Pulp Healing
Pulp Healing
Pulp Healing
Endodontic Topics 2012, 26, 41–56 2013 © John Wiley & Sons A/S
All rights reserved ENDODONTIC TOPICS
1601-1538
Dentistry has not escaped the exciting new therapeutic advances of regenerative medicine. The accumulating
knowledge about dental stem cells, differentiation, and the signaling cascades of tooth development and
morphogenesis has enabled the implementation of dental biomimetics. This domain offers novel approaches to
oral restoration, such as whole tooth organ bioengineering and targeted regeneration of specific dental and
periodontal tissues, including bone, as recently achieved in rodent models in several laboratories. These
procedures have resulted in successful growth of a tooth and its periodontium with appropriate functional
properties, including vascularisation, innervation and responses to biomechanical forces (1). However, the length
of time required to perform tooth bioengineering has hampered the application of these procedures to the clinical
setting. Nevertheless, there are several strategies that can be used to regenerate specific parts of the dental-bone
complex which have been destroyed by oral disease.
Recent advances in biotechnology have opened rates similar to those of primary dentin formation.
opportunities for development of applications in the This reactionary dentin is usually only secreted focally
maintenance of pulp vitality, reactionary dentinogen- at sites of injury and therefore shows only limited
esis, and revascularisation of the infected canal. distribution.
The present chapter provides an overview of the It is probable that the processes involved in pulp
management of pulp repair and regeneration as repair (reactionary and reparative dentinogenesis)
accessible and preferred alternatives to classical end- recapitulate those of physiological dentinogenesis,
odontics in which the whole pulp is removed and although regulation of odontoblast secretory
replaced by inert materials. behaviour may differ in tertiary dentinogenesis (2,3).
Traditionally, after completion of root formation,
secondary dentinogenesis is regarded as proceeding at
From generation to regeneration
a much slower rate than primary dentinogenesis,
Odontoblasts are actively secreting cells during gradually reducing the size of the pulp chamber and
primary dentinogenesis but become largely quiescent root canal system over many years. When obliteration
during secondary dentinogenesis. Under physiological of the pulpal space occurs, it appears that dentinogen-
conditions of normal aging, there is a gradual esis is still very active, implying dysregulation of the
reduction in the size of both the pulp chamber and normal physiological control of odontoblast cells
canal, which explains why the teeth of elderly persons during secondary dentinogenesis.
show diminution of the root canal system compared to The switch from primary to secondary cell behavior
the teeth of younger individuals. Under pathological is still poorly understood. However, the continuity of
conditions, odontoblasts can upregulate their the dentinal tubule strongly indicates that the same
secretion again in response to an injurious challenge, cells are secreting dentin, but at a different rate.
resulting in secretion of tertiary reactionary dentin at Morphological evidence also provides the basis of our
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Simon et al.
understanding of the downregulation of odontoblast internal third of the tubules only (14–17). Dentinal
secretion during secondary dentinogenesis. permeability is an unavoidable factor that must be
Recently published data suggest that there is a considered during therapeutic procedures in dentistry.
change in the gene expression profile of odontoblasts Surgical intervention of teeth will inevitably cause
from primary to secondary dentinogenesis (4), and it some damage to the pulp; the responding defence
is hypothesized that this change may be reversible, processes are numerous and complex and their
as odontoblast secretion is seen to be upregulated interplay is not yet fully understood. Nevertheless,
during reactionary dentinogenesis (5). they are the basis of the healing process, and post-
Pulp capping—the procedure of placing a dedicated surgical pain is sometimes encountered after even
material over exposed pulp to induce the formation of conservative treatment. Therefore, it is necessary to
a barrier of reparative dentin so as to allow the pulp understand the defence processes occurring in the
cells to express their dentinogenic potential—is still a tooth in order to manage post-treatment discomfort
controversial treatment in endodontics. The indication optimally and facilitate the regenerative process.
for and the effectiveness of therapeutics directed Pulpal hydrodynamic theory (18) probably pro-
at maintaining pulp vitality are difficult to establish, vides our best understanding of pulpal pain. On the
and recommendations are often based on rather basis of histological and physiological observations,
limited scientific evidence. Pulp capping is traditionally Brannström in 1963 proposed that dentinal sensitivity
recommended on young teeth only, due to the greater is closely associated with very fast and brief movements
reparative potential of younger pulp tissue, its better of dentinal fluid inside the tubules, which may trigger
blood supply and higher cell density; however, responses within the vascular and neural structures at
retrospective studies show clearly that age of the the pulpal level (18). Since Brannström’s seminal
patient should not be considered a limiting factor in publication, recent findings suggest the possible
decisions on treatment options (6–8). existence of sensory properties for the odontoblast and
its role in sensory transmission of stimuli to the tooth
(19,20).
The dentin-pulp complex
Dentin is a mineralized connective tissue made Three types of dentin
of various types of collagen such as collagen type I
Three types of dentin are commonly described (9):
(the major collagenous constituent), and of non-
collagenous proteins (proteoglycans, glycoproteins, Primary dentin is the earliest secreted tissue and gives
dentin phosphoprotein, and so on), including dentin rise to the overall morphology of the crown and the
sialo-protein (DSP) and dentin phospho-protein root. It “patterns” the tooth organ. The mantle dentin
(DPP), considered as being the most specific to dental is the most external layer of the primary dentin. As the
tissues. Nevertheless, these proteins have also been very first layer secreted as the odontoblast layer it is not
found in other mineralized tissues, such as bone, but at well structured. The thickness of mantel dentin is
significantly lower concentrations than in dentin (9). about 10 mm and the tissue is atubular.
The non-collagenous proteins initiate and control Secondary dentin is the second tissue to be secreted
mineralization of the extracellular matrix (ECM) in the during tooth development. Continuous secretion
area termed the “mineralization front” (10), and then of this tissue is responsible for the progressively
ensure the transformation of predentin into dentin. asymmetrical loss of endodontic volume improperly
Dentin is a permeable tissue that is traversed by called “calcification.” This biological process explains
tubular structures called dentinal tubules, which the differences in canal volume between a young and
contain dentinal fluid and the odontoblast processes. an older tooth. Secondary dentin is physiologically
The extent of these odontoblast processes in the secreted and not pathologic. Histologically, primary
tubules remains controversial, as some authors claim and secondary dentins are identical (21). Only their
that the processes extend from the pulp chamber rate of secretion differs: 4 mm/day for primary dentin
to the enamel dentin junction (EDJ) or cemental and 0.4 mm/day for secondary dentin (22–24). The
dentin junction (CDJ) (11–13) whereas other interface between primary and secondary dentin is
authors suggest that the processes are limited to the sometimes demarcated by a subtle calciotraumatic line.
42
The pulp healing process: from generation to regeneration
43
Simon et al.
44
The pulp healing process: from generation to regeneration
regulated by the IDE. These changes are fundamental regulates Msx1 and Msx2 expression. In turn,
for the regulation of tooth development. transcription factors regulate further growth factor ex-
The main components of the BM are collagen pression; for example, Msx1 up regulates BMP4
IV, fibronectin, laminin (35), nidogen, tenascin, synthesis in the mesenchyme and Msx2 regulates
hyaluronic acid and proteoglycans, including heparan Runx2 and Osteocalcin gene expression during
sulphate (36). odontogenesis (46,47).
Growth factors and transcription factors are thus
central to the cascade of molecular and cellular events
Growth factors
during tooth development and are responsible for
Various growth factors and their receptors have been many of the temporo-spatial morphological changes
shown to be present at the enamel organ–dental observed in the developing tooth germ.
papilla interface by immunohistochemistry and in situ
hybridization during tooth development and have
Other cells of the dental pulp
been implicated in odontoblast differentiation:
• Growth hormone (GH) plays a paracrine and/or The second layer of the pulp is a dense zone of cells
autocrine role in dental development (37). (the “cell-rich layer of Höhl,” separated from the
• Insulin-like growth factor (IGF)-1 and -2 (38– odontoblasts by an acellular layer called the “cell-free
40). zone of Weil”). During tooth development, as
• Transforming growth factor b (TGFb)-1, -2 and mentioned above, the cellular differentiation process
-3 (41,42) and bone morphogenetic protein requires a minimum number of mitoses of the odon-
(BMP)-2 -4 and -6 (43) are necessary for the toblast progenitor cells before they are competent to
proper polarization and differentiation of odonto- differentiate into odontoblasts. The final mitosis has
blasts (40). Notably in adult pulp, TGFb-1 plays important spatial implications because it occurs
an important role in the regulation of the perpendicularly to the dental BM, resulting in two
inflammatory response and tissue regenerative daughter cells: the one adjacent to the BM receives the
processes. inductive signal to differentiate into an odontoblast
The sequestration of these growth factors in the dentin whereas the other cell does not and contributes to the
matrix and their subsequent fossilization during the Höhl layer instead (27). This layer has long been
mineralization process appear to be key to the pulp considered as a potential reservoir of cells, containing
healing process, where their release from the matrix incompletely differentiated cells that could be involved
may be responsible for various signaling events. Their in the healing process for reparative dentinogenesis
precise localization in the dentin (44) and the full (48).
scope of their roles remain to be elucidated. The capillary and nerve plexi that exist between
both layers are significant; only a few nerve fibres
accompany the cytoplasmic extensions into the den-
Transcription factors
tinal tubules and then only for a short distance (49).
A second level of regulation exists during dental Capillaries are closely associated with the odontoblast
development mediated through transcription palisade and provide these cells with the necessary
factors. Notably, Msx1 is expressed in polarized nutrients for their mineralizing/synthetic activities.
preodontoblasts and Msx2 is present in mature odon-
toblasts (40). Msx1 protein and transcripts have been
Dental pulp stem cells
identified in the pulp mesenchyme at early stages of
tooth development and their concentrations decreased The growing interest in stem cells by the scientific
at the bell stage (45). Msx1 sense RNA is mainly community is also a key area in dental research. The
expressed in the dental pulp of the mouse at the 15th description of dental pulp stem cells (DPSC) (50)
day of tooth development. inside the pulp parenchyma demonstrated that the
Expression of these transcription factors is under dental organ provides a “niche” environment for
the control of growth factors, which can ultimately replacement cells. Another population of stem cells has
have broad-ranging effects. Significantly, BMP4 up- also been reported in the pulp of deciduous teeth.
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Simon et al.
These cells, or SHED (stem cells from human the pulpal responses will likely differ. Injury of weak
exfoliated deciduous teeth) (51), are singularly or moderate intensity will often be resolved by a
interesting because they are relatively easy to collect brief inflammatory response followed by reactionary
when the deciduous tooth is shed and replaced by the dentinogenesis. With a more severe injury, odonto-
permanent successor. blast death will occur (e.g. deep caries or severe
More recently, a further group of mesenchymal stem trauma), and as long as inflammation does not become
cells has been reported in the apical papilla of human uncontrolled, differentiation of a new generation of
immature teeth. These pluripotent cells have been odontoblast-like cells may occur, leading to dentin
termed stem cells of apical papilla (SCAP) (52). bridge formation at the sites of exposure: this process
Because they may be bone marrow-derived cells, is termed reparative dentinogenesis (54).
SCAPs have potential for osteogenic and dentinogenic
differentiation. Growth factor receptor genes are
Reactionary versus reparative dentinogenesis:
similar on SCAPs and DPSCs. SCAPs also express
two different pathways
neurogenic factors such as nestin and neurofilament M
when stimulated with neurogenic medium (53). Reactionary and reparative dentinogenesis are two
The presence of stem cells in the dental pulp offers very different pathways for pulp repair. The
exciting possibilities for their exploitation in description above of the two types of tertiary dentino-
regenerative medicine both for dental and other genesis highlights the need for different therapeutic
diseases. These cells are easier to collect than are cells strategies for pulp healing depending on which
from bone marrow, which is currently one of the main pathway is involved. Clinically, the choice of
sources of post-natal stem cells. Furthermore, the regenerative endodontic therapeutic approaches will
dental pulp appears to be a promising reservoir of necessarily be based on the extent of pulpal disease
multipotent cells, and as such offers significant and, particularly, on odontoblast survival.
potential for use in various dental and non-dental Translation of biological knowledge into the clinical
biotechnological applications. In the case of setting can be achieved simply by adoption of a more
regenerative dentistry, the presence of a population of biological thought process during treatment planning;
stem/progenitor cells in the dental pulp provides a however, it is not always that easy. For instance, the
local source of cells for generating new “odontoblast- importance of tooth structure on biological events can
like” cells for both natural pulp wound healing or be fairly readily appreciated, such as in the thickness of
regeneration and direct pulp capping after injury to the residual dentin separating a cavity from the pulp,
the tooth. It is still unclear whether these stem cells which can be an important factor in pulp protection.
derive from the dental papilla or migrate to the pulp In deeper cavities, where the thickness of the
through the vasculature. An important focus of future cavity floor is less than 0.5 mm, the number and
studies will be to characterize more precisely these the length of the “opened” tubules is such that the
stem cells and their potential so as to enable their most communication with the pulp is possibly comparable
effective application in new regenerative therapies. to that of an actual cavity exposure (56). Also,
The discovery of stem cells in the dental pulp clinically it can be very difficult, if not impossible, to
represents a significant advancement for dentistry. know both the inflammatory status of the pulp as well
Although many questions remain unanswered, the as the cytological state of the odontoblasts because
identification of “post-natal” stem cells in the tooth pulpal histology does not necessarily correlate well
provides a new platform for development of exciting with clinical presentation; this makes it very difficult to
biological approaches for vital pulp therapy. design an effective treatment plan in such situations,
and there is an urgent need for more reliable means of
diagnosis of the activity of carious lesions and the level
Pulpal responses to injury
of pulpal inflammation. Whereas thermal or electrical
During injury to the tooth (caries, trauma, or wear), a tests provide information on the innervation of the
cascade of pulpal responses is initiated. Depending on pulp, there is a need for tests which evaluate the
the nature of the injury (whether it is brief or vasculature and, in particular, the effects thereon of
prolonged, or of low or high intensity), the scope of any inflammation that may be present. Unfortunately,
46
The pulp healing process: from generation to regeneration
the hard tissue shell enclosing the pulp constrains use necrosis factor (TNF)-alpha stimulates differentiation
of techniques such as Laser Doppler scanning or of dental pulp cells towards an odontoblastic
scintography, which provide valuable information in phenotype via p38 phosphorylation of the MAP kinase
other medical specialities. pathway (62).
Dentin contains trace amounts of very potent bio-
active molecules, including cytokines and growth
Reactionary dentinogenesis
factors, which are sequestrated within the matrix
Although the rate of dentin secretion is clearly reduced during the mineralization process and become
in the adult, the metabolic activity of the odontoblasts essentially fossilized therein. During the decay process,
can be upregulated in response to injury. Following demineralization of the tissue is accompanied by the
injury, odontoblasts are released from their quiescent release of these molecules (63). In this pool of
state and their secretory activity is subsequently up- substances, many growth factors can be found,
regulated, resulting in deposition of reactionary dentin especially those of the TGF-b family (39,44). These
(Fig. 3). Because the same cells are responsible for growth factors are extremely potent and have a variety
secretion, it can be postulated that the molecular of cell signaling properties which enable them to act at
control processes that cause downregulation of odon- very low concentrations. Once liberated, these factors
toblast activity during the change from primary to traverse the tubules to the pulp and induce various
secondary dentinogenesis may be reversed to stimulate cellular responses, including activation of the odonto-
the odontoblasts again during tertiary dentinogenesis. blasts (Fig. 4) (64). The members of the TGFb family
It is important to consider the nature of the signaling present in the dentin may be solubilized by plaque
process between the injurious agent and the odonto- bacterial acids during caries (44,64) or by restorative
blasts. Bacteria and their toxins are key candidates in treatments. These molecules could be responsible for
the direct stimulation of odontoblasts during caries the stimulation of odontoblast activity. The organic
formation (57). Also, lipopolysaccharides and other components secreted in response to injury give
bacterial toxins initiate intra-pulpal inflammatory pro- rise to the dentin matrix termed “reactionary,”
cesses, but other signaling processes may also be corresponding to an increase in matrix secretion by the
critical in the overall balance of pulpal cell responses stimulated odontoblasts.
leading to healing and tissue regeneration (2,58–61).
For example, authors reported recently that tumour
At the molecular level
By comparing the published data on dentin secretion
rates (23,65) and differential gene expression patterns
between primary and secondary odontoblasts (66), it
can be concluded that the functional status of the
odontoblast evolves, and the lower level of deposition
by the cell observed during secondary dentinogenesis
is associated with important changes in its
transcriptome. In future studies, it would be
interesting to compare the gene expression patterns
reported here with those of odontoblasts or
odontoblast-like cells taking part in tertiary dentino-
genesis, in which secretory activity becomes up-
regulated again (3,67).
One of the unique features of the odontoblast is that
it may be re-activated after injury and secrete
reactionary dentin at similar rates to primary dentin.
As similarities have been described between develop-
Fig. 3. The different steps of the two pathways of ment and the healing process (2,3), we secondly
tertiary dentinogenesis according to Smith (55). sought to investigate the variation in protein secretory
47
Simon et al.
Fig. 4. Non-collagenous proteins, including growth factors, are fossilized in the matrix of the dentin during the
physiological process of mineralization. After dissolution of the mineral matrix, these molecules are released and can
reach and reactivate the quiescent odontoblasts through the dentinal tubules. These molecules should play an
important role of signaling pathway during the reactionary dentinogenesis process.
processes concomitant with the switch from early- proteins on p38 protein persisted past the point where
stage to late-stage odontoblasts to examine whether the effect of growth factors alone had culminated. It is
key pathways could be identified which might regulate likely that the response profile elicited by the dentin
the switch from secondary to tertiary dentinogenesis. matrix proteins better mirrors the events occurring in
The MAPK/ERK pathway is a signal transduction carious disease, in which dentin matrix components
pathway that couples intracellular responses to the are released in combination. In view of the fact that
binding of growth factors to cell surface receptors. tissue regeneration is a balance between inflammation
This pathway is complex and includes many signaling and repair (54), the comparatively weaker effect of
mediators. It is also well established that the dentin matrix proteins may serve the biological role of
MAPK signaling pathway is involved in cellular protecting the dental pulp by preventing pulpal
differentiation. inflammation.
Notably, the role of TGF-b1 is well established Bacterial contamination of the pulp is usually
in odontoblast differentiation during primary described as the most important factor in pulp disease.
development and in tertiary dentinogenesis (3,68– In our experiments, when cells were stimulated with
70), and, significantly, recent publications indicate Streptococcus mutans, only half of the activated p38
that TGF-b1 may regulate the MAPK pathway (71, protein was translocated. Based on this observation,
72). we hypothesise that bacteria might stimulate the
Stimulation of odontoblast-like cells by several cytoplasmic pathway better, whereas growth factors
growth factors, as an in vitro model of tertiary might directly induce transcription. It should be
dentinogenesis, or with Streptococcus mutans, as an noted that bacteria alone were not able to induce
in vitro model of caries, caused an increase in p38 odontoblast activation, but that they produce a
phosphorylation and its nuclear translocation (5). synergistic effect when combined with growth factors.
TNF-a, adrenomedullin (ADM), and TGF-b1 It is thus critical when evaluating the healing and toxic
produced similar patterns of p38 activation, whereas effects of various agents, that they be tested both alone
isolated dentin matrix proteins appeared to induce a and in combination. Further study is needed to
different pattern. The cocktail of growth factors in the determine the effect of a range of concentrations
preparation of isolated dentin matrix proteins of dentin matrix proteins and other agents on odon-
appeared to have a weaker, but a more enduring effect toblast activation to allow the development of a more
on cells than did the growth factors or bacterial accurate and reliable in vitro model of the carious
stimulants alone. The effect of these dentin matrix disease process.
48
The pulp healing process: from generation to regeneration
Understanding cellular behaviour in response to Currently, a lack of trust in pulp capping frequently
carious disease may allow the development of new motivates many practitioners to remove the pulp
approaches in regenerative dentistry that utilise of the tooth rather than attempt to maintain its
biological and pharmacological control of cell viability.
behaviour, much as p38 phosphorylation is currently
exploited as a target of anti-inflammatory drugs.
Pulp capping
Better understanding of the regulation of the p38
pathway during tertiary dentinogenesis might also Many factors intervene in the prognosis of a pulp
allow the development of new therapies, in particular capping treatment (74,75); lack of inflammation,
for novel pharmaceuticals which facilitate bonding infection control, and biocompatibility of the material
systems to better control the healing process and used are reported to be the key factors for improving
enhance the secretory activity of odontoblasts. the clinical outcome (76,77).
The role of the MAPK pathway therefore warrants As it has also been established that an inflammatory
further investigation to try to better understand its response occurs in pulp tissue as soon as a caries
role during the odontoblast maturation process reaches the dentin (even at a superficial layer), it
and its possible involvement in the reactivation of appears that treatment of non-inflamed dental pulp
odontoblast secretory activity during tertiary dentino- would be an unlikely event, except after pulp exposure
genesis. Characterization of such key pathways due to trauma. Pulp exposure often occurs after
involved in odontoblast secretion may provide exciting trauma, and as the pulp is generally free of
targets for development of novel regenerative inflammation, pulp capping in such situations
therapies. Finally, a growing body of information represents a good approach for treatment. However, it
suggesting similarities between pulp cells and bone is important to consider management of such cases in
cells may help us to better understand the physiology the context of the biological behaviour of the pulp,
and pathology of the mineralized tissues of the body especially in immature teeth which are still developing.
and allow more insightful comparison of data derived The ultimate goal of pulp capping with a dedicated
from bone and dental studies. material is to induce the formation of a barrier of
reparative dentin between the pulp and the material
of obturation, by allowing the pulp cells to express
Reparative dentinogenesis and
their dentinogenic potential (78). In 1965, Kakehashi
pulp capping
demonstrated the systematic formation of a dentin
Odontoblasts are the only cells that secrete dentin. bridge after pulp exposure in laboratory “germ-free”
However, if they become damaged, formation of a animals (79). His study highlighted that the ability of
dentin bridge at sites of pulpal exposure is still the pulp to heal depends on its environment, and can
possible, provided that new odontoblast-like cells are occur in the absence of bacterial infection (80).
“available” in the area. Conventionally, wound healing Over the years, many materials have been used for
involves cell migration from the edge of the injury, and pulp capping, with calcium hydroxide having long
through cell division the superficial cells advance to the been considered the gold standard. Indeed, a search of
centre of the injury, regenerating and repairing the PubMed (search keywords: calcium hydroxide and pulp
tissue and allowing its reorganisation. capping) currently reveals more than 650 references
Following pulp exposure, and after placement of an (July 2009). Characterized by a very basic pH (81),
appropriate material, a dentin bridge is formed in a few calcium hydroxide no longer seems to be the ideal
weeks by new odontoblast-like cells. The origin of material for the following reasons:
these secreting cells has not been firmly established. • The induced dentin bridge is inconsistent and
Several authors assert that the reparative processes are porous (82).
likely to be the same as those involved in tooth devel- • Calcium hydroxide does not adhere to the dentinal
opment (3,73). Nevertheless, the true origin of the walls.
progenitors is still unclear, and a possible migration • The sealing ability of calcium hydroxide is quite
origin from outside the tooth via the vasculature poor.
cannot be excluded. • The material has poor antibacterial properties.
49
Simon et al.
Because of its high basicity, calcium hydroxide in The healing process in connective tissues is always
direct contact with the pulp locally destroys a layer of characterized by these successive steps. Failure to
pulp tissue, and thus creates an uncontrolled necrotic resolve the inflammatory process leads to chronic
zone; this necrotic layer induces an inflammatory inflammation, and eventually to pulp necrosis. Pulp
reaction which persists in time, or leads to formation tissue adjacent to an exposure is characterized by the
of intra-pulpal calcifications (83). presence of necrotic debris, of blood clot formation,
Currently, there is considerable research focus and of a cellular response involving significant
directed towards identification of other materials able infiltration of neutrophils. Yamamura characterized
to induce the formation of a well-formed dentin the chronology of the healing process in the dog
bridge (84); however, thus far, results remain after pulp capping with calcium hydroxide (96) as
inconsistent. Other approaches, including protection follows: exudative phase (3 to 5 days), proliferative
of the pulp with a hybrid layer of new adhesive phase (3 to 7 days), formation of osteodentin (5 to
systems, have also been studied (85). 14 days), formation of tubular dentin (14 days and
The introduction of mineral trioxide aggregate more). After 3 to 6 days, the inflammatory layer is
(MTA) (86–88) has perhaps challenged the position replaced by granulation tissue. This tissue is arranged
of calcium hydroxide as the gold standard pulp along the wound and contains many fibroblasts and
capping material. Although our understanding of its newly formed blood capillaries (48). New ECM and
composition and biological effects is limited, recent nodules of mineralization are seen during healing
data suggest a better quality of the dentin bridge (97). The first mineral deposits are found in matrix
compared to that obtained with calcium hydroxide vesicles, indicating significant similarities between
(89). Moreover, cells in direct contact with the reparative dentinogenesis and the formation of
dentin bridge express protein markers of odonto- mantle dentin (98). At 11 days, the newly formed
blasts (90). In a recent randomised prospective study matrix surrounds cuboidal cells, and a few cells
on human teeth, Nair et al. concluded that, clinically, exhibit the first features of odontoblast differentia-
MTA is more appropriate than calcium hydroxide tion (99). At 14 days, cells are reorganised in a
and should be considered as the new gold standard palisade of cells similar to that seen in primary or
(89). secondary dentin (99). At 1 month, the dentin
Several in vivo studies have shown that MTA induces bridge and a necrotic layer associated with an
the creation of a dentin bridge of good quality, with an inflammatory response in the adjacent pulp tissue can
effective hermetic seal, which can merge with the den- be seen (48). At the ultrastructural level, “tunnel
tinal walls at the edge of the defect (90). The superior defects” are clearly visible in the dentin bridges of
quality of the dentin bridge obtained with MTA versus 89% of the cases studied (82).
calcium hydroxide has been recently demonstrated in a Reparative dentinogenesis is a complex process
randomised clinical trial (89). comprising a cascade of biological processes.
In spite of the lack of published information from Interactions of pulpal cells with growth factors, cyto-
the manufacturer on the composition of MTA, recent kines, and other molecular mediators during the
data suggest that Portland cement resembles the active healing process are at the origin of each of the three
ingredient of this material and exhibits similar steps of the reparative process:
properties (91–95). (i) recruitment of progenitor cells;
(ii) cellular differentiation; and
(iii) upregulation of cell synthetic and secretory
Pulp capping and pulp repair
activity.
In most injury situations, pulp exposure is inevitably
associated with an inflammatory response, and the
Progenitor cells of the “second generation”
following steps ensue (54):
odontoblasts
• hemostasis and formation of a blood clot;
• inflammatory response; Reparative dentinogenesis during pulp healing
• cell proliferation and/or recruitment; and requires progenitor cell recruitment and differentia-
• tissue remodeling. tion of these cells into odontoblast-like cells. The
50
The pulp healing process: from generation to regeneration
newly formed odontoblast-like cells result from the Pulp healing and growth factors
proliferation and differentiation of a population of
During dentin degradation in carious injury several
stem/progenitor cells, probably residing within dental
cytokines, including growth factors, are released
pulp (100). Fitzgerald et al. (101) studied the
from the dentin and likely also from the pulp ECM
migration and proliferation of cells in the pulp after
(55,60,112,113). These cytokines play a key role
capping with calcium hydroxide in the monkey. They
in the regulation of progenitor cell recruitment,
stressed that the migration of cells occurred from the
cell proliferation and differentiation of new dentin
central pulp tissue to the pulp/material interface. They
secreting cells. Members of the TGFb family have
also showed that two DNA replications were necessary
clearly been identified as having roles in dental
before the migration of these cells and their differen-
tissue healing events (39,114–117). The differentia-
tiation occurred.
tion of new odontoblast-like cells has also been
Despite our substantial knowledge of tooth
reported after pulp capping with basic fibroblast
development, our understanding of these stem/
growth factor (bFGF), TGFb1 (118), and BMP-7
progenitor cells is still limited. Pulp cells cultured
(119).
under certain conditions can differentiate into cells
Direct application of growth factors to pulp tissue
with an odontoblast-like phenotype and have the
offers an interesting therapeutic approach; however, it
capacity to form nodules of mineralization in vitro
is important that we first derive a clear understanding
(102), although it is unclear whether all pulp cells or
of the biological and molecular processes involved in
just a sub-population can exhibit this behaviour.
their action before attempting to develop a reliable,
More is known of the multipotent cells of bone
reproducible and efficacious new clinical therapy based
marrow (BMSCs) and their potential to differentiate
on their use (2).
into osteoblasts, chondrocytes, adipocytes, myocytes
It is with this new knowledge and an understanding
and neuronal cells (103–107). In the pulp, the origin
of these processes that new therapeutic strategies can
of replacement odontoblast-like cells has not yet
be developed to promote pulp vitality and healing.
been clearly identified. For a long time, the cell-rich
Contrary to many of the studies reported with
layer of Höhl was regarded as a reservoir of
calcium hydroxide (97,101,120), neither a necrotic
progenitor cells, although several origins for these
layer nor a persistent inflammatory zone is noticed
stem/progenitor cells have now been proposed,
when MTA is used as the pulp capping material.
including a local origin in the pulp mesenchyme and
Continuous bridge formation is generally observed, in
a remote one derived from the bone marrow.
good continuity with the dentin of the walls of the
Pericytes in the pulp have also been proposed as
cavity, and with a discontinuity between the bridge
candidate repair cells, although whether such cells
and the dentinal wall (90,94,121–124).
originate from within the pulp or are transported
there through the vasculature is unclear (108–
Conclusions
110).
Pluripotent cells have been described in the dental Research on pulp regeneration is growing and pro-
pulp (50,111). These cells, called DPSCs (dental vides exciting possibilities for greater biological
pulp stem cells), are able to form dentin-like tissue approaches to endodontics in the future. However,
after ectopic transplantation; they can also differenti- for significant progress to be made in translation to the
ate into fat cells or neuronal cells. These DPSCs are clinic we need a much deeper understanding of
probably progenitor cells and able to undergo the molecular control of odontoblast secretion and
self-renewal. the physiological cues responsible for regulation
To date, involvement of DPSCs in the pulp healing of odontoblast behaviour. Pulpectomy represents
process has not been definitively demonstrated. The a radical treatment for non-necrotic pulp, but
definitive characterization of the origin of the cells pulpotomy or pulp capping are only likely to find
responsible for the healing process in pulp would allow broader use if we can extend our knowledge of pulp
elucidation of their specific behaviour in the repair regenerative processes. Such developments will likely
process, and help to inform the most appropriate bring significant progress to the area of vital pulp
treatment after pulp exposure. therapy.
51
Simon et al.
Differentiation and genetic regulation of cells are also 7. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF.
interesting to investigate during reparative dentino- Pulp capping of carious exposures: treatment outcome
after 5 and 10 years: a retrospective study.
genesis, as differentiation is one step of the complex
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