The human genome has 24 matrixin genes, including a duplicated Mmp23 gene.

Thus, there are 23

members in the human MMP family, including the classic MMPs (collagenases: MMP-1, -8, and -13; gelatinases:
MMP-2 and -9), stromelysins (MMP -3 and -10), matrilysins (MMP-7, -11, and -26), the membrane-bound MMPs
(MMP-14, -15, -16, -17, -24, and -25), and other MMPs (MMP-12, -19, -20, -21, -23, -27, and -28). Most of the
MMPs are synthesized as inactive latent enzymes. Conversion to the active enzyme is generally mediated by
activator systems that include plasminogen activator or the prohormone convertase, furin.
More recently, two additional metalloproteinases have been discovered: a disintegrin and metalloproteinase
(ADAM)143 and a disintegrin and metalloproteinase with thrombospondin motif (ADAMTS). 144 Functional ADAMs
are involved in ectodomain shedding of diverse growth factors, cytokines, receptors, and adhesion molecules. An
important ADAM family member (ADAM-17) is a TNF-α–converting enzyme that activates pro–TNF-α. The
ADAMTSs are extracellular, multidomain enzymes. Their known functions include: collagen processing as
procollagen N–proteinase; cleavage of the matrix proteoglycans aggrecan, versican, and brevican; and inhibition of
angiogenesis.
Because ADAMs and ADAMTSs are new classes of metalloproteinases, they have not been reported in
dental tissues. Interstitial collagenase (MMP-1) was detected in ameloblasts and odontoblasts of the developing
enamel organ.145 Gelatinases (MMP- 2 and -9) were found in the dentinoenamel junction 146 and in ameloblasts,
odontoblasts, and pulp of rodent incisors. 146 Another collagenase (MMP-13) was found to be present in equivalent
amounts in the pulp of normal and carious teeth. 147 Enamelysin (MMP-20) was first detected in the enamel organ
and dental papilla but was also found in the pulp of mature teeth with or without caries. 148
An extensive analysis of the presence and upregulation of MMPs in odontoblasts and the dental pulp tissue
revealed that MMP-1, -2, -9, -10, -11, -13, -14, -15, -16, -17, -19, -20, and -23 were expressed by both odontoblasts
and pulp tissue. MMP-7, -8, -24, and -25 were expressed only in the odontoblasts. MMP-2, -10, -11, -14, and -20
were expressed more abundantly by odontoblasts, whereas pulp tissue expressed more MMP-13 and MMP-17. TGF-
β1 alone or with bone morphogenetic protein 2 significantly upregulated MMP-9 but not MMP-20 messenger RNA
(mRNA) in odontoblasts; however, in pulp tissue no effects could be detected. 149
In teeth with symptomatic irreversible pulpitis, MMP-2 and MMP-3 were found to be upregulated in one
study150 but downregulated in another study.151 In the latter study, MMP-9 was significantly increased and correlated
with an overall increase in gelatinolytic activity,151 a finding that was corroborated by a more recent report.152 It has
also been demonstrated that painful stimulation of teeth induces an increase in MMP-8, sampled from the crevicular
fluid.153
Host MMP-8 (collagenase) and MMP-2 and -9 (gelatinases), probably of salivary rather than pulpal origin,
participated in the degradation of demineralized dentin under a caries lesion. 154 More recently, MMP-2, -8, and -9
were detected in human radicular dentin155 and may have significance in degrading hybrid layers created by
contemporary resin-based root canal sealers. Clearly, MMPs may contribute to the remodeling of dentin and pulp
that take place in physiologic and pathologic situations. Clinically, the potential significance of MMP-9 as a
diagnostic molecule for irreversible pulp pathosis was recently demonstrated. This molecule was found to be
significantly elevated in dentinal fluid of patients with irreversible pulpitis, although this finding was not universally
present in all patients studied.156

Protease inhibitors
Protease inhibitors serve the important function of limiting the normal proteases, including metalloproteinase,
defense functions that may damage the host tissue if they are not regulated. The balance between activated MMPs
and the so-called TIMPs controls the extent of extracellular matrix remodeling. 142 TIMP- 1, -2, and -3 were found to
be expressed by both odontoblasts and pulp tissue.149

Nitric oxide and oxygen - derived free radicals

Nitric oxide
Nitric oxide has received a lot of attention since its discovery in the late 1980s. Despite its high reactivity and short
life, it contributes to a large array of biologic functions. NO is a soluble gas that was first identified because of its
action of relaxing smooth muscle, causing vasodilation. This effect was also shown in the dental pulp. 45,157
NO is synthesized, via L-arginine oxidation, by a family of NO synthases (NOS) and several cofactors,
including nicotinamide adenine dinucleotide phosphate (NADPH). Three different isoforms of the NOS enzyme
exist: neuronal NOS (nNOS), endothelial NOS (eNOS), and inducible NOS (iNOS). 3 The nNOS and eNOS isoforms
are constitutively expressed in the respective tissues and are calcium dependent. Conversely, iNOS is induced in
macrophages and a number of other cells, primarily by cytokines such as IL-1 and TNF-α or microbial products
such as LPS, and are calcium independent. The cytokines IL-4, IL-10, and TGF-β regulate the expression of iNOS
in macrophages.158
Depending on the site of production, the amount of NO produced, and the targets within the local
environment, NO can exert very different effects. A small quantity of NO released by the vascular endothelium
regulates the relaxation of adjacent smooth muscle and protects against the adhesion of leukocytes and platelets to
the blood vessel wall. These properties may be considered protective and anti-inflammatory (Box 11-1). In contrast,
the much larger amounts of NO released by cells in response to cytokines can destroy host tissues and impair
discrete cellular responses. Finally, by affecting the functions of lymphocytes and macrophages, induced NO can
exert an immunomodulatory role that modifies the course of disease 159 (see Box 11-1).
Neuronal NOS was demonstrated in feline teeth. 160 There was evidence of a dramatic increase in NO
activity, as evidenced by immunoreactivity to NOS and the NADPH cofactor at the site of pulpal irrita-tion. These
activities increased to a maximum at 4 days postoperatively and declined at 14 days with
evidence of necrosis161 (Fig 11-14).
In human pulp, eNOS was identified in the endothelial cells and odontoblasts of healthy tissues, and an
elevation of eNOS mRNA and protein and a concomitant dilation of vessels were characteristic in inflamed tissue. 162
Healthy pulp tissue failed to exhibit any iNOS; however, acute inflammation enhanced the mRNA and protein levels
of iNOS, mainly in the leukocytes. 162 Pretreatment of pulp with the NOS inhibitor NG-nitro-L-arginine methyl ester
in vivo did not affect vasodilatation but significantly potentiated SP–mediated vasodilation, possibly via increased
activity of the enzyme guanylate cyclase. 163 Likewise, SP induced NO production by activating NOS in pulpal
endothelial cells.164