The role of inflammation modulation in dental pulp regeneration

A vital and healthy dental pulp (DP) is required for teeth to remain functional throughout a lifespan . Appreciating its value for the tooth, the regeneration of the DP is a highly researched goal. While inflammation of the DP marks the beginning of an eventual necrosis, it is also the prerequisite for the regenerative events of neovascularisation, stem cells mobilisation and reparative dentine deposition. In the light of a pro-regenerative inflammatory process, the present review discusses the role of macrophage population shift from pro- to anti-inflammatory in reversible versus irreversible pulpitis, while also analysing the overlooked contribution of pulp innervation and locally derived neuropeptides to the process. Then, the currently practiced (pulp capping and revascularisation) and researched (cells transplantation and cell homing) approaches for DP regeneration are discussed. Focusing on the role of cell homing in modulating inflammation, some potential strategies are highlighted to harness the inflammatory process for DP regeneration, mainly by reversing inflammation through macrophage induction. Next, some potential clinical applications are discussed - especially with capping materials - that could boost macrophage polarisation and complement system activation. Finally, current challenges facing the regeneration of the DP are presented, while underlining the importance of promoting an anti-inflammatory environment conducive to a regenerative process.

Induction of M2 Macrophages Prevents Bone Loss in Murine Periodontitis Models

Periodontitis is characterized by the progressive destruction of tooth-supporting alveolar bone, which is mainly caused by chronic inflammation in response to persistent bacterial insult. It has recently become clear that the pathogenesis of periodontitis is associated with a high ratio of proinflammatory M1 (classically activated) macrophages to anti-inflammatory M2 (alternatively activated). To decrease the inflammatory activity, we locally delivered the C-C motif chemokine ligand 2 (CCL2) using controlled-release microparticles (MPs). CCL2 is known to promote chemotaxis of M0 or M2 phenotype macrophages to the inflamed site and induce M2 phenotype polarization locally. Our in vitro data showed that CCL2 increased the number of M2 phenotype macrophages, decreased TNF-α secretion, and enhanced chemotaxis of RAW264.7 cells toward CCL2 MPs. Moreover, we induced periodontal disease in 2 animal models through inoculation of Porphyromonas gingivalis and ligature around the murine molar. Micro-computed tomography analysis showed significant reduction of alveolar bone loss in the CCL2 MP treatment group when compared with a blank MP group and a no-treatment periodontitis group in both models. Immunohistologic analysis showed a significant increase in the M2 phenotype subset and a decrease in the M1 phenotype subset in the CCL2 MP group of the P. gingivalis-induced model. Also, in both models, tartrate-resistant acidic phosphatase staining showed significantly fewer numbers of osteoclasts in the CCL2 MP group in alveolar bone area. Moreover, quantitative polymerase chain reaction results showed a significant increase in IL-1RA (interleukin 1 receptor antagonist) mRNA expression and a decrease in RANKL (receptor activator of nuclear factor kappa-Β ligand) mRNA expression in the CCL2 MP group in the ligature model. In summary, manipulation of endogenous M2 phenotype macrophages with CCL2 MPs decreased the M1 phenotype:M2 phenotype ratio and prevented alveolar bone loss in mouse periodontitis models. The delivery of CCL2 MPs provides a novel approach to treat periodontal disease.

Decellularized Swine Dental Pulp Tissue for Regenerative Root Canal Therapy

In the current theme of dental pulp regeneration, biological and synthetic scaffolds are becoming a potential therapy for pulp revitalization. The goal is to provide a suitable environment for cellular infiltration, proliferation, and differentiation. The extracellular matrix (ECM) represents a natural scaffold material resembling the native tissue chemical and mechanical properties. In the past few years, ECM-based scaffolds have shown promising results in terms of progenitor cells recruitment, promotion of constructive remodeling, and modulation of host response. These properties make ECM-derived scaffolds an ideal candidate for pulp regenerative therapy. Development of strategies for clinically relevant tissue engineering using dental pulp extracellular matrix (DP-ECM) can provide an alternative to conventional root canal treatment. In this work, we successfully decellularized ECM derived from porcine dental pulp. The resulting scaffold was characterized using immunostaining (collagen type I, dentin matrix protein 1, dentin sialoprotein, and Von Willebrand factor) and enzyme-linked immunosorbent assay (transforming growth factor β, vascular endothelial growth factor, and basic fibroblast growth factor) for extracellular proteins where the ECM retained its proteins and significant amount of growth factors. Furthermore, a pilot in vivo study was conducted where the matrix was implanted for 8 wk in a dog root canal model. Our in vitro and preliminary in vivo data show that the decellularized ECM supports cellular infiltration together with the expression of pulp-dentin and vascular markers (DSP and CD31) compared to the controls. Herein, we show the feasibility to produce a decellularized ECM scaffold and validate the concept of using ECM-based scaffolds for pulp regeneration.

Poly (glycerol sebacate) elastomer supports bone regeneration by its mechanical properties being closer to osteoid tissue rather than to mature bone

Mechanical load influences bone structure and mass. Arguing the importance of load-transduction, we investigated the mechanisms inducing bone formation using an elastomeric substrate. We characterized Poly (glycerol sebacate) (PGS) in vitro for its mechanical properties, compatibility with osteoprogenitor cells regarding adhesion, proliferation, differentiation under compression versus static cultures and in vivo for the regeneration of a rabbit ulna critical size defect. The load-transducing properties of PGS were compared in vitro to a stiffer poly lactic-co-glycolic-acid (PLA/PGA) scaffold of similar porosity and interconnectivity. Under cyclic compression for 7days, we report focal adhesion kinase overexpression on the less stiff PGS and upregulation of the transcription factor Runx2 and late osteogenic markers osteocalcin and bone sialoprotein (1.7, 4.0 and 10.0 folds increase respectively). Upon implanting PGS in the rabbit ulna defect, histology and micro-computed tomography analysis showed complete gap bridging with new bone by the PGS elastomer by 8weeks while minimal bone formation was seen in empty controls. Immunohistochemical analysis demonstrated the new bone to be primarily regenerated by recruited osteoprogenitors cells expressing periostin protein during early phase of maturation similar to physiological endochondral bone development. This study confirms PGS to be osteoconductive contributing to bone regeneration by recruiting host progenitor/stem cell populations and as a load-transducing substrate, transmits mechanical signals to the populated cells promoting differentiation and matrix maturation toward proper bone remodeling. We hence conclude that the material properties of PGS being closer to osteoid tissue rather than to mineralized bone, allows bone maturation on a substrate mechanically closer to where osteoprogenitor/stem cells differentiate to develop mature load-bearing bone.

SIGNIFICANCE OF SIGNIFICANCE

The development of effective therapies for bone and craniofacial regeneration is a foremost clinical priority in the mineralized tissue engineering field. Currently at risk are patients seeking treatment for craniofacial diseases, traumas and disorders including birth defects such as cleft lip and palate, (1 in 525 to 714 live births), craniosynostosis (300-500 per 1,000,000 live births), injuries to the head and face (20 million ER visits per year), and devastating head and neck cancers (8000 deaths and over 30,000 new cases per year). In addition, approximately 6.2 million fractures occur annually in the United States, of which 5-10% fail to heal properly, due to delayed or non-union [1], and nearly half of adults aged 45-65 have moderate to advanced periodontitis with associated alveolar bone loss, which, if not reversed, will lead to the loss of approximately 6.5 teeth/individual [2]. The strategies currently available for bone loss treatment largely suffer from limitations in efficacy or feasibility, necessitating further development and material innovation. Contemporary materials systems themselves are indeed limited in their ability to facilitate mechanical stimuli and provide an appropriate microenvironment for the cells they are designed to support. We propose a strategy which aims to leverage biocompatibility, biodegradability and material elasticity in the creation of a cellular niche. Within this niche, cells are mechanically stimulated to produce their own extracellular matrix. The hypothesis that mechanical stimuli will enhance bone regeneration is supported by a wealth of literature showing the effect of mechanical stimuli on bone cell differentiation and matrix formation. Using mechanical stimuli, to our knowledge, has not been explored in vivo in bone tissue engineering applications. We thus propose to use an elastomeric platform, based on poly(glycerol sebacate (PGS), to mimic the natural biochemical environment of bone while enabling the transmission of mechanical forces. In this study we report the material's load-transducing ability as well as falling mechanically closer to bone marrow and osteoid tissue rather than to mature bone, allowed osteogenesis and bone maturation. Defying the notion of selecting bone regeneration scaffolds based on their relative mechanical comparability to mature bone, we consider our results in part novel for the new application of this elastomer and in another fostering for reassessment of the current selection criteria for bone scaffolds.

Scaffoldless tissue-engineered dental pulp cell constructs for endodontic therapy

A major cause of apical periodontitis after endodontic treatment is the bacterial infiltration which could have been challenged by the presence of a vital pulp. In this study, self-assembled, scaffoldless, three-dimensional (3D) tissues were engineered from dental pulp cells (DPCs) and assessed as a device for pulp regeneration. These engineered tissues were placed into the canal space of human tooth root segments that were capped on one end with calcium phosphate cement, and the entire system was implanted subcutaneously into mice. Histological staining indicated that after three- and five-month implantations, tooth roots containing 3D scaffoldless engineered tissues maintained a cellular, fibrous tissue throughout, whereas empty tooth roots remained predominantly empty. Immunostaining indicated that the tissue found in the root canals containing scaffoldless DPC engineered tissues was vascular, as characterized by the expression of CD31, and contained odontoblast-like cells organized along the length of the root wall as assessed by immunostaining for dentin sialoprotein. This study shows that 3D self-assembled scaffoldless DPC engineered tissues can regenerate a vital dental pulp-like tissue in a tooth root canal system and are therefore promising for endodontic therapy.

Biomimetic coating of magnesium alloy for enhanced corrosion resistance and calcium phosphate deposition

Degradable metals have been suggested as biomaterials with revolutionary potential for bone-related therapies. Of these candidate metals, magnesium alloys appear to be particularly attractive candidates because of their non-toxicity and outstanding mechanical properties. Despite their having been widely studied as orthopedic implants for bone replacement/regeneration, their undesirably rapid corrosion rate under physiological conditions has limited their actual clinical application. This study reports the use of a novel biomimetic peptide coating for Mg alloys to improve the alloy corrosion resistance. A 3DSS biomimetic peptide is designed based on the highly acidic, bioactive bone and dentin extracellular matrix protein, phosphophoryn. Surface characterization techniques (scanning electron microscopy, energy dispersive X-ray spectroscopy and diffuse-reflectance infrared spectroscopy) confirmed the feasibility of coating the biomimetic 3DSS peptide onto Mg alloy AZ31B. The 3DSS peptide was also used as a template for calcium phosphate deposition on the surface of the alloy. The 3DSS biomimetic peptide coating presented a protective role of AZ31B in both hydrogen evolution and electrochemical corrosion tests.

Efficient bone formation by gene transfer of human LIM mineralization protein-3

LIM mineralization protein (LMP) is a novel positive regulator of the osteoblast differentiation program. In humans, three different LMP splice variants have been identified: LMP-1, LMP-2, and LMP-3. Gene transfer of human LMP-1 (hLMP-1) induces expression of genes involved in bone formation, including certain bone morphogenetic proteins (BMPs), promotes bone nodule formation in vitro, ectopic bone formation in vivo, and is therapeutic in animal models of posterior thoracic and lumbar spine fusion. To examine the osteoinductive properties of the LMP-3 in vitro and in vivo, we have generated plasmid and adenoviral vectors expressing codon-optimized hLMP-3. Here we demonstrate that gene transfer of hLMP-3 induces expression of the bone-specific genes osteocalcin, osteopontin, and bone sialoprotein and induced bone mineralization in preosteoblastic and fibroblastic cells. We also demonstrate that hLMP-3 is able to induce bone mineralization and the expression of the bone-specific genes, BMP-2, OSX, RunX2, and alkaline phosphatase in human mesenchymal stem cells in a dose-dependent manner. Finally, we demonstrate that direct gene transfer of hLMP-3 into murine skeletal muscle results in ectopic bone formation more efficiently than BMP-2. These results demonstrate that hLMP-3 gene transfer can be used to promote bone formation in cell culture and in vivo as or more efficiently than BMP-2, thus establishing feasibility and efficacy of direct gene delivery of hLMP-3 to produce bone in vivo. These results suggest that gene transfer of hLMP-3 could be developed as a bone-inductive therapeutic agent for clinical applications.

Critical aspects of tissue-engineered therapy for bone regeneration

Recent advances in bone tissue engineering are established on the understanding of an engineered scaffold, the molecular milieu within the osteogenic site, and the cell(s) predisposed to an osteogenic lineage. Advances in the incorporation of a generative vehicle into a skeletal defect require temporal and spatial distribution of the scaffold, growth factor, and cell compatible with enhanced bone healing. Monitoring events culminating in osteogenesis has focused on phenotypic and intracellular indicators. Phenotypic and intracellular indicators include the presence of receptors and intracellular signals that enable cell proliferation and differentiation. Progress in the areas of scaffold design, growth factor utilization, bone cell lineage, and intracellular signaling are reviewed.

Therapeutic potential of bone morphogenetic proteins

Recently, there has been substantial progress in the area of bone morphogenetic protein (BMP) research. This review serves as an up-to-date summary of the history of BMPs, the mechanisms of BMP signalling and the role of BMPs in adipose, kidney, liver, bone and nervous system. The potential of BMPs as therapeutic agents will also be discussed.

Gene therapy approaches for modulating bone regeneration

Following injury, bone has the ability to regenerate itself to a form and function nearly indistinguishable from the pre-injury state. However, if the injury is beyond a critical limit, recovery will not occur without therapeutic interventions. Autografts and implants with banked bone continue as the treatments of choice, although each exhibits limitations and liabilities. Alternatives have included the utilization of bone-graft substitutes that may incorporate bone derivatives and soluble signaling molecules such as mitogens and morphogens. In addition, an evolving treatment modality, gene therapy, offers an exciting avenue for bone regeneration. This review presents some of the current concepts for developing a rational gene therapy approach in bone regeneration.

Treatment of intrabony defects by polylactic acid matrix barrier--a one-year follow-up study

The present investigation was conducted to evaluate the effect of a polylactic acid-citric acid softened membrane barrier during guided tissue regeneration (GTR) surgery on human intrabony defects. Eighteen patients were treated in the study and 16 patients completed the 1-year follow-up. In all, 27 intrabony defects were treated and clinical soft tissue measurements, including probing depth (PD), probing attachment level (PAL), and recession, were recorded. Results of the investigation demonstrated a significant reduction in PD (3.7 mm), a significant gain in PAL (4.2 mm), and a slight increase in recession (1.2 mm).

Properties of the (DSS)n triplet repeat domain of rat dentin phosphophoryn

Phosphophoryns (PPs) are unique aspartic acid and phosphoserine-rich proteins present in all species of dentin. Rat incisor odontoblast cDNA libraries contain messages encoding several acidic phosphorylated, serine-rich proteins. At least two of these share a common C-terminal domain coding region sequence. The polypeptide sequences in the N-terminal direction immediately adjacent to the conserved C-terminal domains of these two proteins (DMP2, DMP3) are distinctly different. In this domain, the DMP2 has extensive sequences of (DSS)n repeats with n as large as 24. DMP3 has fewer and shorter triplet sequences, n = 3, 4. The major rat incisor PPs (90-95 kDa) probably have the (DSS)n>>3. We propose that the name phosphophoryn be reserved for the extracellular matrix proteins with these extended repeats. DMPI, although strongly acidic, does not fit this category. If the S residues are phosphorylated and n > 3, conformational energy minimization computations show the (DSS)n sequence to assume a unique extended structure with parallel arrays of carboxylate and phosphate groups which may function as Ca2+ ion interaction edges. The phosphorylation of recombinant DMP2 C-terminal domain by various kinases has been examined. The repeat domains are not direct substrates for the CK2-like kinases but the kinases act in concert, so that the phosphorylation is hierarchical, apparently controlled by the presence of specific interruptions between the triplet domains.

Phosphorylation of the proteins of the extracellular matrix of mineralized tissues by casein kinase-like activity

The extracellular matrix of the connective tissue contains non-collagenous proteins (NCP) which are acidic in character. The NCP of mineralizing systems (bone, dentin) differ from those of the non-mineralizing systems (skin, tendon) in that the mineralized tissue NCP are frequently phosphorylated. The phosphorylated proteins have been implicated in various aspects of the mineralization process. Thus, it is of interest to consider the mechanism and regulation of phosphorylation of the major matrix NCP. The majority of the phosphorylation takes place at Ser or Thr residues embedded within acidic sequences, and therefore are targets for casein kinase I (CK1) or casein kinase II (CK2)-like kinases. CK1 and CK2 are distantly related members of the protein kinase family. They are ubiquitous, constitutively active, second-messenger-independent kinases. CK1 is found in a variety of isoforms, all homologous to the alpha-subunit of the protein kinase family. It acts as a monomer. The active form of CK2 is a tetrameric holoenzyme, with 2 alpha catalytic subunits and 2 beta regulatory subunits. The CK2 alpha has activity alone, but the holoenzyme is four- to five-fold that activity. CK2 can use either ATP or GTP as the phosphate donor, but CK1 can use only ATP. The CK2 activity which phosphorylates the mineralized tissue NCP appears to be localized to membrane-associated cell fractions, and is present in the endoplasmic reticulum and Golgi compartments in osteoblasts, where phosphorylation of the secreted proteins appears to take place as co- and post-translational processes. Data indicate that both alpha and beta subunits of the membrane-associated CK2 are isoforms of the cytosolic CK2 in the same cells. The CK1 has not been specifically localized. Studies of dephosphorylated NCP such as phosphophoryn (PP) have shown that CK1 will not phosphorylate dephosphorylated dPP unless prior phosphorylation with CK2 has been carried out. In turn, CK2 activity may be initiated only after an initial phosphorylation of one of the messenger-dependent kinases. Thus, the phosphorylation reactions in mineralized tissues may be a tightly regulated hierarchical or sequential cascade of intracellular phosphorylation events.

The membrane associated kinases which phosphorylate bone and dentin extracellular matrix phosphoproteins are isoforms of cytosolic CKII

Bone and dentin contain many phosphoproteins in their extracellular matrix. It has been postulated that the anionic character of these proteins, and the presence of phosphate groups in particular, is important for various functions related to biomineralization. Phosphophoryns (PP), are the most highly phosphorylated dentin matrix components. However, the tissue form of PP can be further phosphorylated in vitro by cytosolic and membrane associated-endogenous messenger-independent kinases from osteoblast-like cells. To examine the kinases, a 2-dimensional zymogram technique has been developed for the detection of casein kinase II (CKII) activity of purified kinases using intact PP as the substrate. After isolation by subcellular fractionation and ion-exchange chromatographic techniques, the enzymes are electrophoresed on an isoelectric focusing gel in the absence of SDS and disulfide bond breaking reagents. This first dimension gel is then layered on the zymogram gel containing PP + SDS. After electrophoresis, the gels are incubated in 250-500 microCi [gamma-32P] ATP. Autoradiography then detects kinase activity. Comparison of the UMR 106 CKII cytosolic and membrane-bound fractions showed that they were different in M(r) and focusing pH, suggesting the presence of CKII isoforms. CKI, which could phosphorylate the native PP in vitro, could not phosphorylate a dephosphorylated preparation (dPP). However, if the dPP was first exposed to CKII and unlabeled ATP then reacted with CKI and [gamma-32P]ATP, the PP was phosphorylated. This prerequisite phosphorylation by CKII indicates that in vivo PP phosphorylation probably occurs in a series of regulated steps as a co- or post-translational process.

Casein kinase localization in the endoplasmic reticulum of the ROS 17/2.8 cell line

Phosphophoryns (PPs) are phosphoproteins specific to the dentin matrix and are the major noncollagenous matrix proteins in rat incisor dentin. It has been hypothesized that their phosphate groups are important in dentin mineralization. PPs have many sequences which are substrates for membrane-associated endogenous messenger-independent kinases. The objective of this study was to localize the protein kinases involved in phosphorylating the PPs. Osteoblast-like ROS 17/2.8 cells, which secrete extracellular matrix phosphoproteins, were lysed. After removal of the nuclei and mitochondria by low-speed centrifugation, the membrane associated organelles were isolated at higher speed from the cytosol. The Golgi vesicle and rough microsome fractions were collected from 29-43.7% sucrose density gradients. Each fraction was tested for casein kinase II (CKII) activity using an in vitro phosphorylation assay with PPs as substrate. To characterize and confirm the nature of the components of the sucrose gradient fractions, the activities of specific enzymes such as N-acetylglucosamine galactosyltransferase and cytochrome c reductase, which are exclusively associated with the Golgi and rough microsomes, respectively, were determined. Electron microscopy of the isolated fractions confirmed the enzyme assay characterizations. CKII activity capable of phosphorylating the PP was found in the rough microsome fraction but not in the Golgi. Thus, phosphorylation of the secreted phosphoproteins would appear to take place in the endoplasmic reticulum as a cotranslational event.