JOURNAL OF BONE AND MINERAL RESEARCH

Volume 8, Supplement 2, 1993

Mary Ann Liebert, Inc., Publishers

Growth Factors to Stimulate Bone Formation

DAVID J. BAYLINK, RICHARD D. FINKELMAN, and SUBBURAMAN MOHAN

ABSTRACT

During the past decade we and others have shown that bone is a storehouse for growth factors. Accordingly,
bone contains a number of growth factors including insulin-like growth factors I and I1 (IGF-I, IGF-11)
transforming growth factor (TGF-PI, TGF-P,), platelet-derived growth factor, basic and acidic fibroblast
growth factor, and bone morphogenetic proteins (BMPs). Osteoblasts have been shown to produce many of
these growth factors, which then act in an autocrine and paracrine fashion. The production of these growth
factors is regulated by both systemic hormones and local mechanical stress. Recent studies on the relative
distribution of bone growth factors during different physiologic and pathologic situations indicate that the
concentration of bone growth factors is not invariant and provide indirect evidence that growth factors
deposited in bone have physiologicsignificance. In addition, many of these bone growth factors have been shown
to increase bone formation either systemically or locally in vivo. Based on the past findings, we propose that
different growth factors may have a specific role in regulating proliferation and differentiation of different
stages of osteoblast lineage cells and play important roles in the local regulation of bone formation.

INTRODUCTION mones (e.g., parathyroid hormone, vitamin D, calcitonin) and

(2) local regulation. Local mechanisms are believed to involve

B ONE HAS A REMARKABLE REGENERATIVE potential that

enables it to remodel itself in response to changing physical
demands and to repair itself after injury. This regenerative
property of skeleton is essential for the maintenance of the
structural mass, strength, and shape of bone and for fracture
healing. Since the early studies of Harris and Heany (1969), it
has been known that the volume of bone and ultimately its
strength are determined by the balance between two opposing
processes, osteoblastic bone formation and osteoclastic bone
resorption (i.e., coupling). The balance is shifted toward bone
formation by increased mechanical stress and toward bone
resorption by disuse or by chronic disease states, such as
osteoporosis. Thus, in order for us to understand how the bone
volume changes during physiologic and pathologic situations,
we need to understand the mechanisms by which osteoblastic
bone formation and osteoclastic bone resorption are regulated at
the local sites of bone. In this regard, two mechanisms have been
postulated for regulation of bone formation and resorption: (1)
systemic regulation by calcium- and phosphatt:-regulating hor-
the actions of growth factors that act as autocrine or paracrine
effectors of osteoblastic and osteoclastic proliferation and dif-
ferentiation. This is not to say that systemic regulation of bone
does not use growth factors. Indeed, there is evidence that the
skeletal effects of at least some hormones (e.g., PTH,vitamin
D) are mediated by production of local growth factors under the
influence of these systemic hormones (Mohan and Baylink,
1991a,b). Recent findings that skeletal tissue is a major storage
site for growth factors and that bone cells in culture produce and
respond to bone growth factors support the concept that regula-
tion of bone volume may in part depend on the local growth-
promoting activities of bone growth factors. In this article, we
evaluate the potential roles of bone-derived growth factors as
determinants of local bone formation by discussing (1) growth
factors stored in bone and dentin, (2) growth factors produced by
bone cells, (3) biologic actions of bone-derived growth factors in
vitro and in vivo, and (4) models illustrating how bone-derived
growth factors could be involved in mediating the local regula-
tion of bone formation to resorption.

Departments of Medicine, Orthopedics, Periodontics, Biochemistry, and Physiology, Loma Linda University and Pettis VA Hospital, Lorna
Linda, California.

S565

TABLE1. GROWTH
F A ~ O RSTORED
S IN BONE
Factor Synonym
IGF-I Somatomedin-C
IGF-II Skeletal growth factor
TGF-p, Cartilage inducing factor-A
TGF& Cartilage inducing factor-B
Basic FGF
Acidic FGF
PDGF
BMP-2 BMP-2A
BMP-3 0steogenin
BMP-4 BMP-2b
BMP-5
BMP-6
BMP-7 Osteogenic protein-1
a t ,increase; 1,decrease;?, not known.
GROWTH FACTORS STORED
IN BONE AND DENTIN
During the past decade, studies on identification of bone
growth factors have been pursued in several laboratories. In
these studies, two assay system have been used frequently for
identification of active factors from bone extract during purifi-
cation. They are ( I ) bone cell proliferation assay using embry-
onic fetal bone cells in serum free culture and (2) induction of
bone formation at an extraskeletal ectopic site. By using these
asqy systems, several bonederived osteogenic protein factors
have been successfully isolated from human, bovine, and rat
bones (Table I). Farley and Baylink (1982) reported that
extracts of human bone contained abundant mitogenic activity
for embryonic chick calvarial bone cells in serum-free culture.
Subsequently, it was found that extracts from chicken, rat, and
bovine bones contained similar mitogenic activity, termed
“skeletal growth factor” (SGF) (Mohan and Baylink, 1991b). In
1988, SGF, the most abundant growth factor stored in human
bone was purified to homogeneity and was shown to be very
similar if not identical to insulin-like growth factor-11 (IGF-11)
purified from human serum (Mohan et al., 1988).
During the purification of IGF-II from human bone extract,
evidence was found for the presenceof additionalgrowth factors
in human bone. Characterization of these additional growth
factor activities revealed that (1) human bone matrix contains
multiple growth factors, including IGF-I, IGF-11, transforming
growth factor+ (TGF-p), plateletderived growth factor
(PDGF), and basic fibroblast growth factor (basic FGF), (2)
human bone matrix does not contain detectable amounts of
epidermal growth factor, and (3) IGF-I1 and TGF-p are the two
most abundant growth factors present in human bone matrix,
and IGF-I, PDGF, and basic FGF are severalfold less abundant
(Mohan et al., 1987). Consistent with these data, studies by
Seyedin et al. (1985), Hauschka et al. (1986), Jennings and
Mohan (1990), and Canalis et al. (1988) have shown that bovine
bone also contains multiple growth factors, including TGF-p, ,
TGF-p,, IGF-I, PDGF, acidic FGF, and basic FGF. It was also
BAYLINK ET AL.
Actions on osteoblasts
kDa Proliferation Differentiation
7.7 7“ t
7.5 t t
25 t t
25 t t
16 t 1
17 t 1
35 t 1
30-35 t t
30-40 t t
30-35 t t
30-35 t ?
30-35 t ?
30-35 t t
found that proteins extracted from skeletal tissues of 10 animals
representing five of the six vertebrate classes exhibited mitoge-
nic activity to embryonic chick bone cells. These studies
showed that IGF-I and IGF-I1 extractable from skeletal tissues
are conserved from the mammalian class down through the
cartilaginous fish class, thus suggesting that storage of growth
factors in bone is an active process (Bautista et al., 1990).
In 1%5, it was discovered that demineralized bone extract
could induce bone formation ectopically (Urist, 1965). Since
Urist’s discovery, scotes of articles have been published further
demonstrating the role of extracellular matrix in local bone
induction. The finding that the bone-inducingactivity elicited by
demineralized bone matrix could be dissociated into a soluble
component and assayed by implanting with an appropriate
collagenous matrix carrier in rats permitted the isolation of
several osteogenic proteins, bone morphogenetic proteins
(BMPs) (Celeste et al., 1990; Luyten et al., 1989; Sampath et
al., 1990;Wozney et al., 1988). The subsequent isolation of the
genes encoding these proteins from human cDNA libraries
identified a family of proteins including BMP-2 through
BMP-7. The predicted amino acid sequences of BMPs indicate
that they are all members of the TGF-p superfamily, sharing a
high degree of homology within the C-terminal 7cysteine
domain (Celeste et al., 1990; Luyten et al., 1989; Ozkaynak et
al., 1990, Sampath et al., 1990). The significance of why there
are so many BMPs in bone can only be speculated at this time.
Extracts of human dentin have been shown to be mitogenic to
embryonic chick bone cells, suggesting that human dentin, like
human bone, may contain growth factors (Finkelman et al.,
1990). Subsequently, we found that dentin extracts contained
IGF-I, IGF-11, and TGF-P. The concentrations of these growth
factors were found to be similar to those found for human bone.
Dentin proteins also have been shown to exhibit osteoinductive
properties (Bang and Urist, 1967a,b; Somerman et al., 1987;
Yeomans and Urist, 1969). In addition, extracts of cementum
have been shown to be mitogenic to gingivial fibroblasts in
culture (Miki et al., 1987). Thus, growth factors are present in
abundance not only in bone but also in other hard tissues, such as
dentin and cementum.
BONE GROWTH FACTORS
GROWTH FACTORS PRODUCED
BY BONE CELLS
If growth factors are fixed in bone for future actions (see next
section), it follows that these bone cell regulatory proteins
should be produced by bone cells and deposited as a constituent
of bone matrix. Consistent with this interpretation, we have
found that human bone cells in culture produce a number of
growth factors, many of which are known to be stored in human
bone, including IGF-I, IGF-11, TGF-P, and PDGF. Bovine bone
cells have been shown to produce basic FGF (Globus et al.,
1989), and since basic FGF is found in human bone, it seems
likely that human bone cells also produce basic FGF. Of these
growth factors, IGF-I1 seems to be the most abundant mito-
gen produced by human bone cells. IGF-I is produced by human
bone cells at 50-100-fold less concentration than IGF-I1
(Mohan et al., 1990). In contrast to human bone cells, adult
mouse and rat bone cells in culture produce and adult rat and
mouse bone extract contain severalfold more IGF-I than IGF-11.
Thus, the relative distribution of IGF-I and IGF-I1 appears to be
different between rodents and humans (Mohan and Baylink,
1991b).
Recent studies suggest that systemic hormones may modulate
local bone formation, at least in part, through regulation of
synthesis and release of bone growth factors (Mohan and
Baylink, 1991b). For example, PTH has been shown to stimu-
late IGF-I release in fetal rat bone cells (McCarthy et al., 1989b)
and in newborn mouse calvaria (Linkhart and Mohan 1989).
Progesterone has been shown to stimulate human bone cell
proliferation and production of IGF-I1 (Tremollieres et al.,
1992), and 17Pestradiol has been shown to increase release of
IGF-I, IGF-11, and TGF-P in rat osteosarcoma cell line UMR
106 (Gray et al., 1989a,b). In addition to the systemic regula-
tion, there is evidence for the regulation of IGF-I and IGF-I1
production by local factors. For example, low-amplitude, fre-
quency-specific electric fields increase the release of IGF-I1 in
TE85 human osteoblast-like osteosarcoma cell line (Fitzsim-
mons et al., 1992). We consider electric fields to be. a local factor
because we believe that exercise, which is a Itxal effector of
bone, may mediate its actions on bone through creating electric
fields. In addition, IGF-I1 and TGF-P have been shown to
modulate production of IGF-I in a mouse osteoblastic cell line
(Tremollieres et al., 1991). Because all of these growth factors
are anabolic for bone cells in culture, it seems possible that
systemic and local stimulators of bone formation may mediate
their effects by the elaboration of growth factors.
Human bone cells in culture produce, in addition to IGFs,
IGF-binding proteins (IGFBPs), which have been shown to
modulate IGF actions in bone. Five different IGFBPs, desig-
nated IGFBP-2 through IGFBP-6, have beer) shown to be
produced by human bone cells (Bautista et al., 1991; Mohan et
al., 1989; Mohan and Baylink, 1991b). Secretion of IGFBPs
from bone cells in vitro, however, appears to be cell-line specific
(Hassager ct al., 1992). Studies have shown also that both
systemic and local agents regulate production of IGFBPs in bone
cells (Chen et al., 1991b; LaTour et al., 1990; Scharla et al.,
1991). Based on the findings that IGFBPs can modulate IGF
actions either positively (Andress and Birnbaum, 1992) or
negatively (Mohan et al.. 1989). it is proposed that local and
systemic agents may modulate bone cell proliferation by modu-
SS67
lating not only the production of IGFs but also the secretion of
various IGFBPs.
There have been few reports on the regulation of TGF-P
production in bone cells. Kasperk et al. (1990a) have shown that
treatment of normal human bone cells with dihydroxytestoster-
one increased the TGF-P mRNA level. In addition, Oursleret al.
(1991) and Finkelman et al. (1992) have shown that 17P-
estradiol increased the level of protein and mRNA for TGF-P in
a dose-dependent manner in normal human osteoblast-like cells
and normal mouse bone cells, respectively. Coincubation of
l7P-estradiol with an equimolar concentration of PTH abolished
the stimulation of TGF-P seen with estradiol alone. Finkelman
et al. (1991) have shown that I ,25(OH),D, increased production
of TGF-P in mouse osteoblasts. In addition, recent studies have
shown that TGF-P is autoinductive in human bone cells and that
dexamethasone reduces both its constitutive and autoinduced
release (Firek et al., 1992). These findings are consistent with
the idea that systemic agents may modulate their effects in the
local areas of bone by altering regulation of bone growth factors.
With regard to BMPs, very little is known about which cell
types produce BMPs and how they are regulated. Harris et al.
(1991) have shown that retinoic acid regulates induction of
BMP-4 and BMP-2 mRNA level at the transcriptional level,
suggesting that retinoic acid may exert some of its morphoge-
netic effects by enhancing expression of BMPs.
BIOLOGIC ACTIONS OF BONE-DERIVED
GROWTH FACTORS IN VITRO AND IN VIVO
IGF-I and IGF-I1 have been shown to stimulate proliferation
in serum-free cultures of human bone cells derived from iliac
crest and calvarial bone cells derived from embryonic chick,
fetal mouse, and fetal rat (Mohan and Baylink, 1991b). In
addition to its effect on bone cell proliferation, IGF-I1 has been
shown to stimulate the synthesis of type I collagen in untrans-
formed normal human bone cells (Mohan and Baylink,
1991a,b). IGF-I and IGF-I1 have been shown to increase bone
collagen synthesis and decrease collagen degradation in intact
rat calvaria in vitro (McCarthy et al., 1989a). Presumably, these
responses were from relatively mature osteoblasts. In contrast to
the actions of IGF-I and IGF-11, the biologic effects of TGF-P
depend on cell type, cell density, and culture conditions. For
example, TGF-P has been shown to be. a potent mitogen for
calvaria cells derived from embryonic chick and newborn mouse
osteoblasts, where it inhibited proliferation of MC3T3-EI
mouse osteoblasts (Tremollieres et al., 1991). In normal human
osteoblasts, the effects of TGF-P appeared to be dependent on
cell density and dose. At low density, TGF-P stimulated cell
proliferation at low doses, whereas it inhibited cell proliferation
at high doses (Datta et al., 1989). In addition, TGF-P has been
shown to stimulate production of type I collagen in human bone
cells (Strong et al., 1988). In chick growth plate chondrocytes,
TGF-P inhibited collagen synthesis but stimulated noncollagen
protein synthesis and sulfate incorporation (O’Keefe et al.,
1988). In contrast to IGFs and TGF-P, which stimulate both
proliferative and differentiative functions of bone cells, PDGF
and basic FGF have been shown to stimulate human bone cell
proliferation under certain culture conditions but had no effect
ssa
on collagen synthesis. Both PDGF and basic FGF have been
shown to be potent mitogens for bone cells derived from
embryonic chick calvaria, newborn mouse calvaria, bovine
bone, and cultured rat calvaria in organ culture (Mohan and
Baylink, 1991a,b). Interactions among growth factors are likely
to be important regarding their actions on bone cells (Centrella et
al., 1987; Kasperk et al., 1990b; Pfeilschifter et al., 1990).
Thus, bone-derived growth factors have been shown to stimulate
bone cell proliferation or both proliferation and differentiated
cell function.
There have been very few reports on the biologic actions of
BMPs on bone-derived cells in vitro. Thies et al. (1992) have
shown that recombinant BMP-2 increased alkaline phosphatase
activity and osteocalcin production in the bone marrow stromal
cell line W-20-17, raising the possibility that BMP-2 may be
involved in the differentiation of osteoblasts from progenitor
cells resident in the bone marrow. Osteogenin, which has been
shown to be identical to BMP-3, increased alkaline phosphatase
activity and collagen synthesis in rat bone cells in vitro (Luyten
et al., 1992). Chen et al. (1991a) have reported that BMP-4
stimulated cell proliferation, alkaline phosphatase activity, and
collagen synthesis in rat osteoblast-like cells in vitro. Luyten et
al. (1992) have shown that highly purified osteogenin (BMP-3)
and recombinant human BMP-4 stimulated in a dose-dependent
manner the synthesis of proteoglycans and decreased their rate
of degradation in bovine articular cartilage explant cultures, thus
suggesting that BMPs are capable of stimulating and maintain-
ing the chondrocyte phenotype in vitro. Sampath et al. (1992)
have shown that human recombinant osteogenic protein- 1
(BMP-7) stimulated both bone cell proliferation and collagen
synthesis in a dose-dependent manner in rat osteoblast-enriched
bone cell cultures. Consistent with these data, Knutsen et al.
(1991) have reported that BMP-7 stimulated both bone cell
proliferation and alkaline phosphatase activity in human bone
cells and that these effects may in part be mediated by the
increased production of IGFs. Based on these in vitro findings, it
can be concluded that BMPs may act to stimulate bone formation
in vivo in skeletal or ectopic sites by stimulating undifferentiated
cells to proliferate and differentiate to bone cells.
With regard to the actions of bone-derived growth factors in
vivo, both IGF-I and IGF-I1 have been shown to stimulate bone
formation in vivo in hypophysectomized rats (Zapf and Froesch,
1986). Spencer et al. (1991) have shown that continuous
infusion of IGF-I for 14 days increased both cortical and
trabecular bone formation in adult female rats. In addition, there
have been two studies reported on the systemic effects of IGF-I
to prevent bone loss in ovariectomized rats. Ammann et al.
(1991) have shown that chronic infusion of IGF-I for 6 weeks in
adult rats made osteopenic by ovariectomy increased bone
mineral density as measured by dual-energy x-ray absortiometry
in lumbar spine, proximal tail, and total tibia. Kalu et al. (1991)
have shown that daily subcutaneous injections of IGF-I for 5
weeks caused partial prevention of loss of femur calcium and
trabecular bone volume. These studies are consistent with in
vitro effects of IGF-I and suggest that IGF-I has anabolic effects
on bone formation in vivo.
In contrast to the IGFs, there have been virtually no studies on
the systemic effects of other bone-derived growth factors on
bone formation parameters in vivo. However, there have been
several reports on the local effects of TGF-P and BMPs on bone
BAYLINK ET AL.
formation in vivo. Noda and Camilliere (1989) have shown that
daily injections of TGF-P directly onto the periostea of parietal
bones of neonatal rats stimulated the formation of woven bone.
Consistent with these data, Joyce et al. (1990b) have shown that
daily injections of TGF-P, for 14 days in the subperiosteal
regions of newborn rat femurs resulted in localized intramem-
branous bone formation and chondrogenesis. Beck et al. (1991)
have reported that a single topical application of TGF-P, can
accelerate the onset of bone formation and increase the area of
bone formation in a soft-tissue wound-healing model in which
ear cartilage and surrounding connective tissue are exposed to
the growth factor. A role for TGF-P, in fracture repair has been
reported (Joyce et al., 1990a). These in vivo findings are
consistent with the possibility that TGF-P may have therapeutic
application in hard tissue repair.
With regard to the in vivo actions of BMPs, there have been
several studies demonstrating that implantation of recombinant
BMPs can induce bone formation using the rat ectopic bone
formation assay system (Celeste et al., 1990; Luyten et al.,
1989; Sampath et al., 1990; Wozney et al., 1988). Wang et al.
(1990) have shown that implantation of 0.5-1 15 p g of partially
purified human recombinant BMP-2 resulted in cartilage by day
7 and bone formation by day 14 in a dose-dependent manner.
Luyten et al. (1992) have shown that purified osteogenin
(BMP-3) when implanted ectopically in conjunction with colla-
gen induced both cartilage and bone formation. In addition,
Sampath et al. (1992) have shown that recombinant human OP-1
(BMP-7) induced new bone formation in the rat subcutaneous
bone induction model with a specific activity comparable to that
exhibited by highly purified bovine OP-1. Implantation of the
OP- 1 into surgically created large diaphyseal segmental defects
in rabbits leads to the regeneration of new bone (Sampath et al.,
1992). Taken together, these observations suggest that BMPs
may have an important role in skeletal development and in the
regeneration of new bone after fracture.
With regard to alveolar bone, great interest has been gener-
ated concerning the use of growth factors to restore and regen-
erate mineralized tissues lost as a result of human periodontal
disease. Toward this end, initial studies have reported that a
combination of PDGF and IGF-I will stimulate periodontal
tissue regeneration in the Beagle dog and in the monkey (Lynch
et al., 1989, 1991b; Rutherford et al., 1992). Growth factors
may improve the incorporation of dental implants into bone
(Lynch et al., 1991a). However, further research using well-
characterized models is necessary to demonstrate conclusively a
role for growth factors in periodontal therapy.
MODELS FOR LOCAL ACTIONS OF
BONE-DERIVED GROWTH FACTORS
Based on the findings that bone is a storehouse for growth
factors and that human bone cells in culture produce and respond
to many of the bone-derived growth factors, we and others have
proposed the concept that bone-derived growth factors play an
important role in the local regulation of bone formation. To
illustrate how bone-derived growth factors may act in bone cell
microenvironment, we have developed a model (Fig. 1). In this
model, bone cells secrete growth factors, such as IGF-11, that
either are incorporated into bone matrix or diffuse to the
BONE GROWTH FACTORS
a PRE-
- OSTEOBLASTS
EXTRA
A U T O C R I N E PARACRINE-
~~ CELLULAR
FLUID
f 0
1
0
f
GROWTH OSTEOBLASTS
FACTOR
MATRIX
FIG. 1. Model for autocrine/paracrine actions of growth
factors in bone. Growth factors produced by osteoblasts can
diffuse toward and be deposited in bone or diffuse into the
extracellular fluid to act on the same cell in an autocrine manner
or on a nearby cell in a paracrine manner.
extracellular fluid. Growth factors secreted into extracellular
fluid will have acute actions on osteoblast-like cells. Growth
factors may act on the same osteoblast line of cells that produce
them in an autocrine manner, or they may act on a different
osteoblast line of cells in the near vicinity in a paracrine manner.
Our findings suggest that IGF-I1 is fixed into bone matrix by
means of an IGF-binding protein (IGFBP-5) that has strong
affinity for hydroxyapatite and selective affinity for IGF-II over
IGF-I (Bautista et al., 1991). Studies have shown also that
TGF-P is fixed in bone by binding to a specific proteoglycan,
termed beta-glycan (Lopez-Casillas et al., 1991). What is the
significance of growth factors stored in bone? We propose that
growth factors are fixed in large amounts in the mineralized
matrix of bone for future actions (Fig. 2). According to this
model, growth factors, such as IGF-11, are deposited for a time
and then released by osteoclastic bone resorption in a bioactive
form to act on preosteoblasts and mature osteoblasts, thus
allowing for site-specific replacement of bone that is lost to
resorption (i.e., coupling of bone formation to resorption).
OSTEOBLASTS
-
OST E! OCL AST
PREOSTEOBLAST
FIG. 2. Model for delayed paracrine actions of growth factors
stored in bone. Growth factors deposited in bone are postulated
to be released during the osteoclastic bone resorption to act on
precursor osteoblasts and mature osteoblasts to ensure site-
specific bone replacement.
S569
Thus, the amount and nature of growth factors stored in bone
may be one of the determinants of the efficiency with which
coupling occurs. The following findings support this model.
Farley et al. (1987) have shown that there is a proportionality
between the extent of bone resorption and the amount of
mitogenic activity released from bone in organ culture. The
concentration of bone growth factors is not invariant. For
example, Finkelman et al. (1991) have shown that bones from
vitamin D-deficient rats contained less TGF-P and were less
osteoinductive than age-matched controls. In addition, the levels
of both IGF-I and IGF-11 are increased in bones from osteoar-
thritic subjects, who have higher bone density than that seen in
osteoporotic patients (Mohan et al., 1991).
Since bone volume depends on net balance between bone
formation and bone resorption, the efficiency of coupling
between these two processes ultimately may determine the
extent to which bone mass is maintained. Accordingly, an
impairment in the coupling of bone formation to resorption may
lead to the decline in bone mass seen during aging or during
postmenopausal osteoporosis. If coupling is determined in part
by bone growth factors as proposed in the model, a decline in
bone growth factors could contribute to bone loss seen during
normal physiologic or pathologic situations. In this regard, we
have found an age-related decline of IGF-I in bone in both men
and women, a finding that could lead to decreased efficiency of
coupling between bone formation and bone resorption and, thus,
to an age-related decrease in mean wall thickness (Nicolas et al.,
1992). It has been shown also that demineralized bone matrix
from ovariectomized rats is less osteoinductive in vivo (Cesnjaj
et al., 1991) and contains less TGF-P (Finkelman et al., 1992),
suggesting that the bone loss associated with estrogen deficiency
may in part be mediated by the decreased TGF-P concentration
in bone.
With regard to the tooth, since dentin normally does not
remodel as does bone, the discovery of growth factors in dentin
raises the question of their functions. That odontoblasts make
more dentin in response to dental caries has long been known,
but the mechanisms remained obscure. A possible mechanism
could involve growth factors (Fig. 3). In this model, the
demineralization that occurs during dental caries could release
growth factors that may stimulate odontoblasts or odontoblast
precursors. In addition, odontoblasts may release additional
growth factors, which amplify the response. Stimulated odonto-
blasts could elaborate additional extracellular matrix, which
mineralizes to form dentin. In support of this concept, it has been
reported that recombinant OP- 1 stimulated dentin formation in
monkeys (Rutherford and Tucker, 1992).
SUMMARY AND FUTURE DIRECTIONS
During the past decade, a number of bone growth factors have
been isolated and sequenced. With regard to the physiologic role
of these growth factors in regulating bone formation in vivo, we
speculate that each growth factor may have a specific role in
regulating proliferation and differentiation of different stages of
osteoblast lineage cells. In vitro and in vivo studies thus far
suggest that bone-derived growth factors are potential therapeu-
tic agents in the treatment of bone loss during osteoporosis,
fracture repair, and other bone disorders. However, many
S570
FIG.3. Model illustrating the proposed autocrine, paracrine,
or delayed paracrine function of growth factors to stimulate the
formation of reparative dentin. Dentin demineralization (i.e.,
during dental caries) releases growth factors stored in dentin.
These growth factors enter dentinal tubules ultimately to interact
with odontoblasts or odontoblast precursors to stimulate the
growth or differentiation of new odontoblasts or the function of
existing odontoblasts. Odontoblasts also may secrete growth
factors to stimulate themselves or adjacent cells. Stimulated
odontoblasts secrete new extracellular matrix, which then min-
eralizes to form reparative dentin.
problems must be resolved before the use of bone growth factors
as systemic agents in the treatment of bone loss can become a
reality. Future studies are needed in the following areas to
determine the therapeutic applications of bone growth factors for
treatment of human bone diseases: ( I ) Efforts should be made to
establish that a deficiency of growth factor actions is involved in
the pathogenesis of osteoporosis or other disorders. (2) Methods
must be developed that allow measurement of various bone
growth factors in sera from patients with various metabolic bone
diseases to determine if the serum level for one or more growth
factors correlates with bone formation. (3) Suitable delivery
systems must be developed so that growth factors can be targeted
to areas of interest. (4) Studies on the interactions among various
known growth factors for their effects on bone cell proliferation
and differentiation in vitro and in vivo must be pursued. ( 5 )
Model systems must be developed to determine the role of
different growth factors in regulating proliferation and differen-
tiation of various stages of osteoblast cell lineage. In terms of
future prospects, it would seem that we are a long way from
accomplishing the goal of producing a stimulation of bone
formation throughout the skeleton with the optimal combination
of growth factors. However, the most immediate uses for bone
growth factors would be the therapeutic applications of these
factors locally to the skeleton (e.g., in bone grafts and dental
implants and for treatment of fracture nonunions).
ACKNOWLEDGMENTS
This work was supported by funds from NIH (AR31062), the
Veterans Administration, and the Department of Medicine,
Loma Linda University.
BAYLMK ET AL.
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