Distorted Patterns of Dentinogenesis and Eruption in Msx2 Null Mutants: Involvement of Sost/Sclerostin.

The muscle segment homeogenes Msx1 and Msx2 play a major role in tooth and bone formation. Periodontal osteoclast impairment also occurs in Msx2 null mutant mice, which is restored by overexpression of the receptor activator of NF-κB targeted in osteoclast lineage. Here, we investigated the role of Msx2 in dentinogenesis. Experiments were performed on Msx2(-/-) mice and the MDPC-23 odontoblastic cell line. After Msx2 gene silencing, real-time quantitative RT-PCR data showed significant overexpression of Runx2, Bglap, Dspp, and Alpl. Of three inhibitors of Wnt/ß-catenin signaling (Dkk1, SostDc1, and Sost/Sclerostin), only Sost was expressed in postnatal teeth and overexpressed in Msx2(-/-) tooth samples. Initial crown dentin formation-primary dentinogenesis-occurred fairly normally in Msx2(-/-) teeth, albeit with distorted cusp patterns. Later stages of tooth development were characterized by a deviation from secondary toward tertiary dentinogenesis with osteodentin formation and impaired dentin deposition leading to limited root elongation. In Msx2(-/-)/receptor activator of NF-κB-transgenic double mutants, the dentin phenotype, notably in the roots, was rescued and sclerostin levels were normalized. These data suggest that Msx2 may act indirectly on dentinogenesis by controlling osteoclast activity and the signaling network related to eruption, supporting and further extending the concept that Msx2 controls formation of mineralized tissues by inhibition of the Wnt/ß-catenin pathway; Sost in dentin and Dkk1 in bone, as previously demonstrated.

Plithotaxis, a collective cell migration, regulates the sliding of proliferating pulp cells located in the apical niche.

Using the proliferating cell nuclear antigen (PCNA) immunostaining, we previously identified, after pulp exposure, three zones of proliferating cells in the rat molar pulp. Zones I and II were in the crown near the pulp. Zone III was near the apex revealing a recruitment of mitotic cells at distance from the lesion. To gain further insight into the spatio-temporal evolution of proliferating pulp cells of zone III, we performed a longitudinal study of PCNA staining in rat molar mesial root at 3, 8, and 15 d after pulp exposure associated to implantation of unloaded or amelogenin loaded agarose beads. At day 3 after implantation, PCNA-positive cells were located in the central part of the radicular pulp. At day 8, PCNA-labeled cells were aligned in the lateral part of the pulp beneath the odontoblast/sub-odontoblast layer. At day 15, PCNA labeling became undetectable in the root and was located in the coronal pulp. These results suggest that after pulp exposure, PCNA-positive cells may migrate from the central part of the radicular pulp to the sub-odontoblast cell layer and then from the apical root to the crown. Electron microscopy and immunostaining analysis showed that pulpal cells were linked by desmosome-like and gap-junctions. Extracellular matrix was composed of thin collagen fibrils associated with glycosaminoglycans favoring cell mobility. These data suggest that the syncytium-like structure formed by pulp radicular cells may be a pre-request for plithotaxis, a collective cell migration process. This emergent mechanism may govern pulp healing and regeneration after dental lesion.

Validation of the French version of the ICHOM adult oral health standard set.

INTRODUCTION: The ICHOM Adult Oral Health Standard Set (AOHSS) recently developed by the ICHOM Oral Adult Health Working Group is a standard set of outcomes designed for its collection in clinical practice in dental health. The outcome standard set is made up of clinical-reported outcome measures (CROMs) and patient-reported outcome measures (PROMs). The purpose of this study was to translate and cross-culturally adapt the PROM section of the Standard Set in French for France to enable comprehensive evaluation of the patients' oral health quality of life in a French population. METHODS: The questionnaire was translated following the guidelines of the International Society for Pharmacoeconomics and Outcome Research (ISPOR). We included patients consulting in a dentistry clinic (n = 127) and seeking dental care. The PROM and CROM data were collected from all patients. Both reliability and the internal consistency were evaluated. RESULTS: The ICHOM AOHSS was successfully translated into French. We sampled and surveyed 126 patients in a dentistry clinic in France using the French translation of the ICHOM AOHSS. Cronbach's α was calculated to measure the internal consistency. The resulting Cronbach's α was 0.8, indicating acceptable homogeneity. CONCLUSIONS: The French version of the ICHOM AOHSS shows acceptable psychometric properties in terms of reliability and internal consistency. This translation is suitable for its implementation in a French-speaking patient population.

Enamel protein regulation and dental and periodontal physiopathology in MSX2 mutant mice.

Signaling pathways that underlie postnatal dental and periodontal physiopathology are less studied than those of early tooth development. Members of the muscle segment homeobox gene (Msx) family encode homeoproteins that show functional redundancy during development and are known to be involved in epithelial-mesenchymal interactions that lead to crown morphogenesis and ameloblast cell differentiation. This study analyzed the MSX2 protein during mouse postnatal growth as well as in the adult. The analysis focused on enamel and periodontal defects and enamel proteins in Msx2-null mutant mice. In the epithelial lifecycle, the levels of MSX2 expression and enamel protein secretion were inversely related. Msx2+/- mice showed increased amelogenin expression, enamel thickness, and rod size. Msx2-/- mice displayed compound phenotypic characteristics of enamel defects, related to both enamel-specific gene mutations (amelogenin and enamelin) in isolated amelogenesis imperfecta, and cell-cell junction elements (laminin 5 and cytokeratin 5) in other syndromes. These effects were also related to ameloblast disappearance, which differed between incisors and molars. In Msx2-/- roots, Malassez cells formed giant islands that overexpressed amelogenin and ameloblastin that grew over months. Aberrant expression of enamel proteins is proposed to underlie the regional osteopetrosis and hyperproduction of cellular cementum. These enamel and periodontal phenotypes of Msx2 mutants constitute the first case report of structural and signaling defects associated with enamel protein overexpression in a postnatal context.

Diagnostic accuracy and acceptability of molecular diagnosis of COVID-19 on saliva samples relative to nasopharyngeal swabs in tropical hospital and extra-hospital contexts: The COVISAL study.

A prospective study was conducted among different intra and extra-hospital populations of French Guiana to evaluate the performance of saliva testing compared to nasopharyngeal swabs. Persons aged 3 years and older with mild symptoms suggestive of COVID-19 and asymptomatic persons with a testing indication were prospectively enrolled. Nasopharyngeal and salivary samples were stored at 4°C before analysis. Both samples were analyzed with the same Real-time PCR amplification of E gene, N gene, and RdRp gene. Between July 22th and October 28th, 1159 persons were included, of which 1028 were analyzed. When only considering as positives those with 2 target genes with Ct values <35, the sensitivity of RT-PCR on saliva samples was 100% relative to nasopharyngeal samples. Specificity positive and negative predictive values were above 90%. Across a variety of cultures and socioeconomic conditions, saliva tests were generally much preferred to nasopharyngeal tests and persons seemed largely confident that they could self-sample. For positive patients defined as those with the amplification of 2 specific target genes with Ct values below 35, the sensitivity and specificity of RT-PCR on saliva samples was similar to nasopharyngeal samples despite the broad range of challenging circumstances in a tropical environment.

Endodontic shaping with an adapted Pitch.

UNLABELLED: Cleaning and shaping a root canal are two inseparable concepts of endodontics. Shaping facilitates the penetration of disinfecting solutions into the deepest regions of the root canal system, including those that cannot be reached by instruments. The Hero Shaper is a leading system in the European market, and the concept of the 'adapted Pitch' is of particular interest. Modifying the pitch of this instrument has made it possible to limit the screwing effect of the file in the canal considerably and to improve flexibility. In this paper, the guidelines for use of these instruments are described. Manufacturer's recommendations are presented and modified by the use of Hero Apical to achieve the fundamental principles of endodontics published by Herbert Schilder more than 30 years ago. CLINICAL RELEVANCE: The Hero Shaper system and the concept of 'adapted Pitch' may enhance the shaping of root canals prior to root filling.

Retreatment of Root Canals Filled with BioRoot RCS: An In Vitro Experimental Study.

INTRODUCTION: The purpose of this study was to compare the speed of removal of root canal filling material and re-establishment of apical patency in root canals filled with a tricalcium silicate-based sealer (BioRoot RCS [BRCS]; Septodont, Saint-Maur-des-Fossés, France) versus a zinc oxide-eugenol sealer (Pulp Canal Sealer [PCS]; Sybron Endo Kerr, Orange, CA) and to analyze the effect of the operator's experience. METHODS: One hundred twenty root canals of 40 Dentalike dental simulators (Dentsply Sirona, York, PA) were shaped with a WaveOne (Dentsply Sirona) reciprocating file using short 3-mm strokes. Root canals were obturated using a single gutta-percha cone and either BRCS or PCS. Samples treated either with BRCS or PCS were equally dispatched between experienced practitioners and junior practitioners. The time required to remove root filling material and establish apical patency was recorded for each root canal. Samples were compared according to the sealer used and the practitioner's experience (Mann-Whitney test). RESULTS: One hundred fifteen root canals were successfully retreated. No differences in the time required to remove the filling material were observed between the 2 materials for mesiobuccal or distobuccal canals (P > .05). In contrast, the procedure was longer for palatal canals filled with BRCS compared with PCS (79.10 vs 182.45 seconds, P < .01). Experienced practitioners took significantly less time than junior practitioners (P < .05). CONCLUSIONS: BRCS can be successfully removed from root canals as quickly as a zinc oxide-eugenol sealer in both mesiobuccal and distobuccal canals but not in palatal ones. The duration of the procedure was affected by the operator's experience independent of the filling material used or the canal type.

Apical limit and working length in endodontics.

UNLABELLED: Establishing the working length is an important step in endodontic treatment as inaccurate length determination may lead to failure. There is an ongoing debate regarding the extent of the apical limit of root canal preparation. This controversy is based upon different clinical opinions concerning the distance between the end point of the root canal preparation and the periodontal tissues. In this paper, we review the different schools of thought for working length determination, and how apex locators work and how they must be used for optimal accuracy. The reliability of these devices has been proven; the price is moderate and apex locators are now part of the basic armamentarium in the achievement of quality and predictable endodontic treatment. CLINICAL RELEVANCE: The technique of determining the working length from a single radiograph remains empirical, and apex locators should be considered an essential aid in establishing working length.

Protaper--hybrid technique.

UNLABELLED: Crown down preparation is the most known and described technique since the introduction of Nickel Titanium (NiTi) rotary instruments in endodontics. This technique gives good results but has limitations, such as not addressing the initial anatomy of oval or dumb-bell shaped canals. The specific design of the Protaper instruments allows use of them with a different technique and, specifically, with a brushing motion in the body of the canal. The recent introduction of hand Protaper files has expanded the range of application of this system, especially in curved canals. The 'hybrid technique', using rotary and hand files, and the advantages of the combination of both instruments, are clearly described in this article. Used with this technique, the Protaper is a very safe system to use, and more controllable, for both inexperienced and experienced practitioners alike, than other systems. CLINICAL RELEVANCE: To understand the precautions needed with rotary files, and how to use them to preserve the anatomy of the canal and get a tapered shaping, even in severely curved canals.

Influence of fractured instruments on the success rate of endodontic treatment.

UNLABELLED: The fracture of an instrument is a recognized complication in endodontics. The immediate response to a fractured instrument is frequently to regard the treatment as a failure. Several factors must, however, be taken into account to evaluate the prognosis of the tooth in this situation. The objective of the endodontic treatment with or without a fractured instrument remains the same, namely to disinfect the root canal system and prevent its recontamination. The time at which file fracture occurred during treatment and the degree of canal infection should be considered when determining the potential effect of instrument fracture on treatment outcome. Patients must be informed about an instrument fracturing in their tooth for ethical and legal reasons. The aim of this paper is to attempt to place fractured instruments in context, not to provide an in depth description of fractured instrument management techniques. CLINICAL RELEVANCE: To understand the influence of fractured instruments on prognosis in endodontics.

In vitro effects of two silicate-based materials, Biodentine and BioRoot RCS, on dental pulp stem cells in models of reactionary and reparative dentinogenesis.

BACKGROUND: Calcium silicate-based cements are biomaterials with calcium oxide and carbonate filler additives. Their properties are close to those of dentin, making them useful in restorative dentistry and endodontics. The aim of this study was to evaluate the in vitro biological effects of two such calcium silicate cements, Biodentine (BD) and Bioroot (BR), on dental stem cells in both direct and indirect contact models. The two models used aimed to mimic reparative dentin formation (direct contact) and reactionary dentin formation (indirect contact). An original aspect of this study is the use of an interposed thin agarose gel layer to assess the effects of diffusible components from the materials. RESULTS: The two biomaterials were compared and did not modify dental pulp stem cell (DPSC) proliferation. BD and BR showed no significant cytotoxicity, although some cell death occurred in direct contact. No apoptosis or inflammation induction was detected. A striking increase of mineralization induction was observed in the presence of BD and BR, and this effect was greater in direct contact. Surprisingly, biomineralization occurred even in the absence of mineralization medium. This differentiation was accompanied by expression of odontoblast-associated genes. Exposure by indirect contact did not stimulate the induction to such a level. CONCLUSION: These two biomaterials both seem to be bioactive and biocompatible, preserving DPSC proliferation, migration and adhesion. The observed strong mineralization induction through direct contact highlights the potential of these biomaterials for clinical application in dentin-pulp complex regeneration.

Pulp Inflammation Diagnosis from Clinical to Inflammatory Mediators: A Systematic Review.

INTRODUCTION: Similar to other tissues, the dental pulp mounts an inflammatory reaction as a way to eliminate pathogens and stimulate repair. Pulp inflammation is prerequisite for dentin pulp complex repair and regeneration; otherwise, chronic disease or pulp necrosis occurs. Evaluation of pulp inflammation severity is necessary to predict the clinical success of maintaining pulp vitality. Clinical limitations to evaluating in situ inflammatory status are well-described. A molecular approach that aids clinical distinction between reversible and irreversible pulpitis could improve the success rate of vital pulp therapy. The aim of this article is to review inflammatory mediator expression in the context of clinical diagnosis. METHODS: We searched PubMed and Cochrane databases for articles published between 1970 and December 2016. Only published studies of inflammatory mediator expression related to clinical diagnosis were eligible for inclusion and analysis. RESULTS: Thirty-two articles were analyzed. Two molecular approaches were described by study methods, protein expression analysis and gene expression analysis. Our review indicates that interleukin-8, matrix metalloproteinase 9, tumor necrosis factor-α, and receptor for advanced glycation end products expression increase at both the gene and protein levels during inflammation. CONCLUSIONS: Clinical irreversible pulpitis is related to specific levels of inflammatory mediator expression. The difference in expression between reversible and irreversible disease is both quantitative and qualitative. On the basis of our analysis, in situ quantification of inflammatory mediators may aid in the clinical distinction between reversible and irreversible pulpitis.

Position paper for the evaluation and management of oral status in patients with valvular disease: Groupe de Travail Valvulopathies de la Société Française de Cardiologie, Société Française de Chirurgie Orale, Société Française de Parodontologie et d'Implantologie Orale, Société Française d'Endodontie et Société de Pathologie Infectieuse de Langue Française.

Oral health is of particular importance in patients with heart valve diseases because of the risk of infective endocarditis. Recommendations for antibiotic prophylaxis before dental procedures have been restricted, but the modalities of oral evaluation and dental care are not detailed in guidelines. Therefore, a multidisciplinary working group reviewed the literature to propose detailed approaches for the evaluation and management of buccodental status in patients with valvular disease. Simple questions asked by a non-dental specialist may draw attention to buccodental diseases. Besides clinical examination, recent imaging techniques are highly sensitive for the detection of inflammatory bone destruction directly related to oral or dental infection foci. The management of buccodental disease before cardiac valvular surgery should be adapted to the timing of the intervention. Simple therapeutic principles can be applied even before urgent intervention. Restorative dentistry and endodontic and periodontal therapy can be performed before elective valvular intervention and during the follow-up of patients at high risk of endocarditis. The detection and treatment of buccodental foci of infection should follow specific rules in patients who present with acute endocarditis. Implant placement is no longer contraindicated in patients at intermediate risk of endocarditis, and can also be performed in selected high-risk patients. The decision for implant placement should follow an analysis of general and local factors increasing the risk of implant failure. The surgical and prosthetic procedures should be performed in optimal safety conditions. It is therefore now possible to safely decrease the number of contraindicated dental procedures in patients at risk of endocarditis.

Contemporary Cleaning and Shaping of the Root Canal System.

Prevention or treatment of apical periodontitis is aimed at disinfecting the root canal system so that the periradicular tissues are not vulnerable to attack from microbiota within the tooth. This is achieved by a process of cleaning and shaping the root canal space. The fundamental principles underlying this process have not changed in decades. In contrast, the armamentarium available to the clinician continues to evolve rapidly. The use of specially designed nickel titanium (NiTi) files to create a glidepath allows the clinician to manage tight curved canals more predictably in situations which would otherwise have proved too difficult using conventional techniques. Other files, designed to shape the canal, have been developed using metallurgic principles which permit NiTi files to be more flexible and resistant to cyclic fatigue. These newer systems also require fewer instruments to prepare a canal and some, which have adopted a reciprocating (rotational) motion, may only require one file. Progress is also being made in enhancing efficacy of irrigant activity using negative apical pressure systems, sonic and ultrasonic agitation techniques. These contemporary techniques used to clean and shape the root canal system should result in improved confidence and predictability when managing endodontic disease.

Comparative Physicochemical Analysis of Pulp Stone and Dentin.

INTRODUCTION: Odontoblasts are responsible for the synthesis of dentin throughout the life of the tooth. Tooth pulp tissue may undergo a pathologic process of mineralization, resulting in formation of pulp stones. Although the prevalence of pulp stones in dental caries is significant, their development and histopathology are poorly understood, and their precise composition has never been established. The aim of the present study was to investigate the physicochemical properties of the mineralized tissues of teeth to elucidate the pathologic origin of pulp stones. METHODS: Areas of carious and healthy dentin of 8 decayed teeth intended for extraction were analyzed and compared. In addition, 6 pulp stones were recovered from 5 teeth requiring root canal treatment. The samples were embedded in resin, sectioned, and observed by scanning electron microscopy and energy-dispersive spectroscopy. X-ray diffraction was performed to identify phases and crystallinity. X-ray fluorescence provided information on the elemental composition of the samples. RESULTS: Pulp stones showed heterogeneous structure and chemical composition. X-ray diffraction revealed partially carbonated apatite. X-ray fluorescence identified P, Ca, Cu, Zn, and Sr within dentin and pulp stones. Zn and Cu concentrations were higher in pulp stones and carious dentin compared with healthy dentin. CONCLUSIONS: Pulpal cells produce unstructured apatitic mineralizations containing abnormally high Zn and Cu levels.

Exploiting the Bioactive Properties of the Dentin-Pulp Complex in Regenerative Endodontics.

INTRODUCTION: The development of regenerative endodontic therapies offers exciting opportunities for future improvements in treatment outcomes. METHODS: Advances in our understanding of regenerative events at the molecular and cellular levels are helping to underpin development of these therapies, although the various strategies differ in the translational challenges they pose. The identification of a variety of bioactive molecules, including growth factors, cytokines, chemokines, and matrix molecules, sequestered within dentin and dental pulp provides the opportunity to present key signaling molecules promoting reparative and regenerative events after injury. RESULTS AND CONCLUSIONS: The protection of the biological activity of these molecules by mineral in dentin before their release allows a continuing supply of these molecules, while avoiding the short half-life and the non-human origin of exogenous molecules. The ready release of these bioactive molecules by the various tissue preparation agents, medicaments, and materials commonly used in endodontics highlights the opportunities for translational regenerative strategies exploiting these molecules with little change to existing clinical practice.

Assessment and Quantification of Noncollagenic Matrix Proteins Released from Human Dentin Powder Incorporated into a Silated Hydroxypropylmethylcellulose Biomedical Hydrogel.

INTRODUCTION: The dentin extracellular matrix is a reservoir of bioactive molecules sequestered into dentin during dental initial development. They can be released under pathological conditions but also by controlled demineralization with bioactive materials. The purpose of this study was to investigate the ability of a biomedical hydrogel to extract and release these proteins from smashed dentin. METHODS: Smashed dentin was obtained with 2 different kinds of grinders: a blade mill and a zirconia mortar grinder. The particle size was measured by scanning electron microscopy. Dentin powder was incorporated into a silated hydroxypropylmethylcellulose hydrogel. Several types of mixtures with variable parameters were tested. The mixtures were immersed into phosphate-buffered saline. The supernatants were collected, and the total released proteins were quantified by gel shift migration and Coomassie staining. The presence of transforming growth factor beta 1 was investigated by Western blot analysis and the ELISA. RESULTS: The mixture dentin powder/hydrogel released proteins (from 49.1 µg/mL-137.9 µg/mL according to the mixtures). The release kinetics was growing and started from the first day until stabilization at 14 days. The quantity of released proteins was directly related to the size of the particles and the weight of the powder incorporated into the hydrogel. Gel shift with direct revelation by ultraviolet and Western blot analyses confirmed the presence of transforming growth factor beta 1 using ELISA. CONCLUSIONS: We showed that silated hydroxypropylmethylcellulose hydrogel was able to extract dentin matrix proteins from smashed dentin powder. This mixture could be considered a new way of dental treatment for the dentin-pulp complex and bone regeneration.

Regenerative endodontics: regeneration or repair?

Recent advances in biotechnology and translational research have made it possible to provide treatment modalities that protect the vital pulp, allow manipulation of reactionary and reparative dentinogenesis, and, more recently, permit revascularization of an infected root canal space. These approaches are referred to as regenerative procedures. The method currently used to determine the origin of the tissue secreted during the repair/regeneration process is largely based on the identification of cellular markers (usually proteins) left by cells that were responsible for this tissue production. The presence of these proteins in conjunction with other indicators of cellular behavior (especially biomineralization) and analysis of the structure of the newly generated tissue allow conclusions to be made of how it was formed. Thus far, it has not been possible to truly establish the biological mechanism controlling tertiary dentinogenesis. This article considers current therapeutic techniques to treat the dentin-pulp complex and contextualize them in terms of reparative and regenerative processes. Although it may be considered a semantic argument rather than a biological one, the definitions of regeneration and repair are explored to clarify our position in this era of regenerative endodontics.