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DOI: 10.5958/j.2319-5886.2.2.


International Journal of Medical Research & Health Sciences Volume 2 Issue 2 April - June Coden: IJMRHS

Copyright @2013

ISSN: 2319-5886

Received: 23
Review article


Jan 2013

Revised: 22

Feb 2013

Accepted:28 Feb 2013

STEM CELLS: A NEW PARADIGM IN PERIODONTAL REGENERATION Ameet Mani1, Subhangi Mani1, Marawar PP2, *Shinde Sagar K3, Patil Ishwardas D1

Reader, 2Prof and H.O.D, 3PGStudent, Department of Periodontology and Implantology, Pravara Institute of Medical Sciences, Rural Dental College, Loni, Maharashtra.

*Corresponding author


Stem cells are a unique type of cell that forms the basis of the development, growth and survival of a living organism. Though the term is often used to describe controversial embryonic stem cells, there are many different types of stem cells, classified by their original location and/or method of formation. Stem cells are undifferentiated cells that go on developing into any of more than 200 type of cells that adult Human body hold. Now a days stem cells have significant use in regenerative periodontal therapy. Recently, reports have begun to emerge demonstrating that populations of adult stem cells reside in the periodontal ligament of humans and other animals. This opens the way for new cell-based therapies for periodontal regeneration.This review provides an overview of adult human stem cells and their potential use in periodontal regeneration. Key words: Adult stem cell, Periodontal ligament stem cells, Periodontal regeneration

The stem cell is the origin of life. As stated first by the great pathologist Rudolph Virchow, All cells come from cells. The ultimate stem cell, the fertilized egg, is formed by fusion of the haploid progeny of germinal stem cells. The fertilized egg is totipotent; since it forms all the tissues of the developing embryo. In the adult, tissue is renewed by the proliferation of specialized stem cells, which divide to form one cell that remains a stem cell and another cell that begins the process of differentiation to the specialized function of a mature cell type.1 Stem cells are defined by their potential to self-renew and differentiate into more specialized cell types within a given tissue.

Certain terms need to be known before understanding stem cells: I. Progenitor cell: It is an undifferentiated precursor cell with the capacity to undergo differentiation into specialized cell types; unlike putative stem cells, they do not retain the capacity for self-renewal. II. Multipotent stem cells: They are cells that self-renew and differentiate into several different specialized cell types, often within a tissue (e.g., hematopoietic stem cells). III. Pluripotent stem cells: They are cells capable of self-renewing and differentiating into any of the three germ layers (endoderm, ectoderm, and mesoderm).

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IV. Totipotent stem cells: They are cells derived from the first few divisions of the fertilized egg which have the potential to give rise to all the differentiated cells of the fully developed organism. A stem cell "self-renews" i.e., when a stem cell is called into action, it undergoes cell division. One daughter cell remains a stem cell, while the other becomes more committed to forming a particular cell type (a "committed progenitor") by a process called "asymmetric division". A stem cell forms multiple cell types (i.e., it is "multipotent"). Single stem cell completely re-forms a particular tissue when it is transplanted within the body. The first definitive evidence came with the work of Till and McCulloch on blood-forming (hematopoietic) stem cells in the 1960s. Researchers believe that virtually every tissue in the body contains some type of stem cell, conjuring up thoughts of all types of strategies for tissue repair. Scientists have found ways of coaxing these stem cells to develop into most types of human cells including the periodontium. Classification of Stem Cells Embryonic stem cells: They are responsible for the development of an entire organism. Adult stem cells: They provide a mechanism for maintenance of tissue homeostasis by replacing damaged cells throughout the life of the organism. An adult stem cell is defined by several properties, including its ability to self-renew i.e. forming a particular cell type (a progenitor) and one daughter cell that remains a stem cell (asymmetric division). Committed progenitors are thought to have a limited capacity for proliferation by symmetric division; their daughter cells then form differentiated cells within the tissue.(fig 2) The human body contains 220 different types of cells such as blood, brain, heart tissue, nerve cells, bones, etc. In 1998, researchers at the University of Wisconsin and the Johns Hopkins University in Baltimore MD found a way of harvesting stem cells from embryos and maintaining their growth in the lab.

Origin, Properties And Culture Of Stem Cells Origin Embryonic stem cells (ES cells):(fig 3) They are derived from embryos at a developmental stage before the time that implantation would normally occur in the uterus. The first documentation of the isolation of embryonic stem cells from human blastocysts was done in 1998 by Thomson and co-worker. Since then, techniques for deriving and culturing human ES cells have been refined. Blastocysts with a large and distinct inner cell mass tend to yield ES cultures most efficiently.2 Adult stem cells: No one knows the origin of adult stem cells in any mature tissue. Some have proposed that stem cells are somehow set aside during fetal development and restrained from differentiating. The list of adult tissues reported to contain stem cells is growing and includes bone marrow, peripheral blood, brain, spinal cord, dental pulp, blood vessels, skeletal muscle, epithelia of the skin and digestive system, cornea, retina, liver, and pancreas Properties of both adult and embryonic stem cells: (fig 4) Self-renewal: It is defining property of stem cells that allows them to undergo repeated mitotic cell divisions to create at least one daughter cell equivalent to the mother cell that retains latent capacity for differentiation. Clonogenicity: A stem cell is thought to be "clonogenic," which means that it can proliferate to form a colony of cells. Sources Of Dental Stem Cells The ultimate goal of tooth regeneration is to replace the lost structure. Dental stem cells can be obtained from following tissue 3: 1. Bone marrow stromal cells(BMMSC) 2. Human Pulp Tissue (DPSCs, post-natal dental pulp stem cells) 3.Exfoliated Deciduous Teeth (SHED) 4. Periodontal Ligament (PDLSC) 5. Apical Papilla (SCAP) 6. Dental Follicle Precursors (DFPC) 7.Mesenchymal stem cells from gingival


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Periodontal Ligament (PDLSC):(fig 5) Recent study has clearly mentioned presence of periodontal ligament stem cells in perivascular niches of periodontal ligaments. Periodontal ligament stem cells represent a unique population of postnatal stem cells distinct from bone marrow-derived derived mesenchymal stem cells. They have potential to form cementoblasts and osteoblasts. They form unique cementum PDL structure. Mesenchymal Stem Cells From Gingiva Tomas I. Mitrano et al in 2010 studied if gingival connective ective tissue could be a reservoir of MSCs that could be used in regenerative procedures based on tissue engineering.4 The results clearly demonstrate that it is possible to isolate MSCs from the gingival connective

tissue and obtain their differentiation into osteoblasts, cartilage and adipose cells in the same way that has been described regarding samples obtained from bone marrow.4 Possible applications of stem cells in dentistry. Now the areas where these stem cells are used in dentistry are included in the following text: In Place Of Connective Tissue Graft:(fig 6) Michael K. McGuire in 2008 studied to evaluate the safety and effectiveness of a tissuetissue engineered skin product composed of viable neonatal keratinocytes and fibroblasts and compared it to a free gingival graft (FGG) in a procedure to enhance keratinized tissue (KT) and wound healing around teeth that do not require root coverage.5

Fig 1: Embryonic and adult stem

Fig 2: Differentiation of adult stem cells

Fig 3: Embryonic stem cells derived

Fig 4: Plasticity of adult stem cells 256

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Fig 5: Sources of stem cells

Fig 6: Regenerating Potential of adult stem cells

Stem Cells And Periodontal Regeneration Periodontal regeneration can be dened dened as the complete srestoration of the lost tissues to their original architecture and function by recapitulating the crucial wound healing events associated with their develo pment. The periodontium is complex tissue once damaged, the periodontium has a limited capacity for regeneration. Resents approaches have included gene therapy and the local administration of biocompatible scaffolds with or without ithout the presence of selected growth factors.6 The concept that stem cells may reside in the periodontal tissues was first proposed almost 20 years ago by Melcher, who queried whether the three cell populations of the periodontium (cementoblasts, alveolar alveolar bone cells and periodontal ligament fibroblasts) were ultimately derived from a single population of ancestral cells or stem cells7. The most compelling evidence that these cells are present within the periodontal tissues has been provided by the in vivo and histological studies of McCulloch and co-workers workers 8, 9, 10. Cell kinetic study of mice have indicated that group of progenitor cells exhibiting some classical features of stem cells exist in the periodontal ligament. In the event of injury injury to the periodontium these mesenchymal stem cells could be activated towards terminal differentiation and tissue repair or regeneration.

Using cloning techniques, a large number of cells of differing phenotype have been isolated from the periodontal liga ligament ment and regenerating periodontal tissue. Preliminary studies suggested that some of the clonal cell lines had characteristics of stem cells, warranting further investigation into these properties and their utilization in cell-based cell based periodontal regenerative regenerativ 11 therapies . The identification of putative mesenchymal stem cell populations within the periodontium has stimulated interest in the potential use of stem cell-based cell based therapies to treat the damaged caused by trauma or periodontal disease. Bartold et al discussed the stem cell cell-like like properties and characteristics of stem cells residing within the periodontal ligament and speculate on their future clinical utility. Periodontal Therapies For Periodontal Regeneration: Once tissue destruction has occurred, one of the major goals of periodontal therapy is to regenerate the affected tissues to their original architecture and function 12. Many surgical procedures have been advocated for periodontal regeneration. More recent recently, , synthetic barrier membranes have been used to encourage the appropriate progenitor cell population of the wound site. This procedure has demonstrated potential for regeneration of the root surface cementum, alveolar bone and periodontal

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ligament. Unfortunately, the clinical results using this method vary greatly and are often unpredictable 13. With improving understanding of the molecular processes associated with tissue repair and regeneration, polypeptide growth factors applied to root surfaces have been used to facilitate periodontal regeneration . To date, these have included epidermal growth factor, fibroblast growth factor, insulin- like growth factor, platelet-derived growth factor, tumourderived growth factor and bone morphogenetic proteins. Combinations of growth factors such as those present in platelet-rich plasma preparations may also be useful in promoting periodontal regeneration 14. However, the current literature concerning the clinical outcomes of using such combinations is still scant. At the same time that polypeptide growth factors were being considered for periodontal regeneration, another approach was being developed based on our understanding of tooth root formation and, in particular, cementum formation. While the precise molecular mechanisms of cementum formation are still unclear, one theory (yet to be fully accepted) suggests that a special matrix is deposited on the newly formed dentin surface that is instrumental in permitting the attachment and differentiation of progenitor cells into cementoblasts .Extracts of this matrix have been applied to root surfaces at the time of periodontal surgery with the aim of inducing periodontal regeneration through the recreation of the molecular events of cementogenesis. Whether these proteins act as instructional messengers, similar to growth factors, for cells to undergo the processes of regeneration, or merely as a scaffold permitting regeneration to proceed is unclear. Nonetheless, clinical results have been encouraging and these proteins appear capable of promoting regeneration of periodontal tissues, albeit not in a completely predictable or consistent manner. Thus, key factors in attaining successful periodontal regeneration are the correct recruitment of cells to the site and the production of a suitable extracellular matrix consistent with

the periodontal tissues. Since cell seeding to enhance regeneration of other tissues (skin, cartilage, bone, cardiovascular components, pancreas, etc.) has been used success-fully, it is seems logical that autologous periodontal ligament stem cells cultured within a suitable delivery scaffold, in conjunction with the growth and differentiation factors present in an autologous blood clot, will lead to new periodontal tissue attachment via a tissue engineering approach. Potential Clinical Applications For Human Derived Dental Stem Cells: For some time the use of mobilized peripheral blood stem cells has been a recognized therapy for hematopoietic bone marrow reconstitution in cancer patients undergoing myeloablative therapy. The successful outcome of this therapy has led to investigations of other stem cell populations, such as bone marrow stromal stem cells, as potential novel cellular-based therapies for a number of diseases and congenital defects of neural, bone, cartilage and muscle tissues. Together, these studies demonstrate the clinical potential of bone marrow stromal stem cells and other mesenchymal stem cells for different tissue engineering strategies for tissue regeneration. Importantly, the presence of different mesenchymal stem cells residing in dental or craniofacial tissues invites further clinical investigations into regeneration of tissues of the orofacial region, including the periodontium, using these cells. To test whether periodontal ligament stem cells possess a tissue regenerative capacity similar to that of bone marrow stromal stem cells, researchers have initiated a number of studies to investigate the use of these cells for periodontal regeneration. To date, cultured human periodontal ligament stem cells have been implanted into surgically created periodontal defects in nude rats 15. The results indicated that the periodontal ligament stem cells attached to both the alveolar bone and cementum surfaces and there was evidence of formation of a periodontal ligament-like structure.

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Periodontal fibroblasts and pericyte were postulated to be potential osteoprogenitor cells by Wendell W. Neeley et al and they studied a viable co-culture model for the in vitro study of osteogenesis16. Human micro vascular endothelial cells (HMVEC) and human periodontal ligament (HPDL) fibroblasts were co-cultured in a layered model and monitored for the development of runt-related transcription factor 2 (runx2) and desmin expression by realtime polymerase chain reaction. Conditions shown to be osteogenic (bone morphogenetic protein [BMP]-2 and enamel matrix derivative [EMD]) were compared to a control co-culture that was unstimulated. The HMVEC migrated into a layer of collagen containing only HPDL cells as monitored by fluorescent labelling. Runx2 and desmin expressions were increased in stimulated cocultures in week 2 compared to controls. At week 3, the unstimulated control co-cultures developed the expression of runx2 and desmin, and the cocultures that were stimulated with EMD and BMP-2 achieved significantly higher levels of these factors than any of the other conditions. Signs of osteogenesis were present in the cocultures in unstimulated and stimulated conditions. However, in the stimulated condition, osteogenic markers were increased at earlier time points. As such, this model may provide a good method for the study of specific cellular processes that may lead to osteogenesis and eventually for understanding the regeneration of periodontal bone in vivo. 16 A new approach to anchor teeth back in the jaw using stem cells has been developed and successfully tested in the laboratory for the first time by researchers at the University of Illinois at Chicago. The new strategy represents a potential major advance in the battle against gum disease, a serious infection that eventually leads to toothloss.17 Researchers Smit Dangaria et al in UIC's Brodie Laboratory for Craniofacial Genetics in 2010 used stem cells obtained from the periodontal ligament of molars extracted from mice,

expanded them in an incubator, and then seeded them on barren rat molars. The stem cell-treated molars were reinserted into the tooth sockets of rats. After two and four months, the stem cells aligned and formed new fibrous attachments between the tooth and bone, firmly attaching the replanted tooth into the animal's mouth. Tissue sections showed that the replanted tooth was surrounded by newly formed, functional periodontal ligament fibres and new cementum, the essential ingredient of a healthy tooth attachment. In contrast, tooth molars that were replanted without new stem/progenitor cells were either lost or loosely attached and were resorbed.18

The dawn of this century is brightened by the growing understanding and experimentation with stem cells as primary tools in the expanding regenerative medicine and tissue engineering revolution. The tradition of using prosthetic artificial implants to restore lost or damaged dental tissue will gradually be supplanted by more natural alternatives, including biological tooth replacement or induction. The practice of dentistry is likely to be revolutionized by biological therapies based on growth and differentiation factors that accelerate and/or induce a natural biological regeneration. This prospect has flourished from the gained knowledge provided by the molecular biological characterization of the genetic makeup of human cells and from a growing understanding of the effect of environmental factors. Prevention of dental diseases will also gain new ground as more insight is gained into the genetic makeup of microbial pathogens, their interactions with the host, and the host repair mechanisms. It is very important to analyze the current knowledge, barriers, and challenges in the clinical use of stem cells with an emphasis on applications in dentistry. Research on stem cells continues to advance knowledge about how an organism develops from a single cell and how

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healthy cells replace damaged cells in adult organisms Pamela Robey19, says that because no one knows for certain what the full possibilities are for the cells isolated from dental pulp, nor can they accurately predict if or when they will be used in clinical settings, patients and professionals need to make informed decisions.

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9. McCulloch CA. Progenitor cell populations in the periodontal ligament of mice. Anat Rec 1985; 211: 25862. 10. McCulloch CA. Origins and functions of cells essential for periodontal repair: the role of fibroblasts in tissue homeostasis. Oral Dis 1995; 1: 271278. 11. Ivanovski S, Haase HR, Bartold PM. Expression of bon matrix protein mRNAs by primary and cloned cultures of the regenerative phenotype of human periodontal fibroblasts. J Dent Res 2001: 80: 166571. 12. Polson AM. Periodontal regeneration. Chicago: Quintessence Publishing Co., 1994;8-137. 13. Laurell L, Gottlow J. Guided tissue regeneration update. Int J Dent 1998: 48: 38698. 14. Carlson NE, Roach RB. Platelet-rich plasma: clinical applications in dentistry. J Am Dent Assoc 2002;133: 1383 86. 15. Seo BM, Miura M, Gronthos S, Barthold PM, Batouli S Brahim J, Young M, Robey PG, Wang CY, Shi S. Investigation of multipotent postnatal stem cells from human periodontal ligament. Lancet 2004: 364: 14955. 16. Wendell W. Neeley II, David L. Carnes, and David L. Cochran; Osteogenesis in an In Vitro Coculture of Human Periodontal Ligament Fibroblasts and Human Microvascular Endothelial Cells. J Periodontol 2010; 81: 139-49. 17. Ben C. Dental implants could be grown inside patients' mouths. International cool hunting magazine; Future Tech and Medicine 2010;5:16-21 18. Smit Dangaria et al. Technique to Reattach Teeth Using Stem Cells Developed Source: University of Illinois at Chicago.The Journal Tissue Engineering . 2010;29:22 -33. 19. American Medical Association April 20, 2009 Dental stem cell potential explored, Availsble from: 1088.aspx

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