Reducerea rezorbtiei osoase prin imbunatatirea raportului OPG/RANKL indus de activarea celulelor stem

1. Reducerea rezorbtiei osoase prin
imbunatatirea raportului
OPG/RANKL indus de activarea
celulelor stem
Dr Bogdan Vladila

2. Immune response: the key to bone resorption in periodontal disease-
Taubman MA, Valverde P, Han X, Kawai T-Journal of Periodontology 2005
Nov;76(11 Suppl):2033-41.
• Periodontal disease infection with oral biofilm microorganisms initiates host immune response and signs of
periodontitis, including bone resorption. This review delineates some mechanisms underlying the host immune
response in periodontal infection and alveolar bone resorption. Activated T lymphocytes have been historically
implicated in experimental periodontal bone resorption. An experimental rat adoptive transfer/gingival challenge
periodontal disease model has been demonstrated to require antigen-specific T lymphocytes and gingival
instillation of antigen and LPS for bone resorption. Interference with costimulatory interactions between T cells
and antigen-presenting cells abrogated bone resorption, further emphasizing the significance of immune response
in periodontal disease. Receptor activator of nuclear factor kappaB ligand (RANKL), a critical osteoclast
differentiation factor, is expressed on T lymphocytes in human periodontal disease as determined by
immunohistochemical and confocal microscopic analyses. Interference with RANKL by systemic administration of
osteoprotegerin (OPG), the decoy receptor for (and inhibitor of) RANKL, resulted in abrogation of periodontal
bone resorption in the rat model. This finding indicated that T cell-mediated bone resorption is RANKL-dependent.
In additional experiments, treatment of T cell-transferred rats with kaliotoxin (a scorpion venom potassium
channel inhibitor) resulted in decreases in T-cell RANKL expression, diminished induction of RANKL-dependent
osteoclastogenesis, and abrogation of bone resorption, implicating an important role of immune response/RANKL
expression in osteoclastogenesis/bone resorption. In other experiments, adoptive transfer of antigen-specific,
RANKL-expressing B cells, and infection with the antigen-bearing Actinobaccillus actinomycetemcomitans gave rise
to periodontal bone resorption, indicating that B cells also have the capacity to mediate bone resorption, probably
via RANKL expression. In humans, prominent T lymphocytes have been identified in periodontal disease, and
diseased tissues showed elevated RANKL mRNA expression, as well as decreased OPG mRNA expression.
Mononuclear cells from periodontal lesions involving T cells and B cells of patients induced osteoclastogenesis in
vitro. In summary, a biofilm interface initiates immune cell infiltration, stimulating osteoclastogenesis/bone
resorption in periodontal disease. This resorption can be ameliorated by inhibition of RANKL activity or by
diminishing immune cell stimulation. These two procedures, if localized, have the potential to lead to the
prevention or therapeutic management of periodontal disease and therefore require further study.

3. Cochran DL-Journal of Periodontology 2008
Aug79(8Suppl):1569-76.doi:10.1902/jop.2008.080233
Adevarata cauza a
Parodontopatiei o reprezinta
cronicizarea inflamatiei osoase
evidentiata prin scaderea
OPG/RANKL
• Multiple lines of evidence in
models of periodontal disease
clearly indicate that increases in
RANKL mRNA expression and
protein production increase the
RANKL/OPG ratio and stimulate
the differentiation of macrophage
precursor cells into osteoclasts.
They also stimulate the
maturation and survival of the
osteoclast, leading to bone loss.
Ironic, parodontologii s-au
canalizat doar pe calea
eliminarii bacteriilor bucale, fara
sa trateze esentialul=efectul
final al bacteriilor asupra osului
• Ironically, periodontal practitioners have
focused on the bacterial etiology of PD and
believed that plaque removal was aimed at
eliminating specific bacteria or bacterial
complexes. However, it seems that the
reduction of inflammation and attenuation of
the host's immune reaction to the microbial
plaque, eventually leading to a decrease in
the ratio of RANKL/OPG and a decrease in
associated bone loss, are the actual and
desired outcomes of periodontal therapy.
Future therapeutic options are likely to have
regulation of the RANK-RANKL-OPG axis as
their goal.

4. Studii clinice care demonstreaza imbunatatirea prognosticului din
Parodontopatie dupa imbunatatirea raportului OPG/RANKL
Cytokine pattern determines the progression of
experimental periodontal disease induced by
Actinobacillus actinomycetemcomitans through
the modulation of MMPs, RANKL, and their
physiological inhibitors.
Garlet GP, Cardoso CR, Silva TA, Ferreira BR,
Avila-Campos MJ, Cunha FQ, Silva JS.-Oral
Microbiology andImmunology 2006
Feb;21(1):12-20
• CONCLUSIONS:
• It is possible that the pattern of
cytokines produced in periodontal
tissues determines the progression and
the severity of experimental
periodontal disease, controlling the
breakdown of soft and bone tissues
through the balance between
MMPs/TIMP and RANKL/OPG
expression in gingival tissues.
RANKL Inhibition Through Osteoprotegerin
Blocks Bone Loss in Experimental
Periodontitis
Qiming Jin, Joni A. Cirelli, Chan Ho Park,
James V. Sugai, Mario Taba, Jr.,Paul J.
Kostenuik, William V. Giannobile-Journal
of Periodontology 2007 Jul; 78(7): 1300–
1308.
• Conclusion:
• Systemic delivery of OPG-Fc
inhibits alveolar bone resorption
in experimental periodontitis,
suggesting that RANKL inhibition
may represent an important
therapeutic strategy for the
prevention of progressive alveolar
bone loss.

5. Expunerea de lunga durata la Campul magnetic imbunatateste raportul RANKL/OPG
prin productia de Osteoprotegerin (OPG) fara sa modifice RANKL. Tratatamentul
parodontal clasic (scaling) nu modifica cu nimic raportul OPG/RANKL
Osteoprotegerin (OPG) production by cells
in the osteoblast lineage is regulated by
pulsed electromagnetic fields in cultures
grown on calcium phosphate substrates.-
Schwartz Z, Fisher M, Lohmann CH, Simon
BJ, Bovan BD-Annals of Biomedical
Engineering, 2009 Mar;37(3):437-44.
• The results showed that when
osteoblast-like cells were cultured
on CaP, Pulsed ElectroMagnetic
Field decreased cell number and
increased production of paracrine
factors associated with reduced
bone resorption like OPG. RANKL
was unaffected, indicating that
the OPG/RANKL ratio was
increased,
The RANKL‐OPG system in clinical
periodontology-Belibasakis
BN,Bostanci N-Journal of Clinical
Periodontology,2012,39,239-248,
• Results
• Papers fulfilling the inclusion criteria demonstrate
that RANKL is up‐regulated, whereas OPG is
down‐regulated in periodontitis, compared to
periodontal health, resulting in an increased
RANKL/OPG ratio. This ratio is further up‐regulated
in smokers and diabetics, and is not affected by
conventional periodontal treatment.
• Conclusions
The RANKL/OPG elevated levels post treatment
may indicate that the molecular mechanisms of
bone resorption are still active, holding an
imminent risk for relapse of the disease. Additional
adjunct treatment modalities that would
“switch‐off” the RANKL/OPG ratio may therefore be
required.

6. Laserul stimuleaza osteoclastele si rezorbtia osoasa prin
inrautatirea indicelui (cresterea RANKL fara sa se modifice OPG)
Effect of low-level laser therapy on
bisphosphonate-treated osteoblasts
Sang-Hun Shin1, Ki-Hyun Kim, Na-Rae
Choi, In-Ryoung Kim, Bong-Soo Park,
Yong-Deok Kim,Uk-KyuKim, Cheol-Hun
Kim-Maxillofacial Plastic and
Reconstructive Surgery (2016) 38-48,
• Conclusions
• The LLLT does not affect the OPG
expression in the hFOB cell line,
but it may increase the RANKL
and M-CSF expressions, thereby
resulting in positive effects on
osteoclastogenesis and bone
remodeling.
Effect of Low Level Laser Therapy on
Orthodontic Tooth Movement: A Review Article
Soghra Yassaei, Reza Fekrazad,Neda Shahraki,,
Journal of Dentistry,Tehran University of Medical
Science,2013,Vol 10, No3.
• Based on different researches, it may be concluded
that low level laser therapy may increase the rate of
tooth movement during orthodontic treatment by
the following mechanisms:
• - Increasing levels of RANKL in PDL which leads to
increased osteoclastogenesis.
• - Increased M- CSF levels and osteoclastogenesis
(Macrophage-colony stimulating factor (M- CSF) not
only stimulates proliferation of osteoclastic
progenitors, but it also affects their differentiation
into mature osteoclasts. Based on a study carried
out by Yamaguchi et al., low level laser therapy can
increase M- CSF on the compressed side and may
also increase osteoclastogenesis leading to tooth
movement)

7. Interactions between MSCs and Immune Cells: Implications for Bone Healing-Tracy K.
Kovach, Abhijit S. Dighe, Peter I. Lobo, Quanjun Cui-_Journal of Immunology Research.
2015; 2015: 752510.
Celulele stem reduc osteoliza prin
reducerea semnalelor NF-kB RANKL si
polarizarea macrofagelor catre fenotipul
antiinflamator M2
• More recent studies provide
evidence that allogeneic MSCs
promote the shifting of
monocytes toward an anti-
inflammatory M2 phenotype
(through the NF-κB and STAT3
pathways) -Mouse bone marrow-
derived mesenchymal stem cells
induce macrophage M2
polarization through the nuclear
factor-κB and signal transducer
and activator of transcription 3
Celulele stem moduleaza
raspunsul sistemului imun
• Conclusion:
• MSCs can be effectively
used for this purpose since
they possess abilities to
modulate immune cells
differentiation and
functions in specific
microenvironments.

8. Stabilitatea Implantelor Dentare creste in momentul in care OPG creste
datorita stimularii celulelor stem
Combined Hydroxyapatite Scaffold and Stem Cell
from Human Exfoliated Deciduous Teeth
Modulating Alveolar Bone Regeneration via
Regulating Receptor Activator of Nuclear Factor-
Κb and Osteoprotegerin System-Prahasanti Ch,
Subrata LH, Saskianti T, Suardita K, Ernawati DS.
Iran Journal of Medical
Science,September,2019,Vol 44, no5,
• Stem cells from Human Exfoliated
Deciduous Teeth increase OPG
and decrease RANKL expression
via regulating OPG-RANKL system
that has a high potential to be
used as an effective alternative
tissue engineering biomaterial for
alveolar bone defect
regeneration.
Correlation analysis between bone
metabolism factors and the stability
of dental implant in the
postoperative recovery of dental
implanted patients-Puyu Ma,
Haoyang Wu- International Journal
of Clinical and Experimental
Medicine 2018;11(4):3924-3931
• The higher the OPG was,
the lower of Implant
Stability Quotient would be

9. Rezorbtia osoasa dupa grefele osoase este mai
redusa cu cat OPG/RANKL este mai ridicat
Maxillary sinus augmentation procedures
through equine-derived biomaterial or
calvaria autologous bone:
immunohistochemical evaluation of
OPG/RANKL in humans-S. Tetè, R. Vinci, V.L.
Zizzari, S. Zara, V. La Scala, A. Cataldi, E.
Gherlone, A. Piattelli-European Journal of
Histochemstry 2013 Jan 15; 57(1): e10
• To better elucidate the host
tissue response to the
different bone substitutes,
attention was focused on
the OPG/RANKL ratio, often
used as a bone resorption
index
RANK/RANKL/OPG role in distraction
osteogenesis-Pérez-Sayáns M, Somoza-
Martín JM, Barros-Angueira F, Rey JM,
García-García A-Oral Surgery Oral
Medicine Oral Pathol ogyOral Radiol ogy
and Endodontology2010
May;109(5):679-86
• The aim of this review is to analyze the
influence of the RANK/RANKL/OPG
system on the bone healing and
remodeling processes that occur in
distraction osteogenesis, with a view to
possibly developing molecular
mechanisms that stimulate bone
regeneration and inhibit resorption,
thereby improving the clinical outcome
for distraction osteogenesis.

10. Imbunatatirea raportului OPG/RANKL este demonstrat in studii clinice ca
reduce rezorbtia osoasa,administrarea trebuind sa fie facuta cu o frecventa
cu atat mai mare de utilizat cu cat persoanele inainteaza in varsta
Osteoprotegerin and its ligand: A new
paradigm for regulation of
osteoclastogenesis and bone
resorption-Aubin JE, Bonnelye-
Osteoporosis International
2000;11(11):905-13
• Recently, the results of the
first clinical trial with OPG
supported its potential as a
therapeutic agent for
osteoporosis.
Aging increases stromal/osteoblastic cell-
induced osteoclastogenesis and alters the
osteoclast precursor pool in the mouse-
Cao JJ, Wronski TJ, Iwaniec U, Phleger L,
Kurimoto P, Boudignon B, Halloran BP-Journal of
Bone and Mineral Research 2005
Sep;20(9):1659-68. Epub 2005 May 2
• Our results show that aging
significantly increases
stromal/osteoblastic cell-
induced osteoclastogenesis,
promotes expansion of the
osteoclast precursor pool and
alters the relationship
between osteoblasts and
osteoclasts in cancellous bone.

11. In perioada de contentie a tratamentului ortodontic trebuie restabilit raportul OPG/RANKL
destabilizat de semnalele intense de rezorbtie din timpul aplicarii fortelor ortodontice
Levels of RANKL and OPG in gingival crevicular
fluid during orthodontic tooth movement and
effect of compression force on releases from
periodontal ligament cells in vitro-Nishijima Y,
Yamaguchi M, Kojima T, Aihara N, Nakajima R,
Kasai K-Orthodontics &Craniofacial Research
2006 May;9(2):63-70.
• RESULTS:
• GCF levels of RANKL were significantly higher, and
the levels of OPG significantly lower, in the
experimental canines than in the control teeth at 24
h, but there were no such significant differences at
0, 1, or 168 h. In vitro study indicated that the
compression force significantly increased the
secretion of RANKL and decreased that of OPG in
hPDL cells in a time- and force magnitude-
dependent manner. The compression-stimulated
secretion of RANKL increased approximately 16.7-
fold and that of OPG decreased 2.9-fold, as
compared with the control.
RANK/RANKL/OPG during orthodontic
tooth movement-Yamaguchi M- K-
Orthodontics &Craniofacial Research
2009 May;12(2):113-9
• In vivo studies have shown the
presence of RANKL and RANK in
periodontal tissues during
experimental tooth movement of
rat molars, and that Periodontal
Ligament cells under mechanical
stress may induce
osteoclastogenesis through
upregulation of RANKL expression
during orthodontic tooth
movement.

12. Osteoimmunology of Oral and Maxillofacial Diseases: Translational Applications Based on
Biological Mechanisms- Carla Alvarez, Gustavo Monasterio, Franco Cavalla, Luis A. Córdova,
Marcela Hernández, Dominique Heymann, Gustavo P. Garlet, Timo Sorsa,Pirjo Pärnänen, Hsi-Ming
Lee, Lorne M. Golub, Rolando Vernal, Alpdogan Kantarci- Frontiers in Immunology 2019; 10: 1664
Caracterul Stabil sau Evolutiv al Granulomul
ui apical depinde de raportul RANKL/OPG
este
• Active periapical lesions are
characterized by high
RANKL/OPG ratio is an
association with a pro-
inflammatory milieu,
• Conversely, inactive lesions
are characterized by a low
RANKL/OPG ratio is an
association with an anti-
inflammatory milieu,
Distrugerea sau nu a tesuturilor
Articulatiei Temporo-Mandibulare in
cazul unei ocluzii incorecte depinde
de raportul RANKL/OPG
• This dysfunctional remodeling is
characterized by increased oxidative
stress, due to hypoxia/reperfusion
effect, and higher levels of catabolic
enzymes that degrade the fibrocartilage
extracellular matrix and induce
chondrocyte apoptosis. The molecular
products derived from cartilage
breakdown (e.g., LMW-HA or PG) can
trigger the immuno-inflammatory
response by interacting with APCs and
finally resulting in the activation of
Th17 lymphocytes and the
RANK/RANKL/OPG axis, leading to
subchondral bone resorption.

13. Riscul la rezorbtie osoasa a fiecarui pacient depinde si factorii
bucali care afecteaza continuu raportul OPG/RANKL
Factorii locali dentari care genereaza
inflamatia cronica a osului maxilar
• Exotoxinele eliminate de
microbii din tartru sau
infectia endodontica
• Fortele ocluzale de orice
intensitate se transmit
osului
• Prezenta metalelor in
componenta implantelor
dentare si a lucrarilor
protetice
Factorii generali care sunt permanenti
si nu pot fi influentati de dentist
• Diabet
• Varsta pacientului
• Dezechilibre hormonale
• Actiunea unor
medicamente

14. Clasificarea riscului la rezorbtie osoasa
functie de lucrarile dentare existente
Risc Mare
• -Reabilitari All in 4
• -Implante cu Incarcare
imediata
• -multe implante inserate
• -lucrari dentare totale
• -aparate ortodontice la varste
inaintate
• Grefa osoasa (sinus-lift) sau
gingivala
• Punti cu distanta mare intre
stalpi si suprasarcina la nivelul
stalpilor
Risc mediu
• Lucrari dentare reduse
• Anomalii de ocluzie

15. In momentul prezentarii pacientului in Clinica de Parodontologie se decide daca sunt suficiente
mijloacele de preventie clasice sau este nevoie sa se instituie tratament pentru imbunatatirea
raportului OPG/RANKL deja afectat
Raportul OPG/RANKL nu este
modificat
• Pacient sub 35 ani
• Dentitie cu Risc mic sau mediu la
rezorbtie
• Lipsa factorilor generali de crestere a
inflamatiei cronice osoase
• Pentru mentinere sunt suficiente
tehnicile clasice, NEEXISTAND DEJA
ACTIVAT UN SEMNAL DE OSTEOLIZA.
EFECTUL DETERTRAJULUI SI AL
REGLAJULUI OCLUZAL ESTE DOAR
PENTRU VIITOR FATA DE MOMENTUL
INTERVENTIEI, IN SCOP PREVENTIV
deoarece nu au nici un efect ca si
tratament asupra raportului
OPG/RANKL
Raportul OPG/RANKL este deja
afectat
• Pacient peste 35 ani
• Prezenta oricarui factor general
de crestere a inflamatiei cronice
osoase
• Dentitie cu risc mediu sau mare la
rezorbtie
• NICI DETARTRAJUL URMAT DE
LASER SI NICI REGLAJUL
COMPUTERIZAT OCLUZIE NU POT
IMBUNATATI RAPORTUL
OPG/RANKL DEJA AFECTAT SI NU
POT STINGE SEMNALUL DE
REZORBTIE OSOASA DEJA
EXISTENT. SE RECOMANDA
TRATAMENTUL ESG

16. Pastrarea dintilor si a implantelor depind de
Reducerea CONTINUA a riscului la rezorbtie prin
imbunatatirea raportului OPG/RANKL
Prima prezentare in Clinica
Parodontologie
• Majoritatea pacientilor se
prezinta cand Inflamatia
Cronica este deja instalata si
raportul OPG/RANKL este deja
afectat
• Dupa asanarea cavitatii bucale
se recomanda tratamentul ESG
la domiciliu si se realizeaza
lucrari provizorii pana la
reducerea semnelor de
inflamatie osoasa si a
mobilitatii dintilor.
Realizarea interventiilor chirurgicale
si a lucrarilor definitive
• Doar dupa reducerea
inflamatiei cronice a osului
si imbunatatirea raportului
OPG/RANKL se pot realiza
inserarile de implante, grefa
de os sau de gingie si
lucrarile protetice definitive

17. Dispensarizarea dupa realizarea
lucrarilor definitive
Pacientii cu Risc redus si mediu
• Detartraj clasic la 6 luni
• Reglaj computerizat ocluzie
la 6 luni
• Tratament ESG la 3 ani
Pacientii cu Risc Mare
• Detartraj clasic la 6 luni
• Sterilizare a pungilor
parodontale cu Laser la 1
an, in sedinte scurte pentru
a nu stimula RANKL si liza
osoasa
• Reglaj computerizat ocluzie
la 6 luni
• Tratament ESG in fiecare an

18. Mecanism de actiune ESG
• Stimularea celulelor progenitoare (stem adulte) din os si
periost determina actiunea antiinflamatorie in toata masa
osului maxilar si imbunatatirea raportului ESG/RANKL. Acest
mecanism celular aplicat minim 100 ore la domiciliul
pacientului s a dovedit:
1) mult mai eficient decat antiinflamatoriile orale
2) repara liza osoasa posibil generata prin activarea
osteoclastelor (cresterea RANKL) de catre sedintele cu laser
folosite cu scop antimicrobian in cabinetul stomatologic.
3) Pastreaza reactia imuna din jurul dintilor mobili si a
implantelor in limita in care sa nu fie permisa rezorbtia osoasa
accelerata

19. Combinarea ESG cu alte manopere
stomatologice
Inaintea interventiilor
chirurgicale
• Pentru o mai buna eficienta
a implantelor dentare si a
grefelor osoase sau de
gingie, pentru a pregati
patul receptor din punct de
vedere al reactiei imune
existente
Dupa realizarea lucrarilor
definitive
• Pentru a reduce retractia gingiei si a
osului la nivelul dintilor sau
implantelor folosite ca stalpi.
• In toate zonele grefate (sinus-lift) si
implantate, pentru reducerea
gradului de rezorbtie osoasa
• Dupa sedintele antimicrobiene cu
Laser pentru reducerea activarii
osteoclastelor
• La toate implantele deja inserate
pentru mentinerea Indicelui de
Stabilitate

20. Pentru dintii cu implantare 5-8 mm se
recomanda limitarea inciziilor in santul gingival
• Conform Fiziologiei Umane dupa orice incizie plaga se vindeca prin
RETRACTIA MARGINILOR PLAGII.
• De asemenea se reaminteste ca irigarea materialelor de aditie
pozitionate langa radacina este deficitara deoarece radacina este o
simpla ceramica iar gingia are o vascularizatie foarte slaba in zona
terminala. Procentul cresterii osoase dupa grefarea din operatia cu
lambou este foarte mic si improbabil, in timp ce retractia cauzata de
incizia in santul gingival este un risc sigur.
• Daca in cazul altor discipline medicale retractia nu afecteaza decisiv
viitorul zonei operate, in cazul chirurgiei parodontale trebuie tinut
cont ca dintele este o parghie si orice milimetru pierdut de zona de
implantare din cauza inciziei poate face diferenta dintre salvarea
dintelui si extractia lui.

21. Plan de tratament personalizat dupa trimiterea
ortopantomogramei la www.stemgenerator.ro
Reabilitare Initiala
• -Decizia dintilor care nu ar
mai putea fi salvati
• -Recomandarea numarului
de ore de tratament ESG
necesar reducerii
inflamatiei cronice osoase si
a semnalulul celular de
activare a rezorbtiei osoase
RANKL/OPG, existente in
momentul primei prezentari
la medic
Mentinere a dintilor si a implantelor
pe perioade succesive de 3 ani
• Analiza radiografiilor la
fiecare 6 luni pt a surprinde
debutul rezorbtiei osoase si
recomandarea imediata a
tratamentului ESG

22. Va multumim pentru interes!
Dr Bogdan Vladila
0722660766
www.stemgenerator.ro