dentistry journal

Review
Polydeoxyribonucleotides Pre-Clinical Findings in Bone Healing:
A Scoping Review
Mattia Manfredini 1,2 , Pier Paolo Poli 1,2, * , Mario Beretta 1,2 , Matteo Pellegrini 1,2 , Federica Eugenia Salina 1,2
and Carlo Maiorana 1,2

1 Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy;
mattia.manfredini@unimi.it (M.M.); mario.beretta@unimi.it (M.B.); matteo.pellegrini@unimi.it (M.P.);
federicaeugenia.salina@studenti.unimi.it (F.E.S.); carlo.maiorana@unimi.it (C.M.)
2 Implant Center for Edentulism and Jawbone Atrophies, Maxillofacial Surgery and Dental Unit,
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
* Correspondence: pierpaolo.poli@unimi.it

Abstract: Aim: Polydeoxyribonucleotide (PDRN) is a chain-like polymer derived from DNA. Recent
in vitro and animal studies have showcased the beneficial impacts of PDRN on the process of bone
mending, whether used on its own or in conjunction with other substances that aid in regeneration.
This scoping review aims to synthesize the current understanding of how PDRNs influence bone
healing. Materials and Methods: The studies included in the screening procedure were randomized
controlled clinical trials (RCTs), both retrospective and prospective case–control studies, as well
as in vitro and in vivo investigations. Articles were sourced from PubMed (MEDLINE), Scopus,
EMBASE, Web of Science, and Google Scholar electronic databases using the following MeSH
terms: (polydeoxyribonucleotide) and (bone) and (regeneration). Results: Initially, 228 articles
were identified. Following the review process, a total of eight studies were ultimately examined.
Among these, two were confined to laboratory studies, five were conducted on living organisms,
and one encompassed both evaluations on living organisms and in vitro assessments. A descriptive
qualitative approach was employed to present the data extracted from the studies that were included.
Conclusions: PDRN has the potential to enhance the process of bone healing and the quantity of
newly generated bone when combined with grafting materials. Future clinical studies are warranted
Citation: Manfredini, M.; Poli, P.P.;
to ascertain the appropriate clinical application of PDRN based on the dosage under consideration.
Beretta, M.; Pellegrini, M.; Salina, F.E.;
Maiorana, C. Polydeoxyribonucleotides
Keywords: biopolymers; bone regeneration; dental implants; dentistry; polydeoxyribonucleotide;
Pre-Clinical Findings in Bone Healing:
A Scoping Review. Dent. J. 2023, 11,
polynucleotides
280. https://doi.org/10.3390/
dj11120280

Academic Editors: Daniele Botticelli

1. Introduction
and Fawad Javed
Polydeoxyribonucleotide or polyideribotide (PDRN) is a linear DNA-derived poly-
Received: 23 August 2023 mer with healing activity used in the treatment of skin and connective tissue lesions
Revised: 10 November 2023 associated with dystrophic and dystrophic-ulcerative diseases. It consists of a mixture
Accepted: 30 November 2023 of purines, pyrimidines, deoxyribonucleotides, and deoxyribonucleosides with different
Published: 4 December 2023
lengths (50–2000 base pairs), and a molecular weight between 50 and 1500 kDa [1].
PDRN is typically sourced from the gonads of salmon trout (Oncorhynchus mykiss)
due to their provision of high-grade DNA without the presence of pharmacologically active
Copyright: © 2023 by the authors.
proteins and peptides, thereby mitigating potential associated adverse effects. [2]. After
Licensee MDPI, Basel, Switzerland. extraction, a purification and sterilization process is performed, achieving >95% purity [3].
This article is an open access article PDRN is available in the pharmaceutical market in the form of vials for parenteral
distributed under the terms and administration, as well as in the form of eye drops and ointment. After administration, it can
conditions of the Creative Commons be detected freely in the plasma, exhibiting a bioavailability within the range of 80–90% [4].
Attribution (CC BY) license (https:// Its concentration peaks around one hour post-administration, and it possesses a half-life
creativecommons.org/licenses/by/ of approximately 3.5 h. Importantly, PDRN does not undergo hepatic metabolization;
4.0/). instead, it is broken down by non-specific plasma or membrane nucleases. Ultimately, the

Dent. J. 2023, 11, 280. https://doi.org/10.3390/dj11120280 https://www.mdpi.com/journal/dentistry

Dent. J. 2023, 11, 280 2 of 21

substance is excreted primarily through urine, with a smaller proportion being eliminated
via feces [4].
Enzymatic breakdown of PDRN produces biologically active byproducts, including
oligo- and mononucleotides, purines, and pyrimidines. These substances interact with
purinergic adenosine A2A receptors (ADORA2A), prompting wound healing by facilitating
cell migration and proliferation, ensuring proper deposition of the extracellular matrix,
stimulating angiogenesis, and reducing inflammation [5]. The administration of dimethyl-
1-propargyl xanthine (DMPX), a selective ADORA2A antagonist, counteracts these effects,
enhancing the safety profile of PDRN compared to other ADORA2A agonists [6]. The
combination of high therapeutic effectiveness, a low likelihood of provoking an immune
response, and a lack of adverse effects, regardless of the method of administration, allows
for the utilization of PDRN in patients with compromised health, such as those with
diabetes [6].
Furthermore, PDRN facilitates DNA synthesis and repair, reinvigorating cellular
proliferation and growth in damaged or oxygen-deprived tissues through the “salvage
pathway”. This metabolic route allows PDRN to supply cells, which are unable to indepen-
dently generate new DNA, with nucleotides sourced from its breakdown [3].
Currently, PDRNs find application in the treatment of conditions affecting bone, carti-
lage, and tendons [7]. Recent studies conducted in vitro and on animals have demonstrated
their beneficial effects on bone healing, particularly in the presence of bone defects, either
when used alone or in combination with other regenerative materials [8,9].
The goal is to enhance bone healing with the aim of reducing biological timeframes for
regeneration, thus providing prosthetic solutions to patients more rapidly while minimizing
the invasiveness of the procedure and reducing the need for autologous bone grafts.
Given the critical need to enhance the process of bone healing in oral and maxillofacial
surgery, it is imperative to explore which compound may provide superior benefits in terms
of the speed of new bone formation, the attachment of bone grafts, and overall post-surgical
recovery, this scoping review aims to examine whether the use of PDRN can improve bone
healing in oral surgery with analysis of in vitro, animal, and clinical studies.

2. Materials and Methods

2.1. Protocol
This scoping review adhered to the guidelines outlined in the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-
ScR) to comprehensively synthesize existing evidence and pinpoint key concepts regarding
the application of PDRNs in bone regeneration (Table S1 Supplementary Materials) [10].
The present protocol has been registered within the Open Science Framework platform
(Registration DOI-10.17605/OSF.IO/MCBZD).
An adapted version of the PICO (Population, Intervention, Comparison, and Outcome)
model was employed to formulate a focused question structured around a PEO (Population,
Exposure, and Outcome) framework. This approach was utilized to assess the relation-
ship between a specific exposure and its resulting outcomes. It was originally designed
for conducting qualitative systematic reviews of healthcare interventions, encompassing
procedures in oral surgery as well [11,12].
The main question was, “Does PDRN improve the ability to regenerate bone in the oral
environment?”. To answer this question, studies reporting on bone regeneration following
PDRNs application were analyzed with the aim to understand the possible impact PDRNs
have on bone healing.
Dent. J. 2023, 11, 280 3 of 21

2.2. Eligibility Criteria

2.2.1. Inclusion Criteria
All sources of evidence had to satisfy specific inclusion criteria to be included. These
criteria encompassed articles written exclusively in English and did not impose any re-
strictions based on publication date. The screening process encompassed randomized
controlled trials (RCTs), as well as retrospective and prospective case–control studies. Both
in vivo and in vitro studies were incorporated in this review.
The primary focus of the investigation in these studies was to assess the bone regener-
ative effects of PDRN, with a particular emphasis on experimental research.

2.2.2. Exclusion Criteria

Any studies that did not meet the specified inclusion criteria were excluded from
the review. This included articles written in languages other than English, case reports,
literature reviews, and studies that primarily focused on the healing of soft tissues following
the application of PDRN.

2.2.3. Search Strategies and Information Source

To perform this review, the PEO model (Population, Exposure, and Outcome) was
used through a literature search of the electronic databases PubMed, Scopus, EMBASE,
Web of Science, and Google Scholar databases.
The PEO model [13] is based on the two elements population (in this case, the review
was not limited to a specific population) and exposure (evidence from in vivo and in vitro
clinical trials related to the potential PDRN employment in bone regeneration).
Specific Medical Subject Headings (MeSH) were employed to search through all elec-
tronic databases to locate pertinent studies in alignment with the exact parameters of
the PEO query. Articles were chosen from electronic databases based on specific MeSH
terms, including polydeoxyribonucleotide, bone, and regeneration. Consequently, a con-
sistent search strategy was applied to screen publications across all electronic databases,
structured as (“polydeoxyribonucleotide” (MeSH)) AND (“bone” (MeSH)) AND (“regener-
ation” (MeSH)).
Further examination of the reference lists of all relevant articles was conducted, but
no additional pertinent studies were discovered. It is important to note that no filters
were applied to each search string during the electronic research process. The years from
1968 to March 2023 were considered in all databases. The last search was performed on
20 August 2023.

2.2.4. Selection of Sources of Evidence

Two independent reviewers (F.E.S. and M.P.) carried out the initial screening of titles
and abstracts for all included articles. Any duplicate entries in the databases were iden-
tified and subsequently eliminated using the EndNote Web reference manager software
(version 20) by Clarivate Analytics, based in Philadelphia, PA, USA. Full-text articles were
then individually assessed, with the results duly recorded, and any similar studies meeting
the inclusion criteria were identified. The two researchers compared their selections, and in
case of any discrepancies, they were brought to the attention of the other four researchers
(M.M., M.B., P.P.P. and C.M.) for resolution.
Dent. J. 2023, 11, 280 4 of 21

2.2.5. Methodological and Reporting Quality Assessment

Since this scoping review aims to map the scientific literature on the role of PDRN in
bone healing by synthesizing all studies published to date, i.e., in vitro and in vivo studies,
in accordance with the PRISMA-ScR guidelines, the quality assessment of the included
studies was not performed.

2.2.6. Analysis of Included Studies

Following the review of the publications, a spreadsheet was generated and subse-
quently updated in a sequential manner. Two separate tables were created, one for in vivo
studies and one for in vitro studies. For the in vitro studies, the collected data were or-
ganized into tables, which provided a structured presentation of the information: the
name of the first author of the article and the year of publication, the type of PDRN used,
the experimental groups investigated, the follow-up period, analyses performed on the
samples, and the results of this analysis. Analyses performed on the samples means the
explanation of how some variables, such as stimulation of osteoblasts by PDRN, were
evaluated and analyzed in the in vitro studies.
As for the in vivo studies, the gathered data were organized into tables, allowing
for a systematic presentation of the information: the name of the first author of the arti-
cle and the year of publication, the animal model, the type of study, the type of PDRN
used, the experimental groups investigated, the follow-up period, complications that oc-
curred during the healing period, analysis of newly formed bone volume, and qualitative
histological analysis.

3. Results
Initially using MeSH terms, 9 articles were identified in PubMed, 19 in Embase, 17 in
SCOPUS, 18 in the Web of Science, and 165 in Google Scholar.
After removing duplicates, 177 articles were left for initial screening. Upon reviewing
titles and abstracts, 166 publications were deemed ineligible and subsequently excluded.
The full texts of the remaining 11 articles were carefully examined. Out of these, three
studies had to be excluded after a thorough review of the full texts, as they did not
meet the inclusion criteria. Specifically, one article [8] was excluded because sodium-
DNA was used instead of PDRN, and the other two articles because they were concerned
with the effectiveness of PDRN in the management of osteonecrosis [2,14]. Finally, eight
studies [1,15–21] were included after the review process.
The selected studies included two in vitro studies [15,18], five in vivo studies [1,16,19–21],
and finally, one study that reported both in vivo and in vitro evaluations [18]. The flowchart
of the review process is shown in Figure 1. All included studies were RCTs except one
animal case series.

Results of Individual Sources of Evidence

A meta-analysis of the selected articles could not be carried out due to the differences
in the type of studies included (in vivo and in vitro) and within the same type of studies, the
difference between the treatments and the commercial formulations of PDRN. A qualitative
descriptive approach was employed to present and summarize the collected data. Data
collection and study outcomes are contained in Table 1 for in vitro studies and Table 2 for
in vivo studies.
Dent. J. 2023, 11, x FOR PEER REVIEW 5 of
Dent. J. 2023, 11, 280 5 of 21

Figure 1. Flowchart of the review process [8].

Figure 1. Flowchart of the review process.

Results of Individual Sources of Evidence

A meta-analysis of the selected articles could not be carried out due to the differenc
in the type of studies included (in vivo and in vitro) and within the same type of studie
the difference between the treatments and the commercial formulations of PDRN.
qualitative descriptive approach was employed to present and summarize the collecte
data. Data collection and study outcomes are contained in Table 1 for in vitro studies an
Table 2 for in vivo studies.
Dent. J. 2023, 11, 280 6 of 21

Table 1. Data collection and outcomes of in vitro studies.

Article Cell Model PDRN Employed Experimental Group Follow-Up Sample Analysis Results
Guizzardi Human osteoblasts PDRN at the PDRN stimulation on PDRN stimulation PDRN stimulation on osteoblast PDRN stimulation on osteoblast
et al., 2003 obtained from jawbone concentration of osteoblasts on osteoblasts - PDRN has no effect in cultures without
- Cell Culturing:
[15] specimens subsequently 100 µg/mL - FBS 1% (CTR) 0, 2, 4, 6 days FBS.
surgical intervention on distributed by Osteoblasts cultured in DMEM medium with
- FBS 5% (CTR) - PDRN at a high FBS concentration (10%)
a 5-year-old patient. Mastelli, Sanremo, ascorbic acid. PDRN’s impact on cell growth
- FBS 10% (CTR) significantly increases osteoblast growth,
The gender of the donor Italy measured by direct counting. Cell growth
- PDRN + FBS 1%, peaking at 6 days with a 21% increase.
is not specified in the assessed in DMEM with varying FBS levels (1%,
- PDRN + FBS 5%
article. 5%, 10%) and ascorbic acid.
- PDRN + FBS 10%
- Test sample:
Cells treated with PDRN (100 µg/mL) in DMEM
medium with various FBS concentrations (1%, 5%,
10%) and 250 µg ascorbic acid for 2, 4, and 6 days.
- Control Sample:
Cells not treated with PDRN.
DMPX Inhibitors effect DMPX Inhibitors DMPX Inhibitors effect DMPX Inhibitors effect
- PDRN (CTR) effect Growth rate during PDRN treatment was On day 6, DMPX-treated cells presented a
- PDRN + DMPX 50 µM 0, 2, 4, 6 days assessed with and without DMPX (an A2 receptor reduction of 42.9% in comparison to the
inhibitor) control samples.
- In the test group, cells were treated with PDRN
+ DMPX for 2, 4, and 6 days
- the control group received only PDRN for the
same duration.

Suramin inhibitors effect Suramin inhibitors Suramin inhibitors effect Suramin inhibitors effect
- PDRN (CTR) effect Growth inhibition during PDRN treatment with The addition of this inhibitor at 10 µM
- PDRN + Suramin 0, 2, 4, 6 days Suramin (a specific P2 inhibitor) was assessed. suramin had no significant effect on PDRN
10 µM - In the test group, cells were treated with PDRN induced cell growth. Higher suramine
- PDRN + Suramin + Suramin at various concentrations concentrations determined a strong
50 µM (10/50/100 µM) for 2, 4, and 6 days. reduction in cell number also in comparison
- PDRN + Suramin - The control group received only PDRN for the to control just after 48 h.
100 µM same duration.
Dent. J. 2023, 11, 280 7 of 21

Table 1. Cont.

Article Cell Model PDRN Employed Experimental Group Follow-Up Sample Analysis Results
ALP ALP ALP ALP
- CTR 0, 2, 4, 6, 8, 10 days An increase in alkaline phosphatase activity The PDRN-treated cells examined on day 6
indicates an increase in cell duplication. present a significantly lower phosphatase
PDRN
- In test group cells were treated for 2, 4, 6, 8 and activity when compared with controls
10 days with PDRN 100 µg/mL in DMEM (p < 0.01). While there was not significant
complete medium plus 10% FBS and ascorbic discrepancy between the two groups on day
acid 250 µg. 10.
- In control sample, cells were not treated with
PDRN, cells growth was evaluated in DMEM
plus FBS 10% and ascorbic acid 250 µg.

Kim et al., hBMSCs PDRN distributed by - PLGA (CTR) Scaffold Characterization Scaffold Characterization
2021 The article does not Goldbio St. Louis, - PME: PLGA (P) WCA was conducted to evaluate the wettability of The PMEP scaffold has more hydrophilic
[17] specify how these cells MO, USA. scaffold was combined the scaffold. property than the PLGA and PME ones.
were obtained. The concentration of with mMH (M) and Biocompatibility of Biocompatibility of the scaffold Biocompatibility of the scaffold
PDRN used was not bECM € the scaffold The biocompatibility of the scaffolds was The population of live cells was getting
reported. - PMED: PLGA (P) 1, 3, and 7 days evaluated since LIVE/DEAD staining [calceinAM increased in the PME and the PMEP than the
scaffold was combined (acetoxymethyl ester) and ethidium homodimer 1 PLGA at 1, 3, and 7 days, respectively.
with MH (M), bECM € (EthD-1)]. The cell viability on the PME and
and the bioactive particularly, the PMEP scaffold was
PDRN (P) remarkably enhanced for 7 days, p < 0.05
and p < 0.001, respectively.
Angiogenesis and Angiogenesis and ant-inflammation properties Angiogenesis and ant-inflammation
ant-inflammation RNA Extraction and Quantitative Real-Time PCR properties
properties (qRT-PCR) were conducted to determine the - The PME scaffold restricted the
7 and 21 days expression of inflammation and expression of inflammatory genes, IL-6 and
angiogenesis-related genes on 3D scaffolds with IL-1β, compared to the PLGA scaffold.
hBMSCs. - The PMEP scaffold statistically significantly
suppressed the abovementioned gene
compared with PME.
- The PME scaffold exhibited a negligible
difference in the expression of
angiogenesis-related gene.
- The PMEP scaffold promoted the highest
angiogenesis-related gene (VEGF and
MMP2) expression on both days. The
expression of these genes was statistically
significant compared with the other groups.
Dent. J. 2023, 11, 280 8 of 21

Table 1. Cont.

Article Cell Model PDRN Employed Experimental Group Follow-Up Sample Analysis Results
Confirm of Confirm of angiogenic ability and wound healing Confirm of angiogenic ability and wound
angiogenic ability The angiogenesis ability was examined by healing
and wound healing tubule-forming assay with HUVECs. This When PDRN-treated, HUVECs had formed
7 and 21 days samples were stained with calcein AM then a significant number of branch points and
photographed with a fluorescence microscope. longer lengths of tubes. On the same side,
because PDRN could enhance the growth
and migratory ability of hBMSCs, the wound
closure rates also highly increased to 34.8 and
31.9% in PDRN-treated groups compared to
control at 24 and 48 h, respectively.
Osteogenesis in 3D Osteogenesis Osteogenesis in 3D Scaffold
Scaffold The osteogenic capacity of the scaffold was The PME scaffold could induce osteogenic
7 and 21 days assessed through qRT-PCR on differentiation of hBMSCs effectively, and
osteogenesis-related genes expression, such as by adding PDRN (PMEP), the osteogenesis
RUNX2, OPN, osteocalcin OCN using hfbMSCs. was more enhanced.
The results exhibited that the PMEP
scaffold significantly up-regulated RUNX2,
OPN and OCN at all days.
Attenuation of Attenuation of Osteoclastogenesis Attenuation of Osteoclastogenesis
Osteoclastogenesis The attenuation of ostotoclastogenesis by PDRN Bioactive molecules secreted by scaffold
Not reported was evaluated using macrophages cells, in detail PME and PMEP statistically significantly
RAW264.7. RAW264.7 were induced to attenuated differentiation into osteoclasts of
differentiate into osteoclasts by stimulation of RAW264.7 cells by 31.7 and 74.4%,
receptor activator of RANKL and M-CSF. These respectively, compared with control.
macrophages were investigated using TRAP
staining and activity assay.
Kim et al., hBMSCs 1 mg of PDRN - PLGA (CTR) Not reported Angiogenic efficacy of NC Angiogenic efficacy of NC
2021 The article does not dissolved in 1 mL of - PME + BMP2 Immunocytochemistry with an anti VEGF The PDRN- and NC-treated groups
[18] specify how these cells nuclease-free water. - PME + PDRNPME + antibody using HUVECs was conducted to demonstrated an increase in the number of
were obtained. The PDRN was NC: the NC was evaluate increased VEGF production due to VEGF positive cell observation compared to
distributed by formed by the union PDRN. the control and BMP2-treated groups in 3 days.
Goldbio St. Louis, of PDRN and BMP2 To confirm the angiogenic effect on NC, was The gene expression levels of VEGF in the
MO, USA. executed qRT-PCR on angiogenesis. PDRN- and NC-treated groups significantly
increased (p < 0.01 and p < 0.001). The group
treated with NC exhibited a statistically
significant increase in the expression levels
of ANG2, which is one of the most
prevalent angiogenic factors.
Dent. J. 2023, 11, 280 9 of 21

Table 1. Cont.

Article Cell Model PDRN Employed Experimental Group Follow-Up Sample Analysis Results
Biocompatibility of the hybrid scaffold Biocompatibility of the hybrid scaffold with
The biocompatibility of the hybrid scaffold with NC
NC (PME/NC) was evaluated based on This analysis showed that hfMSCs were
LIVE/DEAD staining [calcein AM (acetoxymethyl viable one day after seeding and the cells
ester) and ethidium homodimer 1 (EthD-1)]. proliferated well on each scaffold,
especially PME/NC.
Osteogenic potential of the hybrid scaffold with Osteogenic potential of the hybrid scaffold
NC with NC
The osteogenic capacity of the scaffold was The BMP2-treated group showed a
assessed using qRT-PCR on osteogenesis-related significant increase in ALP activity and
genes expression, such as RUNX2, OPN, OCN mineralization. However, PDRN also
and ON using hfMSCs. ALP is a marker of affected osteogenesis compared to control.
osteogenesis, so ALP staining was conducted on Consequently, the NC has a brilliant
each scaffold. osteogenic ability, which is made by a
combinational effect from BMP2 and PDRN.
RUNX2, OPN, OCN, and ON were
expressed to higher levels in the PME/NC
scaffold compared to any other scaffolds.
Attenuation of osteoclastogenesis and Attenuation of osteoclastogenesis and
inflammatory gene expression inflammatory gene expression
The attenuation of osteoclastogenesis by PDRN In the groups containing PDRN, the
and BMP-2 was evaluated using RAW264.7. differentiation of osteoclast was statistically
RAW264.7 were induced to differentiate into inhibited as compared with the control and
osteoclasts by stimulation of RANKL and M-CSF. BMP2 and the PDRN and NC groups
These macrophages were investigated using decreased the expressions of IL-1β and IL-6.
TRAP staining and activity assay. To confirm the
anti-inflammatory effect on NC, was executed
qRT-PCR on inflammatory gene expression.
Abbreviation: hBMSCs, human bone-marrow mesenchymal stem cells; HUVECs, human umbilical vein endothelial cells; IL-1β, interleukin-1β; IL-6, interleukin-6; M-CSF, macrophage
colony-stimulating factor; mMH, magnesium hydroxide; MMP2, matrix metalloproteinase-2; NC, nanocomplex; OCN, osteocalcin; ON, osteonectin; PDRN, polydeoxyribonucleotide;
PLGA, Poly(lactic-co-glycolic) acid; PME, PLGA, mMH, bECM complex; PMEP, PLGA, mMH, bECM, PDRN complex; qRT-PCR, polymerasechain reaction; RANKL, receptor activator
of the nuclear factor B ligand; RUNX2, runt-related transcription factor 2; TRAP, tartrate-resistant acid phosphatase; VEF, Vascular Endothelial Growth Factor; WCA, Water Contact
Angle; BMP2, bone morphogenetic protein.
Dent. J. 2023, 11, 280 10 of 21

Table 2. Data collection and outcomes of in vivo studies.

Animal Study Experimental Analysis of Newly Formed Qualitative Histological

Article Surgical Procedure PDRN Follow-Up Complication
Model Design Grup Bone Volume Analysis
Kim Mice (20) Case The dorsal portion was PDRN 1.875 Group 1: DDM + The animals Not reported. The valuation of bone - At 1 week, a fibrous capsule
et al., Series incised, and a subcutaneous w/v% solution PDRN were regeneration was a which was well bounded
2016 The gender pouch was formed in both distributed by sacrificed at 1, histomorphometric analysis. with neighboring tissue was
[1] of these sides. DDM and PDRN was Mastelli, 2, and 4 - Quantitative level of bone- observed.
animals has implanted into the Sanremo, Italy. weeks. forming cells around DDM - At 2 weeks, much greater
not been subcutaneous pouch. bone-forming cells were
The average values of this
reported. observe than in the first
parameter were 10, 20, and
week and development of
23 at 1, 2, and 4 weeks.
the blood vessels and newly
- Area of newly formed formed collagen matrix
mineralized bone to were.
obtained image area - At 4 weeks, the deposition
(NB%) NB% was 7, 20, and and calcification of new bone
17% at 1, 2, and 4 weeks, matrix were observed.
respectively.

Guizzardi Male RCT Two round holes in the PDRN at the For each No inflammatory Not reported. - Group 1: At 12 weeks, the
et al., Sprague- cortical bone of both tibiae of concentration of - Group 1: CRT group 2 or adverse bone defect had been almost
2007 Dawley each rat were created. 95% distributed (8) the defects animals were reactions to PDRN completely replaced by new
[16] Rats (32) by Mastelli, were left empty. sacrificed at 1, gel and/or formed trabecular bone.
Sanremo, Italy - Group 2: HDB 2, 4, 12 weeks HDB/PDRN paste - Group 2: After 12 weeks, the
(8) were detected; defect was filled by new
- Group 3: PDRN only a weak formed bone along with the
(8) lymphocyte embedded HDB granules.
- Group 4: HDB + infiltrate was - Group 3: After 4 weeks,
PDRN (8) detectable at new-formed trabecular bone
1 week. was seen departing from the
border. The defect was filled
by new bone after 12 weeks.
- Group 4: no granules of HDB
detected outside the surgical
defect and a faster formation
of new bone than in the other
experimental conditions.
Dent. J. 2023, 11, 280 11 of 21

Table 2. Cont.

Animal Study Experimental Analysis of Newly Formed Qualitative Histological

Article Surgical Procedure PDRN Follow-Up Complication
Model Design Grup Bone Volume Analysis
Kim Rats RCT On both sides of rat calvaria, 1 mg of PDRN - Group 1: CTR The animals The valuation of bone - Considerably newly
et al., a defect (diameter 5 mm and dissolved in the defect was were regeneration was performed developed bone tissue was
2021 The gender 1.5 mm thickness) was made 1 mL of left empty. sacrificed after on micro-CT. observed in the defected area
[18] of these using micro drill and nuclease-free - Group 2: PLGA 8 weeks Bone volume density for the PME/NC scaffold
animals has trephine bur. The scaffolds water. - Group 3: PME post-operative (BV/TV%) and BMD (%) than control.
not been were implanted within the The PDRN was - Group 4: were analyzed.
Additional
reported. defect. distributed by PME/NC - In the group implanted immunohistochemistry
Goldbio St. with PME/NC, analysis to assess
Louis, MO, regenerated bone was vascularization and
USA. detected in the defect area. anti-inflammatory effect of
In the other groups, the scaffolds in vivo was
formation of new bone performed.
was minor.
- In the PME/NC scaffold, the
- The bone volume density
expression of angiogenetic
for the PME/NC
and osteogenetic genes was
implanted group was
statistically significantly
significantly higher than
higher than the other groups.
the control (p < 0.0001).
- Also, in PME/NC groups
- The BMD of the PME/NC
decreased the expressions of
increased by
IL-1β and IL-6.
approximately four times
higher than control.
In addition, the vessel
volume density and vessel
number were quantified at
micro CT.
- PME/NC appeared with
numerous newly thick
vessels and showed
negligible difference with
the control group
(p > 0.05).
Dent. J. 2023, 11, 280 12 of 21

Table 2. Cont.

Animal Study Experimental Analysis of Newly Formed Qualitative Histological

Article Surgical Procedure PDRN Follow-Up Complication
Model Design Grup Bone Volume Analysis
Lee Male Beagle RCT Both premolars (P2, P3, and The concentration - Group 1: The animals None of the In this study the valuation of In augmented area, new bone
et al., Dogs (4) P4) in the maxilla were of PDRN used Collagenated were animals showed bone regeneration was a formation was observed in the
2022 extracted. The alveolar was not reported synthetic bone sacrificed after any serious histomorphometric analysis. augmented sinus cavity in both
[19] ridges were allowed to heal in this study, nor - Group 2: 2 months post- complications, To evaluate the new bone, groups.
for 2 months. At the site of was the Collagenated operative. including infection three rectangular area of In the test group, the apical
extracted premolars in the company that synthetic bone + and postoperative interest (1 × 1 mm) were set region of the augmented area
maxilla, implants were manufactured it. PDRN bleeding around within the augmented sinus exhibited a greater tendency
placed in each dog with a the surgical area: AOI_C, AOI_M, towards osteogenesis
sinus elevation procedure wound area. AOI_A. compared to the coronal
(lateral approach). - The variables AH, PH, region.
BICp, BICa total, BICa
coronal, and BICa middle
did not demonstrate
significant statistical
differences between the
control and test groups.
BICa apical of samples in
the test group
(76.7 ± 9.3%) showed a
statistically significantly
higher value than that of
samples in the control
group (55.6 ± 22.1%;
p = 0.038).
- pNB, pRBP, and pFVT in
AOI_A showed
statistically significant
differences between
samples in the 2 groups
(p = 0.038, p = 0.028, and
p = 0.007, respectively).
Dent. J. 2023, 11, 280 13 of 21

Table 2. Cont.

Animal Study Experimental Analysis of Newly Formed Qualitative Histological

Article Surgical Procedure PDRN Follow-Up Complication
Model Design Grup Bone Volume Analysis
Lim Rabbit (32) RCT Four round-shaped borders PDRN at - Group 1: Only 8 animals There were no The valuation of bone
et al., of 7 mm diameter were different Scaffold were apparent regeneration was a
2021 The gender designed and drawn on the concentrations (HA/TCP) sacrificed on abnormal histomorphometric analysis.
[20] of these calvaria bone. Additional (0.1 mg/mL, - Group 2: the 4th and symptoms of
animals has 9 holes of 1 mm diameter 1 mg/mL, HA/TCP + 8th week post- infection or Percent bone volume (%) =
not been were formed within each 5 mg/mL, and 0.1 mg/mL operative. inflammation on New bone volume/Total
reported. round border for enhancing 10 mg/mL). PDRN the operated sites. volume in scaffold × 100
bone regeneration capacity The producing - Group 3: At 8 weeks, new bone
and blood supply. company was HA/TCP + formation in the groups
Prefabricated polycarbonate not reported. 1 mg/mL PDRN administered with 5 mg/mL
tubes (7 mm diameter × - Group 4: and 10 mg/mL PDRN was
5 mm height) were fitted into HA/TCP + significantly more than that
the 7 mm round borders, and 5 mg/mL in the control group.
the block-type ceramic PDRN Additionally, there was no
scaffolds were designed and - Group 5: significant difference in bone
inserted into the tubes. HA/TCP + formation in the group
10 mg/mL treated with 5 mg/mL
PDRN PDRN compared to that in
the group treated with
- Group A:
10 mg/mL PDRN (p > 0.05).
HA/TCP +
0.01 mg/mL
At 8 weeks post-operation,
BMP2
new bone formation was
- Group B:
significantly higher in the
HA/TCP +
groups administered with
0.05 mg/mL
0.05 and 0.1 mg/mL
BMP2
rhBMP-2 compared to that in
- Group C:
the control group.
HA/TCP +
The extent of bone formation
0.1 mg/mL
differed significantly in the
BMP2
groups administered with
0.05 and 0.1 mg/mL of
rhBMP-2, and the extent of
new bone formation
increased at higher
concentrations (p < 0.05).
Dent. J. 2023, 11, 280 14 of 21

Table 2. Cont.

Animal Study Experimental Analysis of Newly Formed Qualitative Histological

Article Surgical Procedure PDRN Follow-Up Complication
Model Design Grup Bone Volume Analysis
Farley Beagle Dogs RCT 2nd and 3rd premolars in PDRN - Group 1: 2 animals One dog of the The valuation of bone The amount of bone formation
JR et al., (6) both sides of the mandible of distributed by Xenogenic bone were group of the 4th regeneration was performed was more in group 1, 2 than
2014 beagle dogs were extracted. Mastelli, graft was sacrificed at a week showed on micro-CT. group 3, 4 at 2 weeks.
[21] The gender An implant was placed in Sanremo, Italy. positioned in in time after 2, 4, edema in the left Bone volume ratio = Bone At 4 weeks there was a small
of these each socket, in the buccal The the 2nd 8 weeks. area of surgery. volume/total volume quantity of immature bone
animals has area a dehiscence defect was concentration of premolar region The total volume is defined formation around the grafted
not been formed (5 mm in length and PDRN used was in the left of as the ROI which is the bone.
reported. 5 mm in diameter) and a not reported. maxilla. inside (width: 0.4 mm/
bone graft was performed. - Group 2: length: 3.3 mm) of the
Xenogenic bone implant threads.
graft was In group 2, 4, the bone
positioned in in volume ratio was highest in
the 3rd the 8th week compared to
premolar region other groups and group 2
in the right of and 4 showed 55.9% and
maxilla. 55.4%, respectively. But there
- Group 3: was no significant difference
Xenogenic bone among group.
graft and PDRN The number of specimens
was positioned was small so statistical
in the 3rd analysis was hard to
premolar region performed.
in the left
maxilla.
- Group 4:
Xenogenic bone
graft and PDRN
was positioned
in the 2nd
premolar in the
right of maxilla

Abbreviation: AH, augmented height; AOI_A, apical region; AOI_C, most coronal region; AOI_M, middle region; BICa%, bone-to-implant contact in augmented bone; BICp%,
bone-to-implant contact in pristine bone; BMD, bone mineral density; BMP2, bone morphogenetic protein; BV, bone volume; CT, computed tomographic; DDM, demineralized dentin
matrix; HA, hydroxyapatite; HDB, high temperature-deproteinated bone; IL-1β, interleukin-1β; IL-6, interleukin-6; PDRN, polynucleotides; pFVT%, Fibrovascular connective tissue area
percentage; PH, protruding height; pNB%, new bone area percentage; pRBP%, residual bone graft particle area percentage; ROI, region of interest; TCP, tricalcium phosphate scaffolds;
TV, tissue volume.
Dent. J. 2023, 11, 280 15 of 21

4. Discussion
The long-term success rate of endosseous implants is ensured by adequate bone
volume at the recipient site. In the presence of bone defects caused by atrophy, dental
trauma, extractions, or periodontal disease, regenerative surgical procedures are required
before implant placement [22]. Among the different surgical procedures described to
augment the bony envelope for implant placement purposes, guided bone regeneration
(GBR) showed promising results in the long term. GBR involves using a barrier membrane
placed over a bone defect or extraction site to promote the selective growth of osteogenic
cells and prevent defect colonization by soft tissue [22].
The barrier effect in combination with blood clot alone requires a significant amount of
time to regenerate even limited amounts of bone. Thus, autologous bone grafts eventually
combined with biomaterials were introduced as filling materials to improve efficacy and
reduce the healing time of the regenerative process [23]. Autogenous bone is considered
the gold-standard grafting material due to its excellent osteogenic and osteoinductive
properties associated with the highest biocompatibility. Nevertheless, main drawbacks are
the limited intraoral availability and the need for a second surgical site for harvesting [24].
To overcome these limitations, allogeneic, xenogeneic, and synthetic bone substitutes and
graft materials based on extracted teeth, which exhibit osteoconductive and osteoinductive
properties, have been developed and clinically used [24–26]. Such materials are osteo-
conductive but not osteoinductive; therefore, the association with autologous grafts is
suggested [27].
To further improve the regenerative outcome, the search for molecules that can stimu-
late osteoblastic proliferation remains a topic of interest in oral surgery. Such biomolecules
can be used in bone defects mixed with biomaterials to stimulate faster osteoblastic prolif-
eration, and, consequently, reduce healing time with the formation of new bone [28]. To
this aim, PDRNs are being assessed in vitro and in animal models to promote bone healing
and improve hard tissue regeneration.
In one of the initial in vitro studies, the researchers investigated the potential of
PDRNs to stimulate growth and enhance the activity of cultured human osteoblasts that
were isolated from the jawbone following surgery. This was achieved by increasing the
synthesis of alkaline phosphatase [15]. The study demonstrated that osteoblasts treated
with PDRN (at a concentration of 100 µg/mL) exhibited an optimal and significant growth
rate when exposed to a 10% concentration of fetal bovine serum (FBS), with noticeable
effects as early as 48 h and peaking at 6 days. This resulted in a 21% increase in cell count.
In contrast, cultures lacking FBS showed no discernible impact from PDRN. The authors
explained this phenomenon with the presence of enzymes that, through a depolymerization
process, generated purine nucleotides and free nucleosides capable of binding to purinergic
receptors [15].
Furthermore, the results obtained from treatment with DMPX and Suramine (inhibitors
of purinergic A2 and P2 receptors, respectively) indicated the involvement of A2 receptors
in the stimulation of osteoblastic growth by oligonucleotides produced through cellular
catabolic degradation. The findings also suggested the likely absence of a role for purinergic
P2 receptors. Additionally, they proposed that the adenosine A2 receptor may not be the
exclusive mechanism of action of PDRNs [15].
Regarding the assessment of alkaline phosphatase activity, the authors observed an
increase in activity in cells treated with PDRN. However, after 10 days, the activity levels
were comparable between treated and untreated cells. Since alkaline phosphatase synthesis
takes place only in the last G phase before the M phase of the cell cycle, a PDRN-induced
rise in cell proliferation led to a reduction in the G phase. These findings suggest that
PDRNs may have stimulating effects on osteoblasts and play an important role in the repair
of bone defects [15].
For almost two decades, no other in vitro studies evaluated the effects of PDRNs on
bone metabolism. In 2021, Kim Da-Seul et al. published two studies using PDRN and
biological scaffolds to investigate osteoclastogenesis, osteoconductivity, and the proan-
Dent. J. 2023, 11, 280 16 of 21

giogenic role of PDRN [17,18]. The first study adopted an in vitro approach, while the
latter consisted of both in vitro and in vivo models. In both studies, a porous scaffold
of Poly(lactic-co-glycolic) acid (PLGA) (P) was associated with a magnesium hydroxide
modified with a ricinoleic acid (mMH) (M), and, finally, bovine-derived decellularized bone
extracellular matrix (bECM) (E) to create a PME scaffold [17,18]. In the test group of the
first study, bioactive polydeoxyribonucleotide (PDRN, P) was incorporated into the PME,
creating a PMEP scaffold [17]. In the test group of the second study, the authors designed a
PME hybrid scaffold with nano complex (NC), consisting of positively charged bone mor-
phogenetic protein-2 (BMP-2) and negatively charged PDRN [18]. In both studies, mMH
showed the exceptional capability of neutralizing the acidic microenvironment created by
PLGA degradation. At the same time, bECM, composed mainly of calcium and phosphate,
improved the scaffold’s biocompatibility and osteoconductivity [17,18]. In the first in vitro
study, the PMEP scaffold demonstrated better hydrophilicity and biocompatibility than the
test groups (PME and PLGA) [17]. Furthermore, the PMEP scaffold statistically significantly
suppressed the expression of inflammatory genes IL-6 and IL-1β and promoted the highest
angiogenesis-related gene (VEGF and MMP2) expression compared with the control [17].
Additionally, the PME scaffold induced osteogenic differentiation, but osteogenesis was
only enhanced by adding PDRN (PMEP) [17]. Lastly, the bioactive molecules secreted by
PME and PMEP scaffolds showed a significant reduction in differentiation into osteoclasts
by 31.7% and 74.4%, respectively, compared to the control group (PLGA) [17].
The results obtained in the former analysis were confirmed in the second study [18].
The groups treated with PDRN and NC exhibited enhanced angiogenesis compared to both
the control and BMP2-treated groups. Cell proliferation was robust on all scaffolds, with
PME/NC showing particularly promising results. Notably, NC demonstrated remarkable
osteogenic potential, which was attributed to a synergistic effect of BMP2 and PDRN.
Additionally, in groups containing both PDRN and NC, the differentiation of osteoclasts
and the expressions of IL-1β and IL-6 were statistically suppressed when compared to the
control, BMP2, and PDRN groups [18].
In the subsequent in vivo phase, bone defects were created on both sides of rat calvaria
using micro drills and trephine burs. In the control group, the defect was left untreated,
while in the other two groups, either PME/NC or PME or PLGA were, respectively,
placed in the defect. Evaluation of bone regeneration was conducted using micro-CT. The
PME/NC-treated group displayed a noticeable increase in bone formation within the defect
area, surpassing the other groups in terms of efficacy [18]. The bone volume density, the
number of newly formed vessels, and the expression of angiogenetic and osteogenetic
genes in the PME/NC-treated defects were significantly higher than those in the other
groups [18].
Previous in vivo studies have provided substantial support for the role of PDRN
in bone regeneration. An initial animal study investigated the impact of PDRN on the
regeneration of cortical bone after creating round defects in 32 rats. The study assessed the
performance of three different compounds: PDRN gel, high-temperature protected bone
(HDB), and a combination of HDB and PDRN paste [16]. PDRN gel exhibited stimulation
of cells and tissues, but its application in gel form during surgery was constrained by
challenges in maintaining it at the implantation site. Granular HDB also demonstrated
effectiveness; although, the absence of a bonding agent led to some granules leaking
out, resulting in ectopic bone formation. Ultimately, the paste composed of HDB and
PDRN emerged as a manageable, biocompatible, osteoconductive, and osteostimulating
compound that proved applicable for mending bone defects [16]. Histologically, at 12 weeks,
no HDB granules were detected outside the surgical defect, and new bone formation was
faster than under the other experimental conditions [16].
Subsequently, the effects of PDRNs on hard tissue were examined in beagle dogs. In
particular, the bone healing process was evaluated following grafting of xenogeneic bone
and anorganic bovine bone in combination or not with PDRNs in bone defects created
following immediate post-extractive implant placement [21]. Histological and micro-CT
Dent. J. 2023, 11, 280 17 of 21

assessments performed at 4 and 8 weeks, respectively, showed that regenerated bone

volume in the groups treated with xenogeneic bone and PDRN was greater than that
observed in groups treated with xenogeneic bone alone [21]. The authors’ conclusion
highlighted that the combination of grafting materials with PDRN has the potential to
enhance the bone healing process and lead to an increase in the quantity of newly formed
bone over time [21].
Thereafter, in a different animal model, PDRN and human demineralized dentin
matrix (DDM) made from an extracted human tooth were simultaneously placed under
the skin of 20 nude rats to observe the bone-forming capability [1]. In this case series,
bone regeneration was evaluated using histomorphometric analysis. The latter showed an
encouraging number of osteoprogenitor cells compared with the dentin particles present.
Upon histological examination at 4 weeks, the deposition of new bone matrix and absorp-
tion of dentin particles were also observed. Subcutaneous implantation of PDRN and
DDM resulted in excellent osteoinductive activity, inducing the growth and proliferation of
fibroblasts, osteoblasts, and new bone [1].
A recent study examined the bone inductive potential of a block graft composed of
hydroxyapatite/tricalcium phosphate (HA/TCP), which was treated with recombinant
human bone morphogenic protein 2 (rhBMP2) or PDRN. This graft was placed in surgical
holes created in the neurocranium of white rabbits [20]. In the control group, the defect was
filled with the HA/TCP scaffold. In the other groups, PDRN or rhBMP2 were incorporated
into the scaffold at various concentrations: 0.1 mg/mL, 1 mg/mL, 5 mg/mL, and 10 mg/mL
for PDRN, and 0.01 mg/mL, 0.05 mg/mL, and 0.1 mg/mL for rhBMP2. After 8 weeks, the
groups treated with 5 mg/mL and 10 mg/mL PDRN, and 0.05 mg/mL and 0.1 mg/mL
rhBMP-2 exhibited significantly higher levels of new bone formation compared to the
control group [20]. In conclusion, HA/TCP blocks demonstrated suitable compressive
strength for clinical application and exhibited significant potential for bone regeneration
when combined with the appropriate concentration of PDRN or rhBMP2 [20].
The latest animal study published to date shifted the interest toward the evaluation of
surgical techniques typically performed on humans. In this study, four dogs underwent
lateral sinus floor elevation simultaneously with implant insertion. PDRN in addition
to a synthetic bone substitute were used as grafting materials to investigate early bone
formation [19]. The primary objective was to evaluate the osteoinductive effect of PDRNs
below the Schneiderian membrane and, consequently, to assess how PDRNs could promote
bone neoformation in areas with low osteogenic potential, as the maxillary sinus [19].
Histomorphological analyses revealed that in the test group treated with PDRN, there was
a statistically significant increase in bone regeneration at the apical level compared to the
control group, which was treated solely with synthetic collagenated bone. Additionally,
within the test group, the apical region of the augmented area showed a stronger inclination
towards osteogenesis in comparison to the coronal region [19].
From the analysis of the available in vitro literature, it can be concluded that PDRN
may represent a novel material that could significantly stimulate osteoblastic proliferation
within the first 6 days by reducing the G phase of mitosis. In addition, the use of PDRN in
combination with biological and biocompatible scaffolds based on PLGA, mMH, bECM,
and BMP-2 seems to improve regenerative capabilities by reducing gene expression related
to inflammatory processes, osteoclastogenesis, as well as stimulating angiogenesis, which
is essential for wound healing and bone repair, and osteogenesis. These findings have
been corroborated in different animal species such as rats, rabbits, and dogs, following
the creation of critical size defects or maxillary sinus floor elevation. Histological analyses
confirmed how the application of PDRN with biocompatible scaffolds or collagenated
synthetic bone allows to significantly increase the amount and density of newly formed
bone and the anti-inflammatory and neo-angiogenic effects. The effects of PDRN on bone
regeneration should be explored in future human randomized controlled clinical trials to
confirm the promising results reported herein.
Table 3 shows an overview of the main results obtained with this scoping review.
Dent. J. 2023, 11, 280 18 of 21

Table 3. Overview of key findings achieved through this scoping review.

Property/Characteristics Description
PDRN appears to interact with adenosine A2 receptors and,
Interaction with adenosine
contributing to its osteoblastic growth-stimulating effects, is
A2 receptors
supported by experimental evidence
PDRN:
- stimulates osteoblastic proliferation.
- contributing to osteogenesis and exhibiting osteoinductive
properties by showing increased expression of
osteogenesis-related genes such as RUNX2, OPN, and OCN.
Promotes tissue regeneration
- promotes angiogenesis: highest angiogenesis-related gene
(VEGF and MMP2) expression.
- anti-inflammatory properties: increased expression of
inflammatory genes, IL-6 and IL-1β.
- attenuated differentiation into osteoclasts.

This review has some limitations. The manufacturers, concentrations, carriers, and
doses employed in the studies are heterogeneous. This could have affected the results
obtained. Therefore, the minimum effective concentration of PDRN should be investigated
to determine a concentration/effect relationship. Another limitation was that bone heal-
ing times were hardly comparable, as animal models have different bone metabolisms
depending on the animal chosen.
Future human studies are thus needed to determine the proper clinical application of
PDRNs in oral bone regeneration and to confirm the results obtained from the in vitro and
animal studies analyzed in this systematic review.

5. Conclusions
This scoping review found that in the analyzed in vitro and in vivo studies:
1. enzymatic degradation of PDRN generates biologically active metabolites that interact
with various receptors including purinergic adenosine A2A receptors.
2. Activation of these receptors promotes angiogenesis, osteoblast migration, proper
extracellular matrix deposition, and reduces inflammation.
3. PDRN demonstrated a high therapeutic effect, low immunogenicity, and absence of
side effects, regardless of the route of administration.
4. PDRN application with biocompatible scaffolds or collagenous synthetic bone allows
the amount and density of newly formed bone to be significantly increased.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/dj11120280/s1, Table S1. PRISMA-ScR Checklist.
Author Contributions: Conceptualization: M.M., M.B., C.M. and P.P.P.; data curation: M.M., M.B.,
C.M. and P.P.P.; formal analysis: M.M., M.B., C.M. and P.P.P.; investigation: M.M., M.B., C.M. and
P.P.P.; methodology: M.M., M.B., C.M. and P.P.P.; project administration: M.M., M.B., C.M. and P.P.P.;
resources: M.M., M.B., C.M. and P.P.P.; software: M.M. and F.E.S.; supervision: M.M., M.B., C.M.
and P.P.P.; validation: M.B. and C.M.; visualization: M.M., M.B., C.M. and P.P.P.; writing—original
draft: F.E.S. and M.P.; writing—review and editing: F.E.S., M.P. and P.P.P. All authors commented on
previous versions of the manuscript. All authors have read and agreed to the published version of
the manuscript.
Funding: This study was funded by Italian Ministry of Health—Current research IRCCS.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Upon request to the corresponding author, the data are available
for use.
Dent. J. 2023, 11, 280 19 of 21

Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations

AH augmented height
ALP alkaline phosphatase
ANG2 angiopoietin-2
AOI_A apical region
AOI_C most coronal region
AOI_M middle region
bECM bone-extracellular matrix
BICa% bone-to-implant contact in augmented bone
BICp% bone-to-implant contact in pristine bone
BMD bone mineral density
BMP2 bone morphogenetic protein
BV bone volume
CT computed tomographic
DDM demineralized dentin matrix
FBS foetal bovine serum
HA hydroxyapatite
hBMSCs human bone-marrow mesenchymal stem cells
HDB high temperature-deproteinated bone
HUVECs humanumbilical vein endothelial cells
IL-1β interleukin-1β
IL-6 interleukin-6
M-CSF macrophage colony-stimulating factor
mMH magnesium hydroxide
MMP2 matrix metalloproteinase-2
NC nanocomplex
OCN osteocalcin
ON osteonectin
PDRN polydeoxyribonucleotide
pFVT% fibrovascular connective tissue area percentage
PH protruding height
PLGA poly(lactic-co-glycolic) acid
PME PLGA, mMH, bECM complex
PMEP PLGA, mMH, bECM, PDRN complex
pNB% new bone area percentage
pRBP% residual bone graft particle area percentage
qRT-PCR polymerasechain reaction
RANKL receptor activator of the nuclear factor B ligand
ROI region of interest
RUNX2 runt-related transcription factor 2
TCP tricalcium phosphate scaffolds
TRAP tartrate-resistant acid phosphatase
TV tissue volume
VEF vascular endothelial growth factor
WCA water contact angle

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