Repurposing Metformin for periodontal disease management as a form of oral-systemic preventive medicine.

BACKGROUND: Despite the improvements in treatment over the last decades, periodontal disease (PD) affects millions of people around the world and the only treatment available is based on controlling microbial load. Diabetes is known to increase the risk of PD establishment and progression, and recently, glucose metabolism modulation by pharmaceutical or dietarian means has been emphasised as a significant modulator of non-communicable disease development. METHODS: The impact of pharmaceutically controlling glucose metabolism in non-diabetic animals and humans (REBEC, UTN code: U1111-1276-1942) was investigated by repurposing Metformin, as a mean to manage periodontal disease and its associated systemic risk factors. RESULTS: We found that glucose metabolism control via use of Metformin aimed at PD management resulted in significant prevention of bone loss during induced periodontal disease and age-related bone loss in vivo. Metformin also influenced the bacterial species present in the oral environment and impacted the metabolic epithelial and stromal responses to bacterial dysbiosis at a single cell level. Systemically, Metformin controlled blood glucose levels and age-related weight gain when used long-term. Translationally, our pilot randomized control trial indicated that systemic Metformin was safe to use in non-diabetic patients and affected the periodontal tissues. During the medication window, patients showed stable levels of systemic blood glucose, lower circulating hsCRP and lower insulin levels after periodontal treatment when compared to placebo. Finally, patients treated with Metformin had improved periodontal parameters when compared to placebo treated patients. CONCLUSION: This is the first study to demonstrate that systemic interventions using Metformin in non-diabetic individuals aimed at PD prevention have oral-systemic effects constituting a possible novel form of preventive medicine for oral-systemic disease management.

Beyond oral hygiene, are capacity-altering, biologically based interventions within the moral domain of dentistry?

Oral diseases such as dental caries (DC) and periodontitis are widely prevalent, and existing approaches to managing these conditions have only a limited effect. Accordingly, there is growing interest in the development of novel biological interventions (including, among others, CRISPR-Cas9) that might, in the future, be used to prevent the development of or cure these conditions. However, in addition to familiar concerns about using biological interventions in children who cannot provide valid consent, it is not clear whether the provision of these interventions would fall within the proper domain of dentistry. In this opinion paper, we defend the view that the provision of reasonably safe and effective novel biological interventions aimed at preventing DC and periodontitis should be understood to fall within the proper domain of dentistry. To do so, we first argue that their use would be consistent with existing practice in dentistry. We then argue that: i) they may substantially increase the recipient's wellbeing and future autonomy; and ii) that their use could constitute a form of indirect preventative medicine by addressing a threat to systemic health.

Macrophage modulation of dental pulp stem cell activity during tertiary dentinogenesis.

The interaction between immune cells and stem cells is important during tissue repair. Macrophages have been described as being crucial for limb regeneration and in certain circumstances have been shown to affect stem cell differentiation in vivo. Dentine is susceptible to damage as a result of caries, pulp infection and inflammation all of which are major problems in tooth restoration. Characterising the interplay between immune cells and stem cells is crucial to understand how to improve natural repair mechanisms. In this study, we used an in vivo damage model, associated with a macrophage and neutrophil depletion model to investigate the role of immune cells in reparative dentine formation. In addition, we investigated the effect of elevating the Wnt/ß-catenin pathway to understand how this might regulate macrophages and impact upon Wnt receiving pulp stem cells during repair. Our results show that macrophages are required for dental pulp stem cell activation and appropriate reparative dentine formation. In addition, pharmacological stimulation of the Wnt/ß-catenin pathway via GSK-3ß inhibitor small molecules polarises macrophages to an anti-inflammatory state faster than inert calcium silicate-based materials thereby accelerating stem cell activation and repair. Wnt/ß-catenin signalling thus has a dual role in promoting reparative dentine formation by activating pulp stem cells and promoting an anti-inflammatory macrophage response.

Dental cell type atlas reveals stem and differentiated cell types in mouse and human teeth.

Understanding cell types and mechanisms of dental growth is essential for reconstruction and engineering of teeth. Therefore, we investigated cellular composition of growing and non-growing mouse and human teeth. As a result, we report an unappreciated cellular complexity of the continuously-growing mouse incisor, which suggests a coherent model of cell dynamics enabling unarrested growth. This model relies on spatially-restricted stem, progenitor and differentiated populations in the epithelial and mesenchymal compartments underlying the coordinated expansion of two major branches of pulpal cells and diverse epithelial subtypes. Further comparisons of human and mouse teeth yield both parallelisms and differences in tissue heterogeneity and highlight the specifics behind growing and non-growing modes. Despite being similar at a coarse level, mouse and human teeth reveal molecular differences and species-specific cell subtypes suggesting possible evolutionary divergence. Overall, here we provide an atlas of human and mouse teeth with a focus on growth and differentiation.

A new perspective to push forward a stagnated dental world.

Despite the major improvements in clinical dentistry, resulting from dental science efforts to shape current clinical dentistry, it has been almost forty years since a new therapy has reached dental practice. The focused scientific effort on evolving dental materials and equipment to facilitate their use has overshadowed the most important aim for developing new dental techniques: human biology. This opinion piece argues a new mindset in dentistry is crucial for the birthing of innovative treatments. It also discusses the path for a new era of dentistry that welcomes new biologically based approaches, including whole dental pulp and bioengineered tooth regeneration, currently being tested in cutting-edge laboratories around the world. Suggestions will be made to justify the reason clinicians must be educated in molecular biology and how universities and the General Dental Council need to prepare in-qualification or qualified dentists. A new biologically-based era of dentistry is around the corner and dentistry as we know it is changing forever.

Promotion of natural tooth repair by small molecule GSK3 antagonists.

The restoration of dentine lost in deep caries lesions in teeth is a routine and common treatment that involves the use of inorganic cements based on calcium or silicon-based mineral aggregates. Such cements remain in the tooth and fail to degrade and thus normal mineral volume is never completely restored. Here we describe a novel, biological approach to dentine restoration that stimulates the natural formation of reparative dentine via the mobilisation of resident stem cells in the tooth pulp. Biodegradable, clinically-approved collagen sponges are used to deliver low doses of small molecule glycogen synthase kinase (GSK-3) antagonists that promote the natural processes of reparative dentine formation to completely restore dentine. Since the carrier sponge is degraded over time, dentine replaces the degraded sponge leading to a complete, effective natural repair. This simple, rapid natural tooth repair process could thus potentially provide a new approach to clinical tooth restoration.