Rci i c w t r t iclc

By Dr Harold E. h o d i s , DDS, Clniversity of California, San Francisco.

Address for correspondence: Dr tlarold Goodis, University of California. School of Denlislry, San Francisco, CA 94143. Email: Harold.Gwdis@ucsf.cdu

Endodontics And Pulp Biology: The Impact Clinically

Editor's Note: This article is a precis of a presentation given at the Fourth TPEC conference in Port Douglas in September 2004.
standing of the underlying biology, leading to development of new clinical interventional strategies. Improvements will be seen in diagnosis and treatment of pulpal and periradicular diseases T o lead this new revolution, and effectivelytranslate new science and technology, clinicians must guide scientists (2). The following topics will review the latest investigations that may lead to changes in thinking and care delivery in the 2 Ist century

Abstract
Endodontists in clinical practice are uniquely situated to lead the effort of transferring translational laboratory and clinical research to their practices. This paper reviews the investigations presently being conducted around the world. The work presented is an overview of the progress being made to ensure retention of teeth with various forms of pulpal and periradicular diseases.

Ageing
A survey of Diplomates of the American Board of Endodontists found that the character of specialist practices was changing (3) A substantial majority (59%) indicated that the number of patients 65 years of age or older in their practices was increasing and the endodontic treatment of generally healthy teeth (absence of caries, restorations. periodontal diseases) was more common (40% of respondents) The study concluded that it is increasingly important to define the impact of ageing on the biology of the dental pulp, pulpal diseases and their impact on treatment modalities available Access to a cohort of men enrolled in a normative longitudinal ageing study allowed review of full mouth radiographs and the results of oral and physical examinations (4) Records were recorded from the inception of the study in 1963 to date Radiographs taken every three years of lower premolars. unrestored and caries-free with no periodontal disease. were reviewed for possible diminution of the root canal space, both for loss in height and narrowing Typical radiographs taken in subjects at 45 to 80 years of age disclosed marked narrowing of the root canal space. The study concluded that ageing is a major determinant of root canal closure and the physiologic closure that occurs in ageing may result in more difficult treatment choices in teeth that are uninvolved from the standpoint of previous dental treatment This study confirmed earlier work (5) which found reductions in mesiodistal widths. heights and diameters of root canal spaces with advancing age (40 to 60 year olds) Age-related cell density changes in rat incisor pulp tissue were quantified (6) Numbers of odontoblast, sub-odontoblast and fibroblast densities were reported. Numbers decreased in each cell population and the reduction in odontoblasts and sub-odontoblasts might influence the repair capability of the dental pulp as it ages Increases in fibroblasts may influence the ability to treat pulpal diseases successfully Ageing changes of pulp tissue occurs in the vasculature These changes were examined usinga laser Ooppler flowmeter and tooth cooling to assess changes in central incisors in a group of patients between 8 and 75 years of age (7). Blood flow was reduced in all teeth at all ages with the magnitude of reduction significantly
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Introduction
The specialty of endodontics has undergone a major shift in the delivery of care over the last 15 years. The use of enhanced magnification and illumination. coupled with rotary instrumentation and digital radiography, has driven the level of care to areas of treatment never before imagined. Today, endodontics is again moving forward. not necessarily through new instrumentation. but into a better understanding of the biology of the dental pulp. The research will lead to better treatment modalities and retention of more natural teeth, with a lessening dependence on artificial replacements. Endodontists are now charged not only with delivering care, but also with developing, evaluating and applying appropriate research to prevent and treat pulpal and periradicular diseases ( I ). To accomplish this paradigm shift, the specialty needs to educate a new generation of clinical scientists who are trained to conduct translational biological research based on genomic medicine. Many oral diseases and conditions result from interactions between and among host genetics. infectious agents, environmental factors and behavioural and social systems. Together with the continuing interest in dental caries, periodontal and temporomandibular diseases and oral cancers are pulpal and periradicular diseases. Advances in genetics, genomics, proteomics and bioinformatics provide (endodontic) clinical scientists with the ability to analyse health and disease at cellular and molecular levels (2) and apply their findings to clinical modalities. This research. translational in nature, will test novel treatment plans that will increase underAUSTRALIAN CNDODONTIC JOURNALVOLUME 3 I N o I AFRlL 2005

occurring with increased age of participants. An ultrastructuralstudy of age-related changes in human pulp blood capillary endothelium used TEM to examine harvested tissue from two age groups: I0 to I7 years and over 60 years Structures such as pinocytotic vessels and microvesicles. with lipid-like vacuoles and extensive golgi complexes were seen in the older age group (8). These studies indicate a need for the development of better diagnostic methods and treatment modalities in an ageing population in order to retain their natural dentition This will allow ageing individuals to maintain a healthy diet and live better lives.

Dental Pulp Stem Cells

Recent emphasis in basic and translational cellular and molecular research has occurred in identification of clonogenic cells capable of both self-renewal and multi-lineageregeneration for their potential application in restoration of vital pulp tissue Post-natal and adult stem cells have been isolated from bone marrow, skin. neural tissue and dental epithelium (9,10) Since pulp cells express bone markers (bone sialoprotein. Type I collagen, osteocalcin) (I I ), it is possible that dental pulp stem cells (DPSCs) may have the potential through expression of these markers to engineer pulp tissue growth and reconditution of dentine. The most striking feature of DPSCs is their ability to regenerate a dentine-pulp tissue complex composed of mineralised matrix with tubules lined with odontoblasts and fibrous tissue containing blood vessels in arrangements similar to that found in normal human teeth ( 12) More recently, explants of DPSCs were compared to bone marrow stromal cells (BMSCs) in their ability to generate related tissues DPSCs were found to have formed a regenerated connective tissue with a dentine-pulp-like structure without an active haematopoietic marrow Equivalent BMSC transplants were composed of ectopic bone, demonstrating active haemopoeisis and presence of osteoclasts at the regenerated surfaces This suggests that transplanted DPSCs can not only form an odontoblast lineage. but also reside in the pulp-like connective tissues as fibroblast-like cells ( 13) Others have demonstrated that the coronal portion of the dental pulp isolated from transgenic mice contains progenitoi-stem cells capable of giving rise to new generations of odontoblast-like cells ( 14) Differences between stem cell-mediated bone and dentine regeneration found that expression of dentine sialoprotein specifically marks dentine synthesis in DPSC transplants and the cells were able to generate reparative-dentinetissue on surfaces of human dentine in VIVO (I 5) This study indicated that osteogenesis and dentinogenesis mediated by BMSCs and DPSCs might be regulated by distinct mechanisms A recent study indicated that human bone morphogenic protein-2 (BMPZ). when transplanted onto the amputated pulp stump in a dog. stimulated reparative dentine formation ( 16) These studies are exciting because the laboratory and animal studies presented indicate a possible role for specialist endodontists in reconstituting dental pulp tissue and encouraging dentine formation in teeth with iatrogenic or traumatic exposures These new methods may indeed replace vital pulp therapeutic treatments (pulp capping procedures) utilising chemical preparations such as calcium hydroxide and composite resins. neither of which are predictable in their outcomes.

of microorganisms over time This results in the continued contamination or long-term recontaminationof the root canal system, with the possibility of eventual failure of treatment A new form of treatment has been suggested that attempts the reconstitution of dental pulp tissue through revascularisation Necessary for revascularisation and reconstitutionof dental pulp tissue is a scaffold on which tissue may be rebuilt. and a blood supply to nourish the forming tissue Therefore, it is not surprising that several studies to date have used teeth with immature roots and necrotic pulp tissue to attempt revascularisation Two papers reported on young permanent teeth with immature apices The first case was an immature mandibular second premolar with an intraoral sinus tract ( 17) Cleaning and shaping was not attempted. rather. copious irrigation and antimicrobial agents were employed in the root canal system While the authors thought they had remaining vital tissue apically. more likely present was a necrotic pulp (sinus tract) On initial access, bleeding was encountered (scaffold and nourishment) At later visits. the system was irrigated and metronidazole and ciprofloxin placed At the sixth visit. calcium hydroxide was introduced into the root canal system Thirty months after initiation of treatment, radiographs disclosed complete root canal formation and diminution of the root canal space, as is generally seen with calcium hydroxide treatment The tooth responded to electrical stimulation A more recent case of an immature mandibular second premolar presented with lingual swelling, a sinus tract and an apical lesion (I8) The tooth was accessed, the canal system irrigated with sodium hypochlorite and peridex and temporised At the next appointment an endodontic explorer was placed into the canal space and then gently agitated to create bleeding to within 3 mm of the CE] and allowed to clot (scaffold and nourishment). Over the next months the sinus tract closed, the lesion healed and, at two years post procedure the root was fully formed with thickened dentine walls (canal system partial closure) Teeth were autotransplanted in dogs and pulpal tissue removed before replacement Histological examination carried out at 2 I days after treatment, showed all teeth with more than half of their pulp chambers containing pulp tissue. with total ingrowth in 75% at 30 days The new tissue consisted of well-organised and wellvascularised connective tissue ( 19) A similar study in dogs replanted immature teeth after coating with minocycline. doxycycline or saline (20) Post-operative radiographs and laser Doppler flowmeter readings were taken for two months after replantation Revascularisation was found to have recurred in 91% of the minocycline group, with less success in the other groups Various healing patterns were observed. including internal reactive dentine formation with connective and osteoid tissue present, reactive dentine with loose connective tissue. or normal pulp tissue with odontoblasts These studies are exciting from the standpoint of using a scaffold and vascular supply naturally present However, the use of various antibiotic regimens introduced another layer that might not be necessary in clinical situations Further, an attempt should be made to treat teeth more fully formed using the same protocols In so doing. treatment procedures may be developed that would result in retention of teeth that otherwise would be lost and replaced with implants or fixed prostheses

Dental Pulp Revascularisation

Contemporary root canal treatment involves the cleaning and shaping of the canal space in order to receive a three-dimensional packing material Neither the cleaning process nor the packing procedure appear to guarantee sterility or prevention of leakage
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Tissue Engineering
Interrelated with the topics presented above is the concept of maintenance of the dentine-pulp complex Considerations of health and disease present new methods of treatment in the preservation
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of the dental pulp and continued formation of dentine The reader is referred to excellent reviews of the results of this research. which has led to developments 01 treatment modalities using growth factors as the key mediators in the healing process (21. 22) Conclusions stress that intrinsic and extrinsic gi owth factors may be utilisedto affect healing and play a pivotal role signaling the events of tissue formation and repair The suggested biological approaches to tissue regeneration repair provide blueprints for regeneration of dental tissues. The process necessitates the use of growth factors as components of the matrix critical in providing regulation of cell behaviour to ensure physiologic-like function These approaches offer significant potential for clinical management of dental diseases to maintain tooth vitality Several studies have used different growth factors in these pimesses Bone sialoprotein(BSP) was found to be the most effective molecule when compared to bone morphogenic protein 7 (BMP7) in induction of a homogeneous and wellmineralised reparative dentine. BMP7 formed an osteodentine type of reparative dentine (23) There were differences in the type of dentine formed coronally and radicularly. indicating different mechanisms in recruitment of cells capable of differentiation into osteoid or dentine-like structures While the last study required a natural scaffold (dentine matrix) in regenerating dentine. others have suggested the use of biodegradable polymer scaffolds (24) Porcine third molar tooth buds were dissociated into single-cell suspensions and seeded onto biodegradable polymers and grown in rat hosts After 20 to 30 weeks recognisable tooth structures formed containing dentine. odontoblasts, a well-defined pulp chamber. the start of Hertwig's root sheath epithelium. putatative cementoblasts and a morphologically-correct enamel organ with fully-formed enamel The results confirmed the successful generation of a tooth crown. suggesting the presence of epithelial and mesenchymal DPSCs in porcine tooth tissues The use of transforming growth factor beta (TGF-f3)available in dentine matrix may provide a pool of bio-active molecules for tissue regeneration Associated with these growth factors are latencyassociated peptides (LAPS).which may influence their activity (25) A LAP was associated with each TGF-P factor and were found in odontoblasts. pulpal cells and predentine and may be important in regulationof TGF-P activity and modulate tissue response to injury An interesting review of the application of BMPs in dental tissue engineering was recently presented The authors concluded that, despite increasingly complex and redundant signaling pathways that underlie irritation. pattern formation. morphogenesis and cytodifferentiation. it remains unclear how these pathaays specify discrete tooth morphogenesis. that is. incisors. cuspids. bicuspids and molars (26) In summary, the ultimate goals of regenerative pulp treatment strategies are to reconstitute normal tissues at the pulp-dentine junction. and regulation of tissue-specific processes of reparative dentine formation Promising biologically-active substances should be investigated by careful evaluation in well-designed pre-clinical investigations as well as in long-term clinical trials prior to their introduction in clinical situations (27) An overall approach to a better understanding of the biology of the dental pulp-dentine complex in relation to clinical treatment modalities to benefit dental patients is at hand The specialty of endodontics arid the clinicians involved are well positioned to lead these endeavours

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20. de Souza Ritter AL. Ritter AV. Murrah V. Sigurdsson A. Trope M. Pulp revascularisation of replanted immature dog teeth after treatment with minocycline and doxycycline assessed by laser Doppler flowmetry. radiography and histology. Dent Traumatol 2004; 20:75-84. 2 I. Smith AJ. Vitality of the dentin-pulp complex in health and disease; growth factors as key mediators. J Dent Ed 2003; 67~678-89. 22. Goldberg M. Smith AJ. Cells and extracellular matrices of dentin and pulp: a biological basis for repair and tissue engineering. Crit Rev Oral Biol Med 2004; I 5: 13- 17. 23. Goldberg M. Six N. Decup F. Buch D. Maid Sohelli E. Lasfargues J-J. et ol. Application of bioactive molecules in pulpcapping situations. Adv Dent Res 200 I ; I5:9 1-5.

24. Young CS. Terada 5. Vacanti JF! Honda M. Bartlett JD, Yelick PC. Tissue engineering of complex tooth structures on biodegradable polymer scaffolds. J Dent Res 2002; 81:695 700. 25. Sloan AJ. Moseley R. Dobie K, Waddington RE Smith AJ. TGF-P latency-associated peptides (LAPS) in human dentin matrix and pulp. Tissue Res 2002; 43:38 I ..86. 26. Nakashima M, Reddi AH. The application of bone morphogenetic proteins to dental tissue engineering. Nature Biotech 2003: 9: 1025-32. 27. Tziafas 0. The future role of a molecular approach to pulpdentinal regeneration. Caries Res 2004; 28:3 14-20.

Pain Management

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