Host Modulated Therapy

Host Modulated Therapy – Adjuntive use of Periosat (SDD)

Sub-antimicrobial dose doxycycline 20mg (SDD), also called PerioStat, is an effective way to therapeutically control, or “down-regulate”, exaggerated levels of harmful enzymes associated with chronic periodontal disease destruction (bone loss around the teeth).  This post will help clarify the adjunctive benefit of  Periostat (SDD – sub-antimicrobial dose doxycycline) as an important part of  the PerioPeak Innovations protocol called RPE, or Regenerative Periodontal Endoscopy.

Periodontal research has revealed that the body’s exaggerated and chronic inflammatory response is what causes periodontal destruction in many individuals.  While inflammation is a normal and healthy immune response, we now know that chronic inflammation can be very harmful and destructive – especially the chronic inflammation associated with periodontal disease. Periodontal research published on PerioStat demonstrates that it is an effective adjunct to periodontal therapy – reducing chronic inflammation, periodontal pockets, and arresting or slowing bone loss.  Periodontal inflammation can be well controlled with Periostat used adjunctively with professional care (periodontal therapy).  Meanwhile, all risk factors (host factors) contributing to the chronic inflammation can be revealed and defintively addressed (we recommend comprehensive medical labs and molecular testing on all of our clients to determine underlying cause beyond plaque and calculus).

Why is Periostat (host modulated therapy) such an integral part of the Regenerative Periodontal Endoscopy protocol?

Down regulating chronic inflammation with host modulation (Periostat – SDD), starting one – two weeks before performing a microscope procedure called Regenerative Periodontal Endoscopy, reduces bleeding and inflammation significantly, allowing clear vision into all deep periodontal pockets with a periodontal endoscope – allowing for more definitive treatment overall.  Down-regulating the chronic inflammation immune response with host modulation prior to treatment  also firms all gum tissues, promoting more rapid healing (reattachment of gum pockets) following RPE.  But most importantly, Periostat reduces the levels of bone destroying (osteoclasts), while activating the bodies bone building cells (osteoblasts).

Host factors contributing to chronic periodontal inflammation may include presence of pathogenic bacteria, genetic predisposition (exaggerated host response), smoking, diabetes and prediabetes (elevated glucose levels), obesity, AIDS or other immune diseases,  neglect, inadequate professional cleanings, depression, certain medications, oxidative stress, depleted or excess hormones including thyroid, poor diet, vitamin deficiencies (especially D), anemia, dry mouth (xerostomia), alcoholism, contraceptives, medications for high blood pressure (calcium channel blockers), and stress.

More about risk factors in periodontal disease:

Sub-antimicrobial dose doxycycline (Periostat) 20mg tablet, taken up to twice daily, slows the progression of periodontal disease by suppressing or down-regulating the “over-production” of a destructive enzyme called collagenase.   At only 20mg, this low dose of doxycycline puts the body back into balance by reducing inflammation and allowing periodontal health to be restored when combined with active periodontal therapy (professional care).  If  used with periodontal endoscopy and emdogain, Periostat can actually enhance and promote reattachment and regeneration – Regenerative Periodontal Endoscopy -RPE.   

Important note about SDD (Periostat):  At this very low dose, 20mg doxycycline is sub-clinical (sub-antimicrobial dose), meaning it has no effect on the bacteria whatsoever. The therapeutic benefit of this medication has nothing to do with killing bacteria anywhere in the body.  In addition, research demonstrates that there has been no evidence of antibacterial resistance using SDD (Periostat), even long term (12 months).

Suggested important reading on SDD:  “Host reponse modulation in Periodontics” – by Philip Preshaw, DDS, MS, Periodontology 2000, Volume 48, 2008, 92-110.

-exerpts from the above paper below –

 Certain individuals appear to be more susceptible to periodontal disease, and this increased susceptibility is largely determined by the immune-inflammatory response that develops in the periodontal tissues following chronic exposure to bacterial plaque. Periodontal pathogenesis has been extensively reviewed by a number of authors (52, 54, 73) and it is not the purpose of this paper to cover this ground again. Suffice to say, the microbial challenge presented by subgingival plaque results in an upregulated host immune-inflammatory response in the periodontal tissues that is characterized by the excessive production of inflammatory cytokines (e.g. interleukins, tumor necrosis factor- (e.g. prostaglandin E matrix metalloproteinases (MMPs)]. These proinflammatory mediators are responsible for the majority of periodontal breakdown that occurs, leading to the clinical signs and symptoms of disease.

 Effects of low dose doxycycline (SDD)

• Direct inhibition of active MMPs by cation chelation (dependent on Ca2+- and Zn2+-binding properties)

• Inhibits oxidative activation of latent MMPs (independent of cation-binding properties)

• Downregulates expression of key inflammatory cytokines (interleukin-1, interleukin-6 and tumor

necrosis factor-a) and prostaglandin E2

• Scavenges and inhibits production of reactive oxygen species produced by neutrophils

• Inhibits MMPs and reactive oxygen species thereby protecting a1-proteinase inhibitor, and thus

indirectly reducing tissue proteinase activity 

 • Stimulates fibroblast collagen production (stimulates regeneration of collagen)

• Reduces osteoclast activity and bone resorption

• Inhibits osteoclast MMPs

Clearly, SDD has regenerative benefits as chronic inflammation subsides.  Thus, it is one of the most valuable tools available in the fight against periodontal disease, especially if there are systemic host factors which cannot be controlled such as a genetic hyper-inflammatory immune response. 

Published research also demonstrates that added benefits of taking SDD daily include lowering blood glucose levels,  lowering CRP (C-Reactive Protein) and other biomarkers for cardiovascular disease, and lowering cholesterol in patients with chronic periodontitis and cornonary artery disease.  This is profound, and it demonstrates well that SDD has a positive effect throughout the body.  SDD is also effective in the treatment of rosacea and rheumatoid arthritis.

Preventative periodontal care is about helping our patients to understand what is causing their disease, discussing options for treatment, and empowering them to move forward in health.  There are host factors (risk factors) which cannot be controlled with all the best intentions – such as genetic predisposition – without modifying the host response.  SDD is an excellent and effective adjunct to alter the course of periodontal disease safely and effectively.

Note:  SDD (Periostat) requires a prescription and is available in generic form to reduce the expense.  Generic sub-antimicrobial dose doxycycline 20mg is avialable in most drug stores.   The brand name of SDD is PerioStat.

Excerpts from the Journal of Clinical Periodontology 2004 Sept. re SDD:

Subantimicrobial dose doxycycline as adjunctive treatment for periodontitis. A review.

Preshaw PM, Hefti AF, Jepsen S, Etienne D, Walker C, Bradshaw MH.

School of Dental Sciences, University of Newcastle upon Tyne, UK.

Studies have shown that SDD, when prescribed as an adjunct to scaling and root planing (SRP), results in statistically and clinically significant gains in clinical attachment levels and reductions in probing depths over and above those that are achieved by SRP alone. SRP must be thorough and performed to the highest standard to maximise the benefits of adjunctive SDD.

SDD does not result in antibacterial effects, or lead to the development of resistant strains or the acquisition of multiantibiotic resistance. The frequency of adverse events is low, and does not differ significantly from placebo.

Article about sub-antimicrobial dose doxycycline (SDD)

What about published research with Periostat (sub-antimicrobial dose doxycycline). There are numerous papers published on SDD demonstrating the therapeutic benefits in the treatment of periodontal disease as well as the positive systemic effects of Periostat with multiple inflammatory diseases.  Click on the links below and browse through additional links there.

Periodontal therapeutics: Current host‐modulation agents and future directions

Lorne M. Golub 1 and Hsi‐Ming Lee 1

More studies below: