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Modern dentistry

Article · March 2019

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Giovanna Orsini Pierfrancesco Pagella

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Thimios A Mitsiadis
University of Zurich
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G. Orsinia, b, P. Pagellaa and T.A. Mitsiadisa

aInstitute of Oral Biology, University of Zurich, Switzerland;

ABSTRACT

Traumatic injuries, genetic diseases and external harmful agents such as bacteria and acids often compromise tooth
integrity. There is an unmet medical need to develop alternative, innovative dental treatments that complement traditional
restorative and surgery techniques. Stem cells have transformed the medical field during the last years. The combination of
stem cells with bioactive scaffolds and nanostructured materials turn out to be increasingly beneficial in regenerative dental
medicine. Stem cell-based regenerative approaches for the formation of dental tissues will significantly improve treatments
and will have a major impact in dental practice. To date there is no established and reliable stem cell-based treatment
translated into the dental clinics, however, the advances and improved technological knowledge are promising for successful
dental therapies in the near future. Here, we review some of the contemporary challenges in dental medicine and describe
the benefits and future possibilities of certain novel approaches in the emerging field of regenerative dentistry.

INTRODUCTION

Teeth exert fundamental roles in physiological functions, such as mastication and speech, and are a key feature of facial
aesthetics. Tooth functioning relies on its unique combination of hard and soft tissues. Enamel is the hardest tissue of the
human body with exceptional physical characteristics to withstand masticatory forces and to protect dental tissues from
chemical and bacterial assaults (Figure 1A).1 Ameloblasts synthesize the organic components of enamel, where
hydroxyapatite prisms are formed, but these cells are lost upon tooth eruption, making human teeth incapable of
regenerating enamel. Dentin forms a less mineralized matrix tightly interconnected with the enamel and dental pulp, a richly
vascularized and innervated soft connective tissue that occupies the central portion of teeth (Figure 1A). Dentin is
synthesized by pulp-derived odontoblasts and is characterized by the presence of dentinal tubules that contain the
cytoplasmic extensions of odontoblasts as well as sensory nerve endings, thus making dentin highly sensitive to external
stimuli and permeable to bacteria upon enamel destruction. Upon tooth injury, a newly formed dentin- or bone-like matrix
(i.e., tertiary dentin) protects pulp vitality, but more important damage often leads to pulp necrosis.1 Teeth are anchored to
the alveolar bone by their roots that consist of dentin and cementum. The roots are connected to the bone via the periodontal
ligament, a connective tissue that provides stability to the teeth and absorbs mechanical stresses during mastication.2
Traumatic injuries, infections and genetic diseases, combined with age, often result in tooth loss. It is therefore necessary to
develop innovative approaches for the repair/regeneration of damaged or missing dental and alveolar bone tissues.3
However, the unique characteristics of enamel and dentin make tooth regeneration particularly challenging. Technological
advancements ranging from digitalization to nanotechnology have become an inherent aspect of many medical fields, and
the same applies to dentistry. These progresses aim to offer improved, faster, painless and more effective treatments when
compared to methods traditionally used in dental clinics.

TECHNOLOGICAL INNOVATIONS IN CURRENT DENTAL TREATMENTS

The great improvements in computing-related technologies has helped in establishing new diagnostic tools, more precise
therapeutic plans and alternative dental treatments.4 High definition microscopes combined with novel imaging techniques
such as digital radiography, computer aided design/computer aided manufacture (CAD/CAM) technology, and computer
aided implant surgery contributed to the improvement of the daily dental practice.5
The success of dental treatments aiming to restore damaged or lost dental tissues relies on innovative biomaterials.
Nanotechnology has remarkably improved their performance as well as the clinical outcome of dental treatments. Innovative
3D printing systems are used in prosthetic dentistry to manufacture customized products based on computer-designed digital
tools.6 Modern materials have also upgraded aesthetic dentistry, the field aiming to optimize the aesthetic appearance of
dentition. Similarly, pain management has enormously benefited from the advent of these novel imaging and computing-
based technologies.7 The capacity of stem cells to repair damaged tissues has been also explored in dentistry. Stem cell-
based regenerative approaches are closely linked to advanced tissue engineering products and have created an important
clinical shift toward the functional regeneration of dental tissues.
Stem cells are characterized by their potential to self-replicate and their capacity to differentiate into a vast diversity of cell
populations.3 Epithelial and mesenchymal stem cell populations are present in almost all adult human tissues and organs,
including teeth. A variety of dental mesenchymal stem cells (DMSCs) have been isolated from both deciduous and
permanent teeth, characterized, and tested for their potential applications in regenerative dentistry.3, 8 Adult DMSCs localized

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in the dental pulp and periodontal tissues ensure human tooth homeostasis and regeneration, and therefore represent
optimal clinical tools for the repair of damaged dental tissues. Actual efforts are oriented towards pulp and periodontal tissue
repair, where these tissues can be regenerated by transplantation of stem cells alone or in combination with scaffolds (Figure
1B, C). Biodegradable scaffolds act as temporary niches for transplanted stem cells and can guide them towards a precise
cell type (e.g., osteoblast, odontoblast, chondroblast) that will fulfill the needs of the dental treatment.9 Transplanted stem
cells can be tracked for long periods with modern imaging systems such as Magnetic Resonance Imaging (MRI) and
Computed Tomography (CT), and provide precious information about their role in the repair of dental tissues.2 This
knowledge will allow evaluating the therapeutic efficacy of specific dental stem cell populations and consolidate their
accuracy in dental treatments.
The regeneration of tooth enamel using epithelial cells is more challenging, since neither dental epithelial stem cells (DESCs)
nor ameloblasts are present in the crown of adult functional teeth.3 Finally, more exciting is the perspective to generate entire
brand-new teeth by mixing DESCs and DMSCs. Although very challenging and ambitious, several attempts towards this
direction have been pursued in animal models.2
Almost all dental disciplines can benefit from the recent advances of stem cell biology and material sciences. The present
review covers current and future therapeutic approaches for managing the (1) injury of the tooth crown, including harm to
enamel and dentin-pulp tissues, (2) damage of the periodontium, and (3) replacement of lost or missing teeth.

DENTAL RESTORATIVE TREATMENTS

Enamel and dentin of the tooth crown are most often the first tissues to be affected following traumatic injuries or carious
lesions. Prompt and efficient repair of enamel and dentin is fundamental to prevent bacterial propagation towards the vital
dental soft tissues of the pulp and periodontium, as well as the alveolar bone. The most used approach for treating injured
enamel and dentin is their substitution and tooth restoration by advanced composite materials. Traditional adhesive systems
are unstable and fail over time, leading to marginal leakage and poor retention of the restoration in the tooth.10 Innovative
adhesive materials with improved enamel- and/or dentin-bonding performance increased the longevity of the restorations,
thus preventing repeated dental treatments. The incorporation of nanostructures in dental composites enhanced their
stability and aesthetic properties, as well as reduced the degradation of the resin-tooth bonded interface.11 These new
materials could also control the propagation of oral bacteria as well as the formation of dental plaque. Furthermore,
hydroxyapatite particles are used in dentifrices to stimulate the re-mineralization process of hypersensitive teeth with
deteriorated enamel.12
Tooth crowns using ceramic-based materials display superior aesthetic appearance and biocompatibility and therefore are
privileged by dentists for the restoration of damaged teeth.13 However, ceramic-based crowns are brittle and prone to cracks
but recent technological advances permitted the development of higher aging resistant-ceramics such as zirconia that exhibit
exceptional toughness and flexibility.13
The ideal alternative solution to overcome all problems related to the use of dental materials would be the de novo formation
of natural enamel, one of the greatest challenges in dental medicine. The recent advances in stem cell-based technology
generated great enthusiasm and hopes. Efforts to isolate DESCs from periodontal tissues of adult human teeth were
successful and increased the expectations for enamel regeneration. Several studies using animal models have shown that
these cells can form enamel after their transplantation in vivo.14 However, DESCs are not abundant in human teeth and
therefore could not be routinely used in clinics for restorative purposes. Therefore, it is necessary to identify other human
epithelial stem cell populations of non-dental origin that would be able to generate enamel. Another problem linked to the
formation of enamel by DESCs is that this process requires several years in humans, a time frame clearly incompatible with
clinical needs.15 Procedures allowing the considerably acceleration of this process would be beneficial to both dental
practitioners and patients.
The preservation of the dental pulp vitality is of prime importance during the treatment of damaged teeth. However, severe
tooth injuries often lead to pulp inflammation and necrosis, and therefore the endodontic therapy that consists of pulp tissue
removal is imposed in order to prevent further bacterial progression and tissue damage. This is followed by disinfection of the
dental root canals and the replacement of the pulp tissue with inorganic materials.2 Devitalized teeth are more fragile than
physiological intact teeth and are consequently predisposed to postoperative fractures.2 To overcome this, new endodontic
treatments intent to regenerate physiological pulp tissues using a combination of biomaterials, antibacterial and anti-
inflammatory molecules, growth factors and stem cells.16 Scaffolds containing human DMSCs have been used to achieve
regeneration of the entire dental pulp tissue (Figure 2B). Human DMSCs transplanted into empty tooth root canals
immediately after pulp removal were able to regenerate vascularized dental pulps and to form dentin.8, 17 Dentin production is
accelerated and enhanced by bone morphogenetic proteins (BMPs), which are growth factors commonly used in dental
practice.18 However, most of these approaches led to the formation of pulp fibrotic tissue that can undergo degeneration over
time or be replaced with bone. This could be overcome with the transplantation of scaffolds composed by decellularized
human dental pulps.19 However, by the exception of hydroxyapatite-based injectable gels, most of these proposed materials
have not received the approval from the Food and Drug Administration (FDA).20 Recent regenerative endodontic procedures
involve the formation of blood clots within the root canals. These clots act as natural scaffolds hosting DMSCs that will
contribute to dental pulp repair.2 While significant efforts with promising results have been produced so far, substantial
improvements are still needed for proper pulp regeneration.2, 16

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THERAPIES FOR PERIODONTAL REPAIR

Periodontal pathologies strongly affect tooth functionality and overall oral health. Severe periodontal inflammation leads to
significant alterations in both the structure and quantity of the alveolar bone and periodontal ligament that could ultimately
cause tooth loss.21 Contemporary periodontal therapies include a wide range of surgical procedures along with the use of
natural or synthetic bone grafts, barrier membranes and growth factors.21, 22 Application of these products in clinics allowed
the formation of novel osseous tissues with characteristics similar to those of pre-existent native bone.22 Nonetheless, these
approaches do not always ensure a predictable and desirable outcome of periodontal regeneration and often result in
healing with epithelial lining rather than new periodontal tissue formation.22
A fundamental goal in dentistry is to recreate a healthy, functional periodontium in the damaged tooth root area (Figure 2B).
Transplantation of DMSCs from the periodontal space of human teeth improved periodontal healing.23 In addition, diverse
scaffolds, growth factors (e.g., platelet-derived growth factors, BMPs) and dentin matrix molecules have been used for
improving the regenerative efficacy of DMSCs in the periodontium.24 However, a frequent side effect following the use of
BMPs is excessive bone formation that results in tooth ankylosis. Advanced bone grafting materials containing platelet-rich
plasma and enamel matrix derivatives further improved the clinical performances aiming at periodontal tissue regeneration.25,
26

TOOTH REPLACEMENT

The use of dental implants has become a common and successful treatment for replacing missing teeth.27 A typical dental
implant is composed of a metal screw part, which interfaces and integrates within the alveolar bone, and another part where
a tooth crown substitute is placed. Despite their large and regular usage in dental clinics, implants still need significant
improvements, particularly in their capacity to stimulate bone formation and promote angiogenesis at the implantation site.28
The integration of dental implants to the alveolar bone as well as their longevity have been considerably improved by
modifying their surface using various coating materials (e.g., gold nanoparticles) that allow a faster healing and adhesion.28
However, there is a major risk of infection of tissues surrounding the implant, a pathology termed peri-implantitis.29
Incorporation of antibacterial agents to titanium dental implants, such as silver nanoparticles, can limit bacterial growth, thus
avoiding infection, improving implant performances and increasing the success of treatment.28 To date, only few randomized
preclinical and clinical trials have been performed for guided bone regeneration around implants using growth factors and
protein delivery systems.30 Therefore, the realization of larger clinical trials is absolutely necessary for validating the
efficiency of all these novel materials and techniques.
Regeneration of entire brand-new teeth for the replacement of missing or lost teeth is the most ambitious goal in dentistry.15,
31 Two main strategies have been elaborated for the formation of new teeth.15, 32 One approach consists in forming tooth

germs by recombining DESCs and DMSCs that will be subsequently transplanted into the alveolar bone. It is expected that
these teeth will further develop and erupt into the oral cavity. Another approach relies on tooth-shaped biodegradable
scaffolds filled with both DESCs and DMSCs and implanted into the alveolar bone, assuming that they will finally form
functional teeth.32 Experiments in mice have shown that these approaches can be successful since they allowed the
generation of functional teeth.15, 33 Similar results have not yet been obtained in humans, due mainly to the limited number of
adult human DESCs. This problem could be resolved by using the inducible pluripotent stem cells (iPSCs) technology for the
generation of enamel.2, 34 Although promising, these approaches need further investigation, as effective protocols for the use
of iPSCs in clinics are not available yet.

NOVEL TECHNOLOGICAL PLATFORMS IN DENTISTRY

Translation of preclinical results into effective cell-based therapies remains poor, highlighting the need for accurate human-
emulation systems.35 Recently, 3D in vitro systems, termed organoids or spheres, that contain an important number of stem
cells and allow the recreation of similar to the in vivo conditions, have been successfully generated from both dental epithelial
and mesenchymal tissues. These 3D structures might be valuable sources of DMSCs and DESCs for dental regenerative
purposes.36 Furthermore, they represent tools for studying the effects of novel pharmaceutical products and materials to
dental tissues before their clinical use.
Miniaturized “organ-on-chip” devices are based on recent technological advancements in microfluidics. These devices
successfully emulate human pathophysiological conditions of specific tissues and organs in vitro.37 Microfluidics have been
used for the first time to analyze the role of innervation in dental tissues and DMSCs.38 These devices might be also
important to understand the interconnection of teeth with other organs and study their responses to the various dental
pathologies.37
Graphene-based sensors, temporary printed at the surface of enamel, permitted the detection of tooth-specific oral bacteria
and the evaluation of food properties such as pH, temperature and sugar levels.39, 40 These sensors represent excellent tools
for the refined control and understanding of oral environment that will greatly help the field of preventive dentistry.

3
CONCLUSIONS

Technological advances and innovative treatments using stem cells and biomaterials are revolutionizing the field of dentistry.
Although these pioneering stem cell-based therapeutic approaches aim at improving dental care in the near future, they are
not yet applicable in clinics. Computing-related and tissue engineering technologies offer a plethora of exciting perspectives
to dental medicine and might provide new, non-invasive, techniques for the formation of brand new dental tissues. Advanced
biomaterials are pivotal in regulating the activities of stem cells, thus ensuring suitable tooth repair and functionality.

ACKNOWLEDGMENTS

This work was supported by funds from the University of Zurich. We thank Professor Ronald Jung, DDS, PhD, Centre of
Dental Medicine, University of Zurich, for providing photos with treatments involving dental implants.

FIGURES

Figure 1. Dental structures and proposed stem cell-based approaches for dental pulp and periodontal regeneration. A) Histological section
stained with toluidine blue of a human molar tooth. B, C) Schematic representation of proposed strategies using dental mesenchymal stem
cells stem-cells (DMSCs) for the regeneration of the (B) dentin-pulp complex and (C) periodontium.

Figure 2. Dental implants for tooth replacement. A) Dental implants (yellow arrowheads) inserted into the alveolar bone of a patient. B)
Progressive tissue regeneration following insertion of implants. C) Application of ceramic crowns (red arrowheads) onto the inserted dental
implants. Courtesy: Professor Ronald Jung.

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