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Mechanisms and control of

pathologic bone loss in

The periodontal diseases range from the relatively
benign form of periodontal disease known as gingi-
vitis, to chronic and aggressive forms of periodontal
disease, all of which not only threaten the dentition
but may also be a threat to general health (72). All
forms of inammatory periodontal disease are asso-
ciated with chronic inammation, resulting in
destruction of the periodontal ligament and bone. If
left untreated, signicant tissue damage occurs; the
affected teeth can become loose and may be lost if
the disease continues to be active. The periodontal
diseases are very prevalent, with up to 90% of the
adult population suffering from gingivitis, 60%
having chronic periodontitis and 515% having
aggressive periodontitis (72).
Histologically and biochemically the periodontal
lesions of patients with chronic and aggressive peri-
odontitis appear to be similar. While there may be
some differences in the cellular inltrate between
these two diseases (discussed elsewhere in this edi-
tion of Periodontology 2000), the molecular mediators
and pathologic processes are generally the same. The
only differences between chronic periodontitis and
aggressive periodontitis with regard to tissue
destruction appear to be perhaps the magnitude,
sequelae and control of the response. Otherwise the
mechanisms are remarkably similar.
While a great deal of focus has been on managing
the inammation in the gingival tissues, advances in
our understanding of bone metabolism are opening
up new avenues of understanding regarding the
pathologic bone loss in periodontitis. This knowl-
edge, together with the development of novel drugs
that can inhibit bone loss destruction, provides us
with opportunities to target not only soft tissue
inammation but also the destructive bone loss seen
in periodontitis.
This review aims to demonstrate that, in the future,
periodontal treatments will not only target the
inammatory response but will also utilize adjunct
agents to prevent alveolar bone loss associated with
progressing periodontitis.
Mechanism of tissue damage in
Periodontitis (both aggressive and chronic) repre-
sents a specic inammatory response to microbial
residents of the subgingival biolm. Within the con-
ditions known as periodontitis there is considerable
variability in terms of clinical manifestation and
disease progression rates. This variability may be
attributed to differences in the composition of the
subgingival microbial ora. However, emerging evi-
dence strongly suggests that it is the inammatory
response of the host that drives the tissue destruc-
tion, and the variability of host responses can ac-
count for much of the variability in the clinical
manifestation of periodontitis. Hence, although bac-
teria are necessary for disease initiation, they are not
sufcient to cause disease progression unless there is
an associated inammatory response within a sus-
ceptible host (73).
Effector mechanisms of tissue
destruction in periodontitis
It is now well accepted that a large consortia of
cytokines, cell-signaling molecules and matrix me-
talloproteinases are dysregulated and intimately in-
volved in the pathogenesis of periodontitis. The task
Periodontology 2000, Vol. 53, 2010, 5569
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2010 John Wiley & Sons A/S
ahead of us is to identify the various roles of these
important biological mediators of inammation and
how to control them; for example, their cellular
sources, their concentrations, the cells they affect in
vivo, the stages in which they are active, the role and
concentrations of their inhibitors and, perhaps most
importantly, their site of action. Regarding this last
point, it is becoming apparent that the mechanisms
of soft tissue destruction (gingival and periodontal
ligament) and hard tissue destruction (alveolar bone)
are quite different. Indeed, the effects of cytokines
and cell-signaling molecules on normal and patho-
logical cellular process are important, and it is pro-
posed that their roles in the pathophysiology of
extracellular matrix destruction result from their
excessive production, dysregulation or inadequate
inhibition (80). Hence, the destruction of soft and
hard tissues seen in periodontitis is the result of not
only a large number of cytokines but also the sus-
tained presence of other effector molecules released
by resident and migrating cells. Together these
inammatory mediators of inammation are able to
induce the cascade of molecular events associated
with extracellular matrix degradation and resultant
tissue damage.
Mechanisms of bone loss in
A principal feature of inammatory-mediated bone
loss in periodontitis is enhanced osteoclast activity
without a corresponding increase in bone formation.
Osteoclasts are multinucleated cells that are derived
from the monocyte macrophage lineage and are
considered to be the principal cell responsible for
bone resorption (9, 54, 84). Studies in mice lacking
osteoclasts have demonstrated the pivotal role of the
cells in bone resorption (76, 79). Multinucleated os-
teoclasts have been shown to resorb alveolar bone in
both animal and human studies of periodontitis. The
formation of osteoclasts is driven by cytokines pres-
ent in the inamed periodontal tissues, and under-
standing this process is central in the development of
strategies to control this process. Figure 1 demon-
strates the inammatory cytokines involved in
periodontal bone resorption.
It is well established that the immune and inam-
matory systems are central to the development of
periodontitis. More recently the role of the immune
system in bone metabolism and bone resorption has
been recognized (104). The relationship between the
immune system and bone metabolism has been
termed osteoimmunology, and this is a rapidly
evolving eld of investigation (3). Osteoimmunology
seeks to dene and understand the interactions of
immune cells and their cytokines with skeletal cells.
Both the immune system and bone share a large
number of regulatory cytokines and other molecules
in common. It is clear that understanding osteoim-
munology will be central for the development of new
means to prevent and control pathologic bone loss in
diseases such as periodontitis. To date, a number of
key regulatory molecules have been identied and
these are generally related to the receptor activator of
nuclear factor kappaB ligand (RANKL), its receptor,
receptor activator of nuclear factor kappaB (RANK),
as well as associated signaling molecules and tran-
scription factors. The key elements of this system are
discussed below.
Macrophage colony-stimulating factor
Macrophage colony stimulating factor (M-CSF) was
one of the earliest signaling molecules identied to
play a role in osteoclast development and activation.
M-CSF is produced mainly by osteoblasts or bone
marrow stromal cells and binds to a receptor on
pre-osteoclasts known as cFMS, a member of the
tyrosine kinase receptor superfamily. The binding of
M-CSF to cFMS results in the activation of several
transcription factors, including c-fos, which leads to
the initiation of osteoclastogenesis. It appears that
the main role of M-CSF is to promote the prolifer-
ation and survival of pre-osteoclasts as well as ma-
ture osteoclasts (13). M-CSF knockout mice have
been found to have an osteopetrotic phenotype as a
result of the lack of osteoclasts and thus lack of
bone resorption. Administration of M-CSF to these
animals reverses the osteopetrotic condition and
restores osteoclast development and subsequent
bone resorption, conrming the importance of M-
CSF in osteoclastogenesis (48).
RANKL is a key mediator in the process of osteoclast
formation. This membrane-bound protein is a
member of the tumor necrosis factor superfamily and
is expressed by a variety of cells, including osteo-
blasts, broblasts and T-cells. During normal bone
metabolism, RANKL is expressed by osteoblasts.
However, at inammatory sites RANKL is also
Bartold et al.
expressed by immune cells such as T-lymphocytes
(106). The expression of RANKL is also regulated by
other modulators of bone metabolism including
parathyroid hormone, vitamin D3 and interleukin-11
(51, 61).
The binding of RANKL to its receptor RANK on the
surface of pre-osteoblasts results in the activation of
c-jun terminal kinase and the subsequent activation
of nuclear factor-kappaB, leading to osteoclast for-
mation. While RANKL is considered to be essential
for osteoclast-driven bone resorption, tumor necrosis
factor has also been reported to be capable of
inducing osteoclast bone resorption in the absence
of RANKL (47). However, this nding has been chal-
lenged and RANKL is generally accepted as the
essential ingredient for osteoclast formation (52).
Indeed, RANKL knockout mice demonstrate an
osteopetrotic phenotype as a result of the absence
of osteoclasts (76). Subsequent administration
of RANKL to these animals restores osteoclast for-
mation and function, leading to enhanced bone
resorption and the development of osteoporosis (51).
RANKL also plays an important role in osteoim-
munology. The production of RANKL is regulated in
response to the presence of inammatory cytokines
such as tumor necrosis factor-alpha and interleukin-
1 (12, 39). A number of studies have conrmed a role
for RANKL in periodontal bone resorption. Elevated
expression of RANKL has been noted in inamed
periodontal tissues (16). We have also demonstrated
a high expression of RANKL in broblasts and
mononuclear cells in inamed periodontal tissues
and this appears to be closely associated with sites of
bone loss (19). The distribution of RANKL in inamed
periodontal tissues associated with bone loss is
shown in Fig. 2.
Osteoprotegerin is a natural inhibitor of RANKL. It
is a soluble tumor necrosis factor receptor-like
molecule that acts as a decoy and blocks the
binding of RANKL to RANK and thus prevents
osteoclastogenesis. Studies on osteoprotegerin
knockout mice have shown the animals to have an
osteoporotic phenotype (11). However, mice that
overexpress osteoprotegerin develop osteopetrosis;
this is because of a lack of osteoclast formation and
hence a lack of bone resorption (65). Further tumor
necrosis factor-mediated bone destruction can be
prevented through the administration of osteopro-
tegerin, thus reducing the osteoclast numbers (78).
Osteoprotegerin is produced by human periodontal
ligament cells, gingival broblasts and epithelial
cells (44, 86), and its expression is modulated by
inammatory cytokines. We have previously dem-
onstrated that there is a reduction in osteoproteg-
erin levels in the granulomatous tissue adjacent to
Fig. 1. Role of inammatory cytokines in periodontal
bone resorption. Osteoclast formation occurs locally and
on the external surface of the bone via several mecha-
nisms. The inammatory cytokines result in the produc-
tion of receptor activator of nuclear factor kappaB (RANK)
by lymphocytes and broblasts. In addition, the inam-
matory cytokines can directly activate monocytes to
differentiate into macrophages and pre-osteoclasts. In
conjunction with receptor activator of nuclear factor
kappaB ligand (RANKL), the inammatory cytokines can
act directly on the pre-osteoclasts leading to osteoclast
Bone loss in periodontitis
alveolar bone loss (19), suggesting that the balance
between RANKL levels and osteoprotegerin levels
regulates the bone destruction observed in perio-
RANKL osteoprotegerin ratio in
inamed periodontal tissues
A number of studies to date have analysed the con-
centrations and distribution of osteoprotegerin and
RANKL in healthy and in inamed periodontal tis-
sues. The RANKL osteoprotegerin ratio in inamed
periodontal tissues has been found to increase either
because of an increase in RANK or a decrease in os-
teoprotegerin, or both. Such ndings are consistent
with studies investigating the role of RANKL osteo-
protegerin in bone resorption in conditions such as
rheumatoid arthritis. Not only is the RANKL osteo-
protegerin ratio increased at sites of periodontal
inammation, but recent reports suggest that this
ratio also correlates with disease severity. For exam-
ple, the RANKL osteoprotegerin ratio is increased in
the gingival crevicular uid obtained from patients
with chronic periodontitis or aggressive periodontitis
compared to that obtained from patients with gingi-
vitis or from healthy patients (8). These ndings
identify a promising therapeutic target and have
encouraged the development and use of drugs that
modulate the RANKL RANK osteoprotegerin axis,
leading to an increase in osteoprotegerin and a de-
crease in RANKL, consistent with an equilibrium
state between bone formation and bone destruction.
Intracellular regulators of
When RANKL binds to RANK, a number of intracel-
lular signaling pathways are activated, including
those responsible for producing factors such as tu-
mor necrosis factor receptor factor-6 and c-Fos, all of
which are involved in osteoclast differentiation and
activation (Fig. 1). All of these pathways are also in-
volved in the induction and activation of nuclear
factor of activated T-cells-1, which is considered to
be the master transcription factor for osteoclasto-
genesis (105).
Tumor necrosis factor receptor factor-6
Tumor necrosis factor receptor factor-6 plays an
important role in linking the intracellular events fol-
lowing RANK RANKL interactions. An initial step in
RANK signaling is the binding of tumor necrosis
factor receptor factor adaptor proteins to the cyto-
plasmic domain of RANK. This role in osteoclast
formation has been demonstrated through tumor
necrosis factor receptor factor-6-decient mice,
which have been found to have an osteopetrotic
phenotype. In these animals, osteoclast formation is
impeded as a result of incomplete signaling following
RANK RANKL binding (68). Some of the main
downstream targets of tumor necrosis factor receptor
factor-6 include transcription factors (nuclear factor-
kappaB, activator protein-1 and nuclear factor of
activated T-cells-1) and various mitogen-activated
protein kinases, including p38 stress kinase, c-jun N-
terminal kinase, extracellular signal-regulated kinases
(ERK) and phosphoinositide 3-kinases (Pi3K)
protein kinase B (AKT) (108).
Nuclear factor kappa-light-chain-
enhancer of activated B cells
A crucial transcription factor that is needed for suc-
cessful osteoclast formation and activation, and
which is involved in RANK signaling, is nuclear fac-
tor-kappaB. This has been demonstrated by the fact
that nuclear factor-kappaB knockout mice develop
Normal gingiva Periodontitis
Fig. 2. Immunolocalization of osteoprotegerin (OPG) and
receptor activator of nuclear factor kappaB ligand
(RANKL) in healthy tissue and in inamed (periodontitis)
gingival tissues. The amount of osteoprotegerin (A and B)
staining in the inamed tissues appears to decrease and
the amount of RANKL (C and D) staining appears to in-
crease with the presence of inammation in the gingival
Bartold et al.
osteopetrosis because of a lack of osteoclasts (42).
Following activation by the binding of RANKL to
RANK, nuclear factor-kappaB, which is located in the
cytoplasm of nonstimulated cells, enters the nucleus
and activates the inhibitor of NfkappaB kinase (IkB)
kinase complex (97). There are two catalytic sites
within the IkappaB kinase (IKK) complex IKK-a
(IKK-1) and IKK-b (IKK-2) which are linked to a
third regulatory component IKK-c. Of these com-
ponents it is the IKK-b that is essential for nuclear
factor-kappaB activation through the phosphory-
lation of IKK-a, leading to its degradation and
subsequent activation of nuclear factor-kappaB (85).
Alternatively, IKK-a can activate nuclear factor-
kappaB through phosphorylation and proteosome
processing of P-100, which generates an active p52
product (4). Both of these pathways are considered to
be of central importance for osteoclast formation.
Activator protein-1 family
The transcription factor complex known as activator
protein-1 is activated following RANK RANKL
binding. Activator protein-1 is a dimeric complex
composed of the Jun (c-Jun, JunB, JunD), Fos (c-Fos,
FosB, Fra-1, Fra-2) and activating transcription fac-
tor (ATF) (ATFa, ATF2, ATF3, ATF4, B-ATF) proteins
(115). Of these, c-Fos is the major activator protein-1
induced by RANK RANKL binding. Mice decient in
c-Fos develop a severe osteopetrotic phenotype as a
result of their inability to form osteoclasts (34).
Another major component of the activator protein-1
complex is the Jun family of proteins. Unlike c-Fos,
mice with conditional knockout of c-Jun and JunB
do not show complete inhibition of osteoclast for-
mation, and this indicates that these activator pro-
tein-1 components may be able to substitute for
each other during osteoclastogenesis (115). The
crucial role of c-Fos in osteoclastogenesis is further
demonstrated by the observation that the induction
of nuclear factor of activated T-cells-1 by RANKL
does not occur in c-Fos-decient cells (103). The
importance of nuclear factor of activated T-cells-1 in
osteoclastogenesis is discussed below.
Nuclear factor of activated T-cells
As detailed above, RANKL RANK binding activates
nuclear factor-kappaB, activator protein-1 and mito-
gen-activated protein kinses, which are considered to
be important in osteoclastogenesis. However, be-
cause these pathways can also be activated by inter-
leukin-1, which does not induce osteoclastogenesis,
other, more specic, pathways of terminal osteoclast
differentiation are likely to be specic for osteoclast
development. As such, nuclear factor of activated T-
cells-1 has been identied as a key intracellular
molecule specically involved in the regulation of
terminal osteoclast differentiation (4). Nuclear factor
of activated T-cells-1 expression relies upon the
expression of tumor necrosis factor receptor factor-6,
nuclear factor-kappaB and c-Fos, all of which are
activated by RANKL. Evidence for a central role of
nuclear factor of activated T-cells-1 in osteoclast
formation comes from the observations that nuclear
factor of activated T-cells-1-decient embryonic stem
cells are unable to differentiate into osteoclasts and
the expression of ectopic nuclear factor of activated
T-cells-1, in the absence of RANKL, can stimulate
bone marrow-derived precurser cells to differentiate
into osteoclasts (103). Nuclear factor of activated T-
cells-1 has been determined to be the end point factor
that leads to the expression of osteoclast genes such
as the calcitonin receptor (CTR), cathepsin K, tartrate-
resistant acid phosphatase (TRAP) and the b3 integrin
and osteoclast-associated receptor (OSCAR).
Therapeutic approaches to treat
pathologic bone loss
Conventional therapies in conditions such as rheu-
matoid arthritis which, like periodontitis, involve
both soft and hard tissue destruction have included
the use of agents such as nonsteroidal anti-inam-
matory drugs, glucocorticoids and disease-modifying
anti-rheumatic drugs. Unfortunately, while these
therapies may reduce the inammation, none of
these medications appear to have any direct effect on
controlling or reversing bone resorption. This, to-
gether with a number of well-documented unwanted
(and sometimes life-threatening) side-effects, makes
these medications of limited use in the treatment of
pathologic bone loss in periodontitis.
Tumor necrosis factor-alpha
More recently, anti-tumor necrosis factor-alpha
therapy has become a well-accepted therapy for the
management of rheumatoid arthritis as a result of its
rapid onset of action, which reduces joint destruction
compared with the medications listed above. Tumor
necrosis factor-alpha is produced by activated mac-
rophages as well as by many other connective tissue
Bone loss in periodontitis
cells such as synoviocytes and periodontal bro-
blasts. Tumor necrosis factor-alpha has been re-
ported to act either directly on osteoclasts (47) or
indirectly to induce osteoclast formation through the
stimulation of RANKL production by osteoblasts (90).
Because tumor necrosis factor-alpha can inuence
osteoclast formation in the presence or absence of
RANKL it is a potential therapeutic target to control
pathologic bone loss.
There are currently at least ve tumor necrosis fac-
tor-alpha antagonists that are commercially available
and approved for use in the treatment of rheumatoid
arthritis (Table 1). While effective, these medications
are generally used only if more traditional therapies
have failed. Hence, by the time that anti-tumor
necrosis factor-alpha medications are used, bone
resorptionwill already have occurred, thus limiting the
effectiveness of anti-tumor necrosis factor-alpha in
eliminating bone resorption. Recent evidence indi-
cates that even if anti-tumor necrosis factor-alpha is
administered at the onset of rheumatoid arthritis,
bone damage can still occur (40). Other reports have
indicated that treatment with anti-tumor necrosis
factor-alpha can result in small increases in bone
mineral density, but this may be of limited clinical
signicance (87). Nonetheless, bone loss at sites of
inammation and in conditions such as osteoporosis
are associated with the presence of tumor necrosis
factor-alpha, and hence anti-tumor necrosis factor-
alpha therapy may have the potential to be benecial
for bone loss in inammatory diseases (36, 87).
Tumor necrosis factor-alpha has been recognized
for some time as an important cytokine in peri-
odontal inammation and tissue destruction (74).
Overexpression of tumor necrosis factor-alpha has
been associated with osteoclastogenesis in patients
with periodontitis (10), and tumor necrosis factor
antagonists have been shown to inhibit the inam-
matory response and bone loss in experimental
periodontitis (5). However, more recently, results
from studies investigating the effects of tumor
necrosis factor-alpha inhibitors on periodontal
parameters have produced conicting results (23, 32,
62, 71, 75). While the currently available anti-tumor
necrosis factor-alpha agents have shown some
promise, further studies are needed to determine
their true efcacy relative to their expense and side
effects as an adjunct to periodontal treatment.
Apart from tumor necrosis factor-alpha a large
number of other inammatory cytokines are involved
in inammatory diseases associated with bone loss
and have therefore become logical targets for the
development of therapeutic agents (Table 1).
One of the rst cytokines to be targeted was
interleukin-1 as a result of its key regulatory role in
bone resorption in diseases such as rheumatoid
arthritis and periodontitis. In addition to interleukin-
1, agents targeting interleukin-3, interleukin-6,
interleukin-15 interleukin-12 and interleukin-23 have
been studied (6, 26, 70, 92, 119).
These anti-cytokine agents provide new opportu-
nities to modulate host responses in inammatory
diseases. In particular, most seem to inuence the
secondary effects of cytokines on RANKL expression
and therefore may not inuence osteoclast-mediated
bone resorption directly. Future efforts in this area, to
ensure more effective control of pathologic bone
resorption, should try to target those cytokines that
directly inuence osteoclast formation and function.
Surprisingly few studies have investigated the ef-
fect of interleukin antagonists, such as those listed in
Table 1, on periodontitis. One study investigating
inammation and tissue loss in a nonhuman primate
model of periodontitis using human soluble inter-
leukin-1 receptor type 1 as an inhibitor of interleu-
kin-1 reported that the inhibition of interleukin-1 has
a signicant effect on the reduction of inammation,
connective tissue attachment loss and bone resorp-
tion (22). Given the emerging use of these agents as
anti-inammatory and anti-resorptive agents, further
investigations in experimental models of periodonti-
tis are warranted.
Antiresorptive therapies
It is apparent that despite the use of the above
medications, which generally target inammation
and its suppression, bone loss can still progress. In
light of this, agents that specically target bone
turnover have been investigated.
The bisphosphonates act through their ability to in-
hibit osteoclast activity and have been used in a
variety of bone disorders including osteoporosis, tu-
mor-associated osteolysis, arthritis and periodontitis
(28, 37). The actions of bisphosphonates can differ,
with some being more suited to the management of
systemic bone loss and others being better for con-
trolling focal or local areas of bone loss. As most
bisphosphonates act directly on osteoclasts and have
Bartold et al.
Table 1. Medications currently available for controlling inammation bone resorption
Tumor necrosis factor-alpha antagonists
Adalimumab Product name: Humira
Manufacturer: Abbott Laboratories
Description: human monoclonal antibody
Cetrolizumab pegol Product name: Cimzea
Manufacturer: UCB (Union chimique belge)
Description: humanized tumor necrosis factor-alpha antibody
Entanercept Product name: Enbrel
Manufacturer: Amgen and Wyeth
Description: Tumor necrosis factor receptor (p75): Fc1IgG construct
Golimumab Product Name: Simponi
Manufacturer: Centocor
Fully human monoclonal tumor necrosis factor-alpha antibody
Iniximab Product name: Remicade
Manufacturer: Centocor Schering-Plough elsewhere
Description: chimeric monoclonal antibody
Inhibitor of cytokines from the tumor
necrosis factor superfamily
Atacicept Product name: BLys
Manufacturer: Human Genome Sciences
Description: a recombinant fusion protein that binds and neutralizes
B-lymphocyte stimulator and a proliferation-inducing ligand
Anti-cytokine agents
Anakinra Product name: Kineret
Manufacturer: Amgen
Description: a recombinant, nonglycosylated form of the human interleu-
kin-1 receptor antagonist (IL-1Ra)
Canakinumab Product name: Ilaris
Manufacturer: Novartis
Description: recombinant, human anti-hu
man-interleukin-1 monoclonal antibody
that belongs to the IgG1 j isotype subclass.
Tocilizumab Product name: RoActemra
Manufacturer: Roche
Description: interleukin 6 (IL-6) receptor-inhibiting monoclonal antibody
AMG714 Product name: AMG714
Manufacturer: Novartis
Description: human monoclonal antibody against interleukin-15
Ustekinumab Product name: Stelara
Manufacturer: Centacor
Description: human monoclonal antibody. It is directed against
interleukin-12 and interleukin-23
Bone loss in periodontitis
little effect on inammation (95), they are often used
in combination with anti-inammatory agents for the
management of inammation-associated bone loss.
A number of studies have been carried out to assess
the potential for bisphosphonates to be used in the
management of periodontal bone loss (33, 53, 82, 94,
101, 102, 114). Although some of these studies have
demonstratedanimprovement inalveolar bone height
following bisphosphonate treatment and conven-
tional periodontal treatment, the improvements were
generally quite modest and of questionable clinical
signicance. Overall, the data published to date do not
support the use of bisphosphonates for the manage-
ment of periodontitis. Moreover, with the emergence
of osteonecrosis of the jaws being reported in people
undergoing bisphosphonate treatment (25, 50), the
wisdom of using these medications for the mana-
gement of periodontitis has been questioned (2, 28).
Hormone replacement therapy
Hormonal control of bone metabolism is well rec-
ognized, and the use of hormone replacement
therapy for the management of postmenopausal
osteoporosis has been shown to be benecial (20).
However, whether hormone replacement therapy is a
benecial treatment for other bone-resorptive con-
ditions is debatable. Indeed, the use of hormone
replacement therapy for the management of rheu-
matoid arthritis has produced conicting results (98,
116). Hormone replacement therapy in postmeno-
pausal women may produce some slight improve-
ment in their periodontal condition but generally
such improvements appear to be small and of
debatable value (35, 58). Therefore, given the poten-
tially large number of signicant side-effects associ-
ated with hormone replacement therapy, it is difcult
to see this being a recommended management
strategy for periodontitis.
RANKL RANK interactions
As detailed above, the RANKL RANK osteoproteg-
erin axis is central to the regulation of bone metab-
olism. Under normal homeostasis there is a balance
between bone resorption and bone formation. This
Table 1. Continued
Rilonacept Product name: Araclyst
Manufacturer: Cigna
Description: a dimeric fusion protein blocks interleukin-1
beta and, to a lesser extent, interleukin-1 alpha from
interacting with cell-surface receptors.
AIN457 Product name: AIN457
Manufacturer: Novartis
Description: fully human IgG1j monoclonal anti-interleu-
kin17 antibody that selectively neutralizes interleukin-17A
B-cell targets
Rituximab Product name: Rituxin
Manufacturer: Genetech
Description: monoclonal anti-CD20
Inhibitor of costimulation
Abatacept Product name: Orencia
Manufacturer: Bristol-Meyers Squibb
Description: fusion protein CTLA-4 with immunoglobulin
Inhibitor of RANK RANKL
Denosumab Product name: Denosumab
Manufacturer: Amgen
Description: a fully human monoclonal antibody that
specically targets RANKL
CTLA4, cytotoxic T-lymphocyte antigen 4; RANK, receptor activator of nuclear factor kappaB; RANKL, receptor activator of nuclear factor kappaB ligand.
Bartold et al.
appears to be mediated via the RANK RANKL os-
teoprotegerin axis, whereby excessive bone formation
may be related to an excess of osteoprotegerin or to a
reduction in RANKL levels (i.e. an increase in the
osteoprotegerin RANKL ratio). By contrast, a de-
crease in the osteoprotegerin RANKL ratio will be
associated with pathologic bone loss. A number of
studies have addressed these ratios in periodontitis
(16) and, in general, the ratio of RANKL osteopro-
tegerin is increased owing to an increase in the level
of RANKL and to a decrease in the level of osteo-
protegerin (19).
Thus, the RANKL RANK pathway is an attractive
target for the treatment of pathological bone loss. In
an early study, osteoprotegerin fused to the human
IgG constant region was injected into postmeno-
pausal osteoporotic women and it was found that a
single injection of this osteoprotegerin led to a rapid,
signicant and sustained reduction in bone turnover
(7). This demonstrated that the osteoprotegerin-
mediated inhibition of RANKL has the potential to
reduce bone loss in osteoporosis. Since this study was
carried out, a number of studies have investigated the
inhibition of RANKL by other mechanisms in a
number of conditions involving pathologic bone loss.
Denosumab is a monoclonal antibody to RANKL that
has been investigated in women with osteoporosis
and rheumatoid arthritis (17, 55). Studies to date
indicate that RANKL inhibitors, such as denosumab,
can lead to increased bone mineral density and de-
creased bone resorption. Currently, the use of deno-
sumab and similar agents in periodontitis has been
restricted to animal intervention studies (43, 45, 107,
111). In these studies, inhibitors of RANK-mediated
osteoclastogenesis led to a protective effect on
pathologic bone loss in experimental periodontitis
lesions. Notwithstanding these encouraging results,
there are concerns that the use of RANK RANKL
inhibitors can inhibit both physiological and
inammatory bone resorption and may have an un-
wanted systemic effect on bone.
Cathepsin K inhibitors
The enzyme cathepsin K is a cysteine proteinase of
the papain superfamily, which is selectively ex-
pressed in osteoclasts and plays a pivotal role in the
degradation of bone matrix. It is the only known
mammalian proteinase that can solubilize both type I
and II collagens by cleavage of the telopeptide region.
Cathepsin K knockout mice develop an osteopetrotic
phenotype as a result of the lack of bone resorption.
Cathepsin K has been identied in periodontal tis-
sues and in gingival crevicular uid. Increased con-
centrations of cathepsin K have been detected in the
gingival crevicular uid from patients with perio-
dontitis, which correlated with an increased con-
centration of RANKL, suggesting that both contribute
to osteoclastic bone destruction in periodontal dis-
ease (27, 66). Accordingly, cathepsin K has been
viewed as an attractive target for modulating bone
resorption. Indeed, animal (nonhuman primate)
studies have demonstrated that the inhibition of
cathepsin K induces a reduction in bone resorption
(99). A number of prototype cathepsin K inhibitors
have now entered clinical trials for the management
of osteoporosis (21). To date there are no reports on
the effect of cathepsin K inhibitors on periodontal
bone loss.
IKK-b inhibition
As detailed earlier, IKK-b is activated following the
binding of RANK to RANKL. As such, this process is a
target for the inactivation of nuclear factor-kappaB
activation because IKK-b is essential for nuclear fac-
tor-kappaB activation by proinammatory cytokines
(85). Oral administration of a selective potent inhib-
itor of IKK-b has demonstrated both anti-inamma-
tory and anti-bone-resorbing effects in an animal
model (91). Hence, the dual effect of inhibiting
inammation and inhibiting bone resorption indi-
cates some potential for these drugs. To date there
are no reports on the effect of inhibition of IKK-b on
periodontal bone loss.
Alternative approaches to
modulating bone resorption
Vitamin D
Vitamin D, which is derived from dietary sources and
the action of sunlight, is essential for bone formation.
A chronically low intake of vitamin D can lead to a
negative calcium balance, leading to an increased
loss of calcium from bone. There are numerous
studies conrming that vitamin D deciency is
associated with bone loss (49). In addition to its role
in bone homeostasis, vitamin D has anti-inamma-
tory and immunomodulatory properties (117). On
the basis of these functions, modifying vitamin D
levels is an attractive way of regulating bone loss in
periodontitis (38). However, to date the use of vita-
min D in periodontics has received little attention. In
a recent study, it was noted that patients who took
Bone loss in periodontitis
vitamin D and calcium supplements had slightly
better clinical periodontal parameters than those
who did not (63). It was concluded that larger lon-
gitudinal studies were required to fully understand
the signicance of this relationship.
Statins 3-hydroxy-3-methylglutaryl-CopA (HMG-
CoA) reductase inhibitors have been widely used to
prevent cardiovascular disease through controlling
lipid metabolism. In addition to their capacity to re-
duce serum cholesterol levels, statins also possess
signicant anti-inammatory properties (64). One of
the most common statins is simvastatin, which has
shown interesting results regarding the control of
alveolar bone loss by simvastatin. Although two
studies have questioned any benecial effect of
simvastatin on periodontal bone loss (67, 88), several
studies have demonstrated protective features with
concerning periodontitis and alveolar bone loss (57,
69, 93, 112). Most recently the dual effect of statin
medications on the periodontium was demonstrated
to be dependent on the inammatory status of the
periodontal tissues (89). Overall, these studies indi-
cate that statins may have some benecial thera-
peutic benets for the periodontium through their
immunomodulatory, anti-inammatory and reduced
bone-resorptive actions but conrmation awaits
more denitive studies.
Novel approaches to the
management of bone resorption
With the expanding knowledge in bone biology and
the mechanisms involved in the regulation of bone
metabolism and periodontal pathology, new ap-
proaches for the management of periodontal bone
loss may be developed.
Kinase inhibitors
Kinase inhibitors are potential new targets for peri-
odontal therapies. They are low-molecular-weight
peptides that are relatively inexpensive and have
efcacy similar to that of other, more expensive,
biological agents, but with reduced risks (92). Kinases
are intracellular molecules involved in signal trans-
duction during inammation. Following binding of
a ligand to a cell-surface receptor, numerous cyto-
plasmic kinases are activated that then modulate the
activity of transcription factors and thus regulate
gene expression. Two types of kinases can be tar-
geted: mitogen-activated protein kinases (p38, ERK
and c-jun N-terminal kinase) and tyrosine kinases
(Janus Kinase 3 [JAK-3] and Syk). A number of oral
drugs that target these complexes have been tested in
animal models of periodontitis and found to reduce
inammatory cytokine production and osteoclast
formation and thus protect against inammatory-
mediated alveolar bone loss (46, 83).
Wnt pathway
A number of reports have indicated that the Wnt
canonical pathway and the transcription factor acti-
vator protein-1 are important for the regulation of
osteoprotegerin production in osteoblasts (29). It has
been proposed that the net production of osteopro-
tegerin in these cells depends on the interplay be-
tween the activation by the Wnt canonical pathway
and the suppression by the transcription factor acti-
vator protein-1 (100). Within this process, beta-cate-
nin plays an important role in the Wnt signaling
pathway and in bone remodeling (30). The relation-
ship between Wnt signalling and activator protein-1
in osteoprotegerin production has been demon-
strated in the periodontal ligament and in gingival
broblasts (100). It was shown that beta-catenin
could enhance interleukin-1alpha-induced osteopro-
tegerin production, and activator protein-1 sup-
pressed interleukin-1alpha-induced osteoprotegerin
production in periodontal ligament cells. Further-
more, a high expression of c-Fos (a component of the
activator protein-1 transcription dimeric complex)
has been reported in periodontal ligament cells
compared with gingival broblasts, and this suggests
a role for periodontal ligament broblasts in alveolar
bone resorption in periodontitis. Because the Wnt
pathway seems to form an important link between
inammation and bone metabolism, it provides a
novel target for treating bone-erosive conditions by
changing the balance between bone formation and
bone resorption. A glycoprotein that can inhibit the
Wnt pathway is Dickkopf-1 (DKK-1). Osteopenia and
osteoporosis have been reported when DKK-1 is over-
expressed in osteoblasts (31, 77). In addition, an in-
crease in the number of erosive lesions in arthritis has
been reported to be related to DKK-1. Recent pre-
clinical studies have shown efcacy in treating bone
erosion when DKK-1 has been neutralized or the
Wnt beta-catenin signaling has been enhanced. Use
of a DKK1-neutralizing antibody led to an increase in
the amount of trabecular bone, an increased number
Bartold et al.
of osteoblasts and increased osteocalcin levels. It was
proposed that DKK1 may regulate osteolytic bone
disease and disease progression by impeding the
Wnt-regulated differentiation of osteoblasts. The
resultant increased production of interleukin-6, in
turn, leads to increased osteoclastogenesis through
increased RANKL:osteoprotegerin ratios (77).
Protease-activated receptor 2
agonists antagonists
Protease-activated receptors are a group of related G
protein-coupled receptors which are activated
following proteolytic cleavage of their extracellular
domain and play important roles in chronic inam-
mation (18, 60, 113). To date, four protease-activated
receptors have been identied, of which protease-
activated receptor 2 has received particular attention
regarding bone resorption. Activation of this protein
results in the release of a variety of prostanoids and
cytokines, including interleukin-6 and interleukin-8
(59). A potential role for protease-activated receptor
2, which can be activated by Porphyromonas gingi-
valis gingipains, in periodontitis has been suggested
on the basis of its expression by alveolar bone os-
teoblasts, gingival broblasts and gingival epithelial
cells (1, 59, 110). However, there is conicting evi-
dence regarding the role of protease-activated
receptor 2 in osteoclastogenesis and bone resorption.
For example, one study has shown that protease-
activated receptor 2 activation can inhibit bone
resorption through inhibiting osteoclast differentia-
tion (96). A recent study found that protease-acti-
vated receptor 2 null mice infected with P. gingivalis
did not demonstrate any signs of periodontal bone
resorption, in contrast to wild-type mice (118). Sev-
eral other studies have demonstrated that protease-
activated receptor 2 activation is associated with in-
creased production of interleukin-6 and associated
periodontal destruction and that a synthetic prote-
ase-activated receptor 2 agonist could lead to in-
creased interleukin-8 production, which also led to
periodontal destruction (59, 110). Additional studies
have supported a role for protease-activated receptor
2 antagonists in inhibiting inammation and sub-
sequent pathological bone resorption (24, 41). While
further studies are needed to determine whether
agents such as protease-activated receptor 2 antag-
onists are effective in reducing alveolar bone loss,
protease-activated receptor 2 remains a potential
novel target to control unwanted bone resorption in a
number of diseases.
Histone deacetylase inhibitors
Histone deacetylases are a group of enzymes
emerging as potential targets for a number of dis-
eases, including those involving pathological bone
resorption (14). The properties of histone deacety-
lases include inhibition of angiogenesis, inhibition
of the production of proinammatory cytokines and
also protective effects on bone. Histone deacetylases
act by removing the acetyl groups from histone
proteins that condense chromatin and regulate
protein expression (81). Histone deacetylase inhibi-
tors lead to the hyperacetylation of histones and
thus modify the expression of genes, leading to
stimulation of the cell cycle inhibitors, down-regu-
lation of immune stimulators, a reduction in the
levels of inammatory cytokines and the suppres-
sion of osteoclast-mediated bone resorption (15, 81).
Histone deacetylase inhibition may also result in the
acetylation of other nonhistone proteins and this
may have a variety of effects, including regulating
the transcription of genes. The regulation of nuclear
factor-kappaB by histone deacetylases seems to be a
critical feature of their role in osteoclast develop-
ment and inammation (109).
Histone deacetylase inhibitors have been studied
in animal models of rheumatoid arthritis where they
were shown to reduce bone destruction (56). How-
ever, to date there are no reports on the use of his-
tone deacetylases for periodontitis. Nonetheless,
histone deacetylase inhibitors appear to have the
potential to provide another therapeutic module for
the management of pathological bone loss and
therefore further studies are warranted on these
While this volume of Periodontology 2000 is generally
directed at the comparative biology of chronic peri-
odontitis and aggressive periodontitis, there is little
evidence to suggest that the mechanisms of bone loss
are any different between these two diseases.
Therefore, this review has covered the principal
mechanisms involved in osteoclast-mediated bone
resorption and provided an overview of current and
future treatment prospects. There is an emerging
case for the use of anti-resorptive agents in the
management of periodontitis in conjunction with
current anti-inammatory and anti-infective
treatments. It is anticipated that effective targeted
treatments for controlling bone resorption will soon
Bone loss in periodontitis
become available. These will provide valuable ad-
juncts to conventional mechanical therapy aimed at
reducing the infective and inammatory components
of periodontitis.
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Bone loss in periodontitis