Outcome assessment methods of bioactive and biodegradable materials as pulpotomy agents in primary and permanent teeth: a scoping review.

BACKGROUND: Pulpotomy procedures aiming to preserve and regenerate the dentin-pulp complex have recently increased exponentially due to developments in the field of biomaterials and tissue engineering in primary and permanent teeth. Although the number of studies in this domain has increased, there is still scarcity of evidence in the current literature. OBJECTIVES: (1) Report the methods of outcome assessment of pulpotomy clinical trials in both primary and permanent teeth; (2) Identify the various bioactive agents and biodegradable scaffolds used in pulpotomy clinical trials in both primary and permanent teeth. MATERIALS AND METHODS: A scoping review of the literature was performed, including a search of primary studies on PubMed, Scopus, Web of Science, ProQuest and Clinicaltrials.gov. A search for controlled trials or randomized controlled trials published between 2012 and 2023 involving primary or permanent teeth receiving partial or full pulpotomy procedures using bioactive/regenerative capping materials was performed. RESULTS: 127 studies out of 1038 articles fulfilled all the inclusion criteria and were included in the current scoping review. More than 90% of the studies assessed clinical and radiographic outcomes. Histological, microbiological, or inflammatory outcomes were measured in only 9.4% of all included studies. Majority of the studies (67.7%) involved primary teeth. 119 studies used non-degradable bioactive cements, while biodegradable scaffolds were used by 32 studies, natural derivates and plant extracts studies were used in only 7 studies. Between 2012 (4 studies) and 2023 (11 studies), there was a general increase in the number of articles published. India, Egypt, Turkey, and Iran were found to have the highest total number of articles published (28, 28,16 and 10 respectively). CONCLUSIONS: Pulpotomy studies in both primary and permanent teeth relied mainly on subjective clinical and radiographic outcome assessment methods and seldom analyzed pulpal inflammatory status objectively. The use of biodegradable scaffolds for pulpotomy treatments has been increasing with an apparent global distribution of most of these studies in low- to middle-income countries. However, the development of a set of predictable outcome measures as well as long-term evidence from well conducted clinical trials for novel pulpotomy dressing materials are still required.

Nanoscale borosilicate bioactive glass for regenerative therapy of full-thickness skin defects in rabbit animal model.

Bioactive glass (BG) occupies a significant position in the field of hard and soft tissue regeneration. Different processing techniques and formulas have been introduced to expand their regenerative, angiogenic, and antibacterial properties. In the present study, a new formula of bborosilicate bioactive glass nanofibers was prepared and tested for its wound-healing efficacy in a rabbit animal model. The glass formula ((1-2) mol% of B2O3 (68-69) mol% of SiO2, and (29-30) mol% of CaO) was prepared primarily by the sol-gel technique followed by the electrospinning technique. The material was characterized for its ultrastructure using scanning electron microscopy, chemical composition using FTIR, and its dynamic in vitro biodegradability using ICP-AES. Twelve rabbits were subjected to surgical induction of full-thickness skin defects using a 1 cm2 custom-made stainlessteel skin punch. The bioactive glass nanofibers were used as a grafting material in 6 experimental rabbits, while the defects in the remaining rabbits were considered as the negative control samples. All defects were assessed clinically for the decrease in wound size and clinical signs of healing and histologically for angiogenesis, collagen density, inflammatory response, cell recruitment, epithelial lining, and appendages at 1,2 and 3 weeks following the intervention. Structural analysis of the glass fibers confirmed their nano-size which ranged from 150 to 700 nm. Moreover, the chemical analysis confirmed the presence of SiO2 and B2O3 groups within the structure of the nanofibers. Additionally, dynamic biodegradation analysis confirmed the rapid degradation of the material starting from the first 24 h and rapid leaching of calcium, silicon, and boron ions confirming its bioactivity. The wound healing study of the nanofibrous scaffold confirmed its ability to accelerate wound healing and the closure rate in healthy rabbits. Histological analysis of the defects confirmed the angiogenic, regenerative and antibacterial ability of the material throughout the study period. The results unveil the powerful therapeutic properties of the formed nanofibers and open a new gate for more experimental and clinical applications.

Microbial identification from traumatized immature permanent teeth with periapical lesions using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

BACKGROUND: This study aims at identifying the microbiota in traumatized immature permanent teeth with periapical lesions using Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). METHODS: The study included 16 immature maxillary central incisors with periapical lesions in 13 patients. Field decontamination and negative control samples were performed before and after access cavity preparation. Root canal samples were taken using sterile stainless-steel hand files following field decontamination. In-office inoculation and pure sub-cultures were performed. Bacterial isolates were prepared for MALDI-TOF MS (Bruker, Billerica, MA USA) analysis using the formic acid extraction method. A comparison of the prevalence of isolated microorganisms was done using a one-sample chi-square test. Comparisons between identified microbial species with the, cone beam computed tomography periapical index (CBCT PAI) scores and lesion volume were also conducted. The Chi-square test was applied to investigate the association between the categorical variables . RESULTS: Out of the forty isolates recovered from the 16 traumatized teeth included in the present study with the mean patients' age of 10.93 ± 1.77, 37 isolates were reliably identified by MALDI-TOF MS. Twelve teeth (62.5%) were polymicrobial. The recovered bacteria belonged to five phyla, 15 genera and 25 species. Firmicutes were the predominant phylum (P < 0.001) over Bacteroidetes, Proteobacteria, Actinobacteria and Fusobacteria. Gram positive bacteria were significantly more prevalent than Gram negative (p = 0.03). Facultative anaerobes were the most prevalent (P < 0.001) compared to the obligate anaerobes and the obligate aerobes. The latter were the least prevalent. Statistically, significant differences existed in the comparison between CBCT PAI scores according to bacterial gram staining. CONCLUSION: Traumatized immature permanent teeth with periapical lesions showed a significant predominance of Gram-positive facultative anaerobes. MALDI-TOF MS provided accurate identification of numerous viable endodontic microbes.

Human Treated Dentin Matrix Hydrogel as a Drug Delivery Scaffold for Regenerative Endodontics.

Introduction: The objective of the current study was to develop a human treated dentin matrix (hTDM) hydrogel for use as a scaffold to allow the controlled release of an antimicrobial agent for regenerative endodontics. Materials and Methods: Human extracted teeth were treated via chemical demineralization using ethylene diamine tetra-acetic acid solution to produce hTDM powder. Fourier transform infrared spectroscopy (FTIR) was conducted to determine the functional groups of hTDM, scanning electron microscopy (SEM) was used to define the morphology/particle size of hTDM, and energy dispersive X-ray analysis was performed to identify the superficial apatite groups. Prepared hTDM powder was added to the amoxicillin-clavulanate mixture with a mass ratio of 1:1. Then, the combination was dripped into a 5% (w/v) calcium chloride solution. Antibiotic release profiles were evaluated for 14 days via high performance liquid chromatography (HPLC). Hydrogel degradation properties were studied for 14 days using 10 mL of phosphate buffered saline (PBS). Encapsulation efficiency was determined by HPLC, while minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of amoxicillin-clavulanate were determined against Enterococcus faecalis (E. faecalis). The antibacterial activity of amoxicillin-clavulanate against E. faecalis was investigated for 14 days via agar diffusion test. Statistical analysis was performed with the Shapiro-Wilk test (P=0.05). Results: hTDM showed statistically a significant difference for percentage weight change (P=0.1). The encapsulation efficiencies for hTDM hydrogel with antibiotic and hydrogel with antibiotic was 96.08%±0.02 and 94.62%±0.11, respectively. MIC and MBC values of amoxicillin-clavulanate against E. faecalis were 2.4 µg/mL and 9.6 µg/mL, respectively. The antibacterial activity of antibiotic loaded hTDM hydrogels was significantly greater than loaded hydrogels alone by 31% after 4 days and 100% at 14 days, respectively (P≤0.001). Conclusions: This in vitro study showed antibiotic-loaded injectable hTDM hydrogel could be an alternative system to transfer antibiotic-based intracanal medicaments for use in regenerative endodontics.

Multidisciplinary management of a fused maxillary incisor: Case report with 5-year follow-up.

Detailed treatment planning and execution are crucial if regenerative approaches are to be attempted to retain fused permanent teeth. Long-term follow-up is necessary to monitor the stability of the final outcome, both esthetically and functionally.

Tailored 70S30C Bioactive glass induces severe inflammation as pulpotomy agent in primary teeth: an interim analysis of a randomised controlled trial.

OBJECTIVES: This study compared clinical, histologic, and inflammatory outcomes of Biodentine and Bioactive glass (70S30C-BAG) as pulpotomy agents in primary teeth. METHODS: A randomised, clinical trial was performed recruiting 70 children, 5-9 years old, having ≥ 1 tooth indicated for vital pulpotomy. Participants were randomised to Biodentine or 70S30C-BAG groups. Clinical evaluation was scheduled at 1, 3, 6, 9, and 12 months. Additional 16 teeth were extracted after 6 weeks to assess histologic and inflammatory response (IL-8/IL-10 ratio) using ELISA. Fisher exact, Mann Whitney U test, and t test were used to compare clinical, histologic outcomes and IL-8/IL-10 ratio. RESULTS: After 3 months, 10 teeth treated with Biodentine were clinically successful, while 9 teeth treated with 70S30C-BAG failed (P < 0.001) necessitating trial termination. Causes of failure were analysed by assessing the pH and ionic release of 70S30C-BAG. Biodentine-treated teeth showed minor inflammation, normal pulp, and hard tissue formation.70S30C-BAG-treated teeth showed severe inflammation, abscesses, root resorption without hard tissue formation. There was a significantly greater percent reduction of IL-8/IL-10 ratio in Biodentine than 70S30C-BAG (mean ± SD = 66.39 ± 18.56 and 40.66 ± 0.86, P = 0.02). CONCLUSIONS: Biodentine showed favourable clinical, histologic, and anti-inflammatory outcomes, promoting pulp healing and regeneration. 70S30C-BAG resulted in pulp necrosis-through persistent inflammation-causing clinical failure. CLINICAL RELEVANCE: Biodentine is a promising pulpotomy agent in primary teeth; it promoted healing and regeneration of the dentine-pulp complex. In its current form, 70S30C-BAG is not a suitable pulpotomy agent; it induced persistent inflammation, negating the pulp ability to heal and regenerate. TRN: NCT03786302, 12/19/2018.

Effect of different irrigation protocols for applications in regenerative endodontics on mechanical properties of root dentin.

The objective of this study was to evaluate the effect of different concentrations of NaOCl with and without passive ultrasonic irrigation (PUI) on mechanical properties of human dentin for applications in regenerative endodontics (RE). Sixty single-rooted teeth were sectioned into 2 halves (n = 120). Dentin bars were produced from one half for flexural strength and the other half was used for microhardness. Specimens were randomly assigned into 10 groups: G1 and G2 (control): distilled water for 30 and 60 min, respectively; G3: 1.5%NaOCl for 30 min; G4:1.5%NaOCl for 60 min; G5: 1.5%NaOCl + PUI for 30 min; G6: 1.5%NaOCl + PUI for 60 min; G7: 5.25%NaOCl for 30 min; G8: 5.25%NaOCl for 60 min; G9: 5.25%NaOCl + PUI for 30 min; G10: 5.25%NaOCl + PUI for 60 min. An increase in NaOCl concentration showed highly significant reduction in mechanical properties. There was no significant difference between 1.5% NaOCl and control group except for specimens treated with PUI for 60 min. NaOCl in concentrations recommended for RE did not have a significant effect on mechanical properties of dentin. However, PUI with increased irrigation time might have an effect even with low NaOCl concentration.

Evaluation of the Efficacy of Three Antimicrobial Agents Used for Regenerative Endodontics: An In Vitro Study.

Aim: To evaluate the antibacterial efficacy of double antibiotic paste (DAP), silver nanoparticle (AgNP) gel, and tailored amorphous multiporous bioactive glass (TAMP-BG) in concentrations suitable for regenerative endodontics (RE) against 3-week-old Enterococcus faecalis biofilms after 24 hours and 7 days. Results: Radicular human dentin specimens were prepared and inoculated with E. faecalis to form 3-week-old biofilms. DAP (1 mg/mL), AgNPs 0.02%, and TAMP-BG 100 mg/mL, in methylcellulose gel formulations, were used as antimicrobials. The biofilm disruption assay was done followed by quantification of bacterial colony-forming units and scanning electron microscopic analysis. Results showed that 1 mg/mL of DAP or AgNPs 0.02% provided significant antibiofilm effects at both time intervals. Both DAP and AgNPs significantly reduced bacterial counts and biofilms after 7 days compared with 24 hours. Furthermore, 100 mg/mL of TAMP-BG had a comparable antibiofilm effect, but it was less potent than DAP and AgNPs at both time intervals. Conclusions: DAP (1 mg/mL), 0.02% AgNPs, and TAMP-BG (100 mg/mL) can significantly reduce E. faecalis biofilms. However, complete elimination was only possible with DAP and AgNPs.

Stem Cells From the Apical Papilla (SCAP) as a Tool for Endogenous Tissue Regeneration.

Stem cells extracted from developing tissues possibly exhibit not only unique but also superior traits against their developed counterparts. Indeed, stem cells from the apical papilla (SCAP); a unique group of dental stem cells related to developing roots have been shown to be a promising tool for regenerative endodontic procedures and regeneration in general. Studies have characterized the phenotypic traits as well as other regenerative potentials of these cells. Specific sub-populations have been highlighted as well as their neurogenic and angiogenic properties. Nevertheless, in light of the previously discussed features and potential applications of SCAP, there is still much to understand and a lot of information to unravel. The current review will discuss the role of specific markers for detection of different functional populations of SCAP; including CD146 and STRO-1, as well as their true multilineage differentiation potential. In particular, the role of the secretome in association with paracrine signaling in inflammatory microenvironments is also tackled. Additionally, the role of SCAP both in vitro and in vivo during regenerative approaches and in response to different growth factors and biologic scaffolds is highlighted. Finally, this review will shed light on current knowledge regarding the clinical translational potential of SCAP and elucidate possible areas for future research applications.

Dental Mesenchymal Stem Cell-Based Translational Regenerative Dentistry: From Artificial to Biological Replacement.

Dentistry is a continuously changing field that has witnessed much advancement in the past century. Prosthodontics is that branch of dentistry that deals with replacing missing teeth using either fixed or removable appliances in an attempt to simulate natural tooth function. Although such "replacement therapies" appear to be easy and economic they fall short of ever coming close to their natural counterparts. Complications that arise often lead to failures and frequent repairs of such devices which seldom allow true physiological function of dental and oral-maxillofacial tissues. Such factors can critically affect the quality of life of an individual. The market for dental implants is continuously growing with huge economic revenues. Unfortunately, such treatments are again associated with frequent problems such as peri-implantitis resulting in an eventual loss or replacement of implants. This is particularly influential for patients having co-morbid diseases such as diabetes or osteoporosis and in association with smoking and other conditions that undoubtedly affect the final treatment outcome. The advent of tissue engineering and regenerative medicine therapies along with the enormous strides taken in their associated interdisciplinary fields such as stem cell therapy, biomaterial development, and others may open arenas to enhancing tissue regeneration via designing and construction of patient-specific biological and/or biomimetic substitutes. This review will overview current strategies in regenerative dentistry while overviewing key roles of dental mesenchymal stem cells particularly those of the dental pulp, until paving the way to precision/translational regenerative medicine therapies for future clinical use.

Host cell recruitment patterns by bone morphogenetic protein-2 releasing hyaluronic acid hydrogels in a mouse subcutaneous environment.

AIM: This study aimed to identify host cell recruitment patterns in a mouse model in response to rhBMP-2 releasing hyaluronic acid hydrogels and influence of added nano-hydroxyapatite particles on rhBMP-2 release and pattern of bone formation. MATERIALS & METHODS: Implanted gels were retrieved after implantation and cells were enzymatically dissociated for flow cytometric analysis. Percentages of macrophages, progenitor endothelial cells and putative mesenchymal stem cells were measured. Implants were evaluated for BMP-2 release by ELISA and by histology to monitor tissue formation. RESULTS & CONCLUSION: Hyaluronic acid+BMP-2 gels influenced the inflammatory response in the bone healing microenvironment. Host-derived putative mesenchymal stem cells were major contributors. Addition of hydroxyapatite nanoparticles modified the release pattern of rhBMP-2, resulting in enhanced bone formation.

Preparation and characterization of carbon nanofibrous/hydroxyapatite sheets for bone tissue engineering.

Critical size bone defects are orthopedic defects that will not heal without intervention or that will not completely heal over the natural life time of the animal. Although bone generally has the ability to regenerate completely however, critical defects require some sort of scaffold to do so. In the current study we proposed a method to obtain a carbon nanofibrous/Hydroxyapatite (HA) bioactive scaffold. The carbon nanofibrous (CNF) nonwoven fabrics were obtained by the use of the electrospinning process of the polymeric solution of poly acrylonitrile "PAN" and subsequent stabilization and carbonization processes. The CNFs sheets were functionalized by both hydroxyapatite (HA) and bovine serum albumin (BSA). The HA was added to the electrospun solution, but in case of (BSA), it was adsorbed after the carbonization process. The changes in the properties taking place in the precursor sheets were investigated using the characterization methods (SEM, FT-IR, TGA and EDX). The prepared materials were tested for biocompatibility via subcutaneous implantation in New Zealand white rabbits. We successfully prepared biocompatible functionalized sheets, which have been modified with HA or HA and BSA. The sheets that were functionalized by both HA and BSA are more biocompatible with fewer inflammatory cells of (neutrophils and lymphocytes) than ones with only HA over the period of 3weeks.

Platelet rich plasma enhances osteoconductive properties of a hydroxyapatite-ß-tricalcium phosphate scaffold (Skelite) for late healing of critical size rabbit calvarial defects.

The use of platelet rich plasma (PRP) in bone repair remains highly controversial. In this work, we evaluated the effect of lyophilized PRP on bone regeneration when associated with a silicon stabilized hydroxyapatite tricalcium phosphate scaffold in a rabbit calvarial defect (Skelite). Critical defects were created in the calvaria of twenty-four rabbits. The periosteum was removed and the defects were either left empty or filled with allogeneic PRP gel; Skelite particles; Skelite and PRP gel. Four animals were killed after 4 weeks, 10 animals after 8 and 10 after 16 weeks. Specimens were processed for X-ray microtomography (µCT) and for resin embedded histology. µCT analysis revealed significant osteoid-like matrix and new bone deposition in PRP + Skelite group at both 8 and 16 weeks in respect to Skelite alone. Histologically, PRP + Skelite defects were highly cellular with more abundant osteoid deposition and more regular collagen fibres. Moreover, in vitro migration assays confirmed the chemotactic effect of PRP to endothelial and osteoprogenitor cells. We conclude that the addition of PRP influenced the local tissue microenvironment by providing key cryptic factors for regeneration, thereby enhancing progenitor cell recruitment, collagen and bone matrix deposition, and by creating a bridging interface between the scaffold and bone.

A modified rabbit ulna defect model for evaluating periosteal substitutes in bone engineering: a pilot study.

The present work defines a modified critical size rabbit ulna defect model for bone regeneration in which a non-resorbable barrier membrane was used to separate the radius from the ulna to create a valid model for evaluation of tissue-engineered periosteal substitutes. Eight rabbits divided into two groups were used. Critical defects (15 mm) were made in the ulna completely eliminating periosteum. For group I, defects were filled with a nanohydroxyapatite poly(ester urethane) scaffold soaked in PBS and left as such (group Ia) or wrapped with a tissue-engineered periosteal substitute (group Ib). For group II, an expanded-polytetrafluoroethylene (e-PTFE) (GORE-TEX(®)) membrane was inserted around the radius then the defects received either scaffold alone (group IIa) or scaffold wrapped with periosteal substitute (group IIb). Animals were euthanized after 12-16 weeks, and bone regeneration was evaluated by radiography, computed microtomography (µCT), and histology. In the first group, we observed formation of radio-ulnar synostosis irrespective of the treatment. This was completely eliminated upon placement of the e-PTFE (GORE-TEX(®)) membrane in the second group of animals. In conclusion, modification of the model using a non-resorbable e-PTFE membrane to isolate the ulna from the radius was a valuable addition allowing for objective evaluation of the tissue-engineered periosteal substitute.

A platelet-rich plasma-based membrane as a periosteal substitute with enhanced osteogenic and angiogenic properties: a new concept for bone repair.

The periosteum plays a pivotal role during bone development and repair contributing to bone vascularization and osteoprogenitor cells source. We propose a periosteal substitute engineered using a platelet-rich plasma (PRP) membrane incorporating autologous bone marrow-derived mesenchymal stem cells (PRP/BMSC gel membrane) to be wrapped around an osteoconductive scaffold for regeneration of compromised bone defects. The PRP/BMSC gel membrane was optimized using different compositions for optimal release of vascular endothelial growth factor (VEGF) and platelet derived growth factor-BB (PDGF-BB). Survival and proliferation of cells in the PRP gel membrane with time were confirmed in addition to their osteogenic capacity. Furthermore, to evaluate the possible effects of the PRP/BMSC gel membrane on surrounding progenitor cells in the injury area, we found that the PRP gel membrane products could significantly induce the migration of human endothelial cells in vitro, and increased the expression of bone morphogenetic protein 2 in cultured BMSC. These cells also secreted significant amounts of soluble proangiogenic factors, such as PDGF-BB, VEGF, and interleukin-8 (IL-8). Finally, the functionality of the PRP/BMSC gel membrane periosteal substitute for bone regeneration was tested in vivo both in an ectopic mouse model as well as in a rabbit segmental bone defect model providing evidence of its capacity to biomimic a periosteal response enhancing bone regeneration.

Experimental formation of periodontal structure around titanium implants utilizing bone marrow mesenchymal stem cells: a pilot study.

Tissue engineering in the head and neck area, presents numerous advantages. One of the most remarkable advantages is that regeneration of only a small amount of tissue can be highly beneficial to the patient, particularly in the field of periodontal tissue regeneration. For decades, successful osseointegration has provided thousands of restorations that maintain normal function. With the increasing need to utilize dental implants for growing patients and enhance their function to simulate normal tooth physiology and proprioception, there appears to be an urgent need for t concept of periodontal tissue regeneration around dental implants. In the present work, 5 goats wer used for immediate implant placement post canine teeth extraction. Each goat received 2 implan fixtures; the control side received a porous hollow root-form poly (DL-Lactide-co-Glycolide) scaf around the titanium fixture, and the experimental side received the same scaffold but seeded with autogenous bone marrow-derived mesenchymal stem cells. One animal was killed 10 days postoperatively, and the others were killed after 1 month. The results showed that on th experimental side, periodontal-like tissue with newly formed bone was demonstrated both at 1 days and after 1 month, while the control specimens showed early signs of connective tissue regeneration around the titanium fixture at 10 days, but was not shown in the 1 month specimens. I can be concluded that undifferentiated mesenchymal stem cells were capable of differentiating t provide the 3 critical tissues required for periodontal tissue regeneration: cementum, bone, a periodontal ligament. This work may provide a new approach for periodontal tissue regeneration.

Regeneration of dentine/pulp-like tissue using a dental pulp stem cell/poly(lactic-co-glycolic) acid scaffold construct in New Zealand white rabbits.

With the expanding knowledge of tooth regeneration and biological mechanisms of functional dental tissue repair, current treatment strategies are beginning to give way to evolving fields such as tissue engineering and biomimetics. Dental pulp stem cells were isolated from rabbit teeth and seeded onto scaffolds prepared from 50/50 poly(lactic-co-glycolic acid) polymers using two different porogen particle sizes. These cell/scaffold constructs were then transplanted subcutaneously in the rabbits. The expanded rabbit dental pulp stem cells showed high proliferative and clonogenic capacities as well as the ability to give rise to mineralised-like tissues in vitro in culture flasks and after seeding them onto the scaffolds for 12 days. Histological evaluation of transplanted samples revealed the formation of osteodentine-like structures as well as tubular bilayered structures of vertically aligned parallel tubules resembling tubular-like dentine. Using a tissue engineering approach yielded tissues quite similar to normal dentine/pulp-like tissues that can perhaps be used later on for regenerative endodontic or operative procedures.