Evidence for the presence of a proton pump of the vacuolar H(+)-ATPase type in the ruffled borders of osteoclasts

Proton channel part of vacuolar H(+)-ATPase and carbonic anhydrase II expression is stimulated in resorbing osteoclasts

Immobilization causes a transient increase in bone resorption and a prolonged depression of bone formation. We have studied the effect of immobilization on the expression of two proteins believed to have a major functional role in osteoclasts, the proteolipid subunit of vacuolar H(+)-ATPase (VPL) and carbonic anhydrase II (CA II). Trabecular bone from immobilized rat tibiae was analyzed using northern and slot blotting, polymerase chain reaction (PCR), and morphometric analysis. CA II and VPL transcription was rapidly stimulated in trabecular bone of immobilized rat tibiae. Osteoclast number increased and the trabecular bone volume decreased during immobilization. Fluorescein-labeled cDNA probes and a confocal laser scanning microscope were used to study the localization of VPL and CA II mRNAs in situ in osteoclasts and other bone-derived cells attached to bovine bone slices in vitro. CA II and VPL mRNA were highly expressed in actively resorbing osteoclasts, but in nonresorbing osteoclasts mRNA expression was very low or not detectable at all. These results strongly suggest that both CA II and VPL have an important functional role in bone resorption. Finally, in the bone cell population isolated for these studies, CA II was found to be highly specific for osteoclasts whereas VPL was also detected in other cell types.

Characterization of ATP-dependent proton transport in medullary bone-derived microsomes

Proton transport in microsomal vesicles derived from medullary bone of laying hens was observed to be inhibited in a dose-dependent manner with fusidic acid, 7-chloro-4-nitrobenz-2-oxa-1,3-diatzole (NBD-Cl), duramycin and dicyclohexylcarbodiimide (DCCD). The IC50 values were 570 microM, 4.5 microM, 10 micrograms/ml and 32 microM for fusidic acid, NBD-Cl, duramycin and DCCD, respectively. 14C-DCCD labeled a single protein band of 15-17 kDa from bone-derived microsomes in SDS-electrophoresis. A protein of this size is a proton-conducting subunit of the vacuolar ATPases. Further, the proton transport was found to be electrogenic, thus it generates the membrane potential across the vesicle membrane. The generation of membrane potential was inhibited using 100 nM bafilomycin A1, which in low concentrations is a specific inhibitor of vacuolar ATPases. The presence of Cl- was essential for maximal proton transport activity. These results confirm the electrogenicity and extend the characterization of the osteoclastic H(+)-ATPase.

Immunocytochemical localization of cathepsins B and G in odontoclasts of human deciduous teeth

For clarification of the mechanisms by which odontoclasts resorb deciduous teeth during physiological root resorption, cysteine-proteinases such as cathepsins B and G were immunocytochemically localized in odontoclasts at the ultrastructural level. Extracted human deciduous teeth undergoing root resorption were fixed with a mixture of formaldehyde and glutaraldehyde and processed for immunocytochemical detection of these enzymes. Sheep antisera, raised against either human cathepsin B or G, were used as primary antibodies. In odontoclasts, specific immunogold labeling of both anti-cathepsin B and G was clearly localized in lysosomes and pale vacuoles of various sizes, and in a portion of the extracellular canals of odontoclastic ruffled borders. In the presence of either antibody, the cytoplasmic matrix, mitochondria, and nuclei were minimally labeled by immunogold particles. The presence of these proteolytic enzymes in odontoclasts suggests that, during odontoclastic root resorption, these enzymes are involved in the formation of resorption lacunae by means of intra/extracellular degradation of collagen and other non-collagenous matrix proteins of deciduous teeth.

Substrate influences rat osteoclast morphology and expression of potassium conductances

1. We studied the electrophysiological properties of freshly isolated rat osteoclasts using the whole-cell configuration of the patch-clamp technique. Membrane currents were recorded from cells plated on three substates: dentine, type I collagen and glass. 2. Based on their morphology, we defined two categories of osteoclasts. 'Rounded' osteoclasts were dome-shaped and lacked lamellipodia. 'Spread' osteoclasts were flattened and had lamellipodia. The proportion of 'rounded' osteoclasts was significantly greater when cells were plated on dentine or type I collagen than when cells were plated on glass. 3. 'Spread' osteoclasts expressed an inwardly rectifying K+ conductance regardless of the substrate on which they were plated. 4. 'Rounded' osteoclasts, on all substrates, expressed a transient, outwardly rectifying conductance that was selective for K+ based on: reversal of deactivation tail currents at -74 mV; a 60 mV shift in tail current reversal potential for 10-fold change in [K+]o; and blockade of outward current by extracellular 4-aminopyridine, charybdotoxin, and intracellular Cs+. The outward K+ current had an activation threshold of approximately -50 mV, with half-activation at -29 mV. The current also exhibited voltage-dependent inactivation, with half-inactivation at approximately -40 mV. 5. Outward K+ current in 'rounded' osteoclasts was reduced when extracellular Ca2+ was removed and upon addition of Ni2+, but was unaffected by Cd2+ or nifedipine. 6. 'Rounded' osteoclasts had large whole-cell capacitance for their apparent surface area. Capacitance was positively correlated with K+ conductance. The additional surface membrane we detected through capacitance measurements may be the 'ruffled border' of actively resorbing osteoclasts. 7. We conclude that substrate influences the expression of osteoclast phenotype, as defined by morphology and K+ conductances. 'Rounded' osteoclasts express an outwardly rectifying K+ conductance, with no apparent inwardly rectifying K+ conductance. In contrast, 'spread' osteoclasts exhibit an inwardly rectifying K+ conductance with no outwardly rectifying K+ conductance. The 'spread' phenotype may represent a motile phase, while the 'rounded' phenotype may represent a resorptive phase of osteoclastic activity.

RGD-directed attachment of isolated rat osteoclasts to osteopontin, bone sialoprotein, and fibronectin

Osteoclasts isolated from the long bones of 5-day-old rats were seeded onto glass surfaces coated with osteopontin, bone sialoprotein, or fibronectin. Cell binding was promoted by all three proteins and inhibited in a dose-dependent manner by an RGD-containing peptide, while an RGE-containing peptide was ineffective. Immunocytochemistry of bone tissue showed enhanced concentration of osteopontin in bone opposite the clear zone of the osteoclasts, whereas immunolocalization of bone sialoprotein and fibronectin showed no accumulation on bone surfaces facing cells. The observations corroborate previous findings that the osteoclast is attached via an integrin to osteopontin on the bone surface. Although bone sialoprotein and fibronectin can mediate osteoclast binding in vitro, such a role in vivo is not supported by the immunocytochemical observations.

Sensitivity to vanadate and isoforms of subunits A and B distinguish the osteoclast proton pump from other vacuolar H+ ATPases

Analysis of proton (H+) transport by inside-out vesicles derived from highly purified chicken osteoclast (OC) membranes has revealed the presence of a newly discovered type of vacuolar H+ ATPase (V-ATPase). Unlike vesicles derived from any other cell type or organelle, H+ transport in OC-derived vesicles is sensitive to V-ATPase inhibitors (N-ethylmaleimide and Bafilomycin A1) and vanadate (IC50, 100 microM), an inhibitor previously found to affect only P-type ATPases. The OC H+ ATPase contains several V-like subunits (115, 39, and 16 kDa) but subunits A and B of the catalytic domain of the enzyme differ from that of other V-ATPases. In OCs, subunit A has a mass of 63 kDa instead of the 67-70 kDa expressed in monocytes, macrophages, and kidney microsomes, which contain a vanadate-insensitive H+ ATPase. Moreover, two types of 57- to 60-kDa B subunits are also found: one is expressed predominantly in OCs and the other is expressed in kidney microsomes. The OC H+ pump may therefore constitute a class of H+ ATPase with a unique pharmacology and specific isoforms of two subunits in the catalytic portion of the enzyme. This H+ ATPase is involved in resorption of bone and may be expressed in a cell-specific manner, thereby opening possibilities for therapeutic intervention.

Presence and specific concentration of carbonic anhydrase II in matrix vesicles

Matrix vesicles were isolated from the epiphyseal growth plates of normal weanling rats, and the presence of carbonic anhydrase II was demonstrated by Western blotting and ultrastructural immunolocalization using the immunogold technique. Total carbonic anhydrase activity was assayed and showed a statistically significant increase in matrix vesicles as compared to normal rat chondrocytes derived from the same growth plates. These results are the first to establish the presence of carbonic anhydrase in matrix vesicles.

Inwardly rectifying potassium current in rabbit osteoclasts: a whole-cell and single-channel study

Ionic conductances of rabbit osteoclasts were investigated using both whole-cell and cell-attached configurations of the patch-clamp recording technique. The predominant conductance found in these cells was an inwardly rectifying K+ conductance. Whole-cell currents showed an N-shaped current-voltage (I-V) relation with inward current activated at potentials negative to EK. When external K+ was varied, I-V curves shifted 53 mV/10-fold change in [K+]out, as predicted for a K(+)-selective channel. Inward current was blocked by Ba2+ and showed a time-dependent decline at negative potentials, which was reduced in Na(+)-free external solution. Inward single-channel currents were recorded in the cell-attached configuration. Single-channel currents were identified as inward-rectifier K+ channels based on the following observations: (i) Unitary I-V relations rectified, with only inward current resolved. (ii) Unitary conductance (gamma) was 31 pS when recorded in the cell-attached configuration with 140 mM K+ in the pipette and was found to be dependent on [K+]. (iii) Addition of Ba2+ to the pipette solution abolished single-channel events. We conclude that rabbit osteoclasts possess inwardly rectifying K+ channels which give rise to the inward current recorded at negative potentials in the whole-cell configuration. This inwardly rectifying K+ current may be responsible for setting the resting membrane potential and for dissipating electrical potential differences which arise from electrogenic transport of protons across the osteoclast ruffled border.

Immunocytochemical localization of cathepsin D in the rat osteoclast

We performed immunocytochemical localization of cathepsin D in osteoclasts of the proximal growth plate of the rat femurs using both the avidin-biotin-peroxidase complex method for cryo-semi-thin (1 micron) sections and the colloidal gold-labeled IgG method for K4M ultra-thin sections. At the light microscopic level, cathepsin D immunoreactivity in the osteoclasts appeared at the vesicles, granules, and/or small vacuoles. They were distributed throughout the cytoplasm of each cell and were relatively numerous close to the bone surface. This antigen could not be detected at the eroded bone surface. As for other cells, immunoreactivity was seen only in the lysosomes of osteoblast-like cells. Immunoreactivity in the osteoclasts was stronger and greater in the density and number than in osteoblast-like cells. At the electron microscopic level, osteoclasts with well-developed ruffled border possessed numerous cathepsin D-containing lysosomes, vacuoles, and coated vesicle-like structures. Cathepsin D-containing lysosomes fused with cathepsin-negative vacuoles and formed large secondary lysosomes. Osteoclasts with poorly developed ruffled border possessed fewer cathepsin D-containing lysosomes than those with well-developed ruffled border. No immunogold particles were seen in vacuole-like channel expansions of the ruffled borders, between the channels of the ruffled borders, or on the eroded bone surface. These findings demonstrate that osteoclasts contain a large amount of cathepsin D. They suggest that cathepsin D is necessary for osteoclastic bone resorption, that it plays an indirect rather than direct role.

Mitochondrial carbonic anhydrase in osteoclasts and two different epithelial acid-secreting cells

Acid secreting cells are rich in mitochondria and contain high levels of cytoplasmic carbonic anhydrase II. We have studied the ultrastructural distribution of a mitochondrial isoenzyme, carbonic anhydrase V, in two different acid-secreting epithelial cells, gastric parietal cells and kidney intercalated cells as well as in osteoclasts, which are the main bone resorbing cells. The mitochondria differ in carbonic anhydrase V content in these three acid-producing cells: gastric parietal cell mitochondria show strong immunolabelling for this isoenzyme, osteoclast mitochondria faint labelling and kidney intercalated cell mitochondria no labelling. The immunolabelling was located in the mitochondrial matrix, often in close contact with the inner mitochondrial membrane. These results show that mitochondrial carbonic anhydrase levels are not related to acid-transporting activity.

Characteristic localization of carbohydrates in osteoclasts by lectin cytochemistry

Lectin cytochemistry was performed to clarify the process of glycosylation and the localization of glycocalyx in osteoclasts. Microslicer sections of decalcified rat tibiae were incubated in the presence of HRP-conjugated lectins (Con A, PNA, MPA, WGA, UEA-1). Lectin reactions in cell organelles revealed that glucose (Glc) and mannose (Man) are transferred to carbohydrate chains in nuclear envelopes, rough endoplasmic reticuli, and the cis and medial sides of the Golgi apparatus. N-acetylgalactosamine (GalNAc), N-acetylglucosamine (GlcNAc), and/or N-acetylneuraminic acic (NANA) residues are transferred, in turn, in the Golgi apparatus. Lectin reactions detected in lysosomal structures suggest that some sugar residues are incorporated into carbohydrate chains of hydrolytic enzymes, such as acid phosphatase and arylsulfatase. Others would be transported to plasma membranes as glycocalyx. PNA and MPA reactions were most evident on ruffled borders of osteoclasts. On the other hand, cement-line-like structures on bone surfaces displayed Con A, MPA, and WGA positive reactions. The following factors suggest that osteoclasts actively metabolize sugar: characteristic localization of glycocalyx in osteoclasts reflect the polarity of osteoclasts, and carbohydrate complexes in cement-line-like structures seem to play an important role in the coupling phenomenon in bone tissue.

A difference in the enzyme contents of resorption lacunae and secondary lysosomes of osteoclasts

The distributions of tartrate sensitive lysosomal acid phosphatase (LAP) and cathepsin L in osteoclasts and the effect of parathyroid hormone (PTH) stimulation on them were investigated by using the protein A-gold method on ultracryosections of rat trabecular bone. LAP was located in association with the ruffled border membrane, in the resorption lacuna, on the mineral phase surrounding the lacuna, and in some primary lysosomes. After PTH treatment, the extracellular and ruffled border membrane associated LAP apparently increased. Heavy gold labelling for cathepsin L was confined exclusively to secondary lysosomes. No labelling was seen in the extracellular resorption lacuna or at the ruffled border. Acceleration of bone resorption by PTH-treatment did not change detectably the distribution or intensity of labelling. This study shows that the enzyme contents of secondary lysosomes and resorption lacunae are different and suggests that LAP is directly involved in extracellular bone degradation whereas the role of cathepsin L is restricted to lysosomes.

Bisphosphonate action. Alendronate localization in rat bone and effects on osteoclast ultrastructure

Studies of the mode of action of the bisphosphonate alendronate showed that 1 d after the injection of 0.4 mg/kg [3H]alendronate to newborn rats, 72% of the osteoclastic surface, 2% of the bone forming, and 13% of all other surfaces were densely labeled. Silver grains were seen above the osteoclasts and no other cells. 6 d later the label was 600-1,000 microns away from the epiphyseal plate and buried inside the bone, indicating normal growth and matrix deposition on top of alendronate-containing bone. Osteoclasts from adult animals, infused with parathyroid hormone-related peptide (1-34) and treated with 0.4 mg/kg alendronate subcutaneously for 2 d, all lacked ruffled border but not clear zone. In vitro alendronate bound to bone particles with a Kd of approximately 1 mM and a capacity of 100 nmol/mg at pH 7. At pH 3.5 binding was reduced by 50%. Alendronate inhibited bone resorption by isolated chicken or rat osteoclasts when the amount on the bone surface was around 1.3 x 10(-3) fmol/microns 2, which would produce a concentration of 0.1-1 mM in the resorption space if 50% were released. At these concentrations membrane leakiness to calcium was observed. These findings suggest that alendronate binds to resorption surfaces, is locally released during acidification, the rise in concentration stops resorption and membrane ruffling, without destroying the osteoclasts.

Vitronectin receptor has a role in bone resorption but does not mediate tight sealing zone attachment of osteoclasts to the bone surface

During bone resorption, osteoclasts form a tight attachment, the sealing zone, around resorption lacunae. Vitronectin receptor has previously been shown to be expressed in osteoclasts and it has been suggested that it mediates the tight attachment at the sealing zone. In this study we have shown that glycine-arginine-glycine-aspartic acid-serine pentapeptide inhibits bone resorption by isolated osteoclasts and drastically changes the morphology of the osteoclasts. When the vitronectin receptor was localized by immunofluorescence in rat and chicken osteoclasts cultured on bone slices, it was found to be distributed throughout the osteoclast cell membrane except in the sealing zone areas. Immunoperoxidase staining of rat bone sections at the light microscopical level also revealed intense staining of the cell membrane with occasional small unstained areas, probably corresponding to the sealing zones. Immunoelectron microscopy confirmed the results obtained by light microscopy showing specific labeling only at the ruffled borders and basolateral membranes (0.82 and 2.43 gold particles/microns of membrane, respectively), but not at the sealing zone areas (0.06 gold particles/microns of membrane). Both alpha v and beta 3 subunits of the vitronectin receptor were similarly localized. These results strongly suggest that, although the vitronectin receptor is important in the function of osteoclasts, it is not mediating the final sealing zone attachment of the osteoclasts to the mineralized bone surface.

Inhibition of bone resorption by a monoclonal antibody that reacts with a 150 kD membrane protein in chicken osteoclasts

Bone resorption is a multistep process that includes the maturation of osteoclast precursors, the special attachment of fully differentiated osteoclasts to mineralized bone surface, and the dissolution of inorganic mineral, as well as the breakdown of organic matrix. We have produced a large panel of monoclonal antibodies directed against chicken osteoclasts to obtain specific probes for studying the function of osteoclasts. One of our antibodies, K20, inhibited bone resorption of isolated osteoclasts almost completely. Several pieces of evidence suggested that the antigen detected by this antibody was located in the plasma membrane of the osteoclast. In western blot analysis K20 antibody specifically recognized a 150 kD protein in the medullary bone microsome fraction under reducing and nonreducing conditions. In addition to osteoclasts and some bone and bone marrow mononuclear cells, a positive immunoreaction was seen in the kidney tubules. These data suggest that monoclonal antibody K20 reacts with an osteoclast surface antigen that is functionally important in bone resorption.

Kinetics of the osteoclast cytoskeleton during the resorption cycle in vitro

Resorption and migration phases alternate in the life of the osteoclast. We have previously described a specific microfilament structure at the attachment sites in resorbing osteoclasts. In the present study we have examined microfilaments and microtubules in both resorbing and migrating rat osteoclasts cultured on bone slices. In migrating osteoclasts microfilaments form so-called podosome structures containing vinculin, talin, and F-actin at the paramarginal area of the cell. When the osteoclast prepares itself for resorption, the podosomes gather to a certain area and form a broad ring around the area, which is then resorbed. In the resorbing osteoclast, vinculin and talin form a continuous double circle, which may be partially formed by podosomes, and between these double circles a broad zone is formed by F-actin. Narrow vinculin and F-actin rings were found in osteoclasts at the end of the resorption phase. The different configurations of microfilaments in 1 and 2 day cultures were correlated in terms of their relationship to the resorption lacunae. The vitamin A derivative isotretinoin significantly stimulated resorption and increased the number of microfilament configurations associated with the resorption pits. On the other hand, Bt2cAMP abolished resorption and prevented the formation of a specific ring structure of microfilaments. Based on these data, a kinetic model of the whole migration-resorption cycle of the osteoclast cultured on the bone slice is presented. With alpha-tubulin stainings of microtubules two different cytoskeletal organizations were observed. In migrating osteoclasts, microtubules were evenly distributed over the whole cell. In the resorbing osteoclast, there was a noticeable concentration of these cytoskeletal structures at cytoplasmic sites closest to the resorption lacuna. This orientation of microtubules may reflect the active secretory function of the resorbing osteoclast.

Purification and characterization of an osteoclast membrane glycoprotein with homology to manganese superoxide dismutase

The osteoclast is the specialized multinucleated cell primarily responsible for the degradation of the inorganic and organic components of bone matrix. Isolated avian osteoclasts have been used to immunize mice and generate an osteoclast-directed monoclonal antibody library (J. Cell Biology, 100:1592). A subset of these monoclonal antibodies recognizes antigens which are expressed on osteoclasts and which are absent or nearly so on multinucleated giant cells formed in vitro from monocyte or marrow mononuclear cells. One of these antibodies, designated 121F, has been used to identify and purify an osteoclast plasma membrane-associated glycoprotein. Western blot analysis on disulfide bond-reduced extracts from osteoclasts or multinucleated giant cells formed in vitro demonstrates that the 121F antibody recognizes a 150 kDa protein detectable only in osteoclasts. This high molecular weight protein has been purified by a combination of immunoaffinity and gel filtration chromatography procedures, in conjunction with electroelution of a single band from SDS-polyacrylamide gels. Silver staining of the purified antigen on SDS-polyacrylamide gels has revealed a single protein species larger than 200 kDa in its unreduced form and 150 kDa when disulfides are reduced. Isoelectric focusing of the purified antigen reveals a single species, having a neutral pl point of 6.95. Whereas endoglycosidase treatment and lectin affinity chromatographic analyses demonstrate that the antigen recognized by the 121F antibody possesses complex N-linked sugars, trifluoromethanesulfonic acid treatment indicates there are no additional O-linked carbohydrate components. Periodate oxidation and monosaccharide hapten inhibition studies provide no evidence for the antigenic epitope bound by the 121F antibody being carbohydrate in nature. Although the native antigen is blocked at its N-terminus, amino acid analysis of a hydroxylamine generated peptide disclosed a striking relationship between the osteoclast antigen recognized by the 121F monoclonal antibody and manganese and iron superoxide dismutase. Therefore, in addition to serving as a distinguishing cell type-specific marker for osteoclasts, this cell surface glycoprotein may function directly in osteoclast-mediated bone resorption.

Omeprazole and bafilomycin, two proton pump inhibitors: differentiation of their effects on gastric, kidney and bone H(+)-translocating ATPases

The effects of omeprazole and bafilomycin on processes dependent on two different types of H(+)-translocating ATPases were compared. A H(+)-ATPase of the E1E2-type, the H+,K(+)-ATPase, was purified from gastric mucosa. Vacuolar type H(+)-ATPases were prepared both from kidney medulla and from osteoclast-containing medullary bone. H+,K(+)-ATPase-mediated proton transport in gastric vesicles was selectively inhibited by omeprazole with a high potency (inhibitory concentrations greater than or equal to 3 microM) and in time- and pH-dependent manner. This result is consistent with the mechanism of action of omeprazole, which is dependent on acid-induced transformation of the drug into an active inhibitor reacting with luminally accessible sulfhydryl groups of the enzyme. Accordingly, the presence of the membrane-impermeable mercaptane glutathione did not affect the inhibitory action of omeprazole on the H+,K(+)-ATPase. Proton transport in kidney- and bone-derived membrane vesicles was also inhibited by omeprazole, but with a lower potency (inhibitory concentrations greater than or equal to 100 microM). Furthermore, the presence of glutathione totally abolished this inhibition, indicating that cytosolic, rather than luminal, SH-groups of the respective vacuolar H(+)-ATPase were interacting with omeprazole at high concentrations. In line with these results, it was found that omeprazole was much more potent in inhibiting acid production in isolated gastric glands (IC50 approximately 0.25 microM) than in inhibiting osteoclast-mediated 45Ca-release in isolated mouse calvaria (IC50 approximately 200 microM). Bafilomycin, on the other hand, was much more effective in inhibiting proton transport mediated by the vacuolar H(+)-ATPases in the kidney- and bone-derived membrane vesicles (IC50 approximately 2 nM) than in inhibiting H+,K(+)-ATPase-mediated proton transport in gastric membrane vesicles (IC50 approximately 50 microM). Thus, approximately 10(4) times higher concentrations of bafilomycin were needed to inhibit the H+,K(+)-ATPase to the same extent as the vacuolar H(+)-ATPase. A similar difference in potency of bafilomycin was found when its inhibitory effect was determined in isolated mouse calvaria (IC50 approximately 2.5 nM) and in isolated gastric glands (IC50 approximately 5 microM). Hence, omeprazole was found to be a specific inhibitor of the H+,K(+)-ATPase under physiological conditions, i.e. in the presence of glutathione, while bafilomycin was found to be selective towards vacuolar H(+)-ATPases.

Pathogenesis of osteoporosis

The final clinical outcome of the osteoporotic process is a fracture, which can occur as a result of minimal trauma or even spontaneously. At present low bone mass is regarded as the main contributor to bone fragility, but possible qualitative changes in the bone matrix must also be considered. Two factors which determine the level of bone mass at any age are the obtained peak bone mass and duration and rate of bone loss. Peak bone mass is achieved during the first three decades of life. Genetic and nutritional factors as well as mechanical stress on the skeleton obviously play crucial roles in determining peak bone mass. Two phases of bone loss--age-related and menopause-related--dictate the final bone mass at old age. Postmenopausal osteoporosis is a particular example of unbalanced bone resorption leading to net bone loss. An increasing number of systemic and local factors have been found to participate in the regulation of bone remodeling.