Stem cell-based pulp tissue engineering: variables enrolled in translation from the bench to the bedside, a systematic review of literature

Mechanism of Pulp Regeneration Based on Concentrated Growth Factors Regulating Cell Differentiation

Concentrated growth factors (CGF) is the newest generation platelet concentrate product, which has been reported to promote the proliferation and differentiation of human dental pulp cells (hDPCs). However, the effect of liquid phase of CGF (LPCGF) has not been reported. This study was aimed to evaluate the influence of LPCGF on the biological properties of hDPCs, and to explore the in vivo mechanism of dental pulp regeneration based on the hDPCs-LPCGF complex transplantation. It was found that LPCGF could promote the proliferation, migration and odontogenic differentiation of hDPCs, and 25% LPCGF induced the most mineralization nodule formation and the highest DSPP gene expression. The heterotopic transplantation of the hDPCs-LPCGF complex resulted in the formation of regenerative pulp tissue with newly formed dentin, neovascularization and nerve-like tissue. Together, these findings provide key data on the effect of LPCGF on the proliferation, migration, odontogenic/osteogenic differentiation of hDPCs, and the in vivo mechanism of hDPCs-LPCGF complex autologous transplantation in pulp regeneration therapy.

Influence of ethylenediaminetetraacetic acid irrigation on the regenerative endodontic procedure in an immature rat molar model

AIM

To analyse the influence of ethylenediaminetetraacetic acid (EDTA) on the repair process in immature rat molars after a regenerative endodontic procedure (REP).

METHODOLOGY

The lower first molars of 12 4-week-old Wistar rats underwent pulpectomy in the mesial root and were divided into the following groups: sodium hypochlorite (NaOCl; n = 6) - the mesial canals were irrigated with 2.5% NaOCl for 5 min, and NaOCl-EDTA (n = 6) - the canals were irrigated with 2.5% NaOCl, followed by 17% EDTA for 5 min each. After evoking bleeding using a size 10 K-file, the cavities were sealed. Three molars on the untreated side were randomly used as control (control-15 d; n = 3), and three molars from the other three rats untreated were used as immediate control (n = 3). After 15 days (NaOCl, NaOCl-EDTA and control-15 d groups) or immediately (control-immediate), the animals were euthanized, and the teeth were subjected to histologic evaluation of tissue regeneration and presence of collagen fibres. Mann-Whitney U-test was used (p < .05).

RESULTS

The experimental groups had newly formed cementum-like tissue and increased root length and thickness. Half of the specimens in NaOCl-EDTA group showed apical foramen closure, whilst the NaOCl group had partial apical closure. The experimental groups showed inflammatory infiltrate extending mainly to the medium third of the root canal. These parameters were similar between experimental groups (p > .05). Newly formed connective tissue in the pulp space was significantly higher in the NaOCl-EDTA group than in NaOCl group (p < .05). Regarding the collagen fibres, the NaOCl-EDTA group had more collagen fibres in the root tip, but there was no significant difference compared to NaOCl group, and both groups showed greater amount of immature fibres in this area; in the centre of the apical third of root canal, there was equivalence between mature and immature fibres from both groups (p > .05).

CONCLUSIONS

Ethylenediaminetetraacetic acid irrigation improved newly formed intracanal connective tissue after REP in immature molars of rats; however, EDTA did not influence cementum-like tissue formation, apical closure, inflammatory infiltrate and maturation of collagen fibres.

Influence of ethylenediaminetetraacetic acid on regenerative endodontics: a systematic review

BACKGROUND

The effects of ethylenediaminetetraacetic acid (EDTA) on regenerative endodontic procedures (REPs) are controversial, because, despite releasing growth factors from dentine, some studies show negative effects on cell behaviour.

OBJECTIVES

To investigate the influence of the use of EDTA in REP on the growth factors' release, cell behaviour, and tissue regeneration.

METHODS

A systematic search was conducted (PubMed/Medline, Scopus, Cochrane Library, Web of Science, Embase, OpenGrey, and reference lists) up to February 2021. Only in vivo and in vitro studies evaluating the effects of EDTA on the biological factors of dentine, pulp/periapical tissues, and cell behaviour were eligible. Studies without a control group or available full text were excluded. The growth factors' release was the primary outcome. Risk of bias in the in vitro and in vivo studies was performed according to Joanna Briggs Institute's Checklist and SYRCLE's RoB tool, respectively.

RESULTS

Of the 1848 articles retrieved, 36 were selected. Among these, 32 were in vitro, three animal studies, and one with both models. The EDTA concentrations ranged from 3%-15%, at different times. Regarding growth factors' release (17 studies), 15 studies found significant transforming growth factor (TGF)-β release after dentine conditioning with EDTA, and most found no influence on vascular endothelial growth factor (VEGF) release. Regarding cell behaviour (26 studies), eight studies showed no influence of EDTA-treated dentine on cell viability; whereas, five, nine, and six studies showed higher cell migration, adhesion, and differentiation, respectively. No influence of EDTA conditioning was observed in animal studies. In vitro studies had a low risk of bias, whereas animal studies had high risk of bias. Meta-analysis was unfeasible.

DISCUSSION

This review found that EDTA increased TGF-β release and improved cell activity. However, well-designed histological analyses using immature teeth models are needed.

CONCLUSIONS

High quality in vitro evidence suggests that EDTA-treated dentine positively influences TGF-β release, cell migration, attachment, and differentiation; further research to evaluate its influence on tissue regeneration is necessary due to low methodological quality of the animal studies.

A Cell-Based Approach to Dental Pulp Regeneration Using Mesenchymal Stem Cells: A Scoping Review

Despite the recent explosion of investigations on dental pulp regeneration using various tissue engineering strategies, the translation of the findings from such studies into therapeutic applications has not been properly achieved. The purpose of this scoping review was to systematically review the efficacy of mesenchymal stem cell transplantation for dental pulp regeneration. A literature search was conducted using five electronic databases from their inception to January 2021 and supplemented by hand searches. A total of 17 studies, including two clinical trials and 15 animal studies using orthotopic pulp regeneration models, were included for the review. The risk of bias for the individual studies was assessed. This scoping review demonstrated that the regeneration of vascularized pulp-like tissue was achieved using the stem cell transplantation strategy in animal models. Autologous cell transplantation in two clinical studies also successfully regenerated vascularized vital tissue. Dental pulp stem cell subpopulations, such as mobilized dental pulp stem cells, injectable scaffolds such as atelocollagen, and a granulocyte-colony forming factor, were the most commonly used for pulp regeneration. The overall risk of bias was unclear for animal studies and was moderate or judged to raise some concerns for clinical studies. More high-quality clinical studies are needed to further determine the safety and efficacy of the stem cell transplantation strategy for dental pulp regeneration.

hDPSC-laden GelMA microspheres fabricated using electrostatic microdroplet method for endodontic regeneration

The microsphere system has attracted considerable attention as a stem-cell delivery vehicle in regeneration medicine owing to its injectability, fast substance transfer ability, and mimicry of the three-dimensional native environment. However, suitable biomaterials for preparation of microspheres optimal for endodontic regeneration are still being explored. Owing to its excellent bioactivity and biodegradability, gelatin methacryloyl (GelMA) was used to fabricate hydrogel microspheres by the electrostatic microdroplet method, and the potential of GelMA microspheres applied in endodontic regeneration was studied. The average size of GelMA microspheres encapsulating human dental pulp stem cells (hDPSCs) was ~200 μm, and the Young's modulus was approximately 582.8 ± 66.0 Pa, which was close to that of the natural human dental pulp. The encapsulated hDPSCs could effectively adhere, spread, proliferate, and secrete extracellular matrix proteins in the microspheres, and tended to occupy the outer layer. Moreover, the cell-laden GelMA microsphere system could withstand cryopreservation, and the thawed cells exhibited normal functions. After subcutaneous implantation in a nude mouse model, more vascularized pulp-like tissues were generated in the cell-laden GelMA microsphere group compared with that in the cell-laden bulk GelMA group, and this was accompanied by a suitable degradation rate. The GelMA microspheres showed remarkable performances and great potential as cell delivery vehicles in endodontic regeneration.

MTA Enhances the Potential of Adipose-Derived Mesenchymal Stem Cells for Dentin-Pulp Complex Regeneration

The aim of the current study was to investigate the effects of mineral trioxide aggregate (MTA) on the proliferation and differentiation of human adipose-derived mesenchymal stem cells (Ad-MSCs) as a surrogate cell source in futuristic stem-cell-based endodontic therapies. Human Ad-MSCs and mesenchymal stem cells derived from bone marrow (BM-MSCs) were isolated from liposuction waste adipose tissue and femur, respectively, and the effects of MTA-conditioned media on their viability, mineralization potential, and osteo/odontogenic differentiation capacity were subsequently evaluated. Alkaline phosphatase (ALP) activity, quantitative alizarin red S staining, and quantitative reverse transcription-polymerase chain reaction (qRT-PCR) analyses were performed to investigate and compare the osteo/odontogenic induction potential of MTA on the Ad/BM-MSCs. The results of cytotoxicity assay revealed that at different concentrations, MTA-conditioned medium was not only biocompatible toward both cell types, but also capable of promoting cell proliferation. ALP activity assay showed that 0.2 mg/mL was the optimal concentration of MTA-conditioned medium for osteo/odontogenic induction in Ad/BM-MSCs. The expression of osteo/odontogenic gene markers was increased in Ad/BM-MSCs treated with 0.2 mg/mL MTA-conditioned media. Our results indicated that MTA can efficiently enhance the osteo/odontogenic potential of Ad-MSCs, and thus they can be considered as a better cell source for dentin-pulp complex regeneration. However, further investigations are required to test these potentials in animal models.

Ex-vivo recellularisation and stem cell differentiation of a decellularised rat dental pulp matrix

Implementing the principles of tissue engineering within the clinical management of non-vital immature permanent teeth is of clinical interest. However, the ideal scaffold remains elusive. The aim of this work was to assess the feasibility of decellularising rat dental pulp tissue and evaluate the ability of such scaffold to support stem cell repopulation. Rat dental pulps were retrieved and divided into control and decellularised groups. The decellularisation protocol incorporated a low detergent concentration and hypotonic buffers. After decellularisation, the scaffolds were characterised histologically, immunohistochemistry and the residual DNA content quantified. Surface topography was also viewed under scanning electron microscopy. Biocompatibility was evaluated using cytotoxicity assays utilising L-929 cell line. Decellularised scaffolds were recellularised with human dental pulp stem cells up to 14 days in vitro. Cellular viability was assessed using LIVE/DEAD stain kit and the recellularised scaffolds were further assessed histologically and immunolabelled using makers for odontoblastic differentiation, cytoskeleton components and growth factors. Analysis of the decellularised scaffolds revealed an acellular matrix with histological preservation of structural components. Decellularised scaffolds were biocompatible and able to support stem cell survival following recellularisation. Immunolabelling of the recellularised scaffolds demonstrated positive cellular expression against the tested markers in culture. This study has demonstrated the feasibility of developing a biocompatible decellularised dental pulp scaffold, which is able to support dental pulp stem cell repopulation. Clinically, decellularised pulp tissue could possibly be a suitable scaffold for use within regenerative (reparative) endodontic techniques.

Irisin promotes odontogenic differentiation and angiogenic potential in human dental pulp cells

AIM

To determine whether irisin, a newly discovered myokine that links exercise-induced and metabolic homeostasis, is able to promote odontogenic differentiation and angiogenesis in human dental pulp cells (HDPCs).

METHODOLOGY

Cell viability in the presence of irisin was measured. Real-time PCR and Western blot analysis were performed to evaluate the expression levels of irisin, odontogenic and angiogenic markers. The involvement of mitogen-activated protein kinase (MAPK) and the protein kinase B (Akt) signalling pathway was evaluated by Western blot. To evaluate mineralization nodule formation, alkaline phosphatase (ALP) staining and alizarin red S staining were performed. Scratch wound assays were performed to evaluate the effects of irisin on cell migration. The data were analysed using one-way analysis of variance (anova) followed by Tukey post hoc test and Student's t-test. Statistical significance was considered at P < 0.05.

RESULTS

Irisin significantly promoted odontogenic differentiation as evidenced by formation of mineralized nodules, induction of ALP activity and upregulation of odontogenic and angiogenic markers (P < 0.05). Scratch wound assays revealed that irisin significantly increased migration of HDPCs (P < 0.05). Phosphorylation of both MAPK and Akt was increased by irisin. MAPK and Akt inhibitors inhibited mineralization, cell migration and the increased expression of odontogenic and angiogenic markers.

CONCLUSIONS

Irisin promoted odontogenic differentiation and mineralization and has the potential for angiogenesis through activation of the MAPK and Akt signalling pathways in HDPCs.

Dental stem cells: The role of biomaterials and scaffolds in developing novel therapeutic strategies

Dental stem cells (DSCs) are self-renewable cells that can be obtained easily from dental tissues, and are a desirable source of autologous stem cells. The use of DSCs for stem cell transplantation therapeutic approaches is attractive due to their simple isolation, high plasticity, immunomodulatory properties, and multipotential abilities. Using appropriate scaffolds loaded with favorable biomolecules, such as growth factors, and cytokines, can improve the proliferation, differentiation, migration, and functional capacity of DSCs and can optimize the cellular morphology to build tissue constructs for specific purposes. An enormous variety of scaffolds have been used for tissue engineering with DSCs. Of these, the scaffolds that particularly mimic tissue-specific micromilieu and loaded with biomolecules favorably regulate angiogenesis, cell-matrix interactions, degradation of extracellular matrix, organized matrix formation, and the mineralization abilities of DSCs in both in vitro and in vivo conditions. DSCs represent a promising cell source for tissue engineering, especially for tooth, bone, and neural tissue restoration. The purpose of the present review is to summarize the current developments in the major scaffolding approaches as crucial guidelines for tissue engineering using DSCs and compare their effects in tissue and organ regeneration.

Stem/progenitor cell-mediated pulpal tissue regeneration: a systematic review and meta-analysis

BACKGROUND

Stem/progenitor cell-mediated pulpal regeneration could represent a promising therapeutic alternative in the field of clinical endodontics.

AIM

The present study aimed to systematically assess and meta-analyse dental pulpal tissue regeneration, pulpal vitality and apical healing after the transplantation of stem/progenitor cells versus no transplantation.

DATA SOURCES

MEDLINE, Cochrane CENTRAL and EMBASE were searched up to January 2019 for animal experiments and human trials evaluating the pulpal transplantation of stem/progenitor cells. Cross-referencing and hand search were additionally performed.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Based on randomized controlled clinical trials (RCTs) or controlled clinical trials (CCTs), conducted in animals or humans, the effect of the transplantation of stem/progenitor cells compared to no transplantation on pulpal tissue regeneration, pulpal vitality and apical healing was examined.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcome was histologically determined pulpal tissue regeneration, whilst pulpal vitality and apical healing were secondary outcomes. The SYstematic Review Centre for Laboratory animal Experimentation (SYRCLE) guidelines and the revised Cochrane risk of bias tool (RoB 2.0) were used for risk-of-bias assessment. Pooled standardized differences in means (SDM) and 95% confidence intervals (95% CI) were calculated using random-effects meta-analyses.

RESULTS

From 2834 identified articles, eight animal experiments (82 animals with 336 experimental pulpal defects) and one human trial (40 humans with 40 pulpal defects) were included. Risk of bias of most animal studies was high, whilst the human trial revealed 'some concerns'. Stem/progenitor cell-transplanted pulps demonstrated significantly increased pulpal tissue regeneration compared with controls (SDM [95%CI]: 6.29 [3.78-8.80]).

LIMITATIONS

Data on pulpal vitality and apical healing were sparse and inconsistent. Heterogeneity across studies was substantial, publication bias was present, and mainly indirect, surrogate outcome measures were applied. The overall strength of evidence was very low.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The transplanation of stem/progenitor cells shows promise for pulp regeneration, whilst clinical routine application is still not in reach. Further investigations, employing a comprehensive set of outcomes including those demonstrating functional pulp regeneration relevant for patient-centred care, are required.

Parenchymal and stromal tissue regeneration of tooth organ by pivotal signals reinstated in decellularized matrix

Cells are transplanted to regenerate an organs' parenchyma, but how transplanted parenchymal cells induce stromal regeneration is elusive. Despite the common use of a decellularized matrix, little is known as to the pivotal signals that must be restored for tissue or organ regeneration. We report that Alx3, a developmentally important gene, orchestrated adult parenchymal and stromal regeneration by directly transactivating Wnt3a and vascular endothelial growth factor. In contrast to the modest parenchyma formed by native adult progenitors, Alx3-restored cells in decellularized scaffolds not only produced vascularized stroma that involved vascular endothelial growth factor signalling, but also parenchymal dentin via the Wnt/β-catenin pathway. In an orthotopic large-animal model following parenchyma and stroma ablation, Wnt3a-recruited endogenous cells regenerated neurovascular stroma and differentiated into parenchymal odontoblast-like cells that extended the processes into newly formed dentin with a structure-mechanical equivalency to native dentin. Thus, the Alx3-Wnt3a axis enables postnatal progenitors with a modest innate regenerative capacity to regenerate adult tissues. Depleted signals in the decellularized matrix may be reinstated by a developmentally pivotal gene or corresponding protein.

In vivo fate of bone marrow mesenchymal stem cells implanted into rat pulpotomized molars

In our previous work, we established an in vivo coronal pulp regeneration model in which biodegradable hydrogel-made scaffolds carrying rat bone marrow mesenchymal stem cells (BM-MSCs) were implanted in the coronal pulp chamber of pulpotomized rat maxillary first molars. In this study, we investigated the in vivo fate of LacZ-labeled BM-MSCs in our coronal pulp regeneration model. BM-MSCs were nucleofected with pVectOZ-LacZ plasmid encoding β-galactosidase 1 day before implantation, and the LacZ-transfected BM-MSCs were implanted into the pulpotomized pulp chamber with biodegradable preformed scaffold-hydrogel constructs. Empty vector was used as a control. After 3 and 14 days, the molars were retrieved and subjected to β-galactosidase staining. At 3 days, β-galactosidase-expressing cells with a round profile were located mainly around the scaffold. At 14 days, when the pulp-like tissue had been generated, the majority of β-galactosidase-expressing cells were detected under the newly formed dentin bridge-like structure, where nestin-expressing odontoblast-like cells were arranged. Immunoreactivity for dentin sialoprotein, a marker of mature odontoblasts, was strongly detected under the original dentin. No β-galactosidase staining was observed in the control group. Thus, we demonstrated that BM-MSCs survived for 2 weeks after implantation and colonized within the site of potential cytodifferentiation. Our findings indicated that BM-MSCs could differentiate into cells involved in mineralized tissue formation in the functionally relevant region.

Bone, Periodontal and Dental Pulp Regeneration in Dentistry: A Systematic Scoping Review

Abstract The aim of presented systematic scoping review was to investigate the actual and future clinical possibilities of regenerative therapies and their ability to regenerate bone, periodontal and pulp with histological confirmation of the nature of formed tissue. Electronic search was conducted using a combination between Keywords and MeSH terms in PubMed, Scopus, ISI-Web of Science and Cochrane library databases up to January 2016. Two reviewers conducted independently the papers judgment. Screened studies were read following the predetermined inclusion criteria. The included studies were evaluated in accordance with Arksey and O’Malley’s modified framework. From 1349 papers, 168 completed inclusion criteria. Several characterized and uncharacterized cells used in Cell Therapy have provided bone regeneration, demonstrating bone gain in quantity and quality, even as accelerators for bone and periodontal regeneration. Synthetic and natural scaffolds presented good cell maintenance, however polyglycolid-polylactid presented faster resorption and consequently poor bone gain. The Growth Factor-Mediated Therapy was able to regenerate bone and all features of a periodontal tissue in bone defects. Teeth submitted to Revascularization presented an increase of length and width of root canal. However, formed tissues not seem able to deposit dentin, characterizing a repaired tissue. Both PRP and PRF presented benefits when applied in regenerative therapies as natural scaffolds. Therefore, most studies that applied regenerative therapies have provided promising results being possible to regenerate bone and periodontal tissue with histological confirmation. However, pulp regeneration was not reported. These results should be interpreted with caution due to the short follow-up periods.

In vitro response of dental pulp stem cells in 3D scaffolds: A regenerative bone material

Three-dimensional-porous scaffolds of bone graft substitutes play a critical role in both cell targeting and transplantation strategies. These scaffolds provide surfaces that facilitate the response of stem cells related to attachment, survival, migration, proliferation, and differentiation.

Objective

The aim of this study was to evaluate the in vitro behavior of human dental pulp mesenchymal stem cells cultured on scaffolds of polylactic/polyglycolic acid with and without hydroxyapatite.

Method

We performed an in vitro experimental study using dental pulp stem cells obtained from samples of premolars, molars. The cells were cultured on scaffolds with osteogenic differentiation medium. Cell proliferation, adhesion and cell differentiation to an osteoblastic linage in the biomaterial were evaluated at three different time points: 7, 15 and 30 days. Each experiment was performed in triplicate. Analysis of the data was performed with the Split Plot block and MANOVA model.

Results

The differentiation capability of hDPSCs towards the osteoblast lineage was better in the scaffold of PLGA/HA at 7, 15 and 30 days, as indicated by the high expression of osteogenic markers RUNX2, ALP, OPN and COL-I, compared with differentiation in the PLGA scaffold. No statistically significant differences were found in cell adhesion between the two types of scaffolds.

Conclusion

The PLGA/HA scaffold provided better physical and chemical signals, as judged by the ability of dental pulp stem cells to adhere, proliferate and differentiate toward the osteogenic lineage.

Methodological and Reporting Quality of Systematic Reviews and Meta-analyses in Endodontics

INTRODUCTION

The aim of this systematic review (SR) was to evaluate the quality of SRs and meta-analyses (MAs) in endodontics.

METHODS

A comprehensive literature search was conducted to identify relevant articles in the electronic databases from January 2000 to June 2017. Two reviewers independently assessed the articles for eligibility and data extraction. SRs and MAs on interventional studies with a minimum of 2 therapeutic strategies in endodontics were included in this SR. Methodologic and reporting quality were assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), respectively. The interobserver reliability was calculated using the Cohen kappa statistic. Statistical analysis with the level of significance at P < .05 was performed using Kruskal-Wallis tests and simple linear regression analysis.

RESULTS

A total of 30 articles were selected for the current SR. Using AMSTAR, the item related to the scientific quality of studies used in conclusion was adhered by less than 40% of studies. Using PRISMA, 3 items were reported by less than 40% of studies, which were on objectives, protocol registration, and funding. No association was evident comparing the number of authors and country with quality. Statistical significance was observed when quality was compared among journals, with studies published as Cochrane reviews superior to those published in other journals. AMSTAR and PRISMA scores were significantly related.

CONCLUSIONS

SRs in endodontics showed variability in both methodologic and reporting quality.

Venous Blood Derivatives as FBS-Substitutes for Mesenchymal Stem Cells: A Systematic Scoping Review

Although the biological properties of mesenchymal stem cells (MSC) are well-characterized in vitro, MSC clinical application is still far away to be achieved, mainly due to the need of xenogeneic substances for cell expansion, such as fetal bovine serum (FBS). FBS presents risks regarding pathogens transmissions and internalization of animal's proteins, which can unleash antigenic responses in patients after MSC implantation. A wide range of venous blood derivatives (VBD) has been reported as FBS substitutes showing promising results. Thus, the aim of this study was to conduct a systematic scoping review to analyze whether VBD are effective FBS substitutes for MSC ex vivo expansion. The search was performed in SciVerse ScopusTM, PubMed, Web of ScienceTM, BIREME, Cochrane library up to January 2016. The keywords were selected using MeSH and entry terms. Two independent reviewers scrutinized the records obtained considering specific inclusion criteria. The included studies were evaluated in accordance with a modified Arksey and O' Malley's framework. From 184 found studies, 90 were included. Bone marrow mesenchymal stem cells (BMMSC) were presented in most of these studies. Overall, VBD allowed for either, maintenance of MCS's fibroblast-like morphology, high proliferation, high colony-formation ability and maintenance of multipotency. Besides. MSC expanded in VBD supplements presented higher mitogen activity than FBS. VBD seems to be excellent xeno-free serum for ex vivo expansion of mesenchymal stem cells. However, an accentuated heterogeneity was observed between the carried out protocols for VBD isolation did not allowing for direct comparisons between the included studies.

A review of regenerative endodontics: current protocols and future directions

This review outlines the biological basis and clinical protocols currently used in regenerative endodontic procedures (REPs) and discuss future directions in pulp regeneration approaches. The treatment of immature teeth with REPs has been described as a ‘paradigm shift’ as there is the potential for further root maturation. Clinically, REPs involve disinfection of the root canal system without damaging the endogenous stem cell potential present in the apical papilla and other tissues. These stems cells are introduced into the root canal space by inducing a blood clot followed by placement of an intracanal barrier to prevent microleakage. The biological concept of REPs involves the triad of stem cells, scaffold and signalling molecules. Currently, repair rather than true regeneration of the ‘pulp-dentine complex’ is achieved and further root maturation is variable. However, may clinicians consider the treatment of teeth with REPs as the optimal treatment approach for immature teeth with pulp necrosis.

Isolation and prolonged expansion of oral mesenchymal stem cells under clinical-grade, GMP-compliant conditions differentially affects "stemness" properties

Background

Development of clinical-grade cell preparations is central to meeting the regulatory requirements for cellular therapies under good manufacturing practice-compliant (cGMP) conditions. Since addition of animal serum in culture media may compromise safe and efficient expansion of mesenchymal stem cells (MSCs) for clinical use, this study aimed to investigate the potential of two serum/xeno-free, cGMP culture systems to maintain long-term “stemness” of oral MSCs (dental pulp stem cells (DPSCs) and alveolar bone marrow MSCs (aBMMSCs)), compared to conventional serum-based expansion.

Methods

DPSC and aBMMSC cultures (n = 6/cell type) were established from pulp and alveolar osseous biopsies respectively. Three culture systems were used: StemPro_MSC/SFM_XenoFree (Life Technologies); StemMacs_MSC/XF (Miltenyi Biotek); and α-MEM (Life Technologies) with 15% fetal bovine serum. Growth (population doublings (PDs)), immunophenotypic (flow cytometric analysis of MSC markers) and senescence (β-galactosidase (SA-β-gal) activity; telomere length) characteristics were determined during prolonged expansion. Gene expression patterns of osteogenic (ALP, BMP-2), adipogenic (LPL, PPAR-γ) and chondrogenic (ACAN, SOX-9) markers and maintenance of multilineage differentiation potential were determined by real-time PCR.

Results

Similar isolation efficiency and stable growth dynamics up to passage 10 were observed for DPSCs under all expansion conditions. aBMMSCs showed lower cumulative PDs compared to DPSCs, and when StemMacs was used substantial delays in cell proliferation were noted after passages 6–7. Serum/xeno-free expansion produced cultures with homogeneous spindle-shaped phenotypes, while serum-based expansion preserved differential heterogeneous characteristics of each MSC population. Prolonged expansion of both MSC types but in particular the serum/xeno-free-expanded aBMMSCs was associated with downregulation of CD146, CD105, Stro-1, SSEA-1 and SSEA-4, but not CD90, CD73 and CD49f, in parallel with an increase of SA-gal-positive cells, cell size and granularity and a decrease in telomere length. Expansion under both serum-free systems resulted in “osteogenic pre-disposition”, evidenced by upregulation of osteogenic markers and elimination of chondrogenic and adipogenic markers, while serum-based expansion produced only minor changes. DPSCs retained a diminishing (CCM, StemPro) or increasing (StemMacs) mineralization potential with passaging, while aBMMSCs lost this potential after passages 6–7 under all expansion conditions.

Conclusions

These findings indicate there is still a vacant role for development of qualified protocols for clinical-grade expansion of oral MSCs; a key milestone achievement for translation of research from the bench to clinics.

Electronic supplementary material

The online version of this article (doi:10.1186/s13287-017-0705-0) contains supplementary material, which is available to authorized users.

Platelet-Poor Plasma as a Supplement for Fibroblasts Cultured in Platelet-Rich Fibrin

The aim of this study was to evaluate the proliferation and adhesion of mesenchymal cells (3T3/NIH) in Dulbecco’s Modified Eagle Medium(DMEM) supplemented with Platelet-Poor Plasma (PPP) in aPlatelet-Rich Fibrin (PRF) scaffold. Human blood was obtained and processed in a centrifuge considering the equation G=1.12xRx(RPM/1000)² to obtain PRF and PPP.Cell adhesion and maintenance analyses were performed by MTTassays in a 96 well plate withsupplemented DMEM: PPP (90:10) for 24 hours. Besides, the PRF was deposited in a 48 well plate and 10x10⁴ cells were seeded above each PRF (n=3) with 800µl of DMEM: PPP (90:10) and cultured for 7 days. Histological analysis and the immunohistochemical staining for Vimentin were performed. Results were analyzed by one-way ANOVA in Stata12®. A significant decrease (p<0.05) of cells adhesion in relationship to FBSwas observed. However, a similar ability of cell-maintenance for PPP 10% was observed (P>0.05). Fibroblasts culture for 7 days in PRF supplemented with PPP 10% was possible, showing positive staining for Vimentin. Therefore, PPP cell supplementation decreased the initial adhesion of cells but was able to maintain the proliferation of adhered cells and able to support their viability in PRF.It seems that this method has many clinical advantagessince it provides an autologous and natural scaffold with their respective supplement for cell culture by only one process, without using xenogeneic compounds. This could improve the potential of clinical translational therapies based on the use of PRF cultured cells, promoting the regenerative potential for future use in medicine and dentistry.

Current challenges in human tooth revitalization

Tooth vitality and health are related to the presence of a living connective tissue, the dental pulp (DP), in the center of the dental organ. The DP contains the tooth immune defence system that is activated against invading oral cariogenic bacteria during the caries process and the tissue repair/regeneration machinery involved following microorganisms' eradication. However, penetration of oral bacteria into the DP often leads to complete tissue destruction and colonization of the endodontic space by microorganisms. Classical endodontic therapies consist of disinfecting then sealing the endodontic space with a gutta percha-based material. However, re-infections of the endodontic space by oral bacteria can occur, owing to the lack of tightness of the material. Recent findings suggest that regenerating a fully functional pulp tissue may be an ideal therapeutic solution to maintain a tooth defence system that will detect and help manage future injuries. The objective of this paper was to explain the different revascularization and regeneration strategies that have been proposed to reconstitute a living DP tissue and to discuss the main challenges that have to be resolved to improve these therapeutic strategies.

Biological effects of silk fibroin 3D scaffolds on stem cells from human exfoliated deciduous teeth (SHEDs)

The aim is to investigate in vitro biological effects of silk fibroin 3D scaffolds on stem cells from human exfoliated deciduous teeth (SHEDs) in terms of proliferation, morphological appearance, cell viability, and expression of mesenchymal stem cell markers. Silk fibroin 3D scaffolding materials may represent promising suitable scaffolds for their application in regenerative endodontic therapy approaches. SHEDs were cultured in silk fibroin 3D scaffolds. Then, cell numbers were counted and the Alamar blue colorimetric assay was used to analyse cell proliferation after 24, 48, 72, and 168 h of culture. The morphological features of SHEDs cultured on silk fibroin scaffolds were evaluated by scanning electron microscopy (SEM). Finally, cell viability and the expression of mesenchymal stem cell markers were analysed by flow cytometry. One-way analysis of variance (ANOVA) followed by a Bonferroni post-test was performed (P < 0.05). At 24 and 48 h of culture, SHED proliferation on scaffolds was modest compared to the control although still significant (p < 0.05). However, cell proliferation progressively increased from 72 to 168 h compared with the control (p < 0.001; p < 0.01). In addition, flow cytometry analysis showed that the culture of SHEDs on silk fibroin scaffolds did not significantly alter the level of expression of the mesenchymal markers CD73, CD90, or CD105 up to 168 h; in addition, cell viability in silk fibroin was similar to than obtained in plastic. Moreover, SEM studies revealed a suitable degree of proliferation, cell spreading, and attachment, especially after 168 h of culture. The findings from the current study suggest that silk fibroin 3D scaffolds had a favourable effect on the biological responses of SHEDs. Further in vivo investigations are required to confirm these results.

Enhanced regeneration potential of mobilized dental pulp stem cells from immature teeth

OBJECTIVES

We have previously demonstrated that dental pulp stem cells (DPSCs) isolated from mature teeth by granulocyte colony-stimulating factor (G-CSF)-induced mobilization method can enhance angiogenesis/vasculogenesis and improve pulp regeneration when compared with colony-derived DPSCs. However, the efficacy of this method in immature teeth with root-formative stage has never been investigated. Therefore, the aim of this study was to examine the stemness, biological characteristics, and regeneration potential in mobilized DPSCs compared with colony-derived DPSCs from immature teeth.

MATERIALS AND METHODS

Mobilized DPSCs isolated from immature teeth were compared to colony-derived DPSCs using methods including flow cytometry, migration assays, mRNA expression of angiogenic/neurotrophic factor, and induced differentiation assays. They were also compared in trophic effects of the secretome. Regeneration potential was further compared in an ectopic tooth transplantation model.

RESULTS

Mobilized DPSCs had higher migration ability and expressed more angiogenic/neurotrophic factors than DPSCs. The mobilized DPSC secretome produced a higher stimulatory effect on migration, immunomodulation, anti-apoptosis, endothelial differentiation, and neurite extension. In addition, vascularization and pulp regeneration potential were higher in mobilized DPSCs than in DPSCs.

CONCLUSIONS

G-CSF-induced mobilization method enhances regeneration potential of colony-derived DPSCs from immature teeth.

Stem Cells of Dental Origin: Current Research Trends and Key Milestones towards Clinical Application

Dental Mesenchymal Stem Cells (MSCs), including Dental Pulp Stem Cells (DPSCs), Stem Cells from Human Exfoliated Deciduous teeth (SHED), and Stem Cells From Apical Papilla (SCAP), have been extensively studied using highly sophisticated in vitro and in vivo systems, yielding substantially improved understanding of their intriguing biological properties. Their capacity to reconstitute various dental and nondental tissues and the inherent angiogenic, neurogenic, and immunomodulatory properties of their secretome have been a subject of meticulous and costly research by various groups over the past decade. Key milestone achievements have exemplified their clinical utility in Regenerative Dentistry, as surrogate therapeutic modules for conventional biomaterial-based approaches, offering regeneration of damaged oral tissues instead of simply “filling the gaps.” Thus, the essential next step to validate these immense advances is the implementation of well-designed clinical trials paving the way for exploiting these fascinating research achievements for patient well-being: the ultimate aim of this ground breaking technology. This review paper presents a concise overview of the major biological properties of the human dental MSCs, critical for the translational pathway “from bench to clinic.”

Immunohistochemical Expression of TGF-β1 and Osteonectin in engineered and Ca(OH)2-repaired human pulp tissues

The aim of the present study was to evaluate the expression of transforming growth factor-β1 (TGF-β1) and osteonectin (ON) in pulp-like tissues developed by tissue engineering and to compare it with the expression of these proteins in pulps treated with Ca(OH)2 therapy. Tooth slices were obtained from non-carious human third molars under sterile procedures. The residual periodontal and pulp soft tissues were removed. Empty pulp spaces of the tooth slice were filled with sodium chloride particles (250-425 µm). PLLA solubilized in 5% chloroform was applied over the salt particles. The tooth slice/scaffold (TS/S) set was stored overnight and then rinsed thoroughly to wash out the salt. Scaffolds were previously sterilized with ethanol (100-70°) and washed with phosphate-buffered saline (PBS). TS/S was treated with 10% EDTA and seeded with dental pulp stem cells (DPSC). Then, TS/S was implanted into the dorsum of immunodeficient mice for 28 days. Human third molars previously treated with Ca(OH)2 for 90 days were also evaluated. Samples were prepared and submitted to histological and immunohistochemical (with anti-TGF-β1, 1:100 and anti-ON, 1:350) analyses. After 28 days, TS/S showed morphological characteristics similar to those observed in dental pulp treated with Ca(OH)2. Ca(OH)2-treated pulps showed the usual repaired pulp characteristics. In TS/S, newly formed tissues and pre-dentin was colored, which elucidated the expression of TGF-β1 and ON. Immunohistochemistry staining of Ca(OH)2-treated pulps showed the same expression patterns. The extracellular matrix displayed a fibrillar pattern under both conditions. Regenerative events in the pulp seem to follow a similar pattern of TGF-β1 and ON expression as the repair processes.

Critical Assessment of Search Strategies in Systematic Reviews in Endodontics

INTRODUCTION

The aim of this study was to perform an overview of literature search strategies in systematic reviews (SRs) published in 2 endodontic journals, Journal of Endodontics and International Endodontic Journal.

METHODS

A search was done by using the MEDLINE (PubMed interface) database to retrieve the articles published between January 1, 2000 and December 31, 2015. The last search was on January 10, 2016. All the SRs published in the 2 journals were retrieved and screened. Eligible SRs were assessed by using 11 questions about search strategies in the SRs that were adapted from 2 guidelines (ie, AMSTAR checklist and the Cochrane Handbook).

RESULTS

A total of 83 SRs were retrieved by electronic search. Of these, 55 were from the Journal of Endodontics, and 28 were from the International Endodontic Journal. After screening, 2 SRs were excluded, and 81 SRs were included in the study. Some issues, such as search of grey literature and contact with study authors, were not fully reported (30% and 25%, respectively). On the other hand, some issues, such as the use of index terms and key words and search in at least 2 databases, were reported in most of the SRs (97% and 95%, respectively). The overall quality of the search strategy in both journals was 61%. No significant difference was found between the 2 journals in terms of evaluation criteria (P > .05).

CONCLUSIONS

There exist areas for improving the quality of reporting of search strategies in SRs; for example, grey literature should be searched for unpublished studies, no language limitation should be applied to databases, and authors should make an attempt to contact the authors of included studies to obtain further relevant information.

Evaluation of cytocompatibility of calcium silicate-based endodontic sealers and their effects on the biological responses of mesenchymal dental stem cells

AIM

To investigate in vitro the cytocompatibility of the calcium silicate-containing endodontic sealers MTA Fillapex and TotalFill BC Sealer on human periodontal ligament stem cells (hPDLSCs) by assaying their biological responses and compare them with that observed when using an epoxy resin-based sealer (AH Plus).

METHODOLOGY

Specimens from the three different endodontic sealers were eluated with culture medium for 24 h. The cytotoxicity of these eluates was evaluated using the MTT assay. In addition, an in vitro scratch wound healing model was used to determine their effects on cell migration. Cell adhesion to collagen type I after treatment with the different sealer eluates was also measured, whereas cytotoxicity was determined using the DNA-specific fluorochrome Hoechst 33342. Finally, to assess cell morphology and attachment to the different sealers, hPDLSCs were directly seeded onto the material surfaces and analysed by scanning electron microscopy (SEM). One-way analysis of variance (anova) followed by a Bonferroni post-test were performed (P < 0.05).

RESULTS

hPDLSCs exposed to different dilutions of TotalFill BC Sealer eluates had significantly higher cell proliferation compared with that observed when cells were treated with AH Plus and MTA Fillapex eluates (P < 0.001). In addition, TotalFill eluates were associated with significantly increased cell adhesion to collagen type I and migration of hPDLSCs in a concentration-dependent manner than displayed after treatment with MTA Fillapex or AH Plus eluates (P < 0.001). Moreover, TotalFill BC Sealer-induced cytotoxicity was significantly lower than observed using AH Plus and MTA Fillapex eluates (P < 0.001). Finally, SEM studies revealed suitable proliferation, cell spreading and attachment, especially when using TotalFill BC Sealer discs.

CONCLUSION

TotalFill BC Sealer exhibited a higher cytocompatibility than AH Plus and MTA Fillapex. Further investigations using in vivo animal models are required to validate the potential biological responses of TotalFill BC Sealer on hPDLSCs.

In vitro osteogenic and odontogenic differentiation of human dental pulp stem cells seeded on carboxymethyl cellulose-hydroxyapatite hybrid hydrogel

Stem cells from human dental pulp have been considered as an alternative source of adult stem cells in tissue engineering because of their potential to differentiate into multiple cell lineages. Recently, polysaccharide based hydrogels have become especially attractive as matrices for the repair and regeneration of a wide variety of tissues and organs. The incorporation of inorganic minerals as hydroxyapatite nanoparticles can modulate the performance of the scaffolds with potential applications in tissue engineering. The aim of this study was to verify the osteogenic and odontogenic differentiation of dental pulp stem cells (DPSCs) cultured on a carboxymethyl cellulose—hydroxyapatite hybrid hydrogel. Human DPSCs were seeded on carboxymethyl cellulose—hydroxyapatite hybrid hydrogel and on carboxymethyl cellulose hydrogel for 1, 3, 5, 7, 14, and 21 days. Cell viability assay and ultramorphological analysis were carried out to evaluate biocompatibility and cell adhesion. Real Time PCR was carried out to demonstrate the expression of osteogenic and odontogenic markers. Results showed a good adhesion and viability in cells cultured on carboxymethyl cellulose—hydroxyapatite hybrid hydrogel, while a low adhesion and viability was observed in cells cultured on carboxymethyl cellulose hydrogel. Real Time PCR data demonstrated a temporal up-regulation of osteogenic and odontogenic markers in dental pulp stem cells cultured on carboxymethyl cellulose—hydroxyapatite hybrid hydrogel. In conclusion, our in vitro data confirms the ability of DPSCs to differentiate toward osteogenic and odontogenic lineages in presence of a carboxymethyl cellulose—hydroxyapatite hybrid hydrogel. Taken together, our results provide evidence that DPSCs and carboxymethyl cellulose—hydroxyapatite hybrid hydrogel could be considered promising candidates for dental pulp complex and periodontal tissue engineering.