Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Host modulation therapy: An indispensable part of perioceutics


Published on

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.

Published in: Health & Medicine
  • Login to see the comments

Host modulation therapy: An indispensable part of perioceutics

  1. 1. 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@ 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: DOI: 10.4103/0972-124X.134559 Quick Response Code: Review Article [Downloaded free from on Monday, August 04, 2014, IP:]  ||  Click here to download free Android application for this journal
  2. 2. 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 [Downloaded free from on Monday, August 04, 2014, IP:]  ||  Click here to download free Android application for this journal
  3. 3. Gulati, et al.: Host modulation 284 Journal of Indian Society of Periodontology - Vol 18, Issue 3, May-Jun 2014 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] [Downloaded free from on Monday, August 04, 2014, IP:]  ||  Click here to download free Android application for this journal
  4. 4. Gulati, et al.: Host modulation Journal of Indian Society of Periodontology - Vol 18, Issue 3, May-Jun 2014 285 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 on Monday, August 04, 2014, IP:]  ||  Click here to download free Android application for this journa
  5. 5. Gulati, et al.: Host modulation 286 Journal of Indian Society of Periodontology - Vol 18, Issue 3, May-Jun 2014 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 [Downloaded free from on Monday, August 04, 2014, IP:]  ||  Click here to download free Android application for this journal
  6. 6. Gulati, et al.: Host modulation Journal of Indian Society of Periodontology - Vol 18, Issue 3, May-Jun 2014 287 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 [Downloaded free from on Monday, August 04, 2014, IP:]  ||  Click here to download free Android application for this journal
  7. 7. Gulati, et al.: Host modulation 288 Journal of Indian Society of Periodontology - Vol 18, Issue 3, May-Jun 2014 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 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 or for the free applications. [Downloaded free from on Monday, August 04, 2014, IP:]  ||  Click here to download free Android application for this journal