEM CELLS IN ENDODONTIC REGENERATION: A SYSTEMATIC REVIEW

INTRODUCTION

Regenerative endodontic procedures (REPs) aim to regenerate structural and functional integrity of necrosed or infected dental pulp, while promoting root development and closure. Conventional treatment methods often fail to regenerate dental pulp tissues effectively. This systematic review investigates the efficacy of stem cell therapy in REPs.

METHODOLOGY

An electronic search was conducted on the following research databases and registers: PubMed (includes MEDLINE and PubMed Central), Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and ClinicalTrials.gov. The study was registered in PROSPERO and PRISMA guidelines were followed to report the review. 19 original studies comprising 1 randomized clinical trial and 18 animal studies were included after applying inclusion and exclusion criteria. The studies evaluated different types of endodontic procedures, including pulp capping, pulpotomy, pulpectomy, and furcation repair, using various types of mesenchymal stem cells, such as dental pulp stem cells, bone marrow-derived stem cells and umbilical cord mesenchymal stem cells (UCMSCs). The outcomes assessed in the studies included pulpal regeneration, resolution of periapical radiolucency, and restoration of tooth vitality. The Systematic Review Center for Laboratory and Animal Experimentation (SYRCLE) and Risk of Bias 2.0 was used for assessing the risk of bias in animal studies and randomized trials, respectively.

RESULTS

The findings indicate that stem cell therapy holds promise for inducing dental pulp regeneration. However, synthesizing the overall efficacy of stem cell therapy compared to conventional methods remains challenging due to variations in methodologies and outcome measures used in animal studies. Despite these inconsistencies, most animal studies reported positive results for pulpal regeneration, regardless of the stem cell type, scaffold type or animal model used. Notably, a clinical trial utilizing umbilical cord mesenchymal stem cells (UCMSCs) combined with platelet-poor plasma demonstrated favorable outcomes in dental pulp revascularization and reperfusion.

CONCLUSION

The long-term safety and clinical efficacy of stem cell therapy in regenerative endodontic procedures (REPs) require validation through randomized clinical trials before widespread clinical adoption.

Nanoemulgel Development of Stem Cells from Human Exfoliated Deciduous Teeth-Derived Conditioned Medium as a Novel Nanocarrier Growth Factors

OBJECTIVE

 We aimed to develop a nanoemulgel of stem cells from human exfoliated deciduous teeth-derived conditioned medium (SHED-CM) for oral wound biotherapy candidate.

MATERIALS AND METHODS

 Deciduous tooth pulp was collected from two patients aged 6 years. The mesenchymal stem cell marker expression was analyzed by immunocytochemistry of CD45, CD90, and CD105. Alizarin red staining was performed to differentiate SHEDs from osteoblasts. The quantitative and quantification of transforming growth factor-β (TGF-β) and vascular endothelial growth factor (VEGF) secreted into conditioned media were measured using sodium dodecyl sulfate polyacrylamide gel electrophoresis and enzyme-linked immunosorbent assay. The characteristics of the nanoemulgel of SHED-CM (NESCM) were analyzed in terms of organoleptic properties, pH, and homogeneity. The cytotoxicity of NESCM 1.5% was analyzed in human gingival fibroblast (hGF) cell and osteoblast cell line (MC3T3) by 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide assay.

STATISTICAL ANALYSIS

 The results were presented as mean ± standard deviation (X ± SD), and the differences between groups were analyzed using the post hoc Tukey's test at a significance level of p-value < 0.05.

RESULTS

 SHEDs were successfully isolated, which were characterized for positive marker expressions of CD90 and CD105 and negative expression of CD45 as well as their osteogenic commitment. In SHED-CM, TGF-β and VEGF were detected on day 1 of conditioning and afterward. Notably, the growth factor enriched as the duration of conditioning increased. The generated nanoemulgel with SHED-CM was stable and homogeneous, and had limited cytotoxic effects on hGF and MC3T3 cell culture.

CONCLUSION

 SHED-CM containing the growth factors can potentially be used as oral wound biotherapy in the form of nanoemulgel.

Tissue engineering approaches for dental pulp regeneration: The development of novel bioactive materials using pharmacological epigenetic inhibitors

The drive for minimally invasive endodontic treatment strategies has shifted focus from technically complex and destructive root canal treatments towards more conservative vital pulp treatment. However, novel approaches to maintaining dental pulp vitality after disease or trauma will require the development of innovative, biologically-driven regenerative medicine strategies. For example, cell-homing and cell-based therapies have recently been developed in vitro and trialled in preclinical models to study dental pulp regeneration. These approaches utilise natural and synthetic scaffolds that can deliver a range of bioactive pharmacological epigenetic modulators (HDACis, DNMTis, and ncRNAs), which are cost-effective and easily applied to stimulate pulp tissue regrowth. Unfortunately, many biological factors hinder the clinical development of regenerative therapies, including a lack of blood supply and poor infection control in the necrotic root canal system. Additional challenges include a need for clinically relevant models and manufacturing challenges such as scalability, cost concerns, and regulatory issues. This review will describe the current state of bioactive-biomaterial/scaffold-based engineering strategies to stimulate dentine-pulp regeneration, explicitly focusing on epigenetic modulators and therapeutic pharmacological inhibition. It will highlight the components of dental pulp regenerative approaches, describe their current limitations, and offer suggestions for the effective translation of novel epigenetic-laden bioactive materials for innovative therapeutics.

Towards a New Concept of Regenerative Endodontics Based on Mesenchymal Stem Cell-Derived Secretomes Products

The teeth, made up of hard and soft tissues, represent complex functioning structures of the oral cavity, which are frequently affected by processes that cause structural damage that can lead to their loss. Currently, replacement therapy such as endodontics or implants, restore structural defects but do not perform any biological function, such as restoring blood and nerve supplies. In the search for alternatives to regenerate the dental pulp, two alternative regenerative endodontic procedures (REP) have been proposed: (I) cell-free REP (based in revascularization and homing induction to remaining dental pulp stem cells (DPSC) and even stem cells from apical papilla (SCAP) and (II) cell-based REP (with exogenous cell transplantation). Regarding the last topic, we show several limitations with these procedures and therefore, we propose a novel regenerative approach in order to revitalize the pulp and thus restore homeostatic functions to the dentin-pulp complex. Due to their multifactorial biological effects, the use of mesenchymal stem cells (MSC)-derived secretome from non-dental sources could be considered as inducers of DPSC and SCAP to completely regenerate the dental pulp. In partial pulp damage, appropriate stimulate DPSC by MSC-derived secretome could contribute to formation and also to restore the vasculature and nerves of the dental pulp.

The Potential Application of Human Gingival Fibroblast-Conditioned Media in Pulp Regeneration: An In Vitro Study

Regenerative endodontic treatment based on tissue engineering has recently gained interest in contemporary restorative dentistry. However, low survival rates and poor potential differentiation of stem cells could undermine the success rate of pulp regenerative therapy. Human gingival fibroblast-conditioned medium (hGF-CM) has been considered a potential therapy for tissue regeneration due to its stability in maintaining multiple factors essential for tissue regeneration compared to live cell transplantation. This study aimed to investigate the potency of hGF-CM on stem cells from human dental pulp (DPSC) in pulp regeneration. A series of experiments confirmed that hGF-CM contributes to a significant increase in proliferation, migration capability, and cell viability of DPSC after H2O2 exposure. Moreover, it has been proved to facilitate the odontogenic differentiation of DPSC via qRT-PCR, ALP (alkaline phosphatase), and ARS (Alizarin Red S) staining. It has been discovered that such highly upregulated odontogenesis is related to certain types of ECM proteins (collagen and laminin) from hGF-CM via proteomics. In addition, it is found that the ERK pathway is a key mechanism via inhibition assay based on RNA-seq result. These findings demonstrate that hGF-CM could be beneficial biomolecules for pulp regeneration.

Hypoxia Induces DPSC Differentiation versus a Neurogenic Phenotype by the Paracrine Mechanism

As previously described by several authors, dental pulp stem cells (DPSCs), when adequately stimulated, may acquire a neuronal-like phenotype acting as a favorable source of stem cells in the generation of nerves. Besides, it is known that hypoxia conditioning is capable of stimulating cell differentiation as well as survival and self-renewal, and that multiple growth factors, including Epidermal Growth factor (EGF) and basic fibroblast growth factor (bFGF), are often involved in the induction of the neuronal differentiation of progenitor cells. In this work, we investigated the role of hypoxia in the commitment of DPSCs into a neuronal phenotype. These cells were conditioned with hypoxia (O₂ 1%) for 5 and 16 days; subsequently, we analyzed the proliferation rate and morphology, and tested the cells for neural and stem markers. Moreover, we verified the possible autocrine/paracrine role of DPSCs in the induction of neural differentiation by comparing the secretome profile of the hypoxic and normoxic conditioned media (CM). Our results showed that the hypoxia-mediated DPSC differentiation was time dependent. Moreover, conditioned media (CM derived from DPSCs stimulated by hypoxia were able, in turn, to induce the neural differentiation of SH-SY5Y neuroblastoma cells and undifferentiated DPSCs. In conclusion, under the herein-mentioned conditions, hypoxia seems to favor the differentiation of DPSCs into neuron-like cells. In this way, we confirm the potential clinical utility of differentiated neuronal DPSCs, and we also suggest the even greater potential of CM-derived-hypoxic DPSCs that could more readily be used in regenerative therapies.

The Therapeutic Potential of Secreted Factors from Dental Pulp Stem Cells for Various Diseases

An alternative source of mesenchymal stem cells has recently been discovered: dental pulp stem cells (DPSCs), including deciduous teeth, which can thus comprise potential tools for regenerative medicine. DPSCs derive from the neural crest and are normally implicated in dentin homeostasis. The clinical application of mesenchymal stem cells (MSCs) involving DPSCs contains various limitations, such as high cost, low safety, and cell handling issues, as well as invasive sample collection procedures. Although MSCs implantation offers favorable outcomes on specific diseases, implanted MSCs cannot survive for a long period. It is thus considered that their mediated mechanism of action involves paracrine effects. It has been recently reported that secreted molecules in DPSCs-conditioned media (DPSC-CM) contain various trophic factors and cytokines and that DPSC-CM are effective in models of various diseases. In the current study, we focus on the characteristics of DPSC-CM and their therapeutic potential against various disorders.

Regenerative Endodontics and Minimally Invasive Dentistry: Intertwining Paths Crossing Over Into Clinical Translation

Regenerative endodontic procedures have been described for over a decade as a paradigm shift in the treatment of immature necrotic permanent teeth, owing to their ability to allow root maturation with subsequent enhancement of the tooth’s fracture resistance in addition to the potential for regeneration of vital intracanal tissues. Concomitantly, minimally invasive endodontics is another rising concept with the main concern of preservation of tooth structure. Stemming from their potential to preserve the original tooth structure, both regenerative and minimally invasive endodontics could be considered as two revolutionary sciences with one common goal. Achieving this goal would entail not only employing the appropriate strategies to recreate the ideal regenerative niche but modifying existing concepts and protocols currently being implemented in regenerative endodontics to address two important challenges affecting the outcome of these procedures; conservation of tooth structure and achieving effective disinfection. Therefore, the search for new biomimetic cell-friendly disinfecting agents and strategies is crucial if such a novel integratory concept is to be foreseen in the future. This could be attainable by advocating a new merged concept of “minimally invasive regenerative endodontic procedures (MIREPs),” through modifying the clinical protocol of REPs by incorporating a minimally invasive access cavity design/preparation and biomimetic disinfection protocol, which could enhance clinical treatment outcomes and in the future; allow for personalized disinfection/regeneration protocols to further optimize the outcomes of MIREPs. In this review, we aim to introduce this new concept, its realization and challenges along with future perspectives for clinical implementation.

Cell-Based Transplantation versus Cell Homing Approaches for Pulp-Dentin Complex Regeneration

Regenerative dentistry has paved the way for a new era for the replacement of damaged dental tissues. Whether the causative factor is dental caries, trauma, or chemical insult, the loss of the pulp vitality constitutes one of the major health problems worldwide. Two regenerative therapies were introduced for a fully functional pulp-dentin complex regeneration, namely, cell-based (cell transplantation) and cell homing (through revascularization or homing by injection of stem cells in situ or intravenously) therapies, with each demonstrating advantages as well as drawbacks, especially in clinical application. The present review is aimed at elaborating on these two techniques in the treatment of irreversibly inflamed or necrotic pulp, which is aimed at regenerating a fully functional pulp-dentin complex.