Comparative Analysis of Different Origin-Derived Exosomes for Future Regenerative Endodontic Therapies: A Systematic Review

Abstract

Background

Exosomes are gaining considerable attention as a cell-free approach for regenerative endodontic procedures, because they naturally regulate cell signaling and actively drive tissue healing. However, the regenerative potential of exosomes may vary by cellular origin, highlighting the need to evaluate source-dependent therapeutic applications.

Objective

This systematic review aimed to compare the regenerative potential of exosomes derived from different cellular sources and assess their biological effects, molecular mechanisms, and translational relevance for regenerative endodontic therapies.

Methods

A systematic review following PRISMA flow chart 2020 guidelines and a percentage summary of risk-of-bias assessment using the Modified SYRCLE Risk of Bias tool identified 216 eligible studies from PubMed, Web of Science, and Scopus, with 30 studies included in the final detailed synthesis.

Results

Evidence consistently demonstrated that exosomes promote cell proliferation, migration, odontogenic differentiation, angiogenesis, and immunomodulation through signaling pathways including AKT, ERK, PI3K/AKT, Wnt/β-catenin, and TGF-β/SMAD. Exosomes derived from dental stem cells exhibited superior tissue-specific regenerative and odontogenic potential, making them particularly suitable for dental pulp regeneration. In contrast, exosomes from non-dental sources offered advantages in accessibility, scalability, and enhancement of early proliferative and angiogenic responses. Furthermore, engineered exosomes and advanced delivery platforms, including hydrogels and biomaterial-based scaffolds, improved therapeutic efficacy by enhancing cargo stability, retention, and targeted tissue regeneration.

Conclusion

Exosome-based therapies represent a promising strategy for regenerative endodontics, with therapeutic outcomes strongly influenced by exosome source. Endogenous sources, such as DPSC-derived exosomes, appear most suitable for pulp–dentin complex regeneration but are less practical than exogenous sources, such as PRP, WJMSC, and ADSVF exosomes, for scalable clinical applications. To reach the clinic, upcoming studies need to standardize exosome isolation and profiling, pinpoint specific clinical uses for each source, and incorporate modern delivery biomaterials.

Plain Language Summary

Exosomes are tiny particles (30- 150 nm) naturally released by cells that help cells communicate and coordinate tissue repair. Because they can carry proteins, genetic material, and signaling molecules, researchers are exploring exosomes as a safer alternative to stem cell transplantation for regenerative endodontic therapy.

This systematic review analyzed studies investigating exosomes from different cellular sources and their potential to regenerate dental pulp tissue. The evidence showed that exosomes can stimulate important healing processes, including cell growth, blood vessel formation, immune regulation, and dentin production. Exosomes derived from dental stem cells, particularly dental pulp stem cells and stem cells from the apical papilla, demonstrated the strongest ability to support pulp–dentin regeneration because they contain tissue-specific regenerative signals. Exosomes from other sources, such as platelet-rich plasma, adipose tissue, and Wharton’s jelly stem cells, are easier to obtain and may be more suitable for large-scale clinical use because of their strong angiogenic and proliferative effects.

We also observed that modifying exosomes and pairing them with biomaterials, such as collagen or hydrogels, helps these vesicles survive and remain active within the root canal space. Although exosome-based therapies show great promise for regenerative endodontics, further research is needed to standardize production methods, confirm long-term safety, and determine the most appropriate exosome source for specific clinical applications.

Introduction

Instead of simply replacing damaged tissue, regenerative endodontics seeks to fully rebuild the natural structure and function of the pulp-dentin complex through biologically driven treatments. Over the past decade, regenerative endodontic treatment have evolved from traditional root canal treatments toward tissue engineering strategies that integrate stem cells, scaffolds, signaling molecules, and biomaterials to facilitate dental tissue regeneration.1,2 Despite significant advances, achieving predictable and complete regeneration of the pulp–dentin complex remains a major clinical challenge, necessitating the development of more effective therapeutic approaches.

Extracellular vesicles (EVs) are membrane-bound particles released by both prokaryotic and eukaryotic cells. Their heterogeneous size, composition, and biogenesis make EV classification complex. According to current guidelines from the International Society for Extracellular Vesicles, EVs can be broadly categorized by biogenesis into exosomes (approximately 30–150 nm), which originate from endosomal compartments, and ectosomes (approximately 50 nm–5 µm), which form through direct budding of the plasma membrane. Other EV subtypes include apoptotic bodies, released during programmed cell death, and migrasomes, which originate from retraction filaments of migrating cells.3,4

EVs have attracted increasing interest in tissue engineering and regenerative medicine because they can mediate intercellular communication and regulate processes involved in tissue repair. Among these, exosomes are nanosized vesicles that carry diverse bioactive cargo, including proteins, lipids, messenger RNAs, microRNAs, and other signaling molecules, enabling them to modulate recipient cell behavior and function.3–5 These properties make exosomes promising candidates for cell-free regenerative therapies. Compared with direct stem cell transplantation, cell-free approaches may offer potential advantages, including reduced immunogenicity, lower risk of cell-associated complications, and greater practicality in storage, handling, and clinical application.

In regenerative endodontics, exosomes have demonstrated the capacity to promote angiogenesis, odontogenic differentiation, neurogenesis, and immunomodulation, all of which are essential for successful pulp–dentin complex regeneration and restoration of tooth vitality.6,7

The growing interest in exosome-based therapies is further supported by the high prevalence of dental pulp diseases and the limitations of conventional endodontic treatments, which often result in loss of pulp vitality and increased susceptibility to fracture.8 Consequently, exosomes have emerged as promising cell-free therapeutic agents capable of overcoming many of the challenges associated with current regenerative approaches. However, accumulating evidence suggests that the regenerative potential of exosomes depends heavily on their cellular origin. Exosomes derived from endogenous dental stem cells, including human dental pulp stem cells (hDPSCs), stem cells from human exfoliated deciduous teeth (SHED), stem cells from the apical papilla (SCAP), and periodontal ligament stem cells (PDLSCs), have demonstrated strong odontogenic and tissue-specific regenerative capabilities.9,10 In contrast, exosomes derived from exogenous sources, such as platelet-rich plasma (PRP), adipose-derived stromal vascular fraction (AD-SVF), and Wharton’s jelly mesenchymal stem cells (WJMSCs), offer advantages in accessibility, scalability, and clinical feasibility.11–15

Despite promising findings, the optimal exosome source for regenerative endodontic applications remains unclear. Variations in exosome cargo composition, donor cell characteristics, isolation techniques, and uptake mechanisms contribute to considerable heterogeneity among studies and complicate direct comparisons of therapeutic efficacy.16,17 Furthermore, conflicting reports regarding the angiogenic and immunomodulatory properties of exosomes derived from inflammatory versus non-inflammatory conditions highlight persistent uncertainties concerning their mechanisms of action and therapeutic applications.18,19 These unresolved issues continue to limit standardization and represent major barriers to clinical translation.17

Recent advances have also expanded the scope of exosome-based regenerative therapies through engineered exosomes and biomaterial-assisted delivery systems. Hydrogels, collagen matrices, fibrin-based scaffolds, and other biomimetic platforms have been investigated to improve exosome retention, stability, and targeted delivery within the root canal environment, thereby enhancing regenerative outcomes.20,21 Moreover, studies have identified multiple signaling pathways, including AKT, ERK, PI3K/AKT, Wnt/β-catenin, and TGF-β/SMAD, through which exosomes regulate proliferation, migration, differentiation, angiogenesis, and immune responses.22,23 Understanding how these mechanisms vary according to exosome source is essential for optimizing future regenerative strategies.

Therefore, this systematic review aims to comparatively analyze exosomes derived from different endogenous and exogenous sources for regenerative endodontic applications. Specifically, the review evaluates their molecular cargo, biological mechanisms, regenerative outcomes, immunomodulatory properties, and translational potential. In addition, it examines emerging engineering strategies and biomaterial-assisted delivery systems to provide a comprehensive perspective on future exosome-based regenerative endodontic therapies. By synthesizing current evidence, this review seeks to establish a source-dependent framework for exosome selection, identify current research gaps, and support the development of standardized and clinically translatable regenerative endodontic treatments.

Material and Methods

Study Design and Search Strategy

We conducted a comprehensive literature search in PubMed, Web of Science, and Scopus in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search aimed to identify studies investigating the biology, underlying mechanisms, and therapeutic applications of exosomes in regenerative medicine (Figure 1).

Figure 1.

PRISMA Flow chart of the number of studies that include this systematic review according to 2020 guidelines.

Search terms included combinations of keywords and synonyms related to exosomes and regenerative medicine, such as “exosome”, “extracellular vesicle*” “small extracellular vesicle*” “sEVs”, “regenerative medicine”, “tissue regeneration”, “tissue repair”, “wound healing”, “tissue engineering”, “mechanism*” “biology”, “therapeutic*”, “treatment*” and “therapy*” connected using Boolean operators (AND/OR). Additional searches incorporating terms related to stem cells, including “mesenchymal stem cells” and “MSC,” were performed to capture relevant studies on exosome-mediated regenerative processes. Reference lists of eligible articles and relevant review papers were also manually screened to identify additional studies. After removing duplicate records, titles and abstracts were screened for relevance, followed by full-text assessment based on predefined inclusion and exclusion criteria.

Eligibility Criteria (PICOS Framework)

The eligibility criteria were established using the Population, Intervention, Comparator, Outcomes, and Study Design (PICOS) framework. Population (P): Studies involving human subjects, animal models, or cell cultures relevant to regenerative medicine and tissue repair were included. Intervention (I): Studies investigating exosomes or exosome-derived products as therapeutic agents, biological mediators, or delivery systems for regenerative applications were considered. Comparator (C): Eligible studies included those comparing exosome-based interventions with untreated controls, placebo treatments, conventional therapies, other extracellular vesicles, or alternative regenerative approaches; studies without a comparator were also included if they provided relevant mechanistic or therapeutic evidence. Outcomes (O): Studies reporting outcomes related to exosome biology, molecular mechanisms, tissue regeneration, wound healing, angiogenesis, immunomodulation, stem cell regulation, functional recovery, or other regenerative effects. Study Design (S): We included primary peer-reviewed experimental research, ranging from laboratory cell cultures and animal models to full clinical trials.

We excluded literature reviews, opinion pieces, conference abstracts, theses, and papers missing key methods or data. Only English publications were eligible. We first screened the titles and abstracts, then thoroughly evaluated the full texts against our PICOS criteria to determine the final selection.

Study Selection

We compiled all records identified through the database searches and screened them according to the predefined eligibility criteria. Duplicate records were removed before screening. We initially screened titles and abstracts to identify studies potentially relevant to the review objectives.

Records considered potentially eligible underwent full-text assessment. During full-text screening, studies were evaluated against the predefined PICOS criteria, with particular attention to relevance to dental pulp regeneration and adequate identification of the exosome source. Studies were excluded when the exosome source was insufficiently or unclearly described, when the study did not investigate dental pulp regeneration, or when the publication was a systematic review or meta-analysis rather than primary research (Figure 1).

We initially identified 216 records from electronic databases. After initial screening, 95 records were excluded, and two reports could not be retrieved in full text. The remaining reports underwent full-text assessment for eligibility. Full-text studies were subsequently excluded according to the predefined exclusion criteria, including unclear identification of the exosome source, lack of relevance to dental pulp regeneration, and secondary research publications such as systematic reviews and meta-analyses. The complete study selection process is presented in the PRISMA 2020 flow diagram (Figure 1).

Data Extraction

Data were systematically extracted from the eligible studies using a predefined data extraction framework. Extracted information included the publication characteristics, study design, biological model, source of exosomes, method of exosome isolation and characterization, experimental intervention, comparator, treatment concentration or dose, duration of treatment, outcome measures, and principal findings.

Particular attention was given to the source of the exosomes, as this was considered an important characteristic for interpreting their regenerative potential. Information regarding the source of exosomes was categorized according to the biological origin reported by each study. For studies investigating dental pulp stem cells or dental pulp regeneration, we extracted information on cell proliferation, migration, odontogenic differentiation, angiogenic responses, inflammatory modulation, mineralization, and relevant molecular markers, where available. This review provided a percentage summary of risk-of-bias assessment using the Modified SYRCLE Risk of Bias Tool, with a very low risk of baseline similarity (Figure 2).

Figure 2.

Percentage summary of risk of bias assessment using the Modified SYRCLE Risk of Bias Tool. Most studies demonstrated low risk regarding baseline characteristics, standardized experimental conditions, and outcome reporting. The greatest sources of bias were related to random allocation and blinding procedures, which were frequently unclear or inadequately reported.

Results

Descriptive Summary of the Studies

This section maps the research landscape of comparative analyses of different types of exosomes (endogenous and exogenous) and other treatment modalities in endodontics, focusing on their influence and underlying mechanisms, and encompassing a diverse range of studies investigating exosomes derived from various dental stem cell sources and alternative regenerative treatments. The studies predominantly employ in vitro and in vivo experimental designs, with some reviews synthesizing mechanistic insights and translational challenges. The geographic and disciplinary focus spans regenerative dentistry, molecular biology, and tissue engineering, reflecting a multidisciplinary approach. This comparative analysis is crucial for addressing research questions related to several focuses, such as high tissue specificity, natural odontogenic potential, high yield, accessibility, potent early-stage proliferative induction, targeted molecular delivery, and overcoming the hostile, inflammatory root canal microenvironment; delivery system category, specific biomaterial, key properties/advantages, principal regenerative outcome (Tables 1–4).

Table 1.

Endogenous Dental Sources and Their Regenerative Profiles

Cell Source	Key Molecular Cargo	Target Pathways/Mechanisms	Principal Regenerative Outcomes	Representative Studies
hDPSCs	Odontogenic proteins, RNAs	CD73-mediated adenosine receptor, AKT, ERK	Complete pulp-dentin regeneration, enhanced angiogenesis and proliferation	Wang et al,7 Mansour A et al,8 Shi et al,9 Shi Z,10 Ganesh et al24
SCAP	DSPP, mineralization-related proteins, factors recruiting SCAPs	Foxp3 demethylation, Treg conversion	Specific tubular dentinogenesis, immune regulation in pulpitis, cell homing	Zhuang et al,25 Yu et al,26 Chen et al27
PDLSCs	miRNAs regulating osteogenesis and inflammation	Exosomal miR-34c-5p inhibited osteogenic differentiation of PDLSCs via SATB2/ERK pathway.	In vitro results unveiled that exosomes induced by PGE2 inhibited osteogenic differentiation A potential target for bone remodelling.	Lin C. et al28
SHED	miR-26a	TGF-β/SMAD2/3	Improved pulp tissue regeneration and vascularization	Wu M. et al29
DPSCs & HERS	Pro-migration/osteogenesis proteins, un-specified ELVs	Wnt/β-catenin signaling activation	Comparable periodontal regeneration to exosomes, DPC proliferation	Liang et al,30 Zhang et al31

Table 2.

Exogenous and Systemic Sources for Endodontic Repair

Cell Source	Key Molecular Cargo	Target Pathways/Mechanisms	Principal Regenerative Outcomes	Representative Studies
PRP	TGF-β1, PDGF, VEGF	TGF-β1 and DSPP expression modulation	Potent angiogenic inducer, enhanced odontogenic differentiation and mineralization	Bagio et al,11 Bagio et al13
AD-SVF	Unspecified miRNAs targeting wound healing	Not explicitly specified	High purity, potent time- and dose-dependent induction of hDPSC proliferation and migration at low concentrations	Alinda et al,32 Alinda et al14
WJMSCs	Osteogenic proteins promoting mineralization	Not explicitly specified	Enhanced osteogenic differentiation at low concentrations	Ricardo et al15

Table 3.

Preconditioned and Engineered Exosomes

Modification Strategy	Source Cell	Enhanced Cargo/Mechanism	Principal Regenerative Outcomes	Representative Studies
Inflammatory Preconditioning	LPS-stimulated hDPSCs, M2 Macrophages	Differential miRNA expression, Chemokine receptor modulation	Increased vessel density, inflammation modulation, enhanced HUVEC proliferation	Lan et al,18 Huang et al,19 Wang et al6
Odontogenic Priming	OM-SHED	Activation of AMPK/mTOR pathway via miRNA and proteins	Promoted DPSC proliferation, robust dentinogenesis in vivo	Lu et al22
Genetic / Structural Engineering	SCAP, hDPSCs	DSPP mRNA cargo, miR-126-3p via DNA nanostructures	Highly specific tubular dentin regeneration, sustained pro-angiogenic gene expression	Zhuang et al,33 Wei et al34
Surface Modification	Dual-engineered EVs (EphrinB2)	EphrinB2/EphB4 axis activation, Akt/ERK1/2	Enhanced capillary morphogenesis, pulp organoid vascularization	Liu et al35

Table 4.

Biomimetic Scaffolds and Exosome Delivery Systems in Regenerative Endodontics

Delivery System Category	Specific Biomaterial	Key Properties/Advantages	Principal Regenerative Outcomes	Representative Studies
Injectable & Smart Hydrogels	GelMA (Gelatin Methacryloyl)	Tunable degradation, photo-cross linkable, sustained EV release	Promoted robust dentinogenesis and vascularized pulp organoid formation in vivo.	Xie et al,36 Liu et al35,37
	Photo-cross linkable Hydrogel (combination with DMEP)	Injectable, biomimetic microenvironment mimicking dentin matrix	Enhanced odontogenic and angiogenic differentiation; in vivo pulp-like tissue	Xie et al36
	Thermosensitive Chitin Hydrogel	Injectable at room temp, solidifies at body temp, highly biocompatible	Improved retention of exosomes; new pulp-like tissue formation.	Wang et al38
Natural Protein-Based Matrices	Injectable hydrogel	Clinically available, highly biocompatible for pulp regeneration	EVs from DPSCs can promote angiogenesis in an injectable hydrogel in vitro, offering a novel and minimally invasive strategy for regenerative endodontic therapy.	Zhang et al39
Pre-formed Matrices (Ectopic Models)	Matrigel Plugs	High growth factor baseline, gold-standard for subcutaneous testing	Supported complex vascularization and complete pulp-dentin regeneration in vivo.	Wang et al,6 Wang et al7
Advanced Nano platforms	Tetrahedral DNA Nanostructures	Protects nucleic acid cargo, highly targeted	Sustained delivery of miRNAs (eg, miR-126-3p) promoting pronounced angiogenesis.	Wei et al34
Fibrin Base Root Filling Material	Fibrinogen-based and thrombin-based solutions	Uptake of Exosomes by HBMMSCs	Exosomes attracted MSCs, and the fibrin gel enhanced their effect. Exosomes improved the proliferation of MSCs. Pulp-derived exosomes in combination with a fibrin gel has a potential in dental pulp regeneration.	Ivica A., et al40

Discussion

This review shows that the regenerative potential of exosomes in regenerative endodontic treatment depends heavily on their cellular origin, molecular cargo, and delivery platform. Across the included studies, exosomes consistently promoted key regenerative processes, including stem cell proliferation, migration, angiogenesis, immunomodulation, and mineralized tissue formation. However, significant differences were observed among endogenous dental-derived exosomes, exogenous systemic-derived exosomes, and engineered exosome formulations, suggesting that source selection plays a critical role in determining therapeutic outcomes. The overall risk-of-bias assessment revealed that most included studies adequately reported baseline characteristics, standardized culture conditions, and outcome measurements, resulting in predominantly low-risk ratings for these domains. However, random allocation procedures and blinding of investigators and outcome assessors were frequently insufficiently described, leading to a substantial proportion of studies being classified as having unclear or high risk of bias. These findings reflect common methodological limitations in laboratory-based exosome research and should be considered when interpreting the regenerative outcomes reported across studies (Figure 2).

Endogenous Dental-Derived Exosomes Exhibit Superior Odontogenic Potential

Among the various exosome sources, dental tissue-derived exosomes, particularly those isolated from human dental pulp stem cells (hDPSCs) and stem cells from the apical papilla (SCAPs), demonstrated the greatest capacity to regenerate the pulp-dentin complex. This superiority likely reflects their tissue-specific molecular cargo, which recapitulates the signaling environment of native dental tissues. hDPSC-derived exosomes have been shown to activate AKT and ERK signaling pathways through CD73-mediated adenosine receptor signaling, resulting in enhanced angiogenesis, stem cell proliferation, and complete pulp-dentin regeneration.7–10,24 The reason why exosomes derived from dental stem cells are more suitable than mesenchymal stem cells from other organs for regenerating the dentin-pulp complex can also be explained by their embryonic origin. Dental mesenchymal stem cells originate from the neural crest and differentiate into odontoblasts, cementoblasts, and osteoblasts.10 Therefore, dental mesenchymal stem cells are also referred to as ectomesenchymal cells. These findings are consistent with the concept that exosomes retain the biological characteristics of their parent cells and can therefore serve as cell-free mediators of dental tissue repair.

Similarly, SCAP-derived exosomes exhibited strong odontogenic activity by delivering dentin sialophosphoprotein (DSPP) and other mineralization-related proteins that promote tubular dentin formation.25–27 Notably, SCAP-derived exosomes also demonstrated immunomodulatory properties through Foxp3 demethylation and regulatory T-cell (Treg) induction, suggesting a dual role in both tissue regeneration and inflammation control.26 Because persistent inflammation is a major obstacle to successful regenerative endodontic treatment, the ability of SCAP-derived exosomes to simultaneously regulate immune responses and stimulate tissue regeneration may provide a significant therapeutic advantage.

Other endogenous dental sources also contributed to regenerative outcomes through distinct molecular mechanisms. SHED-derived exosomes promoted angiogenesis and pulp regeneration through miR-26a-mediated activation of the TGF-β/SMAD2/3 pathway.29 Likewise, exosomes derived from DFSCs and HERS activated Wnt/β-catenin signaling and stimulated both periodontal regeneration and dental pulp cell proliferation.30,31 Collectively, these findings indicate that endogenous dental-derived exosomes possess inherent odontogenic programming that makes them particularly suitable for pulp-dentin complex regeneration (Figure 3).

Figure 3.

Integrated source-dependent framework of exosome-based regenerative endodontics. Exosome sources may affect their potential (A): Endogenous dental-derived exosomes (hDPSC, SCAP, SHED, PDLSC, DFSC/HERS) (A.i) exhibit superior odontogenic specificity and pulp–dentin regenerative potential. Exogenous sources (PRP, AD-SVF, and WJMSC) (A.ii) provide advantages in accessibility, scalability, and early angiogenic stimulation. Therapeutic efficacy may be further enhanced through preconditioning and engineering approaches (As shown by the box next to the blue arrow; B. Engineering Strategies), including inflammatory priming (B.i), odontogenic induction (B.ii), genetic modification (B.iii), and surface functionalization (B.iv). Biomaterial-assisted delivery systems (As shown by the box next to the blue arrow; (C) Delivery System), such as injectable hydrogels (C.i), thermosensitive hydrogels (C.ii), collagen matrices (C.iii), pre-formed matrices (C.iv) and DNA nanostructures (C.v), improve exosome retention and targeted delivery, ultimately supporting predictable pulp–dentin complex regeneration (blue arrow to box (D) Clinical Goal). (Originality and accuracy of this illustration content have been confirmed by the authors; generated by GPT-5.6 Luna, OpenAI).

Exogenous and Systemic Sources Offer Scalability and Potent Early Regenerative Effects

While dental-derived exosomes exhibit superior tissue specificity, exosomes obtained from systemic or non-dental sources provide several practical advantages for clinical translation, including greater accessibility, higher cell yields, and easier large-scale production. PRP-derived exosomes were consistently associated with strong angiogenic and odontogenic effects due to their enrichment in growth factors such as VEGF, PDGF, and TGF-β1.11,13 Since revascularization is a prerequisite for successful pulp regeneration, the potent angiogenic capacity of PRP-derived exosomes may be particularly valuable during the early stages of tissue repair.

Similarly, adipose-derived stromal vascular fraction (AD-SVF)-derived exosomes demonstrated a dose-dependent ability to stimulate hDPSC proliferation and migration.13,32 These findings suggest that AD-SVF-derived exosomes may provide a readily available source of regenerative signals capable of accelerating wound healing and cellular recruitment. In addition, exosomes derived from Wharton’s Jelly mesenchymal stem cells (WJMSCs) promoted osteogenic differentiation and mineralized tissue formation, highlighting their potential utility in hard tissue regeneration (Figure 3).15

Despite these advantages, systemically derived exosomes generally appear less specialized than dental-derived exosomes in directing odontogenic differentiation. Most studies reported enhanced proliferation, migration, and angiogenesis rather than the formation of organized dentin-pulp structures. Therefore, exogenous sources may be particularly beneficial as supportive regenerative agents or adjunctive therapies, while dental-derived exosomes remain more suitable for targeted pulp-dentin regeneration. Even though the potential for scalable mass production of exosomes seems to be more promising compared to endogenous sources or dental-derived exosomes.

Preconditioning and Engineering Enhance Exosome Therapeutic Efficacy

Recent advances have focused on modifying exosomes to overcome the hostile inflammatory microenvironment commonly encountered in infected root canals. Preconditioning donor cells with inflammatory stimuli has emerged as an effective strategy to enhance exosome bioactivity. Exosomes derived from lipopolysaccharide (LPS)-stimulated hDPSCs and M2 macrophages exhibited altered miRNA profiles that improved angiogenesis, endothelial cell proliferation, and inflammatory regulation.6,18,19 These findings suggest that inflammatory preconditioning may “prime” exosomes to function more effectively within diseased tissues.

Odontogenic priming represents another promising approach. Lu et al22 reported that exosomes derived from odontogenic medium-treated SHED activated the AMPK/mTOR signaling pathway, leading to enhanced DPSC proliferation and robust dentinogenesis in-vivo. This finding highlights the potential to manipulate donor cell culture conditions to selectively enrich regenerative cargo before exosome isolation.

Genetic and structural engineering further expand the therapeutic capabilities of exosomes. For example, exosomes enriched with DSPP mRNA promoted highly organized tubular dentin formation, whereas tetrahedral DNA nanostructure-assisted delivery of miR-126-3p resulted in sustained angiogenic signaling and improved vascularization.33,34 Surface-modified exosomes functionalized with EphrinB2 also enhanced capillary morphogenesis and pulp organoid vascularization through activation of the EphrinB2/EphB4 and Akt/ERK pathways.35 Together, these findings demonstrate that engineered exosomes can overcome some of the limitations of native vesicles and enable more precise control over regenerative outcomes (Figure 3).

Biomaterial-Assisted Delivery Systems are Essential for Clinical Translation

The successful clinical application of exosomes depends not only on their biological activity but also on efficient delivery and retention within the root canal system. Because exosomes can be rapidly degraded or cleared following administration, biomaterial-based delivery systems have become increasingly important in regenerative endodontics.

Hydrogel-based platforms, particularly GelMA, have emerged as leading candidates due to their tuneable degradation rates, injectability, and ability to provide sustained exosome release. Studies have shown that GelMA-based systems significantly enhance dentinogenesis, angiogenesis, and vascularized pulp organoid formation compared with exosomes alone.35–37 Similarly, photo-crosslinkable hydrogels combined with dentin matrix-inspired components created biomimetic microenvironments that promoted both odontogenic and angiogenic differentiation.36 Thermosensitive chitin hydrogels further improved exosome retention and supported the formation of pulp-like tissues in vivo.38

Natural biomaterials such as fibrin and collagen also demonstrated considerable promise. Fibrin gel mimics the natural blood clot used in conventional RET and effectively recruits endogenous mesenchymal stem cells.39 More advanced delivery systems, including Matrigel plugs, tetrahedral DNA nanostructures, or fibrin-based and thrombin-based vehicles of pulp-derived exosomes, provide additional benefits by protecting nucleic acid cargo and enabling targeted delivery of regenerative miRNAs.6,7,34,40 These findings indicate that scaffold-assisted exosome delivery is likely to become a critical component of future regenerative endodontic therapies (Figure 3).

Future Directions

The collective evidence suggests that no single exosome source is universally optimal for all regenerative applications. Instead, the therapeutic effectiveness of exosomes appears to depend on matching the source’s biological properties to the desired regenerative objective. Dental-derived exosomes, particularly those from hDPSCs and SCAPs, demonstrate superior odontogenic specificity and are therefore promising candidates for true pulp-dentin complex regeneration.7–10 In contrast, PRP-, AD-SVF-, and WJMSC-derived exosomes offer advantages in accessibility, scalability, and stimulation of early angiogenic and proliferative responses. Emerging engineering strategies further enhance these properties by enabling targeted cargo loading and functional customization.3,11,14,15,32

Advancing the clinical application of exosome-based regenerative endodontics will require standardized isolation and characterization protocols, direct comparisons among exosome sources, and comprehensive evaluation of source-specific molecular cargo. Furthermore, integrating optimized exosome populations with biomaterial-assisted delivery systems may enhance therapeutic efficacy and support predictable pulp–dentin complex regeneration (Figure 4).

Figure 4.

Future source-dependent exosome strategy in regenerative endodontic therapy. Future regenerative endodontic therapies are expected to adopt a source-dependent (A) approach in which exosome selection matches specific clinical objectives (A.i–ii). Dental-derived exosomes provide superior odontogenic potential, whereas systemic-derived exosomes offer greater scalability and accessibility. Exosome engineering (B.i–iv) and optimized biomaterial delivery systems (C.i–v) can enhance therapeutic performance. Successful clinical translation will depend on standardization (D.i), safety validation (D.ii), patient-specific treatment strategies (D.iii), safety evaluation (D.iv) and clinical evidence (D.v), ultimately enabling predictable and personalized pulp–dentin complex regeneration. (Originality and accuracy of this illustration content have been confirmed by the authors; generated by GPT-5.6 Luna, OpenAI).

Future studies should move beyond proof-of-concept investigations toward establishing clinically translatable exosome platforms. Systematic head-to-head comparisons using standardized preclinical models and clinically relevant outcome measures will be essential to identify the most appropriate exosome source for specific regenerative indications.41 Advances in multi-omics profiling, single-vesicle characterization, and artificial intelligence-assisted biomarker discovery may further elucidate the molecular determinants of exosome potency and enable the development of predictive quality-control criteria.42 In parallel, scalable Good Manufacturing Practice (GMP)-compliant production, robust storage strategies, and regulatory frameworks must be established to facilitate clinical translation. Ultimately, personalized exosome therapies, potentially incorporating engineered vesicles tailored to patient-specific biological and inflammatory profiles, may represent the next generation of regenerative endodontic therapeutics, providing more consistent and durable restoration of the pulp–dentin complex.

Conclusion

Exosomes represent a promising cell-free therapeutic approach for regenerative endodontics by promoting proliferation, angiogenesis, immunomodulation, and pulp–dentin complex regeneration. The evidence indicates that their regenerative potential is highly source dependent. Dental-derived or endogenous exosomes, particularly those from hDPSCs and SCAPs, demonstrate superior odontogenic potential and tissue specificity, whereas exogenous exosomes from PRP, AD-SVF, and WJMSCs offer advantages in accessibility, scalability, and early regenerative stimulation. In addition, engineered exosomes and biomaterial-based delivery systems further enhance therapeutic efficacy. Despite encouraging preclinical findings, challenges remain in standardization, large-scale production, and clinical translation. Future studies should focus on direct comparisons among exosome sources in specific clinical cases, optimizing delivery strategies, and establishing standardized protocols to facilitate the clinical application of extracellular vesicles or exosome-based regenerative endodontic therapies. Collectively, the available evidence indicates that exosomes are a promising cell-free modality for regenerative endodontics. Their successful clinical translation will depend on a deeper understanding of source-dependent biological functions, optimization of delivery systems, and the establishment of standardized production frameworks. Addressing these challenges may enable the development of precise and predictable exosome-based therapies for pulp–dentin complex regeneration.

Funding Statement

The authors received no specific funding for this work.

Use of Artificial Intelligence

AI-assisted tools, including GPT-5.6 Luna OpenAI, were used only for limited editorial support, estimated at less than 10% of the manuscript preparation process, specifically for English grammar refinement and assistance in preparing the graphical abstract and schematic drawing. No AI tools were used for data generation, data analysis, interpretation of findings, or decision-making. The authors confirm that the manuscript is original and that all content has been carefully reviewed and verified for accuracy. The authors take full responsibility for the integrity of the entire manuscript, including the accuracy and appropriateness of all references and citations. The authors also confirm that the terms of use of AI-assisted tools were reviewed and found suitable for use in preparing this manuscript and for publication.

Abbreviations

DPSC, dental pulp stem cell; LPS, lipopolysaccharide; EV, extracellular vesicle; NTA, nanoparticle tracking analysis; AD-SVF, Adipose-derived stromal vascular fraction; WJMSCs, Wharton’s Jelly mesenchymal stem cells; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; TEM, transmission electron microscopy; UC-MSC, umbilical cord mesenchymal stem cell; WB, Western blot; MSC, mesenchymal stem cell; SHED, stem cells from human exfoliated deciduous teeth; SCAP, stem cells from the apical papilla; PDLSCs, periodontal ligament stem cells; PRP, platelet-rich plasma (PRP).

Data Sharing Statement

All data generated or analysed during this study are included in this published article.

Ethics Approval and Consent to Participate

Ethical approval was not required for this study because this work is a systematic review of previously published literature and did not involve direct research on human participants or animals.

Author Contributions

All authors made substantial contributions to the conception and design of the study, acquisition of data, analysis and interpretation of data, and drafting or critical revision of the manuscript. All authors agreed on the journal to which the article will be submitted, reviewed and approved all versions of the manuscript, and agreed to be accountable for all aspects of the work.

Disclosure

The authors declare no competing interests.