Cyclooxygenase Structure and Mechanism How Aspirin and NSAIDs Work\ Prostaglandins and NSAIDS Prostaglandins are potent

mediators of inflammation. The first and committed step in the production of prostaglandins from arachidonic acid is the bis-oxygenation of arachindonate to prostaglandin PGG2. This is followed by reduction to PGH2 in a peroxidase reaction. Both these reactions are catalyzed by cyclooxygenase, also known as PGH synthase. Cyclooxygenase (COX) is inhibited by the family of drugs known as non-steroidal anti-inflammatory drugs or NSAIDs. Aspirin, ibuprofen, flurbiprofen and acetaminophen (trade name Tylenol) are all NSAIDs. There are two isoforms of COX in animals: COX-1, which carries out normal, physiological production of prostaglandins, and COX-2, which is induced by cytokines, mitogens and endotoxins in inflammatory cells, and which is responsible for the production of prostaglandins in inflammation. The structure shown at left is that of COX-1 from sheep, inactivated by bromoaspirin, the structure of which is shown below.

The Enzyme Structure The first 24 residues of COX-1 are a signal sequence. This domain is removed in the mature enzyme and will not be discussed here. Similarly , residues 25-32 do not yield interpretable electron density, and are not shown in the structure shown. The remaining 551 residues of the enzyme (residues 33-583) comprise three distinct domains. The first of these, residues 33-72, form a small compact module that is similar to epidermal growth factor . The second domain, composed of residues 73-116, forms a right-handed spiral of four alpha-helical segments along one side of the protein . . This domain of the protein forms a membrane-binding motif. The helical segments are amphipathic, with most of the hydrophobic residues (shown in green ) facing away from the protein, where they can interact with a lipid bilayer. Turn off the hydrophobic residues and we will consider the third domain of the COX enzyme, the catalytic domain (in blue), a globular structure that contains both the cyclooxygenase and peroxidase active sites. The peroxidase site includes a heme . The iron(III) in the center of this heme is coordinated by His-388 and by His-207 . Let's return to our view of the whole molecule .and consider the cyclooxygenase active site. The cyclooxygenase active site lies at the end of a long, narrow, hydrophobic tunnel or channel. Three of the alpha helices of the membrane-binding domain lie at the entrance to this tunnel. . The walls of the tunnel are defined by four alpha helices, formed by residues 106-123, 325-353,379-384, and 520-535. In the following animation, these helices will flash red and orange. In this bromoaspirin-inactivated structure, Ser-530 is bromoacetylated , and a molecule of salicylate is bound in the tunnel

Deep in the tunnel, at the far end, lies Tyr-385, a catalytically important residue. Heme-dependent peroxidase activity is implicated in the formation of a proposed Tyr-385 radical, which is required for cyclooxygenase activity. Now take another look at the tunnel with the bromoacetyl-Ser 530, the salicylate, and the essential Tyr-385 all shown within the tunnel. At this point in this exercise, you are literally looking at the view an arachidonic acid substrate has of the active site at the end of the tunnel. The yellow helices, you will recall form the membrane interface. Arachidonic acid substrates flow up into the tunnel from the membrane interior. With this view, it should also be clear why aspirin and other NSAIDs block the synthesis of prostaglandins. In various ways, they all act by filling and blocking the tunnel, preventing the migration of arachidonic acid to the active site at the back of the tunnel. There are thought to be at least four different mechanisms of action for NSAIDs. Aspirin (and also bromoaspirin) is the only one which covalently modifies a residue in the tunnel, thus irreversibly inactivating both COX-1 and COX-2. Ibuprofen (shown below) acts instead by competing in a reversible fashion for the substrate binding site in the tunnel.

Flurbiprofen and indomethacin, members of the third class of inhibitors, are shown below.

Fluribiprofen and indomethacin cause a slow, time-dependent inhibition of COX-1 and COX-2, apparently via formation of a salt bridge between a carboxylate on the drug and Arg-120(shown here in green), which lies in the tunnel. The drug SC-558 acts by a fourth mechanism, specifically inhibiting COX-2. It is a weak competitive inhibitor of COX-1 but inhibits COX-2 in a slow, time-dependent process. Specific COX-2 inhibitors will likely be the drugs of the future, since they will be able to selectively block the inflammation mediated by COX-2, without the potential for stomach lesions and renal toxicity that arise from COX-1 inhibition. NON STEROIDAL ANTI INFLAMMATORY DRUGS NSAIDs They are also called non-norcotic, non-opioid or Aspirin like analgesics. They act primarily on peripheral pain mechanisms, but also in the CNS to raise pain threshold Compare with opioid analgesics (usually required for moderate to severe pain, narcotic, usually addictive) e.g. morphine; codeine

CLASSIFICATION A. Nonselective COX inhibitors (traditional NSAIDs) 1. Salicylates: Aspirin. 2. Propionic acid derivatives: ibuprofen, Naproxen, Ketoprofen, Flurbiprofen 3. AnthraniIic acid derivatives: Mephenamic acid 4. Aryl -acetic acid derivatives: Diclofenac, Aceclofenac. 5. Oxicam derivatives: piroxicam, Tenoxicam. 6. Pyrrolo-Pyrrole derivatives: ketorolac 7. lndole derivatives: indomethacin. 8. Pyrazolone derivatives: phenylbutazone. Oxyphenbutazone. B. Preferential COX-2 inhibitors Nimesulide, Meloxicam, Nabumetone. C. Selective COX -2 inhibitors Celecoxib, Rofecoxib, Etoricoxib, Lumiracoxib, D. Analgesic-antipyretics with poor antiinflammatory action 1. paraaminophenol derivative: paracetamol (acetaminophen) 2. Pyrazolone derivatives: Metamizol (dipyrone) Propiphenazone. 3. Benzoxazocine derivative: Nefopam. NSAIDs Types Salicylates (Salicylic acid derivatives) Acetic Acid derivatives Aspirin, Diflusinal, Sodium Salicylate Indometacin, Sulindac, Etodolac Diclofenac Parecoxib, Valdecoxib

Propionic Acid Derivatives

Ibuprofen, Naproxen, Ketoprofen Flurbiprofen

Enolic Acids Non-acidic compounds

Piroxicam, Phenylbutazone Nabumetone

COMMON PHARMACOLOGICAL EFFECTS Analgesic (CNS and peripheral effect) may involve non-PG related effects. Antipyretic (CNS effect) , Antiinflammatory (except acetaminophen) due mainly to PG inhibition. Some shown to inhibit activation, aggregation, adhesion of neutrophils & release of lysosomal enzymes , Some are Uricosuric, Diverse group of chemicals, but all inhibit cyclooxygenase. Resultant inhibition of PG synthesis is largely responsible for their therapeutic effects. But, inhibition of PG synthase in gastric mucosa GIT damage (dyspepsia, gastritis). Common Adverse: Effects Platelet Dysfunction , Gastritis and peptic ulceration with bleeding (inhibition of PG + other effects) Acute Renal Failure in susceptible , Sodium+ water retention and edema, Analgesic nephropathy, Prolongation of gestation and inhibition of labor. Hypersensitivity (not immunologic but due to PG inhibition) GIT bleeding and perforation Indications Pain and inflammation in rheumatic diseases , Musculoskeletal disorders, Post-operative analgesia, Acute Gout, Migraine, Dysmenorrhoea, Fever and pain in children (including post-immunization pyrexia), Pyrexia, Dental pain, Less well-defined conditions of back pain and soft-tissue disorders Patients NOT responsive to one NSAID may well respond to another need to tailor treatment to the individual patient. Full analgesic effect may take up to three weeks ROLE OF PROSTAGLANDINS PATHOLOGIC FEVER, ASTHMA, ULCERS, DIARRHEA, DYSMENORRHEA, INFLAMMATION, BONE EROSION, PAIN PHYSIOLOGIC TEMPERATURE CONTROL, BRONCHIAL TONE, CYTOPROTECTION, INTESTINAL MOBILITY MYOMETRIAL TONE, SEMEN VIABILITY, FUNCTION OF PROSTAGLANDINS IN INFLAMMATION PGE2, PGI2 VASODILATION, ACT SYNERGISTICALLY WITH OTHER MEDIATORS, HISTAMINE, COMPLEMENT, LTB4, BRONCHODILATATION, INHIBITION OF PLATELET AGGREGATION TXA2

PROMOTION OF PLATLET AGGREGATION Eicosanoids Eicosanoids a family of compounds that are the products of three main pathways which use oxygen as a major cosubstrate. The three pathways are: the cyclooxygenase pathway, the lipoxygenase pathway , the epoxygenase pathway. Cyclo-oxygenase (COX) Exists in the tissue as constitutive isoform (COX-1). At site of inflammation, cytokines stim the induction of the 2 nd isoform (COX-2). Inhibition of COX-2 is thought to be due to the anti-inflammatory actions of NSAIDs. Inhibition of COX-1 is responsible for their GIT toxicity. Most currently used NSAIDs are somewhat selective for COX-1, but selective COX-2 inhibitors are available. Celecoxib, etoricoxib, valdecoxib are selective COX-2 inhibitors Have similar efficacies to that of the nonselective inhibitors, but the GIT side effects are decreased by 50%. But, no cardioprotection and there is actually increased MI. FUNCTIONS OF COX COX-1 CONSITUTIVELY EXPRESSED, HOUSEKEEPING FUNCTIONS, PRESENT IN EVERY ORGAN STOMACH, INTESTINE, KIDNEY PLATLETS, VASCULAR ENDOTHELIUM COX-2 INDUCIBLE, INFLAMMATORY AND NEOPLATIC SITES ALSO PRESENT IN KIDNEY, UTERUS. OVARY, BRAIN, SMALL INTESTINE MECHANISM OF ACTION Most NSAIDs act as non-selective inhibitors of the enzyme cyclooxygenase, inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. Cyclooxygenase catalyzes the formation of prostaglandins and thromboxane from arachidonic acid (itself derived from the cellular phospholipid bilayer by phospholipase A2). Prostaglandins act as messenger molecules in the process of inflammation. This mechanism of action was elucidated by John Vane (1927-2004), who later received a Nobel Prize for his work Inhibition of prostaglandin synthesis Inhibition of Cox-1 Inhibition of Cox-2 Cox-2 is induced 10-80 fold in inflammation Inhibition of Cox-2 is the main mechanism for the anti-pyretic, analgesic and anti-inflammatory actions

Inhibition of Cox-1 leads to side effects Most NSAIDS are non-selective but there are selective Cox-2 inhibitors Cox-2 Newer Selective Cox-2 inhibitors have lower risk of serious upper GI side effects than non-selective NSAIDS The Salicylates - Aspirin Duration of action ~ 4 hr. Orally taken. Weak acid (pKa ~ 3.5); so, non-ionized in stomach easily absorbed. Hydrolyzed by esterases in tissues and blood to salicylate (active) and acetic acid. Most salicylate is converted in liver to H2O-sol conjugates that are rapidly excreted by kids. Effect on Respiration: triphasic Low doses: uncoupling phosphorylation CO2 stimulates respiration. Direct stimulation of respiratory center Hyperventilation resp. alkalosis renal compensation Depression of respiratory center and cardiovascular center BP, respiratory acidosis, no compensation + metabolic acidosis also GI system Dose dependent hepatitis, Reyes syndrome Metabolic Uncoupling of Oxidative Phosphorylation Hyperglycemia and depletion of muscle and hepatic glycogen Endocrine: corticosteroids, thyroid Cardiovascular Platelets: Inhibition of platelet COX-1-derived TxA2 with the net effect of increasing bleeding time (inhibition of platelet aggregation) Endothelial COX-2 derived PGI2 can inhibit platelet aggregation (inhibition augments aggregation by TxA2). Aspirin (acetylsalicylic acid) covalently modifies and, irreversibly inhibits platelet COX. The enzyme is inhibited for the lifetime of the platelet (~8 -11 days). Effect achieved at very low dose. Basis of therapeutic efficacy in stroke and MI (reduces mortality and prevents recurrent events). Additional Cardiovascular Considerations Blood vessels/smooth muscle

COX-2 derived PGI2 can antagonize catecholamine- and angiotensin II-induced vasoconstriction (NSAIDs can elevate bp). Atherosclerosis Inhibition of COX-2 can destabilize atherosclerotic plaques (due to its anti-inflammatory actions) Renal COX-1 and COX-2 generated PGs (TxA2, PGF2 , PGI2 (glom), PGE2 (medulla), powerful vasodilators) can both incr and decr Na+ retention (natriuresis predominates), usually in response to changes in tubular Cl -, extracellular tonicity or low bp. NSAIDs tend to promote Na+ retention and can therefore increase bp. Can counteract effects of many antihypertensives (diuretics, ACE inhibitors and -AR antagonists). PGs have minimal impact on normal renal blood flow, but become important in the compromised kidney. Patients (particularly elderly and volume depleted) are at risk of renal ischemia with NSAIDs. Gastrointestinal PGs (generated via COX-1) 1) inhibit stomach acid secretion, 2) stimulate mucus and HCO3- secretion, vasodilation and therefore, 3) are cytoprotective for the gastric mucosa. Therefore, NSAIDs with COX-1 inhibitory activity will produce opposite effects, leading to: Gastric distress, gastric bleeding, sudden acute hemorrhage (effects are dose-dependent) Gestation PGs (generated from COX-2) are involved in the initiation and progression of labor and delivery. Therefore, inhibition of their production by NSAIDs can prolong gestation. Respiratory system High doses (salicylates) cause partial uncoupling of oxidative phosphorylation with increased CO2 production (COX-independent effects). Increase in plasma CO2 hyperventilation. Even higher doses cause depression of respiration. Other uses of NSAIDs (mechanisms less understood) - Decreased risk of fatal colon carcinoma Aspirin - Therapeutic Uses Antipyretic, analgesic Anti-inflammatory: rheumatic fever, rheumatoid arthritis (joint dis), other rheumatological diseases. High dose needed (5-8 g/day). But many ptients cannot tolerate these doses (GIT); so, proprionic acid derivatives, ibuprofen, naproxen tried first. Prophylaxis of diseases due to platelet aggregation (CAD, post-op DVT)

Pre-eclampsia and hypertension of pregnancy (excess TXA2) Paracetemol (tylenol) no significant anti-inflammatory effect, but used for its mild analgesic effect. Well-absorbed and without GIT irritation. Serious disadvantage: at high doses, severe hepatotoxicity results. Mechanisms of Action Analgesia both centrally and peripherally. - associated with anti-inflammatory actions. - results from inhibition of PG synthesis in inflamed tissues. - [PGs little pain relief themselves, but potentiate the pain caused by other mediators of inflammation (e.g., histamine, bradykinin). Anti-inflammatory action PGs in inflammation vasodilation and incr vasc permeability. - Inhibition of PGs by NSAIDs attenuates, not abolish, inflammation (NSAIDs do not inhibit mediators of inflammation). - Very modest relief from pain, stiffness, swelling for RA often prescribed for their antiinflammatory actions. Antipyretic actions Fever, heat stroke, increase Temperature are hypothalamic problems. - So, NSAIDs do not decrease body Temperature. - Fever release of endog pyrogens (e.g., interleukin-1) released from leucocytes acts directly on the thermoregulatory centers in hypothalamus increase body T. - This is associated with increase in brain PGs (pyrogenic). - Aspirin prevents the Trising effects of interleukin-1 by preventing the increase in brain PGs. Mechanism of Action on the Active Site of COX Possess a long channel (COX-2 channel is wider than in COX-1). Non-selective NSAIDs enter channel (but not aspirin). Block channels by binding with H-bonds to an arg half of the way in. This reversibly inhibits the COX by preventing arachidonic acid from gaining access. Aspirin acetylates COX (at ser530) and is, therefore, irreversible. Selective COX-2 inhibitors generally more bulky molecules - can enter and block the channel of COX-2, but not that of COX-1. Paracetamol reducing cytoplasmic peroxide Recall: peroxide is necessary to activate heme enzyme to the Fe. Acute inflammation: paracetamol is not very effective because neutrophiles and monocytes produce much H 2O2 and lipid peroxide, which overcome the actions of the drug.

Selective COX-2 Inhibitors Anti-inflammatory with less adverse effects, especially GI events. Potential toxicities: kidney and platelets - ? increased risk of thrombotic events. Associate with MI and stroke because they do not inhibit platelet aggregation. Thus,.. should not be given to patients with CV disease Role in Cancer prevention, Role in Alzheimers disease Lipoxins Anti-inflammatory Mediators During inflammation, cells die by apoptosis. Lipoxins signal macrophages to clean up. During the acute inflammatory process, cytokines (e.g., IFN- and IL-1) can induce the expression of antiinflammatory mediators (lipoxins and IL-4), which promote the resolution phase of inflammation. Aspirin Toxicity - Salicylism Headache - timmitus - dizziness hearing impairment, dim vision, Confusion and drowsiness, Sweating and hyperventilation, Nausea, vomiting, Marked acid-base disturbances, Hyperpyrexia, Dehydration, Cardiovascular and respiratory collapse, coma convulsions and death Aspirin Toxicity Treatment Decrease absorption - activated charcoal, emetics, gastric lavage Enhance excretion ion trapping (alkalinize urine), forced diuresis, hemodialysis Supportive measures - fluids, decrease temperature, bicarbonate, electrolytes, glucose, etc Other NSAIDs Phenylbutazone: additional uricosuric effect. Aplastic anemia. Indomethacin: Common adverse rxns: gastric bleeding, ulceration, CNS most common: hallucinations, depression, seizures, headaches, dizziness. Acetaminophen: differs in effects and adverse rxn from rest. Main toxicity: hepatitis due to toxic intermediate which depletes glutathione. Treat with N-acetylcysteine. Ibuprofen: Lowest incidence of side effects, Lowest potency, Maximum daily dose 2.4g Useful alternative to aspirin in children under 12 (16 years!) Reyes syndrome Sustained-Release preparations , Various oral preparations, Combination products with paracetamol, codeine, Topical preparations Useful in dysmenorrhoea, dentistry, Not strong enough in acute gout, Bioavailability 49 73%, Protein binding 99%, Metabolism Hepatic (CYP2C9), Half-life 1.82 h, Excretion Renal Diclofenac:

Moderate potency, Useful in acute gout, Moderate side effects (compared to ibuprofen), Maximum daily dose is 150mg, Tablets, Suppositories, Gels, Injections, Sustained Release Products, Protein binding more than 99%, Metabolism hepatic, no active metabolites exist, Half-life 1.2-2 hr (35% of the drug enters enterohepatic recirculation), Excretion biliary, only 1% in urine Naproxen commonly used for the reduction of pain, fever, inflammation and stiffness caused by conditions such as: osteoarthritis, kidney stones, rheumatoid arthritis, psoriatic arthritis, gout, ankylosing spondylitis, menstrual cramps, tendinitis, bursitis It works by inhibiting both the COX-1 and COX-2 enzymes. Bioavailability 95% (oral), Protein binding 99%, Metabolism Hepatic (to 6-desmethylnaproxen), Half-life 12 24 hours, Excretion Renal Meloxicam Bioavailability 89%, Protein binding 99.4%, Metabolism Hepatic (CYP2C9 and 3A4-mediated), Half-life 15 to 20 hours, Excretion Urine and faeces equally, Side-Effects, Most notorious side effect adverse gastrointestinal events including gastric or intestinal ulceration, 2 mechanisms responsible for GI side effects, Local erosion of orally administered agents (THEREFORE they are to be taken with or after meals), Inhibition of biosynthesis of cytoprotective prostaglandins PGI2 and PGE2 Hence NSAIDs still do cause GI side effects despite the ROUTE of administration Administration of cytoprotectants e.g. misoprostol [AVOID IN PRE-MENOPAUSAL WOMEN] for GI protection May be given with proton pump inhibitors e.g. omeprazole, esomeprazole, rabeprazole, lansoprazole for GI protection Others include: Nephrotoxicity - possible interactions with ACE Inhibitors Renal failure may be provoked by NSAIDs especially in patients with pre-existing renal impairment Hypersensitivity reactions including rashes, urticaria, bronchoconstriction, Anaphylaxis (rare), Hepatotoxicity Caution/Contraindication Avoid ALL NSAIDs in patients with active peptic ulceration Caution in those with peptic ulceration (risk/benefit) Asthma any worsening of asthma should be investigated, Pregnancy, Breastfeeding , allergic conditions NSAIDs in periodontics

Effect of Systemically Administered Naproxen Sodium on Clinical Parameters and Myeloperoxidase and Elastase-Like Activity Levels in Gingival Crevicular Fluid
Hamit Aras,* Feriha alayan, Gliz N. Gnc, Atilla Berberolu, and Kamer Kln

Background: The present study was conducted to determine the possible effect of naproxen sodium on clinical status and the enzymatic profile of gingival crevicular fluid (GCF) when given as adjunct to periodontal treatment. Methods: A total of 34 subjects with chronic periodontitis were selected and divided into two groups to receive either naproxen sodium or placebo. At baseline, GCF samples were obtained and probing depths (PD), gingival index (GI), plaque index (PI), and gingival bleeding index (GBI) scores were recorded. In the non-steroidal anti-inflammatory drug (NSAID) group, patients were treated with a protocol consisting of baseline periodontal treatment (scaling, root planing) and naproxen sodium (275 mg) administration daily for 6 weeks. In the placebo group, patients received the same treatment except placebo was given instead of naproxen sodium. At the end of the experimental period, clinical recordings and GCF sampling were repeated. Myeloperoxidase (MPO) and elastase-like enzyme activity (ELA) levels were determined in GCF samples by a spectrophotometric method. GCF enzymatic content was calculated both as total enzyme activity and enzyme concentration. Results: All of the clinical parameters, except mean GBI, were significantly lower in the experimental group (P<0.05). At baseline and at the end of the experimental period, there were no significant differences between theNSAID and placebo groups regarding GCF MPO and ELA levels in either mode of data presentation (P <0.05). However, in the NSAID group, mean ELA concentration (P = 0.002) and mean total ELA (P = 0.003) presented significant decreases with treatment. Also, with treatment, a general reduction in MPO levels was seen; however, this difference was not significant. Although constant and stable correlations between GCF enzyme levels and clinical parameters could not be found, positive and strong correlations were observed between total enzyme activity and enzyme concentrations. Conclusion: Based on the positive clinical effect and the ELA profile of GCF, it can be suggested that NSAIDsgiven as an adjunct to baseline periodontal treatment could be beneficial in the outcome of treatment.

Subantimicrobial Dose Doxycycline Efficacy as a Matrix Metalloproteinase Inhibitor in Chronic Periodontitis Patients Is Enhanced When Combined With a Non-Steroidal Anti-Inflammatory Drug
Hsi-Ming Lee Sebastian G. Ciancio Glay Tter Maria E. Ryan Eugene Komaroff Dr. Lorne M. Golub Background: Administration of subantimicrobial dose doxycycline (SDD) to chronic periodontitis (CP) patients has repeatedly been found to reduce mammalian collagenase and other matrix metalloproteinase (MMP) activity in gingival tissues and crevicular fluid, in association with clinical efficacy, without the emergence of antibiotic-resistant bacteria either orally or extra-orally. More recently, SDD adjunctive to repeated mechanical debridement resulted in dramatic clinical improvement in patients (>50% smokers) with generalized aggressive periodontitis. As an additional pharmacologic approach, nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce gingival inflammation and

alveolar bone resorption, at least under experimental conditions. In the current study, we determined the effect of administering a combination (combination) of these two host-modulating drugs (SDD plus low-dose NSAID) to CP patients, on selected neutral proteinases in gingiva, enzymes believed to mediate periodontal breakdown. Earlier preliminary studies in humans with bullous pemphigoid, which is also associated with excessive levels of host-derived proteinases including MMPs, indicated improved clinical efficacy of combination therapy. Methods: Nineteen CP patients, scheduled for mucoperiosteal flap surgery bilaterally in the maxillary arch, were randomly distributed into three experimental groups administered either 1) low-dose flurbiprofen (LDF) alone, 50 mg q.d.; 2) SDD (20 mg b.i.d.) alone; or 3) a combination of SDD plus LDF (combination). The gingival tissues were biopsied during surgery from right and left maxillary posterior sextants, before and after a 3-week regimen of medication, respectively. The tissues were then extracted, the extracts partially purified, then analyzed for the endogenous proteinase inhibitor, 1-PI, and its breakdown product, and for host-derived matrix metalloproteinases (i.e., collagenases, gelatinases) and neutrophil elastase activities. Results: Short-term therapy with SDD alone produced a significant reduction and LDF alone produced no reduction in host-derived neutral proteinases. However, the combination therapy produced a statistically significant synergistic reduction of collagenase, gelatinase, and serpinolytic (1-PI degrading) activities (69%, 69%, and 75% reductions, respectively) and a lesser reduction of the serine proteinase, elastase (46%). Conclusions: Consistent with previous studies on animal models of chronic destructive disease (e.g., rheumatoid arthritis), the SDD and NSAID combination therapy synergistically suppressed MMP and other neutral proteinases in the gingiva of CP patients. A mechanism, suggested by earlier animal studies, involves the NSAID, in the combination regimen, increasing the uptake of the tetracycline-based MMP inhibitor in the inflammatory lesion, thus synergistically enhancing the efficacy of this medication. J Periodontol 2004;75:453-463.

Comparison of Analgesic and Anti-Inflammatory Efficacy of Selective and Non-Selective Cyclooxygenase-2 Inhibitors in Dental Implant Surgery
Zihni Cuneyt Karabuda,* Nilufer Bolukbasi,* Ali Aral,* Cansu BasegmezZeren,* and Tayfun Ozdemir* Background: The analgesic and anti-inflammatory efficacy of tenoxicam and meloxicam were evaluated in this double-masked, randomized, prospective study by analyzing pain scores and the need for rescue-analgesic agents following dental implant surgery. Methods: One hundred patients, in whom 241 dental implants were placed, were divided into two groups. For 4 days beginning the day before surgery, the first group received meloxicam, 15 mg daily, and the second group received tenoxicam, 20 mg daily, followed by 1 hour preoperatively and for 2 days thereafter. Pain intensity was rated by the subjects based on a visual analog scale on the operation day and on the following 6 days. The patients were recommended to use a rescue analgesic if the pain score was 4. Postoperative complications, such as edema, hematoma, infection, severe pain, paresthesia, or gastrointestinal complaints, were also noted. Results: Statistical analysis revealed that 54% of patients in the tenoxicam group and 66% of patients in the meloxicam group used rescue analgesics on day 1. However, the

difference between the groups was not significant (2 = 1.05; P = 0.30). The relationship between the reduction of consumption and time was not significant in either group (Z = 0.84; P = 0.40). The relationship between the use of rescue analgesics and the number of implants placed was not significant. Among patients who reported postoperative complications, there was not a statistically significant difference between the groups (2 = 0.04; P = 0.84). Conclusion: Meloxicam and tenoxicam exhibited a similar analgesic and antiinflammatory efficacy in the present investigation.

The Effect of Postsurgical Naproxen and a Bioabsorbable Membrane on Osseous Healing in Intrabony Defects
Jean Bichara Dr. Henry Greenwell Connie Drisko John W. Wittwer Tracey M. Vest John Yancey Jane Goldsmith George Rebitski Background: Previous reports in the literature have shown that non-steroidal antiinflammatory drugs (NSAID) may affect osseous tissues by either stimulating or inhibiting bone formation. This effect can be drug specific and different NSAIDs may produce opposite results. There are also reports showing that NSAlDs inhibit bone loss due to inflammatory disease process. The purpose of this randomized, controlled, blinded, clinical investigation was to determine the effect of a one week course of postsurgical naproxen on the osseous healing in intrabony defects. Methods: Twenty-four vertical osseous defects in 24 patients were treated with either a bioabsorbable membrane plus twice daily postsurgical naproxen 500 mg for one week (test or GPN group) or with a polylactide bioabsorbable membrane alone (control or GA group). Twelve patients were included in each group. Treatment was performed on either 2- or 3-wall or combination defects. All measurements were taken from a stent by a calibrated, blinded examiner and open measurements were repeated at the 9-month second stage surgery. Power analysis to determine superiority of naproxen treatment showed that a 12 per group sample size would yield 87% power to detect a 2.0 mm difference and 64% power to detect a 1.5 mm difference. Results: Open defect measurements from baseline to 9 months showed a statistically significant (P < 0.05) mean defect fill of 1.96 1.27 mm and 2.04 1.71 for the GPN and GA groups, respectively. This corresponded to a mean defect fill of 42% and a mean defect resolution of approximately 75% for both groups. The differences between GPN and GA groups were not statistically significant (P > 0.05). Defect fill of 50% was seen in 6 defects (50%) in the GPN group and in 5 defects (42%) in the GA group.

Conclusions: The administration of postsurgical naproxen failed to produce osseous healing that was statistically superior to that obtained with polylactide bioabsorbable membranes alone. J Periodonto1 1999;70:869-877.

Effect of Meloxicam and Diclofenac Sodium on Peri-Implant Bone Healing in Rats

Alethia B. Pablos,* Saturnino A. Ramalho,* Bruno Knig Jr., Cristiane Furuse, Vera C. de Arajo,and Patricia R. Cury Background: This study evaluated the effects of diclofenac sodium and meloxicam on peri-implant bone healing. Methods: Thirty male rats were divided into three groups: the control group (CG) received no drug; the diclofenac sodium group (DSG) received 1.07 mg/kg twice a day for 5 days; and the meloxicam group (MG) received 0.2 mg/kg daily for 5 days. A screwshaped titanium implant was placed in the tibia. Fluorochromes, oxytetracycline (OxT), calcein (CA), and alizarin (AL), were injected at 7, 14, and 21 days, respectively, after implantation, and the animals were sacrificed 28 days after implant placement. The percentages of OxT-, CA-, and AL-labeled bone as well as the percentages of bone-toimplant contact (BIC), cortical bone area (CBA), and trabecular bone area (TBA) within the implant threads were evaluated. Results: Bone healing was delayed in the DSG during the first 14 days after implant placement (OxT-labeled bone: DSG: 5.3% 7.3% versus CG: 13.2% 9.8%, P = 0.002, and versus MG:14.4% 13.1%, P = 0.05). The percentages of BIC (DSG: 49.6% 21.9%; MG: 67.1% 22.8%; and CG: 68.1% 22.8%) and CBA (DSG: 63.7% 21.2%; MG: 82.7% 12.4%; CG: 84.9% 10.6%) were lower in the DSG compared to the MG and CG (P<0.001). The percentage of TBA was significantly greater in the DSG compared to the MG and CG (DSG: 36.3% 21.2% versus MG: 17.3% 12.7% and versus CG: 15.1% 10.6%; P <0.001). Conclusion: Diclofenac sodium seemed to delay peri-implant bone healing and to decrease BIC, whereas meloxicam had no negative effect on peri-implant bone healing.

The Efficacy of AcetaminophenCaffeine Compared to Ibuprofen in the Control of Postoperative Pain After Periodontal Surgery: A Crossover Pilot Study
Weam A.M. Rashwan* Background: Previous studies showed that non-steroidal anti-inflammatory drugs (NSAIDs) have significant benefits in the control of pain after periodontal surgery. Acetaminophen (centrally acting NSAID) is believed to provide less analgesic efficacy than ibuprofen (centrally and peripherally acting NSAID). This study compared an alternative combination of acetaminophen, 500 mg, with caffeine, 30 mg, to ibuprofen, 400 mg, in pain management after periodontal surgeries. Methods: A prospective, randomized, double-masked crossover clinical trial was conducted on 15 patients. Open flap debridement was performed on two quadrants with a 3-week interval in between. Each quadrant was randomly assigned to acetaminophen, 500 mg, with caffeine, 30 mg, or ibuprofen, 400 mg, immediately after surgery and 8 hours after the first dose. Postoperative pain was assessed during the first 8 hours and

on the following day using the 101-point numeric rate scale (NRS-101) and the fourpoint verbal rating scale (VRS-4). Results: Using the NRS-101, the acetaminophen-caffeine group showed statistically significantly lower mean pain scores than the ibuprofen group at 1 and 2 hours (P = 0.002), whereas at 6, 7, and 8 hours, the ibuprofen group showed statistically significantly lower mean pain scores (P <0.001). Using the VRS-4, there was no statistically significant difference between the two groups at all periods (P >0.05). Conclusion: Acetaminophen, 500 mg, with caffeine, 30 mg, can be used efficiently in controlling postoperative pain after open flap debridement, especially in patients with gastric ulcers or bleeding tendency because acetaminophen is less hazardous than ibuprofen.

Efficacy of Ibuprofen-Hydrocodone for the Treatment of Postoperative Pain After Periodontal Surgery
Dr. James W. Betancourt Leo I. Kupp Samuel J. Jasper Owais A. Farooqi Background: Previous studies have shown that non-steroidal anti-inflammatory drugs (NSAIDs) have significant benefits in the control of postoperative pain after periodontal or oral surgical procedures. The combination of a peripherally acting NSAID with a centrally acting opioid drug is found to be more effective. The purpose of this study was to compare an alternative combination of ibuprofen 400 mg with 5 mg of hydroxycodone to ibuprofen 400 mg used alone in the management of pain following periodontal surgery. Methods: This study used a double-masked cross-over design with the patients acting as their own controls. Twelve patients underwent two periodontal surgeries in different quadrants of the same dental arch at least 2 weeks apart. A standardized amount of local anesthetic and similar extent and duration of surgery for each side was required. The patients received four doses of medication at predetermined intervals and filled out a visual analog pain scale every 2 hours for the first 12 hours after surgery. Results: The overall pain reported by the patients on visual analog scale was 1.55 (SE 0.16), out of a possible 10. More pain was reported with ibuprofen alone, 1.81 (SE 0.12), compared to the ibuprofen with hydrocodone combination, 1.30 (SE 0.16). The difference was statistically significant (P <0.05). Conclusion: The findings suggest that a combination analgesic preparation of ibuprofen (400 mg) with hydrocodone (5 mg) results in better pain control compared to ibuprofen used alone. J Periodontol 2004;75:872-876.

The Effect of Non-Steroidal Anti-Inflammatory Drugs on Bleeding During Periodontal Surgery

Annabel Braganza Dr. Nabil Bissada

Craig Hatch Anthony Ficara Background: With the increasing prevalence of individuals taking non-steroidal antiinflammatory drugs (NSAIDs), there is concern as to whether low-dose NSAIDs cause bleeding problems during periodontal surgery. Methods: A controlled, single-blind study was designed to measure the effect of ibuprofen at peak plasma levels on intraoperative bleeding. Fifteen medically healthy subjects (seven males and eight females), each having two sites requiring periodontal surgery of similar complexity, type, and duration, were selected for the study. The subjects were instructed to take ibuprofen prior to one of the surgeries. A standard bleeding time and papillary bleeding index score were recorded at initial consultation, and prior to the first and second surgeries. The volume of aspirated blood was measured during each surgery by subtracting the amount of water used for irrigation from the total volume of fluid (blood + irrigation water) collected at 15-minute intervals during the surgery. Results: An analysis of the results showed an increase in intraoperative bleeding when ibuprofen was taken prior to surgery (31.93 15.72 versus 17.80 9.57 ml; P <0.01). Ibuprofen appeared to have its greatest effect on bleeding mid-surgery. The average bleeding time also increased significantly (P <0.01) when ibuprofen was preadministered (4.17 0.96 versus 3.8 0.92 minutes), although the bleeding remained within the normal range. Papillary bleeding did not show a significant difference between the two surgeries. Surgeries involving osseous resection showed a significant increase in bleeding when ibuprofen was preadministered. Conclusion: Taken prior to periodontal surgery, ibuprofen increases intraoperative blood loss in patients up to almost two times that of those who did not take ibuprofen. J Periodontol 2005;76:1154-1160.

Decreased Interleukin-1 and Elastase in the Gingival Crevicular Fluid of Individuals Undergoing Anti-Inflammatory Treatment for Rheumatoid Arthritis
Letcia A. Miranda,* Alexandre G. Islabo, Ricardo G. Fischer, Carlos M.S. Figueredo, Rui V. Oppermann, and Anders Gustafsson*

Background: The primary aim of this study was to compare the inflammatory activity in the gingival crevicular fluid (GCF) in a group of patients with rheumatoid arthritis (RA) and a group of matched controls. Secondarily, we aimed to evaluate the effect of rheumatologic treatment on periodontal inflammation. Methods: Seventeen individuals with RA with a mean duration of disease of 12.1 ( 9.9) years and the same number of systemically healthy individuals matched for age, gender, periodontal status, and tobacco use were selected. Medication data were registered, and GCF was collected by means of an intracrevicular washing method. Besides clinical registrations, periodontal inflammation was assessed by analysis of the cytokines interleukin (IL)-1 and -18 and of elastase activity. Results: Amounts of IL-1 and total elastase were significantly lower in the patient group. IL-1 and total elastase had a significant and strong correlation in the RA group (rs = 0.883). This correlation was not observed in the control group.

Conclusion: The anti-inflammatory treatment taken by RA patients might influence the periodontal inflammation status represented by IL-1 and elastase in the GCF.

Effects of Selective Cyclooxygenase-2 Inhibition on Gingival Tissue Levels of Prostaglandin E2 and Prostaglandin F2 and Clinical Parameters of Chronic Periodontitis
Dr. Saynur Vardar Haluk Baylas Afig Huseyinov Background: The purpose of the present study was to evaluate the effect of a relatively selective cyclooxygenase (COX)-2 inhibitor (nimesulide) and non-selective COX-1/COX-2 inhibitor (naproxen) used as an adjunct to non-surgical (scaling and root planing [SRP]) periodontal therapy in chronic periodontitis patients on the gingival tissue (GT) levels of prostaglandin (PG)E2 and PGF2. Methods: Thirty patients with chronic periodontitis were divided into 3 groups of 10 each. One group received 100 mg of nimesulide; one received 275 mg of naproxen sodium; and the third group received placebo tablets in a 2 1 regimen for 10 days as an adjunct to SRP. GT samples were obtained before drug intake and on day 10. Plaque index (PI) and papillary bleeding index (PBI) scores were recorded at baseline, day 10, and at 3 months; probing depth (PD) and clinical attachment level (CAL) were recorded at baseline and at 3 months. The levels of PGE2 were detected using an enzyme immunoassay (EIA), and the levels of PGF2 were analyzed by radioimmunoassay (RIA). Differences among and within the groups were assessed using non-parametric statistical analysis. Ten periodontally healthy individuals served as controls. Results: All 3 groups showed statistically significant reductions in PBI and PI on day 10 and at 3 months (P<0.02), and in PD and CAL at 3 months (P<0.02, P<0.05, respectively). In the naproxen group, GT PGE2 levels exhibited a significant decrease (P<0.05). However, the decrease of GT PGE2 levels in the nimesulide group was insignificant (P>0.05), while a significant increase was observed in the placebo group (P<0.05) on day 10. Both the nimesulide and naproxen groups showed a significant decrease (P<0.05) in PGF2 level, while the placebo group showed a significant increase (P<0.05). Conclusions: Nimesulides, relatively selective COX-2 inhibitors, may have additional inhibitory effects on GT PGF2 levels in the first week following non-surgical periodontal treatment. However, nimesulide has an insignificant effect on reducing PGE 2 levels in gingival tissue. The determination of GT levels of COX-1 and COX-2 enzymes as well as PGE2 and PGF2 in long-term studies may provide further support for the adjunctive use of selective COX-2 inhibitors in treatment of chronic periodontitis. J Periodontol 2003;74:57-63.

Altering the Progression of Human Alveolar Bone Loss With the NonSteroidal Anti-Inflammatory Drug Flurbiprofen
Ray C. Williams,*Marjorie K. Jeffcoat,T. Howard Howell,*Arturo Rolla,Derek Stubbs,Kok W. Teoh,Michael S. Reddy,* and Paul Goldhaber* THE TREATMENT OF HUMAN PERIODONTAL DISEASES relies on mechanical and antimicrobial suppression of the etiologic bacteria. The ability to alter the progression of periodontitis

by additionally blocking host pathways involved in the destructive process is an area of current research. Prostaglandins and other metabolites of arachidonic acid are believed to be important host mediators of the bone resorption of diseases such as periodontitis. We have previously examined the effect of inhibitors of Prostaglandin production, nonsteroidal antiinflammatory drugs (NSAIDs), on inhibiting alveolar bone loss in beagles. The present study was designed to examine the effect of the NSAID, flurbiprofen, on slowing the radiographic loss of alveolar bone in the human. Fifty-six individuals with radiographic evidence of alveolar bone loss were recruited for study. Forty-four patients remained in the study for the data analysis of loss of alveolar bone. Following a 6 month baseline pretreatment period to measure the radiographic progression of bone loss, half of the patients were administered flurbiprofen, 50 mg. b.i.d., while half were administered a placebo. All patients received a subgingival scaling and pumice by a hygienist every 6 months. The rate of alveolar bone loss in a 2-year treatment period was compared to the baseline 6 month pretreatment period within and between patient groups. Throughout the study, teeth exhibiting obvious loss of bone were exited from study and treated with conventional mechanical therapy. At the end of the pretreatment period both patient groups had a similar mean rate of alveolar bone loss. In individuals given placebo tablets, the rate of bone loss was significantly (P < .05) less than baseline at 6 and 12 months of treatment, but not thereafter. Individuals given flurbiprofen twice daily had a significant (P < .05) decrease in rate of bone loss compared to baseline at 6, 12 and 18 months of treatment. In addition we found that at 12 and 18 months of flurbiprofen use the rate of bone loss in the flurbiprofen treated individuals was significantly less than in the placebo patients. However at 24 months of the treatment period there was no difference in the rate of bone loss between the placebo and flurbiprofen treated patients. These data suggest that the NSAIDflurbiprofen, as an inhibitor of cyclooxygenase, can inhibit human alveolar bone loss as measured radiographically. This finding suggests that pharmacologic agents whose main action is the blocking of host responses involved in the disease process may become adjuncts to anti-infective therapy in the management of bone resorption diseases such as periodontitis. (J Periodontol 1989;60:485-490)

Modulation of Host PGE2 Secretion as a Determinant of Periodontal Disease Expression*

Steven Offenbacher, Peter A. Heasman, and John G. Collins AN INCREASING BODY OF EVIDENCE supports the concept that host-produced PGE2 mediates much of the tissue destruction that occurs in periodontal disease. PGE2 levels within the crevicular fluid can serve as a static assessment of ongoing disease activity; i.e., rate of attachment loss and bone resorption. New insights into the mechanisms that regulate PGE2 synthesis provide an altered paradigm of periodontal disease which places the emphasis on host response, rather than the bacterial etiology, as the principal determinant of disease expression. We describe a PGE 2 host response model as a hypothetical framework to discuss new, possible explanations for host susceptibility to periodontal disease. J Periodontol 1993;64:432444.

GCF MMP-8 Levels in Smokers and Non-Smokers With Chronic Periodontitis Following Scaling and Root Planing Accompanied by Systemic Use of Flurbiprofen
Blent Kurtis,* Glay Tter,* Muhittin Serdar, Selin Pinar,* Ilkim Demirel,* and Utku Toyman*

Background: Cigarette smoking has been identified as an important risk factor for the initiation and progression of chronic periodontitis (CP). The aim of this study was to investigate the effects of phase I periodontal therapy and adjunctive flurbiprofen administration on matrix metalloproteinase (MMP)-8 levels in gingival crevicular fluid (GCF) samples from smoking and non-smoking patients with CP. Methods: Twenty-nine non-smoking and 29 smoking patients with CP were divided into four groups according to periodontal treatment modalities. Group 1 (non-smokers with CP) and group 3 (smokers with CP) patients received daily 100-mg flurbiprofen tablets in a 2 1 regimen for 10 days together with scaling and root planing (SRP). Patients in group 2 (non-smokers with CP) and group 4 (smokers with CP) received placebo tablets in a 2 1 regimen for 10 days together with SRP. Plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment level (CAL) measurements were recorded; GCF samples were collected from each sampling area at baseline and after the 10-day period of drug intake by a single examiner who was unaware of the treatment modality. Assays for GCF MMP-8 were carried out by an enzyme-linked immunosorbent assay. Results: All groups showed statistically significant reductions in PI and GI scores following the phase I periodontal treatment (P <0.05), but no statistical differences were observed in PD and CAL scores after therapy. In all groups, the reduction of GCF MMP-8 levels after therapy was statistically significant compared to baseline levels (P <0.001). When groups 1 and 3 and 2 and 4 were compared according to GCF MMP-8 levels after the therapy, no statistically significant differences were observed (P = 0.117 and P = 0.485, respectively). Conclusion: Flurbiprofen administration had no additional inhibitory effect over SRP alone on GCF levels of MMP-8 in smokers compared to non-smokers with CP.

Gingival Crevicular Fluid Matrix Metalloproteinase-8 Levels Following Adjunctive Use of Meloxicam and Initial Phase of Periodontal Therapy
Dr. Nurcan Buduneli Saynur Vardar Gl Atilla Timo Sorsa. Hanne Luoto Haluk Baylas Background: The purpose of the present study was to assess the effects of adjunctive meloxicam on the matrix metalloproteinase- 8 (MMP-8) levels of gingival crevicular fluid (GCF) in chronic periodontitis patients following the initial phase of periodontal therapy. Methods: Twelve chronic periodontitis patients received 7.5 mg meloxicam, and 10 patients received placebo tablets together with scaling and root planing in a 1 1 regimen for 10 days. Scaling and root planing were performed on day 3 of drug intake. The MMP-8 levels in GCF samples obtained before and on day 10 of drug intake were determined by using the immunofluorescence assay. Plaque index (PI), papilla bleeding index (PBI), and GCF MMP-8 levels were compared within each patient group, between the 2 patient groups, and also with a clinically healthy control group using nonparametric statistical analyses.

Results: Both meloxicam and placebo groups showed statistically significant reductions in PBI, PI, and GCF MMP-8 levels on day 10 compared to baseline (P <0.01). The GCF MMP-8 level on day 10 in the meloxicam group was similar to the clinically healthy control group (P >0.05), while it was significantly higher in the placebo group (P<0.01). Positive correlations were found between MMP-8 total amounts and PBI scores at baseline and day 10 of drug intake in the patient groups. Conclusions: Meloxicam showed a tendency to reduce GCF MMP-8 levels in vivo within the first 10 days when used as an adjunct in the initial phase of periodontal treatment that consists of scaling and root planing. Verification of this effect on collagenase-2 downregulation, as well as on the clinical periodontal parameters in long-term studies using larger test and control groups, is needed to provide further support for the adjunctive use of selective cyclooxygenase (COX)-2 inhibitors in the treatment of chronic periodontitis. J Periodontol 2002;73:103-109.

The Effect of Aspirin on the Periodontal Parameter Bleeding on Probing

Janet Schrodi Luisa Recio Joseph Fiorellini Howard Howell Max Goodson Dr. Nadeem Karimbux Background: The absence or presence of bleeding on probing (BOP) is a sign of periodontal health or disease, but the presence of BOP is not an accurate predictor of disease progression. Aspirin is increasingly used in the prevention of cerebrovascular and cardiovascular diseases and is a non-disease factor that may modify bleeding indices given its antithrombolytic activity. The purpose of this double-blind placebo-controlled randomized clinical trial was to study the effect of short-term daily aspirin ingestion on the clinical parameter BOP. Methods: A total of 46 periodontally healthy subjects were included in this study: 16 received placebo, 15 low-dose aspirin (81 mg), and 15 regular dose (325 mg) aspirin. Clinical parameters assessed included plaque index, periodontal probing depth, and BOP using an automated pressure-sensitive probe. Measurements were recorded before and after 7-day exposure to placebo and aspirin regimens. Results: A statistically significant difference in BOP was found in patients with 20% of bleeding sites during the visit prior to placebo or aspirin exposure (n = 11). The group treated with 325 mg aspirin exhibited a moderate yet statistically significant increase in BOP (12.4%) compared to the placebo group (there was no significant difference between the 81 mg aspirin group and placebo). The tendency to bleed was not statistically significant in the group which exhibited <20% (n = 35) of bleeding sites during the visit prior to exposure. Conclusion: Aspirin intake of 325 mg daily for 7 days moderately increased the appearance of bleeding on probing in a population that had 20% BOP sites. J Periodontol 2002;73:871-876.

Adjunctive Benefits of Systemic Etoricoxib in Non-Surgical Treatment of Aggressive Periodontitis: Short-Term Evaluation
Maria Ceclia F. Azoubel,* Viviane A. Sarmento, Virna Canguss, Eduardo Azoubel, Sandro Bittencourt, Fernando Q. Cunha, Ronaldo A. Ribeiro, and Gerly Anne C. Brito Background: This pilot study assessed the effect of short-duration treatment with etoricoxib as adjuvant therapy to scaling and root planing (SRP) on the clinical and radiographic parameters and prostaglandin E2(PGE2) levels in aggressive periodontitis. Methods: Subjects were randomly allocated to test or control treatment (n = 10 in each group) and submitted to SRP and treatment with etoricoxib, 120 mg/day, or placebo for 7 days. Probing depth, clinical attachment level (CAL), gingival recession, visible plaque index, bleeding on probing, linear distance (LD) from the cemento-enamel junction to the alveolar crest, and analysis of the gray levels were recorded before and 1 month after the therapies. The prostaglandin E2 (PGE2) level in the gingival crevicular fluid (GCF) was measured by radioimmunoassay at the beginning of the study and 7 and 30 days after treatment. Results: No significant difference in the clinical parameters was observed between the groups at the end of the experimental period, although both groups presented significant improvement in all variables examined. There was a decrease in CAL from 5.54 0.47 mm to 3.59 0.53 mm in the test group and from 5.92 1.10 mm to 3.69 0.80 mm in the control group. A significant reduction in PGE 2 was found after 7 days of treatment. LD differed between the groups. Conclusion: Etoricoxib did not promote additional improvement in the clinical parameters; however, it produced an initial reduction in the PGE 2 levels in the GCF, which could be related to the discrete improvement in the bone condition.

Interaction Between Piroxicam and Azithromycin During Distribution to Human Periodontal Tissues
Tecla Malizia Giovanna Batoni Emilia Ghelardi Fabio Baschiera Filippo Graziani Corrado Blandizzi Mario Gabriele Mario Campa Prof. Mario Del Tacca Sonia Senesi

Background: Non-steroidal anti-inflammatory drugs and antibiotics are important in the prevention of infections and pain associated with periodontal surgery as well as in the adjunctive therapy of periodontal disease. In this study, patients undergoing oral surgery were treated with piroxicam and azithromycin to examine the interactions of these drugs on periodontal tissues. Methods: Sixty-six patients were assigned to 3 groups and treated for 3 days as follows: 1) piroxicam 20 mg/day; 2) azithromycin 500 mg/day; or 3) piroxicam 20 mg/day plus azithromycin 500 mg/day. Samples of blood, saliva, gingiva, and alveolar bone were collected during surgery and at days 0.5, 2.5, 4.5, and 6.5 after last dose. Piroxicam concentrations were assayed by high-performace liquid chromatography and azithromycin concentrations by microbiological assay. Results: In patients treated with piroxicam alone, the highest drug concentrations were found in plasma at each time point, but consistent piroxicam levels were also detected in gingival samples up to 4.5 days. The combined treatment with piroxicam plus azithromycin was associated with a reduction of piroxicam concentrations in periodontal tissues. In patients receiving azithromycin alone, high drug levels were measured in periodontal tissues up to 6.5 days. This distribution pattern did not vary in patients treated with piroxicam plus azithromycin. Conclusions: Treatment with piroxicam or azithromycin alone ensures a favorable distribution of these drugs into periodontal tissues. However, upon combined administration, azithromycin interferes negatively with the periodontal disposition of piroxicam. This interaction might depend on the displacement of piroxicam from acceptor sites at the level of periodontal tissues. J Periodontol 2001;72:1151-1156.

Selective Cyclooxygenase-2 Inhibition Prevents Alveolar Bone Loss in Experimental Periodontitis in Rats
Mirna M. Bezerra Vilma de Lima Veruska B.M. Alencar Ivana B. Vieira Gerly Anne C. Brito Ronaldo A. Ribeiro Dr. Francisco Airton C. Rocha Background: Prostaglandins are implicated in periodontal bone destruction. We investigated the effect of a non-selective cyclooxygenase (COX) inhibitor (indomethacinIND) or a type 2 COX inhibitor (meloxicam-MLX) in an experimental periodontal disease (EPD) model. Methods: Wistar rats were subjected to placement of a nylon thread ligature around the maxillary molars and sacrificed after 7 days. Alveolar bone loss (ABL) was measured in one quadrant as the distance between the cemento-enamel junction and the alveolar bone. The other quadrant was processed for histopathologic analysis. Daily weight and white blood cell count were recorded. Groups were treated subcutaneously for 7 days with either IND (0.5, 1, or 2 mg/kg) or MLX (0.75, 1.5, or 3 mg/kg). Controls received no treatment. Macroscopic analysis of the gastric mucosa was done. The control group

did not receive any manipulation, and a non-treated group consisted of rats subjected to periodontitis that received no pharmacological treatment. Results: In the non-treated (NT) group, there was significant ABL, severe mononuclear influx, and an increase in osteoclast numbers. Significant neutrophilia and lymphomonocytosis occurred at 6 hours and at 7 days, respectively, as compared to controls. Significant weight loss persisted until the seventh day in the NT group. Both IND and MLX reduced ABL and histopathologic changes. Neutrophilia and lymphomonocytosis were also significantly reversed. Both IND and MLX induced earlier weight recovery. The stomachs of the IND (1 and 2 mg/kg) groups presented hemorrhage and ulcers, whereas in the MLX-treated groups, there were mild petechiae just in the 3 mg/kg group. Conclusions: COX inhibition prevented ABL in this experimental periodontal disease model. MLX displays similar efficacy and less gastric damage than IND. MLX may provide a better risk/benefit ratio in the treatment of human periodontitis than non-selective COX inhibitors. J Periodontol 2000;71:1009-1014.

The Use of Etoricoxib and Celecoxib for Pain Prevention After Periodontal Surgery: A Double-Masked, Parallel-Group, PlaceboControlled, Randomized Clinical Trial
Joao Paulo Steffens,* Fbio Andr Santos, and Gibson Luiz Pilatti Background: Postoperative pain is an adverse effect of periodontal surgeries and may therefore be prevented or minimized. This study was conducted to evaluate the clinical efficacy of two selective cyclooxygenase-2 inhibitors, celecoxib and etoricoxib, on pain prevention after periodontal surgery. Methods: For this double-masked, parallel-group, placebo-controlled, and randomized clinical trial, 56 open-flap debridement surgeries were performed. The groups received three different protocols 1 hour before surgery: 1) 200 mg celecoxib (and another 200 mg 12 hours after the first dose); 2) 120 mg etoricoxib; or 3) placebo. Pain intensity and discomfort were assessed up to 2 days after surgery using the visual analog scale and the four-point verbal rating scale, respectively. Patients were instructed to take 750 mg acetaminophen as a rescue medication if necessary. Results: Pain intensity levels in the etoricoxib group were lower than in the placebo group at the 2-, 3-, 4-, 5-, 6-, and 7-hour periods after surgery (Kruskal-Wallis test; P <0.05). There was no statistically significant difference between celecoxib and etoricoxib. Discomfort in the celecoxib group was significantly lower than in the placebo group only at the 3-hour period (P = 0.03). Rescue medication intake was significantly less frequent in the etoricoxib group than in the placebo and celecoxib groups (analysis of variance; P = 0.009). Conclusion: It was concluded that a single etoricoxib dose is not superior to two split doses of celecoxib when used for pain prevention after open-flap debridement surgery.

Selective Cyclooxygenase-2 Inhibitor May Impair Bone Healing Around Titanium Implants in Rats
Fernanda V. Ribeiro,* Joo B. Csar-Neto,* Francisco H. Nociti Jr.,* Enilson A. Sallum,* Antonio W. Sallum,* Srgio De Toledo,* and Mrcio Z. Casati*

Background: The aim of this study was to investigate the effect of a selective cyclooxygenase-2 inhibitor, meloxicam, on bone healing around titanium implants in rats. Methods: Thirty-one adult male Wistar rats were included in this study, and one screwshaped titanium implant was inserted in the tibiae of each rat. The animals were randomly assigned to one of the following groups for daily subcutaneous injections: control (N = 14): saline solution; and test (N = 17): 3 mg/kg of meloxicam, each administered daily for 60 days. After the treatment, animals were sacrificed, and undecalcified sections were obtained. Bone-to-implant contact (BIC) and bone area (BA) within the limits of implant threads and bone density (BD) in a 500 m-wide zone lateral to the implants were obtained and arranged for cortical (zone A) and cancellous (zone B) bone regions. Results: Intergroup comparisons demonstrated that meloxicam significantly reduced bone healing around implants. For zone A, significant differences were observed regarding BIC (47.01 10.48 A; 35.93 12.25 B), BA (86.42 3.66 A; 61.58 12.09 B), and BD (96.86 0.96 A; 91.06 3.05 B) for control and test groups, respectively (P <0.05). For zone B, data analysis also showed significant differences among groups for BIC (30.76 13.80 A; 16.86 11.48 B), BA (34.83 8.18 A; 25.66 9.16 B), and BD (15.76 7.05 A; 7.73 4.61 B) for control and test groups, respectively (P <0.05). Conclusion: Meloxicam may negatively influence bone healing in the cortical and cancellous bone around titanium implants inserted in rats after continuous administration.

Effect of Selective Cyclooxygenase-2 Inhibition on the Development of Ligature-Induced Periodontitis in Rats

Marinella Holzhausen Carlos Rossa Jr. Elcio Marcantonio Jr. Patrcia O. Nassar Denise M.P. Spolidrio Dr. Luis C. Spolidrio Background: The purpose of this study was to evaluate the effect of a selective cyclooxygenase-2 inhibitor on the progression of alveolar bone loss in an experimental periodontitis model in rats. Methods: One hundred eighty (180) Wistar rats were separated into 3 experimental groups. Cotton ligatures were placed at the gingival margin level of lower right first molars. The rats were randomly assigned to one of the following groups that received: a daily oral dose of 10 mg/kg body weight of celecoxib (Cel); 20 mg/kg body weight of celecoxib (Ce2); or 10 ml/kg of saline solution (C). Serum levels of celecoxib and white blood cell count were determined. Standardized digital radiographs were taken after sacrifice at 3, 5, 10, 18, and 30 days to measure the amount of bone loss around the mesial root surface of the first molar tooth in each rat.

Results: Two-way analysis of variance (ANOVA) indicated that groups treated with celecoxib had significantly less bone loss compared to controls (P <0.0001) and that there was a sig- nificant interaction between treatment with celecoxib and time (P <0.03). Post-hoc comparisons showed that in both groups treated with celecoxib, the bone loss became significant only after 10 days of ligature placement, while in the control group it was already significant after 5 days. However, differences in mean bone loss between control and Ce1 were significant only at 18 days and, between control and Ce2, at 5 and 18 days. There was no significant difference in bone loss among experimental groups at the end of the experimental period. Conclusion: These data provide evidence that systemic therapy with celecoxib can modify the progression of experimentally induced periodontitis in rats.J Periodontol2002;73:1030-1036.

Gingival Crevicular Fluid Prostaglandin E2 and Thiobarbituric Acid Reactive Substance Levels in Smokers and Non-Smokers With Chronic Periodontitis Following Phase I Periodontal Therapy and Adjunctive Use of Flurbiprofen
Blent Kurti,* Glay Tter,* Muhittin Serdar, Selin Pnar,* lkim Demirel,* and Utku Toyman* Background: It has been established that smoking is an important risk factor for the initiation and progression of chronic periodontitis (CP). This study investigates the effects of phase I periodontal therapy and adjunctive flurbiprofen administration on prostaglandin E2 (PGE2) and thiobarbituric acid reactive substance (TBARS) levels in gingival crevicular fluid (GCF) samples from smoker and non-smoker patients with CP. Methods: Twenty-one non-smoker and 21 smoker patients with CP were divided into four groups according to treatment modalities. Group 1 (non-smokers with CP) and group 3 (smokers with CP) patients received daily 100-mg flurbiprofen tablets in a 2 1 regimen for 10 days together with scaling and root planing (SRP). Patients in group 2 (non-smokers with CP) and group 4 (smokers with CP) received placebo tablets in a 2 1 regimen for 10 days together with SRP. Plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment level (CAL) measurements were recorded and GCF samples were collected at baseline and on day 10 of drug intake from each sampling area by a single examiner who was unaware of the treatment modality. Assays for GCF PGE2 and TBARS were carried out by an enzyme-linked immunosorbent assay and fluorometric method, respectively. Results: All groups showed statistically significant reductions in PI and GI scores following the phase I periodontal treatment on day 10 (P <0.05), but no statistical differences were observed in PD and CAL scores after the therapy. In groups 1 and 2, the reduction of GCF PGE2 and TBARS levels were not significant after the therapy compared to baseline levels. In group 3, GCF PGE2 and TBARS levels exhibited a statistically significant decrease (P <0.05) after the therapy. Group 4 showed significant reductions (P <0.05) in GCF PGE2 levels after the therapy. No statistically significant reductions were observed in group 4 with regard to GCF TBARS levels. When groups 1 and 3 were compared according to GCF TBARS levels after the therapy, a more statistically significant reduction was observed in group 3 (P = 0.001). Conclusion: These results suggest that additional flurbiprofen administration may have more inhibitory effects on GCF levels of PGE2 and TBARS in the groups of smokers compared to non-smokers with CP.

The Effect of a Selective Cyclooxygenase-2 Inhibitor (Celecoxib) on Chronic Periodontitis

C. Alec Yen,* Petros D. Damoulis,* Paul C. Stark, Patricia L. Hibberd, Medha Singh,* and Athena S. Papas* Background: Non-steroidal anti-inflammatory agents inhibit the production of cyclooxygenase (COX) products and can attenuate bone loss. In this double-masked, placebo-controlled, randomized clinical trial, the efficacy of celecoxib (COX-2 inhibitor) was evaluated in conjunction with scaling and root planing (SRP) in subjects with chronic periodontitis (CP). Methods: A total of 131 subjects were randomized to receive SRP and either celecoxib (200 mg) or placebo every day for 6 months. Clinical outcomes were assessed every 3 months for 12 months as mean changes from baseline. Primary efficacy parameters included clinical attachment level (CAL) and probing depth (PD). Secondary outcomes included percentages of tooth sites with CAL loss or gain 2 mm, changes in bleeding on probing (BOP), plaque index, and mobility. Prior to analysis, tooth sites were grouped based on baseline PD as shallow (1 to 3 mm), moderate (4 to 6 mm), or deep (7 mm). Results: Mean PD reduction and CAL gain were greater in the celecoxib group, primarily in moderate and deep sites, throughout the study (PD: 3.84 mm versus 2.06 mm, P <0.001; CAL: 3.74 mm versus 1.43 mm, P <0.0001 for deep sites at 12 months). The celecoxib group also exhibited a greater percentage of sites with 2 mm CAL gain and fewer sites with 2 mm CAL loss. Both groups showed improved plaque control and BOP scores. Demographic, social, and behavioral factors did not affect treatment outcomes. Conclusions: Celecoxib can be an effective adjunctive treatment to SRP to reduce progressive attachment loss in subjects with CP. Its beneficiary effect persisted even at 6 months postadministration. However, given the increased cardiovascular risks associated with the use of this drug, close patient supervision and strict adherence to dosage and administration guidelines established by the Unites States Food and Drug Administration are of paramount importance.

Evaluation of Novel Adhesive Film Containing Ketorolac for Post-Surgery Pain Control: A Safety and Efficacy Study
Khalid Al-Hezaimi,* Mansour Al-Askar,* Zuied Selamhe, Jia-Hui Fu, Ibrahim A. Alsarra, and Hom-Lay Wang* Background: Prescribing analgesics after periodontal surgery is a common practice. However, it can become a challenge for patients with systemic diseases or who are on long-term medications. Ketorolac tromethamine (KT), a non-steroidal anti-inflammatory drug, is incorporated into an adhesive film to overcome the limitations associated with oral, intravenous, intramuscular, or sublingual routes of drug administration. This study evaluates the analgesic effect of a KT adhesive film for pain management after periodontal surgery. Methods: Aqueous solvents of two bioadhesive polymers (hydroxypropyl methylcellulose and polyacrylic acid), together with 30 mg of KT, were used to formulate the adhesive film. Sixty-eight patients, who each received a free gingival graft, were randomly divided into treatment and control groups. In the treatment group, the prepared adhesive film was applied over the surgical site, whereas in the control group adhesive film without KT was placed initially. Two hours after surgery, the KT adhesive

film was applied on the surgical site in the control group. A visual analog scale was used to assess the degree of pain encountered at 0, 1, 2, 3, 4, 5, 24, and 48 hours postsurgery. Results: The treatment group reported a significant reduction of pain intensity during the first 2 hours after surgery (P <0.05). After the KT adhesive film was applied in the control group, pain intensity was reduced to a non-significant level by the third hour after surgery. No adverse reaction or undesirable gastrointestinal side effect was observed. Conclusion: Adhesive film containing 30 mg of KT was effective in controlling postsurgical pain with no observable gastrointestinal effects.

The Effect of Aspirin on Gingival Crevicular Fluid Levels of Inflammatory and Anti-Inflammatory Mediators in Patients With Gingivitis
David M. Kim,* Kristian L. Koszeghy, Rachel L. Badovinac, Toshihisa Kawai, Ikuko Hosokawa, T. Howard Howell,* and Nadeem Y. Karimbux* Background: Inflammatory and anti-inflammatory mediators may play a significant role in patients with gingivitis. The purpose of this study was to assess the short-term effects of the systemic administration of two different concentrations of aspirin (81 and 325 mg/day, by mouth) on clinical periodontal parameters and gingival crevicular fluid (GCF) levels of 15-epi-lipoxin A4 (15-epi-LXA4), lipoxin A4, leukotriene B4 (LTB4), prostaglandin E2(PGE2), and interleukin (IL)-6 and -1 in a sample of naturally occurring gingivitis patients. Methods: At day 0, after initial screening for entry, baseline periodontal parameters, including bleeding on probing (BOP), periodontal probing depths (PDs), and plaque index (PI) were measured, and GCF was sampled from 12 intrasulcular sites with filter paper strips for the measurement of six types of inflammatory and anti-inflammatory mediators using competitive enzyme immunoassay and enzyme-linked immunosorbent assay (prevalues). Forty-seven subjects were assigned randomly to one of three treatment groups: placebo (15 subjects); aspirin, 81 mg (16 subjects); and aspirin, 325 mg (16 subjects) once daily. On day 7, subjects were recalled for the measurement of periodontal parameters and collection of GCF samples for the measurement of six types of mediators (postvalues). Results: Changes in inflammatory and anti-inflammatory mediator levels were not statistically significant for any of the three treatment groups. However, when pre- and postvalues were compared in the subjects receiving aspirin, 325 mg, there was a negative trend in the relationship between 15-epi-LXA4 and PGE2, whereas the relationship between LTB4 and PGE2 was not as strong. This might indicate that the subjects responding to aspirin-mediated PGE2 suppression effects produced higher 15epi-LXA4 in GCF than non-responders. No statistically significant differences in PD and PI between pre- and postvalues were found for any of the three treatment groups. However, the results demonstrated a significant increase in BOP when aspirin, 325 mg was compared to placebo (P <0.001) and aspirin, 81 mg (P = 0.001). Conclusions: Aspirin can have an affect on BOP in naturally occurring gingivitis patients. Although most of the inflammatory mediators did not show significantly detectable changes after aspirin treatment for 7 days, the trend of aspirin-associated increases of 15-epi-LXA4 implied that this recently discovered aspirin-dependent eicosanoid may be associated with the increased incidence of BOP observed in the subjects who received aspirin therapy.

The Effect of Aspirin Intake on Bleeding on Probing in Patients With Gingivitis

Daniel Royzman Luisa Recio Rachel L. Badovinac Joseph Fiorellini Max Goodson Howard Howell Dr. Nadeem Karimbux Background: Bleeding indices are used as a screen for periodontal disease activity, a measure of disease prevalence, and a measure of effectiveness in clinical trials. Bleeding on probing (BOP) is widely interpreted as a sign of disease activity whereas its absence is interpreted as both a sign and predictor of health. Aspirin use has become increasingly common in the prevention of cerebrovascular and cardiovascular diseases. Because of its anti-platelet activity, aspirin is a non-disease factor that has the potential to affect the appearance of BOP. The hypothesis being tested is that short-term aspirin use in doses of 81 mg and 325 mg will increase the number of bleeding sites in a population with gingivitis. Methods: Fifty-four subjects were screened initially, those subjects with 20% to 30% whole mouth BOP were randomly assigned to one of three arms: placebo group, 81 mg aspirin group, or 325 mg aspirin group. Before and after exposure to the respective regimens, clinical parameters were measured on all the teeth: the plaque index was recorded at four sites per tooth, and probing depth and BOP were evaluated at six sites per tooth using an automated pressure-sensitive probe. Results: The data obtained in this clinical trial were analyzed utilizing a linear regression analysis to control for confounding variables. The primary measure of interest was BOP in patients clinically demonstrating naturally occurring gingivitis. The results of this study indicate that while controlling for age, gender, and plaque, "low dose" 81 mg and "regular dose" 325 mg of aspirin demonstrated a statistically significant 5.30 (P = 0.001) and 4.13 (P = 0.010) increase from baseline, respectively, in percent BOP. Conclusion: Failure to consider the effects of aspirin on BOP could impair proper diagnosis and treatment planning for clinicians and introduce a significant confounding variable in research situations. J Periodontol 2004;75:679-684.

Involvement of Cyclooxygenase-2 in Interleukin-1-Induced Prostaglandin Production by Human Periodontal Ligament Cells

Kazuyuki Noguchi Miki Shitashige Isao Ishikawa

Background: Human periodontal ligament (PDL) cells produce prostaglandin (PG) E2 in response to proinflammatory cytokines. However, the mechanism of PGE 2 production is not well understood. The purpose of the present study was to investigate the involvement of cyclooxygenase (COX)-1 and COX-2 in PGE, production by PDL cells to examine the regulation of PGE2 production by cell-cell interaction of human gingival keratinocytes and PDL cells. stimulated with a proinflammatory cytokine, interleukin-1 (IL-1 ), and Methods: The levels of PGE2 in the culture media of PDL cells stimulated with IL-1 or culture media of human gingival keratinocytes were determined by an enzyme-linked immunosorbent assay. Expression of COX-1 and -2 mRNA and protein was studied by Northern blot analysis and Western blot analysis, respectively. Results: IL-1 -stimulated PDL cells produced PGE2 in a time-dependent manner. Indomethacin, a non-selective COX-1/COX-2 inhibitor, and NS-398, a selective COX-2 inhibitor, completely inhibited PGE2 production by the IL-1 -stimulated cells. COX-2 mRNA was detected after IL-1 stimulation, although it was not detected in unstimulated cells. There was no difference in expression of COX-1 mRNA between unstimulated cells and IL-1 -stimulated cells. Expression of COX-2 protein in IL-1 stimulated cells was increased, compared with that in unstimulated cells, whereas COX-1 protein expression was almost the same in both the cells. Treatment of IL-1 stimulated PDL cells with dexamethasone, known to inhibit COX-2 expression, prevented PGE2 production and COX-2 mRNA expression. Addition of the culture media of human gingival keratinocytes to PDL cells increased PGE2 production. The PGE2 production was depressed by treatment of the cells with IL-1 receptor antagonist and anti- IL-1 antibody, not with anti-IL-1 antibody. The PGE2 production was also inhibited by treatment with NS-398 and dexamethasone. Conclusions: We suggest that PDL cells stimulated with IL-1 produce PGE2 through de novo synthesis of COX-2 and that the cell interaction of gingival keratinocytes and PDL cells controls COX-2 expression and PGE2production via IL-1 or a IL-1 -like factor(s). Selective COX-2 inhibitors, which have the advantage of reduced gastric toxicity, may provide a useful approach to treatment of periodontal disease. J Periodontol 1999; 70:902-908.

The Use of Celecoxib and Dexamethasone for the Prevention and Control of Postoperative Pain After Periodontal Surgery
Gibson Luiz Pilatti,* Fbio Andr dos Santos,* Audilene Bianchi,* Rodrigo Cavassim,* and Claudinia W. Tozetto* Background: Conventional non-steroidal anti-inflammatory drugs have been widely used in the control of postoperative pain, but sparse information is available on the efficacy of celecoxib, a selective cyclooxygenase-2 inhibitor, or dexamethasone, a steroidal anti-inflammatory drug, after periodontal surgeries. The purpose of the present study was to compare the use of celecoxib and dexamethasone in the management of pain after mucoperiosteal flap surgery. Methods: A randomized double-masked cross-over clinical trial was conducted on 20 patients from 27 to 52 years old with generalized moderate to advanced chronic periodontitis. Mucoperiosteal flap surgeries for scaling and root planing were performed under local anesthesia on at least three quadrants, with a 4-week interval between. Each quadrant was randomly assigned to one of the following medication protocols: placebo, 4 mg dexamethasone 1 hour before surgery and 8 hours after the first dose, and 200 mg celecoxib 1 hour before surgery and 12 hours after the first dose. Postoperative pain was

accessed during the first 8 hours and on the following 3 days using the visual analog scale (VAS), the 101-point numerical rate scale (NRS-101), and the four-point verbal rating scale (VRS-4). Results: Pain perception was statistically significantly lower in the celecoxib group than in the placebo group during the first 4 hours using VAS (P = 0.01) and at 1, 2, 3, 4, 6, and 7 hours using NRS-101 (P = 0.03). The level of pain was lower in the dexamethasone group than in the placebo only at the 3-hour period (P = 0.001). Statistically significant differences could be found among the groups at 1 hour (P = 0.015), 3 hours (P = 0.004), 4 hours (P = 0.02), and 7 hours (P = 0.05) using VRS-4. There was no statistically significant difference between the celecoxib and dexamethasone groups. Conclusion: The findings of this study suggest that the preemptive and postoperative use of celecoxib or dexamethasone were effective in the management of postoperative pain following open-flap debridement.

Preemptive Dexamethasone and Etoricoxib for Pain and Discomfort Prevention After Periodontal Surgery: A Double-Masked, Crossover, Controlled Clinical Trial
Joao Paulo Steffens,* Fbio Andr Santos,* Rafael Sartori, and Gibson Luiz Pilatti* Background: Several anti-inflammatory drugs have been used to reduce pain and discomfort after periodontal surgeries. This study evaluates the efficacy of using etoricoxib and dexamethasone for pain prevention after open-flap debridement surgery. Methods: For this prospective, double-masked, crossover, placebo-controlled, randomized clinical trial, open-flap debridement surgeries were performed on 15 patients (eight males and seven females, age range 20 to 56 years: mean age SD: 40 9.7 years) who presented with chronic periodontitis after non-surgical periodontal therapy at three quadrants. Each patient underwent three surgical procedures at intervals of 30 days and received one of the following premedication protocols 1-hour before surgery: group 1 = placebo, group 2 = 8 mg dexamethasone, and group 3 = 120 mg etoricoxib. Rescue medication (750 mg acetaminophen) was given to each patient who was instructed to take it when necessary. Pain intensity and discomfort were evaluated by a 101-point numeric rate scale and a four-point verbal rate scale, respectively, hourly for the first 8 hours after surgery and three times a day on the following 3 days. Results: The results demonstrate that groups 2 and 3 present reduced postoperative pain-intensity levels compared to group 1. There were statistically significant differences at the 4, 5, 6, 7, and 8 hour-periods after surgery (Friedman test; P <0.05). Furthermore, rescue-medication intake was significantly lower for groups 2 and 3 than for group 1 (analysis of variance; P <0.02). Conclusion: The adoption of a preemptive medication protocol using etoricoxib or dexamethasone may be considered effective for pain and discomfort prevention after open-flap debridement surgeries.

Cyclooxygenase-2 Inhibitors Decrease Interleukin-1Stimulated Prostaglandin E2 and IL-6 Production by Human Gingival Fibroblasts
Dr. David A. Tipton

Jon C. Flynn Sidney H. Stein Mustafa Kh. Dabbous Background: Previous work showed that normal and aggressive periodontitis (AgP) gingival fibroblasts produce the boneresorbing cytokine IL-6. PGE2 is important in regulating IL-6 production. Non-steroidal anti-inflammatory drugs inhibit PG synthesis via COX-1 and/or COX-2 isoenzymes and may inhibit periodontal destruction. COX-2 is induced after cellular activation (i.e., by inflammatory cytokines such as IL-1). Little is known about IL-1-stimulated AgP fibroblast IL-6 and PGE2 production and their regulation by COX inhibitors. The objective of this study was to determine the effects of COX-2 inhibitors on amounts of PGE2 and IL-6 made by IL-1-stimulated gingival fibroblasts. Methods: Gingival fibroblasts (2.5 104) from healthy or severe periodontitis patients were cultured in serum-free medium, with or without IL-1 (1011M) for 24 hours, with or without the COX-1/2 inhibitor indomethacin or the selective COX-2 inhibitors NS-398, celecoxib, or rofecoxib. PGE2 and IL-6 in culture supernatants were determined by specific enzyme-linked immunosorbent assay (ELISA)s. Results: All of the COX inhibitors caused dose-dependent decreases in IL-1-stimulated PGE2, to a maximum of >90% in all cell lines (P 0.0001). The selective COX-2 inhibitors, but not indomethacin, caused partial (generally up to approximately 60%), dose-dependent decreases in IL-1-stimulated IL-6 in all cell lines (P 0.003). When exogenous PGE2 was added concurrently with COX-2 inhibitors before addition of IL-1, IL-6 production returned to levels at or approaching that produced by cells exposed only to IL-1 (P 0.04). Conclusion: The results suggest that COX-2 inhibition may be useful in helping to control fibroblast production of IL-6 in patients with severe periodontitis. J Periodontol 2003;74:1754-1763.

Effects of Enamel Matrix Derivative on Bone-Related mRNA Expression in Human Periodontal Ligament Cells In Vitro
Kazuaki Takayanagi,* Ginko Osawa, Hiroshi Nakaya, David L. Cochran, Kyuich Kamoi,* and Thomas W. Oates Background: Enamel matrix derivative (EMD) has demonstrated the potential to stimulate periodontal regeneration with mineralized tissue formation. Molecular regulators of bone metabolism include osteoprotegrin (OPG), receptor activator of nuclear factor kappa B ligand (RANKL), cyclooxygenase 2 (COX2), and core binding factor alpha 1 (Cbfa1). The role of these regulatory molecules within the context of EMD stimulation of mineralized tissue formation is unknown. Therefore, the purpose of this investigation was to explore the effects of EMD on these bone-related molecules in human periodontal ligament (PDL) cells. Methods: Human PDL-cell cultures were treated with EMD (5 to 100 g/ml) for 24 hours. Total RNA was isolated using phenolchloroform, and reverse transcriptionpolymerase chain reaction (RT-PCR) was performed using primers specific for OPG, RANKL, COX2, Cbfa1, and aldolase, with amplification in the exponential range for each molecule studied.

Results: The results of this study show that there is a significant (P <0.05) increase in COX2 mRNA levels with EMD treatment, and no effects were noted on mRNA levels for Cbfa1. RANKL mRNA levels were significantly decreased (P <0.01) up to 50% with EMD treatment 25 g/ml. OPG levels showed minimal effects with EMD treatment. However, the RANKL/OPG ratio showed a 40% to 55% reduction with EMD 25 g/ml. Conclusion: This study supports a role for EMD stimulation of mineralized tissue formation consistent with periodontal regeneration by modulating regulatory molecules critical to bone metabolism at the RNA level.

COX-2 Inhibition Decreases VEGF Expression and Alveolar Bone Loss During the Progression of Experimental Periodontitis in Rats
Thais M. Oliveira,* Vivien T. Sakai,* Maria Aparecida A.M. Machado,* Thiago J. Dionsio, Tania Mary Cestari, Rumio Taga, Sandra L. Amaral, and Carlos F. Santos Background: Vascular endothelial growth factor (VEGF) is a macromolecule of importance in inflammation that has been implicated in periodontitis. The aims of this study were to investigate VEGF expression during the progression of periodontal disease and to evaluate the effect of a preferential cyclooxygenase (COX)-2 inhibitor meloxicam on VEGF expression and alveolar bone loss in experimentally induced periodontitis. Methods: A total of 120 Wistar rats were randomly separated into groups 1 (control) and 2 (meloxicam, 3 mg/kg/day, intraperitoneally, for 3, 7, 14, or 30 days). Silk ligatures were placed at the gingival margin level of the lower right first molar of all rats. VEGF expression was assessed by reverse transcription-polymerase chain reaction (RTPCR), Western blot (WB), and immunohistochemical (IHC) analyses. The hemiarcades were processed for histopathologic analysis. RT-PCR and WB results were submitted to analysis of variance, the Tukey test, and Pearson correlation analysis (P <0.05). Results: A reduction in alveolar bone resorption was observed in the meloxicam-treated group compared to the control group at all periods studied. There was a positive correlation between COX-2 mRNA and VEGF mRNA in the gingival tissues and periodontal disease (R = 0.80; P = 0.026). Meloxicam significantly reduced the increased mRNA VEGF expression in diseased tissues after 14 days of treatment (P = 0.023). Some alterations in VEGF receptor 1 mRNA expression were observed, but these were not statistically significant. VEGF protein expression in WB experiments was significantly higher in diseased sites compared to healthy sites (P <0.05). After 14 days of treatment with meloxicam, an important decrease in VEGF protein expression was detected in diseased tissues (P = 0.08). Qualitative IHC analysis revealed that VEGF protein expression was higher in diseased tissues and decreased in tissues from rats treated with meloxicam. Conclusions: The present data suggest an important role for VEGF in the progression of periodontal disease. Systemic therapy with meloxicam can modify the progression of experimentally induced periodontitis in rats by reducing VEGF expression and alveolar bone loss.

Local Simvastatin Effects on Mandibular Bone Growth and Inflammation

David Stein,* Yeonju Lee,* Marian J. Schmid,* Byron Killpack,* Mikala A. Genrich,* Nagamani Narayana,* David B. Marx, Diane M. Cullen, and Richard A. Reinhardt*

Background: Simvastatin has been shown to increase bone growth when applied topically to murine bone; however, it causes considerable soft tissue inflammation at high doses (2.2 mg), making future clinical use problematic. This study evaluated the effect of lower simvastatin doses and cyclooxygenase (COX) synthase inhibitors on tissue inflammation and bone growth in rats and gene expression in mice. Methods: Adult female rats were untreated or treated with a single dose of 0.1, 0.5, 1.0, 1.5, or 2.2 mg simvastatin in methylcellulose gel in a polylactic acid membrane (SIM) on the lateral aspect of the mandible. The contralateral mandible side was implanted with methylcellulose gel/polylactic acid membrane alone (GEL), and five rats in each dose pairing were evaluated histomorphometrically after 3, 7, and 24 days. Subsequent rats were similarly treated with 0.5 mg simvastatin (optimal dose) and daily intraperitoneal injections of COX-2 inhibitor (NS-398; 1 mg/kg 7 days; N = 16), general COX inhibitor (indomethacin; 1 mg/kg 7 days; N = 16), or no inhibitor (N = 10) and evaluated histomorphometrically after 7 or 24 days by analysis of variance (ANOVA). Gene arrays were also used to evaluate osteogenic gene expression from 0.5 mg simvastatin in murine calvaria (N = 12). Results: There was a 45% increase in bone area with 0.5 mg simvastatin versus gel control (P <0.001; similar to the 2.2-mg dose), and clinical swelling was reduced compared to the high simvastatin dose (P <0.05). The 0.1-mg simvastatin dose failed to stimulate significant bone growth. NS-398 and indomethacin reduced inflammation and bone growth. Simvastatin significantly upregulated procollagen, fibronectin, and matrix metalloproteinase-13 genes. Conclusion: Reducing the simvastatin dose from 2.2 to 0.5 mg reduced inflammation to a more clinically acceptable level without sacrificing bone-growth potential, but COXassociated inflammation appears to be necessary for in vivo bone growth.

Oral Administration of EP4 Antagonist Inhibits LPS-Induced Osteoclastogenesis in Rat Periodontal Tissue
Hiroko Oka, DDS, PhD,* Mutsumi Miyauchi, DDS, PhD,* Hisako Furusho, DDS,* Tatsuji Nishihara, DDS, PhD,and Takashi Takata, DDS, PhD* Background: Lipopolysaccharide (LPS) from periodontal pathogens is one of the main causes of alveolar bone destruction. Prostaglandin E2 (PGE2) produced by host cells after LPS-stimulation may contribute to the bone destruction. PGE2 regulates osteoblastmediated osteoclastogenesis via PGE-specific receptor 4 (EP4). We examined the effects of the PGE2-EP4 pathway on the expression of osteoclastogenesis-related factors and studied the inhibitory effect of orally applied EP4-specific antagonist (EP4A) on LPSinduced bone destruction in comparison with complete inhibition of endogenous PGE2 by indomethacin (IND). Methods: ST2 cells were treated with IND or EP4A and stimulated by LPS. The mRNA expressions of interleukin (IL)-6, tumor necrosis factor-(TNF-), the receptor activator of NFB ligand (RANKL) and osteoprotegerin (OPG) in ST2 cells were examined by quantitative RT-PCR. LPS-induced bone destruction was examined using rat model for the periodontal tissue destruction with topically-applied LPS. Results: IND and EP4A inhibited the upregulation of TNF- mRNA expression and only EP4A inhibited IL-6 and RANKL mRNA expressions in ST2 cells with LPS-stimulation. Topically applied LPS induced a two-phase increase in osteoclasts along the alveolar bone margin, peaking after 3 hrs and 3 days. Oral administration of EP4A and IND

downregulated the later phase increase of osteoclasts. While, the early phase of increase at 3 hrs was upregulated in IND-treated rats but not in EP4A-treated rats. Conclusion: It indicates that PGE2-EP4 pathway has an important role in LPS-induced osteoclastogenesis and the specific blocking of the PGE 2-EP4 pathway by EP4A can effectively downregulate bone destruction caused by LPS without unexpected increased number of osteoclasts.

Cyclooxygenase-2 Is Upregulated in Inflamed Gingival Tissues

Rakhi Sinha Morton Dr. Anna I. Dongari-Bagtzoglou Background: Increased release of prostaglandins (PG) within periodontal tissues is considered to play a pathogenetic role during periodontal disease progression. The ratelimiting step in the formation of PG from arachidonic acid is catalyzed by cyclooxygenase (COX). Currently there are 2 known isoforms of the enzyme. COX-1 is constitutively expressed in various tissues whereas COX-2 is an inducible enzyme believed to be responsible for PG synthesis at sites of inflammation. The purpose of this study was to compare COX-2 expression in inflamed and healthy human gingiva and further explore some of the pathogenetic mechanisms which may lead to elevated COX-2 expression in vivo. Methods: Thirty-two gingival biopsies were obtained during routine oral surgical procedures and were processed histologically using hematoxylin and eosin to determine the degree of inflammation. Of these biopsies, 7 with low and 7 with high histological levels of inflammation were further processed immunohistochemically in order to assess the levels of COX-2 expression in situ. To explore some potential mechanisms of COX-2 upregulation, gingival connective tissue primary cell cultures were established and challenged with periodontal bacteria or proinflammatory cytokines in vitro. The levels of COX-2 expression were analyzed by Western blot of cell lysates. COX-2 activity was assessed by quantifying prostaglandin E2 (PGE2) levels in culture supernatants by competitive EIA. Results: We have shown by immunohistochemistry that COX-2 expression was significantly higher (P <0.01) in tissues with higher levels of inflammatory infiltrates. Expression of COX-2 was detected in gingival epithelium, endothelial cells as well as cells with fibroblast morphology. In vitro studies indicated that gingival fibroblasts (GF) did not express COX- 2 constitutively. However, when these cells were challenged with interleukin (IL)-1 or bacterial cells (A. actinomycetemcomitans JP2 or B. forsythus ATCC 43037), COX-2 expression as well as COX-2 activity were upregulated. COX-2 expression was upregulated as early as 2 hours post IL-1 challenge and was accompanied by a sustained PGE2 release in the culture supernatants. Cyclosporin A (CsA) did not inhibit COX-2 expression induced by bacterial challenge. In contrast, NS398, a selective inhibitor of COX-2 activity, almost completely abolished PGE2 synthesis by these cells in response to bacterial or cytokine challenge. Conclusions: We conclude that COX-2 expression is significantly upregulated in inflamed periodontal tissues. Both inflammatory cytokines such as IL-1 and bacterial constituents may be responsible for the enhanced COX-2 expression and PGE2 synthesis in vivo. J Periodontol 2001;72:461-469.

Individual and Combined Effects of Selective Cyclooxygenase-2 Inhibitor and Omega-3 Fatty Acid on Endotoxin-Induced Periodontitis in Rats

Dr. Saynur Vardar Eralp Buduneli Haluk Baylas Afig Hseyinov Berdeli Nurcan Buduneli Gl Atilla Background: The present study was planned to evaluate the individual and combined effects of selective cyclooxygenase-2 (COX-2) inhibitor, celecoxib, and omega-3 fatty acid on the gingival tissue levels of prostaglandin E2 (PGE2), prostaglandin F2 (PGF2), leukotriene B4 (LTB4), and platelet activating factor (PAF) in endotoxin-induced periodontitis in rats. Methods: Experimental periodontitis was induced by repeated injection of Escherichia coli endotoxin (LPS). Forty-four adult male Sprague-Dawley rats were divided into five study groups: saline control, LPS, celecoxib, omega-3 fatty acid, and combination celecoxib and omega-3 fatty acid. Celecoxib and omega-3 fatty acid were given either as a single agent or as a combination therapy during 14 days of the study period. At the end of the 2-week protocol, the rats were sacrificed, the gingival tissues were dissected and extracted, and the extracts were analyzed for PGE2, PGF2, and LTB4 levels by enzyme immunoassay and for PAF levels by radioimmunoassay. The defleshed jaws were analyzed morphometrically for alveolar bone loss. Data were evaluated statistically by using parametric tests. Results: LPS injection resulted in significantly more bone loss than the saline controls (P <0.05) and significant elevations in the gingival tissue levels of all the analyzed mediators except PGF2. Individual administration of celecoxib revealed significant reductions in PGE2 and PAF levels (P <0.05), while omega-3 fatty acid provided significant reduction in PGE2, PGF2, and LTB4 levels compared to the LPS group (P <0.05). Combined administration of celecoxib and omega-3 fatty acid exhibited significantly lower values than those of the LPS group in all the analyzed membrane phospholipid mediators (P <0.05), which approximated the levels in the saline control group (P >0.05). Conclusions: The results of the present study indicate that celecoxib and omega-3 fatty acid, when used individually, show a rather partial effect on the control of the analyzed mediators, but when combined they show a synergic effect and provide significant reductions in the gingival tissue levels of PGE2, PGF2, LTB4, and PAF in LPS-induced experimental periodontitis. These findings may pioneer further clinical human studies investigating the possible place of celecoxib and omega-3 fatty acid in periodontal treatment. J Periodontol 2005;76:99-106.

Serum Cytokine and Periodontal Profiles in Relation to Disease Activity of Rheumatoid Arthritis in Japanese Adults
Tetsuo Kobayashi,* Tomoko Yokoyama, Kohei Ishida, Asami Abe, Kouji Yamamoto, and Hiromasa Yoshie Background: Rheumatoid arthritis (RA) and periodontitis are common chronic inflammatory conditions and share many pathologic features. A similar profile of

cytokines is involved in the pathogenesis of the two diseases. The relationship between the disease activity of RA and the periodontal condition remains unclear. This study examines whether the disease activity of RA affects serum cytokine and periodontal profiles. Methods: The study subjects consisted of 84 Japanese adults with RA and 22 racematched control individuals. After periodontal and rheumatologic examination, the disease activity of RA was determined with the Disease Activity Score including 28 joints using C-reactive protein (DAS28-CRP). Serum levels of cytokines including interleukin (IL)-1, IL-6, IL-12, IL-12 p40, IL-18, and tumor necrosis factor- (TNF-) were determined by an enzyme-linked immunosorbent assay. High-sensitive CRP was also measured with a latex particle-enhanced nephelometric method. Results: Of 84 patients with RA, 28 and 56 patients exhibited low and moderate to high disease activity, respectively. Serum levels of IL-6, TNF-, and CRP were significantly different between the two groups (P<0.05). Additionally, a significant correlation was observed between DAS28-CRP and percentage of sites with bleeding on probing (BOP) (P = 0.008) and between serum TNF- levels and percentage of sites with BOP (P = 0.01) in 56 patients with RA with moderate to high activity. Conclusion: These results suggest that the disease activity of RA correlated with serum levels of IL-6, TNF-, and CRP, and it might influence BOP in the patients with moderate to high disease activity.

Impact of an Anti-Inflammatory Therapy and Its Withdrawal on the Progression of Experimental Periodontitis in Rats
Bruno Csar de Vasconcelos Gurgel Poliana Mendes Duarte Francisco H. Nociti, Jr. Dr. Enilson A. Sallum Mrcio Zaffalon Casati Antonio Wilson Sallum Srgio de Toledo Background: Anti-inflammatory agents have been reported as a bone loss mediator in periodontitis. This study aimed to investigate in rats the impact of a selective cyclooxygenase-2 inhibitor (meloxicam) on bone loss in ligature-induced periodontitis and its post-treatment effect after administration withdrawal. Methods: Seventy-five adult male Wistar rats were included. After anesthesia, a mandibular first molar was randomly assigned to receive the cotton ligature in the sulcular position, while the contralateral tooth was left unligated. The animals were randomly assigned to one of the following five treatment groups (15 animals each), including daily subcutaneous injections: 1) saline solution for 15 days; 2) saline solution for 45 days; 3) 3 mg/kg of meloxicam for 15 days; 4) 3 mg/kg of meloxicam for 45 days; or 5) 3 mg/kg of meloxicam for 15 days followed by saline solution for 30 days. The animals were sacrificed and the specimens routinely processed. The volume of bone loss was histometrically measured and statistical analysis performed.

Results: Intergroup comparisons demonstrated that the drug may significantly reduce periodontitis-related bone loss (group 3: 5.83 2.04); however, this effect is less evident when the drug is administered in a short period (group 4: 3.59 1.57). Moreover, after drug withdrawal, no residual effect was observed (6.86 3.59, 6.09 2.66, groups 2 and 5, respectively) (P >0.05). Conclusions: Within the limits of the present study, it can be concluded that selective cyclooxygenase-2 inhibitors may reduce bone loss associated with experimental periodontitis and that no remaining effect can be expected after its withdrawal. J Periodontol 2004;75:1613-1618.

The Management of Inflammation in Periodontal Disease

Thomas E. Van Dyke* It has become clear in recent years that periodontitis is an inflammatory disease initiated by oral microbial biofilm. This distinction implies that it is the host response to the biofilm that destroys the periodontium in the pathogenesis of the disease. As our understanding of pathways of inflammation has matured, a better understanding of the molecular basis of resolution of inflammation has emerged. Resolution of inflammation is an active, agonist-mediated, well-orchestrated return of tissue homeostasis. There is an important distinction between anti-inflammation and resolution; anti-inflammation is pharmacologic intervention in inflammatory pathways, whereas resolution is biologic pathways restoring homeostasis. A growing body of research suggests that chronic inflammatory periodontal disease involves a failure of resolution pathways to restore homeostasis. This article reviews the resolution of inflammation in the context of periodontal disease and the potential for the modification of resolution pathways for the prevention and treatment of periodontal diseases. Proof-of-concept studies in the 1980s demonstrated that pharmacologic anti-inflammation prevented and slowed the progression of periodontal diseases in animals and man. However, the side-effect profile of such therapies precluded the use of non-steroidal anti-inflammatory drugs or other enzyme inhibitors or receptor antagonists in periodontal therapy. The isolation and characterization of resolving agonist molecules has opened a new area of research using endogenous lipid mediators of resolution as potential therapeutic agents for the management of inflammatory periodontitis. Work in animal models of periodontitis has revealed the potential of this therapeutic approach for its prevention and treatment and forced the reconsideration of our understanding of the pathogenesis of human periodontal diseases.

Effect of Periodontal Treatment on Serum C-Reactive Protein Levels: A Systematic Review and Meta-Analysis
Effie Ioannidou,* Tannaz Malekzadeh,* and Anna Dongari-Bagtzoglou* Background: Systemic inflammation is increasingly being recognized as a risk factor for adverse cardiovascular events. Evidence is accumulating that associates periodontal disease with a higher risk for atherosclerotic plaque formation. A positive association between circulating C-reactive protein (CRP) levels and periodontal disease may be responsible for these observations. We undertook a systematic review and conducted a meta-analysis of the available evidence to examine the effect of periodontal treatment on systemic CRP levels and to assess the quality of the available evidence. Methods: We conducted a systematic search of the English-language literature on the effect of periodontal treatment on CRP levels, as assessed by high-sensitivity assays, at least 2 months after periodontal treatment. The search was conducted in MEDLINE

between 1966 and July 2005 and the Cochrane Central Register of Controlled Trials. We performed a meta-analysis using the DerSimonian and Laird random-effects model. Results: The literature search yielded 814 citations of which 10 met the inclusion criteria. The meta-analysis of the randomized controlled trials (RCTs) showed that the difference in serum CRP levels is not significantly different between the two arms. Similarly, results from the single-cohort studies showed that the difference on serum CRP levels was not significantly different before and after treatment. Conclusions: There is now a large body of evidence to indicate that systemic inflammation is present in patients with periodontal disease. Thus, information from RCTs and single-cohort studies does not support the hypothesis that periodontal treatment can reduce systemic CRP levels.

Cyclooxygenase-2-Dependent Prostaglandin Production by Peripheral Blood Monocytes Stimulated With Lipopolysaccharides Isolated From Periodontopathogenic Bacteria
Dr. Kazuyuki Noguchi Masayuki Yanai Miki Shitashige Tatsuji Nishihara Isao Ishikawa Background: Prostaglandin E2 (PGE2) plays important roles in the pathogenesis of periodontal disease. Recent studies have revealed the existence of 2 isozymes of cyclooxygenase (COX), called COX-1 and COX-2. The purpose of the present study was to investigate the contribution of COX-1 and COX-2 to PGE2 production by human peripheral blood monocytes that are stimulated with lipopolysaccharides (LPS) from periodontopathogenic bacteria. Methods: LPS were isolated from Actinobacillus actinomycetemcomitans (A. actinomycetemcomitans) andPorphyromonas gingivalis (P. gingivalis) by the phenolwater method. Peripheral blood monocytes were stimulated with LPS for the indicated periods, and the levels of PGE2 or interleukin (IL)-1 in the culture media were measured by enzyme-linked immunosorbent assay. Expression of COX-1 and -2 proteins was studied by immunocytochemical staining, and COX-2 mRNA expression was examined by Northern blot analysis. Results: Peripheral blood monocytes stimulated with A. actinomycetemcomitans- or P. gingivalis-LPS produced PGE2 in a time- and dose-dependent manner. Indomethacin, a non-selective COX-1/COX-2 inhibitor, and NS-398, a specific COX-2 inhibitor, completely inhibited PGE2 production. Immunocytochemical staining of COX-1 and COX-2 proteins showed that expression of COX-2 protein was increased in monocytes that were stimulated with A. actinomycetemcomitans- or P. gingivalis- LPS, compared with that in unstimulated monocytes, whereas expression of COX-1 protein was not altered. Northern blot analysis showed that monocytes stimulated with A. actinomycetemcomitans- or P. gingivalis- LPS expressed COX-2 mRNA, while COX-2 mRNA was not detectable in unstimulated cells. Treatment of A. actinomycetemcomitans-LPS-stimulated monocytes with NS-398 induced a significant increase of IL-1 production to the same extent as treatment with indomethacin.

Conclusions: These results suggest that COX-2 is induced in monocytes stimulated with LPS derived from A. actinomycetemcomitans and P. gingivalis and that the COX-2 is primarily responsible for PGE2 production. COX- 2 may be pivotal in PGE2 production in periodontal lesions and may be involved in inflammatory responses. J Periodontol 2000;71:1575-1582.

Cytokine Profiles in Peripheral Blood and Whole Blood Cell Cultures Associated With Aggressive Periodontitis, Juvenile Idiopathic Arthritis, and Rheumatoid Arthritis
Anne Havemose-Poulsen,* Lars Korsbk Srensen,* Kaj Stoltze,* Klaus Bendtzen, and Palle Holmstrup* Background: Cytokines play a key role in the pathogenesis of inflammatory diseases. An obvious question is whether patients with aggressive periodontitis, juvenile idiopathic arthritis, or rheumatoid arthritis share blood cytokine profiles distinguishing them from individuals free of disease. Methods: The study population consisted of Danish white adults, <35 years of age, diagnosed with localized aggressive periodontitis (LAgP; N = 18), generalized aggressive periodontitis (GAgP; N = 27), juvenile idiopathic arthritis (JIA; N = 10), or rheumatoid arthritis (RA; N = 23) and healthy individuals with no systemic or oral diseases (control [CTRL]; N = 25). Enzyme-linked immunosorbent assays were used to determine the levels of interleukin (IL)-1, IL-1, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-10, tumor necrosis factor (TNF)-, and lymphotoxin (LT)- in peripheral blood (plasma) and unstimulated and stimulated whole blood cell cultures from the same blood collection. Autoantibodies (aAb) to IL-1 and IL-6 were quantitated by radioimmunoassay. Results: Similar patterns of slightly higher IL-10 levels in plasma were found for GAgP and RA patients and in unstimulated cultures for GAgP, RA, and JIA patients. Interestingly, unstimulated cultures also demonstrated similar patterns of higher TNF- levels for these three groups of patients. Similar group patterns of periodontitis patients (LAgP and GAgP) included increased IL-1Ra levels in stimulated cultures, which also showed similar group patterns of arthritis patients (JIA and RA) with respect to higher IL-1 and lower LT- levels. Low titers of aAb to IL-1 and IL-6 were found in almost all individuals. Conclusion: Patients with aggressive periodontitis and types of arthritis presented with similar components of blood cytokine profiles distinguishing them from individuals free of disease.

Effects of Selective Cyclooxygenase-2 Inhibitor and Omega-3 Fatty Acid on Serum Interleukin-1, Osteocalcin, and C-Reactive Protein Levels in Rats
Saynur Vardar-engl,* Nurcan Buduneli,* Eralp Buduneli,* Haluk Baylas,* Gl Atilla,* David Lappin,and Denis F. Kinane Background: The aim of this study was to evaluate the effects of selective cyclooxygenase-2 inhibitor, celecoxib, and omega-3 fatty acid on serum levels of interleukin 1-beta (IL-1), osteocalcin (OC), and C-reactive protein (CRP) in experimental periodontitis.

Methods: Experimental periodontitis in rats was induced by repeated injection of purified lipopolysaccharide (LPS) derived from Escherichia coli endotoxin. Forty-seven adult male Sprague-Dawley rats were divided into five study groups as follows: saline control, LPS, LPS + celecoxib, LPS + omega-3 fatty acid, and LPS + celecoxib + omega3 fatty acid. Celecoxib and omega-3 fatty acid were given alone or in combination during 14 days of the experimental study period. At the end of the 2-week protocol, serum samples were obtained, and the rats were sacrificed. Serum samples were analyzed for IL-1, OC, and CRP concentrations by enzyme-linked immunosorbent assay. Defleshed jaws were analyzed morphometrically for alveolar bone loss. Data were evaluated statistically by non-parametric tests. Results: According to the morphometric measurements, the LPS and drug treatment groups showed significantly higher bone loss than the saline control group (P <0.05). Omega-3 fatty acid, both alone and in combination with celecoxib, revealed significantly higher IL-1 levels than LPS and celecoxib groups (P <0.05). Individual and combined administration of celecoxib and omega-3 fatty acid significantly increased OC levels compared to the LPS group (P <0.05). There were no significant differences in serum CRP levels. Conclusions: Celecoxib and/or omega-3 fatty acid administration does not significantly influence circulating levels of CRP. The significantly increased serum OC level observed after individual and combination administration suggests that celecoxib and omega-3 fatty acid may influence bone remodeling and thereby inhibit the progression of alveolar bone resorption. However, the failure to observe any significant inhibition of bone loss in celecoxib- and/or omega-3 fatty acid-treated rats compared to the LPS group suggests that their therapeutic effect may be reduced by other factors, such as increases in serum IL-1 promoting osteoclast activity.

Host-Response Therapeutics for Periodontal Diseases

William V. Giannobile* Periodontal diseases are initiated by Gram-negative tooth-associated microbial biofilms that elicit a host response, with resultant osseous and soft tissue destruction. In response to endotoxins derived from periodontal pathogens, several osteoclast-related mediators target the destruction of alveolar bone and supporting connective tissues. Major drivers of this aggressive tissue destruction are matrix metalloproteinases (MMPs), cathepsins, and other osteoclast-derived enzymes. This article focuses on the downstream factors of the osteoclast responsible for the degradation of bone and soft tissues around teeth and oral implants. Furthermore, therapeutic approaches that target MMP-2, -8, and -9 inhibition, such as MMP inhibitors, chemically modified tetracyclines, and subantimicrobial formulations of tetracycline analogues, are discussed. The use of rapid, chair-side tests of MMP activity, in particular for MMP-8 and bone collagen fragments, show strong potential as non-invasive measures of tissue health or disease. In addition, studies using other agents for the preservation of bone mass, such as bisphosphonates that inhibit osteoclast recruitment, are highlighted. The application of these bone-preservation strategies to periodontal management and treatment are discussed in the context of high-risk patients susceptible to disease reactivation or disease complications.

The Modulation of Androgen Metabolism by Estradiol, Minocycline, and Indomethacin in a Cell Culture Model
A. Tilakaratne

Dr. M. Soory Background: This investigation attempts to clarify the proanabolic effects of minocycline and indomethacin by studying their effects on androgen metabolism and mediation by estradiol. A cell culture model was used with androgen substrates because of the proanabolic effects of androgen metabolites. Methods: Monolayer cultures of human gingival fibroblasts (HGF) derived from 6 patients were incubated in duplicate with 14C- testosterone or 14C-4-androstenedione as substrates and optimal concentrations of estradiol (E1,3 g/ml) and minocycline (M25 g/ml) or indomethacin (I, 1 g/ml) alone and in combination (E1,3+I1 or E1,3+M25 g/ml); similar experiments were carried out with human oral periosteal fibroblasts (HPF), M, I, E, and the combinations. At the end of a 24-hour incubation period in Eagle's MEM, the medium was solvent extracted with ethyl acetate and the metabolites were separated by TLC in a benzene:acetone solvent system (4:1 v/v). The separated metabolites were quantified using a radioisotope scanner. Results: Both androgens were metabolized to 5-dihydrotestosterone (DHT) and 4androstenedione (4-A) or testosterone (T) at baseline and in response to the agents tested, by HGF and HPF. With HGF, there were significant increases in the yields of DHT and 4-A or T in response to M, E, and M+E, resulting in 50% to 2.4-fold increases in these metabolites over control incubations (n = 6; P <0.01). The responses to I and combinations of I+E were similar. HPF also demonstrated significant increases of 29% to 4-fold in the yields of androgen metabolites in response to M, E, and M+E (n = 6; P <0.01). I and E similarly increased the yields of androgen metabolites, alone and in combination. Conclusions: Adjunctive periodontal treatment with minocycline or indomethacin can contribute to hormone-modulated anabolic responses in males and females in gingival and periosteal fibroblasts derived from a chronically inflamed source. J Periodontol 2002;73:585-590.

Resolution of Inflammation in Periodontitis

Alpdogan Kantarci* and Thomas E. Van Dyke* Chronic inflammatory illnesses such as diabetes, arthritis, and heart disease are now seen as problems that might have impacts on the periodontium, and reciprocal effects of periodontal diseases are being considered as factors potentially affecting the progression of these diseases. Successful management of the inflammatory disorders in the human body depends on the identification of common pathways that would lead to a better understanding of the disease processes and development of novel treatment strategies. In this review, our objective is to identify the inflammatory basis of periodontal disease and common inflammatory mechanisms underlying several disorders elsewhere in the body, with an emphasis on how the potential extrinsic and intrinsic control methods could be used to prevent or treat the harmful effects linked to inflammation.

Effect of a Cyclooxygenase-2 Inhibitor on Interleukin-1Stimulated Activation of the Transcription Factor Nuclear Factor-Kappa B in Human Gingival Fibroblasts
David A. Tipton,* Denise C. Gay, and Vaughn A. DeCoster Background: In previous work, the cyclooxygenase-2 inhibitor NS-398 inhibited interleukin (IL)-1stimulated prostaglandin E2 (PGE2) production almost completely

while partially inhibiting IL-6 production in aggressive periodontitis (AgP) human gingival fibroblasts. PGE2 and the transcription factor nuclear factor-kappa B (NF-B) regulate IL1stimulated IL-6 production. Cytoplasmic NF-B is bound to inhibitors (IB proteins). IL-1 initiates a cascade resulting in phosphorylation and degradation of IB, allowing nuclear translocation of NF-B and target gene activation. The purpose of this study was to determine whether NS-398 inhibited phosphorylation of IB and NF-B activation. Methods: AgP fibroblasts (1 to 2 106) were exposed to IL-1 (1 1011M) with or without NS-398 (10 nM) in serum-free medium. The NF-B subunit p65 and phosphoIB were measured in whole cell, cytoplasmic, or nuclear extracts, using colorimetric assays. Enzyme-linked immunosorbent assays were used to measure PGE2and IL-6 production by 2.5 104 cells after exposure to IL-1 with or without NS-398 in serumfree medium. Results: Consistent with previous results, NS-398 reduced IL-1stimulated PGE2 by 98% (P <0.001) and IL-6 by 65% (P <0.001). IL-1 increased nuclear and cytoplasmic p65 ( 8-fold [P <0.001] and 2.5-fold [P <0.03], respectively) over control levels. NS398 reduced IL-1stimulated nuclear and cytoplasmic p65 to control levels. IL-1 increased phospho-IB in whole cell extracts by a maximum of approximately 9.5 times (P = 0.0001), and this was inhibited significantly by NS-398 (P 0.008). Conclusions: NS-398 inhibited NF-B activation and nuclear p65 levels in human gingival fibroblasts. This seemed to be due to inhibition of the phosphorylation cascade resulting in formation of phospho-IB and free p65. NF-B inhibition may be useful in treating inflammatory diseases such as AgP.

Adjunctive Treatment of Chronic Periodontitis With Daily Dietary Supplementation With Omega-3 Fatty Acids and Low-Dose Aspirin
Hesham El-Sharkawy,* Nayer Aboelsaad,* Mohamed Eliwa,* Mahmoud Darweesh,* Mohammad Alshahat,* Alpdogan Kantarci, Hatice Hasturk, and Thomas E. Van Dyke Background: Host modulatory therapy has been proposed as a treatment for periodontal diseases. Omega-3 (-3) polyunsaturated fatty acids (PUFAs), including docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), were shown to have therapeutic anti-inflammatory and protective actions in inflammatory diseases including periodontitis. The goal of this study was to test an innovative strategy for periodontal treatment in a clinical experiment. Methods: Eighty healthy subjects (40 in each group) with advanced chronic periodontitis were enrolled in Mansoura, Egypt, in a parallel-design, double-masked clinical study. The control group was treated with scaling and root planing (SRP) and a placebo, whereas the -3 group was treated with SRP followed by dietary supplementation of fish oil (900 mg EPA + DHA) and 81 mg aspirin daily. Saliva samples were obtained from all patients at baseline and 3 and 6 months for evaluation of receptor activator of nuclear factor-kappa B ligand (RANKL) and matrix metalloproteinase-8 (MMP-8). Plaque and gingival indices, bleeding on probing, probing depths, and attachment levels were recorded at the same time points. Results: Statistical analyses demonstrated a significant reduction in probing depths and a significant attachment gain after 3 and 6 months in the -3 group compared to baseline and the control group (P <0.05). Salivary RANKL and MMP-8 levels showed significant reductions in the -3 group in response to treatment at 3 and 6 months and compared to the control group at 6 months (P <0.01). Supplementation with -3 +

aspirin resulted in a significant shift in the frequency of pockets with probing depths <4 mm (P <0.05). Conclusion: The results of this preliminary clinical study suggest that dietary supplementation with -3 PUFAs and 81 mg aspirin may provide a sustainable, low-cost intervention to augment periodontal therapy.

Inflammatory Responses of Gingival Epithelial Cells Stimulated With Porphyromonas gingivalis Vesicles Are Inhibited by HopAssociated Polyphenols
Yurong Kou,* Hiroaki Inaba,* Takahiro Kato,* Motoyuki Tagashira, Daiki Honma, Tomomasa Kanda,Yasuyuki Ohtake, and Atsuo Amano* Background: Periodontitis is induced by an imbalance between bacterial virulence and host defense ability.Porphyromonas gingivalis, a predominant periodontal pathogen, triggers a series of host inflammatory responses that aggravate the destruction of periodontium. Thus, anti-inflammatory reagents are considered desirable for effective periodontal therapy. In the present study, we examined the inhibitory effects of hop bract polyphenol (HBP) on cellular inflammatory responses induced by P. gingivalis membrane vesicles. Methods: Immortalized human gingival epithelial cells were stimulated with P. gingivalis membrane vesicles, and the effects of HBP on mRNA expression of cyclooxygenase (COX)-2, interleukin (IL)-6 and -8, and matrix metalloproteinase (MMP)1 and -3 were examined using real-time reverse transcription-polymerase chain reaction. Results: HBP inhibited the mRNA expression of COX-2, IL-6 and -8, and MMP-1 and -3 in a dose-dependent manner, whereas epigallocatechin gallate (a control polyphenol) inhibited COX-2 mRNA expression only. Following further fractionation of HBP to identify the effective components, 2-[(2-methylpropanoyl)-phloroglucinol]1-O--Dglucopyranoside (MPPG) was identified as a significant anti-inflammatory element that completely inhibited the inflammatory mRNA induction. Kaempferol 3-O-glucopyranoside (astragalin) also was found to have anti-inflammatory effects. Conclusions: HBP is suggested to be a potent inhibitor of cellular inflammatory responses induced by P. gingivalis vesicles. Further, MPPG and astragalin, identified here as effective components of HBP, also may be useful for the prevention and/or attenuation of periodontitis.

Neutrophil-Mediated Tissue Injury in Periodontal Disease Pathogenesis: Findings from Localized Aggressive Periodontitis
Alpdogan Kantarci Kosuke Oyaizu Dr. Thomas E. Van Dyke Neutrophils play a major role in the host response against invading periodontopathogenic microorganisms. Localized aggressive periodontitis (LAgP) is associated with various functional abnormalities of neutrophils. Based on the recent findings, LAgP neutrophils are not "hypofunctional" or "deficient." They are "hyperfunctional," and their amplified activity is responsible for the tissue destruction in periodontal disease. Several signal transduction abnormalities are associated with

elevated neutrophil function in LAgP. There is a strong correlation between defective chemotaxis and decreased intracellular Ca2+ levels; total calcium-dependent protein Kinase C (PKC) activity of neutrophils is significantly lower than healthy subjects; and there is a marked increase in diacylglycerol (DAG) accompanied by a pronounced decrease in DAG kinase activity. In a separate set of experiments on the involvement of the inducible cyclooxygenase isoform (COX-2) and the role of novel lipid mediators in the pathogenesis of periodontal disease, crevicular fluid samples from LAgP patients were found to contain prostaglandin E2 (PGE2) and 5-LO-derived products, leukotriene B4(LTB4), and the biosynthesis interaction product, lipoxin LXA4. Neutrophils from peripheral blood of LAgP patients, but not from healthy volunteers, also generated LXA4, suggesting that this immunomodulatory molecule may have a role in periodontal disease. Lipoxin generation and its relationship to PGE 2 and LTB4can be visualized as an important marker for the pathogenesis of periodontal disease. Thus, major advances in our understanding of the role of the neutrophil in host defense against periodontal organisms have been made through studies of LAgP. LAgP is used as an example of a severe periodontal disease that is related to abnormal neutrophil function. In this model, it appears that a hyperresponsiveness of the neutrophil, due to cell priming/predisposition, results in enhanced tissue damage. J Periodontol 2003;74:66-75.

Effect of Alendronate on Periodontal Disease in Postmenopausal Women: A Randomized Placebo-Controlled Trial

Miriam L. Rocha Dr. Juan M. Malacara Francisco J. Snchez-Marin Carlos J. Vazquez de la Torre Martha E. Fajardo. Background: We investigated the effect of oral alendronate (ALN) treatment on radiological and clinical measurements of periodontal disease in postmenopausal women without hormone replacement therapy. Methods: We evaluated the effect of 6 months of ALN treatment in 40 postmenopausal women, 55 to 65 years old with established periodontal disease, in a controlled, doublemasked, prospective study. Volunteers were paired by age and randomized to receive ALN (10 mg/day) or placebo for the study period. Periodontal mechanical treatment was carried out in both groups. At baseline and after treatment, clinical evaluation, hormone blood levels, distance from the crestal alveolar bone (CAB) to the cemento-enamel junction (CEJ), calcaneus bone mineral density (BMD), hormone levels, serum Ntelopeptide (NTx), and bone-specific alkaline phosphatase (BSAP) were assessed. Results: Periodontal disease conditions improved in both groups, but greater improvement in probing depth (0.8 0.3 mm versus 0.4 0.4 mm, P = 0.02) and gingival bleeding (0.3% 0.13% versus 0.2% 0.06%, P = 0.006) was found in the ALN treated group. Calcaneus BMD increased in the ALN treated group (68 47 mm3versus 26 81 mm3, P = 0.0006). CAB-CEJ distance diminished in the ALN group (0.4 0.40 mm versus 0.60 0.53 mm, P = 0.00008). Marginal reduction in both NTx and BSAP levels was found in the ALN group (9.4 6.6 nmol versus 4.3 4.7 nmol bone collagen equivalents, P = 0.08, and 7.7 8.4 versus 1.5 5.0 U/l, P = 0.1, respectively). Hormone levels were unchanged after treatment. Similar improvement of calcaneus BMD and CAB-CEJ distance with ALN treatment was found in obese and nonobese women.

Conclusion: ALN treatment improved periodontal disease and bone turnover in postmenopausal women. J Periodontol 2004; 75:1579-1585.

Effect of Topical Cimetidine Rinse on Gingival Crevicular Neutrophil Leukocyte Function

Thomas E. Van Dyke Christopher W. Cutler Michael Kowolik Robert S. Singer William Buchanan Dr. Aaron R. Biesbrock Background: Three coordinated mechanism-of-action clinical studies were conducted to examine the effects of topical cimetidine rinse on neutrophil function in the gingival crevice. Methods: The first study was a randomized, double-blind, placebo-controlled, 28-day experimental gingivitis study involving 21 healthy adults, in which subjects rinsed twice a day with placebo or 0.5% cimetidine rinses. At baseline and days 14, 21, and 28, neutrophils were harvested from prespecified gingival sulcular sites, purified, stained, and examined by trifluorochrome phagocytosis and killing microassay. The second and third studies were placebo-controlled, 9-week, three-period (each of 3 weeks duration), longitudinal studies involving seven and nine adults with moderate periodontitis, respectively. Subjects rinsed twice a day during periods 1 and 3 with placebo and during period 2 with 0.5% cimetidine. At baseline and weekly intervals, neutrophils were harvested from prespecified periodontal pockets, purified, stained, and examined by trifluorochrome phagocytosis and killing microassay in the second study. In the third study, neutrophils were examined spectrophotometrically for superoxide production and in a luminol-enhanced chemiluminescence assay. Results: In the first study, the mean number of phagocytosing neutrophils was statistically significantly increased (P = 0.016) in the cimetidine group (31.1 cells/subject) versus the placebo group (13.7 cells/subject) at day 28. In addition, a statistically significant increase (P = 0.036) in bacterial killing was observed in the cimetidine rinse group; in the cimetidine group, 63.4% of bacteria in the neutrophils were killed compared to 46.2% in the placebo group. Additional data from the other two studies support these findings. Conclusion: Collectively, these studies provide evidence that topical 0.5% cimetidine oral rinse enhances the antibacterial function of crevicular neutrophils. J Periodontol 2005;76:998-1005.

Reconstitution of a Hyperinflammatory Prostaglandin E2 Response to Porphyromonas gingivalis Challenge in Severe Combined Immunodeficient Mice
Dr. Giovanni E. Salvi Satu Spets-Happonen

Robert E. Singer Steven Offenbacher Background: The purpose of this study was to determine whether lymphocytic cells regulate the monocytic hyperinflammatory trait (MO+) in chronic periodontitis patients. Using a P. gingivalis challenge model in severe combined immunodeficient (SCID) mice, we tested the effects of adoptively transferred human peripheral blood leukocytes from gingivitis and chronic periodontitis diabetic and non-diabetic individuals on monocytic responses. Methods: This response was examined using the subcutaneous tissue chamber infection model. Three weeks following cell reconstitution, all SCID mice were challenged with 109 colony forming units of live P. gingivalisHG405. Chamber contents were collected at day 7 after bacterial challenge for prostaglandin E2 (PGE2) analysis and chamber rejection monitored up to day 30. Gingival crevicular fluid (GCF) samples were collected from all patients for PGE2 analysis. Both chamber fluid- and GCF-PGE2 levels were determined by enzyme-linked immunosorbent assays (ELISA). Results: Significantly elevated GCF-PGE2 levels were found in diabetic as well as in nondiabetic patients with moderate/advanced periodontitis compared to diabetic and nondiabetic subjects with gingivitis/mild periodontitis at P = 0.01 and P = 0.001, respectively. As reflected in chamber fluid PGE2 levels and percentage chamber rejection, lymphocytic sensitization to P. gingivalis occurred in both diabetics and non-diabetics with moderate/advanced periodontitis, but not in diabetics and non-diabetics with gingivitis/mild periodontitis. Conclusions: These results suggest that the exaggerated monocytic inflammatory response trait (MO+) associated with moderate/ advanced chronic periodontitis is due, at least in part, to lymphocytic modulation, while the directional findings for lymphocytes from diabetic subjects deserve further investigation. Our findings further demonstrate that the SCID mouse model is a useful animal model to study human immune responses to periodontal microorganisms. J Periodontol 2005;76:16-21.

Cyclooxygenase-2-Dependent Prostaglandin (PG) E2 Downregulates Matrix Metalloproteinase-3 Production via EP2/EP4 Subtypes of PGE2 Receptors in Human Periodontal Ligament Cells Stimulated With Interleukin-1
Mingming Yan Dr. Kazuyuki Noguchi Senarath M.P.M. Ruwanpura Isao Ishikawa Background: Prostaglandin E2 (PGE2), which exerts its actions via EP receptors (EP 1, EP2, EP3, and EP4), is a bioactive metabolite produced by cyclooxygenase (COX)-1 and/or COX-2 from arachidonic acid. In the present study, we investigated whether COX-2derived PGE2 regulated matrix metalloproteinase (MMP)-3 production in human periodontal ligament (PDL) cells stimulated with interleukin (IL)-1 and which EP receptors were involved in PGE2 regulation of IL-1-induced MMP-3 production.

Methods: Human PDL cells obtained from periodontally healthy subjects were stimulated with vehicle or IL-1 in the presence or absence of indomethacin (a COX1/COX-2 inhibitor), NS-398 (a specific COX- 2 inhibitor), PGE2, EP receptor agonists, dibutyryl cAMP, and forskolin. PGE2 levels were assayed by enzyme-linked immunosorbent assay (ELISA). MMP-3 levels and caseinolytic activities were evaluated by ELISA and casein zymography, respectively. Results: IL-1 enhanced both MMP-3 and PGE2 production. Indomethacin and NS-398 enhanced IL-1-induced MMP-3 production in PDL cells, to the same extent, although both the agents completely inhibited IL-1-induced PGE2 production. Exogenous PGE2 reduced IL-1-induced MMP-3 production in a dose-dependent manner. Butaprost, a selective EP2 agonist, and ONO-AE1-329, a selective EP4 agonist, significantly inhibited IL-1-induced MMP-3 production, although butaprost was less potent than ONO-AE-1329. Dibutyryl cAMP, a cAMP analog, and forskolin, an adenylate cyclase activator, significantly inhibited IL-1-stimulated MMP-3 production in PDL cells. Conclusions: These data suggest that COX-2-dependent PGE2 downregulates IL-1elicited MMP-3 production by cAMP-dependent pathways via EP2/EP4 receptors in human PDL cells. cAMP-elevating agents such as EP2/EP4 receptor activators may regulate the destruction of extracellular matrix components in periodontal tissue. J Periodontol 2005;76:929-935.

Interleukin-1Induced Prostaglandin E2 Production by Human Gingival Fibroblasts Is Upregulated by Glycine

Dr. Xiaohui Rausch-Fan Christian Ulm Erika Jensen-Jarolim Andreas Schedle George Boltz-Nitulescu Wolf-Dieter Rausch Michael Matejka Background: Human gingival fibroblasts (GFB) may produce prostaglandin E2 (PGE2) in response to proinflammatory cytokines. Elevated concentrations of glycine were previously found in periodontal pockets and saliva of periodontitis patients and, therefore, we aimed to study the influence of glycine on PGE 2 production. Methods: Human GFB were cultured in the presence of various concentrations of glycine and/or interleukin (IL)-1, tumor necrosis factor (TNF)-, and IL-10 and their influence on PGE2 production was measured. The expression of cyclooxygenases (COX) was analyzed by Western blot and immunocytochemistry. Results: The PGE2 production by IL-1-stimulated GFB was significantly upregulated by glycine. The effect of glycine on IL- 1-induced cell proliferation and PGE2 production was concentration- dependent, reached a peak at 3 mM, and declined slowly at higher doses. The synthesis of PGE2 by human GFB cultured in the absence of glycine was significantly inhibited by IL-10 and partially induced in cells cultured with glycine. Glycine had no effect on TNF--induced PGE2 production. The IL-1-driven PGE2 synthesis was blocked by indomethacin, a COX-1/COX-2 inhibitor, and by COX-2 inhibitor NS-398. The

expression of COX-2 protein was slightly induced by glycine, more evidently by IL-1, and mostly enhanced by combined IL-1 with glycine. Conclusion: Since PGE2 is a potent stimulator of bone resorption, and production of PGE2 and COX-2 protein is augmented by glycine, our results strongly suggest that glycine may be involved in the pathogenesis of periodontitis. J Periodontol 2005;76:1182-1188.

Mediators of Periodontal Osseous Destruction and Remodeling: Principles and Implications for Diagnosis and Therapy
Dr. Laurie K. McCauley Rahime M. Nohutcu Osteoclastic bone resorption is a prominent feature of periodontal disease. Bone resorption via osteoclasts and bone formation via osteoblasts are coupled, and their dysregulation is associated with numerous diseases of the skeletal system. Recent developments in the area of mediators of osteoclastic differentiation have expanded our knowledge of the process of resorption and set the stage for new diagnostic and therapeutic modalities to treat situations of localized bone loss as in periodontal disease. This review describes the current state of knowledge of osteoclast differentiation and activity, mediators, and biochemical markers of bone resorption and their use and potential use in clinical periodontics. Finally, therapeutic strategies based on knowledge gained in the treatment of metabolic bone diseases and in periodontal clinical trials are discussed, and the potential for future strategies is proposed relative to their biologic basis. The intent is to update the field of periodontics on the current state of pathophysiology of the osteoclastic lesion and outline diagnostic and therapeutic strategies with a rational basis in the underlying biology. J Periodontol 2002;73:13771391.

A Combination of a Chemically Modified Doxycycline and a Bisphosphonate Synergistically Inhibits Endotoxin-Induced Periodontal Breakdown in Rats
Analeyda Llavaneras Dr. Nungavaram S. Ramamurthy Pia Heikkil Olli Teronen Tuula Salo Barry R. Rifkin Maria E. Ryan Lorne M. Golub Timo Sorsa

Background: Chemically modified non-antimicrobial tetracyclines (CMTs) have been shown to inhibit pathologically elevated collagenase (and other matrix metalloproteinase, MMP) activity and bone resorption in vivo and in vitro. Methods: In the current study, suboptimal doses of CMT-8 (a non-antimicrobial chemically modified doxycycline) and a bisphosphonate (clodronate, an anti-bone resorption compound) were administered daily, either as a single agent or as a combination therapy, to rats with experimental periodontitis induced by repeated injection of bacterial endotoxin (LPS) into the gingiva. At the end of the l-week protocol, the gingival tissues were dissected, extracted, and the extracts analyzed for MMPs (collagenases and gelatinases) and for elastase, and the defleshed jaws were morphometrically analyzed for alveolar bone loss. Results: LPS injection significantly (P <0.00l) increased alveolar bone loss and increased collagenase (MMP-8), gelatinase (MMP-9), and elastase activities. Treatment of the LPS-injected rats with suboptimal CMT-8 alone or suboptimal clodronate alone produced slight reductions in the tissue-destructive proteinases and no significant reductions in alveolar bone loss. However, a combination of suboptimal CMT-8 and clodronate "normalized" the pathologically elevated levels of MMPs, elastase, and alveolar bone loss, indicating synergistic inhibition of tissue breakdown in this animal model of periodontitis. Conclusions: Combination of a CMT and a bisphosphonate may be a useful treatment to optimally suppress periodontal destruction and tooth loss and in other tissue-destructive inflammatory diseases such as arthritis. J Periodontol 2001;72:1069-1077.

Progression and Treatment of Chronic Adult Periodontitis

Dr. Philip M. Preshaw Brenda Lauffart Elena Zak Marjorie K. Jeffcoat Ian Barton Peter A. Heasman Background: The periodontal status of 41 medically healthy adults with untreated chronic periodontitis was monitored before and after scaling and root planing (SRP). Methods: During a 6-month pretreatment phase, clinical measurements, digital subtraction radiography (DSR) analysis of alveolar bone, and measurement of gingival crevicular fluid (GCF) prostaglandin E2 (PGE2) levels were undertaken. SRP was provided during a 1-month treatment phase. Clinical, radiographic, and biochemical analyses were repeated in a 6-month post-treatment healing period. Results: Pretreatment: no clinically significant changes in mean plaque indices (PI), probing depths (PD), bleeding on probing (BOP), or relative clinical attachment levels (CAL) were detected (P >0.05). DSR revealed small but statistically significant bone height (0.04 mm) and mass (0.97 mg) loss (P <0.001). GCF PGE2 levels gradually increased from 38.8 ng/ml at month 1 to 79.4 ng/ml at month 6. Post-treatment: statistically and clinically significant reductions were observed in mean PI, BOP, and PD (P <0.05). A statistically significant reduction in CAL was noted (P <0.05). The trend

towards progressive bone loss was halted and reversed, and a statistically significant decrease in GCF PGE2 concentrations was detected (P <0.001). Smokers, non-smokers, and ex-smokers did not differ significantly in PI, BOP, CAL, radiographic, or biochemical parameters at any time. Mean PD was significantly greater in current smokers than in non- and ex-smokers (P <0.005). PD reduced comparably in all 3 smoking subgroups following treatment (P <0.01). Conclusions: Conventional clinical measurements failed to identify disease progression over a 6-month period. Significant improvements were observed in clinical parameters after SRP, and a trend towards progressive bone loss was halted and reversed. Regular and frequent maintenance visits are important following treatment to maintain improvements in clinical parameters. Smokers had deeper probing depths than non- and ex-smokers, but pockets were reduced significantly and comparably in all 3 smoking subgroups following efficacious treatment. J Periodontol 1999;70:1209-1220. An evidence-based update of the use of analgesics in dentistry Volume 46, Issue 1, February 2008, Pages: 143164, Novel host response therapeutic approaches to treat periodontal diseases Volume 43, Issue 1, February 2007, Pages: 294315, Modulation of host inflammatory mediators as a treatment strategy for periodontal diseases Volume 24, Issue 1, October 2000, Pages: 239252, The roles of cyclooxygenase-2 and prostaglandin E2 in periodontal disease Volume 43, Issue 1, February 2007, Pages: 85101, Effects of medications on the periodontal tissues in health and disease Volume 40, Issue 1, February 2006, Pages: 120129, The diagnosis and treatment of peri-implantitis Volume 17, Issue 1, June 1998, Pages: 6376, Mechanisms of alveolar bone destruction in periodontitis Volume 14, Issue 1, June 1997, Pages: 158172, Clinical evaluation of dental implant treatment Volume 34, Issue 1, February 2004, Pages: 230239, Host-mediated resolution of inflammation in periodontal diseases Volume 40, Issue 1, February 2006, Pages: 144163, Clinical relevance of the host responses of periodontitis Volume 43, Issue 1, February 2007, Pages: 278293, Clinical parameters: biological validity and clinical utility Volume 39, Issue 1, October 2005, Pages: 3039 Infections of the esophagus and the stomach

Volume 49, Issue 1, January 2009, Pages: 166178, Host response modulation in periodontics Volume 48, Issue 1, October 2008, Pages: 92110 Diabetic periodontitis: a model for activated innate immunity and impaired resolution of inflammation Volume 43, Issue 1, February 2007, Pages: 233244 Radiographic parameters: biological significance and clinical use Volume 39, Issue 1, October 2005, Pages: 7390 Non-steroidal anti-inflammatory drugs (NSAIDs) In the early 1970s it was recognized that prostaglandins (PGs) were important mediators in the pathogenesis of periodontal destruction and activation of mechanisms of bone resumption (19). At the same time, Vane and coworkers were identifying the mode of action of cyclo-oxygenase and subsequent prostaglandin synthesis and their inhibition by aspirin (80). As a consequence of these findings, a significant interest emerged in the possible application of these drugs in the control and management of periodontal diseases. Evidence that such drugs may have an application in the management of periodontal diseases came from controlled studies on patients who had been on long-term NSAID therapy for musculoskeletal reasons (18, 23, 83). In the first of these studies (83) patients on long-term NSAIDs had reduced amounts of gingival inflammation and probing depths compared with age- and plaque-matched controls. In a further study, it was demonstrated that NSAIDs afforded patients some degree of protection against alveolar bone loss (18). By contrast, a cross-sectional study showed no significant differences for a variety of periodontal measures between patients on longterm NSAIDs and a control group (23). However, patients from the NSAID group had significantly lower gingival crevicular fluid flow rate than controls. This was attributed to a possible effect of the NSAID medication on the vascularity and permeability of small blood vessels. Animal studies have confirmed beneficial effects of NSAIDs in ligature-induced periodontitis (41, 42). Another animal study showed that systemic flurbiprofen significantly resolved bone loss in beagle dogs undergoing either surgical or nonsurgical management of periodontitis (85). Clinical studies on NSAIDs when used as adjuncts in the management of periodontal disease have been somewhat equivocal with respect to outcomes. Systemic flurbiprofen taken for 12 months reduces the rate of alveolar bone loss (84) and is beneficial for the resolution of experimental gingivitis (22). Systemic administration of the drugs in asthmatics is associated with an increased risk of unwanted effects including peptic ulceration, interference with platelet aggregation and increased risk of bronchoconstriction. Concerns over these unwanted effects directed interest to the topical application of NSAIDs for adjunctive management of periodontal disease. Such agents could be delivered in the form of a mouthrinse or incorporated into toothpaste. A ketorolac rinse may be of benefit in the treatment of adult periondontitis and appears to have advantages over systemic flurbiprofen in reducing alveolar bone loss (27). By comparison, a 1% w w flurbipropfen toothpaste was shown to exert a small yet significant effect on bone metabolism when used over a 12- month period as an adjunct to root surface instrumentation (22). Whereas systemic NSAIDs appear to afford a patient some degree of protection, their use as a therapeutic measure in the treatment of periodontaldisease is limited. In part this is due to the high prevalence of unwanted effects, which subsequently is encouraging the development of topical preparations. The success of these agents is also somewhat limited and their use as a means of controlling periodontal disease has been surpassed by other more effective compounds. The new COX-2 inhibitors have all the attributes of NSAIDs with a reduced risk of unwanted effects. These drugs have been evaluated as an adjunct to root surface instrumentation in patients with chronic periodontitis (81). The results showed little clinical benefit of COX-2 inhibitors in the management of such patients, but significant reductions in gingival tissue levels of PGE2 and PGF2. The recent scare over the long-term use of these drugs will probably exclude their use in the management of periodontal diseases.