Xerostomia or dry mouth are commonly diagnosed in head and neck cancer patients due to salivary gland (SG) epithelial injury after radiotherapy. Regenerative medicine has fetched the opportunity to replace or regenerate the SG epithelia and restore its secretory function. Early adult stem cell transplantation strategies in rodents have recently shown to improve clinical outcomes in radiotherapy-induced xerostomia in Phase 1/2 human trials. Mesenchymal stem cells from adipose tissue are the most promising, although the ones from the labial mucosa, bone marrow, or dental pulp have an attractive therapeutic value after successful findings in ex vivo and in vivo mouse models of SG injury. Emerging approaches using cell-free therapy with cell "extracts", "soups" or secretome components also exhibit favorable outcomes in the same rodent models. When compared to cell-based approaches, extracellular vesicles (EV) from the secretome (i.e., exosomes) can be easily extracted, quantified, and are more stable for long-term storage and use in SG tissue engineering. Additive manufacturing and three-dimensional bioprinting or bioassembly have an important role on generating spheroids or organoids for cell transplantation to ameliorate SG injury. Moreover, organoids can secrete EV, which may have a therapeutic potential worth to explore in future studies. In this review, we will describe the technological advancements and challenges of these different cell-based and cell-free strategies in SG tissue engineering and regeneration. Impact statement Salivary gland (SG)-like innervated epithelial organoids and the secretome produced from stem cells may constitute feasible therapeutic alternatives to regenerate the SG due to their user-friendly, short-lived, consistent, and scalable additive manufacturing processes. Bioprinting such human SG organoids toward in vitro drug discovery may further reduce the incorporation of animal-derived components to the tissue constructs and minimize the use of animal experimentation in SG regeneration. Despite such advancements, transplantation with human adipose-derived mesenchymal stem cells is the only tissue engineering strategy that has reached Phase 1/2 clinical trials and shown to enlarge the serous SG epithelium and improve salivary flow.
Keywords: bioprinting; exosome; extracellular vesicles; mesenchymal stem cells; organoids; salivary gland; stem cell transplantation; xerostomia.