The inorganic part of hard tissues (bones and teeth) of mammals consists of calcium phosphate, mainly of apatitic structure. Similarly, most undesired calcifications (i.e. those appearing as a result of various diseases) of mammals also contain calcium phosphate. For example, atherosclerosis results in blood-vessel blockage caused by a solid composite of cholesterol with calcium phosphate. Dental caries result in a replacement of less soluble and hard apatite by more soluble and softer calcium hydrogenphosphates. Osteoporosis is a demineralization of bone. Therefore, from a chemical point of view, processes of normal (bone and teeth formation and growth) and pathological (atherosclerosis and dental calculus) calcifications are just an in vivo crystallization of calcium phosphate. Similarly, dental caries and osteoporosis can be considered to be in vivo dissolution of calcium phosphates. On the other hand, because of the chemical similarity with biological calcified tissues, all calcium phosphates are remarkably biocompatible. This property is widely used in medicine for biomaterials that are either entirely made of or coated with calcium phosphate. For example, self-setting bone cements made of calcium phosphates are helpful in bone repair and titanium substitutes covered with a surface layer of calcium phosphates are used for hip-joint endoprostheses and tooth substitutes, to facilitate the growth of bone and thereby raise the mechanical stability. Calcium phosphates have a great biological and medical significance and in this review we give an overview of the current knowledge in this subject.

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Biological and medical significance of calcium phosphates.

The worldwide incidence of bone disorders and conditions has trended steeply upward and is expected to double by 2020, especially in populations where aging is coupled with increased obesity and poor physical activity. Engineered bone tissue has been viewed as a potential alternative to the conventional use of bone grafts, due to their limitless supply and no disease transmission. However, bone tissue engineering practices have not proceeded to clinical practice due to several limitations or challenges. Bone tissue engineering aims to induce new functional bone regeneration via the synergistic combination of biomaterials, cells, and factor therapy. In this review, we discuss the fundamentals of bone tissue engineering, highlighting the current state of this field. Further, we review the recent advances of biomaterial and cell-based research, as well as approaches used to enhance bone regeneration. Specifically, we discuss widely investigated biomaterial scaffolds, micro- and nano-structural properties of these scaffolds, and the incorporation of biomimetic properties and/or growth factors. In addition, we examine various cellular approaches, including the use of mesenchymal stem cells (MSCs), embryonic stem cells (ESCs), adult stem cells, induced pluripotent stem cells (iPSCs), and platelet-rich plasma (PRP), and their clinical application strengths and limitations. We conclude by overviewing the challenges that face the bone tissue engineering field, such as the lack of sufficient vascularization at the defect site, and the research aimed at functional bone tissue engineering. These challenges will drive future research in the field.

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Bone Tissue Engineering: Recent Advances and Challenges

Photodynamic therapy (PDT) employs a non-toxic dye, termed a photosensitizer (PS), and low intensity visible light which, in the presence of oxygen, combine to produce cytotoxic species. PDT has the advantage of dual selectivity, in that the PS can be targeted to its destination cell or tissue and, in addition, the illumination can be spatially directed to the lesion. PDT has previously been used to kill pathogenic microorganisms in vitro, but its use to treat infections in animal models or patients has not, as yet, been much developed. It is known that Gram-(−) bacteria are resistant to PDT with many commonly used PS that will readily lead to phototoxicity in Gram-(+) species, and that PS bearing a cationic charge or the use of agents that increase the permeability of the outer membrane will increase the efficacy of killing Gram-(−) organisms. All the available evidence suggests that multi-antibiotic resistant strains are as easily killed by PDT as naive strains, and that bacteria will not readily develop resistance to PDT. Treatment of localized infections with PDT requires selectivity of the PS for microbes over host cells, delivery of the PS into the infected area and the ability to effectively illuminate the lesion. Recently, there have been reports of PDT used to treat infections in selected animal models and some clinical trials: mainly for viral lesions, but also for acne, gastric infection by Helicobacter pylori and brain abcesses. Possible future clinical applications include infections in wounds and burns, rapidly spreading and intractable soft-tissue infections and abscesses, infections in body cavities such as the mouth, ear, nasal sinus, bladder and stomach, and surface infections of the cornea and skin.

Photodynamic therapy: a new antimicrobial approach to infectious disease?

1.1. Biomineralization
The study of biomineralization is not only important to gain an understanding of how mineral-rich tissues are created in vivo but also because it is a great source of inspiration for the design of advanced materials.1-7 Mineralized tissues have remarkable hierarchical structures that have evolved over time to achieve great functions in a large variety of organisms. Organic phases play a key role in templating the structure of mineralized tissues; therefore, their matrices are often hybrid in composition, varying widely in the relative content of organic and inorganic substances. Understanding the complex integration of hard and soft phases that biology achieves in mineralized matrices across scales and its link to properties is knowledge of great value to materials chemistry. At the same time, the synthetic mechanisms used by biology to create mineralized matrices could also offer some useful strategies to create synthetic hybrid materials. Often, the amount of organic material utilized by Nature to modify mechanical properties of mineralized structures is vanishingly small. One example is the role of occluded proteins in the toughness of biogenic calcite.8 The study of mammalian bone and teeth in the biomineralization and biomimetic context is particularly interesting since the information derived could contribute a significant biomedical impact on therapies and strategies to repair or regenerate human mineralized tissues. This is an important area given the continually rising average life span of humans. The materials of interest could be highly sophisticated bioactive scaffolds to regenerate bone and possibly dental tissues as well. This review focuses on the formation of hydroxyapatite (HA) in synthetic systems designed primarily in the biomimetic context of bone or enamel mineralization for therapeutic approaches in repair of human tissues. Bone and enamel share the same mineral composition, HA, but have different morphologies and organic content. Enamel is almost entirely inorganic in composition, and bone has a relatively high organic composition. Knowledge acquired in this field may inspire the chemical synthesis of novel hybrid materials, including apatite-based structures for the regeneration of human bone and dental tissues.

Biomimetic Systems for Hydroxyapatite Mineralization Inspired By Bone and Enamel

Biologically-formed hard tissues, referred to as biominerals, have intrigued the materials engineering community for years because of the high degree of crystallographic control that is exerted during the precipitation of the bioinorganic crystals. In recent years, there has been a shift in attention, from prior studies that focused on specific organic-inorganic interactions that modulate the crystal morphology via the conventional crystallization pathway, to recent studies that find that many biominerals are formed via an amorphous precursor pathway. It has become clear that the things we thought we had learned about biominerals before, may or may not be relevant to truly understanding the mechanisms involved in biomineralization. Having witnessed this paradigm shift first hand, I am inclined to provide a review from this historical perspective, where I hope to belay some ideas about where we were, where we are, and where we are going, with respect to understanding how these shells and other biominerals are formed. Therefore, one goal of this review is to try and provide a link between the prior literature and the new literature, which might be useful to newcomers in the field, whom I suspect may find it confusing and difficult to integrate the findings in these different types of studies across this time period. A second goal is to try and integrate some of the knowledge obtained from in vitro model systems, which can be more amenable to obtaining mechanistic information, with the in vivo and ex vivo observational studies on biominerals. A third goal is to demonstrate that there may be certain unifying principles found in biomineral systems that seem widely diverse, such as from diatoms, to mollusk shells, to vertebrate bones and teeth. A final goal (the not so hidden agenda), is to demonstrate that not only is there as strong likelihood that many biominerals are formed by an amorphous precursor, but that the amorphous phase may possess fluidic properties that impart new processing capabilities to the system. Of course those who know my work will readily assess that I am referring to the polymer-induced liquid-precursor (PILP) process, which has been a primary focus in my lab. Along these lines, some new hypotheses are presented regarding the morphogenesis of certain biominerals, such as mollusk nacre, kidney stones, and bones and teeth, along with a review of the literature that provides support to these new ideas. The intent is to stimulate thoughtful discussions in this rapidly emerging area, which seemingly provides a unifying principle in biomineralization.

1.1. Biomineral Overview
Biominerals that have intrigued the materials engineer for years. The diversity of biominerals became particularly evident by the variety of books on biominerals that emerged in the late 80’s to 90’s,1–11 which has continued with a few more recent additions to this nice collection.12–16 Many people are probably not even aware of the diversity of biologically formed minerals, so a sampling is provided in Table 1 to illustrate some of the different chemistries that evolved in the formation of various biological hard tissues. The calcium carbonate (CaCO3) biominerals of invertebrates, such as mollusk shells and sea urchin spines, have been particularly well studied due to their accessibility, and because of the high degree of crystallographic control that is achieved in these biologically formed crystals. The calcium phosphate (CaP) biominerals of the vertebrates, such as bones and teeth, have also been extensively investigated because of their remarkable structure and mechanical properties, and for the more obvious reasons of health related issues.14 Calcium oxalate (CaOx) biominerals can be found in plants, but the majority of studies have focused on the pathological form of CaOx that is found in kidney stones, which often occurs in conjunction with CaP deposits.8,14

Table 1

Examples of the diversity of biominerals. This list is by no means comprehensive, where some 70 different mineral phases have been identified to date.1–11

Biomimetic Model Systems for Investigating the Amorphous Precursor Pathway and Its Role in Biomineralization

Rationally designed beta-sheet-forming peptides that spontaneously form three-dimensional fibrillar scaffolds in response to specific environmental triggers may potentially be used in skeletal tissue engineering, including the treatment/prevention of dental caries, via bioactive surface groups. We hypothesized that infiltration of caries lesions with monomeric low-viscosity peptide solutions would be followed by in situ polymerization triggered by conditions of pH and ionic strength, providing a biomimetic scaffold capable of hydroxyapatite nucleation, promoting repair. Our aim was to determine the effect of an anionic peptide applied to caries-like lesions in human dental enamel under simulated intra-oral conditions of pH cycling. Peptide treatment significantly increased net mineral gain by the lesions, due to both increased remineralization and inhibition of demineralization over a five-day period. The assembled peptide was also capable of inducing hydroxyapatite nucleation de novo. The results suggest that self-assembling peptides may be useful in the modulation of mineral behavior during in situ dental tissue engineering.

Self-assembling Peptide Scaffolds Promote Enamel Remineralization

The chemical changes which occur during the process of carious destruction of enamel are complex due to a number of factors. First, substituted hydroxyapatite, the main component of dental enamel, can behave in a very complex manner during dissolution. This is due not only to its ability to accept substituent ions but also to the wide range of calcium phosphate species which can form following dissolution. In addition, the composition, i.e., the extent of substitution, changes throughout enamel in the direction of carious attack, i.e., from surface to interior. Both surface and positively birefringent zones of the lesion clearly illustrate that carious destruction is not simple dissolution. Selective dissolution of soluble minerals occurs, and there is the probability of reprecipitation. The role of fluoride here is crucial in that not only does it protect enamel per se but also its presence in solution means that rather insoluble fluoridated species can form very easily, encouraging redeposition. The role of organic material clearly needs further investigation, but there is the real possibility of both inhibition of repair and facilitation of redeposition. For the future, delivering fluoride deep into the lesion would appear to offer the prospect of improved repair. This would entail a delivery vehicle which solved the problem of fluoride uptake by apatite at the tooth surface. Elucidation of the role of organic material may also reveal putative mechanisms for encouraging repair and/or protecting the enamel mineral.

The chemistry of enamel caries.

The hydroxyapatite crystals of mature enamel are unusually large, uniform and regularly disposed within the tissue, implying that their development is a highly controlled process. The organic matrix of developing enamel is presumed to play an important role in the modulation of mineral deposition and growth during tooth morphogenesis but the precise functions of individual matrix proteins remain unclear. The aim of this review was to survey the current knowledge of enamel matrix proteins with a view to suggesting possible functions. The organic matrix is highly heterogeneous, comprising proteins derived from a number of different genes, including amelogenin, enamelin, ameloblastin (amelin/sheathlin), tuftelin, dentine sialophosphoprotein, enzymes and serum proteins such as albumin. Each of these classes appears to undergo post-secretory sequential degradation which contributes further towards matrix heterogeneity. Possible functions of these proteins include de novo mineral nucleation/initiation (dentine sialophosphoprotein, tuftelin), mineral ion binding as crystal precursors (amelogenin, enamelin), control of crystal growth (amelogenin, enamelin, ameloblastin), support of growing crystals (amelogenin, enamelin), determination of prismatic structure (ameloblastin), cell signalling (tuftelin, ameloblastin), control of secretion (breakdown products) and protection of the mineral phase (amelogenin, enamelin). Failure of these mechanisms could lead to incomplete maturation of the enamel and the eruption of dysplastic tissue.

The developing enamel matrix : nature and function

Biochemistry and molecular biology of amelogenin proteins of developing dental enamel

This review aims to outline the effects of fluoride on the biological processes involved in the formation of tooth tissues, particularly dental enamel. Attention has been focused on mechanisms which, if compromised, could give rise to dental fluorosis. The literature is extensive and often confusing but a much clearer picture is emerging based on recent more detailed knowledge of odontogenesis. Opacity, characteristic of fluorotic enamel, results from incomplete apatite crystal growth. How this occurs is suggested by other changes brought about by fluoride. Matrix proteins, associated with the mineral phase, normally degraded and removed to permit final crystal growth, are to some extent retained in fluorotic tissue. Fluoride and magnesium concentrations increase while carbonate is reduced. Crystal surface morphology at the nano-scale is altered and functional ameloblast morphology at the maturation stage also changes. Fluoride incorporation into enamel apatite produces more stable crystals. Local supersaturation levels with regard to the fluoridated mineral will also be elevated facilitating crystal growth. Such changes in crystal chemistry and morphology, involving stronger ionic and hydrogen bonds, also lead to greater binding of modulating matrix proteins and proteolytic enzymes. This results in reduced degradation and enhanced retention of protein components in mature tissue. This is most likely responsible for porous fluorotic tissue, since matrix protein removal is necessary for unimpaired crystal growth. To resolve the outstanding problems of the role of cell changes and the precise reasons for protein retention more detailed studies will be required of alterations to cell function, effect on specific protein species and the nano-chemistry of the apatite crystal surfaces.

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Steven J. Brookes

Papers

Self-assembling Peptide Scaffolds Promote Enamel Remineralization

The chemistry of enamel caries.

The developing enamel matrix : nature and function

Biochemistry and molecular biology of amelogenin proteins of developing dental enamel

The Effect of Fluoride on the Developing Tooth