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Accepted Article
Article type : Original Article
1
Dumlupnar University, Faculty of Dentistry, Department of Pediatric Dentistry, Ktahya, Turkey
2
Seluk University, Faculty of Dentistry, Department of Pediatric Dentistry, Konya, Turkey
Correspondence to: rem BA, Dumlupnar University, Faculty of Dentistry, Department of Pediatric
Dentistry, Ktahya, Turkey
e-mail: irem.bag@dpu.edu.tr
Key Words: cell differentiation, fibroblast, periodontal ligament, storage media, tooth avulsion
Acknowledgements: We are thankful to Hasan Acar, MD PhD for providing us his labs for our
forever-lasting experiments.
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/edt.12356
This article is protected by copyright. All rights reserved.
ABSTRACT
RESULTS: The percentage of cell numbers and PDT values of groups were
statistically insignificant. In the HBSS groups, RUNX2 expression increased showing
a direction to osteogenic differentiation of PDL fibroblasts. In the DMEM-F12 groups
RANKL expression increased, indicating there was a tendency for osteoclastogenic
differentiation. In the milk groups, RUNX2 expression decreased while other markers
were stable showing PDL fibroblasts could protect fibroblast identity.
INTRODUCTION
Tooth avulsion is defined as the complete displacement of a tooth from its alveolar
1
socket and such injuries demand urgent intervention. During avulsion, the neurovascular
supply surrounding the tooth ruptures and separates. Then fibroblasts and other cells attached
to the root surface degenerate.2 Treatment should include methods to maintain the viability of
the periodontal ligament (PDL) cells preferably by immediate replantation.3,4 The most
serious complication after replantation of a tooth is replacement resorption of the root.
In order to maintain the PDL integrity and viability, avulsed teeth should be stored
immediately in an appropriate solution until replantation.3,4 There are many studies about
storage media, such as tap water, saliva, and saline. Milk, Hanks balanced salt solution
In addition to the advantages described above, milk is a rich liquid with 120 mg/100
mL calcium content. If an avulsed tooth is placed in milk, PDL cells come into contact with
calcium ions. Previous studies have shown that an increased calcium level raises the
osteogenic marker RUNX2s expression.22 Koori et al.23 have revealed that increased
extracellular calcium levels trigger the osteogenic differentiation of PDL stem cells.23
Additionally, in bone resorption studies, it has been shown that extracellular calcium ions
were an inhibitory factor for osteoclast activity.24,25 The proposed hypothesis suggests that
calcium-rich milk causes PDL fibroblast differentiation.
The differentiation outcome can be displayed by markers of the investigated new cell
type. Collagen type XII (COL12) is one of the fibroblast markers used for the identification
of PDL fibroblasts-specific cell lines.26,27 Runt-related transcription factor 2 (RUNX2) is a
transcription factor and its expression indicates osteoblastic cell differentiation from
pluripotent mesenchymal cells. PDL fibroblasts are positive for RUNX2.28 On the other hand,
PDL fibroblasts also have osteoclastic differentiation potential. Osteoblast cells originating
from PDL fibroblasts synthesize receptor activator of nuclear factor kappa-B ligand
(RANKL) and it is a quite realiable indicator for osteoclastic differentiation.29,30
The aim of this study was to investigate whether HBSS and milk help to maintain the
fibroblastic nature of PDL cells.
All procedures were performed with informed consent and were approved by the
Ethics Committee of the Faculty of Dentistry, Selcuk University, Konya, Turkey (2013/06).
Human PDL fibroblasts were harvested from the PDL tissue of 18 freshly extracted
third molar teeth, which had no caries, infection, restoration, periodontal disease or
hypoplasia. Figure 1 summarises the main procedures of the study with.
Third molar teeth were extracted with appropriate indications, cleaned with sterile
saline and stored in either HBSS (LONZA, Walkersville, MD, USA) or whole milk (PINAR
MILK, zmir, Turkey) (3 teeth for each group) for 30- 60 min or for 12 h at 4C. DMEM-
F12 (LONZA, Walkersville, MD, USA) was used as a positive control under the same
conditions.
Adhesion to plastic surfaces of the cells seeded into culture flasks was evaluated
under an inverted microscope. The clonogenic capacity of cells, which is defined as one
progenitor cells ability to form a cell colony, was determined by observing cell colonies
under an inverted microscope.32
In order to determine the cell proliferation dynamics, viable cells were counted and
proliferation graphs were created. The average time it took for a cell population to double the
number of cells, population doubling time (PDT), was calculated with the formula:
T0 was the starting time, T was the end time of the cell culture, while N0 represented
the number of seeded cells and Nt represented the number of harvested cells.33
Statistical analysis of the data was accomplished using the Kolmogorov-Smirnov test
to determine whether the data showed normal distribution or not. As the data showed normal
distribution, parametric tests were used and independent-samples t-tests were done.
On passage 3, cells (5103) were seeded onto coverslips (1818 mm) on a six-well
plate. When cell growth attained confluence, the culture medium was drained and the cells
were gently rinsed three times with PBS. Then, cells were fixed in 3.5% paraformaldehyde
(Merck, Darmstadt, Germany) for 3035 min at room temperature and rinsed with PBS three
times.32
RESULTS
In P1, starting from the first hours of each culture, the cells obtained from the digested
tissue adhered easily to plastic surfaces. In the passage made on the 1014th days of each
culture (P2), the homogenic growth pattern and adhesion to plastic surfaces were observed.
The ability of the cells to adhere to plastic did not show any differences dependent on storage
media and storage time (30- 60 min or 12 h).
Microscopic images of PDL fibroblasts were obtained from different storage media
(HBSS, milk, DMEM-F12) for two time periods (30- 60 min or 12 h). When the microscopic
images were evaluated with morphological terms, typical fibroblastic, spindle-like cell
morphology were observed during the passages (Fig. 2). For all groups, it was observed that
PDL fibroblasts had the ability to form cell colonies from only one cell indicating these cells
had clonogenic capacities.
Figure 3 shows the average cell number ( SD) of groups for P3- P4 passages. In the
milk and DMEM-F12 groups, cell proliferation was decreased by the increased storage time.
Although, in the HBSS group, cell proliferation was increased, no statistically significant
difference was observed among the groups (p>0,05).
Average PDT values ( SD) of the experimental groups were calculated and there was
no statistically significant differences among the groups (p>0,05) (Fig. 4).
In the HBSS groups, RUNX2 expression was observed by bright spots in the nucleus
in all groups. At the 12 h periods for all media, RUNX2 expression was higher than in the
3060 min periods. While increased RUNX2 and decreased COL12 expressions were
detected in the HBSS groups, RANKL expression was stable at all time periods. Results from
the milk groups showed stable RANKL and COL12 expression, however decreased
expression of RUNX2 was observed. In the DMEM-F12 groups, RANKL expression
significantly increased as storage time changed from 3060 min to 12 h. COL12 expression
was stable, while RUNX2 expressions decreased in this group (Fig. 5).
When the averages of the percentage values of the proportion of strongly expressing
and not expressing cells from the 3060 min groups were compared to the results from the 12
h groups, RUNX2 in the HBSS groups, RANKL in the DMEM-F12 groups, and COL12 in
the milk groups were found to have increased dramatically (Fig. 6).
DISCUSSION
Replacement root resorption can develop after tooth avulsion and the root surface can
be repaired with cementum after surface and inflammatory resorption. During bone
remodeling, the resorbed area on a root surface will be replaced by bone.34,35 Osteoblasts are
the main cells responsible for this situation, which is defined as replacement resorption. It has
been proven that PDL cells can maintain their viability in HBSS and milk.7,9 However, very
few studies have been done to examine the effects of HBSS and milk on the PDL fibroblast
differentiation mechanism. In order to observe the possible effects of the storage solutions on
the differentiation of PDL fibroblasts, the present study investigated PDL fibroblasts identity
by using the markers of three different lineages (osteoblastic, osteoclastic and fibroblastic).
Adhesion to plastic surfaces and clonogenic capacity give information about the
survival of the cells at the injury site. Clonogenic activity of precursor cells attached to the
root surface could lead to desirable regeneration activity by preventing this area from
attaching osteoclasts.36 In the present study, all the PDL cells obtained from the groups
showed high clonogenic capacity and quick adhesion to plastic surfaces. These results
showed that a high proportion of excess precursor cells from PDL cells of representative
avulsed teeth could be cultured effectively. The PDT values were used to evaluate the
proliferation dynamics of PDL fibroblasts and statistically insignificant differences were
found between the PDT values of the cells from all the groups.
Cell culture media such as MEM and DMEM have been used as storage media for
avulsed teeth.17,43-45 DMEM is recommended for the short- and long-term storage of avulsed
teeth because it contains 2-4 times more glucose, 4 times more amino acid and vitamin than
MEM. However, DMEM and Hams F12 (DMEM- F12) can provide cell growth without
stimulating premature aging or differentiation of mesenchymal cells.46 For those reasons,
DMEM-F12 was used as a positive control. According to the results of this study, DMEM-
F12 provided a suitable environment for saving fibroblast identity by consistent COL12
expression. However, it also promoted osteoclastogenic activity observed by increased
RANKL expression.
HBSS has been reported as a suitable storage media for avulsed teeth to maintain PDL
cell viability and the morphology of the cells remains unchanged.47 However, even though
the morphology remains unchanged, some markers expressed by cells reveal the identity of
the cell. It was reported that HBSS is less effective for osteogenic differentiation of PDL stem
cells than skimmed milk.10 However, the current results showed that RUNX2 level in HBSS
groups rose when storage time was increased to 12 hours. Similar to these results, Courts et
al.48 also reported that the differentiation ability of PDL cells incubated in milk was lower
than in HBSS.48 These observations can explain why replacement and inflammatory
resorption were seen after replantation of dogs teeth stored in HBSS.17,49 Meanwhile, it
would be reasonable to conclude that replacement resorption is considered a high risk for
teeth stored in HBSS.
maintaining cell viability, the present study showed HBSS caused osteogenic differentiation
of PDL fibroblasts. Conversely, milk is advisable as storage media for avulsed teeth because
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Accepted Article
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Accepted Article
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Figure 3. Average cell number ( SD) of groups according to the cell counting at P3- P4
passages.
HBSS: RUNX2 expression with bright spots in the nucleus in the 12 h group was higher than
in the 30- 60 min group (A, B). RANKL expression was not clear (C, D). COL12 expression
was observed intensively in cytoplasms of the PDL fibroblasts of 30- 60 min group (E, F).
MILK: RUNX2 expression was high in the 30-60 min group (A, B). In the 30-60 min and 12
h groups, RANKL expression was positive (C, D). COL 12 was observed clearly in both
groups (E, F).
DMEM- F12: Runx2 expression was higher in the 30- 60 min group than in the 12 h group
(A, B). RANKL expression was observed clearly in the 12 h group (C, D). In the 30-60 min
and 12 h groups, COL12 was clearly positive (E, F).
Figure 6. Changes in expression of IF markers (the average of the percentage value of the
proportion of strongly expressing and not expressing cells) with experimental solutions and
time.