The effects of mineral trioxide aggregate on osteo/odontogenic potential of mesenchymal stem cells: a comprehensive and systematic literature review

Figures & data

Figure 1. The selection process of the included literature.

Table 1. Cytotoxicity of MTA towards MSCs.

Cell Type	Source	Evaluation	Observation	Reference
BMMSC	Human	DNA quantification assay, Enzyme assay	ProRoot MTA and MTA Plus had stimulatory effects on cell proliferation at different dilutions (1:2–1:20), established from 0.1 g/cm^2/mL extraction medium after 21 days. However, MTA Fillapex showed high toxicity after 1,7, 14, and 21 days at different concentrations.	Costa et al. [28]
BMMSC	Human	AlamarBlue assay	Viability of cells in direct contact with ProRoot MTA was similar to control group after 1, 3, 5, and 7 days of incubation.	D’Anto et al. [29]
BMMSC	Human	MTT assay	No significant difference was observed between cell viability between bone marrow-derived MSCs, cultured in ProRoot MTA-conditioned medium, and control group after 24 h.	Ashraf et al. [30]
BMMSC	Human	MTT assay	Results indicated that cells cocultured with ProRoot MTA and Micro-Mega MTA discs, placed in transwell inserts, had same viability ratio compared with control group on days 1, 3, and 7. Higher cell viability was seen in treated groups on day 14.	Margunato et al. [31]
BMMSC	Rat	MTT assay	MTA was not toxic at different concentrations (0.002, 0.02, 0.2, and 2 mg/mL) after 3 and 5 days.	Wang et al. [32]
DPSC	Human	MTS assay	After 24, 48, and 120 h of incubation in ProRoot MTA conditioned medium, the viability of cells in control group was significantly higher. Moreover, using propylene glycol as mixing liquid did not affect the cytotoxicity of MTA.	Natu et al. [33]
DPSC	Human	MTT assay	DPSC viability in direct contact with ProRoot MTA after 1, 3, and 7 days was statistically lower than control group. It has been shown that on days 1 and 3 MTA, mixed with distilled water, represented lower toxicity in comparison to MTA that was mixed with 10% CaCl2, 5% CaCl2, and 2.5% Na2HPO4.	Kulan et al. [34]
DPSC	Human	MTT assay	Three dimensional DPSC culture, established in collagen type I scaffold, on ProRoot MTA showed similar cell viability compared with control group.	Widbiller et al. [35]
DPSC	Human	MTT assay, Enzyme assay, Flow cytometry	Results confirmed that after setting for 24 h, ProRoot MTA discs in transwell inserts were cytotoxic after 3 days. However, using cyclic aging protocol, re-immersing used-MTA discs in deionized water for 4 days in each cycle and placing them in transwell inserts of new culture vessels for 3 days, reduced the toxicity nature of MTA discs on day 3.	Niu et al. [36]
DPSC	Human	XTT assay, Flow cytometry	By using cyclic aging protocol, they concluded that within the 3^rd and 4^th cycles no difference was observed in MTA Angelus-treated and control groups in terms of cell viability. Furthermore, dilution factor affected the toxicity of the eluent released by the MTA Angelus.	Bortoluzzi et al. [37]
DPSC	Human	MTT assay	Conditioned medium of ProRoot MTA at concentrations of 10 and 20 mg/mL was cytotoxic after 1, 3, and 5 days. However, cell survival was increased after exposure to 0.1, 0.2, 1, and 2 mg/mL ProRoot MTA on day 5.	Zhao et al. [38]
DPSC	Human	MTT assay	Cytotoxicity of 4 types of MTA-conditioned media (ProRoot MTA, RMTA, Nanohybrid MTA, and MTA Angelus) was assessed. Although Nanohybrid MTA exhibited cytotoxicity at all time intervals, all the other three types showed proliferation stimulating potential.	Jaberiansari et al. [39]
DPSC	Human	MTT assay	ProRoot MTA was allowed to set for two time periods, 1 h and 24 h. Cell viability evaluation showed that cytotoxicity in direct contact with MTA was lower in 24-hour group compared with 1-hour and control groups after 7 days.	Agrafioti et al. [40]
DPSC	Rat inflammatory dental pulp	MTT assay, Flow cytometry	ProRoot MTA conditioned medium was made at concentrations of 0.002, 0.02, 0.2, 2, and 20 mg/mL. It was observed that 0.002–0.2 mg/mL MTA-conditioned media showed no cytotoxicity. Cell proliferation was down regulated at concentrations of 2 and 20 mg/mL after 5 days of incubation.	Wang et al. [41]
SCAP	Human	XTT assay, Microscopic examination	ProRoot MTA discs were placed on the bottom surface of the culture vessel for evaluating the toxicity of MTA after 1, 3, and 7 days. It has been shown that after 1 day, cell viability in MTA group was higher than control group. However, no statistical difference was observed after 3 and 7 days.	Peters et al. [42]
SCAP	Human	Coulter counter, Flow cytometry	2 mg/mL ProRoot MTA conditioned medium was not toxic after 1, 3, 5, 7, and 9 days.	Yan et al. [43]
SCAP	Human	MTT assay	Cell coculturing was performed by placing 1 mg of ProRoot MTA in transwell inserts. 24-hour, 48-hour, and 168-hour results indicated that cell viability was not significantly different from control group.	Saberi et al. [44]
SCAP	Human	WST-1 assay	20 mg disc-shaped set ProRoot MTA, allowed to set for 1 or 24 h, was placed in transwell inserts. It was observed that cell proliferation increased in 1-hour and 24-hour groups on day 1 and days 1 and 5 compared with control group, respectively. No statistical difference was observed in term of cytotoxicity of MTA up to 14 days.	Schneider et al. [45]
PDLSC	Human	MTT assay, Microscopic examination	Cytotoxicity and proliferation stimulating potential of various dilutions of MTA Fillapex eluent were determined after 24, 48 and 72 h of cultur. MTA Fillapex exhibited high cytotoxicity at all concentrations and time intervals compared to control group.	Rodriguez-Lozano et al. [46]
PDLSC	Human	MTT assay, Microscopic examination, Flow cytometry	After exposing to different dilutions of Endoseal MTA eluate, produced according to the International Standard ISO 10993-5, for 24, 48 and 72 h, it was revealed that this material was toxic at all concentrations and time intervals compared to control group.	Collado-González et al. [47]
SHED	Human	MTT assay, Flow cytometry	Cell proliferation was stimulated in presence of MTA Angelus eluate, produced according to the International Standard ISO 10993-5, after 2 and 3 days of incubation.	Collado-González et al. [48]
DPSC, PDLSC, BMMSC	Human	MTT assay	Culturing cells in direct contact with ProRoot MTA after 1 day showed no effect on cell proliferation. After 5 days of incubation, cell proliferation was increased in all three cell types.	Chen et al. [49]
TGSC	Human	MTS assay	Cell viability was similar in cells that were in direct contact with ProRoot MTA compared to cells in control group.	Guven et al. [50]
C3H10T1/2	Mouse	XTT assay	Different concentrations of ProRoot MTA conditioned media were produced. viability of cells was not significantly different from control group.	Lee et al. [51]

Cells; BMMSC: bone marrow-derived mesenchymal stem cell, DPSC: dental pulp stem cell, SCAP: stem cell from the apical papilla, PDLSC: periodontal ligament stem cell, SHED: stem cell from exfoliated deciduous tooth, TGSC: tooth germ stem cell, C3H10T1/2: mouse mesenchymal stem cell.

Table 2. Differentiation-inducing potential of MTA.

Cell type	Source	Medium	MTA treatment	ALP activity	Mineralization	Evaluated genetic markers	Altered genetic marker(s)^a	Altered protein marker(s)	Reference
BMMSC	Human	αMEM + Ascorbic acid	MCM	+	+	N	N	N	Costa et al. [28]
BMMSC	Human	DMEM	MCM	M	M	COL1, OCN	Neither	N	Ashraf et al. [30]
BMMSC	Human	OM	TI	+	+	COL1A, ON, RUNX2	RUNX2	M	Margunato et al. [31]
BMMSC	Rat	DMEM	MCM	+	+	S	ALP, RUNX2, OSX, OCN, DSPP	RUNX2, OSX, OCN, DSP	Wang et al. [32]
DPSC	Human	DMEM	MCM	N	–	S	ALP, OCN, RUNX2, DSPP, MEPE	N	Natu et al. [33]
DPSC	Human	αMEM + Ascorbic acid	DC (cells on collagen scaffold)	+	N	COL1, ALP, DSPP, RUNX2	COL1A, DSPP	N	Widbiller et al. [35]
							RUNX2
DPSC	Human	OM	TI	–	–	ALP, OCN, IBSP, DSPP, RUNX2, DMP1	ALP, OCN, IBSP, DSPP, DMP1	N	Bortoluzzi et al. [37]
DPSC	Human	αMEM	MCM	N	N	S	ALP, DSPP, COL1, OCN, IBSP	N	Zhao et al. [38]
DPSC	Human	DMEM	DC	N	+	FGF4/FGF4, BMP2/BMP2, BMP4/BMP4, TGF-β1/TGF-β1, ALP, COL1, DSPP, DMP1	ALP, DSPP, DMP1, TGF-β1	TGF-β1, FGF4	Asgary et al. [67]
							BMP4	BMP4
DPSC	Human	OM	TI	+	+	S	ALP, RUNX2, OSX, IBSP, OCN, DMP1, DSPP	OCN, DMP1, DSPP	Niu et al. [68]
DPSC	Human	OM	MCM	N	+	OPN, RUNX2, OCN, ALP, COL1	OPN, RUNX2, OCN, ALP	N	Hanafy et al. [69]
DPSC	Human	OM	MCM	+	+	RUNX2, OCN, COL1	RUNX2, OCN	N	Maher et al. [70]
DPSC	Rat inflammatory dental pulp	αMEM	MCM	+	+	S	ALP, RUNX2, OSX, OCN, DSPP	RUNX2, OSX, OCN, DSP	Wang et al. [41]
SCAP	Human	αMEM	MCM	+	+	ALP, DSPP, RUNX2/RUNX2, OSX, OCN/OCN, IBSP, IL1α , IL1β, IL6, DSP	ALP, DSPP, RUNX2, OCN, IL1α , IL1β, IL6	DSP, RUNX2, OCN	Yan et al. [43]
SCAP	Human	αMEM	DC (cells were cultured on dentin discs, occluded with MTA)	N	+	ALP, DSPP, RUNX2, IBSP	DSPP, RUNX2, IBSP	N	Miller et al. [71]
SCAP	Human	DMEM	MCM	+	+	S	IBSP, OCN, DSPP, OSX, RUNX2, ALP	N	Saberi et al. [72]
PDLSC	Human	αMEM	MCM	+	+	S	RUNX2, OCN, OSX, OPN, DMP1, ALP, COL1	DSP, RUNX2, OCN, OSX, OPN, DMP1, ALP, COL1	Wang et al. [73]
SHED	Human	DMEM	MCM	N	–	N	N	N	Collado-González et al. [48]
SHED	Human	αMEM	MCM	N	N	S	DMP1	N	Araújo et al. [66]
TGSC	Human	OM	DC	+	M	S	DSPP	N	Guven et al. [50]
C3H10T1/2	Mouse	OM	MCM	+	N	S	ALP, OCN, IBSP	N	Lee et al. [51]

Proteins, and genes; COL1: Collagen type I, OCN: Osteocalcin, ON: Osteonectin, Runx2: Runt-related transcription factor 2, ALP: Alkaline phosphatase, OSX: Transcription factor SP7 also called Osterix, DSPP: Dentin sialophosphoprotein, DSP: Dentin sialoprotein, MEPE: Matrix extracellular phosphoglycoprotein, DMP: Dentin matrix acidic phosphoprotein, FGF: fibroblast growth factor, BMP: bone morphogenetic protein, TGF-β: transforming growth factor β, IBSP: integrin binding sialoprotein. Cells; BMMSC: bone marrow mesenchymal stem cell, DPSC: dental pulp stem cell, SCAP: stem cell from the apical papilla, SHED: stem cell from exfoliated deciduous tooth, TGSC: tooth germ stem cell, C3H10T1/2: mouse mesenchymal stem cell model. Media; DMEM: Dulbecco’s modified Eagle’s medium, αMEM: alpha modified Eagle’s medium, OM: Osteo/odontogenic medium. MTA treatment; MCM: MTA-conditioned medium, TI: transwell insert containing MTA discs, DC: Direct contact with MTA. Assays; (+): significant increase compared to control group, (-): significant decrease compared to control group, M: no significant change has been seen, S: same as elevated gene/protein markers, N: not evaluated.

^a regular cells represent upregulation of gene/protein marker expression, shaded cells represent gene/protein marker downregulation

Figure 2. Involvement of major signaling pathways in osteo/odontogenesis effects of MTA on MSCs. IKK: IκB kinase, IκBα masks the nuclear localization signal (NLS) of NF-κB and inhibits its function, AP-1: Activator protein 1, question mark (?) means that the mechanism of action is unknown.

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