牙髓炎的活髓保存及再生治疗新进展：从基础到临床

近年关于牙髓炎治疗的研究取得了较大进展, 这主要得益于牙髓炎治疗的基础和临床研究的飞速进展, 一些基础研究已转化为临床实践。牙髓炎检测方法的研究进展可以帮助临床医师更准确地诊断牙髓炎的状态, 并采取相应的治疗手段, 包括间接或直接盖髓术、牙髓切断术、牙髓再生术和根管治疗术等。针对牙髓炎的诊断理念、牙髓免疫防御和修复功能研究以及新型盖髓剂材料研究均有了较大进展, 牙髓炎的活髓保存治疗成功率显著提高。对于难以实现活髓保存治疗的弥漫性冠髓炎或根髓炎, 除根管治疗术外, 牙髓血运重建、细胞归巢和牙髓干细胞移植牙髓再生等牙髓再生术也可作为一种治疗选择。本文重点阐述牙髓炎治疗研究进展和相关的临床转化实践, 旨在为牙髓炎的活髓保存和牙髓再生治疗提供参考。     

恒牙牙髓炎的活髓保存治疗

活髓保存治疗是尽最大限度保留健康牙髓组织、提高患牙远期保存率的方法,但其被认为适应范围有限,疗效不确定。牙髓组织的病理学改变是决定临床治疗方案和评估疗效的组织学基础,而常用的检查方法无法全面反映牙髓的病理学改变。随着对牙髓生物学研究的深入、现代诊疗技术及盖髓材料的革新,活髓保存治疗越来越多地被应用在以往被认为需要摘除牙髓的患牙上。本文根据循证文献,就牙髓炎病理改变、恒牙牙髓炎活髓保存治疗的临床研究等方面进行分析讨论和总结。在活髓保存治疗的过程中综合运用包括激光多普勒血流仪、组织氧检测仪、核磁共振成像、牙科显微镜等技术与方法准确判断牙髓炎症状态,并依此决定牙髓的去留程度;结合严格的感染控制与高生物相容性盖髓材料的使用,活髓保存治疗可运用在部分龋源性露髓患牙与出现不可复性牙髓炎症状的恒牙上。未来的研究则需从牙髓修复再生机制、牙髓炎诊断精准化、盖髓材料的升级等方面提高恒牙牙髓炎活髓保存治疗的成功率。     

恒牙活髓切断术-从基础到临床的新进展

活髓切断术是临床常规的活髓保存手段,基于微创牙髓治疗的理论,能够最大限度地保存牙齿软硬组织的生理功能。为提高活髓切断术的临床预后,本文综述了近年来活髓切断术相关的基础和临床研究进展,总结了关于活髓切断的临床操作程序,以期为今后临床实践和研究提供一些参考。     

牙髓再生的临床应用与未来

旨在修复牙髓牙本质复合体的牙髓再生治疗是近年来的研究热点,目前仅有牙髓血运重建技术已实现临床初步应用,而干细胞移植和细胞归巢等技术尚处于临床前阶段.经过多年的基础研究和临床实践,牙髓再生特别是牙髓血运重建技术在取得进展的同时也暴露出不少问题,包括概念混淆、适应证选择不当、评价标准不完善等.为此,本综述从牙髓血运重建技术...     

牙髓炎保髓治疗的临床应用

对牙髓炎的保髓治疗一直是牙髓病学领域所研究的重点［１］,其基础研究（动物实验）目前已取得较好进展,但由于人具有主观反映的特异性,如对疼痛感觉,尤其是隐痛的反映,是动物所无法表达的,而牙髓炎对人类最直接、最强烈的反应是疼痛,或由于疼痛而引起的焦虑现象。...     

不可复性牙髓炎的活髓保存治疗:生物学基础与临床进展

保存牙髓活力、维持根尖周组织的健康、进行最小程度的有创性治疗是当代牙髓病学发展的前沿进展。不可复性牙髓炎是牙髓病学的重要研究内容之一。活髓保存治疗在不可复性牙髓炎领域中的应用与探索,有望推动牙髓炎诊疗的精准化、微创化进程。本文对活髓保存治疗在不可复性牙髓炎诊断、治疗等方面的应用及面临的挑战进行系统阐述。     

成熟恒牙牙髓炎活髓保存治疗的研究与应用

保存活髓对于成熟恒牙的长期保存具有重要意义。近年来,随着牙髓生物学的深入研究,开展牙髓微创治疗,保存剩余健康牙髓组织,成为成熟恒牙牙髓炎治疗的新目标。本文将从成熟恒牙牙髓炎的分类、治疗方法、预后影响及激光应用等方面,对成熟恒牙活髓保存的研究及临床应用进行总结概括。     

龋源性露髓成熟恒牙活髓保存治疗的研究进展

保存牙髓活力、维持牙髓功能、尽可能保留患牙的微创治疗理念是当代成熟恒牙牙髓治疗的重要发展趋势。本文基于最新研究,归纳龋源性露髓的成熟恒牙活髓保存治疗的临床疗效及其影响因素,简要介绍相关研究的新进展,以期为临床开展活髓保存治疗及今后该领域的发展提供参考。     

活髓切断术治疗乳牙牙髓炎的临床观察

本文报道活髓切断术治疗 5 7例 61个乳牙早期或单纯性牙髓炎的近期疗效。男 3 5例 ,女 2 6例 ,年龄 4～ 11岁。配方 :氢氧化钙粉 4份 ,碘仿粉 3份 ,甲哨唑粉 2份 ,双氯灭痛粉 2份 ,强的松粉 2份 ,用丁香油按比例调成糊剂。方法 :局麻下严格按活髓切断术的方法切断冠髓 ,使牙髓在根管口成为整齐的断面。用温热的生理盐水冲洗髓腔 ,棉球吸干。如出血较多 ,可用小棉球蘸 1ｍＬ/Ｌ肾上腺素放到根管口牙髓断面上 ,稍后取出即可止血。将调好的盖髓剂敷于根管口断面上 ,丁香油水门汀垫底 ,玻璃离子水门汀充填。结果 :观察 0 .5～ 1年 ,患牙无自觉症…     

牙髓组织再生中I型胶原支架最佳浓度的体外研究

目的：探讨牙髓组织再生研究中不同浓度的I型胶原支架对牙髓细胞的分布及数量的影响,确定最佳胶原材料的浓度。方法实验组将10μl移液枪头一端封闭,做为人工根管;对照组为两端开放的10μl移液枪头。体外培养转染绿色荧光蛋白的C57BL/6小鼠牙髓细胞,并将其分别接种于1%,2%和3%的I型胶原支架中,注入10μl的实验组和对照组移液枪头内,于6孔板中培养2周。荧光显微镜下观察牙髓细胞的分布,胰蛋白酶消化后计算各浓度中牙髓细胞的数目。结果对照组各浓度的胶原支架内牙髓细胞均生长良好。实验组1%和2%的I型胶原中的牙髓细胞生长良好,且细胞计数无显著性差异（ P〉0.05）;浓度为3%的胶原中牙髓细胞在人工根管的中、上段少有生长,且与1%和2%的胶原支架中的牙髓细胞数目差异有统计学意义（P〈0.01）。结论 I型胶原支架材料浓度从1%提高到2%,可减少材料的收缩,并能保证细胞生长良好,2%的I型胶原浓度是牙髓组织再生中最佳浓度。     

Dental pulp stem cells for in vivo bone regeneration: A systematic review of literature

ObjectiveThis review of literature was aimed to assess in vivo experiments which have evaluated the efficacy of dental pulp stem cells (DPSCs) for bone regeneration.DesignAn electronic search of English-language papers was conducted on PubMed database. Studies that assessed the use of DPSCs in bone regeneration in vivo were included and experiments evaluating regeneration of hard tissues other than bone were excluded. The retrieved articles were thoroughly reviewed according to the source of stem cell, cell carrier, the in vivo experimental model, defect type, method of evaluating bone regeneration, and the obtained results. Further assessment of the results was conducted by classifying the studies based on the defect type.ResultsSeventeen papers formed the basis of this systematic review. Sixteen out of 17 experiments were performed on animal models with mouse and rat being the most frequently used animal models. Seven out of 17 animal studies, contained subcutaneous pockets on back of the animal for stem cell implantation. In only one study hard tissue formation was not observed. Other types of defects used in the retrieved studies, included cranial defects and mandibular bone defects, in all of which bone formation was reported.ConclusionWhen applied in actual bone defects, DPSCs were capable of regenerating bone. Nevertheless, a precise conclusion regarding the efficiency of DPSCs for bone regeneration is yet to be made, considering the limited number of the in vivo experiments and the heterogeneity within their methods.     

Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review

Introduction

This systematic review aims to illustrate the outcome of vital pulp therapy, namely direct pulp capping, partial pulpotomy, and full pulpotomy, in vital permanent teeth with cariously exposed pulp.

Methods

Electronic database MEDLINE via Ovid, PubMed, and Cochrane databases were searched. Hand searching was performed through reference lists of endodontic textbooks, endodontic-related journals, and relevant articles from electronic searching. The random effect method of weighted pooled success rate of each treatment and the 95% confidence interval were calculated by the DerSimonian-Laird method. The weighted pooled success rate of each treatment was estimated in 4 groups: >6 months-1 year, >1-2 years, >2-3 years, and >3 years. All statistics were performed by STATA version 10. The indirect comparison of success rates for 4 follow-up periods and the indirect comparison of clinical factors influencing the success rate of each treatment were performed by z test for proportion (P < .05).

Results

Overall, the success rate was in the range of 72.9%-99.4%. The fluctuation of the success rate of direct pulp capping was observed (>6 months-1 year, 87.5%; >1-2 years, 95.4%; >2-3 years, 87.7%; and >3 years, 72.9%). Partial pulpotomy and full pulpotomy sustained a high success rate up to more than 3 years (partial pulpotomy: >6 months-1 year, 97.6%; >1-2 years, 97.5%; >2-3 years, 97.6%; and >3 years, 99.4%; full pulpotomy: >6 months-1 year, 94%; >1-2 years, 94.9%; >2-3 years, 96.9%; and >3 years, 99.3%).

Conclusions

Vital permanent teeth with cariously exposed pulp can be treated successfully with vital pulp therapy. Current best evidence provides inconclusive information regarding factors influencing treatment outcome, and this emphasizes the need for further observational studies of high quality.     

Comparative evaluation of pulpal repair after direct pulp capping using stem cell therapy and biodentine: An animal study

The response of the dentin–pulp complex in rat teeth was investigated after direct capping with biodentine with or without bone marrow‐derived stem cells (BMDSCs). Following mechanical exposure, pulps were randomly capped with one of the followings materials: calcium hydroxide, biodentine or 1 × 10⁵ BMDSCs mL^?1 + biodentine. Histological examination was performed by light microscopy after 1, 3 and 5 weeks. Inflammatory reaction, necrotic tissue formation and calcific bridge formation were scored. Analysis showed that compared with the effects of calcium hydroxide or biodentine, BMDSCs + biodentine substantially reduced inflammatory reaction and necrotic tissue while promoting calcified tissue formation. Therefore, the combination of biodentine and BMDSCs could potentially stimulate pulp tissue regeneration after direct pulp capping.     

Fabrication and characterization of a novel injectable human amniotic membrane hydrogel for dentin-pulp complex regeneration

ObjectiveInjectable biomaterials that can completely fill the root canals and provide an appropriate environment will have potential application for pulp regeneration in endodontics. This study aimed to fabricate and characterize a novel injectable human amniotic membrane (HAM) hydrogel scaffold crosslinked with genipin, enabling the proliferation of Dental Pulp Stem Cells (DPSCs) and optimizing pulp regeneration.MethodsHAM extracellular matrix (ECM) hydrogels (15, 22.5, and 30 mg/ml) crosslinked with different genipin concentrations (0, 0.1, 0.5, 1, 5, and 10 mM) were evaluated for mechanical properties, tooth discoloration, cell viability, and proliferation of DPSCs. The hydrogels were subcutaneously injected in rats to assess their immunogenicity. The hydrogels were applied in a root canal model and subcutaneously implanted in rats to determine their regenerative potential for eight weeks, and histological and immunostaining analyses were performed.ResultsHydrogels crosslinked with low genipin concentration demonstrated low tooth discoloration, but 0.1 mM genipin crosslinked hydrogels were excluded due to their unfavourable mechanical properties. The degradation ratio was lower in hydrogels crosslinked with 0.5 mM genipin. The 30 mg/ml-0.5 mM crosslinked hydrogel exhibited a microporous structure, and the modulus of elasticity was 1200 PA. In vitro, cell culture showed maximum viability and proliferation in 30 mg/ml-0.5 mM crosslinked hydrogel. All groups elicited minimum immunological responses, and highly vascularized pulp-like tissue was formed in human tooth roots in both groups with/without DPSCs.SignificanceGenipin crosslinking improved the biodegradability of injectable HAM hydrogels and conferred higher biocompatibility. Hydrogels encapsulated with DPSCs can support stem cell viability and proliferation. In addition, highly vascularized pulp-like tissue formation by this biomaterial displayed potential for pulp regeneration.     

脂多糖刺激人牙髓干细胞分泌的外泌体联合基质细胞衍生因子-1对牙髓再生的影响

目的探讨轻度炎症状态下人牙髓干细胞(human dental pulp stem cell,hDPSC)产生的外泌体与基质细胞衍生因子-1(stromal cell-derived factor-1,SDF-1)联合应用对牙髓组织再生的影响。方法分离培养hDPSC,脂多糖(lipopolysaccharide,LPS)刺激hDPSC,超速离心法提取hDPSC经LPS刺激后产生的外泌体(exosomes from lipopolysaccharide-stimulated hDPSC,L-EXO)和正常状态下分泌的外泌体(exosome from normal hDPSC,N-EXO),通过透射电镜和蛋白质印迹法鉴定提取物。将40只6~8周龄的SD大鼠通过随机数字表法分为S组(单独应用SDF-1)、L+S组(SDF-1与L-EXO联合应用)、N+S组(SDF-1与N-EXO联合应用)和空白对照组(根管内不植入任何物质),每组10只。以双侧下颌第一磨牙为实验牙,建立大鼠无髓根管模型,根据分组分别在根管内植入不同的内容物。植入后30 d过量麻醉处死所有大鼠,取大鼠双侧下颌骨组织,应用HE、Masson及免疫组织化学染色法进行组织学评价。结果HE染色结果显示,除空白对照组外,其他3组根管内均可见新生牙髓样组织,其中L+S组根管内新生组织的量及组织中的细胞数量最多,S组最少。Masson染色结果显示,L+S组矿化组织沿根管壁纵向排列,胶原纤维有序排列,N+S组呈无规律紊乱分布。定量分析各组新生血管面积,结果显示L+S组血管密度[(2.03±0.65)%]显著高于S组[(0.65±0.05)%]及N+S组[(1.06±0.38)%](F=5.879,P<0.05)。免疫组织化学结果显示,S组及L+S组的趋化因子受体4表达量显著低于N+S组(F=8.633,P<0.01)。结论hDPSC分泌的外泌体联合SDF-1可提高根管内新生组织的量和组织中的血管密度,L-EXO的作用较N-EXO强,并且新生组织中胶原纤维及矿化组织的排列更规律有序。     

Roles of dental pulp fibroblasts in the recognition of bacterium-related factors and subsequent development of pulpitis

As caries-related bacteria invade deeply into dentin and come into close proximity to the pulp, inflammatory cells (such as lymphocytes, macrophages and neutrophils) infiltrate into the bacterium-invaded area and consequently pulpitis develops. Many types of cytokines and adhesion molecules are responsible for the initiation and progression of pulpitis. Dental pulp fibroblasts, a major cell type in the dental pulp, also have capacity to produce pro-inflammatory cytokines and express adhesion molecules in response to pathogen-associated molecular patterns (PAMPs), including lipopolysaccharide. The innate immune system senses microbial infection using pattern recognition receptors, such as Toll-like receptors (TLRs) and nucleotide-binding oligomerization domain (NOD), for PAMPs. In this review, we summarize the roles of dental pulp fibroblasts in the recognition of invaded bacterium-related factors via TLR and NOD pathways, and the subsequent pulpal immune responses, leading to progressive pulpitis.     

TheraCal LC和Dycal两种盖髓剂用于乳牙和恒牙直接盖髓的疗效比较

目的 比较TheraCal LC和Dycal两种盖髓剂用于乳、恒牙直接盖髓术的临床疗效。方法 选择深龋意外露髓的乳牙180颗和恒牙243颗做直接盖髓术,乳、恒牙均按单双数就诊顺序采用半随机方法分为两组,乳牙TheraCal LC组81例患者（90颗牙）;乳牙Dycal组76例患者（90颗牙）。恒牙TheraCal LC组102例患者（122颗牙）;恒牙Dycal组109例患者（121颗牙）。术后12个月,比较两种材料的治疗成功率。结果 治疗12个月后,恒牙TheraCal LC组成功率为95.1%,恒牙Dycal组成功率为93.3%,两组之间差异无统计学意义（P>0.05）。乳牙TheraCal LC组成功率为87.7%,乳牙Dycal组成功率为46.9%,两组之间有显著差异（P<0.05）。结论 TheraCal LC盖髓剂更适合乳、恒牙的盖髓剂,乳牙的优势可能更为明显。     

Dental pulp stem cells in chitosan/gelatin scaffolds for enhanced orofacial bone regeneration

Objective

Biomimetic chitosan/gelatin (CS/Gel) scaffolds have attracted great interest in tissue engineering of several tissues. However, limited information exists regarding the potential of combining CS/Gel scaffolds with oral cells, such as dental pulp stem cells (DPSCs), to produce customized constructs targeting alveolar/orofacial bone reconstruction, which has been the aim of the present study.