Cytokine 126 (2020) 154896

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Cytokine
journal homepage: www.elsevier.com/locate/cytokine

Review article

Role(s) of cytokines in pulpitis: Latest evidence and therapeutic approaches T

a b,c d
Mohammad M.Y. Khorasani , Gholamhossein Hassanshahi , Aniela Brodzikowska ,
⁎
Hossein Khorramdelazadb,c,e,
a
Department of Endodontics, School of Dentistry, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
b
Molecular Medicine Research Center, Research Institute of Basic Medical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
c
Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
d
Department of Conservative Dentistry, Medical University of Warsaw, Miodowa 18, 00-246 Warsaw, Poland
e
Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

A R T I C LE I N FO A B S T R A C T

Keywords: Pulpitis is known as a typical inflammation of dental pulp tissue, and microorganisms of the oral microbiome are
Pulpitis involved in this opportunistic infection. Studies indicated that several factors related to host response have a
Cytokine crucial role in pulpitis. Among these factors, inflammatory mediators of the immune system such as cytokines
Immune system and chemokines contribute to pulpal defense mechanisms. A wide range of cytokines have been observed in
Inflammation
dental pulp and these small molecules are able to trigger inflammation and participate in immune cell traf-
ficking, cell proliferation, inflammation, and tissue damage in pulp space. Therefore, the aim of this review was
to describe the role of cytokines in the pathogenesis of pulpitis.

1. Introduction
Pulpitis is one of the common dental disorders associated with tooth
pulp inflammation [1]. In fact, microorganisms in normal flora of the
mouth initiate immune responses [2]. Dental caries, trauma, dentinal
cracks, unprotected main apical foramen, and dentinal tubules are
important factors for microbial entry into the dental pulp and its in-
fection [3,4]. On the other hand, immune responses are one of the main
factors involved in inflammation in damaged tooth tissues. A verity of
immune and non-immune cells including macrophages, dendritic cells
(DCs), odontoblasts, and endothelial cells which express toll-like re-
ceptors (TLRs) as innate immune receptors in pulp tissue are able to
recognize pathogen-associated molecular pattern molecules (PAMPs)
and initiate immune responses [5,6]. Cytokines and chemokines are
small molecule immune mediators that play an important role in
growth, proliferation, differentiation, and chemotaxis due to triggerring
immune responses [7,8]. These proteins are generally divided into two
types, inflammatory and anti-inflammatory, and numerous studies
showed that the main mediators of inflammatory responses in inflamed
dental tissue and periapical lesions are monocyte chemoattractant
protein-1 (MCP-1/CCL2), monocyte chemoattractant protein-2 (MCP-
2/CCL8), interleukin-8 (IL-8), macrophage inflammatory protein-1
alpha (MIP-1α), macrophage inflammatory protein-1 beta (MIP-1β),
CXCL10, CCL5 are [9–12]. Clinical pulpal conditions are categorized
into four classes (normal, reversibly inflamed, irreversibly inflamed,
and necrotic) regarding the status and symptoms of patients and ex-
aminations [13,14]. In order to determine reversible pulpitis, histolo-
gical findings have shown lack of bacteria, presence of localized coa-
gulation, and necrosis turned into fluid adjacent to irritant. However,
histologic hallmarks of irreversible pulpitis are presence of bacteria or
their by-products in the dental pulp, infiltration of immune cells such as
neutrophils, acute inflammation, principally in the pulp tissue, under
the lesion [15]. Additionally, case history, clinical and radiographic
examination are potential procedures for pulpal inflammation diag-
nosis. Patients suffer from severe pain in both reversible and irrever-
sible pulpitis [16]. The pulp’s reaction to thermal stimulus used to
differentiate between reversible and irreversible pulpitis and almost
half of the patients with irreversible pulpitis do not feel pain [16].
Furthermore, in reversible pulpitis, the pulp is able to recover after
elimination of the relevant stimulus whereas in irreversible pulpitis,
removal of the stimulant does not help the patient, and only pul-
pectomy can end the pain. Accordingly, given the importance of the
immune system and its components in inflammation of the dental
tissue, this review was designed to summarize the role of cytokines in
the pathogenesis of pulpitis.

⁎
Corresponding author at: Molecular Medicine Research Center, Research Institute of Basic Medical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan,
Iran.
E-mail address: khorramdelazad@gmail.com (H. Khorramdelazad).

https://doi.org/10.1016/j.cyto.2019.154896
Received 10 July 2019; Received in revised form 16 October 2019; Accepted 17 October 2019
1043-4666/ © 2019 Elsevier Ltd. All rights reserved.
M.M.Y. Khorasani, et al.
2. The dental pulp tissue characteristics
The dental pulp is an extremely particular mesenchymal tissue
which is walled by rigid mineralized material while odontoblasts and
stromal fibroblasts are the main cells in this space [17]. This special
tissue is infiltrated by a network of blood vessels and nerve bundles
emanating from the apical region [18]. Along with odontoblasts and
stromal fibroblasts, undifferentiated mesenchymal stem cell popula-
tions are observed predominantly within the perivascular niche and
immune cells [19]. Under normal conditions, neutrophils form the main
population of cells in this area, but dendritic cells and sometimes
macrophages are also observed in the dental pulp. Due to removing of
infectious agents and repair promotion, the mentioned cells can have
various functions, including creation of mechanical barriers by odon-
toblasts, transmission of sensations by neural fibers, dental pulp stem
cell differentiation, and production of inflammatory cytokines and
chemokines by immune cells [20]. Findings of previous studies indicate
that the lymphatic system and lymphatic vessels are present in the
dental tissue, however, an appropriate biomarker for distinguishing
these vessels from the blood vessels present in this area has not been
well-established [21,22]. Some researchers have suggested that vas-
cular endothelial growth factor receptor-3 (VEGFR-3) may be an im-
portant indicator in the diagnosis of lymphatic vessels in dental pulp
because it has a noticeable increase in decayed tooth tissue compared to
healthy teeth, which is an indication of lymphangiogenesis following
pulp tissue inflammation [23,24]. It is theorized that a widespread
lymphatic system exists in dental tissue and that during inflammation,
lymphangiogenesis is responsible for enhancement of transport of fluid,
proteins, and pathogens as well as improvement of locomotion of an-
tigen-presenting cells to the local lymph nodes [23].
3. Immune responses in the pulpitis
Several factors are known to affect dental pulp tissue that include
mechanical, chemical, microbiological and thermal factors. These sti-
mulants are able to trigger inflammatory immune responses and cause
vascular changes, accumulation of immune cells, and ultimately tissue
damage [25] (Fig. 1). The dental pulp tissue has unique anatomical
conditions and, until the dental pulp is exposed, phagocyte cells cannot
kill bacteria. Meanwhile, decay plays an important role, and in cases
where decay rates are low, dental pulp can trigger immune components
and its responses to reduce the rate of decay invasion [26]. Evidence
indicated that intra-tubular immunoglobulins, neuropeptides, odonto-
blasts, natural killer (NK) cells, immature DCs, and T cells, as well as
their cytokines and chemokines, are responsible for early inflammatory
reaction to caries [26,27]. Neuropeptides can directly stimulate and
respond to immune cells. Moreover, increasing vascular permeability
causes infiltration of immune cells and increases the concentration of
immune mediators such as cytokines and chemokines at the site of in-
flammation. Eventually, the sum of these factors leads to odontogenic
or pulpal pain, pulpitis, bone resorption, pulpal necrosis, and apical
periodontitis [28,29]. In pulpitis, immune responses launch with vas-
cular alterations mediated by cells that express CD14, TLR-2, and TLR4
(identified receptors for lipopolysaccharides) and creation of assessable
inflammatory cytokines and chemokines such as IL-8, IL-6, IL-1, CCL2,
CCL5, and others [30]. To prove the involvement of TLR4 in in-
flammatory responses in the acute pulpitis model, Lin, and his collea-
gues showed that TLR4 blocking by TLR4 antagonists such as eritoran
significantly down-regulated signaling adaptor molecules, tumor ne-
crosis factor-α (TNF-α) and IL-1β production [31]. Recent investiga-
tions have proposed that odontoblasts participate in dental pulp im-
mune response to oral pathogens via TLR2 and these types of cells are
able to produce inflammatory cytokines including IL-8 and IL-6 [32].
High Mobility Group Box1 as a non-histone, DNA-binding protein
participates in stimulation and enhancement of TLR2 and TLR4 path-
ways in pulpitis [33]. Additionally, astrocyte elevated gene‐1 is able to
2
Cytokine 126 (2020) 154896
trigger synthesis of inflammatory cytokine through NF‐κB signaling in
the dental pulp [34]. It is well known that neutrophils and their lyso-
somal enzymes are responsible for pulp tissue destruction [35]. Ad-
ditionally, another important innate immune mechanism related to
neutrophils is neutrophil extracellular traps (NETs) which can help trap
invading bacteria and prevent their advance in the pulp tissue, as well
as kill them by phagocytes [36]. Wang et al. reported that IL-1β absent
in melanoma 2 (AIM2) is expressed in inflamed dental pulp tissues and
participates in inflammatory responses during pulpitis [37]. It is
probable that following progressive reversible pulpitis and superficial
caries, innate immune responses switch to adaptive immune responses.
Adaptive immune components such as IL-2, IL-4, IL-5, and IL-13 from
activated T cells participated in related immune responses in pulpitis
[38,39]. Additionally, antibodies secreted from activated B cells have
different and effective functionalities in adaptive immunity [40]. These
magic bullets neutralize bacterial toxins, prevent their adhesion, op-
sonization of the bacteria, which ultimately facilitates the process of
phagocytosis [38]. The end of adaptive immune responses is associated
with inflammation and the removal of infectious agent in the dental
pulp tissue. Studies in the field of epigenetics have also shown that
methylation in nano can have an impact on increased expression of
cytokines. Results of studies indicated that 5-Aza-CdR as a DNA me-
thylation inhibitor, significantly increased the expression of GM-CSF,
IL-8, IL-6, CCL2 and CCL5 in LPS-treated hDPCs [41]. These findings
indicate the importance of DNA methylation in the development of
immune responses and host defense to pulpitis.
4. Role of cytokines in pulpitis
Cytokines, which include interleukins, interferons, lymphokines,
tumor necrosis factors, and chemokines, are small glycoproteins (10–15
kD) that are produced and secreted by a wide range of immune and
non-immune cells and affect many interactions between these cells in-
cluding proliferation, differentiation, cell requirement, apoptosis and
many other actions [42,43]. The downstream impacts of a specific cy-
tokine occur via the high-affinity binding of its receptor expressed on
the surface of a target cell. The effects of these cytokines may occur in
an autocrine, endocrine or paracrine manner. Receptor ligation initiates
intracellular signaling cascades leading to changed expression of the
specific genes in the target cell, which leads to biological consequences.
Another category classified the cytokines in two groups; inflammatory
and anti-inflammatory [44]. In this section, we describe the most im-
portant innate and adaptive immunity cytokines involved in the pa-
thogenesis of pulpitis.
Cytokines play important roles and regulate the intensity and
duration of the immune respons against potentially pathogenic agents.
The occurrence of Interleukin (IL)-1 and IL-1 producing cells has been
demonstrated in human inflamed pulps. The roles of IL-2 and IL-6 have
also been studied in healthy and inflamed dental pulps.
4.1. Experimental studies (in vitro and animal studies)
Previous studies have revealed that inflammation of the dental pulp
can increase IL-1RI expression on sensory nerve fibers as well as blood
vessels [45]. Therefore, it is probable that IL-1β/IL-1RI axis is involved
in the process of pulpal inflammation. In the course of inflammation in
rats with acute pulpitis, TLR4, nuclear factor kappa-light-chain-en-
hancer of activated B cells (NF-ĸB), TNF-α, and IL-1β also augmented in
the pulp tissue in one study [46]. Previous investigations have further
shown amplified IL-1β, IL-6, and TNF-α expressions after 72 h of pulpal
inflammation in mouse pulpitis [47]. In this respect, the findings of a
reversible pulpitis model correspondingly demonstrated that IL-1β, IL-
6, and TNF-α gene expressions were up-regulated in inflamed pulp
tissues induced by LPS [48]. Moreover, Hall et al. reported that the
expression was one of the causes for triggering inflammation in a mouse
pulpitis model [49]. Another study similarly concluded that TNF-α and
M.M.Y. Khorasani, et al. Cytokine 126 (2020) 154896

Fig. 1. Demonstrated that following tooth decay, the invading bacteria entered the tooth pulp and were detected by odontoblasts and other cells. Subsequently,
various signaling pathways initiated, inflammatory cytokines were produced. Inflammation, tissue damage and elimination of the infectious bacteria are further
events. TLR: Toll like receptor; Th: T helper; LPS: Lipopolysaccharides; LTA: Lipoteichoic acid; LT: Lipopeptide; MAPK: Mitogen-activated protein kinase; NFκB:
nuclear factor kappa light chain enhancer of activated B cells.

IFN-γ mRNA expressions were up-regulated by F. nucleatum during that TNF-α could stimulate IL-17 expression partly through WNT5A and
acute and chronic phases of periapical lesion development. Since IL-4 WNT5A [56]. The findings provided by Oliveira et al. similarly de-
had the same levels of response to F. nucleatum in both acute and monstrated that IL-22 could be engaged in the host defense mechanism
chronic phases, it did not seem to play a role in immune responses to and inflammatory response to a periradicular and pulpal tissue infec-
this type of bacteria. However, the results of this study indicated that tion [57].
the expressions of IL-10 and TGF-β as anti-inflammatory cytokines in-
creased during the chronic phase, while inflammatory cytokines in-
4.2. Human studies
cluding IFN-γ and TNF-α expression significantly decreased in the in-
fection caused by F. nucleatum or P. prevotii [50].
It seems that IL-1β is a predominant cytokine in inflammation of the
Previous investigations had further confirmed that NACHT, LRR,
dental pulp [58]; however, other cytokines can be also involved in the
and PYD domain-containing protein (NALP3) inflammasomes are the
host defense mechanisms and pathogenesis of pulpitis [59,60]. In a
main regulators of IL-1β and IL-18 secretion as the development of
study in this domain, Zehnder et al. measured IL-1α, IL-1β, IL-6, IL-8,
periapical lesions in rats [51]. Silva et al. also used mineral trioxide
and IL-18 mRNA levels and reported a significant increase in IL-6, IL-8,
aggregates (MTA) and observed that MTA could down-regulate IFN-γ
and IL-18 gene expressions but not in IL-1α and IL-1β ones. They sug-
and IL-1α expressions in pulpitis [52]. According to the inflammatory
gested that an increase in mRNA expression of these cytokines could be
and anti-inflammatory properties of TGF-β, the results of the study
a part of the host defense mechanism in patients affected with pulpitis
showed that the expression levels of IL-1α, IL-1β, IL-6, and IL-8 cyto-
[61]. Barkhordar et al. observed that fibroblasts of diseased pulp could
kines noticeably boosted after TGF-β1 treatment, whereas there were
contain greater amounts of IL-1β in comparison with healthy one and
no changes in the expression of any anti-inflammatory cytokines [53].
consequently synthesize larger amounts of collagen [62]. Also another
It should be noted that bacteria can also have different mechanisms to
study in this domain indicated that IL-1β could play an important role
escape the immune response. A study in this respect demonstrated that
in stimulating fibroblasts to synthesize collagen, but not in proliferating
E. faecalis might suppress IL-4 and IL-2 expressions by lymphocytes and
fibroblasts and dental pulp repair [63]. Stem cells of the dental pulp
this could be a good reason for the presence of E. faecalis in failed en-
could also stimulate inflammatory responses via release of IL-1β and
dodontic treatments [54]. Moreover, evidence indicated that TGF-β
TNF-α. These inflammatory responses could thus change collagen ma-
secretion via M2 macrophages could play an important role in dentin
trix formation which could be assumed as a reason for poor pulp
regeneration in dental pulp [55]. Moreover, IL-17 as an inflammatory
healing process. Another study showed that suppression of IL-1β and
cytokine could be involved in pulpitis. Furthermore, Liu et al. reported
TNF-α via NF-κB knock-down could lead to differentiation of dental

3
M.M.Y. Khorasani, et al.
pulp stem cells into odontoblasts and consequently produce collagen
[64].
It should be noted that irreversibly inflamed pulp comes with a
variety of pathophysiologic and diagnostic challenges. In this respect,
gingival crevicular fluid (GCF) samples can be used to measure levels of
cytokines, but studies have revealed that some cytokines such as TNF-α
cannot be measured in this type of specimen. For example, Karapanou
et al. reported that IL-8 GCF levels significantly increased in patients
with irreversibly inflamed pulp [65]. Results of another study showed
that IL-1β had little cytotoxicity to human dental pulp cells and it was
able to induce CCL2 expression at mRNA and protein levels and also
stimulate CCL2 secretion [66]. In addition, IL-1β and TNF-α were able
to induce matrix metalloproteinase-3 mediated cell proliferation and
inhibit apoptosis in dental pulp cells [67–70]. Findings by Chi Chang
et al. further demonstrated that IL-1β could play a part in inflammatory
responses in pulpitis through stimulation of vascular cell adhesion
molecule 1 (VCAM-1) expression and soluble form of VCAM-1 pro-
duction [71]. Another study correspondingly revealed that IL-8, IL-6,
IL-8, IL-10, TNF-α, and IFN-γ expression levels were increased in irre-
versible pulpitis compared with normal dental pulp, and the ratios of IL-
8/IL-10 and IL-6/IL-10 were considered as potential markers for pulpal
inflammation in patients exposed to caries [72]. Farges et al. also found
that odontoblasts could produce IL-6 and IL-8 as inflammatory cyto-
kines and IL-10 as an anti-inflammatory cytokine following use of TLR2
agonists. Their results even confirmed that GM-CSF, IFN-γ, IL-1β, IL-2,
IL-4, IL-5, IL-7, IL-12 (p70), IL-13, and TNF-α led to no alteration in this
axis [32]. This could be indicative of the fact that no change in ex-
pression of the mentioned cytokines in pulpitis might be due to the use
of another signaling pathway such as TLR4 or others. In contrast,
findings by Horst et al. demonstrated that IL-1β, IL-1α, and TNF-α
expressions could significantly amplify in odontoblast layers of human
teeth and IL-1β might intensify production of antimicrobial peptides
such as human beta-defensin-2 by odontoblasts [73,74]. In this regard,
Shida et al. reported that; among IL-1β, IL-6, IL-8, and TNF-α in-
flammatory cytokines, only IL-8 was affected by dental pulp neuro-
peptides and its increased expression could be responsible for neu-
trophil recruitment and infiltration [75,76]. Furthermore, IL-17 might
be also involved in pulpitis via stimulation of IL-6 and IL-8 production
through NF-κB and mitogen-activated protein kinase (MAPK) signaling
pathways [77]. Also, irreversible pulpitis could be concomitant with a
rise in the number of pulpal T-cells and IL-2 can be thus responsible for
T-cell proliferation. Signals of IL-2 can also stimulate the release of pro-
inflammatory cytokines in degraded connective tissues. Due to in-
creased levels of IL-2 in pulpitis, it has been also proposed as a valuable
biomarker of pathologic inflammatory activity in periodontal diseases
[78,79]. Other studies have shown that levels of Th1 cytokines such as
IFN-γ and IL-4 can increase in the early phase of pulpitis induced by
Porphyromonas endodontalis [80]. In addition, findings of another study
revealed that IL-4 and IL-6 expressions increased in dental granulomas
and inflamed pulp tissues [81]. These findings indicated that Th2 re-
sponses to dental pulp granuloma could be associated with inflamma-
tion. With regard to the anti-inflammatory role of IL-10 and TGF-β,
some studies also reported that IL-10 could inhibit NF-κB, IL-8, and IL-6
expressions in inflamed dental pulp [82]. Recently, Haug et al. con-
cluded that acute dental pains following periapical or pulpal in-
flammation were related to amplified expression levels of IL-1β and IL-6
in saliva [1]. Assessment of salivary levels of IL-6 (before and after
comprehensive full mouth rehabilitation) in children with early child-
hood caries also showed that they decreased after comprehensive full
mouth rehabilitation [83]. Accordingly, Giuroiu et al. analyzed all
samples with acute and chronic pulpitis and their findings revealed that
73.80% of the samples contained IL-6 positive cells and 26.20% had IL6
negative ones in the rich-cell zone of the crown dental pulp. The au-
thors also observed that IL-6 levels in acute and chronic pulpitis sig-
nificantly increased compared with normal pulp tissues [84]. The re-
sults of the study by Chang et al. also revealed that IL-1β might be
4
Cytokine 126 (2020) 154896
involved in pulpitis via promoting intercellular adhesion molecule 1
and IL-1RI expression [85]. Besides, Th17 cells and their products could
play an important role in recruitment of neutrophils to the site of in-
flammation. One of the inflammatory products of Th17 is IL-17A, and
studies have shown that the expression of this cytokine in periapical
lesions could be significantly boosted, and neutrophil infiltration could
be realized in this area [86].
An imbalance in the extracellular matrix and also infiltration of the
inflammatory cells are thus considered as two main symptoms of pul-
pitis. In inflammatory joint diseases, TNF-α can thus inhibit sex-de-
termining region Y-box 9 (SOX9) transcription factor involved in the
balance of extracellular matrix, IL-8 expression, and related immune
response in pulpitis [87]. Due to the trigger of dental composites and
polymerization of adhesives, camphorquinone (CQ) can be thus used as
a photo-initiator. In this respect, Kim et al. demonstrated that expres-
sion levels of MMP3, IL-6, and IL-8 increased following CQ therapy
[88].
4.3. Therapeutic approaches
Several studies have been conducted on the role of different anti-
bacterial [89] and anti-inflammatory materials and drugs in treatment
of pulpitis [90,91]. This section introduces the latest approaches and
therapeutic ideas in treatment of pulpitis (Table1).
Sabir et al. introduced an anti-inflammatory resin substance titled:
Propolis (Trigona sp) [92] which is referred to as bee glue. They
showed that Propolis (Trigona sp) is able to suppress the expression of
IL-6 in a rat model of pulpitis [93]. Recently, Liu et al. used anti-IL-17
neutralizing antibody in rat pulpitis model and their findings revealed
that anti-IL-17 neutralizing antibody is able to inhibit infiltration of
inflammatory cells and also expression of TNF-α in pulpitis [56]. Ha-
shemi et al. showed that quercetin can suppress MAPK signaling
pathway and further reduce Th17 production and decrease levels of IL-
17 [94]. Another study showed that NOS inhibitors can decrease mRNA
expression of inflammatory cytokines and cyclooxygenase-2 (COX2)
enzyme in pulpitis [95]. Lee et al. also demonstrated that Terrein as a
bioactive fungal metabolite has anti-inflammatory effects through in-
hibition of the NF-κB signaling pathway via blocking activation of Akt.
These findings strongly recommend the potential anti-inflammatory
role of Terrein in pulpitis [96]. Takimoto et al. reported that MMP-3
can have anti-inflammatory properties and may be useful for modula-
tion of inflammatory responses in pulpitis [97,98]. Fluocinolone acet-
onide (FA) as one of the steroidal anti-inflammatory drugs is effective in
suppressing inflammatory responses and can exert its effects by reg-
ulation of the NF-κB pathway and activation of the activator protein 1
(AP-1) pathway. Liu et al. suggested that FA is a potential new treat-
ment in inflammatory-based bone/teeth disorders [99]. Isett et al.
showed that in irreversible pulpitis after intraosseous injection of me-
thylprednisolone (an anti-inflammatory glucocorticoid), pulpal levels of
PGE2 were decreased one day after the injection in pulpitis [100].
Catechins including epigallocatechin-3-gallate (EGCG) and epigalloca-
techin (ECG) are a type of phenolic compound very abundant in cocoa,
tea, and berries with potent antioxidant properties [101]. A study re-
ported that increased levels of IL-1β, VEGF, and COX‐2 in stimulated
HDPCs were reduced following treatment with EGCG and ECG [102].
The findings suggest that these compounds may have valuable anti‐-
inflammatory effects in treatment of pulpitis [103]. All-trans retinoic
acid (ATRA) also has an inhibitory effect on the expression of MMP-2 in
HDPCs, which suggests that ATRA may be a potential candidate in
treatment of pulp tissue inflammation [104]. Another study aimed to
evaluate the effects of aminoguanidine (AG) as an inhibitor of iNOS and
further inflammatory response in periapical lesions in canine teeth of
cats [105]. MMP‐inhibitor chemically modified tetracycline‐3 (CMT‐3)
is able to inhibit MMP and pulpal inflammation whereas using this
MMP inhibitor can cause spreading of necrosis in root canals and also
periapical lesion formation [106]. Additionally, Bei et al. reported that
 M.M.Y. Khorasani, et al.

Table 1
Demonstrates the latest studies and therapeutic approaches in the treatment of pulpitis.
Author Name of drug or compound Mechanism of action Type of study Clinical outcome Ref No.

Sabir et al. Propolis (Trigona sp) Suppress the expression of IL-6 Experemental – 93
Liu et al. anti-IL-17 neutralizing antibody IL-17 and also suppress the expression of IL-6 Experemental/Human Decrease inflammation of dental pulp 56
Hashemi et al. Quercetin Inhibition of MAPK, Th17, and IL-17 Human Decrease inflammation of dental pulp 94
Kawashima et al. NOS inhibitor Inflammatory cytokines and COX2 Experemental – 95
Lee et al. Terrein Akt and NF-κB Human Decrease inflammation of dental pulp 96
Eba et al. MMP3 Modulation of inflammatory responses Human Decrease inflammation in mild irreversible pulpitis 98
Liu et al. Fluocinolone acetonide Regulation of the NF-κB pathway Human New treatment for inflammation‐associated bone/teeth diseases. 99
Isett et al. Methylprednisolone PGE2 Human Decrease inflammation of dental pulp 100
Dias et al. EGCG and ECG IL-1β, VEGF, and COX‐2 Human Decrease inflammation of dental pulp 102,103
Kim et al. ATRA MMP-2 Human Control the inflammation of pulp tissue in vital pulp therapy and regenerative endodontics 104
Farhad et al. Aminoguanidine iNOS Experemental – 105
Tjäderhane et al. CMT‐3 MMPs Experemental – 106

5
Bei et al. ASH1L MMPs Experemental – 107
Kim et al. Glutamine Inhibition of the MAPK and NF‐κB Human Decrease inflammation of dental pulp 108
Ko et al. GV1001 peptide Inhibit activation of signaling adaptor Human Anti-inflammatory actions in pulpitis without significantly affecting cell viability 109
molecules
Jeong et al. Sappanchalcone Suppress the expression of IL-1β, NO, TNF-α, Human Anti-inflammatory properties in Periodontal, pulpal and periapical inflammatory lesion 110
PGE2
Choi et al. Ketoprofen MAPK and inflammatory cytokines Human Decrease inflammation of dental pulp 111
Aupaphong et al. Zingiber cassumunar Roxb Decreasing production of PGE2 and COX-2 Human Decrease inflammation of human gingival fibroblasts 112
Yu et al. PPARγ Decreasing production of ICAM-1, VCAM-1, Human Decrease inflammation of dental pulp 113
and MMPs
Wang et al. Betamethasone Inhibition of NF-κB Human Anti inflammatory effects on human dental pulp stem cells and an osteoclast effect on human 114
exfoliated deciduous teeth (SHED)
Martínez-Herrera et al. Eugenol Anti-inflammatory effects Human The findings are relevant for dentistry, when considering the application of safer pulp 116
treatments to grossly carious children’s teeth
Wang et al. Resveratrol Modulating the inhibitory autophagy-JNK Human Resveratrol might be beneficial to improve pulpal damage during the acute phase of 117
signaling pathway inflammation in vital pulp therapy
Kim et al. Scutellaria baicalensis Inhibition of cytokine expression Experemental – 118
Cytokine 126 (2020) 154896
M.M.Y. Khorasani, et al.
ASH1L (a histone-lysine N-methyltransferase enzyme) inhibits the
function of MMPs in pulpitis [107]. Studies also reported that gluta-
mine has an anti‐inflammatory effect through MKP‐1 activation and
inhibition of the MAPK and NF‐κB signaling pathways in LPS‐stimulate
HDPCs [108]. Ko et al. demonstrated that GV1001 peptide with an-
ticancer and anti-inflammation properties can inhibit activation of
signaling adaptor molecules in a wide range of cells. Anti-inflammatory
actions of GV1001 peptide in LPS-stimulated pulpitis does not re-
markably affect cell viability [109]. Sappanchalcone exhibits anti-in-
flammatory effects in LPS-stimulated human periodontal ligament
(hPDL) cells and could possibly constitute a therapeutic approach for
pulpitis [110]. Ketoprofen also suppress expression of inflammatory
cytokines in LPS-stimulate dental pulp cells via regulation of the MAPK
signaling pathway [111]. Anti-inflammatory effects of Zingiber cassu-
munar Roxb was tested by Aupaphong et al. who observed that some
ingredients of Zingiber cassumunar Roxb can suppress inflammatory
responses in HDPCs by decreasing production of PGE2 and COX-2
[112]. It has been well established that peroxisome proliferator acti-
vated receptor gamma (PPARγ) plays a pivotal role in regulating in-
flammatory responses. Yu and his colleagues showed that PPARγ re-
duced production of ICAM-1, VCAM-1, and MMPs [113]. These results
suggested that using PPARγ may be beneficial in treatment of pulpitis.
Recently, Wang et al. showed that Betamethasone has an anti-in-
flammatory effect on LPS- stimulated dental pulp stem cells via in-
hibition of NF-κB signaling pathway [114]. Pita et al. stated that the
capability of pilocarpine to inhibit MMP-3, PGE2, iNOS activity, and
muscarinic acetylcholine receptors mutation induced by pulpitis could
be valuable in treatment of dental pulp inflammation [115]. One of the
most commonly used capping materials of pulp therapy in primary
teeth is Eugenol (mixed with zinc oxide powder). Eugenol known as
phenylpropanoid formally derived from guaiacol with an allyl chain
substituted para to the hydroxy group and it is considered as an anti-
inflammatory mediator in inflamed dental pulp tissue of primary teeth
[116]. Wang et al. reported that resveratrol inhibits inflammatory cy-
tokines expressed by DPSCs via modulating the inhibitory autophagy-
JNK signaling pathway. Furthermore, resveratrol may be useful for
ameliorate pulpal damage throughout the acute phase of inflammation
in treatment of vital pulp [117]. Scutellaria baicalensis (SB) is com-
monly used as a healing plant to treat numerous inflammatory diseases.
It is suggested that SB, thanks to its anti-inflammatory properties and
inhibition of cytokine expression, might be beneficial in ligature-in-
duced periodontitis and pulpitis [118].
The mineral trioxide aggregate (MTA) material is a strongly alkaline
preparation effectively inhibits the growth of microorganisms and in-
flammatory processes in live pulp as well as it stimulates mineralization
processes. Reyes-Carmona et al. in a study of influence of MTA on
biochemical processes in living animal tissues, explain its biominer-
alization and regenerative abilities [119]. Prepared dentin samples
from extracted human teeth, filled with MTA material, calcium hy-
droxide or left empty, were implanted subcutaneously in the back of
mice. In tissues collected from this area, the authors demonstrated
overexpression of pro-inflammatory cytokines and anti-inflammatory
cytokine - interleukin-10. Moreover, the authors observed increased
expression of highly bactericidal myeloperoxidase, the NF-κB involved
in the immune control mechanism of the inflammatory process, cy-
clooxygenase-2 (COX-2) and VEGF. The levels of the above agents were
highest on the first day of the acute inflammatory phase after using
both preparations. Based on these studies it was found that MTA creates
an environment conducive to tissue recovery [119].
Pro-inflammatory cytokines such as IL-1β, TNF-α and pros-
taglandins (PG) play an important role in cell maturation, differentia-
tion and activation. They take part in the initiation of a cascade of re-
generative processes of the pulp tissue. TNF-α has the ability to activate
immune cells. In the course of the immune response, it induces the
synthesis of pro-inflammatory cytokines, including IL-1β. The main role
of IL-1β in the inflammatory response is the induction of COX-2
6
Cytokine 126 (2020) 154896
synthesis. Recent evidence indicates that COX-2 induces the expression
of VEGF and thus angiogenesis. The ability to initiate reparative dentine
formation and cementogenesis by MTA is explained by Reyes-Carmona
et al. with the alkalinity of the material and precipitation of apatites by
MTA in the acute phase of inflammation [119]. This can cause changes
in expression of genes of various cell types, contributing to repair and
mineralization of dental tissues.
In addition, related studies showed that using dental hygienic de-
vices and other mechanical therapies or materials might have different
impacts on cytokine levels and further inflammatory responses in
dental pulp inflammation. O'Beirne et al. stated that the sonic tooth-
brush is more beneficial in resolving inflammation in patients with
moderate periodontal disease in comparison with manual brushes
[120]. Findings by Duarte et al. demonstrated that anti‐infective me-
chanical therapy may locally reduce TNF‐α levels, receptor activator of
nuclear factor‐kappa B ligand (RANKL), and osteoprotegerin (OPG).
These occurrences could improve clinical parameters in peri‐implant
tissues [121]. Another study showed that oral irrigation with water for
two weeks had therapeutic advantages in patients with adult period-
ontitis through reduction of GCF levels of the pro‐inflammatory cyto-
kines and an increase in the GCF levels of anti-inflammatory cytokines
such as IL-10 in comparison with routine oral hygiene alone [122]. An
experimental investigation evaluated the biocompatibility of a novel
calcium aluminate cement (EndoBinder) in subcutaneous tissue of rats
in comparison with calcium hydroxide hard-setting and cement mineral
trioxide aggregate. The results showed that none of these materials had
a significant effect on the levels of inflammatory cytokines over a three-
month period [123]. Recently, Sijari et al. also showed that in chronic
periodontitis patients who used a sonic toothbrush after surgery in
addition to 0.12% chlorhexidine (CHX) rinsing, GCF levels of IL-1β and
IL-8 were decreased and in these patients wound healing was ac-
celerated [124]. Findings of a randomized double‐blind clinical trial
study showed that using a single‐tuft brush containing cetylpyridinium
chloride as a bactericidal agent, dipotassium glycyrrhizate as an anti‐-
inflammatory drug and allantoin as a promotor of cell proliferation and
wound healing (over‐the‐counter (OTC) medication) is able to reduce
IL-1β, IL-6, and IL-6 in patients with chronic periodontitis [125]. These
results showed that OTC is profitable in treatment of chronic period-
ontitis. Treatment with conventional labial fixed appliance and with
aligners can affect GCF levels of inflammatory cytokines. Gujar et al.
showed that GCF levels of IL-1α, IL-1ß, IL-2, IL-6, IL-8, and TNF-α in-
creased after 3 weeks both after treatment with aligners and with
conventional labial fixed appliance [126]. A surface sealant is a dental
treatment proposed to inhibit tooth decay and enamel decalcifications
in patients with fixed orthodontic appliances. A study by Şen et al.
demonstrated that surface sealant had a remarkable effect on the GCF
levels of inflammatory cytokines [127].
5. Concluding remarks
According to findings of the latest studies, inflammatory cytokines
play an important role in initiation of immune responses in the pulp
tissue following bacterial infection. However, production and secretion
of these immune system mediators can act as a double-edged sword. On
the one hand, it causes inflammation and tissue damage of the dental
pulp and, on the other hand, causes infiltration of immune cells and
removal of the infectious agent. Therefore, in order to reduce compli-
cations of cytokines and inflammation, various compounds and drugs
are being studied and it is likely that in the future many of these
compounds will be used as a medicine to treat inflammation of human
pulpitis. Finally, broader studies in this area and measurements of other
cytokines using microarray techniques can help to better understand
the network performance of cytokines in dental pulp inflammation and
other diseases associated with teeth, bone, and gums.
M.M.Y. Khorasani, et al.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Acknowledgment
The Rafsanjan University of Medical Sciences has financially sup-
ported this project.
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