Osteoblasts

Arise from osteoprogenitor cells(pluripotent mesenchymal cells) under the effect of many growth factors - Cytokines
- Bone morphogenetic protein - Fibroblast growth factor(FGF) - Insulin like growth factor(IGF) - Transforming growth factor (TGF-beta)

Osteoblasts express cell surface receptors that bind many hormones like (parathyroid hormone,Vit D, estrogen), cytokines, growth factors, extracellular matrix proteins.

Osteocytes
Derived from hematopoietic progenitor cells that also gives rise to monocytes and macrophages. The cytokines and growth factors crucial for osteoclasts differentiation and maturation are - Interleukin ( IL-1, IL-3, IL-6, IL-11, Tumor necrosis factor Granulocyte and macrophage colony stimulating factor) - They work by stimulating osteoclast progenitor cells or by participating in a paracrine system in which osteoblast and marrow stroma cells take part.

Clinical Implications Of Hormonal Imbalance In Orthodontics

Guided By: Dr.(Mrs). P.V. Hazarey Prof & H.O.D Dr.Sunita Shrivastava Prof & Guide

Presented By Parikshit.R.Rao

Thyroid Hormones (Mechanism Of Action)

Calorigenic action : stimulates heat production by increasing oxygen uptake in all the tissues. CVS : myocardial cells are under the influence of sympathetic nerve and the receptors are beta receptors which increase in response to thyroid hamones.
. CNS

: contributes in myelination in axons of cortical neurons, branching and development of dentrites and vascular bed of brain.

Protein metabolism :
Anabolic effects : Increases the secretion of enzymes necessary for catalyzing reactions for formation of various proteins. Eg : Ketoglutarate glutamate dehydrogenase ( influenced by hormones) Glutamate

Catabolic effects : Ketoglutarate Glutamate Proteases and peptidases(deamination)

Aminoacids

Carbohydrate metabolism : Has got opposing actions in physiological

doses. - Increases peripheral glucose uptake through insulin like action. - Increases blood glucose level : 1 Glycogenolysis : Glycogen phosphorylase (action is enhanced by Camp ) Free glucose 2 Gluconeogenesis : which includes both glycolysis and citric acid cycle

On Vitamins : necessary for conversion of beta carotene to Vit A and of Vit A to retinene.

Lipid metabolism : increases number of LDL receptors and thus promotes cholestrol metabolism. Growth and development : promotes protein synthesis and also causes increased release and action of Growth Hormone.

Functions of Calcitonin
On Bones : lowers osteoclastic activity due to direct action of harmone on the bone (increases alkaline phosphatase synthesis from the osteoblasts). Maintains calcium level of bones in pregnant women.

Hypothyroidism

Features affecting our treatment.

Delayed wound healing ( lack of endothelial growth factor, decreased collagen synthesis ) Delayed tooth movement ( osteoclast activity, blood flow) TREATMENT - Thyroxine should be administered 50g per day for 3 weeks, 100g per day for next 3 weeks finally increase to 150g per day and continue as a single dose.

Hyperthyroidism

Features affecting our treatment.

Osteoporosis (Mobilization of bone proteins decreases the mass). Pain threshold is less.

TREATMENT

Carbimazole - 0-3 weeks 40-60mg daily - 4-8 weeks 20-40mg daily - Maintenance 5-20mg daily for 18-24 months.

PARATHYROID HORMONE (MECHANISM OF ACTION)

Functions of Parathormone
It increases bone resorption by increasing the osteoclastic acivity. Helps to convert Vit D into its active form calcitriol. It acts on renal tubules to increase calcium reabsorbtion. REGULATION OF PTH SECRETION

- Higher serum calcium level inhibits PTH secretion. - Higher calcitriol level inhibits PTH secretion. - Plasma phosphates and magnesium level also affect the PTH secretion.

Hypo parathyroidism

Features affecting our treatment.

Delayed tooth movement Treatment time may be prolonged. Treatment
Administration of Alfacalcidol (1 hydroxycholecalciferol) which is hyfdroxylated in liver to calcitriol.

Hyper parathyroidism
Features affecting our treatment

Increased bone resorption (increased osteoclastic activity). Decreased force levels .

Treatment
- Rehydration with normal saline (4-6 lit)
- Bisphosphonates (90mg i.v over 4 hours) - Surgery.

Functions of Pituitary hormones

Growth Hormone : all actions are IGF mediated. Stimulates production of proteins, Increases blood sugar level. Increases lipolysis and thus FFA in the blood plasma. Increase calcium absorbtion from GIT and in turn increases bone formation.

Prolactin : - Synthesis of milk in females. - Opposes the action of pituitary gonadotrophins.

Thyroid stimulating hormone : - Synthesis of T3 and T4 harmones. FSH, LH :

In males : - formation of spermatozoan. - synthesis of testosterone from testis. In females : - help in estrogen synthesis. - causes ovulation, formation and maintainance of corpus leuteum.
ACTH :

- Synthesis of adrenal hormones.

Anti Diuretic hormone : - increases permeability of distal tubules which increases water
reabsorption. - increases peripheral vasoconstriction and increases BP. Oxytocin : - Stimulates contraction of smooth muscle cells lining the mammary glands and of the uterus.

Clinical implications
- Hypopituitarism :
- Tooth movement is slow.
Hyperpituitarism Osteoporosis (Mobilization of bone proteins decreases the mass). Increased osteoclastic activity. Pain threshold is less.

Treatment - Hypofuntioning : Hydrocortisone (cortisol) 15mg on waking and 5mg in the evening. - Hyper functioning : Dopamine agonist, sugery.

Thymus
At birth thymus weighs 10-12 gms , during childhood and adolscence 20-30gms but during old age it weighs arround 36gms.
With overgrowth of thymus, general bodily growth is accelerated. Hypertrophy of the thymus may result in delayed eruption of the deciduous teeth and poor tooth calcification. The teeth may appear of bluish white color and of uneven size.

Actions of adrenal cortex hormones

PROTEIN Metabolism : Increases protein break down. CARBOHYDRATE Metabolism : increases glucose 6 phosphatase activity and thus increase glucose formation. Electrolyte and water balance : has two antagonizing action - increases water reabsorbtion and Na retention - antagonises the action of ADH CNS : Increase in GC decreases the threshold of electrical exitation of brain cells. Resistance to stress . Bone metabolism : Break down of bone matrix due to protein catabolism , Decrease in Ca deposition because of increased Ca excretion in urine.

Clinical implications
In hypofuntioning condition 2 to 4 times the regular dose should be given on the day of the appointment. In hyperfunctioning condition treatment time should be short per appointment, level of forces should be low. Treatment - Hypofuntioning : Hydrocortisone (cortisol) 15mg on waking and 5mg in the evening. - Hyper functioning : phenoxybenzamine(10-20 mg orally 6-8 hourly) and prepare the patient for surgery.

Hypothalamus
Makes up the 3rd ventricle of the brain, provides neurogenic control to the pituitary gland which controls the target glands ie; thyroid, adrenals, gonads. Tumors of hypothalamus may cause sexual precocity , dental age also increases. Alveodental prognathism is present , dentition otherwise is normal. Gingivitis is present.

Interleukin-1beta and TNF- alpha production by human monocytes cultured with L- Thyroxine and Thyrocalcitonin. AJO-DO 1996 Oct 399-404 Mario Rossi

Effects of corticosteroids induced osteoporosis on orthodontic tooth movement. Ashcarft ,Tolley. 1992 Oct AJO-DO

Thyroid administration to reduce root resorption. Eric L Loberg 1994 No 5 395-400 Angle Orthodontics

Conclusion
Recognition of endocrine dysfunction is of considerable aid in determinig the method and efficacy of treatment in various malocclusions. An orthodontist who suspects an endocrine dysfuntion must insist on obtaining a diagnosis from qualified source.