Host modulation therapy: An indispensable part of perioceutics

282 Journal of Indian Society of Periodontology - Vol 18, Issue 3, May-Jun 2014
Address for
correspondence:
Dr. Minkle Gulati,
c/o Mr. Saranpal
Singh Gulati,
54‑L, Model Town, Karnal,
Haryana, India.
E‑mail: mink_gulati@
rediffmail.com
Submission: 30‑06‑2013
Accepted: 29‑10‑2013
Departments of
Periodontics, Babu
Banarasi Das College of
Dental Sciences, Babu
Banarasi Das University,
1
Chhatrapati Shahuji
Maharaj Medical
University, Lucknow,
2
Department of Oral and
Maxillofacial Surgery,
Vinayaka Missions
Sankarachariyar Dental
College, Salem,
Tamil Nadu, India
Host modulation therapy: An
indispensable part of perioceutics
Minkle Gulati, Vishal Anand,1
Vivek Govila, Nikil Jain2
Abstract:
Traditionally, only antimicrobials have been used as the chemotherapeutic modality for the treatment of
periodontitis. Though bacteria are the primary etiologic factors of periodontal diseases, yet the extent and severity
of tissue destruction seen in periodontitis is determined by the host immuno‑inflammatory response to these
bacteria. This increasing awareness and knowledge of the host‑microbial interaction in periodontal pathogenesis
has presented the opportunity for exploring new therapeutic strategies for periodontitis by means of targeting host
response via host‑modulating agents. This has lead to the emergence of the field of “Perioceutics” i.e. the use of
parmacotherapeutic agents including antimicrobial therapy as well as host modulatory therapy for the management
of periodontitis. These host‑modulating agents used as an adjunct tip the balance between periodontal health
and disease progression in the direction of a healing response. In this article the host‑modulating role of various
systemically and locally delivered perioceutic agents will be reviewed.
Key words:
Bisphosphonate, host modulation, locally delivered, nonsteroidal anti‑inflammatory drugs, perioceutics,
periodontitis, systemically delivered, tetracycline
INTRODUCTION
Although microbial plaque has been
recognized as the primary etiologic agent for
the development of periodontal disease,[1]
yet, the
severity, pattern and progression of this disease
cannotbesolelyexplainedbytheamountofplaque
present.[2]
Periodontal pathogens present within
the microbial biofilms initiate the periodontal
disease by producing harmful by‑products and
enzymes (e.g. hyaluronidases, collagenases,
proteases) that break down extracellular matrices
such as collagen, as well as host cell membranes,
in order to produce nutrients for their growth
and possibly subsequent tissue invasion.[3]
This results in a host immune‑inflammatory
response in the periodontal tissues characterized
by the production of inflammatory
cytokines [e.g. interleukins (IL), tumor necrosis
factor‑a (TNF‑a), prostanoids (e.g. prostaglandin
E2) and enzymes [including the matrix
metalloproteinases (MMPs)].[4,5]
The level
of these inflammatory mediators in the
periodontal tissues is usually balanced by the
anti‑inflammatory cytokines and enzymes of the
host immune system which ultimately functions
to eliminate microbial pathogens and protect
the host.[3,4]
However, an improper or exuberate
immune response in certain individuals directly
leads toward overproduction of destructive
enzymes and inflammatory mediators.[3]
This immune‑inflammatory response that
develops in the periodontal tissues following
chronic exposure to bacterial plaque largely
determines the susceptibility of individuals
to periodontal disease.[4]
The variability in the
host response also results from environmental
and acquired risk factors which can accentuate
the host inflammatory response[6]
and create
an imbalance between the pro‑inflammatory
and anti‑inflammatory activities in the
periodontal tissues that result in the tissue
destruction.[4]
The host immune‑inflammatory
response against bacterial plaque can thus
be viewed as a “dual‑edged sword,” i.e. the
response is protective by intent, yet in susceptible
patients who exhibit exaggerated inflammatory
response to plaque, it ultimately is responsible
for perpetuating destruction of periodontium.[3]
This shift in paradigms, with emphasis on host
response, has led to the development of host
modulatory therapies (HMT) which can improve
therapeutic outcomes, slow the progression of
disease, allow for more predictable management
of patients, and possibly even work as
preventive agents against the development of
periodontitis.[7,8]
The concept of host modulation
was first introduced to dentistry by Williams in
1990[9]
and Golub et al. in 1992[10]
and later on
expanded by many researchers. The rationale
behind this approach is to aid the host in its
fight against infectious agents by supplementing
the natural inherent defence mechanisms or to
modify its response by changing the course of
inflammatory systems.[11]
The purpose of host
modulatory agents, which is an imperative part
of perioceutic, is to restore balance between, on
the one hand, pro‑inflammatory mediators and
destructive enzymes, and on the other hand,
anti‑inflammatory mediators and enzyme
Access this article online
Website:
www.jisponline.com
DOI:
10.4103/0972-124X.134559
Quick Response Code:
Review Article
[Downloaded free from http://www.jisponline.com on Monday, August 04, 2014, IP: 122.161.206.6] || Click here to download free Android application for this journal

Gulati, et al.: Host modulation
Journal of Indian Society of Periodontology - Vol 18, Issue 3, May-Jun 2014 283
inhibitors. The use of perioceutics becomes obligatory when
patients are unable to effectively reduce risks such as the risk
presented by the patient’s genetics, smokers who are unable to
quit the habit, patients who are unable to maintain adequate
oral hygiene, the inability to reduce stress, diabetics who are
poorly controlled despite the physician’s best efforts, and the
inability or unwillingness of the physician to alter medications
of the patients. The term perioceutic (periodontal + therapeutic)
was first introduced by Heska Corporation (Fort Collins, CO).
In 1998, this corporation filed to protect the “perioceutic”
trademark for labeling periodontal therapeutic gels especially
for use in veterinary field, but in 2000 this trademark was
abandoned.[12,13]
However, this term is currently being used to
address the pharmacotherapeutic agents specifically developed
to better manage periodontitis.[14,15]
This field of ‘‘perioceutics,’’
that includes antimicrobial therapy and host modulatory
therapy, to produce beneficial changes in the microflora and
host response, respectively, has emerged as a vital aid in the
management of susceptible patients who develop periodontal
disease.[16]
Compared to other therapeutic modalities employed
against infection, host response modulation, potentially is
non‑invasive, has fewer side‑effects, and does not require
complicated application method.[17,18]
This article highlights
various host modulatory therapeutic agents for the treatment
and management of periodontal diseases, which are an
indispensable part of perioceutics and are used as an adjunct
to the traditional periodontal therapies.
HOST MODULATORY THERAPY
HMTincludessystemicallyorlocallydeliveredpharmaceuticals
that are prescribed as adjuncts to other forms of periodontal
treatment.[4]
Systemically administered HMT
Host modulating agents acting against MMPs
MMPs endopeptidases which are secreted by a variety of host
cells, play key roles in the degradation of the extracellular
matrix, basement membrane and modify the action of cytokines
as well as activation of osteoclasts.[19]
During active periodontal
diseases, microbial attack leads to excessive production as well
as activity of these MMPs which, if not adequately controlled
by the endogenous metalloproteinases inhibitors, results in
enormous tissue destruction. To impede this destruction of host
tissues synthetic inhibitors of MMP as host modulating agents
have been developed which generally contain a chelating
group, inhibiting MMPs by binding to the catalytic zinc atom
at its active site. Though numerous MMP inhibitors have been
investigated, only tetracycline based host modulating agent,
i.e. SDD – sub‑antimicrobial dose of doxycycline (Doxycycline
hyclate 20 mg; Periostat, CollaGenex, Pharmaceuticals Newton
PA) has been approved by Food and drug administration (FDA)
to be used as an adjunct to periodontal treatment.[20]
A typical
prescription for Periostat (20 mg doxycycline tablets) is for at
least 3 months (180 tablets, 1 tablet twice a day until complete),
and refills may be provided for longer courses of therapy.[16]
Tetracycline analogues as host modulating agents
Tetracycline with antibiotic activity consists of a tetracyclic
naphthacene carboxamide ring system having a dimethylamine
group at carbon 4 (C4) in ring “A” which is responsible for
its antibacterial property.[21]
However, about 3 decades ago,
Golub et al. discovered that tetracyclines and its analog have the
unexpected ability to inhibit MMPs, by mechanisms unrelated
to its antibacterial properties.[22,23]
Golub and McNamara et al. synthesized a chemically modified
tetracycline (CMT) by removing the dimethylamino group
from the carbon‑4 position of the “A” ring, resulting in the
4‑de dimethylaminotetracycline, i.e. CMT, which eliminated
the drug’s antimicrobial efficacy but did not reduce the ability
of the drug to block the activity of collagenases.[24,25]
Recently, bisphosphonates which are generally bone‑sparing
agents have been found to inhibit MMPs. Bisphosphonates will
be discussed later in this article.
Host modulating agents acting against arachidonic acid metabolites
Free arachidonic acid (AA) is produced in the hosts when
phospholipase A2 acts on the phospholipids present in
plasma membranes of the cells which can then be metabolized
to produce prostaglandins via the cyclooxygenase (COX)
pathway as well as leukotrienes via the lipoxygenase (LOX)
pathway. Recently, Dybvig also validated that prostaglandins
are an important mediator of bone loss in periodontitis.[26]
Non‑steroidal anti‑inflammatory (NSAIDs) drugs block the
activity of both cyclooxygenase isozymes (COX‑ 1 and ‑2) and
many authors have demonstrated the role of NSAIDs like
flurbiprofen,[27]
indomethacin,[28]
and naproxen,[29]
in inhibiting
gingivitis and progression of periodontitis. Lipoxins (LX) which
are generated endogenously late in inflammation via cell‑cell
interaction when a second lipoxygenase (e.g. 5‑LOX) interacts
with a lipoxygenase product (e.g. hydroxyeicosatetraenoic
acid) generated earlier from archidonic acid,[30]
also possess
both anti‑inflammatory and pro‑resolving potential which have
been summarized by Serhan et al. as reduction of neutrophil
infiltration and recruitment, blocking cytokines and reactive
oxygen species generation, thereby preventing connective
tissue and bone loss.[31]
Hence, LXs can be targets for HMT
against periodontitis.
Lipid - inflammatory mediators as targets for HMT
Among the other endogenous chemical mediators resolvins,
protectins, and newly identified maresins have shown
to mediate resolution and counter‑regulate excessive
acute inflammation.[32]
These are biosynthesized from
precursors like omega‑3 polyunsaturated fatty acids (PUFAs),
eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA)
via sequential steps involving lipoxygenases (LOX), and
cyclooxygenases (COX).[31,33,34]
The role of these endogenous
chemical mediators is similar to that of lipoxins, i.e. inhibition
of neutrophil recruitment etc.[32,33]
These stereoselective players
counter‑regulate excessive acute inflammation and stimulate
molecular and cellular events that define resolution.[35]
Thus,
designing pharmacological mimetics of naturally occurring
pro‑resolving mediators offers exciting new targets for drug
design,[36]
especially for host modulation therapy.
Host modulating agents acting against cytokines
Pro‑inflammatory (e.g. IL‑1α, IL‑1β, IL‑6, TNF‑α, IFN‑γ etc)
and anti‑inflammatory cytokines (IL‑4, IL‑10 etc) hold a great
potential for controlling the adverse effects of the host immune

response, consequently HMT against cytokines (cytokine
therapy) may prove to be an effective strategy for treating
periodontal diseases.[37]
These therapies aim at:
- Antagonizing the pro‑inflammatory cytokines via
• Cytokine receptor antagonist: Binds to the receptor
present on the target cell and prevents the cytokine from
binding to the target cell. E.g. interleukin‑1 receptor
antagonist (IL‑1ra) which is commercially available as
Kineret (Anakinra, Amgen)[38,39]
• Anti‑cytokine antibodies: Some of the anticytokine
antibodies currently available are:
• Anti TNF‑α antibody: Adalimumab (Humira,
manufacturered by Abbott Laboratories), Cetrolizumab
pegol (Cimzea, manufacturered by Union chimique
belge), Golimumab (Simponi, manufacturered by
Centocor) etc.
• Anti IL‑6 antibody: Tocilizumab (RoActemra,
manufacturered by Roche)
• AntiIL‑15antibody:AMG714 (AMG714,manufacturerd
by Novartis)
• Anti IL‑12 and IL‑23 antibody: Ustekinumab (Stelara,
manufacturered by Centacor)
• Anti IL‑17 antibody: AIN457 (AIN457, manufacturered
by Novartis)[38]
• Soluble cytokine receptors: Binds to the cytokines in
solution and prevents signaling. e.g. sIL‑1R, sTNF‑R,
sIL‑6R are the soluble receptors against IL‑1β, TNF‑α
and IL‑6, respectively[39]
- Disrupting inflammatory cell‑signalling pathways
To inhibit the production of pro‑inflammatory
cytokines and/or stimulate anti‑inflammatory
cytokine production. Cell‑signalling pathways
like Mitogen Activated Protein Kinase (MAPK),
Nuclear Factor‑Kappa B (NFκB), Janus kinase/signal
transducers and activators of transcription (JAK/
STAT) and Receptor activator of nuclear factor‑kappa
B (Rank)‑Receptor activator of nuclear factor‑kappa
B ligand (Rankl)‑Osteoprotegerin (OPG) pathways
are dependent on a number of signaling‑intermediate
molecules for its uninterrupted functioning. Targeting
these pathways or the intermediate signaling molecules
for their blockade with HMT may be more effective
than targeting specific cytokines.[6]
It has also been seen
that the activity of cytokines is also controlled by the
suppressors of cytokine signaling (SOCS ‑ SOCS‑1, ‑2
and ‑3) messenger ribonucleic acid (mRNA), which
when expressed, down‑regulate the signal transduction
and inflammatory cytokine production as a part of an
inhibitory feedback loop.[40,41]
The exploration of these
molecules further open up many new possibilities for
modulating host response. Based on the clinical data
Souza et al. have listed some of the inhibitors targeting
these signalling pathways that have been manufactured
and have demonstrated anti‑inflammatory
activity, these are: SD‑282, SC‑409, SB (SmithKline
Beecham) ‑242235, AW‑814141, BIRB‑796 (Boehringer
Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA)
and VX‑702 that act as p38 inhibitors; SP600125 (Celgene
Corporation, San Diego, California, USA) as c‑Jun
N‑terminal kinases (JNK) inhibitor; FR180204 as
Extracellular‑Signal‑Regulated Kinases (ERK)
inhibitor; BMS (Bristol‑Myers Squibb)‑345541 as
NFκB inhibitor; CP‑690550 (Pfizer) as JK3 inhibitor.[6]
Lima et al. (2004) further demonstrated the protective
role of pentoxifylline (PTX), a methylxanthine
derivative, in experimental periodontitis as a
inhibitor of cytokine synthesis, mainly tumor necrosis
factor (TNF).[42]
Likewise, a number of intracellular
signaling pathways involved in osteoclastogenesis,
activated upon RANK‑RANKL binding are blocked by
osteoprotegerin (a natural inhibitor of RANKL), which
acts as a decoy and blocks the binding of RANKL to
RANK. Moreover the protective role of OPG has also
been supported by the association of disease severity
with an increase in RANKL ⁄ osteoprotegerin ratio
at periodontally inflamed sites.[43]
Thus, modulation
of the RANKL ⁄ RANK ⁄ osteoprotegerin axis via
pharmacotherapeutic agents may lead to an increase
in osteoprotegerin and a decrease in RANKL to a level
consistent with an equilibrium state between bone
formation and bone destruction.[38]
Jin et al. (2007)
demonstrated that systemic delivery of OPG‑Fc
fusion protein inhibits alveolar bone resorption in
experimental periodontitis, supporting the fact that
RANKL inhibition may represent an important
therapeutic strategy for the prevention of progressive
alveolar bone loss.[44]
Studies to date have indicated that
RANKL inhibitors, such as a fully human monoclonal
antibody that specifically targets RANKL currently
available as denosumab (Denosumab, Amgen) can lead
to increased bone mineral density and decreased bone
resorption.[38]
- Recombinant anti‑inflammatory cytokine administration
Martuscelli et al. demonstrated that subcutaneous
injections of recombinant human IL‑11 (rh IL‑11:
anti‑inflammatory cytokine) were able to slow the
progression of attachment and radiographic alveolar
bone loss in a ligature‑induced beagle dog model.[45]
Host modulating agents acting against bone resorption
Bisphosphonates (BPs) are pyrophosphate analogs that can
suppress osteoclastic bone resorption[46]
Bisphosphonates are
known to bind to hydroxyapatite crystals and prevent their
dissolution in addition to increasing osteoblast differentiation
and inhibiting osteoclast activation.[4]
Giannobile WV has
summarized and categorized the bone‑specific actions of
bisphosphonates at the tissue level (decrease bone turnover
due to inhibition of bone resorption, decrease the number of
new bone multicellular units resulting in a net positive whole
body bone balance) and at cellular level (decrease osteoclast
recruitment, osteoclast adhesion, depth of resorption site and
release of cytokines by macrophages along with an increase
in osteoclast apoptosis and osteoblast differentiation and
number).[5,47]
FDA has approved the use of these drugs orally
or intravenously in the management of Paget’s disease,
osteoporosis, and bone metastases.[48]
Based on its bone‑sparing
properties there exists a possible use for bisphosphonates
in the management of periodontal diseases as well. Shoji
et al. in 1995 demonstrated that systemic administration of a
bisphosphonate could prevent alveolar bone resorption in rats
with experimental periodontitis.[49]

Furthermore, anti‑integrins can also block the initial osteoclast
adhesion to the matrix and prevent bone resorption.[3]
Based
on the well demonstrated role of estrogen on excessive bone
resorptionaswellasitslackinthepost‑menopausalosteoporosis
affecting the remodeling of the bone tissue in such a way that,
in most patients with periodontitis the amount of bone resorbed
exceeds that being formed, resulting in net bone loss, Inagaki
et al. has also suggested the use of selective estrogen receptor
modulators (SERM) and hormone replacement therapy (HRT)
to improve the clinical outcome of periodontal disease as an
adjunctive treatment to preserve periodontal bone mass.[50]
Shu et al. in 2008 also demonstrated in human periodontal
cells that estrogen may play a significant role in modulating
periodontal tissue responses to lipo‑polysaccharide, and may
exert its bone‑sparing effects on periodontal tissues via altering
the expression of inflammatory cytokines.[51]
Yet, given the
potentially large number of significant side‑effects associated
withhormonereplacement therapy,it is difficult toseethisbeing
recommended as a management strategy for periodontitis.[38]
Modulation of nitric oxide synthase
Nitric oxide is a free radical with important physiological
functions of maintaining homeostasis. While homeostasis
requires low nitric oxide tissue levels, pro‑inflammatory
stimuli such as endotoxins leads to increased expression of the
inducible nitric oxide synthase enzyme (iNOS) that produces
a large amount of nitric oxide (NO) and peroxynitrite, which
acts beneficially for the host as a cytotoxic molecule against
the invading microorganism, yet, it may also cause deleterious
effects to host such as DNA damage, lipid peroxidation,
protein damage, and stimulation of inflammatory cytokine
release.[52‑54]
Lohinai et al. (1998) demonstrated the protective
effects of mercaptoethylguanidine (MEG), which is a selective
inhibitor of iNOS, against bone destruction in ligature‑induced
periodontitis in the rat.[55]
Recently, Leitao et al. (2005) also
proved that NOS inhibitors prevent alveolar bone resorption
in experimental periodontitis.[56]
Other host modulatory therapies
Probiotics
Probiotics have demonstrated significant potential as
therapeutic options for a variety of disease as they have been
known to modulate cytokine secretion profiles, influence
T‑lymphocyte populations, protect against physiologic stress,
and enhance intestinal epithelial cell function and antibody
secretion.[57]
Recently, Teughels et al. (2011) explored the
use of probiotics in influencing the periodontal microbiota
and periodontal health and concluded that probiotics might
offer opportunities to manipulate the oral microbiota, and
periodontal health by either direct microbiological interactions
or by immunomodulatory interactions.[58]
Periodontal vaccines
GeorgeHajishengallisreportedthattolllikereceptors (TLRs)may
offer novel targets for host‑modulation therapy in periodontitis
sincemanipulationofTLRsignallingmaycontributetocontrolof
infection or regulation of inflammation and, moreover, synthetic
or natural TLR agonists could serve as novel periodontal vaccine
adjuvants.[59]
Yokoyama et al. in 2007 also demonstrated that egg
yolk antibody against Porphyromonas gingivalis (IgY‑GP) proved
to be an effective immunotherapeutic agent in the treatment
of periodontitis.[60]
Similarly, Choi et al. reported that prior
immunization of mice to Fusobacterium nucleatum modulated
the host immune responses to Porphyromonas gingivalis at the
humoral, cellular and molecular level.[61]
Nutrients
Nutrients, which include major extracellular antioxidants, like
vitamin C, vitamin E, carotenoids, reduced glutathione and
omega 3 fatty acids can also act as modulators of inflammation
by scavenging free radicals as they are formed, sequestering
transition metal ions and catalyzing formation of other
molecules.[62]
Studies have also demonstrated that cranberry
juice contains molecules (A‑type cranberry proanthocyanidins:
AC‑PACs) that inhibit MMPs, interleukin‑6, interleukin‑8, and
prostaglandin E production by lipopolysaccharide‑activated
gingival fibroblasts and hence show potential of being used
as a novel host‑modulating agent to inhibit tissue destruction
during periodontitis.[63,64]
Locally administered HMT
In addition, a number of local host modulatory agents have
been investigated in clinical trials for their potential use
as adjuncts to surgical procedures, not only to improve on
wound healing but also to stimulate regeneration of lost bone,
periodontal ligament, and cementum, restoring the complete
periodontal attachment apparatus.[16]
Enamel matrix proteins
It is believed that during development of root and attachment
apparatus, there is a secretory phase in which Hertwig’s
epithelialrootsheathssecretesenamel‑relatedmatrixproteins.[65]
Enamel matrix derivative is now commercially available for
the treatment of periodontal defects as Emdogain®
(Biora AB,
Malmö, Sweden) which has received FDA approval.[66]
The
basic rationale behind using Emdogain is that it will act as a
tissue‑healing modulator that would mimic the events that
occur during root development and help stimulate periodontal
regeneration.[66‑68]
Enamel matrix proteins (EMD) initiates
periodontal regeneration through recruitment of cementoblasts
to the root‑surface and stimulates these to form root‑cementum,
which will thereafter secondarily lead to regeneration of
periodontal fibers and alveolar bone.[69]
The above mentioned
actions of EMD justify its role as a host modulating agent.
Bone morphogenetic protein
Bone morphogenetic protein (BMP) guides modulation
and differentiation of mesenchymal cells into bone and
bone marrow cells.[70]
Absorbable collagen sponge (ACS)
containing recombinant human BMP‑2 has been approved
for clinical use in certain oral surgery procedures, including
localized alveolar ridge augmentation, under the name
INFUSE® Bone Graft (Medtronic, Minneapolis, MN, USA)
and InductOS™ (Wyeth, Maidenhead, UK). These ACS release
the protein over time in the location where it is implanted and
provides a scaffold on which new bone can grow. As the graft
site heals, the ACS is absorbed and replaced by bone.[71]
Platelet derived growth factor
FDA has approved Growth‑factor Enhanced Matrix, GEM
21S®
(Osteohealth, Shirley, NY) which is a combination of
a bioactive highly purified recombinant human PDGF‑BB
with an osteoconductive bone matrix.[71]
Platelet derived
growth factor (PDGF), as a host modulating agent can
[Downloaded free from http://www.jisponline.com on Monday, August 04, 2014, IP: 122.161.206.6] || Click here to download free Android application for this journa

increase chemotaxis of neutrophils and monocytes, stimulate
fibroblasts proliferation and extracellular matrix synthesis,
increase proliferation and differentiation of endothelial
cells, stimulate proliferation of mesenchymal progenitor
cells and differentiation of fibroblasts.[72]
Nevins et al. (2005)
demonstrated that the purified rhPDGF‑BB mixed with bone
allograft results in robust periodontal regeneration in both
Class II furcations and interproximal intrabony defects.[73]
Bisphosphonate
Role and action of BPs have already being discussed above. Due
to serious side‑effects of systemically administered BPs leading
to osteonecrosis of the jaws (ONJ) additional studies using
topically administered bisphosphonates have been carried out
which have reported a significant increase in the postoperative
percentage of bone‑defect fill, prevention of bone resorption
as well as the boosting effect of locally delivered BPs on the
osteoconductive and regenerative potential of bone grafts used
in periodontal therapy.[74‑76]
NSAIDs
Role of NSAIDs as a host‑modulating agent has also been
discussed above. Since NSAIDs are lipophilic and are well
absorbed into gingival tissues, its topical application is possible.
NSAIDs that have been evaluated for topical administration
include ketorolac tromethamine rinse and S‑ketoprofen
dentifrice,[77]
piroxicam[78]
and meclofenamic acid[79]
in
inhibiting gingivitis and progression of periodontitis.
Hypochlorous Acid and Taurine‑N‑Monochloramine
It has been reported that hypochlorous acid (HOCl)
and taurine‑N‑monochloramine (TauCl) which are the
end‑products of the neutrophilic respiratory burst, modulate
the host inflammatory response by inhibiting the production
of interleukin‑6, prostaglandins, and other proinflammatory
substances. Thus, HOCl and TauCl, playing a crucial role in
the periodontal inflammatory process offer opportunities for
the development of novel host‑modulating therapies for the
treatment of periodontitis.[80]
Recently, Lorenz et al. (2009)
assessed the influence of 2 and 3% N‑chlorotaurine mouth
rinse on dental plaque and demonstrated that rinsing with
10 mL of the test solution two times daily for 4 days reduced
the plaque vitality.[81]
Cimetidine
Cimetidine is a powerful H2‑(Histamine) receptor antagonist,
and hence eliminates histamine’s inhibitory effects on immune
response, thereby acting as a modulator of inflammation
and immunity by inhibiting neutrophil chemotaxis and
superoxide production, increasing cyclic adenosine
monophosphate (cAMP) levels and down‑regulating cytokines.
Hasturk et al. (2006) provided morphological and histological
evidence to prove that topically active cimetidine is a potent
inhibitor of P. gingivalis‑elicited periodontal inflammation and
can arrest and/or prevent tissue destruction and influence cell
populations present in the inflammatory cell infiltrate.[82]
SUMMARY
The improved understanding of the host‑bacterial interactions
and the host immuno‑inflammatory response leading to
periodontal tissue destruction has led to the development of
HMT. Though the efficacy and usefulness of host modulating
agents have been demonstrated by many clinical trials and have
been approved by FDA for the management of periodontitis,
yet the risk/benefit ratio relating to the use of these drugs has
yet to be established. Multicenter clinical trials are necessary
to fully evaluate the benefits of these agents and to weigh their
usefulness against the risks associated with their long‑term
administration. Furthermore, continuous research in this field
would also enable fabrication of individualized treatment for
periodontal disease targeting inflammatory host response.
The current article emphasizes the promising potential of
various host‑modulating agents (the most crucial component
of perioceutics) in the management of periodontal diseases.
REFERENCES
1. Haffajee AD, Socransky SS. Microbial etiologic agents of
destructive periodontal diseases. Periodontol 2000 1994;5:78‑111.
2. Ryan ME, Preshaw PM. Host Modulation. In: Newman MG,
Takei HH, Klollevold PR, Carranza FA, editors. Carranza’s
Clinical Periodontology. 11th
ed. India: Saunders; 2012. p. 275‑280.
3. Kirkwood KL, Cirelli JA, Rogers JE, Giannobile WV. Novel host
response therapeutic approaches to treat periodontal diseases.
Periodontol 2000 2007;47:294‑315.
4. Preshaw PM. Host response modulation in periodontics.
Periodontol 2000 2008;48:92‑110.
5. Giannobile WV. Host‑Response Therapeutics for Periodontal
Diseases. J Periodontol 2008;79:1592‑600.
6. Souza JA, Rossa C Jr, Garlet GP, Nogueira AV, Cirelli JA.
Modulation of host cell signaling pathways as a therapeutic
approach in periodontal disease. J Appl Oral Sci 2012;20:128‑38.
7. Information Paper. The pathogenesis of periodontal diseases.
J Periodontol 1999;70:457‑70.
8. Thomson RG. Modulating the host response as an adjunctive
treatment for periodontitis. Periodontology 2001;22:26‑34.
9. Williams RC. Periodontal disease. N Engl J Med 1990;322:373‑82.
10. Golub LM, Suomalainen K, Sorsa T. Host modulation with
tetracyclines and their chemically modified analogues. Curr Opin
Dent 1992;2:80‑90.
11. Kantarci A, Hasturk H, Van Dyke TE. Host‑mediated
resolution of inflammation in periodontal diseases. Periodontol
2000 2006;40:144‑63.
12. Assisting with periodontics (Chapter 9). In: Kesel LM, editor.
Veterinary dentistry for the small animal technician. 1st
ed.
Hoboken: Wiley; 2013.
13. A v a i l a b l e f r o m : h t t p : / / t r a d e m a r k s . b r e a n l a w .
com/75537686‑perioceutic.html [Last accessed on 2013 Oct 20]
14. Ryan ME. Host modulation: conceptualization to clinical trials
and integration into clinical practice J. Candian Assoc 2002;6:1‑8
15. Honibald EN, Mathew S, Padmanaban IJ, Sundaram E,
Ramamoorthy RD. Perioceutics: Matrix metalloproteinase
inhibitors as an adjunctive therapy for inflammatory periodontal
disease. J Pharm Bioallied Sci 2012;4:S417‑21.
16. Ryan ME. Nonsurgical approaches for the treatment of
periodontal diseases. Dent Clin N Am 2005;49:611‑36.
17. Lawrence T, Willoughby DA, Gilroy DW. Anti‑inflammatory lipid
mediators and insights into the resolution of inflammation. Nat
Rev Immunol 2002;2:787‑95.
18. Serhan CN. A search for endogenous mechanisms of
anti‑inflammation uncovers novel chemical mediators: missing
links to resolution. Histochem Cell Biol 2004;122:305‑21.
19. Ryan ME, Golub LM. Modulation of matrix metalloproteinase
activities in periodontitis as a treatment strategy. Periodontol
2000 2000;24:226‑38.
20. Caton J, Ciancio S, Crout R, Hefti A, Polson A. Adjunctive use of

subantimicrobial doxycycline therapy for periodontitis. J Dent
Res 1998;77:1001.
21. Sapadin AN, Fleischmajer R. Tetracyclines: Nonantibiotic
properties and their clinical implications. J Am Acad Dermatol
2006;54:258‑65.
22. Golub LM, Lee HM, Lehrer G, Nemiroff A, McNamara TF,
Kaplan R, et al. Minocycline reduces gingival collagenolytic
activity during diabetes: Preliminary observations and a proposed
new mechanism of action. J Periodontal Res 1983;18:516‑26.
23. Golub LM, Wolff M, Lee HM, McNamara TF, Ramamurthy NS,
Zambon J, et al. Further evidence that tetracyclines inhibit
collagenase activity in human crevicular fluid and from other
mammalian sources. J Periodontal Res 1985;20:12‑23.
24. Golub LM, McNamara TF, D’Angelo G, Greenwald RA,
Ramamurthy NS. A non‑antibacterial chemically modified
tetracycline inhibits mammalian collagenase activity. J Dent Res
1987;66:1310‑4.
25. McNamara TF, Golub LM, D’Angelo G, Ramamurthy NS.
The synthesis and characterization of a non‑antibacterial
chemically‑modified tetracycline (CMT). J Dent Res 1986;65:266.
26. Weaks‑Dybvig M, Sanavi F, Zander H, Rifkin BR. The effect of
indomethacin on alveolar bone loss in experimental periodontitis.
J Periodontal Res 1982;17:90‑100.
27. Heasman PA, Offenbacher S, Collins JG, Edwards G, Seymour RA.
Flurbiprofen in the prevention and treatment of experimental
gingivitis. J Clin Periodontol 1993;20:732‑8.
28. Nyman S, Schroeder HE, Lindhe J. Suppression of inflammation
and bone resorption by indomethacin during experimental
periodontitis in dogs. J Periodontol 1979;50:450‑61.
29. Howell TH, Jeffcoat MK, Goldhaber P, Reddy MS, Kaplan ML,
Johnson HG, et al. Inhibition of alveolar bone loss in beagles with
the NSAID naproxen. J Periodontal Res 1991;26:498‑501.
30. Van Dyke TE. Control of inflammation and periodontitis.
Periodontology 2000 2007;45:158‑66.
31. Serhan CN, Chiang N, Van Dyke TE. Resolving inflammation:
dual anti‑inflammatory and pro‑resolution lipid mediators. Nat
Rev Immunol 2008;8:349‑61.
32. Spite M, Serhan CN. Novel lipid mediators promote resolution
of acute inflammation: impact of aspirin and statins. Circ Res
2010;107:1170‑84.
33. Janakiram NB, Rao CV. Role of lipoxins and resolvins as
anti‑inflammatory and proresolving mediators in colon cancer.
Curr Mol Med 2009;9:565‑79.
34. Fredman G, Oh SF, Ayilavarapu S, Hasturk H, Serhan CN,
Van Dyke TE. Impaired Phagocytosis in Localized Aggressive
Periodontitis: Rescue by Resolvin E1. PLoS One 2011;6:e24422.
35. Grover V, Malhotra R, Kapoor A, Singh J, Sachdeva S.
Pro‑resolution mediators and receptors: Novel drug targets for
enhancing pharmacological armamentarium against periodontal
inflammation. Infect Disord Drug Targets 2013;13:75‑84.
36. Kohli P, Levy BD. Resolvins and protectins: Mediating solutions
to inflammation. Br J Pharmacol 2009;158:960‑71.
37. Riccelli AE, Agarwal S, Piesco NP, Hoffman RD, Suzuki JB. Role of
cytokines in periodontal diseases. J Calif Dent Assoc 1995;23:48‑51.
38. Bartold PM, Cantley MD, Haynes DR. Mechanisms and
control of pathologic bone loss in periodontitis. Periodontol
2000 2010;53:55‑69.
39. Waykole YP, Doiphode SS, Rakhewar PS, Mhaske M. Anticytokine
therapy for periodontal diseases: Where are we now? J Indian Soc
Periodontol 2009;13:64‑8.
40. Garlet GP, Cardoso CR, Campanelli AP, Martins W Jr, Silva JS.
Expression of suppressors of cytokine signaling in diseased
periodontal tissues: a stop signal for disease progression? J
Periodontal Res 2006;41:580‑4.
41. de Souza JA, Nogueira AV, de Souza PP, Cirelli JA, Garlet GP,
RossaCJr.Expressionofsuppressorofcytokinesignaling1and3in
ligature‑inducedperiodontitisinrats.ArchOralBiol2011;56:1120‑8.
42. Lima V, Vidal FD, Rocha FA, Brito GA, Ribeiro RA. Effects
of tumor necrosis factor‑alpha inhibitors pentoxifylline and
thalidomide on alveolar bone loss in short‑term experimental
periodontal disease in rats. J Periodontol 2004;75:162‑8.
43. Cochran DL. Inflammation and bone loss in periodontal disease.
J Periodontol 2008;79:1569‑76.
44. Jin Q, Cirelli JA, Park CH, Sugai JV, Taba M Jr, Kostenuik PJ, et al.
RANKL Inhibition Through Osteoprotegerin Blocks Bone Loss
in Experimental Periodontitis. J Periodontol 2007;78:1300‑8.
45. Martuscelli G, Fiorellini JP, Crohin CC, Howell TH. The effect of
interleukin‑11 on the progression of ligature‑induced periodontal
disease in the beagle dog. J Periodontol 2000;71:573‑8.
46. Shinoda H, Takeyama S, Suzuki K, Murakami S, Yamada S.
Pharmacological topics of bone metabolism: a novel
bisphosphonate for the treatment of periodontitis. J Pharmacol
Sci 2008;106:555‑8.
47. Tenenbaum HC, Shelemay A, Girard B, Zohar R, Fritz PC.
Bisphosphonates and periodontics: Potential applications
for regulation of bone mass in the periodontium and other
therapeutic/diagnostic uses. J Periodontol 2002;73:813‑22.
48. Yip RML. Bisphosphonates and Osteonecrosis of the Jaw. Hong
Kong Bull Rheum Dis 2008;8:19‑25.
49. Shoji K, Horiuchi H, Shinoda H. Inhibitory effects of
acbisphosphonate (risedronate) on experimental periodontitis
in rats. J Periodontal Res 1995;30:277‑84.
50. Inagaki K, Kurosu Y, Sakano M, Yamamoto G, Kikuchi T,
Noguchi T, et al. Oral osteoporosis: a review and its dental
implications. Clin Calcium 2007;17:157‑63.
51. Shu L, Guan SM, Fu SM, Guo T, Cao M, Ding Y. Estrogen
modulates cytokine expression in human periodontal ligament
cells. J Dent Res 2008;87:142‑7.
52. Southan GJ, Szabo C. Selective pharmacological inhibition of
distinct nitric oxide synthase isoforms. Biochem Pharmacol
1996;51:383‑94.
53. Chapple IL. Reactive oxygen species and antioxidants in
inflammatory diseases. J Clin Periodontol 1997;24:287‑96.
54. Batista AC, Silva TA, Chun JH, Lara VS. Nitric oxide synthesis and
severity of human periodontal disease. Oral Dis 2002;8:254‑60.
55. Lohinai Z, Benedek P, Feher E, Gyorfi A, Rosivall L, Fazekas A,
et al. Protective effects of mercaptoethylguanidine, a selective
inhibitor of inducible nitric oxide synthase, in ligature‑induced
periodontitis in the rat. Br J Pharmacol 1998;123:353‑60.
56. Leitao RF, Ribeiro RA, Chaves HV, Rocha FA, Lima V, Brito GA.
Nitric oxide synthase inhibition prevents alveolar bone resorption
in experimental periodontitis in rats. J Periodontol 2005;76:956‑63.
57. Thomas CM, Versalovic J. Probiotics‑host communication:
Modulation of signaling pathways in the intestine. Gut Microbes
2010;1:148‑63.
58. Teughels W, Loozen G, Quirynen M. Do probiotics offer
opportunities to manipulate the periodontal oral microbiota? J
Clin Periodontol 2011;38:159‑77.
59. Hajishengallis G. Toll gates to periodontal host modulation and
vaccine therapy. Periodontol 2000 2009;51:181‑207.
60. Yokoyama K, Sugano N, Shimada T, Shofiqur RA, Ibrahim el‑SM,
Isoda R, et al. Effects of egg yolk antibody against Porphyromonas
gingivalis gingipains in periodontitis patients. J Oral Sci
2007;49:201‑6.
61. Choi J, Borrello MA, Smith E, Cutler CW, Sojar H, Zauderer M.
Prior exposure of mice to Fusobacterium nucleatum modulates host
response to Porphyromonas gingivalis. Oral Microbiol Immunol
2001;16:338‑44.
62. Reddy S, Kaul S, Asutkar H, Bhowmik N, Amudha. Host
modulation in periodontics. e‑Journal of Dentistry 2011;1:51‑62.
63. La VD, Howell AB, Grenier D. Cranberry proanthocyanidins
inhibit MMP production and activity. J Dent Res 2009;88:627‑32.
64. Bodet C, Chandad F, Grenier D. Cranberry components inhibit
interleukin‑6, interleukin‑8, and prostaglandin E production by

lipopolysaccharide‑activated gingival fibroblasts. Eur J Oral Sci
2007;115:64‑70.
65. Venezia E, Goldstein M, Boyan BD, Schwartz Z. The use of enamel
matrixderivativeinthetreatmentofperiodontaldefects:A literature
review and meta‑analysis. Crit Rev Oral Biol Med 2004;15:382‑402.
66. Hammarström L, Heijl L, Gestrelius S. Periodontal regeneration
in a buccal dehiscence model in monkeys after application of
enamel matrix proteins. J Clin Periodontol 1997;24:669‑77.
67. Hammarström L. Enamel matrix, cementum development and
regeneration. J Clin Periodontol 1997;24:658‑68.
68. Heijl L, Heden G, Svardström G, Ostgren A. Enamel matrix
derivative (Emdogain) in the treatment of intrabony periodontal
defects. J Clin Periodontol 1997;24:705‑14.
69. Lyngstadaas SP, Wohlfahrt JC, Brookes SJ, Paine ML, Snead ML,
Reseland JE. Enamel matrix proteins; old molecules for new
applications. Orthod Craniofac Res 2009;12:243‑53.
70. Urist MR, Strates BS. The Classic: Bone Morphogenetic Protein.
Clin Orthop Relat Res 2009;467:3051‑62.
71. Chen FM, An Y, Zhang R, Zhang M. New insights into and novel
applications of release technology for periodontal reconstructive
therapies. J Control Release 2011;149:92‑110.
72. Sood S, Gupta S, Mahendra A. Gene therapy with growth factors
for periodontal tissue engineering–A review. Med Oral Patol Oral
Cir Bucal 2012;17:e301‑10.
73. Nevins M, Giannobile WV, McGuire MK, Kao RT, Mellonig JT,
Hinrichs JE, et al. Platelet derived growth factor (rhPDGF‑BB)
stimulates bone fill and rate of attachment level gain, results of
a large, multicenter randomized controlled trial. J Periodontol
2005;76:2205‑15.
74. Mitsuta T, Horiuchi H, Shinoda H. Effects of topical administration
of clodronate on alveolar bone resorption in rats with experimental
periodontitis. J Periodontol 2002;73:479‑86.
75. Houshmand B, Rahimi H, Ghanavati F, Alisadr A, Eslami B.
Boosting effect of bisphosphonates on osteoconductive materials:
a histologic in vivo evaluation. J Periodontal Res 2007;42:119‑23.
76. Veena HR, Prasad D. Evaluation of an aminobisphosphonate
(alendronate) in the management of periodontal osseous defects.
J Indian Soc Periodontol 2010;14:40‑5.
77. Zeshmukh J, Jawali MA, Kulkarni VK. Host modulation
therapy – a promising new concept in treating periodontal
diseases. Int J Dent Clin 2011:3:48‑53.
78. Howell TH, Fiorellini J, Weber HP, Williams RC. Effect of the
NSAID piroxicam, topically administered, on the development
of gingivitis in beagle dogs. J Periodont Res 1991;26:180‑3.
79. Kornman KS, Blodgett RF, Brunsvold M, Holt SC. Effects of topical
applications of meclofenamic acid and ibuprofen on bone loss,
subgingival microbiota and gingival PMN response in the primate
Macaca fascicularis. J Periodont Res 1990;25:300‑7.
80. Mainnemare A, Mégarbane B, Soueidan A, Daniel A, Chapple IL.
Hypochlorous Acid and Taurine‑N‑Monochloramine in
Periodontal Diseases. J Dent Res 2004;83:823‑31.
81. Lorenz K, Mayer D, Bruhn G, Noack B, Brecx M, Heumann C,
et al. Effect of N‑chlorotaurine mouth rinses on plaque regrowth
and plaque vitality. Clin Oral Investig 2009;13:9‑14.
82. Hasturk H, Kantarci A, Ebrahimi N, Andry C, Holick M, Jones VL,
et al. Topical H2 antagonist prevents periodontitis in a rabbit
model. Infect Immun 2006;74:2402‑14.
How to cite this article: Gulati M, Anand V, Govila V, Jain N. Host
modulation therapy: An indispensable part of perioceutics. J Indian
Soc Periodontol 2014;18:282-8.
Source of Support: Nil, Conflict of Interest: None declared.
“Quick Response Code” link for full text articles
The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on its first page has
a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet source, one can reach to the full
text of that particular article on the journal’s website. Start a QR-code reading software (see list of free applications from http://tinyurl.com/
yzlh2tc) and point the camera to the QR-code printed in the journal. It will automatically take you to the HTML full text of that article. One can
also use a desktop or laptop with web camera for similar functionality. See http://tinyurl.com/2bw7fn3 or http://tinyurl.com/3ysr3me for the free
applications.

Host modulation therapy: An indispensable part of perioceutics

More Related Content

What's hot

Viewers also liked

Similar to Host modulation therapy: An indispensable part of perioceutics

Recently uploaded

Host modulation therapy: An indispensable part of perioceutics