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Essay: Stem cell use in dentistry

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  • Published: 22 April 2023*
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£36.2m was spent by the NHS on 42,911 extractions for under 18’s in 2016/17. This equates to a shocking figure of 170 operations per day for just tooth extractions. Problems with our teeth are clearly on the incline with tooth decay being a key factor in this underlying issue. The first area I will cover in my research is the actual structure of a tooth. I will look into each component that makes up a tooth, but most importantly I will focus on what dentine is, what it is made of, how it becomes damaged and what significant role it plays in our overall oral health. Another thing I will look into is a new piece of research that has recently been published by King’s College London which at first was investigating an Alzheimer’s drug, but later their findings became relevant in the field of dentistry. I would like to cover what caused these researchers to find the results they came to in order to assess whether or not this research could be of any importance in dentistry. An alternative idea is if the use of stem cells could advance the improvement of dentine. I will be looking into research to understand if stem cells could aid the development of dentine and I will be looking at the ethical side of stem cell use in dentistry.

One of the fundamental issues of our society today is our diet and lifestyle. This has drastically changed over the years so this must have had a noteworthy effect on our oral health. If we were to stop and change our ways now, would this recover the structure of our teeth and could it possibly benefit and encourage our teeth to repair – this is what I would like to find out. However, amongst the discussion of repairing teeth on our own, dentists who usually guide us with giving us advice and treating our oral health could possibly become extinct if less people needed help with caring for their teeth. If a tooth became damaged and the possibility for repairing the dentine is correct, then the patients could treat their own tooth by repairing the dentine themselves. This would have negative consequences for dentists in the future, as there wouldn’t be a high demand for them. I would like to find out if this revolutionary discovery would actually have a damaging outcome for dentists. The understanding we currently have about our teeth is that they are irreparable, but could there be a possibility in the future where we could change this idea, and if so, would this have a detrimental effect on the careers of future dentists?

How do teeth get damaged and what gets damaged structurally?

Teeth are one of the hardest parts of the body, as they help us to consume food in our daily lives. Yet despite their strength, they still manage to get damaged. The hard outer casing of the tooth is the enamel, which is white in colour. The rock hard mineral compound is made out of calcium phosphate. The layer just underneath the enamel is called dentine. Made up of living cells, the dentine secretes a hard mineral substance. The tiny tubules that also make up the dentine interact with the nerves of our teeth. Hence, when our gums recede and the tubules become exposed, cold drinks may cause a sharp pain in teeth, which is called tooth sensitivity. The more exposed dentine is, the more likely your teeth will feel pain. The significance of dentine in relation to oral health is that it supports the hard enamel by making it stronger and it also protects the interior of the tooth, which consists of the soft pulp and the cementum. Dentine is also the main component of the crown of teeth. If you chip your tooth and expose the dentine or the pulp underneath, this could have a negative impact on the health of that particular tooth. This is because the bacteria from your mouth can access the pulp of your tooth and cause severe damage by demolishing the pulp. This would cause toothache and sensitivity to certain temperatures, in particular heat. The affected tooth would then need to be removed by a root canal and replaced with gutta-percha, which is a plastic filling. This demonstrates that even if a tiny bit of dentine is exposed, then the pulp will begin to show, which would destroy the whole tooth altogether. Currently the only treatments we have today are fillings that replace the gap of the missing dentine and prevent bacteria reaching the soft pulp. Without the dentine, the internal structure of the tooth becomes vulnerable, so is there a way of repairing the dentine naturally and fully before its too late?

King’s College London research

A piece of research has been conducted by King’s College London, which was originally testing out the effects of a drug on Alzheimer’s. However, this research took another turn and has possibly found a solution for naturally repairing the dentine of teeth. The team at King’s College London has recently discovered a new drug called Tideglusib. Without any assistance, the dentine can naturally regrow. However, this is only a thin layer that can be produced, and therefore it is not enough to restore large cavities caused by tooth decay. The study investigated whether stimulating the formation of reparative dentine could enhance natural dentine repair. The first molars of adult CD1 wild-type mice were used in the research. By using a controlling drill, they damaged the first molars and inserted biodegradable sponges made of collagen that they saturated in BIO, CHIR or Tideglusib into the cavities of the tooth. BIO, CHIR and Tideglusib are glycogen synthase kinase-3, (GSK-3) inhibitors. The GSK-3 enzyme inhibits the production of dentine within teeth. After 6 weeks, sections were made in each molar and were stained to reveal construction of new dentine. The results showed that when the teeth were treated with the GSK-3 inhibitors rather than the collagen sponge alone, more reparative dentine was produced at the damaged site. Fascinatingly, only the intact tooth remained as the collagen sponges, named Kolspon, acted as a delivery vehicle for the small molecules of GSK-3 inhibitors. This then dissolved away, leaving the newly produced dentine. The dentine secreted by the teeth treated with BIO, CHIR or Tideglusib completely filled the whole damaged site. Thus, the GSK-3 inhibitors activated dentine regrowth and the damage was restored. So far this has only been tested on mice teeth, but Paul Sharpe, King’s College London Dental Institute Professor and lead author of the study has said, “since the drug has been tested clinically for the Alzheimer’s disease, it shouldn’t be too long to get the dental treatment quickly into clinics.”

This research evidently has significance in dentistry and the future of dentistry as it could potentially remove the need and the practice of fillings in the future. The GSK-3 inhibitors promote a biologically alternative method to repair the cavities in teeth even when the damage at hand is extensive, which provides a promising future for the ability to repair teeth naturally. If the drug gains approval and the results seen in the mice teeth can be replicated in human teeth, then the possibility to repair the dentine of teeth will in fact be very likely. Also, the mechanics and the use of the drug work in a fairly straightforward manner, so using the drug in patients should be quite simple.

Even though these results do show a promising future for the ability to repair the dentine of teeth, they would need to be practiced in dental clinics, which would ultimately require a dentist to be present at the time of the procedure. Given that patients would not actually be trained in how to carry out the technique themselves; the need for dentists in the future would still very much be required. However, these treatments could, nevertheless, possibly abolish the procedure of fillings altogether, which would ultimately lower the revenue generated from filling procedures. As a result of the decrease in revenue, dental practices may not be able to afford and keep on dentists, because less people would be required to visit the dentist frequently, given that fillings are one of the most common procedures, which makes up a large portion of the income received at clinics. So, as a result of the decreased income from the lack of filling procedures being carried out, dental practices would not be able to withstand dentists’ salaries, resulting in the diminishing number of dentists. Another thing to take note of is that the drug may not work in the same way on human teeth, so bearing this in mind the likelihood of repairing human teeth using this method may not be possible. Thus, the possibility of repairing dentine could be doubtful, which would mean the need for dentists in the future would still remain.

Can stem cells be used to repair dentine and is it ethical?

The use of stem cell research to help improve the quality of lives and cure diseases continues to grow till this day. The unspecialised cells have the ability to become tissues, organs or specific cells with specific functions. So understandably the use of stem cells to repair and regrow teeth has been researched by a lot of people and the results from these studies all have different findings as they each use a variety of techniques when using stem cells to repair and regrow teeth.

Pam Yelick, a researcher at Tufts School of Dental Medicine, and her colleagues are trying to research dental stem cells. This particular type of stem cells is a universal type of cell as it can transform into lots of different types of oral cells. The research carried out involved isolating stem cells removed from the pulp of adult teeth and gradually growing these cells into new tooth buds carried out in the lab. These collections of soft tissues ultimately turn into mature teeth. This procedure is fairly simple, however, the issue the research team face is meeting the requirements needed for the tooth buds to grow. These conditions include a balance of having the right nutrients and hormones at the right time. This is because normally as the tooth buds are forming in the embryonic jaw, they have the correct conditions required to grow effectively, but a petri dish does not replicate these conditions, therefore making it harder to grow these tooth buds in a laboratory setting. For this reason, they are instead placed in a biological environment called a “scaffold”, which mimics the three-dimensional structure of tooth buds when they grow in the embryo. This “scaffold” needs to meet the exact requirements in order for the stem cells to develop into the tooth buds. For example, the “scaffold” needs to mimic the precise elasticity and structure of the embryonic tissue. So far this “scaffold” is yet to be perfected as the team are still trying to find the right material that will replicate the embryonic tissue. Yelick’s research looks to be encouraging, as her team has managed to grow tooth buds, which were then transferred into a pig’s jaw. The teeth developed into the early stages of adult teeth over a span of just five months. Yelick states that it will take years in order for humans to be able to grow and replace teeth.

Another piece of research has been carried out by a group of researchers at Harvard’s Wyss Institute, with David Mooney leading the team. The method used for this experiment required rats’ molars which had holes drilled in them to act as tooth decay. The pulp of the tooth had adult stem cells added to it and a low non-ionising laser stimulated the growth factors. The teeth were sealed with a temporary cap and were going to be worn in the next 12 weeks. The results showed that there was more dentine regrowth with the laser treatment than in the control tooth, which shows that the laser can be used to stimulate dentine growth. The protein that was largely influenced by the laser to repair the dentine was transforming growth factor beta-1 (TGFβ-1).

Looking at the results produced from these two studies alone shows a promising future for the use of stem cells for growing and repairing dentine in teeth. These studies show that stem cells placed in the right conditions, for example using a low ionising laser or a ‘scaffold’ to replicate the exact same conditions the dentine would normally be in when forming in the embryo, could possibly be used to regrow and repair the damage in teeth as a prospect for the future.

When examining research into stem cells especially stem cells in dentistry, a problem could be that the conditions needed in order for the stem cells to grow and form into dentine may never be met. For example, the right dose of hormones or the exact temperature may never be discovered or could take a long time to find out. This is an issue because if the solution to these problems is never resolved, then the use of stem cells in dentistry would not be very likely. Therefore, the conditions that need to be replicated in order to create new dentine could take a while or may never happen, which would not affect dentists in the long haul, as there would still be a requirement for their services. In light of all of this, if the use of stem cells for growing and repairing new dentine becomes refined and accessible to the mainstream, then fewer people would need to attend dental practices regularly as they would not require any additional treatment needed to help with their oral health, decreasing the demand for dentists in the future.

How does our eating and lifestyle habits affect our dentine?

One of the main and obvious reasons for our oral health problems is due to poor and unhealthy eating habits. Our teeth come into contact with food everyday and the direct contact between unhealthy food and the tooth surfaces is the main reason as to why people have dental caries (i.e. tooth decay or dental cavities). These habits cause cavities, toothaches and the wearing of the enamel, the outer casing of the tooth, which then exposes the dentine. The exposed dentine becomes increasingly damaged, as the continuation of the unhealthy eating habits doesn’t change, causing more damage to the tooth and dentine. The sugar in fizzy drinks and sweets combine with the bacteria in our mouth producing harmful acids, which cause tooth decay and damage the structure of teeth. The more sugar we consume, the faster the rate of production of harmful acids in our mouth and the more tooth decay occurs. As our diet has changed over the past decades, so has our oral health. Sugar makes up 15% of the daily calories consumed by four to ten year olds. Children and young people in England drink sugary soft drinks more often than anywhere else in Europe. These shocking statistics show that children are adopting these unhealthy habits as they are becoming more addicted to sugary drinks and sweets. 12 This has had a detrimental effect on children’s oral health; for example, there has been almost a 20% increase in children being admitted to hospital with tooth decay between 2010 and 2015. This shows that our diet has a harmful consequence on the health of our teeth.

There has been a study conducted which was published by the British Medical Journal, where they split children with cavities into 3 groups. The first group had to eat a standard diet as well as oatmeal, which contained phytic acid. The second group ate a normal diet plus vitamin D and finally the third group consumed a grain-free diet in addition to vitamin D. The results showed that there was an increase in cavities forming in the teeth of the group 1 children. However, in group 2 saw improvements in cavities, with less cavities forming. But it was group 3 that saw the most improvement in the reduction of cavities, with all cavities nearly healing. From these results it is evident that diet can have a huge impact on our oral health and despite having problems with teeth, like cavities, it is still possible to undo the damage to some extent just by changing our diet alone. To see the most improvement in cavities, the study shows that eating a grain-free diet with nutrient rich foods, for example fruit, vegetables, milk and taking vitamin D, you will see the most progress with healing cavities.

A simple change in eating habits in our daily lives can help protect and prevent teeth from decaying. One way to protect the enamel of teeth is to consume less acidic drinks, such as orange juice. This way the enamel will remain in tact and not dissolve to reveal the dentine, which is vulnerable to damage and tooth decay. 11Consuming calcium and vitamin D enriched foods provide strength and support for teeth as well as protection from tooth decay. Dairy protects such as milk is also associated with the strengthening and development of teeth but another dairy product, cheese, is also believed to have anti-cavity properties. A study conducted, which was published in the General Dentistry; found that there was a link between cheese and anti-cavity characteristics. This was because of the increase in pH level once the cheese was consumed in the mouth. Furthermore, there are various components in cheese that strengthen the enamel of the tooth, so that acidic foods do not damage the outer surface of the tooth. By strengthening the enamel, this protects the dentine layer from becoming exposed and damage, which prevents tooth decay and the chances of dental cavities. So, an uptake in healthier foods instead of sugary foods will mean fewer oral problems including tooth decay and damage to the dentine.

Eating one fruit in particular may help protect and prevent dental cavities. Researchers at Rochester Medical Centre have found that the similar properties that make cranberries great at fighting off bladder infections could also help contribute to fighting off dental cavities as well. The reason why it may help prevent cavities is because the cranberry juice makes it difficult for the bacteria to stay on the tooth surfaces, which if it were to stay on the tooth would contribute to the production of dental cavities. However, too much consumption of cranberry juice is not good for you because of the added sugar. In stead the researchers are looking to figure out the key components, which makes it anti-bacterial and adding these compounds to toothpaste, but the team is still developing this.

Additionally, the consumption of phytic acid, an enzyme inhibitor that blocks minerals, contributes to tooth decay. This acid is found in plants such as seeds, grains and nuts. This has a detrimental effect on teeth, as it not only prevents absorption of minerals, but it is also apart of the removal of minerals from bones and teeth. This is a terrible consequence from eating food that contains phytic acid because it weakens the healthy structure of teeth as well as the overall health of the body. Almonds, rice bran and wheat bran have the highest phytic acid content, with almonds ranging from 0.4-9.4%, rice bran from 2.6-8.7% and wheat bran, which ranges from 2.1-7.3%. A high intake of these foods containing phytic acid will increase in build of the unwanted acid, reducing the amount of minerals entering the teeth which then eventually leads to tooth decay. Therefore, attitudes to healthy eating in our society need to change. Everyone is aware of what the benefits are regarding eating healthily; however the lack of understanding around the impact this has on our teeth is not common knowledge.

In terms of lifestyle changes, smoking is a big habit that contributes to dental caries. In the UK, a shocking figure of 9 million adults smoke with around two/thirds who, before the age of 18, begin to smoke. A study looking at smoking and dental health status in different aged men who either smoked or it did not, found that those who smoked, particularly 35 year old men who smoked, had a much larger number of dental caries compared to those who were non-smokers in the same age bracket. From the evidence shown in this study, it is apparent that there is a clear link between smoking and production of dental caries. Therefore, if people had stopped smoking or even did not smoke altogether, this could help to reduce the number of dental caries so that teeth will remain healthy overall. The cut back on smoking and the change in diet will help conserve the healthiness of teeth, which consequently will mean fewer visits to the dentist. This is because the healthy maintenance of teeth, due to the consumption of healthier foods and lack of smoking, will not require frequent treatments needing to be carried out by dentists because there will be less tooth decay present. This results in the less of a need for extra treatment, resulting in a lower demand for dentists in the future.

How crucial are dentists really, and do they actually play an important role in our oral health?

Dentists are specialised, trained experts in teeth. Not only do they know how to prevent oral cavities, but they also know how to treat them as well. 12In the UK, almost half of the adults in the population have a fear of visiting the dentist. On top of this, going to the dentist was ranked the number one thing to make people the most nervous. Infrequent visits to the dentist could have damaging effects on our oral health and the wellbeing of our teeth. Dentists help diagnose problems with our teeth as well as check that our teeth are in a sound condition. If we don’t visit the dentist regularly, we will not know if there are any problems with our teeth and if we only visit the dentist when we believe there may be a problem, it could be too late to treat the affected tooth effectively.

There are treatments available to help prevent and treat dental caries that dentists are specially trained in. Examples of such treatment include fillings. In order to receive a filling you must have local anaesthetic injection, which numbs the side of the mouth that the infected tooth is located in. One type of filling is a fissure sealant, which prevents dental caries from developing by 80%. The tiny gaps in teeth can be really hard to brush which leads to the build up of plaque. However, with the fissure sealants, this essentially fills these gaps preventing food from getting lodged in these hard to reach spaces, reducing plaque and dental caries. This type of filling can also be applied to the tooth chewing surfaces as well. Another type of filling is composite resin. These are sometimes called white fillings and are used when teeth are already decaying to restore them back to a healthy state. First the dentist has to remove any dental caries present. Then once they are all removed, a protective layer is added. This prevents tooth sensitivity. Another common procedure carried out by dentists is root canals. This is used when the nerve pulp has been affected usually by dental caries. So if the decay has spread into the dental pulp of the tooth, the dentist will then make an opening into the nerve canal. A barbed broach is used to remove the nerve and the pulp-cavity content as well. A plastic material, gutta-percha, is then used to fill the hole.

Therefore, it is clearly evident that dentists play a vital role in our oral health and without them we would not know how to diagnose ourselves with oral problems and more importantly, how to treat them. In present day we do have other means of finding out answers, for example the Internet. However, if people were to look up and search their symptoms on Google for example, they would receive a wide range of results and answers for their problems. This is a huge problem because people wouldn’t know which result is the solution for their problem, hence leading people to misdiagnose themselves, use the wrong treatments and fundamentally making problems worse.

On top of all of this, many people do not know how to perform certain procedures. For instance, if there weren’t any dentists and a tooth did become infected, the person would have to perform a root canal on themselves. Unfortunately, not everyone knows how to do this and if people did have the knowledge to execute a root canal procedure, performing it on oneself would be extremely difficult due to the limited visibility on the particular area the procedure is being carried out. If someone else were to perform the treatment for an individual, this individual would effectively play the role of the dentist anyway.

Even if we were to find a solution to repair the dentine of teeth, this would help improve oral health but would not completely eradicate the need for dentists in the future. This is because dentists would still need to check the condition of people’s teeth and ensure that the patients are still maintaining and looking after their own teeth. A dentist would be the only person to help diagnose problems, as they would know clearly what the underlying issue is after checking the state of the patient’s teeth first hand. If something were to go wrong and a patient needed a root canal treatment or a filling, a dentist would be the only one who can help the patient, as they have the knowledge to carry out the procedure. They have been trained to perform such tasks as well as having the correct equipment and environment in which to execute the procedures. So a possibility without dentists in the future seems highly unlikely.

Conclusion

Overall, the possibility of dentine repair could be likely in the future, with more research and refinement of current studies, the probability looks promising. I believe, with a bit more time and exploration, we will be able to come up with a solution to repair the dentine of teeth as the current research carried out previously and recently shows that there is a great opportunity to find an answer. Once a solution is found, the improvements in oral health will increase, reducing the number of dental carries in the overall population.

Even though the likelihood of finding a solution to dentine repair is possible, the need for dentists will still remain in the future, as they would still play an important role in the health of people’s teeth. Dentists will still need to be available to help maintain patient’s teeth as well as aid patients with treatments in case they need it. However, it is still questionable whether there will be a development found in repairing the dentine of human teeth. Most of the research studying dentine repair were tested and trialled in animal teeth, specifically rat’s and mice molars. Although this is a good indicator as to whether or not similar procedure will work in human teeth, there is still chance that these practices may not be able to be transferred to human teeth, which could be a step back for repairing dentine in human teeth. This could increase the time frame for the possibility of repairing dentine in the future, so the need for dentists will continue to be necessary. Also if the research that has been tested on rat’s molars does not work the same for human teeth, then we would need to find alternative ideas to resolve the issue. This would increase the time to find a result to repair dentine in human teeth.

As a way to refine and further develop my title, I would want to specify how long it would take to find a solution to repair the dentine of human teeth in order to explore whether there will be any need for dentists in the near future. By adding a time frame, I will be able to gauge how long it would take to find a solution, which is still currently an unanswered question. Also by specifying human teeth, I would be able research studies regarding humans in order to se whether it would be viable to repair the dentine of human teeth instead of animal’s teeth, like rats. Also if more primary research was included, for example if I were to ask dentists first hand about their opinions and thoughts on the topic, I would be able to gain more of an insight into what experts in the industry think on this topic, allowing me to make a more informed answer on the issue. Despite the uncertainty of repairing dentine in teeth, I feel as if it would be a development in the field of dentistry to find a solution to repair dentine, but it would not significantly change the roles of dentists to the extent of completely eradicating the need for them in the future.

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