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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Bone Miner Res. Author manuscript; available in PMC 2014 February 1.
Published in final edited form as:
PMCID: PMC3541444

Tooth root dentin mineralization defects in a mouse model of hypophosphatasia

B.L. Foster, PhD,1,* K.J. Nagatomo, DDS, PhD,2,* H.W. Tso, BS,2 A.B. Tran, BS,1 F.H. Nociti, Jr., DDS, PhD,1 S. Narisawa, PhD,3 M.C. Yadav, PhD,3 M.D. McKee, PhD,4 J.L. Millán, PhD,3 and M.J. Somerman, DDS, PhD1


Tissue-nonspecific alkaline phosphatase (TNAP) is expressed in mineralizing tissues and functions to reduce pyrophosphate (PPi), a potent inhibitor of mineralization. Loss of TNAP function causes hypophosphatasia (HPP), a heritable disorder marked by increased PPi, resulting in rickets and osteomalacia. Tooth root cementum defects are well described in both HPP patients and in Alpl−/− mice, a model for infantile HPP. In Alpl−/− mice, dentin mineralization is specifically delayed in the root, however, reports from human HPP patients are variable and inconsistent regarding dentin defects. In the present study, we aimed to define the molecular basis for changes in dentinogenesis observed in Alpl−/− mice. TNAP was found to be highly expressed by mature odontoblasts, and Alpl−/− molar and incisor roots featured defective dentin mineralization, ranging from a mild delay to severely disturbed root dentinogenesis. Lack of mantle dentin mineralization was associated with disordered and dysmorphic odontoblasts having disrupted expression of marker genes osteocalcin and dentin sialophosphoprotein. The formation of, initiation of mineralization within, and rupture of matrix vesicles in Alpl−/− dentin matrix was not affected. Osteopontin (OPN), an inhibitor of mineralization that contributes to the skeletal pathology in Alpl−/− mice, was present in the generally unmineralized Alpl−/− mantle dentin at ruptured mineralizing matrix vesicles, as detected by immunohistochemistry and by immunogold labeling. However, ablating the OPN-encoding Spp1 gene in Alpl−/− mice was insufficient to rescue the dentin mineralization defect. Administration of bioengineered mineral-targeting human TNAP (ENB-0040) to Alpl−/− mice corrected defective dentin mineralization in the molar roots. These studies reveal that TNAP participates in root dentin formation and confirm that reduction of PPi during dentinogenesis is necessary for odontoblast differentiation, dentin matrix secretion, and mineralization. Furthermore, these results elucidate developmental mechanisms underlying dentin pathology in HPP patients, and begin to explain the reported variability in the dentin/pulp complex pathology in these patients.

Keywords: Tissue-nonspecific alkaline phosphatase, TNAP, dentin, pyrophosphate, osteopontin, matrix vesicles


Tissue-nonspecific alkaline phosphatase (TNAP) is an ectoenzyme highly expressed in mineralizing tissues (1). The primary role of TNAP in biomineralization is hydrolysis and reduction of local concentrations of inorganic pyrophosphate (PPi), a potent inhibitor of mineralization. TNAP also dephosphorylates osteopontin (OPN), removing another mineralization-inhibiting determinant from the extracellular matrix (2). Mutations in the human ALPL gene and the resulting loss of TNAP function cause hypophosphatasia (HPP), a heritable disorder resulting in increased PPi leading to the hypomineralization disorders broadly described as rickets and osteomalacia (3). The Alpl−/− mouse (formerly Akp2−/−) is a model for the infantile form of HPP, recapitulating the skeletal manifestations of that disease (4,5).

TNAP activity is high in tissues of the periodontia, the tooth root and supporting dentoalveolar tissues (6,7). The first link between PPi metabolism and the tooth arose from observations that patients with HPP suffered premature tooth loss, often with intact roots being present (8). Subsequently, it was demonstrated that HPP causes severe aplasia or hypoplasia of root acellular cementum, resulting in deficient attachment of the tooth root to surrounding alveolar bone (9). This loss of cementum was confirmed in two independently generated mouse models null for Alpl with TNAP loss-of-function, the so-called EM line (10,11), and the LJ line (4,12). Evidence that the tooth is more sensitive to loss of TNAP than the skeleton derives from the clinical symptoms of odontohypophosphatasia, the mildest subtype of HPP, where serum biochemistry is altered, but only the dentition is affected (3,13).

While the effects of TNAP loss-of-function are well described for bone and cementum, the role for TNAP in tooth dentin formation remains unclear, as does the potential for pathological changes in dentin resulting from HPP. In the human case literature, reports have been inconsistent about the presence of dentin phenotypes in HPP patients, with some declaring no dentin defects, and others citing widened pulp chambers and thin dentin (9,14-19). In previous reports on tooth formation in the EM Alpl−/− mice, dentin formation was described as fundamentally sound, with only a mild delay in rate of mineralization (10), however a more profound dentin mineralization defect was observed in the LJ Alpl−/− model (20,21). In light of the remarkable effects of HPP on bone and cementum, and the variability in reports of associated dentin phenotypes in humans and mice, the role of TNAP in dentin formation remains unclear and deserves further study.

Here, we define the role of TNAP in dentinogenesis through developmental analysis of dentin formation, biomineralization, and the odontoblast molecular profile in the LJ Alpl−/− model, in order to better understand the mechanism of dentin defects and whether mineralization defects persist over time. The extracellular matrix protein OPN was demonstrated previously to contribute to skeletal hypomineralization in the Alpl−/− mouse (22), so we analyzed dentinogenesis in double deficient Alpl−/−;Spp1−/− mice. Finally, we examined the ability of enzyme replacement therapy using mineral-targeting recombinant TNAP to rescue developmental dentin defects in the Alpl−/− mouse.



Preparation and genotyping of Alpl homozygous knockout (Alpl−/−) and wild-type (WT; Alpl+/+) mice were described previously (4,20). Alpl−/− mice were maintained on a mixed background of 129S1/SvImJ and C57BL/6, and prepared by heterozygote breeding. Preparation of Alpl−/−; Spp1−/− double-deficient mice, single knockouts and WT littermates was previously described (22). Spp1−/− mice were maintained in a C57BL/6 background, and double-deficient mice lacking both Alpl and Spp1 were obtained by crossing Alpl+/− mice to Spp1+/− mice, with double heterozygote mice in turn used to generate Alpl−/−;Spp1−/− mice. Mice were allowed access to water ad libitum and fed a rodent diet supplemented with pyridoxine (Vitamin B6) to suppress seizures in Alpl−/− pups. Animal procedures were approved by the Institutional Animal Care and Use Committee, University of Washington (Seattle, WA) or Sanford-Burnham Animal Care and Use Committee (La Jolla, CA).

Tissue preparation

For histology, in situ hybridization, and immunohistochemistry of Alpl−/− and WT samples, heads or mandibles were fixed in Bouin’s solution overnight and stored with 70% ethanol. Samples of age 8 days postnatal (dpn) or older were demineralized in AFS (acetic acid, formaldehyde, sodium chloride), processed, and embedded for paraffin serial sectioning. Tissues were prepared as previously described for Alpl−/−; Spp1−/− double-deficient mice and controls (22), and enzyme replacement therapy-treated Alpl −/− mice and controls (20). Frontal (buccolingual) and sagittal sections were prepared to examine molar and incisor teeth.

Histological procedures

Standard hematoxylin and eosin (H&E) staining was performed for histological observation. Static histomorphometry using SPOT software (Diagnostic Instruments, Sterling Heights, MI) was used to make calibrated measurements of dentin, predentin, and pulp chambers, at fixed distances of 300 μm apical from the cementum-enamel junction of mesial roots of first mandibular molars. Measurements from two central root sections from n=3-4 animals per genotype per age were used in an independent-samples (Student’s) t-test. Immunohistochemistry was performed using an ABC-based kit with a 3-amino-9-ethylcarbazole (AEC) substrate to produce a red reaction product indicating antigen localization, as previously described (23). Primary antibodies included rat anti-human ALPL (R&D Systems, Minneapolis, MN) and LF-175 rabbit anti-mouse OPN (Dr. Larry Fisher, NIDCR, Bethesda, MD). In situ hybridization (ISH) was performed using digoxigenin-labeled (DIG) mouse sense/antisense cRNA probes, employing NBT/BCIP (Nitro blue tetrazolium chloride/5-Bromo-4-chloro-3-indolyl phosphate, toluidine salt) for detection, as previously described (23). Probes included: mouse type I alpha I collagen (Col1)(Benoit de Crombrugghe, M.D. Anderson Cancer Center), mouse osteocalcin (Ocn) (John Wozney, Genetics Institute), and mouse dentin sialophosphoprotein (Dspp) (Helena Ritchie, University of Michigan).

Micro-computed Tomography

Micro-computed Tomography (MicroCT) of nondecalcified hemi-mandible specimens using Skyscan model 1072 (Kontich, Belgium) was performed as previously described (20).

Undecalcified histology, transmission electron microscopy and immunogold labeling

Hemi-mandibles were fixed and processed (without decalcification) in LR White acrylic plastic resin as previously described (24). Thin sections (0.5 μm) for light microscopy were cut on an ultramicrotome and mineralized areas were visualized by von Kossa staining, followed by counterstaining with toluidine blue. For transmission electron microscopy (TEM), tissues were trimmed, and ultrathin sections (80 nm) were placed on polyvinyl formal- and carbon-coated nickel grids. Grid-mounted tissue sections were processed for colloidal-gold immunocytochemistry by incubation of the sections with a goat anti-mouse primary antibody against OPN (R&D Systems), after which immunolabeling patterns were visualized by incubation with protein A-colloidal gold complex (14 nm gold particles), followed by staining with uranyl acetate and lead citrate, as described previously (24). Stained tissues were examined using a Philips Technai transmission electron microscope operated at an accelerating voltage of 120 kV.

Enzyme replacement therapy protocol for Alpl−/− mice

The production and characterization of a bone-targeted, soluble human TNAP – ENB-0040 or Asfotase Alfa (formerly sALP-FcD10) – has been previously reported, and daily subcutaneous delivery of doses of 2.0 mg/kg and 8.2 mg/kg to Alpl−/− mice from birth onward have been demonstrated to increase serum alkaline phosphatase (ALP) activity, extend lifespan, and correct the phenotype of the skeleton, cementum, and enamel (20,21,25). ENB-0040 is currently in clinical trials for treating infantile and adult forms of HPP (26). Histological sections of molars and incisors of Alpl−/− mice treated with 2.0 mg/kg (ENB-0040 Tx-2.0 group) or 8.2 mg/kg (ENB-0040 Tx-8.2 group) were compared to WT controls at 44 dpn.


Loss of alkaline phosphatase causes root dentin mineralization defects

TNAP was highly expressed in newly differentiating odontoblasts, with elevated expression maintained by odontoblasts during both crown and root formation (Figure 1A-1B). TNAP induction in odontoblasts coincided with secretion and mineralization of the predentin matrix, the initial layer of which is known as the “mantle dentin.” Alpl−/− mice featured poorly mineralized tooth molar and incisor roots, in addition to a generalized loss of bone mineralization in the mandible (Figure 1C-1D). Histology of first mandibular molars at 14 dpn revealed that while crown dentin appeared normal in Alpl−/− mice, root dentin suffered from developmental mineralization defects (here seen in decalcified samples, but visualized indirectly by loss of pink/purple staining reflecting mineral-bound noncollagenous proteins) ranging in severity from mild to very severe, often within the same molar (Figure 1E-G for WT, Figure 1H-J for Alpl−/−). Mild effects included a slight delay in mineralization of the predentin matrix to mineralized dentin matrix proper. This lag in mineralization was observed as approximately 100-200 μm of unmineralized predentin in Alpl−/− roots (Figure 1H and 1J), whereas in WT controls, mineralization of predentin followed soon after secretion of the matrix (Figure 1E-1G). Notably, delayed dentin mineralization is entirely consistent with descriptions of tooth development in the EM Alpl−/− model (10). More severe dentin mineralization defects manifested as both complete lack of dentin mineralization, as well as reduction in circumpulpal dentin formation, resulting in thin and unmineralized roots (Figure 1H-1I). Reduced dentinogenesis was associated with disorganization of the odontoblast layer and flattened, dysmorphic odontoblasts lacking the typical columnar morphology.

Figure 1
Loss of alkaline phosphatase causes root dentin mineralization defects

In the majority of Alpl−/− animals analyzed by histology (n=10), the severe inhibition of dentin mineralization was limited to the lingual aspect of the first molar (n=8), while the contralateral buccal side was mildly affected. In a minority of Alpl −/− animals, both aspects were either severely affected (n=2) or both mildly affected (n=2) (Supplemental Figure 1). When the entire root lacked dentin mineralization, pulp chambers were larger, root lengths were noticeably shorter, and root shape was dysmorphic (Supplemental Figure 1C). More severe effects on dentinogenesis were associated with more extensive alveolar bone mineralization defects (increased osteoid accumulation), suggesting local differences were involved in the incongruity of buccal and lingual dentin phenotypes.

Histological examination of maxillary first molars and mandibular second molars at 14 dpn confirmed that Alpl−/− affected root but not crown dentin, a phenotypic pattern also observed in the root analog (lingual aspect) of the continuously erupting mouse mandibular incisor (Supplemental Figure 2).

At 21 dpn, the mildly affected buccal dentin aspects of molars appeared well mineralized, indicating that the delayed mineralization of predentin at 14 dpn was corrected given time, and root development completed normally (Figure 2). Root dentin mineralization of the lingual aspect remained arrested, with little increase in dentin formation. This equated to a root that continued growing in length, but did not advance dentin apposition because of a reduction in circumpulpal dentin formation. An atypical tissue layer formed outside these thin and unmineralized roots, resembling unmineralized cementum, i.e. cementoid. The persistent root dentin defect was reflected in a poorly developed lingual aspect on the Alpl−/− incisor at this age (Figure 2C and 2F).

Figure 2
Arrested dentinogenesis in Alpl−/− molars is maintained over time

Histomorphometry of molars at 14 and 21 dpn confirmed that Alpl−/− root buccal dentin thickness did not differ from that of WT controls, while lingual dentin thickness was diminished at 14 and 21 dpn, and lingual predentin was significantly thicker and pulp chambers were significantly larger at 14 dpn, versus controls (Figure 2G and 2H).

Loss of odontoblast gene expression in Alpl−/− tooth roots

Because of the odontoblast disorganization and dysmorphism observed in association with arrested dentinogenesis, in situ hybridization was used to analyze odontoblast marker gene expression. While type 1 collagen (Col1) expression was unaltered, expression of odontoblast markers genes osteocalcin (Ocn), and dentin sialophosphoprotein (Dspp) was dramatically reduced in association with cell morphology and mantle dentin mineralization and apposition defects (Figure 3). Dentin matrix protein 1 (Dmp1) gene expression was not strong enough to conclude any differences, however DMP1 protein was noticeably reduced in Alpl−/− odontoblasts (Supplementary Figure 3). Expression of marker genes was strong in Alpl−/− crown odontoblasts, and their reduction was less pronounced in regions where dentin was only mildly affected. In areas where mantle dentin remained completely unmineralized, Ocn was expressed in newly differentiated odontoblasts, but expression was lost in regions where cells lost their characteristic morphology and organization, namely the buccal aspect. Dspp, a later-expressed root odontoblast marker, failed to be expressed at any measurable level in dysmorphic odontoblasts.

Figure 3
Loss of odontoblast phenotype in Alpl−/− tooth roots

Matrix vesicle initiation of mineralization in Alpl−/− mantle dentin

Matrix vesicles (MVs) have been suggested to be important in the initiation of mineralization in mantle dentin (27,28). TEM was used to determine if MV formation, distribution, initiation of mineralization, and rupture, contributed to the dentin mineralization defect in the Alpl−/− mice. The region of interest was unmineralized apical mantle dentin of WT and Alpl−/− molars (Figure 4A and 4B). The number, distribution and morphology of MVs in the mantle dentin of Alpl−/− mice appeared normal as compared to WT controls (data not shown), showing varying degrees of mineralization as they progressed from the unmineralized state to the mineralized state, and then to rupture of the MV membrane where the mineral deposits are then exposed to the extracellular milieu (Figure 4C-4J). Osteopontin (OPN) is an extracellular matrix protein and member of the SIBLING protein family expressed in mineralized and nonmineralized tissues (29), with potent actions on regulating hydroxyapatite crystal growth in mineralizing extracellular matrices (2,30-34). Immunogold labeling demonstrated OPN localization to ruptured MVs (Figure 5; see also Figure 6 below for OPN immunohistochemistry) as reported previously (35), but not to unruptured MVs. However, unlike predentin in WT mice, Alpl−/− predentin did not feature a mineralization front, did not proceed to mineralize, and failed to become mineralized dentin proper (Figure 4B), essentially aborting at the ruptured MV stage.

Figure 4
Undecalcified histology and TEM of matrix vesicles in molar mantle dentin of Alpl−/− mice
Figure 5
Immunogold labeling for osteopontin in mantle dentin of Alpl−/− mice
Figure 6
Role of osteopontin in dentin defects of alkaline phosphatase deficient mice

Role of osteopontin in dentin defects of Alpl−/−mice

Systemic circulating OPN concentration is increased in the Alpl−/− mouse, and it was demonstrated that elevated OPN contributes to the skeletal mineralization pathology caused by increased PPi in the Alpl−/− mice (22). In light of these previous findings and our immunogold label demonstrating the presence of OPN at sites of ruptured MVs in unmineralized root mantle dentin matrix in Alpl−/− mice (Figure 5), we further examined the contribution of OPN to Alpl−/− dentin deficiencies, first by immunostaining for OPN in Alpl−/− tooth histological sections, and second by crossing Alpl−/− mice onto the Spp1−/− (OPN-encoding gene) background. In WT molars, OPN localization was observed in bone, acellular cementum, and odontoblast cells (Figure 6A and 6B). In Alpl−/− tissues, OPN staining was concentrated in some regions of alveolar bone (Figure 6C and 6D), consistent with previous demonstrations of increased OPN at other skeletal locations (22,36). OPN protein was also heavily concentrated in the thin region of mantle dentin in Alpl−/− molars (Figure 6D, arrow). While OPN localization in Alpl−/− root odontoblasts was weaker in general, the newly differentiating odontoblasts near the root apex stained strongly for OPN, only losing OPN reactivity in association with dentin mineralization defects, in a pattern matching loss of Ocn and Dspp gene expression in those cells (Figure 3). OPN immunostaining was lacking from the root surface, reflecting the lack of cementum (20,37).

Mice lacking both Alpl and Spp1 exhibited root dentin defects indistinguishable from Alpl−/− mice using histology on decalcified sections (Figure 7E-L). Thus, despite a likely role for OPN in inhibition of mantle dentin mineralization in Alpl−/− mice, ablation of OPN was not sufficient to rescue the observed dentin defects.

Figure 7
Enzyme replacement therapy rescued the dentin phenotype in alkaline phosphatase deficient mice

Enzyme replacement therapy rescues the dentin phenotype in Alpl−/− mice

The production and characterization of a bone-targeted, soluble, human form of TNAP, ENB-0040 has previously been reported, and daily subcutaneous delivery of doses of 2.0 mg/kg and 8.2 mg/kg to Alpl−/− mice from birth has demonstrated increased serum ALP, extended lifespan of the mice, and correction of the phenotype of the skeleton, and tooth crown and root (20,21,25). Compared to WT mice at 44 dpn, Alpl−/− mice treated with either 2.0 mg/kg or 8.2 mg/kg/day exhibited normal molar root dentin formation and mineralization (Figure 8). Interestingly, dentin of the incisor root analog was not rescued at either dose.


The results of the present study demonstrate a developmental defect in dentinogenesis in the Alpl−/− mouse model of hypophosphatasia (HPP). The dentin defect is root-targeted and varies from delayed mineralization in the mildest case, to arrest of root mantle dentin mineralization, lack of circumpulpal dentin, and odontoblast differentiation defects, in the most severe manifestations. The mildly delayed mineralization was corrected given time, but when dentinogenesis was significantly perturbed at the mantle dentin phase, defects persevered throughout molar tooth development. While HPP case reports do not uniformly identify dentin defects, findings in the Alpl−/− mouse are consistent with reports of widened pulp chambers, thin root dentin, and “shell teeth.” Our data further reveal that the Alpl−/− dentin defect resulted from inability of MV-initiated mineralization foci to expand into a mineralization front, and that increased osteopontin (OPN) accumulation likely contributed to the aborted mineralization of Alpl−/− mantle dentin. Importantly, administration of bioengineered TNAP showed that early intervention allows for rescue of dentinogenesis and restoration of molar mineralization.

An important role for TNAP in root dentin development

The dramatic induction of TNAP expression as pulp cells differentiated into polarized, secretory odontoblasts suggests a key role for TNAP in mineralizing the predentin matrix. TNAP expression remains robust in crown and root odontoblasts throughout development, though studies here reconfirm that the root bears the brunt of the Alpl−/− dentin phenotype. This conserved pattern in molars and continually erupting incisors argues for a real difference in the necessity for TNAP in root versus crown dentin, and provides evidence against the possibility that crown dentin is spared owing to its prenatal development under maternal (i.e. Alpl heterozygote) influence. Differences in crown versus root dentin matrix composition and mineralization (38-40) may be related to this observation.

The results here confirm observations of severely hypomineralized root dentin in the LJ model for HPP (20,21), while the previous report on tooth formation in Alpl−/− mice from the EM colony reported a much milder delay in the rate of root dentin mineralization (10), despite similar severity in skeletal phenotypes between the two independently generated lines (5). However, the analysis is not so straightforward. In addition to previously unreported regions of severely arrested and unmineralized root mantle dentin identified here, we also observed a milder dentin delay, often on the contralateral aspect of the same Alpl−/− molar that was consistent with the defect reported by Beertsen et al. Thus, differences in severity of tooth phenotype between HPP patients, and even between Alpl−/− littermates in inbred mice, may be compounded by a large degree of inter-tooth and intra-tooth variations. Possible reasons for these dissimilarities include local tissue differences in concentrations of PPi and OPN, as well as levels of other mineral-binding proteins. TNAP coordinates with other factors including PHOSPHO1, progressive ankylosis protein (ANK), and ectonucleotide pyrophosphatase phosphodiesterase 1 (NPP1), to determine local mineral metabolism (36,37,41), and nuances of these interrelationships warrant further analysis. Ultimately, evidence supports that the mantle dentin phase is very sensitive to disturbance in the mineralization process, and when foci cannot merge to a coherent mineralization front, circumpulpal dentinogenesis is severely affected.

Changes in root odontoblasts resulting from loss of alkaline phosphatase

Establishing the nature and extent of the dentin defect in Alpl−/− mice allowed us to identify an odontoblast cellular defect in situ, associated with those areas of severe failure of dentin mineralization. Odontoblasts lost cell polarity, became flattened and disorganized, and lost expression of key markers of differentiation, Ocn, Dspp and DMP1. These changes suggest a process akin to de-differentiation, where cells still expressed high levels of type I collagen, but lost phenotypic odontoblast characteristics. Whether these cell changes contribute to dentin defects or arise as a result of them is under investigation. Recently we reported that pulp cells from HPP-diagnosed subjects were unable to acquire an odontoblast phenotype and to promote mineralization in vitro, which was partially restored by phosphate/PPi modulation (42).

The role for osteopontin in inhibition of Alpl−/−dentin mineralization

OPN is an extracellular matrix protein with mineral-inhibiting properties in its phosphorylated form (33,43). OPN is expressed by odontoblasts and found in the circulation (44,45). Elevated OPN contributes to the increased PPi in inhibiting bone mineralization in Alpl−/− mice (22) and we sought to determine if there was a pathological role for OPN in Alpl−/− dentin hypomineralization. Two observations argued for such a role. First, OPN was abundant at sites of ruptured matrix vesicles (MV) in Alpl−/− mantle dentin, suggesting that OPN contributes to inhibiting the merger of mineral foci into a mineralization front (“secondary mineralization” that takes place after MV rupture). Secondly, immunostaining at the light microscopy level identified concentrated OPN in the mantle dentin of unmineralized Alpl−/− roots, at the location where mineralization normally starts to propagate following MV rupture. While OPN localization was generally reduced in Alpl−/− root odontoblasts (matching the loss of Ocn and Dspp expression), early odontoblasts featured high OPN staining, suggesting that these cells deposited OPN in the mantle dentin prior to regressive changes. Additional OPN contributions to the mantle dentin matrix might derive from the circulation (44), especially because systemic OPN increased in Alpl−/− mice (22).

While our immunolabeling data support a role for OPN in inhibiting Alpl−/− dentin mineralization, overlaying the TNAP deficiency of the Alpl−/− mice on an Spp1−/− (OPN-deficient) background resulted in a tooth root dentin phenotype comparable to the Alpl−/− mouse, with no indication of rescue. This suggests that PPi, or possibly a factor downstream of PPi, may be the more central mineralization-inhibiting factor, and removal of OPN is not sufficient to overcome the PPi-mediated abortion of mineral crystal growth in the dentin. It should be noted that Spp−/− mice also show high PPi levels, and mice deficient for both Alpl and Spp1 feature increased PPi compared to the single knock-outs (22). Nevertheless, we cannot exclude contributions of other mineralization-inhibiting factors or other types of perturbation in the observed dentin defect, an aspect that remains under investigation. We are currently exploring whether relative correction of PPi in Alpl−/−;Ank−/− and Alpl−/−;Enpp1−/− double deficient mice rescues dentinogenesis, in parallel fashion to bone (36).

Pyrophosphate removal is necessary for complete mineralization of root mantle dentin

The findings reported here shed new light on the function of TNAP in dentinogenesis, and the nature of the dentin defect in Alpl−/− mice. Several roles have been hypothesized for TNAP in biomineralization, including provision of ionic phosphate for mineralization, clearance of mineral inhibitor PPi, dephosphorylation of mineralization-inhibiting proteins such as OPN, and participation in ion transfer or purinergic signaling. These need not be mutually exclusive of one another; however, we propose that the loss of PPi clearance is the primary cause for dentin defects in the Alpl−/− mice. Corroborating evidence for this can be found in papers demonstrating the effects on tooth formation of 1-hydroxyethylidene-1,1-bisphosphonate (HEBP). HEBP is, in a sense, a durable (nonhydrolyzable) PPi analog that also prevents crystal growth. Administration of HEBP to mice, rats, and guinea pigs inhibited root mantle dentin in a manner remarkably similar to that seen in Alpl−/− mice here (46-48). In a description that would aptly portray Alpl−/− tooth roots, Beertsen and colleagues reported that following HEBP administration to mice, mineralization of new dentin was inhibited, mantle dentin was formed but unmineralized, circumpulpal dentin was absent, and there were “regressive changes in the associated odontoblast layer” including loss of morphology and organization, and reduced phosphoprotein secretion (46). Similar inhibition of root dentin mineralization was observed after forced expression of mineralization-inhibiting matrix Gla protein (MGP) in teeth (49).

Our analyses, in conjunction with HEBP studies, strongly support TNAP as a PPi removal agent in dentinogenesis, where Alpl−/− mice suffer from physicochemical inhibition of dentin matrix mineralization due to increased PPi levels. The sensitivity of the mantle dentin phase to PPi inhibition can be explained by a dependence on MV-mediated mineralization, whereas circumpulpal dentin may rely primarily upon the actions of extracellular matrix proteins (27,28). Defective proliferation of mineral crystals outside of MVs also led to hypomineralization in long bones and cartilage in Alpl−/− mice (50). An unresolved aspect is the ability of crown dentin to form properly in Alpl−/− mice, as well as under HEBP treatment (46). A plausible explanation lies in the differences in developmental influences on crown versus root dentin, including intrinsic differences in odontoblast populations, and interactions with different epithelial cells, and in the case of crown, with enamel matrix. Notably, odontoblasts adjacent to crown enamel or mineralized portions of root dentin in Alpl−/− teeth retain their odontoblast characteristics, leading us to speculate that regressive changes in Alpl−/− odontoblasts may stem from disrupted matrix-cell interactions with hypomineralized dentin.

Intriguingly, the HEBP-treatment studies also report a layer of unmineralized cementum matrix (“hyperplastic cementum”) associated with unmineralized root dentin (47,48,51), identical in appearance to the “cementoid” layer found at later time points in Alpl−/− mouse molar teeth. We speculate this to be a functional response of the periodontal compartment to loss of dentin competence in Alpl−/− mice, and this hypothesis is the subject of ongoing studies.

Rescue of dentin mineralization in Alpl−/− mice by injection of mineral-targeting recombinant TNAP (ENB-0040) confirmed that PPi reduction is necessary for root dentin mineralization. Improvement of Alpl−/− mouse skeletal and dental mineralization by ENB-0040 (20,21,25) indicates that to some degree, TNAP activity or PPi reduction is important in physiological mineralization of all the hard tissues, though cell and tissue specific differences are indicated. The modulation of PPi represents a potential paradigm shift in considering therapies directed at dento-osseous regeneration.

We test implicit memory variances between temporal lobectomy patients and controls.

Patients can carry out implicit verbal memory tasks.

Patients activated the left medial frontal gyrus, precuneus and striatum.

Supplementary Material

Supp Figure S1

Supplemental Figure 1. Variation in severity of Alpl−/− root dentin defects. In comparison to (A, D) WT molars at 14 dpn, Alpl−/− molars exhibited dentin (de) defects ranging from (B, E) partial loss of root dentin development (*), usually more severe on the lingual aspect, to (C, F) complete lack of root dentin mineralization. Abbreviations: od=odontoblasts; de=dentin; pd=predentin. Scale bar is 200 μm for panels A-C, and 100 μm for D-F.

Supp Figure S2

Supplemental Figure 2. The root-specific dentin defect in Alpl−/− mice extends across the dentition. In comparison to WT (A, B) maxillary first molars, (E, F) mandibular second molars, and (I, J) mandibular incisors, Alpl−/− teeth feature retardation of root dentin (de) development and mineralization (*), including respective molars (C, D, G, H), as well as the (K, L) root analog of the continuously erupting incisor. Abbreviations: od=odontoblasts; de=dentin. Scale bar is 200 μm for panels A, C, E, G, I, and K, 100 μm for B, D, F, and H, and 50 μm in J and L.

Supp Figure S3

Supplemental Figure 3. Reduction of dentin matrix protein 1 (DMP1) in Alpl−/− root odontoblasts. In comparison to (A, B) WT molar root at 14 dpn, (C, D) Alpl−/− root odontoblasts featured reduced localization of DMP1 protein, in addition to loss of gene expression for osteocalcin (Ocn) and dentin sialophosphoprotein (Dspp) shown in Figure 3. Abbreviations: od=odontoblasts. Scale bar is 200 μm for panels A and C, and 100 μm for B and D.


This research was supported [in part] by the Intramural Research Program of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of the National Institutes of Health (NIH). A portion of this research was completed when BLF, FHN, ABT, and MJS were affiliated with the University of Washington School of Dentistry, Department of Periodontics (Seattle, WA, USA). The authors would like to thank Jirawan Wade and for preparing histological sections, Lydia Malynowsky for her help with immunogold labeling and electron microscopy, Daisy Matsa Dunn for in situ hybridization, and Tracy Popowics for critical reading of the manuscript. Grant funding: NIH R01DE15109 (MJS), NIH R01 AR47908 and R01 DE12889 (JLM), and CIHR MOP-97858 (MDM). Dr. Millán and Dr. McKee are consultants for Enobia Pharma, Inc., now Alexion Pharmaceuticals, and Dr. McKee has received research funding from this company. Authors’ roles: Study design: BLF, KJN, MDM, JLM, and MJS. Acquisition and analysis of data: BLF, KJN, HWT, ABT, MCY, SN, and MDM. Interpretation of data: BLF, KJN, FHN, SN, MCY, MDM, JLM, and MJS. Manuscript writing: BLF and KJN. Final approval of the manuscript: All authors.

Grant support: NIH R01DE15109 (MJS), NIH R01 AR47908 and R01 DE12889 (JLM), and CIHR MOP-97858 (MDM)

Dr. McKee is a consultant for, and received research funding from, Enobia Pharma, Inc., now Alexion Pharmaceuticals.


DISCLOSURES: Dr. Millán is a consultant for Enobia Pharma, Inc., now Alexion Pharmaceuticals.


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