Florian Völlner

Somatic stem cells for regenerative dentistry

Complex human tissues harbour stem cells and/or precursor cells, which are responsible for tissue development or repair. Recently, dental tissues such as periodontal ligament (PDL), dental papilla or dental follicle have been identified as easily accessible sources of undifferentiated cells. The dental stem cell biology might provide meaningful insights into the development of dental tissues and cellular differentiation processes. Dental stem cells could also be feasible tools for dental tissue engineering. Constructing complex structures like a periodontium, which provides the functional connection between a tooth or an implant and the surrounding jaw, could effectively improve modern dentistry. Dental precursor cells are attractive for novel approaches to treat diseases like periodontitis, dental caries or to improve dental pulp healing and the regeneration of craniofacial bone and teeth. These cells are easily accessible and, in contrast to bone-marrow-derived mesenchymal stem cells, are more closely related to dental tissues. This review gives a short overview of stem cells of dental origin.

Comparison of human dental follicle cells (DFCs) and stem cells from human exfoliated deciduous teeth (SHED) after neural differentiation in vitro

Dental stem cells from human exfoliated deciduous teeth (SHED) and dental follicle cells (DFCs) are neural crest-derived stem cells from human dental tissues. Interestingly, SHED and DFCs can successfully differentiate into neuron-like cells. We hypothesized that SHED and DFCs have the same neural cell differentiation potentials. To evaluate neural cell differentiation, we cultivated SHED and DFCs in four different serum-replacement media (SRMs) and analyzed cell morphology, cell proliferation, and gene expression patterns before and after differentiation. In a standard cell culture medium, SHED and DFCs have not only similar cell morphologies, but they also have similar gene expression patterns for known stem cell markers. However, only SHED expressed the neural stem cell marker Pax6. After cultivation in SRMs, cell proliferations of DFCs and SHED were reduced and the cell morphology was spindle-like with long processes. However, differentiated DFCs and SHED had different neural cell marker expression patterns. For example, gene expression of the late neural cell marker microtubule-associated protein 2 was upregulated in DFCs and downregulated in SHED in SRM with the B27 supplement. In contrast, SHED formed neurosphere-like cell clusters in SRM with the B27 supplement, epidermal growth factor, and fibroblast growth factor-2. Moreover, SHED differentially expressed the glial cell marker glial fibrillary acidic protein, which in contrast was weakly or not expressed in DFCs. In conclusion, SHED and DFCs have different neural differentiation potentials under the same cell culture conditions.

A two-step strategy for neuronal differentiation in vitro of human dental follicle cells

Human dental follicle cells (DFCs) derived from wisdom teeth are precursor cells for cementoblasts. In this study, we recognized that naïve DFCs express constitutively the early neural cell marker beta-III-tubulin. Interestingly, DFCs formed beta-III-tubulin-positive neurosphere-like cell clusters (NLCCs) on low-attachment cell culture dishes in serum-replacement medium (SRM). For a detailed examination of the neural differentiation potential, DFCs were cultivated in different compositions of SRM containing supplements such as N2, B27, G5 and the neural stem cell supplement. Moreover, these cell culture media were combined with different cell culture substrates such as gelatin, laminin, poly-L-ornithine or poly-L-lysine. After cultivation in SRM, DFCs differentiated into cells with small cell bodies and long cellular extrusions. The expression of nestin, beta-III-tubulin, neuron-specific enolase (NSE) and neurofilament was up-regulated in SRM supplemented with G5, a cell culture supplement for glial cells, and the neural stem cell supplement. DFCs formed NLCCs and demonstrated an increased gene expression of neural cell markers beta-III-tubulin, NSE, nestin and for small neuron markers such as neuropeptides galanin (GAL) and tachykinin (TAC1) after cultivation on poly-L-lysine. For a further neural differentiation NLCC-derived cells were sub-cultivated on laminin and poly-L-ornithine cell culture substrate. After 2 weeks of differentiation, DFCs exposed neural-like cell morphology with small neurite-like cell extrusions. These cells differentially express neurofilament and NSE, but only low levels of beta-III-tubulin and nestin. In conclusion, we demonstrated the differentiation of human DFCs into neuron-like cells after a two-step strategy for neuronal differentiation.

Gene expression profiles of dental follicle cells before and after osteogenic differentiation in vitro

Recently, osteogenic precursor cells were isolated from human dental follicles, which differentiate into cementoblast- or osteoblast-like cells under in vitro conditions after the induction with dexamethasone or insulin. However, mechanisms for osteogenic differentiation are not understood in detail. In a previous study, real-time RT-PCR results demonstrated molecular mechanisms in dental follicle cells (DFCs) during osteogenic differentiation that are different from those in bone-marrow-derived mesenchymal stem cells. We analysed gene expression profiles in DFCs before and after osteogenic differentiation with the Affymetrix GeneChip® Human Gene 1.0 ST Array. Transcripts of 98 genes were up-regulated after differentiation. These genes could be clustered into subcategories such as cell differentiation, cell morphogenesis, and skeletal development. Osteoblast-specific transcription factors like osterix and runx2 were constitutively expressed in differentiated DFCs. In contrast, the transcription factor ZBTB16, which promotes the osteoblastic differentiation of mesenchymal stem cells as an up-stream regulator of runx2, was differentially expressed after differentiation. Transcription factors NR4A3, KLF9 and TSC22D3, involved in the regulation of cellular development, were up-regulated as well. In conclusion, we present the first transcriptome of human DFCs before and after osteogenic differentiation. This study sheds new light on the complex mechanism of osteogenic differentiation in DFCs.

Proteomic analysis of osteogenic differentiation of dental follicle precursor cells.

Recently, there has been an increased interest in unravelling the molecular mechanisms and cellular pathways controlling the differentiation and proliferation of human stem cell lines. Proteome analysis has proven to be an effective approach to comprehensive analysis of the regulatory network of differentiation. In the present study we applied 2‐DE combined with capillary‐LC‐MS/MS analysis to profile differentially regulated proteins upon differentiation of dental follicle precursor cells (DFPCs). Out of 115 differentially regulated proteins, glutamine synthetase, lysosomal proteinase cathepsin B proteins, plastin 3 T‐isoform, beta‐actin, superoxide dismutases, and transgelin were found to be highly up‐regulated, whereas cofilin‐1, pro‐alpha 1 collagen, destrin, prolyl 4‐hydrolase and dihydrolipoamide dehydrogenase were found to be highly down‐regulated. The group of up‐regulated proteins is associated with actin‐bundling and defence against oxidative cellular stress, whereas down‐regulated proteins were associated with collagen biosynthesis. Bioinformatic analyses of the entire data set confirmed these findings that represent significant steps towards the understanding of DFPC differentiation. The bioinformatic analyses suggest that proteins associated with cell cycle progression and protein metabolism were down‐regulated and proteins involved in catabolism, cell motility and biological quality were up‐regulated. These results display the general physiological state of DFPCs before and after osteogenic differentiation. We also identified regulatory proteins, such as the transcription factors TP53 and Sp‐1, associated with the differentiation process. Further studies will investigate the impact of identified regulatory proteins for cell proliferation and osteogenic differentiation in DFPCs.

Soft matrix supports osteogenic differentiation of human dental follicle cells

The differentiation of stem cells can be directed by the grade of stiffness of the developed tissue cells. For example a rigid extracellular matrix supports the osteogenic differentiation in bone marrow derived mesenchymal stem cells (MSCs). However, less is known about the relation of extracellular matrix stiffness and cell differentiation of ectomesenchymal dental precursor cells. Our study examined for the first time the influence of the surface stiffness on the proliferation and osteogenic differentiation of human dental follicle cells (DFCs). Cell proliferation of DFCs was only slightly decreased on cell culture surfaces with a bone-like stiffness. The osteogenic differentiation in DFCs could only be initiated with a dexamethasone based differentiation medium after using varying stiffness. Here, the softest surface improved the induction of osteogenic differentiation in comparison to that with the highest stiffness. In conclusion, different to bone marrow derived MSCs, soft ECMs have a superior capacity to support the osteogenic differentiation of DFCs.

The state of the art in human dental stem cell research

This review article arranges the current results of stem cell biology for their use in dentistry. There are different types of stem cells, which are applicable for dental treatments. The use of embryonic stem cells, whose possibilities for breeding an artificial tooth were hardly evaluated, is however ethically precarious. On the other side the ethically harmless adult stem cells, which were isolated for example from bone marrow, were little examined for their capability of differentiation into dental tissues. Therefore their forthcoming use in dentistry is rather improbable. However, dental ectomesenchymal stem cells are more promising for dentistry in future. For example dental pulp stem cells (DPSCs) are capable to differentiate into dentin under in vitro conditions. Moreover it is possible to use periodontal ligament (PDL) stem cells and dental follicle precursors for periodontal tissue differentiations in vitro. Recently new populations of stem cells were isolated from the dental pulp and the PDL. These cells distinguish from the initially isolated DPSCs and PDL stem cells in growth and cell differentiation. Therefore stem cell markers are very important for the characterization of dental stem cells. A significant marker for dental stem cells is STRO-1, which is also a marker for bone marrow derived mesenchymal stem cells. Nonetheless dental stem cells are CD45 negative and they express rarely hematopoietic stem cell markers. These research results plead for the participation of dental stem cells in dental practice in future.

Positive medium-term influence of multimodal pain management on socioeconomic factors and health care utilization in patients with lumbar radiculopathy: a prospective study

Background Multimodal pain management (MPM) represents a central approach to avoiding surgery in patients with lumbar radiculopathy. Independent of the type of health system, cost effectiveness and socioeconomic factors are becoming increasingly important. This study investigated the medium-term influence of conservative MPM on health care utilization and socioeconomic factors. Methods This study compared subjective, objective, and socioeconomic factors of 60 patients after inpatient MPM because of lumbar radiculopathy, before and 1 year ± 2 weeks after treatment. Results Over the course of the 1-year follow-up, one-third of the patients had not required any conservative treatment in comparison to 100% of patients before MPM therapy. The number of patients requiring analgesics could be significantly reduced from 26 to 12, and the number of patients who did not require any analgesics had increased from 14 to 32. After 1 year, the number of patients who had to regularly contact a physician because of low back pain (once per month for 6 months) had been reduced from 58 to 27. Conclusion MPM is an effective approach to treating lumbar radiculopathy and reducing its negative influence on socioeconomic factors. Therapeutic benefits also include a decrease in health care utilization. Therefore, health care providers should place the mid-term success for patients and socioeconomic factors before the short-term costs of therapy.

Implementing a benchmarking and feedback concept decreases postoperative pain after total knee arthroplasty: A prospective study including 256 patients

Perioperative pain reduction, particularly during the first two days, is highly important for patients after total knee arthroplasty (TKA). Problems are not only caused by medical issues but by organization and hospital structure. The present study shows how the quality of pain management can be increased by implementing a standardized pain concept and simple, consistent benchmarking. All patients included into the study had undergone total knee arthroplasty. Outcome parameters were analyzed by means of a questionnaire on the first postoperative day. A multidisciplinary team implemented a regular procedure of data analyzes and external benchmarking by participating in a nationwide quality improvement project. At the beginning of the study, our hospital ranked 16th in terms of activity-related pain and 9th in patient satisfaction among 47 anonymized hospitals participating in the benchmarking project. At the end of the study, we had improved to 1st activity-related pain and to 2nd in patient satisfaction. Although benchmarking started and finished with the same standardized pain management concept, results were initially pure. Beside pharmacological treatment, interdisciplinary teamwork and benchmarking with direct feedback mechanisms are also very important for decreasing postoperative pain and for increasing patient satisfaction after TKA.

Even the Intraoperative Knowledge of Femoral Stem Anteversion Cannot Prevent Impingement in Total Hip Arthroplasty

BACKGROUND In this prospective study of 66 patients undergoing cementless total hip arthroplasty through a minimally invasive anterolateral approach, we evaluated the impact of an intraoperative hybrid combined anteversion technique on postoperative range of motion (ROM). METHODS After navigation of femoral stem anteversion, trial acetabular components were positioned manually, and their position recorded with navigation. Then, final components were implanted with navigation at the goals prescribed by the femur-first impingement detection algorithm. Postoperatively, three-dimensional computed tomographies were performed to determine achieved component position and model impingement-free ROM by virtual hip movement, which was compared with published values necessary for activities of daily living. This model was run a second time with the implants in the position selected by the surgeon rather than the navigation program. In addition, we researched into risk factors for ROM differences between the freehand and navigated cup position. RESULTS We found a lower flexion of 8.3° (8.8°, P < .001) and lower internal rotation of 9.2° (9.5°, P < .001) for the freehand implanted cups in contrast to a higher extension of 9.8° (11.8°, P < .001) compared with the navigation-guided technique. For activities of daily living, 58.9% (33/56) in the freehand group compared with 85.7% (48/56) in the navigation group showed free flexion (P < .001) and similarly 50.0% (28/56) compared with 76.8% (43/56) free internal rotation (P < .001). Body mass index, incision length, and cup size were identified as independent risk factors for reduced flexion and internal rotation in the freehand group. CONCLUSION For implementation of a combined anteversion algorithm, intraoperative alignment guides for accurate cup positioning are required using a minimally invasive anterolateral approach. Obese patients are especially at risk of cup malpositioning.