Clinical utility of stem cells for periodontal regeneration

The Osteogenic Role of Biomaterials Combined with Human-Derived Dental Stem Cells in Bone Tissue Regeneration

The use of stem cells in regenerative medicine had great potential for clinical applications. However, cell delivery strategies have critical importance in stimulating the differentiation of stem cells and enhancing their potential to regenerate damaged tissues. Different strategies have been used to investigate the osteogenic potential of dental stem cells in conjunction with biomaterials through in vitro and in vivo studies. Osteogenesis has a broad implication in regenerative medicine, particularly for maxillofacial defects. This review summarizes some of the most recent developments in the field of tissue engineering using dental stem cells.

Regeneration of periodontal bone defects with mesenchymal stem cells in animal models. Systematic review and meta-analysis

The aim of this study was to evaluate the efficacy of mesenchymal stem cells (MSCs) in the regeneration of periodontal bone defects in animal models. A systematic review and meta-analysis were conducted following the PRISMA guidelines, and the study was recorded in PROSPERO under reference number CDR42021247462. The PICO question was: is periodontal regeneration (cementum, periodontal ligament and alveolar bone) with MSCs more effective than other techniques? Three groups were considered: Group 1: MSCs alone or mixed with regenerative materials. Group 2: only regenerative materials. Group 3: no regenerative material nor MSCs. The search was conducted using MeSH with a total of 18 articles for qualitative analysis and 5 for quantitative analysis. For the meta-analysis, a modification of the effect size algorithm was developed, which considered a comparison of means between treatments using the Student's t sample distribution. When comparing the effect size between Group 1 and Group 2, the effect size for the new cementum was 2.83 mm with an estimated confidence interval of 95% (CI 95%) between 0.48 and 5.17 mm. When considering the fit to a random-effects model, the combined variance (τ²) was 6.1573 mm, with a standard deviation (SD) of 5.6008 mm and a percentage of total heterogeneity I² of 92.33% (p < 0.0001). For new bone, the effect size was 0.88 mm, CI 95% - 0.25 to 2.01 mm, τ² = 1.3108 mm (SD = 1.2021 mm) and I² = 80.46%, p = 0.0004). With regard to the new periodontal ligament, it was not possible for the meta-analysis to be performed. MSCs have a greater capacity for tissue regeneration in root cementum than in alveolar bone compared to other regenerative materials.

A Novel Perspective on Tissue Engineering Potentials of Periodontal Ligament Stem Cells

It is challenging to completely and predictably regenerate the missing periodontal tissues caused by the trauma or disease. To regenerate the periodontium, there is a need to consider several aspects that co-occur with periodontal development. This study provides an overview of the most up-to-date investigations on the characteristics and immunomodulatory features of Periodontal Ligament Stem Cells (PDLSCs) and the recent interventions performed using these cells, focusing on cell survival, proliferation, and differentiation. Keeping in mind the relationship between age and potency of PDLSCs, this work also demonstrates the necessity of establishing dental-derived stem cell banks for tissue regeneration applications. The data were collected from Pubmed and Google Scholar databases with the keywords of periodontal ligament stem cells, tissue engineering, characteristics, and stem cell therapy. The results showed the presence of wide-ranging research reports supporting the usability of PDLSCs for periodontal reconstruction. However, a better understanding of self-restoration for adequate regulation of adult stem cell growth is needed for various applied purposes.

Stem cell homing in periodontal tissue regeneration

The destruction of periodontal tissue is a crucial problem faced by oral diseases, such as periodontitis and tooth avulsion. However, regenerating periodontal tissue is a huge clinical challenge because of the structural complexity and the poor self-healing capability of periodontal tissue. Tissue engineering has led to advances in periodontal regeneration, however, the source of exogenous seed cells is still a major obstacle. With the improvement of in situ tissue engineering and the exploration of stem cell niches, the homing of endogenous stem cells may bring promising treatment strategies in the future. In recent years, the applications of endogenous cell homing have been widely reported in clinical tissue repair, periodontal regeneration, and cell therapy prospects. Stimulating strategies have also been widely studied, such as the combination of cytokines and chemokines, and the implantation of tissue-engineered scaffolds. In the future, more research needs to be done to improve the efficiency of endogenous cell homing and expand the range of clinical applications.

Epigenetic Regulation of Methylation in Determining the Fate of Dental Mesenchymal Stem Cells

Dental mesenchymal stem cells (DMSCs) are crucial in tooth development and periodontal health, and their multipotential differentiation and self-renewal ability play a critical role in tissue engineering and regenerative medicine. Methylation modifications could promote the appropriate biological behavior by postsynthetic modification of DNA or protein and make the organism adapt to developmental and environmental prompts by regulating gene expression without changing the DNA sequence. Methylation modifications involved in DMSC fate include DNA methylation, RNA methylation, and histone modifications, which have been proven to exert a significant effect on the regulation of the fate of DMSCs, such as proliferation, self-renewal, and differentiation potential. Understanding the regulation of methylation modifications on the behavior and the immunoinflammatory responses involved in DMSCs contributes to further study of the mechanism of methylation on tissue regeneration and inflammation. In this review, we briefly summarize the key functions of histone methylation, RNA methylation, and DNA methylation in the differentiation potential and self-renewal of DMSCs as well as the opportunities and challenges for their application in tissue regeneration and disease therapy.

Expression of Wnt signaling agonists and antagonists in periodontitis and healthy subjects, before and after non-surgical periodontal treatment: A systematic review

Periodontitis is a preventable and treatable multifactorial chronic inflammatory disease that can lead to irreversible periodontal destruction and tooth loss. Wnt signaling and its regulators play an important role in periodontal inflammation, destruction, regeneration, and reconstruction. This systematic review aimed at investigating the involvement of Wnt signaling agonists and antagonists in periodontitis and healthy subjects, before and after periodontal treatment. Electronic searches were carried out using MEDLINE/PubMed, EMBASE, and Cochrane Library databases in addition to hand searches. Studies having different designs assessing the levels of Wnt signaling antagonist and agonist levels in gingival crevicular fluid, serum, and tissue in patients diagnosed with periodontitis or gingivitis, compared with healthy individuals were included. In addition, studies compared these levels in periodontitis patients before and after non-surgical periodontal therapy were also eligible. Sixteen studies met the eligibility criteria. Sclerostin (SOST) has been mainly investigated in the literature (8 publications). Sclerostin (5 studies), Wnt-5a (2 studies), secreted frizzled-related protein 1 (SFRP1) (3 studies), and β-catenin (3 studies) show increased levels in periodontitis compared with periodontal health. Strong correlations between marker levels and periodontal clinical parameters were identified for SOST (5 studies), SFRP1 (2 studies), and β-catenin (2 studies). SOST (3 studies) and SFRP1 (1 study) levels significantly decrease following non-surgical periodontal treatment. The present systematic review demonstrated an association between Wnt signaling agonist and antagonist levels and periodontitis. Wnt agonists and antagonists may serve as valuable diagnostic and prognostic markers for periodontitis onset and progression. Further case-control and longitudinal studies should be conducted for different Wnt signaling agonists and antagonists.

Role of magnesium-doped calcium sulfate and β-tricalcium phosphate composite ceramics in macrophage polarization and osteo-induction

In the current study, we explored the role of Mg²⁺-doped CaSO₄/β-TCP composite biopolymer in regulating macrophage polarization and its relation with enhanced osteogenic differentiation of periodontal ligament stem cells. Furthermore, mechanism underling the regulation of macrophage polarization by CaSO₄/β-TCP was evaluated. Mg²⁺-doped CaSO₄/β-TCP composite was characterized by scanning electron microscopy (SEM) and X-ray diffraction (XRD). Macrophage polarization was characterized using flow cytometry analysis. Macrophage morphometric analysis was conducted by FITC phalloidin staining. Western blot and qRT-PCR assays were used to assess gene expression levels and miRNAs, respectively. SEM morphology of CaSO₄/β-TCP ceramic revealed a particle size of 10–50 μm, and XRD spectrum showed that characteristic peak of samples was consistent with that of CaSO₄ and β-TCP. Results from flow cytometry evidenced significant upregulation of M2 macrophage markers after adding ceramic biopolymer, indicating the induction of inactivated M0 macrophage polarization to M2 macrophage. Macrophage morphometric analysis revealed development of lamellar pseudopodia on day 7 in CaSO₄/β-TCP group. Furthermore, flow cytometry revealed high positivity rate of 90.34% (CD44) and 89.36% (CD146). qRT-PCR results showed that the level of miR-21-5p was significantly decreased in M2 macrophages. Moreover, western blot analysis revealed upregulated expression levels of RUNX2, osterix (Osx), and osteopontin (OPN), and ELISA exhibited increase in cytokine levels (IL-1β, IL-10, TGF-β1, and BMP-2) in the presence of macrophages, indicating the osteogenic differentiation ability of periodontal ligament stem cells. The study evidenced the regulation of macrophage polarization by Mg²⁺-doped CaSO₄/β-TCP composite ceramic and its mediation through lncRNA PVT1/miR-21-5p/smad2 molecular axis.

Low-Intensity Pulsed Ultrasound Promotes Osteogenic Potential of iPSC-Derived MSCs but Fails to Simplify the iPSC-EB-MSC Differentiation Process

Induced pluripotent stem cell (iPSC)-derived mesenchymal stem cells (iMSCs) are a promising cell source for bone tissue engineering. However, iMSCs have less osteogenic potential than BMSCs, and the classical iPSC-EB-iMSC process to derive iMSCs from iPSCs is too laborious as it involves multiple in vitro steps. Low-intensity pulsed ultrasound (LIPUS) is a safe therapeutic modality used to promote osteogenic differentiation of stem cells. Whether LIPUS can facilitate osteogenic differentiation of iMSCs and simplify the iPSC-EB-iMSC process is unknown. We stimulated iMSCs with LIPUS at different output intensities (20, 40, and 60 mW/cm²) and duty cycles (20, 50, and 80%). Results of ALP activity assay, osteogenic gene expression, and mineralization quantification demonstrated that LIPUS was able to promote osteogenic differentiation of iMSCs, and it worked best at the intensity of 40 mW/cm² and the duty cycle of 50% (LIPUS40/50). The Wnt/β-catenin signaling pathway was involved in LIPUS40/50-mediated osteogenesis. When cranial bone defects were implanted with iMSCs, LIPUS40/50 stimulation resulted in a significant higher new bone filling rate (72.63 ± 17.04)% than the non-stimulated ones (34.85 ± 4.53)%. Daily exposure to LIPUS40/50 may accelerate embryoid body (EB)-MSC transition, but it failed to drive iPSCs or EB cells to an osteogenic lineage directly. This study is the first to demonstrate the pro-osteogenic effect of LIPUS on iMSCs. Although LIPUS40/50 failed to simplify the classical iPSC-EB-MSC differentiation process, our preliminary results suggest that LIPUS with a more suitable parameter set may achieve the goal. LIPUS is a promising method to establish an efficient model for iPSC application.

Microbial-stem cell interactions in periodontal disease

Periodontitis is initiated by hyper-inflammatory responses in the periodontal tissues that generate dysbiotic ecological changes within the microbial communities. As a result, supportive tissues of the tooth are damaged and periodontal attachment is lost. Gingival recession, formation of periodontal pockets with the presence of bleeding, and often suppuration and/or tooth mobility are evident upon clinical examination. These changes may ultimately lead to tooth loss. Mesenchymal stem cells (MSCs) are implicated in controlling periodontal disease progression and have been shown to play a key role in periodontal tissue homeostasis and regeneration. Evidence shows that MSCs interact with subgingival microorganisms and their by-products and modulate the activity of immune cells by either paracrine mechanisms or direct cell-to-cell contact. The aim of this review is to reveal the interactions that take place between microbes and in particular periodontal pathogens and MSCs in order to understand the factors and mechanisms that modulate the regenerative capacity of periodontal tissues and the ability of the host to defend against putative pathogens. The clinical implications of these interactions in terms of anti-inflammatory and paracrine responses of MSCs, anti-microbial properties and alterations in function including their regenerative potential are critically discussed based on literature findings. In addition, future directions to design periodontal research models and study ex vivo the microbial-stem cell interactions are introduced.

Evaluation of Attitude and Knowledge of Endodontic, Pedodontic and SBARD Residents in Saudi Arabia toward Regenerative Endodontics-A National Survey

Background and Objectives: There are no guidelines on the regenerative endodontic procedures that should be followed in dental treatment. Thus, it is essential to learn the knowledge, attitudes, and opinions about regenerative endodontics among dental practitioners, particularly endodontists, as they are the first providers of this type of dental treatment. Aim: This study aimed to assess the knowledge and attitudes among residents of the Saudi Board of Advanced Restorative Dentistry (SBARD) in Saudi Arabia. Methods & Materials: A questionnaire-based survey was conducted among 128 residents of endodontics, pedodontics, and the SBARD in Saudi Arabia. The questionnaire was distributed to participants using the available electronic measures such as emails and social media. The questionnaire was made by Google Forms, and responses were received directly in the excel sheet in the email. The data were exported as an excel file, coded, and analyzed, and the p-value < 0.05 was set as significant. Results: More than 50% (74 dentists) of the participants reported receiving continuing education in regenerative treatment, with a significant difference found among specialty (p = 0.023). No significant association was found between knowledge, gender, and type of postgraduate study. The vast majority (89.1%) of the participants believed regenerative endodontics should be incorporated into dentistry curricula. About two-thirds (78.2%) of the participants declared their ability to attend future training courses in a regenerative endodontic, whereas 10.9% did not, and 10.9% were unsure. Conclusions: The dental practitioners were enthusiastic and interested in regenerative and stem cell treatment. The results also suggested incorporating regenerative treatment into the dental curriculum and signaled the need for more continued training courses.

Dynamically Bioresponsive DNA Hydrogel Incorporated with Dual-Functional Stem Cells from Apical Papilla-Derived Exosomes Promotes Diabetic Bone Regeneration

The regeneration of bone defects in patients with diabetes mellitus (DM) is remarkably impaired by hyperglycemia and over-expressed proinflammatory cytokines, proteinases (such as matrix metalloproteinases, MMPs), etc. In view of the fact that exosomes represent a promising nanomaterial, herein, we reported the excellent capacity of stem cells from apical papilla-derived exosomes (SCAP-Exo) to facilitate angiogenesis and osteogenesis whether in normal or diabetic conditions in vitro. Then, a bioresponsive polyethylene glycol (PEG)/DNA hybrid hydrogel was developed to support a controllable release of SCAP-Exo for diabetic bone defects. This system could be triggered by the elevated pathological cue (MMP-9) in response to the dynamic diabetic microenvironment. It was further confirmed that the administration of the injectable SCAP-Exo-loaded PEG/DNA hybrid hydrogel into the mandibular bone defect of diabetic rats demonstrated a great therapeutic effect on promoting vascularized bone regeneration. In addition, the miRNA sequencing suggested that the mechanism of dual-functional SCAP-Exo might be related to highly expressed miRNA-126-5p and miRNA-150-5p. Consequently, our study provides valuable insights into the design of promising bioresponsive exosome-delivery systems to improve bone regeneration in diabetic patients.

Human Bone Marrow Stromal Cell Exosomes Ameliorate Periodontitis

Human bone marrow stromal cell (hBMSC)-derived exosomes are promising therapeutics for inflammatory diseases due to their unique microRNA (miRNA) and protein cargos. Periodontal diseases often present with chronicity and corresponding exuberant inflammation, which leads to loss of tooth support. In this study, we explored whether hBMSC exosomes can affect periodontitis progression. hBMSC exosomes were isolated from cell culture medium through sequential ultracentrifugation. miRNAs and proteins that were enriched in hBMSC exosomes were characterized by RNA sequencing and protein array, respectively. hBMSC exosomes significantly suppressed periodontal keystone pathogen Porphyromonas gingivalis-triggered inflammatory response in macrophages in vitro. Transcriptomic analysis suggested that exosomes exerted their effects through regulating cell metabolism, differentiation, and inflammation resolution. In vivo, weekly exosome injection into the gingival tissues reduced the tissue destruction and immune cell infiltration in rat ligature-induced periodontitis model. Collectively, these findings suggest that hBMSC-derived exosomes can potentially be used as a host modulation agent in the management of periodontitis.

Mesenchymal stem cells surpass the capacity of bone marrow aspirate concentrate for periodontal regeneration

Regenerative approaches using mesenchymal stem cells (MSCs) have been evaluated to promote the complete formation of all missing periodontal tissues, e.g., new cementum, bone, and functional periodontal ligaments. MSCs derived from bone marrow have been applied to bone and periodontal defects in several forms, including bone marrow aspirate concentrate (BMAC) and cultured and isolated bone marrow mesenchymal stem cells (BM-MSCs). This study aimed to evaluate the periodontal regeneration capacity of BMAC and cultured BM-MSCs in the wound healing of fenestration defects in rats. Methodology: BM-MSCs were obtained after bone marrow aspiration of the isogenic iliac crests of rats, followed by cultivation and isolation. Autogenous BMAC was collected and centrifuged immediately before surgery. In 36 rats, fenestration defects were created and treated with suspended BM-MSCs, BMAC or left to spontaneously heal (control) (N=6). Their regenerative potential was assessed by microcomputed tomography (µCT) and histomorphometry, as well as their cell phenotype and functionality by the Luminex assay at 15 and 30 postoperative days. Results: BMAC achieved higher bone volume in 30 days than spontaneous healing (p<0.0001) by enhancing osteoblastic lineage commitment maturation, with higher levels of osteopontin (p=0.0013). Defects filled with cultured BM-MSCs achieved higher mature bone formation in early stages than spontaneous healing and BMAC (p=0.0241 and p=0.0143, respectively). Moreover, significantly more cementum-like tissue formation (p<0.0001) was observed with new insertion of fibers in specimens treated with BM-MSCs within 30 days. Conclusion: Both forms of cell transport, BMAC and BM-MSCs, promoted bone formation. However, early bone formation and maturation were achieved when cultured BM-MSCs were used. Likewise, only cultured BM-MSCs were capable of achieving complete periodontal regeneration with inserted fibers in the new cementum-like tissue.

Effects of Photobiomodulation Therapy with Various Laser Wavelengths on Proliferation of Human Periodontal Ligament Mesenchymal Stem Cells

Several methods have been proposed to enhance the regeneration and healing time in periodontal therapy. Photobiomodulation therapy (PBMT) is a recently suggested novel technique for this purpose. This study aimed to compare the efficacy of PBMT with various laser wavelengths and energy densities on proliferation of human periodontal ligament mesenchymal stem cells (PDLMSCs). The wells containing PDLMSCs were subjected to laser irradiation at 635, 660, 808, and 980 nm wavelengths with 1, 1.5, 2.5 and 4 J/cm² energy densities. Cell proliferation and viability were evaluated after 1, 3, and 5 days with the methyl thiazolyl tetrazolium (MTT) assay and 4,6-diamidino-2-phenylindole (DAPI) staining. No significant difference was observed among the experimental and the control groups on day 1 (P>0.05). On day 3, 808 nm laser at 4 J/cm² energy density and 980 nm laser at all densities had significant differences with control group. On day 5, the control group had significant differences in cell proliferation with 808 nm laser at 2.5 and 4 J/cm² energy densities, and 980 nm laser at all densities. PBMT with 635, 660, 808, and 980 nm wavelengths increased the proliferation of PDLMSCs but the maximum cell viability was prominent after irradiation by 980 nm laser with energy density of 4 J/cm² on day 3.

Impact of Magnetic Stimulation on Periodontal Ligament Stem Cells

The aim of this study was to evaluate the effect of a time-dependent magnetic field on the biological performance of periodontal ligament stem cells (PDLSCs). A Western blot analysis and Alamar Blue assay were performed to investigate the proliferative capacity of magnetically stimulated PDLSCs (PDLSCs MAG) through the study of the MAPK cascade (p-ERK1/2). The observation of ALP levels allowed the evaluation of the effect of the magnetic field on osteogenic differentiation. Metabolomics data, such as oxygen consumption rate (OCR), extracellular acidification rate (ECAR) and ATP production provided an overview of the PDLSCs MAG metabolic state. Moreover, the mitochondrial state was investigated through confocal laser scanning microscopy. Results showed a good viability for PDLSCs MAG. Magnetic stimulation can activate the ERK phosphorylation more than the FGF factor alone by promoting a better cell proliferation. Osteogenic differentiation was more effectively induced by magnetic stimulation. The metabolic panel indicated significant changes in the mitochondrial cellular respiration of PDLSCs MAG. The results suggested that periodontal ligament stem cells (PDLSCs) can respond to biophysical stimuli such as a time-dependent magnetic field, which is able to induce changes in cell proliferation and differentiation. Moreover, the magnetic stimulation also produced an effect on the cell metabolic profile. Therefore, the current study demonstrated that a time-dependent magnetic stimulation may improve the regenerative properties of PDLSCs.

Potential of Bone-Marrow-Derived Mesenchymal Stem Cells for Maxillofacial and Periodontal Regeneration: A Narrative Review

Bone-marrow-derived mesenchymal stem cells (BM-MSCs) are one of the most widely studied postnatal stem cell populations and are considered to utilize more frequently in cell-based therapy and cancer. These types of stem cells can undergo multilineage differentiation including blood cells, cardiac cells, and osteogenic cells differentiation, thus providing an alternative source of mesenchymal stem cells (MSCs) for tissue engineering and personalized medicine. Despite the ability to reprogram human adult somatic cells to induced pluripotent stem cells (iPSCs) in culture which provided a great opportunity and opened the new door for establishing the in vitro disease modeling and generating an unlimited source for cell base therapy, using MSCs for regeneration purposes still have a great chance to cure diseases. In this review, we discuss the important issues in MSCs biology including the origin and functions of MSCs and their application for craniofacial and periodontal tissue regeneration, discuss the potential and clinical applications of this type of stem cells in differentiation to maxillofacial bone and cartilage in vitro, and address important future hopes and challenges in this field.

The Effects of Porphyromonas gingivalis on Inflammatory and Immune Responses and Osteogenesis of Mesenchymal Stem Cells

Mesenchymal stem cells (MSCs) are increasingly used in tissue regeneration, not only because of their multilineage differentiation ability, but also because of their immunomodulatory function, which allows them to play a role in the inflammatory milieu, especially in periodontitis. Porphyromonas gingivalis (P. gingivalis) is an important pathogen associated with the progression of periodontitis. Heterogeneous MSC sources show differences in their inflammatory-immune responsiveness and osteogenesis capabilities when exposed to P. gingivalis and its virulence factors. This article reviews the promoted inflammatory and immune responses of periodontal ligament stem cells, which are potential pitfalls in bone regeneration. MSCs from other sources showed contradictory inflammatory and immune reactions in the few studies on this topic. We also summarize the mechanisms involved in the inflammatory, immune responses and osteogenic potential of MSCs exposed to P. gingivalis and its virulence factors to inform an improved utilization of MSCs in regenerative therapies for periodontitis.

Minimal influence of chronic inflammation on the potency and differentiation characteristics of gingiva-derived mesenchymal stem cells-An in vitro study

Objective:

Gingiva-derived mesenchymal stem cells (GMSCs) have been identified and characterized from healthy tissues. However, reports on the influence of chronic inflammation on their stemness characteristics are sparse. The present study evaluated the potency and differentiation ability of GMSCs from periodontally healthy GMSC (H-GMSC) and inflamed GMSC (I-GMSC) tissues.

Materials and Methods:

Established H-GMSCs and I-GMSCs were evaluated on their potency characteristics, such as morphology, viability, proliferation rate, population doubling time, colony-forming ability, expression of stemness markers, and mesenchymal differentiation potential.

Results:

H-GMSCs and I-GMSCs exhibited fibroblast-like morphology and showed >95% viability with high proliferation potential and shorter doubling time. H-GMSCs showed fewer and smaller colonies, whereas I-GMSCs exhibited multiple and larger colonies. The evaluation of stemness markers revealed that both H-GMSCs and I-GMSCs were weakly positive for stage-specific embryonic antigen-4, Stro1, and CD105 (Endoglin), strongly positive for CD73 and CD90, and negative for the hematopoietic cell markers, CD34 and CD45. H-GMSCs showed a slightly higher osteogenic potential when compared to I-GMSCs, while I-GMSCs had a higher adipogenic potential than H-GMSCs.

Conclusion:

The findings showed that the inflammatory environment might have a stimulatory effect on the growth kinetics and ability of colony formation in GMSCs. However, varied osteogenic and adipogenic differentiation was observed between H-GMSCs and I-GMSCs.

Decellularized matrix could affect the proliferation and differentiation of periodontal ligament stem cells in vitro

OBJECTIVE AND BACKGROUND

Recently, decellularized matrix (DCM) is considered as a new biomaterial for tissue regeneration. To explore the possible application of DCM in periodontal regeneration, the effect of DCM from three different cells on the proliferation and differentiation of human periodontal ligament stem cells (PDLSCs) was investigated.

METHODS

DCM derived from human periodontal ligament cells (PDLCs), dental pulp cells (DPCs), and gingival fibroblasts (GFs) were fabricated using Triton X-100/NH₄ OH combined with DNase I. Allogeneic PDLSCs were cultured on PDLC-DCM, DPC-DCM, and GF-DCM, respectively. The proliferative capacity of PDLSCs was evaluated by PicoGreen assay kit. The expression of alkaline phosphatase (ALP), runt-related transcription factor-2 (RUNX2), osteocalcin (OCN), collagen I (COL1), periostin (POSTN), and cementum protein 1 (CEMP1) were detected by qRT-PCR and western blotting.

RESULTS

PDLC-DCM, DPC-DCM, and GF-DCM had similar and integrated networks of extracellular matrix, as well as significantly decreased DNA content. Compared with control group in which PDLSCs were directly seeded in culture plates, PDLC-DCM, DPC-DCM, and GF-DCM promoted the proliferation of re-seeded PDLSCs. Additionally, PDLSCs on DCM exhibited higher mRNA and protein expression levels of ALP, RUNX2, OCN, and COL1. The expression of POSTN in PDLC-DCM group was significantly higher than control group at both mRNA and protein levels.

CONCLUSIONS

PDLC-DCM, DPC-DCM, and GF-DCM could enhance the proliferation of PDLSCs. PDLC-DCM facilitated osteogenic differentiation and periodontal ligament differentiation of PDLSCs, while DPC-DCM and GF-DCM promoted osteogenic differentiation.

A tissue-engineered biocomplex for periodontal reconstruction. A proof-of-principle randomized clinical study

AIM

To assess the safety/efficacy of a tissue-engineered biocomplex in periodontal reconstruction.

METHODS

Twenty-seven intrabony defects were block-randomized across three treatment groups: Group-A (N_A  = 9) received autologous clinical-grade alveolar bone marrow mesenchymal stem cells (a-BMMSCs), seeded into collagen scaffolds, enriched with autologous fibrin/platelet lysate (aFPL). In Group-B (N_B  = 10), the collagen scaffold/aFPL devoid of a-BMMSCs filled the osseous defect. Group-C (N_C  = 8) received Minimal Access Flap surgery retaining the soft tissue wall of defects identically with Groups-A/-B. Subjects were clinically/radiographically assessed before anaesthesia (baseline) and repeatedly over 12 months.

RESULTS

Quality controls were satisfied before biocomplex transplantation. There were no adverse healing events. All approaches led to significant clinical improvements (p < .001) with no inter-group differences. At 12 months, the estimated marginal means for all groups were as follows: 3.0 (95% CI: 1.9-4.1) mm for attachment gain; 3.7 (2.7-4.8) mm for probing pocket depth reduction; 0.7 (0.2-1.3) mm increase in recession. An overall greater mean reduction in the radiographic Cemento-Enamel Junction to Bottom Defect (CEJ-BD) distance was found for Groups-A/-C over Group-B (p < .023).

CONCLUSION

Radiographic evidence of bone fill was less pronounced in Group-B, although clinical improvements were similar across groups. All approaches aimed to trigger the innate healing potential of tissues. Cell-based therapy is justified for periodontal reconstruction and remains promising in selected cases.

Human gingival fibroblasts: Isolation, characterization, and evaluation of CD146 expression

Gingival fibroblasts (GFs) that exhibit adult stem cell-like characteristics are known as gingival mesenchymal stem cells (GMSCs). Specific mesenchymal stem cell (MSC) markers have not been identified to distinguish GMSCs from GFs. Recently, the cell surface molecule known as cluster of differentiation (CD) 146 has been identified as a potential MSC surface marker. In the present study, we investigated the differentiation potential of GMSCs based on CD146 expression. GFs were isolated by two techniques: tissue explants or enzymatic digestion. GFs were cultured and expanded then magnetically sorted according to CD146 expression. CD146low and CD146high cells were collected, expanded, and then tested for stem cell markers by flow cytometry as well as osteogenic and chondrogenic differentiation potential. The differentiation of these cells was analyzed after 21 days using histology, immunofluorescence, real-time quantitative PCR (qPCR), and glycosaminoglycan (GAG) to DNA ratio (GAG/DNA) assays. Positive histological staining indicated osteogenic differentiation of all groups regardless of the isolation techniques utilized. However, none of the groups demonstrated chondrogenic differentiation, confirmed by the lack of collagen type II in the extracellular matrix (ECM) of GF aggregates. Our data suggest that identification of gingival stem cells based solely on CD146 is not sufficient to properly carry out translational research using gingival fibroblasts for novel therapeutic methods of treating oral disease.

Influence of Materials Properties on Bio-Physical Features and Effectiveness of 3D-Scaffolds for Periodontal Regeneration

Periodontal diseases are multifactorial disorders, mainly due to severe infections and inflammation which affect the tissues (i.e., gum and dental bone) that support and surround the teeth. These pathologies are characterized by bleeding gums, pain, bad breath and, in more severe forms, can lead to the detachment of gum from teeth, causing their loss. To date it is estimated that severe periodontal diseases affect around 10% of the population worldwide thus making necessary the development of effective treatments able to both reduce the infections and inflammation in injured sites and improve the regeneration of damaged tissues. In this scenario, the use of 3D scaffolds can play a pivotal role by providing an effective platform for drugs, nanosystems, growth factors, stem cells, etc., improving the effectiveness of therapies and reducing their systemic side effects. The aim of this review is to describe the recent progress in periodontal regeneration, highlighting the influence of materials' properties used to realize three-dimensional (3D)-scaffolds, their bio-physical characteristics and their ability to provide a biocompatible platform able to embed nanosystems.

Mesenchymal stem cell-derived small extracellular vesicles as cell-free therapy: Perspectives in periodontal regeneration

Mesenchymal stem cells (MSC) are involved in the regeneration of the different missing or compromised periodontal tissues. MSC-derived small extracellular vesicles (sEV) have recently been explored as a favorable substitution for stem cell therapy, as they are capable of producing therapeutic effects comparable to those of their parent cells, with advantages over cell therapy. The aim of this review is to evaluate the use of mesenchymal stem cells (MSC)-derived sEV as cell-free therapy in periodontal regeneration. A review of the scientific literature on sEV and their use in periodontal regeneration was performed. The main characteristics of sEV are described, and their mechanisms of action and potential biological effects in periodontal regeneration are studied. A summary of existing preclinical studies conducted in animals is performed. The results indicate that sEV derived from MSC are emerging as a promising new therapeutic tool in the field of periodontal regeneration and may become an ideal therapeutic option. In this review, we have summarized recent advances in this regard in order to better understand this newly emerging treatment. First results in vivo are promising and show a favorable potential for cell-free therapy in periodontal regeneration.

CircMAP3K11 Contributes to Proliferation, Apoptosis and Migration of Human Periodontal Ligament Stem Cells in Inflammatory Microenvironment by Regulating TLR4 via miR-511 Sponging

Growing number of studies regarding the role of circRNAs in the development of various diseases have emerged in recent years, but the role of circRNAs in periodontitis pathogenesis remains obscure. Human periodontal ligament stem cells (hPDLSCs) play a critical role in periodontal remodeling, regeneration and repair processes, and their regenerative capacity could be prohibited in local periodontal inflammatory microenvironment. Herein, we sought to uncover the molecular mechanisms of periodontitis pathogenesis by investigating the role of circMAP3K11 (hsa_circ_002284) for regenerative capacity of hPDLSCs under an inflammatory condition. The hPDLSCs isolated from periodontitis patients were used as a cell model of inflammatory microenvironment to study the effect of the circMAP3K11/miR-511-3p/TLR4 axis on the proliferation, apoptosis and migration of hPDLSCs under inflammatory conditions. Compared to the periodontal tissues from normal subjects, those from periodontitis patients exhibited higher expression levels of circMAP3K11 and TLR4, and lower expression level of miR-511-3p. Both the expressions of circMAP3K11 and TLR4 were negatively correlated with the expressions of miR-511-3p in periodontitis. In vitro studies demonstrated that circMAP3K11 is capable of enhancing hPDLSCs proliferation and migration, and reducing the apoptosis of hPDLSCs. We also found that circMAP3K11 could up-regulate the expression of transcription factors that are closely related to periodontal regeneration (Runx2, OSX, ATF4, and BSP). RT-PCR and western blot showed that the inhibitory role of miR-511-3p on TLR4 expression could be reversed by circMAP3K11, which was in line with the results of bioinformatics tools and luciferase reporter assay. Meanwhile, both in vitro and in vivo studies indicated that circMAP3K11 could reverse the effects of miR-511-3p in periodontitis, which further confirmed that circMAP3K11 functioned as a ‘sponge’ of miR-511-3p to positively regulate the expression of TLR4. Taken together, our study preliminarily uncovered a circMAP3K11/miR-511-3p/TLR4 axis that regulates the function of hPDLSCs in periodontitis, providing novel insight and scientific base in the treatment of periodontal tissue regeneration based on stem cells.

Tissue Engineering and Three-Dimensional Printing in Periodontal Regeneration: A Literature Review

The three-dimensional printing of scaffolds is an interesting alternative to the traditional techniques of periodontal regeneration. This technique uses computer assisted design and manufacturing after CT scan. After 3D modelling, individualized scaffolds are printed by extrusion, selective laser sintering, stereolithography, or powder bed inkjet printing. These scaffolds can be made of one or several materials such as natural polymers, synthetic polymers, or bioceramics. They can be monophasic or multiphasic and tend to recreate the architectural structure of the periodontal tissue. In order to enhance the bioactivity and have a higher regeneration, the scaffolds can be embedded with stem cells and/or growth factors. This new technique could enhance a complete periodontal regeneration. This review summarizes the application of 3D printed scaffolds in periodontal regeneration. The process, the materials and designs, the key advantages and prospects of 3D bioprinting are highlighted, providing new ideas for tissue regeneration.

Advanced Biomaterials and Techniques for Oral Tissue Engineering and Regeneration-A Review

The reconstruction or repair of oral and maxillofacial functionalities and aesthetics is a priority for patients affected by tooth loss, congenital defects, trauma deformities, or various dental diseases. Therefore, in dental medicine, tissue reconstruction represents a major interest in oral and maxillofacial surgery, periodontics, orthodontics, endodontics, and even daily clinical practice. The current clinical approaches involve a vast array of techniques ranging from the traditional use of tissue grafts to the most innovative regenerative procedures, such as tissue engineering. In recent decades, a wide range of both artificial and natural biomaterials and scaffolds, genes, stem cells isolated from the mouth area (dental follicle, deciduous teeth, periodontal ligament, dental pulp, salivary glands, and adipose tissue), and various growth factors have been tested in tissue engineering approaches in dentistry, with many being proven successful. However, to fully eliminate the problems of traditional bone and tissue reconstruction in dentistry, continuous research is needed. Based on a recent literature review, this paper creates a picture of current innovative strategies applying dental stem cells for tissue regeneration in different dental fields and maxillofacial surgery, and offers detailed information regarding the available scientific data and practical applications.

EZH2 reduction is an essential mechanoresponse for the maintenance of super-enhancer polarization against compressive stress in human periodontal ligament stem cells

Despite the ubiquitous mechanical cues at both spatial and temporal dimensions, cell identities and functions are largely immune to the everchanging mechanical stimuli. To understand the molecular basis of this epigenetic stability, we interrogated compressive force-elicited transcriptomic changes in mesenchymal stem cells purified from human periodontal ligament (PDLSCs), and identified H3K27me3 and E2F signatures populated within upregulated and weakly downregulated genes, respectively. Consistently, expressions of several E2F family transcription factors and EZH2, as core methyltransferase for H3K27me3, decreased in response to mechanical stress, which were attributed to force-induced redistribution of RB from nucleoplasm to lamina. Importantly, although epigenomic analysis on H3K27me3 landscape only demonstrated correlating changes at one group of mechanoresponsive genes, we observed a genome-wide destabilization of super-enhancers along with aberrant EZH2 retention. These super-enhancers were tightly bounded by H3K27me3 domain on one side and exhibited attenuating H3K27ac deposition and flattening H3K27ac peaks along with compensated EZH2 expression after force exposure, analogous to increased H3K27ac entropy or decreased H3K27ac polarization. Interference of force-induced EZH2 reduction could drive actin filaments dependent spatial overlap between EZH2 and super-enhancers and functionally compromise the multipotency of PDLSC following mechanical stress. These findings together unveil a specific contribution of EZH2 reduction for the maintenance of super-enhancer stability and cell identity in mechanoresponse.

Are teeth superior to implants? A mapping review

STATEMENT OF PROBLEM

There is a long-held assumption that teeth are superior to implants because the periodontal ligament (PDL) confers a preeminent defense against biologic and mechanical challenges. However, adequate analysis of the literature is lacking. As a result, differential treatment planning of tooth- and implant-supported restorations has been compromised.

PURPOSE

Given an abundance and diversity of research, the purpose of this mapping review was to identify basic scientific gaps in the knowledge of how teeth and implants respond to biologic and mechanical loads. The findings will offer enhanced evidence-based clinical decision-making when considering replacement of periodontally compromised teeth and the design of implant prostheses.

MATERIAL AND METHODS

The online databases PubMed, Science Direct, and Web of Science were searched. Published work from 1965 to 2020 was collected and independently analyzed by both authors for inclusion in this review.

RESULTS

A total of 108 articles met the inclusion criteria of clinical, in vivo, and in vitro studies in the English language on the periradicular and peri-implant bone response to biologic and mechanical loads. The qualitative analysis found that the PDL's enhanced vascularity, stem cell ability, and resident cells that respond to inflammation allow for a more robust defense against biologic threats compared with implants. While the suspensory PDL acts to mediate moderate loads to the bone, higher compressive stress and strain within the PDL itself can initiate a biologic sequence of osteoclastic activity that can affect changes in the adjacent bone. Conversely, the peri-implant bone is more resistant to similar loads and the threshold for overload is higher because of the absence of a stress or strain sensitivity inherent in the PDL.

CONCLUSIONS

Based on this mapping review, teeth are superior to implants in their ability to resist biologic challenges, but implants are superior to teeth in managing higher compressive loads without prompting bone resorption.

Preparing polycaprolactone scaffolds using electrospinning technique for construction of artificial periodontal ligament tissue

Objectives

The strategies of tissue-engineering led to the development of living cell-based therapies to repair lost or damaged tissues, including periodontal ligament and to construct biohybrid implant. This work aimed to isolate human periodontal ligament stem cells (hPDLSCs) and implant them on fabricated polycaprolactone (PCL) for the regeneration of natural periodontal ligament (PDL) tissues.

Methods

hPDLSCs were harvested from extracted human premolars, cultured, and expanded to obtain PDL cells. A PDL-specific marker (periostin) was detected using an immunofluorescent assay. Electrospinning was applied to fabricate PCL at three concentrations (13%, 16%, and 20% weight/volume) in two forms, which were examined through field emission scanning electron microscopy (FESEM). The isolated hPDLSCs were implanted on the fabricated PCL. After 21 days, FESEM was conducted to evaluate the implanted scaffolds, and an MTT assay was performed to characterize the biological response of the PCL scaffold at different cell exposure durations (24, 48, and 72 h).

Results

Periostin was expressed in the expanded PDL cells, and this result revealed that 20% weight/volume PCL scaffold with a pore size of more than 10 μm was the best. The growth rates of PDLSCs were high. Cytotoxicity test of fabricated PCL scaffold demonstrated no significant change in the cell viability when compared with the negative control and no deteriorating or inhibitory effect on growth after different durations.

Conclusions

A cell sheet was successfully formed by using PCL as a scaffold to cover dental implants and promote PDL cell attachment, proliferation, and growth for biohybrid implant construction.

Efficacy of autologous stem cells for bone regeneration during endosseous dental implants insertion - A systematic review of human studies

Availability of adequate quantity and quality of bone is prerequisite for longevity and survival of endosseous dental implants. Most of the clinicians face with the problem of lack of bone due to long-standing edentulism during this treatment modality. Conventional therapies with the use of various types of bone grafts and membranes have provided clinicians with unpredictable and compromised results. Cell-based therapies utilizing undifferentiated cells, that have the potential to differentiate into various cell types including osteoblastic lineages, have demonstrated through various previously conducted in-vitro and animal studies, a successful formation of bone in a predictable manner. Thus the main objective of this review was to evaluate the effectiveness of these therapies when applied on human subjects. A search was carried out in MEDLINE (via PubMed) and Cochrane CENTRAL databases for completed randomized and non-randomised clinical trials utilizing stem cell-based therapies with histologic and radiographic analysis written in English up to January 2019. This search of the literature yielded 10 studies meeting the inclusion and exclusion criteria. In all these studies, stem cells were primarily used to achieve bone augmentation during insertion of endosseous dental implants. Results of these therapies conducted on human subjects have shown a positive impact on bone regeneration, in particular, therapies utilizing bone marrow and adipose tissue derived stem cells. But the clinicians need to examine the efficacy, safety, feasibility of these therapies while treating large size defects or planning for shorter healing period and early loading of dental implants.

Promising advances in clinical trials of dental tissue-derived cell-based regenerative medicine

Background

Advances in regenerative medicine with stem cells have led to clinical trials. Dental/oral tissues are emerging as promising cellular sources of human mesenchymal stem cells. Recently, dental tissue-derived cells have been used clinically due to their great potential, easy accessibility, and ability to be obtained via methods with low invasiveness. The aim of this study is to systematically assess the clinical effectiveness of dental cell-mediated therapies compared to current evidence-based methods in human patients.

Methods

The electronic databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched up to December 2019 for clinical trials. Clinical trials with any intervention using stem cells/cells derived from dental tissue were included.

Results

A total of 815 studies were identified by the electronic search, and 38 articles qualified for full-text evaluation. Finally, 20 studies (10 clinical trials using dental pulp-derived cells, 3 clinical trials using periodontal ligament-derived cells, and 7 studies using gingiva-derived cells) were included in this review. No clinical trials using dental follicle- or apical papilla-derived cells were selected in this review. Dental pulp-derived cells were used in clinical trials for bone regeneration, periodontitis, and dental pulp regeneration. All clinical trials using periodontal ligament-derived cells and gingiva-derived cells were conducted for periodontal disease treatment and gingival augmentation, respectively. Among the 20 selected studies, 16 showed clinical benefits of cell transplantation therapies. In addition, no study reported adverse events that may have been associated with cell transplantation.

Conclusions

These findings indicate that dental tissue-derived cells would be useful for cell-based regenerative medicine for various diseases.

Stem cell-directed therapies for osteoarthritis: The promise and the practice

Osteoarthritis (OA) is a disease of an entire synovial joint characterized by clinical symptoms and distortion of joint tissues, including cartilage, muscles, ligaments, and bone. Although OA is a disease of all joint tissues, it is a defined accessible compartment and is thus amenable to topical surgical and regenerative therapies, including stem cells. All tissues arise from stem progenitor cells, and the relative capacity of different cellular compartments, and different individuals, to renew tissues into adulthood may be important in the onset of many different degenerative diseases. OA is driven by both mechanical and inflammatory factors, but how these factors affect the proliferation and differentiation of cells into cartilage in vivo is largely unknown. Indeed, our very basic understanding of the physiological cellular kinetics and biology of the stem-progenitor cell unit of the articular cartilage, and how this is influenced by mechano-inflammatory injury, is largely unknown. OA seems, rather deceptively, to be the low-hanging fruit for stem cell therapy. Without the basic understanding of the stem cell and progenitor unit that generate and maintain articular cartilage in vivo, we will continue to waste opportunities to both prevent and manage this disease. In this review, we discuss the biology of chondrogenesis, the stem cell populations that support articular cartilage in health and disease, and future opportunities afforded through the translation of basic articular chondrocyte stem cell biology into new clinical therapies.

Periodontal regeneration: a bibliometric analysis of the most influential studies

Aim: The aim of the present study is to identify the most influential research articles and their main characteristics in the specialty of periodontal regeneration. Materials & methods: The Web of Science database advance search was performed in the subject category of 'Dentistry, Oral surgery and medicine' from January 2004 to October 2018 to retrieve citations data. Results: The majority of the articles were published in journals dedicated to the specialty of periodontology. Among the top-cited articles most emphasized study types were randomized control trials (n = 25) and reviews (n = 20). Conclusion: The present bibliometric analysis provides comprehensive information regarding the contributions made in the advancement of regenerative periodontal research. The authors from developed countries and affiliated with interdisciplinary/multicenter institutions have predominantly contributed.

Cellular therapy in periodontal regeneration

Periodontitis is a chronic inflammatory condition leading to destruction of the tooth supporting tissues, which if left untreated may cause tooth loss. The treatment of periodontitis mainly aims to arrest the inflammatory process by infection control measures, although in some specific lesions a limited periodontal regeneration can also be attained. Current regenerative approaches are aimed to guide the cells with regenerative capacity to repopulate the lesion and promote new cementum and new connective tissue attachment. The first phase in periodontal tissue regeneration involves the differentiation of mesenchymal cells into cementoblasts to promote new cementum, thus facilitating the attachment of new periodontal ligament fibers to the root and the alveolar bone. Current regenerative approaches limit themselves to the confines of the lesion by promoting the self-regenerative potential of periodontal tissues. With the advent of bioengineered therapies, several studies have investigated the potential use of cell therapies, mainly the use of undifferentiated mesenchymal cells combined with different scaffolds. The understanding of the origin and differentiation patterns of these cells is, therefore, important to elucidate their potential therapeutic use and their comparative efficacy with current technologies. This paper aims to review the in vitro and experimental studies using cell therapies based on application of cementoblasts and mesenchymal stem cells isolated from oral tissues when combined with different scaffolds.

CB1 enhanced the osteo/dentinogenic differentiation ability of periodontal ligament stem cells via p38 MAPK and JNK in an inflammatory environment

Objectives

Periodontitis is an inflammatory immune disease that causes periodontal tissue loss. Inflammatory immunity and bone metabolism are closely related to periodontitis. The cannabinoid receptor I (CB1) is an important constituent of the endocannabinoid system and participates in bone metabolism and inflammation tissue healing. It is unclear whether CB1 affects the mesenchymal stem cell (MSC) function involved in periodontal tissue regeneration. In this study, we revealed the role and mechanism of CB1 in the osteo/dentinogenic differentiation of periodontal ligament stem cells (PDLSCs) in an inflammatory environment.

Materials and methods

Alkaline phosphatase (ALP) activity, Alizarin Red staining, quantitative calcium analysis and osteo/dentinogenic markers were used to assess osteo/dentinogenic differentiation. Real‐time RT‐PCR and Western blotting were employed to detect gene expression.

Results

CB1 overexpression or CB1 agonist (10 µM R‐1 Meth) promoted the osteo/dentinogenic differentiation of PDLSCs. Deletion of CB1 or the application of CB1 antagonist (10 µM AM251) repressed the osteo/dentinogenic differentiation of PDLSCs. The activation of CB1 enhanced the TNF‐α‐ and INF‐γ‐impaired osteo/dentinogenic differentiation potential in PDLSCs. Moreover, CB1 activated p38 MAPK and JNK signalling and repressed PPAR‐γ and Erk1/2 signalling. Inhibition of JNK signalling could block CB1‐activated JNK and p38 MAPK signalling, while CB1 could activate p38 MAPK and JNK signalling, which was inhibited by TNF‐α and INF‐γ stimulation.

Conclusions

CB1 was able to enhance the osteo/dentinogenic differentiation ability of PDLSCs via p38 MAPK and JNK signalling in an inflammatory environment, which might be a potential target for periodontitis treatment.

Dental Follicle Cells: Roles in Development and Beyond

Dental follicle cells (DFCs) are a group of mesenchymal progenitor cells surrounding the tooth germ, responsible for cementum, periodontal ligament, and alveolar bone formation in tooth development. Cascades of signaling pathways and transcriptional factors in DFCs are involved in directing tooth eruption and tooth root morphogenesis. Substantial researches have been made to decipher multiple aspects of DFCs, including multilineage differentiation, senescence, and immunomodulatory ability. DFCs were proved to be multipotent progenitors with decent amplification, immunosuppressed and acquisition ability. They are able to differentiate into osteoblasts/cementoblasts, adipocytes, neuron-like cells, and so forth. The excellent properties of DFCs facilitated clinical application, as exemplified by bone tissue engineering, tooth root regeneration, and periodontium regeneration. Except for the oral and maxillofacial regeneration, DFCs were also expected to be applied in other tissues such as spinal cord defects (SCD), cardiomyocyte destruction. This article reviewed roles of DFCs in tooth development, their properties, and clinical application potentials, thus providing a novel guidance for tissue engineering.

Periodontal regenerative medicine using mesenchymal stem cells and biomaterials: A systematic review of pre-clinical studies

The aim of the systematic review was to analyze the use of mesenchymal stem cells (MSC) and biomaterial for periodontal regeneration from preclinical animal models and human. Electronic databases were searched and additional hand-search in leading journals was performed. The research strategy was achieved according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The including criteria were as follows: MSC, biomaterial, in vivo studies, with histologic and radiologic analysis and written in English. The risk of bias was assessed for individual studies. A total of 50 articles were selected and investigated in the systematic review. These results indicate that MSC and scaffold provide beneficial effects on periodontal regeneration, with no adverse effects of such interventions. Future studies need to identify the suitable association of MSC and biomaterial and to characterize the type of new cementum and the organization of the periodontal ligament fiber regeneration.

Low-intensity pulsed ultrasound promotes tissue regeneration in rat dental follicle cells in a porous ceramic scaffold

The aim of this study was to investigate the effects of low-intensity pulsed ultrasound (LIPUS) on the osteogenic differentiation of dental follicle cells (DFCs) in vitro and on the regenerative effects of DFC-OsteoBoneTM complexes in vivo. DFCs were isolated and characterized. In the in vitro study, DFCs were cultured in an osteogenic medium in the presence or absence of LIPUS. The expression levels of ALP, Runx2, OSX, and COL-I mRNA were analyzed using real-time polymerase chain reaction (RT-PCR) on day 7. Alizarin red staining was performed on day 21. The state of the growth of the DFCs that were seeded on the scaffold at 3, 5, 7, and 9 days was detected by using a scanning electron microscope. In our in vivo study, 9 healthy nude mice randomly underwent subcutaneous transplantation surgery in one of three groups: group A, empty scaffold; group B, DFCs + scaffold; and group C, DFCs + scaffold + LIPUS. After 8 weeks of implantation, a histological analysis was performed by HE and Mason staining. Our results indicate that LIPUS promotes the osteogenic differentiation of DFCs by increasing the expression of the ALP, Runx2, OSX, and COL-I genes and the formation of mineralized nodules. The cells can adhere and grow on the scaffolds and grow best at 9 days. The HE and Mason staining results showed that more cells, fibrous tissue and blood vessels could be observed in the DFCs + scaffold + LIPUS group than in the other groups. LIPUS could promote the osteogenic differentiation of DFCs in vitro and promote tissue regeneration in a DFCs-scaffold complex in vivo. Further studies should be conducted to explore the underlying mechanisms of LIPUS.

Clinical application of mesenchymal stem cells in periodontal regeneration: A systematic review and meta-analysis

OBJECTIVE

To evaluate the potential efficacy of mesenchymal stem cells (MSCs) in periodontal regeneration in humans on the following main outcomes: clinical attachment level (CAL), probing depth (PD), and gingival recession (GR).

BACKGROUND

The clinical application of stem cells in periodontal regeneration has begun in recent years, but clinical practices are not yet standardized and no recommendations are available at this time.

METHODS

Electronic database searches and hand searches were conducted. All types of studies, case series, and case reports were qualitatively described. Double-blind randomized controlled trials (RCTs) evaluating MSCs in periodontal regeneration were included in a meta-analysis if they compared administration of MSCs vs application of stem cell-free therapy in the control group, in healthy patients with periodontal defects, with a minimum of three mo of follow-up.

RESULTS

Fifteen reports were included in qualitative analysis, involving 123 patients and 158 periodontal defects. Only two small RCTs at high risk of bias, with a total of 59 patients and 70 periodontal defects, were included in the meta-analysis. A small but significant difference between test and control groups was found for CAL at three mo (-0.90 mm, 95% CI [-1.51; -0.29]), but not for PD and GR.

CONCLUSION

Low-quality evidence suggests that MSC-based therapy may have a small impact on periodontal regeneration. However, due to the monocentric character, the small sample size, and potential heterogeneity across the two included RCTs, these results must not be considered as definitive. High-quality RCTs are needed before any clinical use of MSCs in periodontal regeneration.

Maintained Properties of Aged Dental Pulp Stem Cells for Superior Periodontal Tissue Regeneration

Owing to excellent therapeutic potential, mesenchymal stem cells (MSCs) are gaining increasing popularity with researchers worldwide for applications in tissue engineering, and in treatment of inflammation-related and age-related disorders. However, the senescence of MSCs over passaging has limited their clinical application owing to adverse effect on physiological function maintenance of tissues as well as disease treatment. An inflammatory microenvironment is one of the key contributors to MSC senescence, resulting in low regeneration efficiency. Therefore, MSCs with high resistance to cellular senescence would be a benefit for tissue regeneration. Toward this end, we analyzed the senescence properties of different types of stem cells during culture and under inflammation, including dental pulp stem cells (DPSCs), periodontal ligament stem cells (PDLSCs), bone marrow mesenchymal stem cells (BMMSCs), and adipose-derived stem cells (ADSCs). Overall, the DPSCs had higher proliferation rates, lower cellular senescence, and enhanced osteogenesis maintenance compared to those of non-dental MSCs cultured from passage three to six. The expression profiles of genes related to apoptosis, cell cycle, and cellular protein metabolic process (contributing to the cell self-renewal ability and metabolic processes) significantly differed between DPSCs and BMMSCs at passage three. Moreover, DPSCs were superior to BMMSCs with regards to resistance to lipopolysaccharide-induced apoptosis and senescence, with enhanced osteogenesis in vitro, and showed improved periodontal regeneration after injection in a miniature pig periodontitis model in vivo. Overall, the present study indicates that DPSCs show superior resistance to subculture and inflammation-induced senescence and would be suitable stem cells for tissue engineering with inflammation.

Application of cell-sheet engineering for new formation of cementum around dental implants

Periodontal disease involves the chronic inflammation of tooth supporting periodontal tissues. As the disease progresses, it manifests destruction of periodontal tissues and eventual tooth loss. The regeneration of lost periodontal tissue has been one of the most important subjects in periodontal research. Since their discovery, periodontal ligament stem cells (PDLSCs), have been transplanted into periodontal bony defects to examine their regenerative potential. Periodontal defects were successfully regenerated using PDLSC sheets, which were fabricated by cell sheet engineering in animal models, and for which clinical human trials are underway. To expand the utility of PDLSC sheet, we attempted to construct periodontal tissues around titanium implants with the goal of facilitating the prevention of peri-implantitis. In so doing, we found newly formed cementum-periodontal ligament (PDL) structures on the implant surface. In this mini review, we summarize the literature regarding cell-based periodontal regeneration using PDLSCs, as well as previous trials aimed at forming periodontal tissues around dental implants. Moreover, the recent findings in cementogenesis are reviewed from the perspective of the formation of further stable periodontal attachment structure on dental implant. This mini review aims to summarize the current status of the creation of novel periodontal tissue-bearing dental implants, and to consider its future direction.

LncRNA-TWIST1 Promoted Osteogenic Differentiation Both in PPDLSCs and in HPDLSCs by Inhibiting TWIST1 Expression

HPDLSCs derived from periodontal ligament tissues contribute to tooth development and tissue regeneration. Exploring the effects of long noncoding RNAs (lncRNAs) in the process of osteogenic differentiation of periodontal ligament stem cells would provide novel therapeutic strategies for tissue regeneration. The expression levels of lncRNA, which significantly changed during osteogenic differentiation, were observed by real-time quantitative PCR (q-PCR). Then, we screened for osteogenic-related lncRNA, which was initially named lncRNA-TWIST1. Moreover, we detected the mRNA expression levels of TWIST1 and osteogenesis-related genes after upregulating and downregulating lncRNA-TWIST1 in PPDLSCs (periodontal mesenchymal stem cells from periodontitis patients) and HPDLSCs (periodontal mesenchymal stem cells from healthy microenvironment), respectively. The osteogenic degree was verified by detecting ALP activity and alizarin red staining. LncRNA-TWIST1 decreased the mRNA levels of TWIST1 and promoted osteogenic differentiation in PPDLSCs, which was confirmed by the increase in osteogenesis-related gene levels (Runx2, ALP, and OCN), the increase in ALP activity, and the formation of more osteogenic nodules. In contrast, downregulating lncRNA-TWIST1 decreased the expression of osteogenesis-related genes, ALP activity, and osteogenic nodules both in PPDLSCs and in HPDLSCs. LncRNA-TWIST1 promoted osteogenic differentiation both in PPDLSCs and in HPDLSCs by inhibiting the TWIST1 expression. LncRNA-TWIST1 may be a novel therapeutic strategy to regenerate dental tissues.

Regeneration of periodontal bone defects with dental pulp stem cells grafting: Systematic Review

Background

The main objective is to evaluate the way to graft the dental pulp stem cells (DPSC) in periodontal defects that best regenerate periodontal tissues. Numerous procedures have been done to promote periodontal regeneration. Bone grafts show good gains clinically and radiographically but histologically seem to have minimal osteoinductive capacity. Another option that exceeds conventional surgery in reducing probing depth and increasing insertion is guided tissue regeneration and tissue engineering that could be an alternative approach to help in the regeneration of living functional bone and peri-dental structures.

Material and Methods

A search was carried out in Cochrane, PubMed-MEDLINE and Scopus databases with keywords: “dental pulp stem cells”, “periodontal regeneration”, “guided tissue regeneration, periodontal”, “tissue regeneration”, “periodontal bone defects”, “periodontal tissue engineering” and “periodontal defect”. Inclusion criteria were articles in English, maximum 10 years old, in which DPSC were used to regenerate a periodontal defect. Exclusion criteria were studies not published in English, case reports, case series, literature reviews, and studies in which periodontal defect was caused by dental extraction.

Results

Out of the 185 articles identified, 101 after excluding duplicates, of which 94 were discarded when reading the title and abstract. 7 articles were obtained for the full text reading: a case report and a case series were eliminated. The systematic review is performed with 5 animal testing studies in vivo. The DPSC sheets regenerate a greater amount of bone than the injection. If HGF (hepatocyte growth factor) is added, the maximum bone volume regenerated (69.3 ± 3.9 mm3; p<0.01) is achieved. Similar results were obtained in all carriers tested except in the controls. The periodontal ligament stem cells (PDLSC) formed more new bone, compared to DPSC (p<0.001). The presence of new cementum and periodontal ligament induced by CMLPs, was detected histologically but DPSC cannot achieve it alone.

Conclusions

Cementum or PDL regeneration does not depend only on DPSC but on other unknown factors. PDLSC has better periodontal regeneration than DPSC. DPSC significantly favours the regeneration of periodontal bone tissue but has few advantages over other grafts. It is necessary to study which growth factors or matrices can enhance their capacity for periodontal regeneration.

Key words:Dental pulp, stem cells, periodontal guided tissue regeneration, periodontal bone loss.

Activation of the ERK/Creb/Bcl‑2 pathway protects periodontal ligament stem cells against hydrogen peroxide‑induced oxidative stress

Periodontal ligament stem cells (PDLSCs) are promising stem cells sources for regenerative medicine, particularly clinical periodontal ligament repair. It is critical to maintain high quality and a large quantity of PDLSCs for clinical usage. However, how PDLSCs respond to environmental stimuli, including reactive oxygen species (ROS), is poorly understood. The aim of the present study was to investigate how PDLSCs react to oxidative stress and the underlying mechanisms. Hydrogen peroxide-induced oxidative stress was used to mimic a ROS increase in rat PDLSCs. The expression levels of Creb were detected under oxidative stress to examine the role that Creb serves in PDLSCs under oxidative stress. The present results demonstrated that the expression of Creb was reduced in a dose-dependent manner in response to the H₂O₂ stimulus. Overexpressing Creb significantly reduced the ROS levels and protein expression levels of apoptotic genes in PDLSCs. The phosphorylation of the ERK pathway is indispensable in the activation of Creb-induced protection. Our results revealed a protective role of Creb in ROS-induced apoptosis, and validated the ERK/Creb/apoptosis regulator Bcl-2 pathway works as an anti-apoptotic signaling in PDLSCs. These findings will facilitate the in vitro culturing of PDLSCs for clinical usage and promote stem cell based therapy for periodontal tissue regeneration.

Osteogenic capacity and cytotherapeutic potential of periodontal ligament cells for periodontal regeneration in vitro and in vivo

Background

The periodontal ligament cells (PDLCs) contain heterogeneous cell populations and possess stem-cell-like properties. PDLCs have attracted considerable attention as an option for periodontal regeneration. However, the osteogenic differentiation of PDLCs remains obscure owing to variable osteo-inductive methods and whether PDLCs could be directly used for periodontal regeneration without stem cell enrichment is uncertain. The aim of the present study was to clarify the osteogenic differentiation capacity of PDLCs and test PDLCs as an alternative to stem cells for periodontal regeneration.

Methods

We tested the performance of human PDLCs in osteo-inductive culture and transplantation in vivo while taking human bone marrow derived mesenchymal stem cells (hMSCs) as positive control. Proliferation of PDLCs and hMSCs in osteo-inductive condition were examined by MTT assay and colony formation assay. The osteogenic differentiations of PDLCs and hMSCs were assessed by Alkaline phosphatase (ALP) activity measurement, von Kossa staining, Alizarin red S staining and quantitative RT-PCR of osteogenic marker gene including RUNX2, ALP, OCN, Col I, BSP, OPN. We transplanted osteo-inductive PDLCs and hMSCs with hydroxyapatite/tricalcium phosphate (HA/TCP) scaffolds to immunodeficient mice to explore their biological behaviors in vivo by histological staining and immunohistochemical evaluation.

Results

After 14 days of osteo-induction, PDLCs exhibited significantly higher proliferation rate but lower colony-forming ability comparing with hMSCs. PDLCs demonstrated lower ALP activity and generated fewer mineralized nodules than hMSCs. PDLCs showed overall up-regulated expression of RUNX2, ALP, OCN, Col I, BSP, OPN after osteo-induction. Col I level of PDLCs in osteo-inductive group was significantly higher while RUNX2, ALP, OCN were lower than that of hMSCs. Massive fiber bundles were produced linking or circling the scaffold while the bone-like structures were limited in the PDLCs-loaded HA/TCP samples. The fiber bundles displayed strong positive Col I, but weak OCN and OPN staining. The in vivo results were consistent with the in vitro data, which confirmed strong collagen forming ability and considerable osteogenic potential of PDLCs.

Conclusion

It is encouraging to find that PDLCs exhibit higher proliferation, stronger collagen fiber formation capacity, but lower osteogenic differentiation ability in comparison with hMSCs. This characteristic is essential for the successful periodontal reconstruction which is based on the synchronization of fiber formation and bone deposition. Moreover, PDLCs have advantages such as good accessibility, abundant source, vigorous proliferation and evident osteogenic differentiation capacity when triggered properly. They can independently form PDL-like structure in vivo without specific stem cell enrichment procedure. The application of PDLCs may offer a novel cytotherapeutic option for future clinical periodontal reconstruction.

Notch pathway deactivation mediated by F-box/WD repeat domain-containing 7 ameliorates hydrogen peroxide-induced apoptosis in rat periodontal ligament stem cells

OBJECTIVE

To investigate the protective role of F-box/WD repeat domain-containing 7 in rat periodontal ligament stem cells under oxidative stress.

MATERIALS AND METHODS

The apoptosis of rat periodontal ligament stem cells was induced by exposure to various concentrations of hydrogen peroxide for 24 h, after which cell viability and the cleaved caspase-3 and -9 levels were determined. The levels of proteins in the Notch signaling pathway were determined by western blotting.

RESULTS

The overexpression of F-box/WD repeat domain-containing 7 increased cell viability following hydrogen peroxide administration and suppressed the activation of caspases-3 and -9. The overexpression of F-box/WD repeat domain-containing 7 inhibited Notch signaling. Furthermore, the protective effect of F-box/WD repeat domain-containing 7 could be resumed by PF-03084014, a Notch-specific inhibitor.

CONCLUSIONS

These observations suggest a protective role of F-box/WD repeat domain-containing 7 against hydrogen peroxide-induced oxidative stress in rat periodontal ligament stem cells. These findings will facilitate the in vitro culturing of periodontal ligament stem cell for clinical usage and promote stem cell-based therapy for periodontal tissue regeneration.

Improved guided bone regeneration by combined application of unmodified, fresh autologous adipose derived regenerative cells and plasma rich in growth factors: A first-in-human case report and literature review

BACKGROUND

Novel strategies are needed for improving guided bone regeneration (GBR) in oral surgery prior to implant placement, particularly in maxillary sinus augmentation (GBR-MSA) and in lateral alveolar ridge augmentation (LRA). This study tested the hypothesis that the combination of freshly isolated, unmodified autologous adipose-derived regenerative cells (UA-ADRCs), fraction 2 of plasma rich in growth factors (PRGF-2) and an osteoinductive scaffold (OIS) (UA-ADRC/PRGF-2/OIS) is superior to the combination of PRGF-2 and the same OIS alone (PRGF-2/OIS) in GBR-MSA/LRA.

CASE SUMMARY

A 79-year-old patient was treated with a bilateral external sinus lift procedure as well as a bilateral lateral alveolar ridge augmentation. GBR-MSA/LRA was performed with UA-ADRC/PRGF-2/OIS on the right side, and with PRGF-2/OIS on the left side. Biopsies were collected at 6 wk and 34 wk after GBR-MSA/LRA. At the latter time point implants were placed. Radiographs (32 mo follow-up time) demonstrated excellent bone healing. No radiological or histological signs of inflammation were observed. Detailed histologic, histomorphometric, and immunohistochemical analysis of the biopsies evidenced that UA-ADRC/PRGF-2/OIS resulted in better and faster bone regeneration than PRGF-2/OIS.

CONCLUSION

GBR-MSA with UA-ADRCs, PRGF-2, and an OIS shows effectiveness without adverse effects.

Recent Advances in Engineered Stem Cell-Derived Cell Sheets for Tissue Regeneration

The substantial progress made in the field of stem cell-based therapy has shown its significant potential applications for the regeneration of defective tissues and organs. Although previous studies have yielded promising results, several limitations remain and should be overcome for translating stem cell-based therapies to clinics. As a possible solution to current bottlenecks, cell sheet engineering (CSE) is an efficient scaffold-free method for harvesting intact cell sheets without the use of proteolytic enzymes, and may be able to accelerate the adoption of stem cell-based treatments for damaged tissues and organs regeneration. CSE uses a temperature-responsive polymer-immobilized surface to form unique, scaffold-free cell sheets composed of one or more cell layers maintained with important intercellular junctions, cell-secreted extracellular matrices, and other important cell surface proteins, which can be achieved by changing the surrounding temperature. These three-dimensional cell sheet-based tissues can be designed for use in clinical applications to target-specific tissue regeneration. This review will highlight the principles, progress, and clinical relevance of current approaches in the cell sheet-based technology, focusing on stem cell-based therapies for bone, periodontal, skin, and vascularized muscles.

The treatment of systematically transplanted gingival mesenchymal stem cells in periodontitis in mice

Cell-based tissue engineering is a promising alternative for periodontal regeneration as current therapies fail to reconstitute tissue damage caused by periodontitis. As newly identified postnatal stem cells, gingiva-derived mesenchymal stem cells (GMSCs) have been focused on for isolation and expansion in vitro of cells with multi-differentiation potential and immunomodulatory capacities. It has been demonstrated that systemically delivered GMSCs can home to the mandibular bone defect sites and promote bone regeneration. However, the role of transplanted GMSCs in the treatment of periodontitis has not been reported. In the present study, GMSCs were transplanted into C57BL/6J mice with periodontitis via the tail vein to investigate the contribution of GMSCs to periodontal tissue regeneration. Results demonstrated that the alveolar bone heights of mice with transplanted GMSCs were significantly increased compared with the control groups and GMSCs were detected in newly formed periodontal ligament and alveolar bone. The results of the present study implied that systemically transplanted GMSCs could home to periodontal injury sites and promote periodontal tissue regeneration.