Terri Lively

Remineralization and Early Lesion Treatments: What Are Some Options to Consider? | Image Credit: © Infinite Gallery - stock.adobe.com / Generated with AI

Dentists often have to choose whether or not to drill into a tooth when they see an early lesion. These decision trees are complicated and influenced by many factors.

However, if an early lesion is detected and operative treatment is not performed, “monitoring” or “watching” the lesion is likely insufficient to provide the best outcome for the tooth.

Remineralization of tooth structure is a conservative but active plan to manage early lesions. Today, we look at the goals of remineralization and the products that can help get you there.

When acid attacks the tooth's enamel, acid made of H+ ions seeps into it and dissolves its most soluble salts, like carbonate apatite and non-stoichiometric apatite crystals, creating the lesion boundary. The lesion boundary moves forward as the damage advances, creating high levels of calcium and phosphate ions in the tooth. These dissolved ions exit the tooth, following a concentration gradient where they can bind with fluoride at the surface and form a new, dense layer of minerals.

Adding new minerals to a damaged tooth to fill holes strengthens the tooth. However, remineralization requires calcium and phosphate ions from an outside source to fill the gaps in the damaged enamel, which needs these concentrations to be higher than what's already in the damaged area. These ions move into the tooth through tiny holes and spaces. However, it is essential to get this flow just right; if they are too concentrated, they block the holes in the tooth's surface, preventing more ions from entering.

Various studies show fluoride improves enamel remineralization. However, when dealing with dental decay, any treatment aiming to remineralize teeth should adhere to 2 important principles:

Controlling dental plaque is imperative for success.

Fluoride use in remineralizations can either stop existing cavities from getting worse or slow down the development of new ones.

Nathaniel Lawson, DMD, Ph.D., assistant professor and director of the Division of Biomaterials at the UAB School of Dentistry, says if a lesion has not yet been cavitated, remineralization is the most conservative treatment to attempt, as long as the patient or their caretaker can perform it. However, he says determining when cavitation occurred is a little more challenging for interproximal and occlusal pit caries.

In the cases where Dr Lawson undertakes remineralization, he likes the home hygiene approach. There are a couple of reasons for this.

“I use 5000ppm fluoride toothpaste for this effort, rather than regular toothpaste, which is 1000ppm,” Dr Lawson explains. “I use this treatment because it is easy for the patient to obtain, meaning they can buy it from my office or get it from a pharmacist, and it is easy to use. They use it just like regular toothpaste.”

Studies have shown fluoride treatments, like rinses, can significantly increase remineralization effects on nearby areas affected by cavities compared to other methods. Fluoride varnish can be a valuable addition to preventive care for adult patients, potentially avoiding surgical intervention in those at lower risk for cavities. Community-based studies have found that biannually applying acidulated phosphate fluoride gel can reverse early cavities.

In addition to fluoride, non-fluoride compounds like casein phosphopeptide (CPP) have shown promise in remineralizing tooth surfaces. CPP stabilizes calcium phosphate in solution, allowing high concentrations of calcium and phosphate ions to penetrate subsurface lesions and promote enamel remineralization. Studies have confirmed that CPPs can effectively promote remineralization of early enamel lesions.

When it comes to remineralization agents, with or without fluoride, the desirable characteristics include:

The chosen remineralizing agent should quickly add minerals to the tooth surface, even if it means losing some.

It should rapidly change the deposited minerals into a stronger type called fluorapatite.

To finish the remineralization process, the agent should quickly spread over the tooth surface and into any areas below.

This process should happen even in patients at high risk for cavities.

So, What Are Your Options for Remineralization Therapy?

There are quite a few, it turns out. Dr Lawson thinks clinicians could also consider other options than high-fluoride toothpaste, which include:

 This product has an even higher concentration of fluoride than high-fluoride toothpaste, around 22,000 ppm, and is applied every 6 months.

Calcium-phosphate gels (e.g., MI Paste): 

These gels contain the ions present in the mineral of teeth (hydroxyapatite).

This option has become popular. Some laboratory trials on these products indicate they can remineralize similarly to fluoride toothpaste.

 This product from Young Innovations contains peptides to help rebuild enamel with embedded ions that are present in saliva.

 To be clear, Dr Lawson points out that this method is not remineralization; instead, it involves replacing missing mineral content with resin.

 also provides a helpful summary of many options for remineralization therapy, starting with an overview of acidated fluoride products.

, including mouth rinses, gels, and foams, are available. Dental materials manufacturers developed these products to address a limitation of traditional fluoride treatments in remineralization therapy. High-concentration fluoride products often lead to surface-zone remineralization, leaving the deeper parts of the lesion untreated. By lowering the pH of the fluoridated vehicle, such as mouth rinse, or gel, mineral ions can penetrate deeper into the lesion, enabling full remineralization. The low pH environment also encourages calcium and fluoride release from bacterial sources, further enhancing remineralization.

 employs self-assembling peptides (P11-4) to regenerate early caries lesions. In this innovative approach, applying the P11-4 monomers to early caries lesions means they permeate the micro-pores of the lesion and organize themselves into a 3D matrix (scaffold) under high ionic strength conditions. This scaffold then attracts calcium phosphate from saliva, serving as a template for forming new hydroxyapatite crystals around the matrix. Essentially, this process initiates biomimetic mineralization, facilitating the regeneration of enamel and dentin. Remineralization of the treated lesion typically requires several weeks to complete.

 incorporates the amino acid arginine into toothpaste formulations, typically at a concentration of 1.5%. This toothpaste also contains insoluble calcium carbonate and 1450 ppm fluoride as sodium monofluorophosphate, tailored for remineralizing early caries lesions and preventing new ones. When used, arginine undergoes deamination by saliva enzymes, producing ammonia, which increases oral pH, promoting remineralization and reducing plaque pathogenicity. The fluoride ions from sodium monofluorophosphate and calcium from calcium carbonate further enhance remineralization.

Functionalized tricalcium phosphate (TCP) technology

 is in toothpaste and fluoride varnishes. These products enhance remineralization through improved formulations and the addition of calcium to complement fluoride. Milling β-tricalcium phosphate with organic materials protects the calcium oxides in TCP, allowing coexistence with fluoride ions without premature interactions. Organic materials, such as surfactants, carry the calcium to the tooth surface, where saliva activates it, releasing calcium and fluoride for remineralization.

 in toothpaste, sealants, composites, and barrier coats. These fillers utilize a ligand exchange mechanism to release and recharge fluoride ions, providing sustained fluoride release influenced by acidity. They also release various other ions at high concentrations, such as aluminum (

. This multi-ion release capability imbues materials containing SPRG fillers with several therapeutic effects, including pH modulation to neutral or weak alkaline conditions, which is ideal for lesion remineralization. The released fluoride and silica promote apatite formation in oral fluid like saliva, while Sr2+ may enhance tooth acid resistance by converting hydroxyapatite to strontiumapatite.

, such as Novamin™, does not contain fluoride. Sodium monofluorophosphate is added separately, risking premature calcium and fluoride reactions to form calcium fluoride (CaF2), which may hinder fluoroapatite formation. Innovators incorporated fluoride, strontium, potassium, and zinc to create fluoride-containing bioactive glass toothpaste. This step enables the simultaneous delivery of Ca2+, PO43−, and F− ions in appropriate amounts for fluoroapatite formation without CaF2 formation. Originally, dentifrice formulations used bioactive glass formulations to treat dentin hypersensitivity by forming a surface layer of hydroxycarbonate apatite on teeth, occluding dentinal tubules. Fluoride-containing bioactive glass serves as a remineralizing additive, releasing fluoride, strontium, zinc, and potassium ions for caries remineralization, prevention, and bactericidal properties. These products release fluoride over 12 hours, forming more stable fluorapatite, aiding in remineralization and acid resistance.

Nanohydroxyapatite-containing toothpaste and oral rinses,

 designed for remineralization and caries prevention, contain nanohydroxyapatite (nHAP) ranging from 5-20%, tailored for remineralization, caries prevention, or dentin hypersensitivity treatment. Other calcifying toothpaste and oral rinses combine nHAP with fluoride for remineralization and caries prevention or with stabilized chlorine dioxide for whitening. Nanohydroxyapatite, a biocompatible material, fills micropores in early caries lesions, acting as a template for remineralization by attracting calcium and phosphate ions from oral fluids and promoting crystal growth. When combined with fluoride, nHAP lowers bioavailable fluoride concentration, with NaF being a slight concern compared to sodium monofluorophosphate.

 has gained attention as a caries-preventive agent. A 38% SDF solution effectively arrests coronal caries. In randomized clinical trials, annual applications of SDF halted more active initial caries and reduced new caries formation compared to quarterly applications of NaF varnish. SDF not only arrests caries progression but exhibits antimicrobial properties and an affinity for tooth tissue's mineral and organic components.

Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)

 and fluoride-containing CPP-ACFP, found in products like Tooth Mousse and MI Paste, are designed to promote enamel remineralization and prevent tooth decay. These nanocomplexes bind to tooth surfaces and dental plaque, increasing the concentration of bioavailable calcium and phosphate ions in the oral biofilm. This process aids in remineralization and alters the dynamics of demineralization-remineralization events, effectively preventing caries development. Studies show that these nanocomplexes can penetrate early caries lesions, releasing calcium and phosphate ions to fill crystal voids and form hydroxyapatite or, in the presence of fluoride, fluorapatite. Clinical evidence strongly supports their remineralizing efficacy, making them valuable tools in dental care for combating early caries and promoting overall enamel health.

 enhances plaque-calcium concentrations. In a caries clinical trial, combining it with sodium monofluorophosphate (SMFP) in toothpaste proved more effective than SMFP alone, suggesting its role in elevating plaque-calcium levels.

is another active ingredient featured in oral hygiene products. Research suggests that theobromine exhibits comparable remineralization effects despite being 71 times less concentrated than fluoride. It's proposed that theobromine enhances apatite crystallite size and crystallinity in the presence of saliva.

Remineralization options are abundant. In some cases, remineralizing might be the best option, providing a conservative way to treat the early stages of disease.

1. Carey CM. Remineralization of Early Enamel Lesions with Apatite-Forming Salt. 

2. González-Cabezas C, Fernández CE. Recent Advances in Remineralization Therapies for Caries Lesions. Advances in Dental Research. 2018;29(1):55-59. doi:10.1177/0022034517740124

3. “Early Carious Lesions Treatment Considerations.” AADC Permissions Committee. Available at: 

https://s3.amazonaws.com/amo_hub_content/Association1002/files/AADC%20Position%20Statement_%20Early%20Carious%20Lesions-%20Treatment%20Considerations.pdf

4. Daruich PM, Brizuela M. Remineralization of Initial Carious Lesions. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: 

https://www.ncbi.nlm.nih.gov/books/NBK573067/

5. Amaechi, Bennett. (2015). Remineralization Therapies for Initial Caries Lesions. Current Oral Health Report. 2. 10.1007/s40496-015-0048-9.

Articles

Let's take a look at the goals of remineralization and what products can get you there for those early lesion cases you want to treat before you have to drill and fill them.


Remineralization and Early Lesion Treatments: What Are Some Options to Consider?

Managing Unrealistic Teeth Whitening Expectations. Image credit: © Tierney – stock.adobe.com

Patient disappointment with whitening treatment manifests in many ways. Maybe the patient is subtle, using body language or subconscious signals, like the set of the patient’s mouth when they first see the results or an almost undetectable squint of their eyes.

You can also detect disappointment in phrases like, “Oh, I thought it would look different than this,” or “Is it going to get brighter after I leave?”

Disappointment could also appear in a rant on social media or in a less-than-flattering online review.

Regardless of how you hear about it, disappointment with whitening treatments is never the outcome you want. We explore ways to avoid patient disappointment with whitening treatments in your dental practice.

Expectations and Personality Contribute to Perceived Outcomes

So, what causes disappointment? Disappointment results from many things that happen during treatment.

A 2020 literature review of medical and dental patient-reported outcome measures in the 

 concluded as much. However, the researchers also say if clinicians and their teams can better understand how to manage patients' expectations by giving them information in a clear and timely way, it could help reduce patients’ chances of feeling unhappy about their medical or dental treatment.

Traditional marketing theories agree that expectations are to blame here. The theory behind consumer satisfaction is called the User's Satisfaction Theory. This theory says that even if someone has a good experience with a product or service, they might still feel unhappy if it fails to meet their expectations. This is called Negative Disconfirmation. By contrast, if the experience is better than expected, it leads to Positive Disconfirmation, a flip-flopped scenario where people feel satisfied.

In other words, people form expectations about how well a product or service will or won’t work, influencing how satisfied they feel. The Disconfirmation Model also explains that satisfaction doesn't depend on whether expectations start negative or if the product's performance ends up negative. What matters is the difference between what people expect and what they experience.

Assimilation Theory might apply, too. This theory describes how people try to avoid unhappiness by changing how they see the product. Some might adjust their expectations to match the product or service's performance. Other people might downplay their performance dissatisfaction by convincing themselves it's not a big deal.

In addition to expectations, the personality type might affect how a patient perceives the outcome of their whitening treatment. A 2015 study in the 

 suggests that most people seeking whitening treatment had common personality traits; moreover, they had moderate expectations and were mostly satisfied. The one exception was the extroverts, who were motivated by social inputs. Their personality type affected their satisfaction more than the other participants. Still, the effect of their personality was that they would be more satisfied with the whitening outcome than other personality groups.

The researchers also concluded that people shared common goals in seeking whitening treatment among personality types. People who seek whitening do so to feel happier and less inhibited, improve self-esteem, and increase their successful participation in social environments. Moreover, knowing these goals should direct clinicians in individual treatment planning.

So, How Do You Communicate Proper Expectations?

Sarah Jebreil, DDS, AAACD, says effective communication is crucial for a positive patient experience. She adds that psychology also plays a key role in facilitating this process, as different personalities respond to communication styles in various ways. Dr Jebreil emphasizes tailoring communication strategies to suit each patient's personality type.

Dr Jebreil says most of her patients are happy with their whitening treatments. In her experience, only about 10% are disappointed. She says their disappointment is likely related to the brightness outcome rather than the whiteness achieved.

“Maybe their color does get whiter on the shade guide,” Dr Jebreil says, “but it’s not as bright as they want. That has to do with the enamel they have.”

Dr Jebreil explains that helping patients understand their enamel type's role in the outcome is essential in managing unrealistic expectations before whitening treatments. Patients with inherent prismatic enamel, or translucency that extends from the middle to the incisal edge have limitations regarding brightness compared to a person with translucency only in the lower third.

Before whitening, she explains how these biological limitations affect the outcome to avoid patient disappointment, particularly with those patients whose biology will affect how bright the smile looks. However, she simplifies the message, removing the clinical terms and making it accessible for patients.

For example, she explains that brightness from whitening is affected by the tooth's translucency and draws patients' attention to how the light shows through their teeth at the present shade. She says photos help, too, by giving patients a before-and-after view to compare after whitening.

“We always do a pre-op shade photo and then post-op,” Dr Jebreil says.

Regarding conversations about procedures with patients, it is essential to recognize that what may seem routine to you is usually new and unfamiliar to patients. Intentional overcommunication is key. Reviewing the treatment and including its details can strengthen trust and improve the patient experience. Additionally, clinicians should:

Reconnect with your empathy and compassion by remembering that you went into the field to help people.

Build trust and rapport with patients by communicating outside the typical interactions in the practice with tools like social media.

Discuss with patients what you consider realistic outcomes.

Dentists and their teams can set proper expectations for dental whitening treatments by first understanding what the patient hopes to achieve and guiding them based on expert knowledge. Asking why patients want to whiten their teeth provides insight into their motivation, and having them show their desired shade on a guide helps determine realistic options. It's also essential to discuss the time it might take to achieve results, as some patients may have specific deadlines or cases that require longer treatment.

Additionally, it is crucial to inform patients about the limitations of whitening on existing dental work and plan for future restorative cases. Discussing potential side effects like gum irritation and tooth sensitivity beforehand can prevent negative surprises.

Lastly, patients should be informed about the temporary nature of whitening and the maintenance required. Explaining how diet and beverage choices can affect results helps manage expectations and ensures patients understand how to maintain their whitened smile.

Dr Jebreil also emphasizes to patients that long-lasting whitening effects do not have a quick fix. She wants patients to understand that from the beginning. Moreover, she explains that patient compliance is a factor in the whitening treatment outcome. Dr Jebreil uses the Kör Whitening system, which takes place over 2 to 4 weeks and requires patient behavioral management (e.g., refraining from drinking beverages that stain, like coffee, for 2 weeks and consistent treatments every night). She finds that patients willing to commit the time and energy involved with this system consistently get the best results.

In cases where this pre-emptive expectation management falls short, or the patient thinks the compliance requirements are too much work, Dr Jebreil sees an opportunity to suggest veneers. With veneers, patients can still have the desired value, even if it isn’t possible with their natural dentition or they are unwilling to stick to the whitening program.

“Either you put the time in and get what you want, or you spend the money and do the permanent fix, like veneers. Nobody will get amazing whitening results without following the protocol and putting the time in,” Dr Jebreil says. “The good whitening systems are where you're spending the time and doing it consistently for 2 to 4 weeks to get those nice results.”

Kelvin I. Afrashtehfar, Mansour K. A. Assery, S. Ross Bryant. Patient Satisfaction in Medicine and Dentistry. 

Martin J, Rivas V, Vildósola P, et al. Personality Style in Patients Looking for Tooth Bleaching and Its Correlation with Treatment Satisfaction. 

. 2016;27(1):60-65. doi:10.1590/0103-6440201600127

Managing Patient Expectations: Communication For Medical Professionals

. Forbes Magazine. Published January 25, 2024. Accessed April 5, 2024. https://www.forbes.com/sites/kwamechristian/2024/01/25/managing-patient-expectations-communication-for-medical-professionals/?sh=7d1a98d3778a

Sinclair, L. Managing Whitening Expectations. Colgate. Published July 2022. Accessed April 9, 2024. https://www.colgateprofessional.com/hygienist-resources/patient-care/managing-whitening-expectations

We explore ways to avoid patient disappointment on the back end of teeth whitening treatments by managing unrealistic patient expectations on the front end. 

Managing Unrealistic Teeth Whitening Expectations

PRF: Here’s Why You Should Consider it for Your Practice | Image Credit: ©    Катерина Євтехова- stock.adobe.com / AI Generated

For the past 2 decades, dental professionals have been using platelet-rich fibrins (PRF) in oral and maxillofacial surgery. PRF can promote faster healing and tissue repair using the patient’s blood and what that could mean for your practice.

PRF is a type of platelet concentrate that helps with healing and recovery. It’s made from the patient’s blood and is easy to produce, making it cost-effective.

PRF contains leukocytes, platelets, cytokines, and stem cells, which form a strong scaffold that helps the body heal wounds. PRF releases growth factors over time, which help with wound healing but are also good for bone and tissue regeneration. It also helps cells attach and encourages bone cells to grow and develop. PRF doesn’t cause inflammation and can be used alone or with other treatments to help stop bleeding, promote bone growth, and strengthen bones. In addition, it has properties that fight off germs and boost the body’s defenses.

International Journal of Clinical and Experimental Medicine, 

clinicians can use PRF in the following ways

PRF can act as a resorbable membrane in surgery to guide bone regeneration. It prevents unwanted cells from entering the bone defect while allowing the growth of bone and blood vessels.

PRF membranes help reshape the alveolar bone and restore gingival tissue, improving mechanical and esthetic properties in natural bone regeneration.

PRF membranes have shown good results in treating periodontal defects, protecting wounds, and speeding up the healing of hard and soft tissues.

PRF membranes can seal sinus membrane perforations during maxillary sinus lift procedures.

PRF membranes aid in wound healing, protect surgical sites, promote soft tissue repair, and attract stem cells when mixed with bone grafts.

PRF and bone grafts can reduce the volume of bone substitutes needed and improve graft revascularization.

PRF can speed up bone regeneration in sinus lift procedures when combined with freeze-dried bone allografts, reducing healing time before implant placement.

Per the SELPHYL® System, a platelet-rich fibrin matrix technology, benefits to discuss with patients include the following

: PRF therapy harnesses the body’s platelets and growth factors, promoting faster tissue repair and reducing recovery time.

: Using the patient’s blood minimizes the risk of allergic reactions or adverse effects, ensuring a safer treatment experience.

 PRF therapy stimulates collagen production and promotes the formation of new blood vessels, leading to robust and sustainable tissue healing support.

 PRF therapy targets the condition’s underlying cause, offering more sustainable results than temporary relief methods.

 PRF therapy shows successful outcomes across various medical and esthetic fields, including orthopedics, dentistry, and dermatology.

 PRF therapy typically allows patients to resume regular activities sooner, minimizing disruption to daily life.

There have been several generations of autologous platelet concentrations. PRF is the second generation, preceded by platelet-rich plasma (PRP). The journal 

provides a helpful summary of the generations, as follows

This involved adding an anticoagulant to venous blood and 2 centrifugations (soft and hard spins) to obtain concentrated PRP.

The clinical protocol was cumbersome, and the use of anticoagulants and bovine serum posed a risk of cross-contamination.

PRF was developed to address PRP’s limitations.

Leukocyte-PRF (L-PRF), or Choukroun PRF, was introduced using a single centrifugation without added anticoagulants or bovine serum.

The fibrin aspect provides better scaffolding, similar to a natural blood clot.

PRF contains platelets, lymphocytes, monocytes, stem cells, granulocytes, and growth factors.

Advanced platelet-rich fibrin formulations were later introduced, using lower centrifugation forces, which resulted in increased platelets and neutrophilic granules.

Injectable platelet-rich fibrin was developed, involving 1 centrifugation cycle at a lower speed.

Due to the low centrifugation speed, it contains larger quantities of leukocytes and plasma proteins.

Like anything in dental or medical procedures, there are tradeoffs with PRF. According to a 2021 study published in the journal 

PRF has advantages and disadvantages, which include

Requires minimal manipulation of blood and no additional chemicals.

There is no need for bovine thrombin, as the fibrin naturally forms.

It contains growth factors, leukocytes, and cytokines that aid in healing.

Releases growth factors over an extended period compared to other platelet concentrates.

The PRF membrane is highly flexible and elastic.

The success of PRF preparation depends on how quickly blood is handled.

PRF membrane should be used immediately as its structure changes over time.

PRF membrane storage is impossible due to the risk of contamination and dehydration.

A limited quantity of PRF is available as it comes from the patient’s blood, making it unsuitable for general surgery.

Incorporating PRF into treatments has many clinical and patient benefits. Is it the right thing for your practice?

International speaker Ankur Gupta, DDS, a private practice general dentist near Cleveland, Ohio who uses the treatment, says yes. Dr Gupta, a member of the 

 Editorial Advisory Board, is part of the advocates for PRF based on how it works in his practice, particularly regarding socket preservation.

Dr Gupta says most dentists feel comfortable pulling teeth if a patient needs an extraction. However, if dentists don’t do anything to preserve the socket, bone loss will occur, either vertical or buccolingual bone or both. Dr Gupta explains that pulling the tooth without considering how to prevent this bone loss will lead to long-term inconvenience for a future dental implant or even dentures.

“What we’ve done in this situation is set the patient up for guaranteed bone loss. It’s our responsibility to at least ask the patient whether we can do something to prevent this inevitable bone loss,” Dr Gupta says, adding that most of his patients say yes when presented with an option to preserve bone.

However, traditional socket preservation is technique sensitive. Using bony particulate and securing a membrane on top is challenging for dentists, including Dr Gupta. He admits he was reluctant to perform traditional socket preservations because he didn’t love his results. Therefore, he was enthusiastic about this new option when he learned about PRF.

“The most valuable thing about using the patient’s blood as a substrate for grafting is that it is much more user-friendly. Anybody can graft using PRF because the actual tissue has the same consistency as gingiva,” he says. “It behaves the way gums behave, and you can stick a needle through it the way you stick a needle through gum.”

Also, Dr Gupta appreciates that because the PRF is made from the patient’s blood, it will be more biocompatible, help the wound heal faster, and have fewer complications. Dr Gupta says that anyone can adopt the PRF procedure in their practice. The most intimidating part is drawing blood.

“By taking that extra step to draw some blood, you are setting yourself up for a much easier procedure and more predictability,” he says.

Moreover, clinicians can take the plasma, another by-product of spinning the patient’s blood to create PRF, and mix it with the bony particulate. The consistency is similar to gelatin, making it easier to work with because it handles like materials clinicians are comfortable using.

Another benefit of implementing PRF is that taking a tissue graft from the patient’s palate in attachment loss cases is only sometimes necessary. The PRF can be the graft, which is far less painful and inconvenient for the patient.

“Getting a palate graft is painful,” Dr Gupta says. “This option mitigates the need for that, which is pretty cool.”

1. Pavlovic V, Ciric M, Jovanovic V, Trandafilovic M, Stojanovic P. Platelet-rich fibrin: basics of biological actions and protocol modifications. 

. 2021;16(1):446-454. doi:10.1515/med-2021-0259

2. Borie E, Oliví DG, Orsi IA, et al. Platelet-rich fibrin application in dentistry: a literature review. 

3. Naheed Al. PRF treatment: the ultimate guide. Selphyl. Updated February 12, 2024. Accessed April 3, 2024. https://www.selphyl.com/post/prf-treatment-the-ultimate-guide 

4. Goel A, Villanueva JJ, Batra C, Satpathy B, Thompson T. Applications for platelet rich fibrin in dentistry. Decisions in Dentistry. April 8, 2021. Accessed April 3, 2024. https://decisionsindentistry.com/article/applications-platelet-rich-fibrin-dentistry/

Platelet-rich fibrins promote faster healing and tissue repair by using the patient’s blood. Here’s how it can work in your dental practice.

PRF: Here’s Why You Should Consider it for Your Practice

How Far Are We from Regrowing Teeth, and What Are the Other Options? | Image Credit: © Yellow - stock.adobe.com / AI Generated

Dental material companies work to create restorative materials that mimic the behavior, function, and esthetics of natural teeth. Many of them do an excellent job, performing admirably in all areas. However, even the best of the best usually fall short of what healthy, natural teeth provide.

A natural tooth free from decay or trauma is typically the best option for any patient. However, in a US population where the Centers for Disease Control and Prevention (CDC) cites statistics that most adult patients over the age of 20 have had at least 1 cavity, and 1 in 4 adults from age 20 to 64 have at least 1 cavity right now,

But what if we could regrow natural teeth?

It sounds futuristic, like something we might achieve someday, and that is accurate as of right now. However, with major strides in dental research regarding dental stem cells, that future is closer than you think. Here’s what we know about how far away we are from regrowing teeth as of today and what treatment options could be available until then.

For around 2 decades, scientists have successfully isolated dental stem cells. Found in permanent and baby teeth and areas around teeth, dental stem cells have unique capabilities 

 the ability to self-renew, transform into different types of cells, and help the immune system.

In dentistry, there are specialized stem cells related to teeth and bones, which include:

are found in human teeth, specifically the dental pulp. They include hDPSCs (human dental pulp stem cells) and MDPSCs (multipotent dental pulp regenerative stem cells).

Stem Cells from Human Exfoliated Deciduous Teeth (SHED)

 are derived from dental pulp, especially from naturally fallen or extracted baby teeth.

Leptin-Receptor-Expressing Stem Cells (LepR+)

 that develop after birth and contribute to bone stability.

Researchers believe these cells have applications in various dental treatments. Many studies and tests using dental stem cells have treated dental issues like inflammation, pulpitis, periapical lesions, gum disease, and conditions like cleft lip and palate or acute ischemic stroke. Most of these treatments had good results, and no harmful effects were reported, concluding that dental stem cells are safe for various conditions.

to read the 2022 review of clinical articles and trials regarding dental stem cells.

How Dental Stem Cells Could Help Treat Patients

Stem cells have several potential uses in dentistry. For patients who have lost teeth due to accidents or untreated dental decay, stem cells could offer promising solutions for regenerating tooth tissues, bones, and dental pulp.

Dental stem cell implants work like this: Stem cells from a healthy tooth are put into a missing or damaged tooth to grow or rebuild it. However, it is important to mention that while this process has been tested in rabbits and humans, it was only to check if it's safe, not to grow a whole new human tooth.

That said, researchers have been making progress in stem cell research for dentistry for some time now. In 2010, researchers at Columbia University grew a whole tooth in 9 weeks in an animal model by building a 3D scaffold and developing the stem cells around it. A few years later, Harvard researchers used their high-powered laser to activate stem cells and stimulate teeth to regenerate faster in mouse models in 2014.

Stem cell treatments have issues, though. For example, host compatibility is critical. If the donor doesn’t match the host, the host’s immune system will attack the invading cells. Plus, we must remember this stem cell approach hasn’t worked on humans (yet); the dentin grown with animal models is similar to natural human teeth but not an exact match.

So, even though researchers have grown a tooth in animals, the regeneration of human teeth is not yet possible. That is the disappointing news.

On the positive side, there have been some recent breakthroughs. There have been major strides in science toward regrowing teeth in dental pulp research and dental bone regeneration.

Regarding dental pulp research, researchers in 2018 identified MDPSCs with specific markers needed for regenerating dental pulp.The researchers now better understand how these work in the MDPSCs, which can be useful in developing treatments for pulpitis and pulp necrosis.

Researchers in 2020 also discovered that implanting hDPSCs into injured teeth could regenerate dental pulp tissue, including blood vessels and sensory nerves. Additionally, the maturation of the roots continued.

Significant findings have been made in dental bone regeneration, too. For example, researchers in 2020 discovered that LepR+ stem cells are crucial to regenerating alveolar bone in upper tooth sockets after tooth extraction.

 In 2020, researchers developed an adhesive hydrogel with stem cells and microparticles to aid oral cavity bone development. With its potential for tissue engineering to activate oral cavity bone regeneration, clinicians might find a way to overcome the challenges of employing hydrogels and the risk of exposure to saliva and blood.

The following year, researchers at Kyoto University discovered that using antibodies can help with tooth growth and be modified to grow teeth in adults. By focusing on inhibiting gene USAG-1, they could stimulate mice biology to grow new teeth. Additionally, the research team discovered they could hinder the same gene in pregnant mice to facilitate normal tooth growth when the condition that prevents it, congenital tooth agenesis, is present.

Later, the team did it again in ferrets. They chose ferrets because they have dental patterns similar to those of humans.

to read the full paper regarding the discoveries about USAG-1 and stealth small interfering RNA (siRNA) interactions.

Building upon those results with USAG-1, the Japan Agency for Medical Research and Development is working to deliver a drug that could help patients with congenital edentulism regrow teeth. The development is the work of the Japan Agency for Medical Research and Development and several medical institutions and research labs throughout the country.

Once the drug is ready for human testing, clinical trials will begin in July 2024. Once the drug's safety is established, the trial will focus on children aged 2 to 6 who exhibit symptoms of anodontia. The participants will receive one drug dose to see if it initiates tooth growth.

The team's full future vision is a tooth-regrowth medicine that becomes a treatment modality for edentulism that clinicians can offer patients along with dentures and implants. They hope the drug will be ready for clinical use by 2030.

Toregem Biopharma is heading up the clinical trials. The lead researcher on the project is Dr. Katsu Takahashi, head of the dentistry and oral surgery department at the Medical Research Institute Kitano Hospital, who has been working on regrowing teeth since he was a graduate student. Takahashi feels confident he can get the job done, too.

So, science has not yet discovered how to regrow natural teeth…yet. However, the collective work in the past couple of decades and the plans for this one portend a future where growing natural teeth is a clinical reality and a treatment modality that dentists can offer their edentulous patients. Moreover, dental cell research could deliver excellent treatment options for patients with decayed or failing teeth. Until then, dentistry can lean on the chemistry of materials science and implant dentistry and dentures to restore patients’ missing or decayed teeth.

1. Cavities (2021) Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/oralhealth/fast-facts/cavities/index.html#:~:text=Among%20adults%20aged%2020%20and,had%20at%20least%20one%20cavity.&text=1%20in%204%20adults%20aged,has%20at%20least%20one%20cavity. (Accessed: 6 March 2024).

2. Song WP, Jin LY, Zhu MD, Wang H, Xia DS. Clinical trials using dental stem cells: 2022 update. 

. 2023;15(3):31-51. doi:10.4252/wjsc.v15.i3.31

3. Can Dentists Use Stem Cells to Grow Teeth? Exploring the Future Possibilities. (2023) Available at: https://www.colgate.com/en-us/oral-health/dental-visits/can-dentists-use-stem-cells-to-grow-teeth-exploring-the-future-possibilities (Accessed: 27 February 2024).

. Available at: https://www.iflscience.com/can-scientists-regrow-teeth-yet-68941 (Accessed: 27 February 2024).

, Regeneration of pulpo-dentinal–like complex by a group of unique multipotent CD24a+ stem cells.

,Deciduous autologous tooth stem cells regenerate dental pulp after implantation into injured teeth.

7. Zhang D, Zhang S, Wang J, et al. LepR-Expressing Stem Cells Are Essential for Alveolar Bone Regeneration. Journal of Dental Research. 2020;99(11):1279-1286. doi:10.1177/0022034520932834

,An engineered cell-laden adhesive hydrogel promotes craniofacial bone tissue regeneration in rats.

,eaay6853(2020).DOI:10.1126/scitranslmed.aay6853

Regrowing teeth would present an excellent restorative option. We look at how close we are to making regrown teeth possible and what the next best option is until then. 