European Cellsetand

TA Mitsiadis al. Materials Vol. 30 2015 (pages 248-257) DOI: 10.22203/eCM.v030a17 ISSN
Stem cells for dental 1473-2262
clinical use

STEM CELL-BASED APPROACHES IN DENTISTRY

T.A. Mitsiadis1*, G. Orsini2 and L. Jimenez-Rojo1

Abstract Introduction

Repair of dental pulp and periodontal lesions remains The tooth is composed of the highly mineralised tissues
a major clinical challenge. Classical dental treatments of enamel, dentin and cementum, as well as by the soft
require the use of specialised tissue-adapted materials with connective tissues of dental pulp and periodontium
still questionable efficacy and durability. Stem cell-based (Mitsiadis and Graf, 2009; Nanci, 2012). Enamel is
therapeutic approaches could offer an attractive alternative formed by the epithelium-derived ameloblasts, while
in dentistry since they can promise physiologically ectomesenchymal cells give rise to all other tooth
improved structural and functional outcomes. These components. Dental pulp cells differentiating into
therapies necessitate a sufficient number of specific stem odontoblasts produce the dentin matrix, while periodontal
cell populations for implantation. Dental mesenchymal cells are involved in cementum and alveolar bone
stem cells can be easily isolated and are amenable to in formation. The periodontal space contains specific fibres
vitro expansion while retaining their stemness. In vivo (i.e., periodontal ligament fibres) that stabilise teeth, since
studies realised in small and large animals have evidenced they connect root cementum to the alveolar bone, as well as
the potential of dental mesenchymal stem cells to promote a variety of cell types such as fibroblasts, epithelial rests of
pulp and periodontal regeneration, but have also underlined Malassez, neuronal and endothelial cells (Mariotti, 1993;
new important challenges. The homogeneity of stem cell Sonoyama et al., 2007).
populations and their quality control, the delivery method, Traumatic injuries, periodontal disease and caries are
the quality of the regenerated dental tissues and their mainly responsible for pathologies affecting teeth and their
integration to the host tissue are some of the key challenges. surrounding tissues (Caton et al., 2011). These pathologies
The use of bioactive scaffolds that can elicit effective tissue remain a major clinical challenge, due mainly to the limited
repair response, through activation and mobilisation of self-healing capability of dental tissues. The reparative
endogenous stem cell populations, constitutes another mechanisms following dental or periodontal lesion involve
emerging therapeutic strategy. Finally, the use of stem cells highly conserved genetic programs that are active during
and induced pluripotent cells for the regeneration of entire embryonic tooth development (Aberg et al., 1997; About
teeth represents a novel promising alternative to dental and Mitsiadis, 2001; Giannobile and Somerman, 2003; Jin
implant treatment after tooth loss. In this mini-review, et al., 2004; Magloire et al., 2001; Mitsiadis and Rahiotis,
we present the currently applied techniques in restorative 2004; Ripamonti, 2007). For example, in severe dental pulp
dentistry and the various attempts that are made to bridge injury or inflammation (i.e., pulpitis), stem cells or/and
gaps in knowledge regarding treatment strategies by progenitors give rise to a new generation of odontoblasts
translating basic stem cell research into the dental practice. that replace the disintegrated odontoblasts. Signalling
molecules released at the pathologic sites may attract
these stem cells and progenitors, thus initiating the healing
Keywords: tooth, dental stem cells, mesenchymal stem process that includes the reparative dentin formation
cells, induced pluripotent cells, tooth regeneration, (Nakashima and Iohara, 2014). However, the reparative
regenerative dentistry, clinical trials. capability of the dental pulp and periodontium is often
insufficient to restore the totality of the damaged tissues.
If untreated, these lesions compromise tooth integrity that
can lead to more severe pathologies and tooth loss.
The increased knowledge on the reparative events within
dental tissues has contributed to the proposal of alternative
methods for the treatment of dental pathologies. However,
traditional treatments continue to be applied in dental
clinics since most of the proposed therapeutic approaches
*Address for correspondence: are still at the experimental level. For example, partial
Thimios Mitsiadis, DDS, PhD dental tissue repair techniques involve specialised dental
University of Zurich, Faculty of Medicine, Orofacial materials with uncertain effectiveness and durability, while
Development and Regeneration, high-tech dental implants are used for tooth replacement
Institute of Oral Biology, ZZM, (Esposito et al., 2013; Fron Chabouis et al., 2013). These
Plattenstrasse 11, 8032 Zurich, Switzerland materials are often used in conjunction with growth factors
Telephone number: +41 4463 43390 and molecules to enhance the regenerative capacity of
Fax number: +41 4463 44310 dental and periodontal tissues (Pilipchuk et al., 2015).
E-mail: [email protected] Recent advances in tissue engineering and regenerative

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medicine offer the potential for a long-term solution by specific scaffolds are able to generate adequate amounts
means of biological repair or replacement of damaged of bone in order to achieve primary implant stability
teeth. The aim of this mini-review is to present the currently (Kitamura et al., 2011; Windisch et al., 2012). These
applied tissue repair techniques and their limitations in new approaches are contributing to the progress of dental
restorative dentistry and to introduce stem cell-based treatments, but should be further studied using controlled
approaches as promising tools for the regeneration of randomised clinical trials.
injured and pathological teeth. Therefore, the different
sources of dental stem cells, their differentiation potential
and the current state of stem cell-based strategies for dental Stem cells within teeth
tissue regeneration are discussed. From a translational point
of view, we summarise the various preclinical models used The theoretical basis for dental tissue repair is the
for the evaluation of stem cell-based therapies in dentistry activation of stem and progenitor cells that will enhance
and report on the recent developments and challenges the regenerative process (Bluteau et al., 2008; Caton et al.,
related to clinical applications of human stem cells in 2011). Mesenchymal stem cells (MSCs) were originally
situations that necessitate pulp and periodontal tissue isolated from bone marrow (Friedenstein et al., 1970).
regeneration. MSCs are fibroblast-like cells capable of adhering to
plastic dishes, to form colonies derived from single cells
(colony forming unit fibroblasts), and to differentiate into
Current therapeutic interventions in dentistry mature cells of mesenchymal lineages such as osteoblasts
and chondrocytes (Caplan and Bruder, 2001; Friedenstein
Contemporary techniques to replace damaged dental hard et al., 1970; Pittenger et al., 1999; Prockop, 1997; Sudo
tissues consist of direct tooth restorations using resin-based et al., 2007; Weissman et al., 2001). The discovery that
composites, or indirect restorations using composite or human adult teeth contain cells with similar functions to
ceramic inlays and onlays (Ferracane, 2011; Fron Chabouis MSC indicated that these organs are important reservoirs
et al., 2013). While adhesion of these materials to enamel is of adult stem cell populations (Gronthos et al., 2000).
stable over time, adhesion to dentin is weaker and unstable Therefore, dental mesenchymal stem cells (DMSCs) can
because of the higher levels of organic matrix of dentin be used for regeneration of teeth, or other organs that have
when compared to enamel (Lehmann et al., 2009). limited intrinsic repair potential (Di Scipio et al., 2014;
Endodontic therapy is a procedure implying the Gandia et al., 2008; Graziano et al., 2008; Kerkis et al.,
removal of contaminated or necrotic dental tissues within 2008; Nosrat et al., 2001). Besides their capacity to give
the pulp. In case of pulp exposure or infection, the damaged rise to various cell types such as chondrocytes, osteocytes
part of the pulp has to be removed, leaving intact the and adipocytes (Bluteau et al., 2008; Gronthos et al.,
healthy part of the pulp at the tooth root level, a process 2000), DMSCs may act as cellular modulators to support
called pulpotomy (DeRosa, 2006). In selected cases, this endogenous reparative mechanisms tissue by secretion
method preserves the vitality of pulp located at the root of bioactive molecules (Choi and Reddy, 2014; van den
canal, thus allowing the accomplishment of the root growth Akker et al., 2013).
(Fuks, 2008). Traditionally, the damaged pulp is entirely Cultures of DMSCs and MSCs are indistinguishable,
replaced with inorganic materials such as gutta-percha, and at present no markers permit selective identification of
after root canal treatment (Ricketts, 2001). Since dental either cell type from culture-expanded DMSC populations
pulp provides nutrition, sensation, and defence against (Pagella et al., 2015). Likewise, it is not yet known whether
the various pathogens, devitalised teeth are subject to DMSC properties reside in distinct cell subpopulations.
various complications causing tooth fragility and fracture Similarly to MSCs, DMSCs are heterogeneous in their
(Ricketts, 2001). Therefore, maintaining of dental pulp phenotype, and this could possibly reflect a coexistence
vitality is of prime importance and this is highlighted by of functionally distinct cell subsets (Jiang et al., 2002;
the emergence of new stem cell-based techniques focusing Muraglia et al., 2000). Markers alone would not be
on pulp regeneration (Potdar and Jethmalani, 2015). sufficient to rule out the presence of other than DMSCs
Currently, missing teeth are replaced with dental within dental tissues. Studies using single cell-derived
implants (Esposito et al., 2013). Their retention requires clonal populations will be needed to determine whether
close contact of implants with the alveolar bone, a process DMSCs differentiation potency is inherent in individual
called osseointegration (Branemark et al., 1977). Most cells from dental tissues.
of dental implants are made of biocompatible titanium Despite similar phenotypic characteristics, DMSCs
alloy and they are inserted into the bone after surgical from different locations have significant functional
intervention. The clinical success of implants depends on heterogeneity both in vitro and in vivo, thus indicating
alveolar bone quality and dimensions, primary implant distinct physiological roles within teeth (Caton et al.,
stability, time of masticatory loading, infections, and 2011; Pagella et al., 2015). In the dental pulp, DMSCs
implant surface characteristics (Esposito et al., 2013; are located mainly in two niches: the apical niche and
Esposito et al., 2007). Recent regenerative technologies the perivascular niche (Mitsiadis et al., 2011; Zhao et al.,
using scaffolds, stem cells, and growth factor delivery have 2014). In these two niches, DMSCs could have distinct
enhanced host tissue response and implant osseointegration functions and still be geographically interchangeable, but
(Naddeo et al., 2015; Pilipchuk et al., 2015). Recent a temporo-spatial hierarchy between the two DMSC niches
clinical trials have demonstrated that stem cells seeded in remains to be investigated. Furthermore, the identification

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TA Mitsiadis et al. Stem cells for dental clinical use

Fig. 1. Schematic representation of the main populations of mesenchymal stem cells found
in human teeth. Abbreviations: DPSCs, dental pulp stem cells; PDLSCs, periodontal
ligament stem cells; SCAPs, stem cells from the apical papilla; SHEDs, stem cells from
human exfoliated deciduous teeth.

and characterisation of other dental stem cell niches, Stem cells from human exfoliated deciduous teeth
and the examination of how niche-derived signals are (SHEDs) are isolated using the same procedure as for
orchestrated towards tooth homoeostasis and repair is of DPSCs. SHEDs express the surface molecules STRO-1 and
prime importance. CD146, and several neural and glial markers such as nestin
The developmental origins of DMSCs in adult teeth and β-III tubulin (Miura et al., 2003). SHEDs proliferate
are not known yet. They could be directly derived from very fast, are capable of differentiating into odontogenic,
dental tissues (e.g., pulp, periodontium), but a contribution osteogenic, chondrogenic, adipogenic, myogenic, and
from blood-derived circulating MSCs has not to be neurogenic cells in vitro, and induce bone and dentin
excluded. Indeed, MSCs are found in the circulation and formation in vivo (Kerkis et al., 2008; Miura et al., 2003).
are likely to engraft in all tissues of the body (Kuroda et Stem cells from the apical part of the dental papilla
al., 2014; Lemoli et al., 2006). The embryonic origins of (SCAPs) are located at the root apex of the developing
circulating MSCs are different from those of DMSCs (La teeth, are highly proliferative, and exhibit increased
Noce et al., 2014; Pagella et al., 2015), thus suggesting migratory and regenerative potentials (Sonoyama et al.,
distinct properties and functions for these two stem cell 2006; Sonoyama et al., 2008). SCAPs express the same
populations. The various dental stem cell populations and DMSCs surface markers, as well as CD24 for which
their potencies are described in Fig. 1. DPSCs are negative, and are able to form dentin in vivo
Dental pulp stem cells (DPSCs) were first isolated from (Huang et al., 2009; Sonoyama et al., 2006).
human teeth in 2000 and are the most common source of Periodontal ligament stem cells (PDLSCs) express
DMSCs (Gronthos et al., 2000). Due to the lack of specific the cell-surface markers STRO-1, CD146 and CD44, and
DMSCs markers, generic MSC markers such as STRO-1, are able to differentiate into adipogenic and osteogenic
CD146 and CD44 are commonly used for the isolation and cells, under defined culture conditions in vitro (Seo et al.,
identification of DMSCs (Pittenger et al., 1999). DPSCs are 2004). PDLSCs can contribute to the regeneration of the
capable of differentiating into odontogenic (Gronthos et al., periodontium by giving rise to cementum and PDL tissues
2000; Hayashi et al., 2015; Miura et al., 2003), osteogenic in vivo (Seo et al., 2004). Alveolar periodontal ligament
(d’Aquino et al., 2009; de Mendonca Costa et al., 2008), stem cells (aPDLSCs) form another PDLSC population
chondrogenic (Waddington et al., 2009), adipogenic that locates close to the alveolar bone and shows great
(Gronthos et al., 2002; Waddington et al., 2009), myogenic osteogenic and adipogenic capabilities (Wang et al., 2011).
(Kerkis et al., 2008; Pisciotta et al., 2015), and neurogenic Stem cells from the dental follicle (DFSCs) are
(Martens et al., 2014; Nosrat et al., 2001) cells in vitro and progenitor cells for the PDL, alveolar bone, and cementum,
in vivo. and express the STRO-1 and CD44 markers (Morsczeck

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TA Mitsiadis et al. Stem cells for dental clinical use

et al., 2005). DFSCs are able to form cementum and bone and continued root development (Chrepa et al., 2015;
tissues in vitro and in vivo (Kemoun et al., 2007; Yokoi et Peters, 2014). Numerous attempts, using human DMSCs
al., 2006). (hDPSCs), have been made in a variety of animal models
Human dental epithelial stem cells (hDESCs) can be in order to achieve complete pulp regeneration. Proper
isolated from the third molar that develops late after birth regeneration requires re-vascularisation and re-innervation
(Honda et al., 2007; Honda et al., 2005). Another source of the pulp and allows new dentin formation (Peters, 2014).
of hDESCs is the epithelial root sheath that disintegrates The very first experimental study using hDMSCs showed
into strands of epithelial cells, also known as epithelial that these cells can differentiate into odontoblasts, which
rests of Malassez (ERM). ERM cells express epithelial form dentin-like structures when transplanted together
stem cell markers such as Bmi-1, E-CAM, and p75, as well with HA/TCP ceramic powder in immunocompromised
as embryonic stem cell markers such as Oct-4 and Nanog mice ex vivo (Gronthos et al., 2000) (Fig. 2). Other, more
(Nam et al., 2011). recent studies, using hDPSCs and SCAPs seeded on poly-
Induced pluripotent stem cells (iPSCs) may represent D,L-lactide/glycol scaffolds have confirmed the ability of
another source of hDESCs. Indeed, iPSCs have the capacity human DMSCs to regenerate vascularised pulp tissues
to differentiate into various cell lineages (Takahashi and when transplanted into the empty mouse tooth root canal
Yamanaka, 2006) and can be technically produced from (Hayashi et al., 2015; Huang et al., 2010; Volponi et al.,
patient’s cells. iPSCs technology can be progressively 2010) (Fig. 2). However, these experimental attempts
applied for the regeneration of dental tissues. iPSCs using DMSCs transplantation were performed in ectopic
are able to differentiate into ameloblast-like cells in the locations and therefore, stem cell-based therapeutic
presence of ameloblastin expressing cells (Arakaki et approaches for entire pulp regeneration cannot be directly
al., 2012). Also, iPSCs are capable of differentiating into translated into the clinics. For this reason, new experimental
mesenchymal odontogenic cells (Otsu et al., 2014). strategies have been elaborated, where DMSCs or other
stem cell population, combined with scaffolds and/or
bioactive molecules, fully fill the empty pulp chamber after
Stem cell-based regenerative treatments in dentistry pulpotomy (partial pulp removal) or pulpectomy (total pulp
removal) (Iohara et al., 2011; Iohara et al., 2013; Zheng et
Although basic research into dental stem cells is well al., 2012 ; Chrepa et al., 2015; Lovelace et al., 2011) (Fig.
documented, only very recently efforts are emerging to 2). Indeed, DPSCs transplanted together with granulocyte-
bridge the gap with translational research. Regenerative colony stimulating factor (G-CSF), in pulpectomised
dentistry aims to regenerate the damaged dental tissues and teeth of dogs, were able to regenerate the entire pulp
to fully restore tooth anatomy and function. The functions and to form new dentin (Iohara et al., 2013). Similarly,
of exogenously administered dental stem cells go beyond bone morphogenetic proteins (BMPs) were used, a long
their differentiation potential and the replacement of cells time ago, in order to stimulate the regenerative response
lost due to injury or disease. Dental stem cells may create of the pulp. While these procedures appear to improve
a repair-conducive microenvironment, stimulating the tissue regeneration, their true effectiveness for achieving
recruitment of endogenous stem cells or progenitors at durable repair is still unclear. For example, the fibrotic
the injury site. This insinuates that accurately designed tissue that has been obtained in experiments focusing on
bioactive scaffolds could generate effective dental tissue dental pulp regeneration may not sustain a long-lasting
repair responses through activation and mobilisation of therapeutic effect. Indeed, this fibrous pulp tissue can
endogenous stem and progenitor cells, thus avoiding undergo degeneration over time or be replaced with bone.
exogenous stem cell administration (Hayashi et al., 2015; Recent regenerative endodontic procedures that have
Lee et al., 2010; Mitsiadis et al., 2012). Such innovative been successfully applied in clinics are based on the
strategies would be easier to apply clinically and likely bleeding technique, where the blood clot acts as a scaffold
to encounter fewer regulatory obstacles. This raises the that delivers MSCs into the root canal of both immature
possibility of repairing entire dental tissues through teeth with pulp necrosis and mature teeth with apical
stimulation of endogenous dental stem and progenitor cells. lesions (Chrepa et al., 2015; Deepak and Nandini, 2012;
However, several studies in other organs – exploring the Lovelace et al., 2011; Sonmez et al., 2013). However, the
possibility of repairing tissues with the exclusive usage current status of stem cell-based endodontic therapy is still
of scaffolds impregnated with chemotactic or growth characterised by an empirical approach (Peters, 2014).
factors – gave uncertain results, judging by the irregular
and fibrotic appearance of the regenerated tissue (Lee et Regeneration of periodontal tissues
al., 2010; Zhang et al., 2013). Human PDLSCs have been shown to improve
The main approaches using stem cells for the repair of periodontal tissue regeneration when transplanted into
specific dental tissue, such as the pulp and the periodontium immunocompromised mice, indicating their big potential
as well as for entire tooth regeneration, are described in for future cell-based therapies in dentistry (Seo et al.,
Fig. 2. 2004) (Fig. 2). The regenerative potential of autologous
and allogeneic PDLSCs, as well as of DPSCs, SHEDs and
Regeneration of pulp-dentin complex bone marrow stem cells for the treatment of periodontitis
Regenerative endodontics represents a new treatment has been also demonstrated in other animal models, such
modality that relies on the intracanal delivery of stem as the miniature swine and dog models (Ding et al., 2010;
cells and focuses on re-establishment of pulp vitality Du et al., 2014; Fu et al., 2014; Khorsand et al., 2013). In

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pulpotomised

Fig. 2. Schematic representation of various stem cell-based strategies used for dental pulp, periodontium, and
entire tooth regeneration. Transplantation of stem cells combined with scaffolds in the kidney or dorsal skin of
immunocompromised mice is commonly used for regenerative purposes. Abbreviations: DE, dental epithelium; DM,
dental mesenchyme; DECs, dental epithelial cells; DMCs, dental mesenchymal cells; DMSCs, dental mesenchymal
stem cells; DPSCs, dental pulp stem cells; DSCs, dental stem cells; PDLSCs, periodontal ligament stem cells; SCAPs,
stem cells from the apical papilla.

an attempt of improving stem cell-based therapies, growth et al., 2013). Another study, with a significant and stable
factors such as platelet-derived growth factors (PDGFs) clinical outcome, was performed in a patient suffering
and BMPs have been used. PDGFs have been proven to from advanced periodontitis. Autologous bone marrow
stimulate periodontal regeneration (Howell et al., 1997; mononuclear cells (BMMNCs) embedded in a thermo-
Lynch et al., 1989), while BMPs enhance alveolar bone reversible gelation polymer scaffold were used successfully
and cementum formation (Selvig et al., 2002). However, for alveolar bone regeneration, which was validated by
BMPs may have undesirable effects on periodontal tissues clinical and radiographic evaluation in this three year
and provoke tooth ankylosis. Commercialised amelogenin follow-up trial (Sankaranarayanan et al., 2013).
extracts have been also used in dental clinics with success
for periodontal tissue regeneration, but their mode of action Regeneration of the entire tooth
is still unclear (Veis et al., 2000). Regeneration of the entire tooth would be the ideal
Regeneration of alveolar bone defects, caused by therapeutic approach after tooth loss. The association of
periodontal diseases, is one of the major challenges for DESCs and DMSCs in vitro allows the formation of tooth
clinicians. The first clinical trial using autologous human germs that can be transplanted into the alveolar bone,
DPSCs, combined with collagen scaffolds, for alveolar where the germs will develop, erupt, and finally become
bone reconstruction was performed successfully several functional teeth (Ikeda and Tsuji, 2008) (Fig. 2). In a
years ago (d’Aquino et al., 2009). However, a three similar assay, dental bud cells were seeded into platelet-
years follow-up study using in-line holotomography rich fibrin scaffolds for tooth regeneration in the miniature
and conventional evaluation procedures has shown that swine model (Yang et al., 2012). Another approach to
the regenerated bone at the grafted sites was entirely obtain new brand teeth is the implantation into the jaw
compact and thus completely different from the normal of tooth-shaped polymeric biodegradable scaffolds filled
spongy alveolar bone found in the mandibles (Giuliani with DESCs and DMSCs (Oshima and Tsuji, 2014) (Fig.

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2). The three-dimensional structure of the scaffolds should Several clinical trials using autologous stem cells for pulp
drive the differentiation of the transplanted stem cells and periodontal tissue regeneration have already been
into odontoblasts and ameloblasts. Indeed, bioengineered approved and initiated, but the outcome of these studies
teeth using human stem cells have been formed, but only has not yet been communicated. For example, a clinical
in ectopic sites, to date. Furthermore, these teeth are trial sponsored by the Fourth Military Medical University
missing some essential tooth elements such as correct in China will evaluate the effects of PDLSCs in periodontal
crown morphology and accomplished root formation. tissue regeneration (https://clinicaltrials.gov/ct2/show/
However, recent experiments in mice, using bioengineered NCT01357785). Similarly, another clinical trial in Japan
approaches, have showed that it is possible to obtain deals with dental pulp regeneration by transplantation of
functional teeth with entire roots (Oshima and Tsuji, autologous pulp stem cells (http://www.stemcellsaustralia.
2014). In fact, tooth germs formed by dental epithelial edu.au/About-Stem-Cells/Stem-Cell-Clinical-Trials/
and mesenchymal cells seeded into collagen drops gave Dental-treatments/Periodontitis.aspx).
rise to new functional teeth after their implantation into It is obvious that stem cell-based regenerative
the mandible of adult mice. Formation of all dental tissues approaches in dentistry are just at the beginning, but have
allows the eruption and full integration of these teeth into the potential to benefit millions of patients worldwide.
the recipient alveolar bone. Other emerging technologies, such as nanotechnology,
Recent studies have shown that re-aggregation of imaging systems and mathematical modelling should be
iPSCs-derived neural crest cells and mouse odontogenic incorporated in the stem cell research field in order to
epithelial tissues results to the generation of entire teeth obtain faster, reliable and qualitative advancements and
ex vivo (Otsu et al., 2014). Although further technical outcomes in dental clinics.
improvements may be needed, the iPSCs technology is
expected to open new horizons in regenerative dentistry.
However, such results have not yet been obtained Acknowledgments
with human cells. Various populations of human DMSCs
are still under investigation, while human DESCs have This work was supported by funds of the University of
not been fully studied. Moreover, time represents a great Zurich (TM and LJR) and the Polytechnic University of
challenge for tooth regeneration: the whole process of Marche (GO). The authors contributed to the planning,
odontogenesis in humans takes more than 7 years. This writing, critical reading, and editing of the manuscript.
long-term physiological procedure may be discouraging for The authors confirm that there are no conflicts of interest
individuals missing teeth and look forward to immediate associated with this work.
treatment outcomes.

Conclusions and perspectives References

During recent decades, several stem cell lines with Aberg T, Wozney J, Thesleff I (1997) Expression
significant variability in potency have been isolated from patterns of bone morphogenetic proteins (BMPs) in the
human adult teeth. Considerable heterogeneity exists developing mouse tooth suggest roles in morphogenesis
between individual cells isolated from the same dental and cell differentiation. Dev Dyn 210: 383-396.
stem cell pool that may affect the clinical outcomes. About I, Mitsiadis TA (2001) Molecular aspects of tooth
Therefore, the identification and purification of stem cell pathogenesis and repair: in vivo and in vitro models. Adv
subpopulations with improved potency is a necessary step Dent Res 15: 59-62.
before application of cell-based treatment in dental clinics. Arakaki M, Ishikawa M, Nakamura T, Iwamoto T,
In addition to the choice of dental stem cell populations, a Yamada A, Fukumoto E, Saito M, Otsu K, Harada H,
variety of factors such as the lesion size and depth, health Yamada Y, Fukumoto S (2012) Role of epithelial-stem cell
status of the surrounding tissues, as well as the delivery interactions during dental cell differentiation. J Biol Chem
methods are also likely to impact on the success of therapy. 287: 10590-10601.
There is still a need for understanding the mechanisms Bluteau G, Luder HU, De Bari C, Mitsiadis TA (2008)
that control the fates and functions of stem cells after their Stem cells for tooth engineering. Eur Cell Mater 16: 1-9.
transplantation into the pathological or injured dental pulp Branemark PI, Hansson BO, Adell R, Breine U,
and/or periodontal tissues. Although applications using Lindstrom J, Hallen O, Ohman A (1977) Osseointegrated
dental stem cells for pulp and periodontal regeneration have implants in the treatment of the edentulous jaw. Experience
been reported in animal models, the number of clinical trials from a 10-year period. Scand J Plast Reconstr Surg Suppl
with long-term follow-up is very limited, if not inexistent. 16: 1-132.
The translation of basic and preclinical stem cell research Caplan AI, Bruder SP (2001) Mesenchymal stem cells:
to the dental clinics is very slow, since technical, safety, building blocks for molecular medicine in the 21st century.
regulatory and ethical concerns exist. It is obvious that Trends Mol Med 7: 259-264.
patients will not benefit from these regenerative treatments Caton J, Bostanci N, Remboutsika E, De Bari C,
until most of the above mentioned issues and concerns Mitsiadis TA (2011) Future dentistry: cell therapy meets
will be resolved, and the possible clinical restrictions will tooth and periodontal repair and regeneration. J Cell Mol
be well examined and taken seriously into consideration. Med 15: 1054-1065.

www.ecmjournal.org
253
TA Mitsiadis et al. Stem cells for dental clinical use

Choi SW, Reddy P (2014) Current and emerging ventricular function, induce angiogenesis, and reduce
strategies for the prevention of graft-versus-host disease. infarct size in rats with acute myocardial infarction. Stem
Nat Rev Clin Oncol 11: 536-547. Cells 26: 638-645.
Chrepa V, Henry MA, Daniel BJ, Diogenes A (2015) Giannobile WV, Somerman MJ (2003) Growth and
Delivery of Apical Mesenchymal Stem Cells into amelogenin-like factors in periodontal wound healing. A
Root Canals of Mature Teeth. J Dent Res Jul 20. pii: systematic review. Ann Periodontol 8: 193-204.
0022034515596527. Giuliani A, Manescu A, Langer M, Rustichelli F,
d’Aquino R, De Rosa A, Lanza V, Tirino V, Laino L, Desiderio V, Paino F, De Rosa A, Laino L, d’Aquino R,
Graziano A, Desiderio V, Laino G, Papaccio G (2009) Tirino V, Papaccio G (2013) Three years after transplants in
Human mandible bone defect repair by the grafting of human mandibles, histological and in-line holotomography
dental pulp stem/progenitor cells and collagen sponge revealed that stem cells regenerated a compact rather than
biocomplexes. Eur Cell Mater 18: 75-83. a spongy bone: biological and clinical implications. Stem
de Mendonca Costa A, Bueno DF, Martins MT, Kerkis Cells Transl Med 2: 316-324.
I, Kerkis A, Fanganiello RD, Cerruti H, Alonso N, Passos- Graziano A, d’Aquino R, Laino G, Proto A, Giuliano
Bueno MR (2008) Reconstruction of large cranial defects MT, Pirozzi G, De Rosa A, Di Napoli D, Papaccio G (2008)
in nonimmunosuppressed experimental design with human Human CD34+ stem cells produce bone nodules in vivo.
dental pulp stem cells. J Craniofac Surg 19: 204-210. Cell Prolif 41: 1-11.
Deepak BS, Nandini DB (2012) Stem cells: Challenges Gronthos S, Brahim J, Li W, Fisher LW, Cherman N,
in endodontics. J Pharm Bioallied Sci 4: 84. Boyde A, DenBesten P, Robey PG, Shi S (2002) Stem cell
DeRosa TA (2006) A retrospective evaluation of properties of human dental pulp stem cells. J Dent Res 81:
pulpotomy as an alternative to extraction. Gen Dent 54: 531-535.
37-40. Gronthos S, Mankani M, Brahim J, Robey PG, Shi S
Di Scipio F, Sprio AE, Folino A, Carere ME, Salamone (2000) Postnatal human dental pulp stem cells (DPSCs)
P, Yang Z, Berrone M, Prat M, Losano G, Rastaldo R, Berta in vitro and in vivo. Proc Natl Acad Sci U S A 97: 13625-
GN (2014) Injured cardiomyocytes promote dental pulp 13630.
mesenchymal stem cell homing. Biochim Biophys Acta Hayashi Y, Murakami M, Kawamura R, Ishizaka R,
1840: 2152-2161. Fukuta O, Nakashima M (2015) CXCL14 and MCP1 are
Ding G, Liu Y, Wang W, Wei F, Liu D, Fan Z, An Y, potent trophic factors associated with cell migration and
Zhang C, Wang S (2010) Allogeneic periodontal ligament angiogenesis leading to higher regenerative potential of
stem cell therapy for periodontitis in swine. Stem Cells 28: dental pulp side population cells. Stem Cell Res Ther 6:
1829-1838. 111.
Du J, Shan Z, Ma P, Wang S, Fan Z (2014) Allogeneic Honda MJ, Shinohara Y, Hata KI, Ueda M (2007)
bone marrow mesenchymal stem cell transplantation for Subcultured odontogenic epithelial cells in combination
periodontal regeneration. J Dent Res 93: 183-188. with dental mesenchymal cells produce enamel-dentin-like
Esposito M, Grusovin MG, Maghaireh H, Worthington complex structures. Cell Transplant 16: 833-847.
HV (2013) Interventions for replacing missing teeth: Honda MJ, Sumita Y, Kagami H, Ueda M (2005)
different times for loading dental implants. Cochrane Histological and immunohistochemical studies of tissue
Database Syst Rev 3: CD003878. engineered odontogenesis. Arch Histol Cytol 68: 89-101.
Esposito M, Grusovin MG, Willings M, Coulthard P, Howell TH, Fiorellini JP, Paquette DW, Offenbacher
Worthington HV (2007) Interventions for replacing missing S, Giannobile WV, Lynch SE (1997) A phase I/II clinical
teeth: different times for loading dental implants. Cochrane trial to evaluate a combination of recombinant human
Database Syst Rev: CD003878. platelet-derived growth factor-BB and recombinant human
Ferracane JL (2011) Resin composite – state of the art. insulin-like growth factor-I in patients with periodontal
Dent Mater 27: 29-38. disease. J Periodontol 68: 1186-1193.
Friedenstein AJ, Chailakhjan RK, Lalykina KS (1970) Huang GT, Gronthos S, Shi S (2009) Mesenchymal
The development of fibroblast colonies in monolayer stem cells derived from dental tissues vs. those from other
cultures of guinea-pig bone marrow and spleen cells. Cell sources: their biology and role in regenerative medicine. J
Tissue Kinet 3: 393-403. Dent Res 88: 792-806.
Fron Chabouis H, Smail Faugeron V, Attal JP (2013) Huang GT, Yamaza T, Shea LD, Djouad F, Kuhn NZ,
Clinical efficacy of composite versus ceramic inlays and Tuan RS, Shi S (2010) Stem/progenitor cell-mediated de
onlays: a systematic review. Dent Mater 29: 1209-1218. novo regeneration of dental pulp with newly deposited
Fu X, Jin L, Ma P, Fan Z, Wang S (2014) Allogeneic continuous layer of dentin in an in vivo model. Tissue Eng
stem cells from deciduous teeth in treatment for Part A 16: 605-615.
periodontitis in miniature swine. J Periodontol 85: 845-851. Ikeda E, Tsuji T (2008) Growing bioengineered
Fuks AB (2008) Vital pulp therapy with new teeth from single cells: potential for dental regenerative
materials for primary teeth: new directions and treatment medicine. Expert Opin Biol Ther 8: 735-744.
perspectives. J Endod 34: S18-24. Iohara K, Imabayashi K, Ishizaka R, Watanabe A,
Gandia C, Arminan A, Garcia-Verdugo JM, Lledo E, Nabekura J, Ito M, Matsushita K, Nakamura H, Nakashima
Ruiz A, Minana MD, Sanchez-Torrijos J, Paya R, Mirabet M (2011) Complete pulp regeneration after pulpectomy by
V, Carbonell-Uberos F, Llop M, Montero JA, Sepulveda transplantation of CD105+ stem cells with stromal cell-
P (2008) Human dental pulp stem cells improve left derived factor-1. Tissue Eng Part A 17: 1911-1920.

www.ecmjournal.org
254
TA Mitsiadis et al. Stem cells for dental clinical use

Iohara K, Murakami M, Takeuchi N, Osako Y, Ito M, Lemoli RM, Catani L, Talarico S, Loggi E, Gramenzi
Ishizaka R, Utunomiya S, Nakamura H, Matsushita K, A, Baccarani U, Fogli M, Grazi GL, Aluigi M, Marzocchi
Nakashima M (2013) A novel combinatorial therapy with G, Bernardi M, Pinna A, Bresadola F, Baccarani M,
pulp stem cells and granulocyte colony-stimulating factor Andreone P (2006) Mobilization of bone marrow-derived
for total pulp regeneration. Stem Cells Transl Med 2: 521- hematopoietic and endothelial stem cells after orthotopic
533. liver transplantation and liver resection. Stem Cells 24:
Jiang Y, Jahagirdar BN, Reinhardt RL, Schwartz RE, 2817-2825.
Keene CD, Ortiz-Gonzalez XR, Reyes M, Lenvik T, Lund Lovelace TW, Henry MA, Hargreaves KM, Diogenes
T, Blackstad M, Du J, Aldrich S, Lisberg A, Low WC, A (2011) Evaluation of the delivery of mesenchymal stem
Largaespada DA, Verfaillie CM (2002) Pluripotency of cells into the root canal space of necrotic immature teeth
mesenchymal stem cells derived from adult marrow. Nature after clinical regenerative endodontic procedure. J Endod
418: 41-49. 37: 133-138.
Jin Q, Anusaksathien O, Webb SA, Printz MA, Lynch SE, Williams RC, Polson AM, Howell TH, Reddy
Giannobile WV (2004) Engineering of tooth-supporting MS, Zappa UE, Antoniades HN (1989) A combination of
structures by delivery of PDGF gene therapy vectors. Mol platelet-derived and insulin-like growth factors enhances
Ther 9: 519-526. periodontal regeneration. J Clin Periodontol 16: 545-548.
Kemoun P, Laurencin-Dalicieux S, Rue J, Farges JC, Magloire H, Romeas A, Melin M, Couble ML, Bleicher
Gennero I, Conte-Auriol F, Briand-Mesange F, Gadelorge F, Farges JC (2001) Molecular regulation of odontoblast
M, Arzate H, Narayanan AS, Brunel G, Salles JP (2007) activity under dentin injury. Adv Dent Res 15: 46-50.
Human dental follicle cells acquire cementoblast features Mariotti A (1993) The extracellular matrix of the
under stimulation by BMP-2/-7 and enamel matrix periodontium: dynamic and interactive tissues. Periodontol
derivatives (EMD) in vitro. Cell Tissue Res 329: 283-294. 2000 3: 39-63.
Kerkis I, Ambrosio CE, Kerkis A, Martins DS, Martens W, Sanen K, Georgiou M, Struys T, Bronckaers
Zucconi E, Fonseca SA, Cabral RM, Maranduba CM, A, Ameloot M, Phillips J, Lambrichts I (2014) Human
Gaiad TP, Morini AC, Vieira NM, Brolio MP, Sant’Anna dental pulp stem cells can differentiate into Schwann cells
OA, Miglino MA, Zatz M (2008) Early transplantation of and promote and guide neurite outgrowth in an aligned
human immature dental pulp stem cells from baby teeth to tissue-engineered collagen construct in vitro. FASEB J 28:
golden retriever muscular dystrophy (GRMD) dogs: Local 1634-1643.
or systemic? J Transl Med 6: 35. Mitsiadis TA, Feki A, Papaccio G, Caton J (2011)
Khorsand A, Eslaminejad MB, Arabsolghar M, Dental pulp stem cells, niches, and notch signaling in tooth
Paknejad M, Ghaedi B, Rokn AR, Moslemi N, Nazarian injury. Adv Dent Res 23: 275-279.
H, Jahangir S (2013) Autologous dental pulp stem cells in Mitsiadis TA, Graf D (2009) Cell fate determination
regeneration of defect created in canine periodontal tissue. during tooth development and regeneration. Birth Defects
J Oral Implantol 39: 433-443. Res C Embryo Today 87: 199-211.
Kitamura M, Akamatsu M, Machigashira M, Hara Y, Mitsiadis TA, Rahiotis C (2004) Parallels between tooth
Sakagami R, Hirofuji T, Hamachi T, Maeda K, Yokota development and repair: conserved molecular mechanisms
M, Kido J, Nagata T, Kurihara H, Takashiba S, Sibutani following carious and dental injury. J Dent Res 83: 896-
T, Fukuda M, Noguchi T, Yamazaki K, Yoshie H, Ioroi 902.
K, Arai T, Nakagawa T, Ito K, Oda S, Izumi Y, Ogata Y, Mitsiadis TA, Woloszyk A, Jimenez-Rojo L (2012)
Yamada S, Shimauchi H, Kunimatsu K, Kawanami M, Nanodentistry: combining nanostructured materials and
Fujii T, Furuichi Y, Furuuchi T, Sasano T, Imai E, Omae stem cells for dental tissue regeneration. Nanomedicine
M, Yamada S, Watanuki M, Murakami S (2011) FGF-2 (Lond) 7: 1743-1753.
stimulates periodontal regeneration: results of a multi- Miura M, Gronthos S, Zhao M, Lu B, Fisher LW, Robey
center randomized clinical trial. J Dent Res 90: 35-40. PG, Shi S (2003) SHED: stem cells from human exfoliated
Kuroda R, Matsumoto T, Kawakami Y, Fukui T, Mifune deciduous teeth. Proc Natl Acad Sci U S A 100: 5807-5812.
Y, Kurosaka M (2014) Clinical impact of circulating CD34- Morsczeck C, Gotz W, Schierholz J, Zeilhofer F, Kuhn
positive cells on bone regeneration and healing. Tissue Eng U, Mohl C, Sippel C, Hoffmann KH (2005) Isolation of
Part B Rev 20: 190-199. precursor cells (PCs) from human dental follicle of wisdom
La Noce M, Mele L, Tirino V, Paino F, De Rosa A, teeth. Matrix Biol 24: 155-165.
Naddeo P, Papagerakis P, Papaccio G, Desiderio V (2014) Muraglia A, Cancedda R, Quarto R (2000) Clonal
Neural crest stem cell population in craniomaxillofacial mesenchymal progenitors from human bone marrow
development and tissue repair. Eur Cell Mater 28: 348-357. differentiate in vitro according to a hierarchical model. J
Lee CH, Cook JL, Mendelson A, Moioli EK, Yao H, Cell Sci 113 ( Pt 7): 1161-1166.
Mao JJ (2010) Regeneration of the articular surface of the Naddeo P, Laino L, La Noce M, Piattelli A, De Rosa
rabbit synovial joint by cell homing: a proof of concept A, Iezzi G, Laino G, Paino F, Papaccio G, Tirino V (2015)
study. Lancet 376: 440-448. Surface biocompatibility of differently textured titanium
Lehmann N, Debret R, Romeas A, Magloire H, implants with mesenchymal stem cells. Dent Mater 31:
Degrange M, Bleicher F, Sommer P, Seux D (2009) Self- 235-243.
etching increases matrix metalloproteinase expression in Nakashima M, Iohara K (2014) Mobilized dental pulp
the dentin-pulp complex. J Dent Res 88: 77-82. stem cells for pulp regeneration: initiation of clinical trial.
J Endod 40: S26-32.

www.ecmjournal.org
255
TA Mitsiadis et al. Stem cells for dental clinical use

Nam H, Kim J, Park J, Park JC, Kim JW, Seo BM, Sonmez IS, Akbay Oba A, Erkmen Almaz M (2013)
Lee JC, Lee G (2011) Expression profile of the stem Revascularization/Regeneration performed in immature
cell markers in human Hertwig’s epithelial root sheath/ molars: case reports. J Clin Pediatr Dent 37: 231-234.
Epithelial rests of Malassez cells. Mol Cells 31: 355-360. Sonoyama W, Liu Y, Fang D, Yamaza T, Seo BM,
Nanci A (2012) Ten Cate’s oral histology: development, Zhang C, Liu H, Gronthos S, Wang CY, Wang S, Shi S
structure, and function (8th edition). Mosby, USA, pp 1-13. (2006) Mesenchymal stem cell-mediated functional tooth
Nosrat IV, Widenfalk J, Olson L, Nosrat CA (2001) regeneration in swine. PLoS One 1: e79.
Dental pulp cells produce neurotrophic factors, interact Sonoyama W, Liu Y, Yamaza T, Tuan RS, Wang S,
with trigeminal neurons in vitro, and rescue motoneurons Shi S, Huang GT (2008) Characterization of the apical
after spinal cord injury. Dev Biol 238: 120-132. papilla and its residing stem cells from human immature
Oshima M, Tsuji T (2014) Functional tooth regenerative permanent teeth: a pilot study. J Endod 34: 166-171.
therapy: tooth tissue regeneration and whole-tooth Sonoyama W, Seo BM, Yamaza T, Shi S (2007) Human
replacement. Odontology 102: 123-136. Hertwig’s epithelial root sheath cells play crucial roles in
Otsu K, Kumakami-Sakano M, Fujiwara N, Kikuchi cementum formation. J Dent Res 86: 594-599.
K, Keller L, Lesot H, Harada H (2014) Stem cell sources Sudo K, Kanno M, Miharada K, Ogawa S, Hiroyama
for tooth regeneration: current status and future prospects. T, Saijo K, Nakamura Y (2007) Mesenchymal progenitors
Front Physiol 5: 36. able to differentiate into osteogenic, chondrogenic, and/
Pagella P, Neto E, Lamghari M, Mitsiadis TA (2015) or adipogenic cells in vitro are present in most primary
Investigation of orofacial stem cell niches and their fibroblast-like cell populations. Stem Cells 25: 1610-1617.
innervation through microfluidic devices. Eur Cell Mater Takahashi K, Yamanaka S (2006) Induction of
29: 213-223. pluripotent stem cells from mouse embryonic and adult
Peters OA (2014) Translational opportunities in stem fibroblast cultures by defined factors. Cell 126: 663-676.
cell-based endodontic therapy: where are we and what are van den Akker F, de Jager SC, Sluijter JP (2013)
we missing? J Endod 40: S82-85. Mesenchymal stem cell therapy for cardiac inflammation:
Pilipchuk SP, Plonka AB, Monje A, Taut AD, Lanis A, immunomodulatory properties and the influence of toll-like
Kang B, Giannobile WV (2015) Tissue engineering for receptors. Mediators Inflamm 2013: 181020.
bone regeneration and osseointegration in the oral cavity. Veis A, Tompkins K, Alvares K, Wei K, Wang L, Wang
Dent Mater 31: 317-338. XS, Brownell AG, Jengh SM, Healy KE (2000) Specific
Pisciotta A, Riccio M, Carnevale G, Lu A, De Biasi S, amelogenin gene splice products have signaling effects on
Gibellini L, La Sala GB, Bruzzesi G, Ferrari A, Huard J, De cells in culture and in implants in vivo. J Biol Chem 275:
Pol A (2015) Stem cells isolated from human dental pulp 41263-41272.
and amniotic fluid improve skeletal muscle histopathology Volponi AA, Pang Y, Sharpe PT (2010) Stem cell-based
in mdx/SCID mice. Stem Cell Res Ther 6: 156. biological tooth repair and regeneration. Trends Cell Biol
Pittenger MF, Mackay AM, Beck SC, Jaiswal RK, 20: 715-722.
Douglas R, Mosca JD, Moorman MA, Simonetti DW, Waddington RJ, Youde SJ, Lee CP, Sloan AJ (2009)
Craig S, Marshak DR (1999) Multilineage potential of adult Isolation of distinct progenitor stem cell populations from
human mesenchymal stem cells. Science 284: 143-147. dental pulp. Cells Tissues Organs 189: 268-274.
Potdar PD, Jethmalani YD (2015) Human dental pulp Wang L, Shen H, Zheng W, Tang L, Yang Z, Gao Y,
stem cells: Applications in future regenerative medicine. Yang Q, Wang C, Duan Y, Jin Y (2011) Characterization
World J Stem Cells 7: 839-851. of stem cells from alveolar periodontal ligament. Tissue
Prockop DJ (1997) Marrow stromal cells as stem cells Eng Part A 17: 1015-1026.
for nonhematopoietic tissues. Science 276: 71-74. Weissman IL, Anderson DJ, Gage F (2001) Stem
Ricketts D (2001) Management of the deep carious and progenitor cells: origins, phenotypes, lineage
lesion and the vital pulp dentine complex. Br Dent J 191: commitments, and transdifferentiations. Annu Rev Cell
606-610. Dev Biol 17: 387-403.
Ripamonti U (2007) Recapitulating development: a Windisch P, Stavropoulos A, Molnar B, Szendroi-Kiss
template for periodontal tissue engineering. Tissue Eng D, Szilagyi E, Rosta P, Horvath A, Capsius B, Wikesjo UM,
13: 51-71. Sculean A (2012) A phase IIa randomized controlled pilot
Sankaranarayanan S, Jetty N, Gadagi JS, Preethy S, study evaluating the safety and clinical outcomes following
Abraham SJ (2013) Periodontal regeneration by autologous the use of rhGDF-5/beta-TCP in regenerative periodontal
bone marrow mononuclear cells embedded in a novel therapy. Clin Oral Investig 16: 1181-1189.
thermo reversible gelation polymer. J Stem Cells 8: 99-103. Yang KC, Wang CH, Chang HH, Chan WP, Chi CH,
Selvig KA, Sorensen RG, Wozney JM, Wikesjo Kuo TF (2012) Fibrin glue mixed with platelet-rich
UM (2002) Bone repair following recombinant human fibrin as a scaffold seeded with dental bud cells for tooth
bone morphogenetic protein-2 stimulated periodontal regeneration. J Tissue Eng Regen Med 6: 777-785.
regeneration. J Periodontol 73: 1020-1029. Yokoi T, Saito M, Kiyono T, Iseki S, Kosaka K, Nishida
Seo BM, Miura M, Gronthos S, Bartold PM, Batouli E, Tsubakimoto T, Harada H, Eto K, Noguchi T, Teranaka T
S, Brahim J, Young M, Robey PG, Wang CY, Shi S (2004) (2006) Establishment of immortalized dental follicle cells
Investigation of multipotent postnatal stem cells from for generating periodontal ligament in vivo. Cell Tissue
human periodontal ligament. Lancet 364: 149-155. Res 327: 301-311.

www.ecmjournal.org
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TA Mitsiadis et al. Stem cells for dental clinical use

Zhang W, Chen J, Tao J, Jiang Y, Hu C, Huang L, Ji J, stem cells in dentistry is available, the approaches may be
Ouyang HW (2013) The use of type 1 collagen scaffold very variable and as a result, the outcomes can be variable
containing stromal cell-derived factor-1 to create a matrix as well. For this reason, the most significant hurdles and
environment conducive to partial-thickness cartilage limitations include:
defects repair. Biomaterials 34: 713-723. 1. Standardisation of clinical operation protocols for
Zhao H, Feng J, Seidel K, Shi S, Klein O, Sharpe P, endodontic treatments using stem cells
Chai Y (2014) Secretion of shh by a neurovascular bundle 2. Sources and standardisation of stem cells for use in
niche supports mesenchymal stem cell homeostasis in the clinics
adult mouse incisor. Cell Stem Cell 14: 160-173. 3. Adaptation of endondontic techniques according to the
Zheng Y, Wang XY, Wang YM, Liu XY, Zhang CM, specific anatomical shape of the roots, volume of the pulp
Hou BX, Wang SL (2012) Dentin regeneration using chamber, age of the patient, status of the general health
deciduous pulp stem/progenitor cells. J Dent Res 91: 676- of the patient
682. 4. Necessity of post-operative follow up
5. Cost of the treatment
6. Specialised manufactures (industrialisation) for covering
Discussion with Reviewer large-scale treatment for all individuals

Jean Christophe Farges: What might be the most

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