Review Article
Volume 3 Issue 4 - 2016
Regenerative Endodontics: A Comprehensive Review
Lisha Thakur1*, Munish Goel2, Gurmeet S Sachdeva3 and Kushal Katoch4
1Department of Conservative Dentistry and Endodontics, Himachal Dental College and Hospital, India
2Department of Conservative Dentistry and Endodontics, Himachal Dental College and Hospital, India
3Department of Conservative Dentistry and Endodontics, Himachal Dental College and Hospital, India
4Dr. Rajendra Prasad Government Medical College and Hospital, India
*Corresponding Author: Lisha Thakur, Department of Conservative Dentistry and Endodontics, Himachal Dental College, Sundernagar, Mandi, HP, India.
Received: October 20, 2015; Published: January 14, 2016
Citation: Lisha Thakur., et al. “Regenerative Endodontics: A Comprehensive Review”. EC Dental Science 3.4 (2016): 556-567.
Abstract
Immature teeth diagnosed with pulp necrosis have been traditionally treated with apexification or apexogenesis approaches. Unfortunately, these treatments provide little or no benefit in promoting continued root development. Regenerative endodontic therapy is a biologically based procedure that aims to replace previously damaged pulp-dentin complex by new vital tissue, resulting in partial restoration of the functional properties of the involved tooth. It has emerged as an important alternative in treating teeth with otherwise questionable long-term prognosis because of thin, fragile dentinal walls and a lack of immunocompetency. Most therapies use the host’s own pulp or vascular cells for regeneration, but other types of dental stem cell therapies are under development. This article reviews the literature related to the various aspects of regenerative procedure including role of stem cells, growth factors and scaffolds, the clinical considerations, outcomes and drawbacks and how these procedures may increase the prognosis for immature teeth with necrotic pulp tissue.
Keywords: Stem cells; Growth factors; Scaffolds; Clinical considerations; Drawbacks; Outcomes
Abbreviations: MTA: Mineral Trioxide Aggregate; hSCAP: Human Apical Papillae Stem Cell; hDPSC: Human Dental Pulp Stem Cell; hSHED: Human Exfoliated Deciduous Teeth Stem Cell; HUVEC: Human Umbilical Vein Cord Cell; DSPP: Dentin Sialo-Phosphoprotein; DMP-1: Dentin Matrix Protein-1
Introduction
The ultimate goal for tissue engineering and regenerative medicine is to develop therapies to restore lost, damaged, or aging tissues using engineered or regenerated products derived from either donor or autologous cells. It involves using a biodegradable scaffold in the shape of the new tissue that is seeded with either stem cells or autologous cells from biopsies of damaged tissues.
Figure 1: Tissue engineering triad.
The regeneration of periodontium was the first tissue-engineering technology in dentistry, and was invented by Nyman and colleagues [1] in 1982. The regenerative procedure can be successful only if the healthy dental pulp tissue is still present and if bacterial contamination is completely removed [2,3]. Findings from previous revascularization studies of traumatized teeth showed that the success of pulp-tissue regeneration in replanted avulsed teeth depends on the diameter of the opening of root apices [4,5]. A diameter of 1mm (1000 µm) of the opening of root apices has been suggested as a minimum requirement to allow new tissues with neural and vascular structures to regrow into the tooth [5]. Because diameters of the neural, vascular, and cellular structures are less than 100 µm (ie, 10-30 µm diameters for eukaryotic animal and human cells; 0.2-20 µm diameters for nerve fibres; and < 100 µm diameters for most arteries in the dental pulp) [6,7], theoretically the regeneration of pulp tissue may not need as much as a 1000 µm diameter opening.
Dental stem cells and their sources
Stem cell niches
Stem cell behavior is regulated by a local microenvironment referred to as ‘‘the stem cell niche,’’ which is characterized by 3 essential properties [8,9]:
  1. A niche provides an environment where the stem cell number is regulated.
  2. It is the place where a stem cell controls the maintenance, quiescence, self-renewal, and recruitment toward differentiation, fate determination, and long-term regenerative capacity.
  3. The niche influences cell motility.
It is assumed that multiple niches exist in teeth.
Beginning in 2000, several human dental stem/progenitor cells have been isolated and characterized. These include:
Dental pulp stem cells (DPSCs)
Dental pulp stem cells were first isolated from human permanent third molars in 2000 [10] and were characterized as clonogenic and highly proliferative. Colony formation frequency was high and produced densely calcified, but sporadic, nodules [13]. Dentin and pulp-like tissues were generated following the transplantation of these cells in hydroxyapatite/tricalcium phosphate scaffolds into immunodeficient mice [11,13]. A follow-up study confirmed that these cells fulfilled the criteria needed to be stem cells: an ability to differentiate into adipocytes and neural cells and odontoblasts and self-renewal capabilities [12].
Stem cells from human exfoliated deciduous teeth (SHED)
Stem cells isolated from human exfoliated deciduous teeth are highly proliferative and capable of differentiating into a variety of cell types, including osteoblasts, neural cells, adipocytes, and odontoblasts, and inducing dentin and bone formation. Like dental pulp stem cells, these cells can generate dentin-pulp-like tissues with distinct odontoblast-like cells lining the mineralized dentin-matrix generated in HA/TCP scaffolds implanted in immunodeficient mice [13]. However, these cells have a higher proliferation rate than dental pulp stem cells and bone marrow mesenchymal stem cells, suggesting that they represent a more immature population of multipotent stem cells [13,14].
Stem cells from apical papilla (SCAP)
Dental papilla is derived from the ectomesenchyme induced by the overlaying dental lamina during tooth development. It evolves into dental pulp after being surrounded by the dentin tissue produced by odontoblasts. The physical and histologic characteristics of the dental papilla located at the apex of developing human permanent teeth was described and termed as apical papilla. This tissue is loosely attached to the apex of the developing root and can be easily detached with a pair of tweezers.
Figure 2: Apical Papilla.
Periodontal ligament stem cells (PDLSCs)
McCulloch[15] reported the presence of progenitor/stem cells in the periodontal ligament of mice in 1985. Subsequently, the isolation and identification of multipotent mesenchymal stem cells in human periodontal ligaments were first reported in 2004. Seo and colleagues[16] demonstrated the presence of clonogenic stem cells in enzymatically digested periodontal ligament and further showed that human periodontal ligament stem cells transplanted into immunodeficient rodents generated a cementum/periodontal ligament-like structure that contributed to periodontal tissue repair. Later work showed that periodontal ligament stem cells differentiation was promoted by Hertwig’s epithelial root sheath cells in vitro [17].
Dental follicle precursor cells (DFPCs)
The dental follicle forms at the cap stage by ectomesenchymal progenitor cells. It contains the developing tooth germ, and progenitors for periodontal ligament cells, cementoblasts, and osteoblasts. Dental follicle precursor cells were first isolated from the dental follicle of human third molars.
Induced pluripotent stem cells and dental pulp pluripotent stem cells (iPSCs)
Recent reports have described successful attempts to develop pluripotent stem cells from pulps recovered from deciduous teeth and third molar [18].
Constructs and scaffolds
The purpose of a scaffold is to provide a physiochemical and biological three-dimensional microenvironment for cell growth and differentiation, promoting cell adhesion, and migration. Scaffold should be effective for transport of nutrients, oxygen and waste, should be biocompatible, nontoxic, and have proper physical and mechanical strength [19].
Scaffolds can be classified into:
  1. Casted (fairly rigid and custom made for specific purposes)
  2. Injectable (low viscosity gels that can be delivered and molded at the site that requires tissue regeneration) [20]
They can also be classified as:
  1. Biological /Natural
  2. Artificial / Synthetic
Physical properties of tissue engineering scaffolds and common types of scaffolds for dental regeneration are given in Table 1 and Table 2 respectively.
Scaffold Type Average Dimensions Hydration Capacity Pores/Linear Inch Average Pore Size Weight/Wet Weight
Polymer 5×4 mm 0.039 cm3 30 ml 120-/+20 100-200 mm 5.2 mg/32 mg
Collagen 4.5×4.2 mm 0.039 cm3 25 ml 120-/+20 100-200 mm 3.5 mg/45 mg
Calcium Phosphate 5×3 mm 0.058cm3 30 ml 60-/+10 200-400 mm 45 mg/ 99 mg
Table 1: Physical Properties Of 3-dimensional tissue engineering scaffolds.
Scaffold Type Properties Advantages Limitations
Hydrogel A colloid jelly-like scaffold Self-assembling peptides often mixed with hydrogel Injectable, biocompatible and  absorbed by body Low stem cell survival, lacks functional strength, variable outcomes
Collagen Polymer Calcium Phosphate Silk Fibrin Sponge Brittle Fibers Centrifuged from peripheral blood Easy to handle, clinically effective absorbed by body Easily made scaffold from host peripheral blood Lacks functional strength to support tissues or muscle movement
Bone Sourced from donor and freeze-dried into a powder Bone grafts are clinically very effective Expensive and requires a donor, risk of contamination
Synthetic bone Bone defect filling material Clinically effective and safe Not as effective as natural bone
Skin Sourced from a cadaver or host Clinically effective Need cadavers or donor skin, risk of contamination
Synthetic skin Wound dressing material Clinically useful and safe Temporary fix, patient will still need skin grafts
Table 2: Common types of scaffolds for dental regeneration.
The development of self-assembling peptides in the past decade has provided a new class of tissue engineering scaffolds, which have good biocompatibility, excellent handling properties, and strong potential as a carrier material for anti-inflammatory and bioactive molecules. For example, multidomain peptides are synthetic peptides that self-assemble into multisubunit nanofibers [21].
Figure 3: Multidomain peptide.
A commercially available self-assembling injectable hydrogel, that is, Puramatrix (BD Biosciences, Franklin Lakes, NJ) presents favorable viscosity for use as an injectable scaffold. When mixed with a sucrose-based solution and/or cell culture medium, it triggers fast self-assembling, leading to its gelification and generation of a tridimensional environment that provides cell adhesion and enables cell proliferation.
Figure 4: Puramatrix.
Morphogenic Factors In Pulp Regeneration
Some common morphogenic factors and their function in dental development, regeneration, and tissue engineering are given in Table 3.
Signaling Molecules Target cells Primary effects Interactions
PDGF Dental pulp cells Cell proliferation Dentin matrix synthesis Odontoblastic differentiation Dentinogenesis Combined with IGF-1 or dexamethasone, increased cell proliferation Combined with PDGF, increased cell proliferation
TGF β1 Dental pulp cells   Dental pulp stem cells Cell proliferation Extracellular matrix synthesis Odontoblastic differentiation Dentinogenesis Chemotaxis   Combined with FGF2, increased odontoblastic differentiation
BMP 2 Dental pulp cells Odontoblastic differentiation Dentinogenesis  
BMP 4 Dental pulp cells Odontoblastic differentiation Dentinogenesis  
BMP 7 (OP-1) Dental pulp cells Dentinogenesis  
BMP 11 (GDF 11) Dental pulp stem cells Odontoblastic differentiation Dentinogenesis  
VEGF Dental pulp stem cells Odontoblastic differentiation Cell proliferation Under osteogenic conditions, increased osteogenic differentiation
FGF 2 (bFGF) Dental pulp stem cells Dental pulp cells Chemotaxis Cell proliferation Cell proliferation Dentinogenesis Combined with  TGFβ 1, increased odontoblastic differentiation
IGF Dental pulp cells Cell proliferation Odontoblastic differentiation Combined with PDGF, increased cell proliferation
NGF Dental papilla cells Odontoblastic differentiation  
Cytokine
SDF-1 Dental pulp cells Chemotaxis Cell proliferation  
Table 3: Morphological factors.
Clinical considerations for regenerative endodontic procedures
Two case reports can be credited with sparking recent interest in regenerative endodontics. The first, which was by Iwaya., et al.[22] showed that sodium hypochlorite and hydrogen peroxide disinfection of necrotic tissue in an immature premolar followed by canal medication with metronidazole and ciprofloxacin resulted in continued root formation and clinical evidence of renervation. The second, by Banchs and Trope [23] showed a similar outcome of continued root development and renervation after canal disinfection with sodium hypochlorite and chlorhexidine and the placement of triple antibiotic paste (TAP; i.e., ciprofloxacin, metronidazole, and minocycline). Both of these case reports supported 3 important principles of regenerative endodontic procedures:
  1. Bacterial elimination from the canal system.
  2. Scaffold creation for the in growth of new tissue.
  3. Creation of a bacteria-tight seal to prevent reinfection.
Following the case reports in the early 2000’s, [23,24] there have been several case studies showing the successful regeneration of tissue in the necrotic canal space of permanent teeth with immature apices. A summary of these case studies is shown in Table 4.
Figure 4a:
Figure 4b:
Figure 4c:
Figure 4d:
Regenerative Endodontics: Regeneration or Repair
Regenerative endodontics should be considered as 2 entities. One is dentin-pulp complex regeneration which relates to preservation of pulp vitality and pulp capping. The second is dental pulp regeneration that relates to regeneration of a vital tissue into an empty but infected root canal space.
Remodeling of dentin does not occur. Histologically, tertiary dentin can appear to be similar to secondary dentin; however, it is never truly the same and does not form a continuum with preexisting dentin. The method currently used to determine the origin of the tissue secreted by the processes of repair/regeneration is generally based on cellular markers (usually proteins). Whereas the synthesis of dentin-like tissue by odontoblast-like cells can be considered as a regenerative process, an ectopic biomineralization process would be considered more as a reparative one. The in vitro and in vivo experiments are usually aimed at investigating a reparative process rather than a true process of regeneration (progenitor migration/recruitment/differentiation). The histologic analysis of teeth treated by simple revascularization [24] or by filling with platelet-rich plasma [25] shows that a mineralized layer was deposited on the radicular walls. This newly formed tissue appeared to be of periodontal origin rather than pulpal origin implying that the progenitor cells migrating from the apical papilla or from the surrounding periradicular tissues would have differentiated into cells of periodontal origin. Radiographic analysis of these cases may have been deceptive and may have led us to think that the mineralized tissue was dentin. Current considerations for regenerative endodontic procedures are summarized in Table 5.
Figure 5: Current Considerations for Regenerative Endodontic Procedures.
Various outcomes of regenerative procedures are summarized in Table 6.
Figure 6: Outcomes of Regenerative Endodontic Procedures.
Drawbacks and Unfavorable Outcomes
Discoloration: Discoloration of the tooth after regenerative endodontic treatments is a problem mostly related to the use of minocycline in the triple antibiotic paste. The main reason for tooth discoloration after treatment was the contact of minocycline in the triple antibiotic paste with coronal dentinal walls during treatment procedure. A recent study suggested sealing dentinal walls of the access cavity by using dentin bonding agent and composite resin before placement of triple antibiotic paste inside the canal.
Treatment Period: The required time for disinfection of the root canal space with triple antibiotic paste or calcium hydroxide and increased number of clinical sessions (compared with one-visit mineral trioxide aggregate apical barrier technique) are other drawbacks of regenerative endodontic treatment.
Challenging Histologic Outcomes of Animal Studies: Histologic and immmunohistologic studies have been performed on the outcome of regenerative endodontic treatments in dogs’ teeth [26]. Thibodeau., et al. demonstrated histologic evidence of hard-tissue deposition on the root canal walls (43.9%), apical closure (54.9%), and formation of vital tissue in root canal space (29.3%) in a dog model. Histologic findings of animal studies showed that the tissue formed inside the canal was not pulp. However, the histologic outcomes of treatment of necrotic immature teeth might differ in humans from that of dogs’ teeth.
Poor Root Development: Ideal regenerative procedure should result in increased root length, increased root wall thickness, and formation of the root apex. In some studies, the outcome of regenerative endodontic treatments of necrotic immature teeth was lower than ideal, including absence of increase in root length, absence of increase in root wall thickness [27], or lack of formation of tooth apex. To test the overall benefit of pulp regeneration, outcome criteria need to go beyond the mere radiographic demonstration of hard tissue deposition.
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Copyright: © 2016 Lisha Thakur., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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