ISSN No: 2582-0559

PERIOSTIN – A FORWARD STEP IN PERIODONTAL

BIOMARKERS – A NARRATIVE REVIEW

Dr. R. Reshmaa, Dr. Sabitha Sudarsan, Dr. U. Arunmozhi, Dr. R. Kadhiresan, Dr. R. A. Jenifer Cynthia

Department of Periodontology and Oral Implantology, Sri Venkateswara Dental College and Hospital, Thalambur, Chennai,

India

Address for Correspondence

Dr. R. Reshmaa,

Post Graduate Student, Department of Periodontology and

Oral Implantology

Sri Venkateswara Dental College and Hospital Off OMR

road, Near Navalur, Thalambur, Chennai-603103

E-mail: reshmaa.rajendran10696@gmail.com

REVIEW ARTICLE

ABSTRACT

Various  biomarkers  of  periodontal  disease  are  involved  in
either  disease  pathogenesis  or  tissue  damage.  The  main  aim
of  biomarkers  research  in  Periodontology  is  to  provide  a
significant  impact  on  clinical  diagnosis  as  well  as  treatment
outcomes.  Periostin,  a  microcellular  protein  is  one  of  the
novel biomarkers which is expressed mostly in collagen rich
tissues.  Its  role  in  systemic  health  and  disease  has  been
studied  for  many  years.  Periostin  plays  a  major  role  in
collagen  development,  cell  migration,  wound  healing  and
repair  and  also  regulates  periodontal  pathogenesis.  This
review  focuses  on  the  different  aspects  of  periostin  in
periodontal health and disease.

Keywords:

Periostin, Biomarker, Periodontitis, Periodontal

regeneration

Received:

12.06.2021

First Published:

02.09.2021

Accepted:

26.08.2021

Published:

27.09.2021

Volume No: 8, Issue No: 3

114

DOI: 1.37841/jidam_2021_V8_I3_04

Reshmaa et al:

Periostin – A Forward Step In Periodontal Biomarkers – A Narrative Review

ISSN No: 2582-0559

INTRODUCTION:

Extracellular matrix (ECM) is an extensive highly

dynamic  structural  and  molecular  network.  The
connective  tissue  is  composed  of  fibroblast  and
extracellular  matrix  which  contains  three  major
components:  proteoglycans,  glycosaminoglycan,  and
glycoproteins.

Components of extracellular matrix

(ECM)  and  cell  adhesion  receptors  interact  with  each
other  and  forms  a  complex  network  in  all  tissues.  These
Cell  surface  receptors  transfers  signals  into  cells  from
ECM, which aids in regulating diverse cellular functions,
such  as  survival,  growth,  proliferation,  migration,
differentiation,  wound  repair  and  some  major  role  in
maintaining cells homeostasis.

ECM also contains “Matricellular proteins” which

are  a  group  of  proteins  contributing  indirectly  to  the
formation  of  structural  elements.  They  also  serve  to
catalyze  cell  to  cell,  cell  to  matrix  interactions  and  cell
functions.  These  Matricellular  proteins  has  a  distinct
characteristic  to  bind  to  many  cell  surface  receptors,
growth  factors,  cytokines,  proteases  and  components  of
the  ECM.

They are expressed during development and

injury  in  high  levels.  The  Matricellular  proteins  are;
osteopontin;  periostin;  Secreted  Protein  Rich  Acidic  and
Rich  in  Cysteine  SPARC  family  members;  tenascin-C;
thrombospondins1 and 2; WISP1, 2, and 3; Nov; galectin
1, 2, 3, 4, 8, and 9; Cyr61; and bone sialoprotein.

One such essential matricellular protein is Periostin

(POSTN) found in 1993.

Periostin helps not only in bone

formation  and  regulation  but  also  is  essential  for
connective  tissue  integrity  by  helping  in  cell  activation
and  cell  binding  in  both  health  and  disease.  In  systemic
health,  Periostin  aids  in  the  formation  of  endogenous
cardiomyocytes,  tendon  cells.  It  also  has  a  negative  role
in  bronchial  asthma  where  increased  periostin  levels
cause  airway  obstruction  by  fibrosis.  It  also  has  a  major
function in tumor genesis by promoting cell proliferation
and adhesion. Present in adipose tissues, periostin helps in
the repair of subcutaneous fat in both obesity and diabetes
patients.  Interestingly,  there  are  studies  showing  that
Periostin has a major role  in periodontal tissue formation
(Figure  1)  and  regeneration.

The aim of this review

article is to provide an extensive assessment of the
implications of Periostin in periodontal tissue biology and
its potential use as a biomarker and also in periodontal
tissue regeneration.

Fig 1: Functions of Periostin

STRUCTURE OF PERIOSTIN:

Periostin was originally named as Osteoblast Specific

Factor 2 (OSF-2) and was later recoined as Periostin due
to its localisation in periosteum and Periodontal ligament
(PDL).  It  was  first  identified  using  subtractive
hybridization  techniques  on  the  mouse  osteoblastic  cell
line  MC3T3-E.  It  is  a  90  kDa  glutamate-containing
secreted

matricellular protein. Periostin is

most

commonly  expressed  in  collagen-rich  fibrous  connective
tissues  which  are  subjected  to  constant  mechanical
strains.  It  is  generally  present  in  periosteum,  PDLs,
tendons,  heart  valves,  and  skin.

Periostin may be

involved in tissue remodeling by promotion of adhesion,
cellular differentiation, cell survival, and fibrogenesis.
Secreted by fibroblasts, Periostin is found to be present in
serum, saliva and also GCF.

Periostin is a member of Fasciclin-I family and the

family of fasciclin genes consists of four highly allied
members

: Periostin, bIG-H3, Stabilin-1 and stabilin-2.

Periostin constitutes of an amino-terminal in the EMILIN
family (EMI domain), a tandem repeat of four Fas I
domains (RD 1–4), a carboxyl-terminal region (CTR),
and a heparin binding site at its C-terminal end. (Figure 2)

Fig 2: Structure of Periostin

Fas-1 domain – Helps in cell adhesion by interacting
with  Tenascin-C  and  Bone  morphogenetic  protein
(BMP-1).  Each Fas-1 domain has glutamate residues
and  an  N-terminal  recognization  site  for  vitamin  K-

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Periostin – A Forward Step In Periodontal Biomarkers – A Narrative Review

ISSN No: 2582-0559

dependent γ-glutamyl carboxylase which is modified
into γ-carboxyglutamate post-translationally.

EMI domain – Helps in protein to protein interaction
by directly interacting with type I collagen and
Fibronectin

C-terminal domain – Helps in producing human
isoforms of Periostin by splitting alternatively.

ROLE OF PERIOSTIN IN DENTAL TISSUES:

Periostin in tooth development:

In tooth germ, Periostin is recognizable at the

interface  between  inner  enamel  epithelium  and  pre-
odontoblasts  and  in  the  mesenchymal  tissues  around  the
cervical loop at the cap stage. During bell stage, Periostin
is expressed in dental follicles and surface of the alveolar
bone.  After  birth,  Periostin  is  intensely  seen  in  the
Periodontal  ligament.

Studies with Periostin null mice

had  reduced  cartilaginous  growth  plates.  Incisors  had
widened  PDLs  and  abnormal  alveolar  bone  remodeling
and destruction. The structurally unstable PDL has lost its
mechanical  properties  leading  to  rapidly  progressive
periodontitis  like  disorder.  Defects  in  ameloblast
morphology  and  function  resulted  in  secretion  of
inappropriate  amorphous  matrix  and  abnormal  enamel
and  dentin  structure,  ultimately  resulting  in  enhanced
tooth wear due to enamel and dentin matrix defects. Thus,
it  was  shown  that  periostin  is  critically  important  in
maintaining  the  integrity  of  PDLs  and  is  essential  for
postnatal development as it controls the morphogenesis of
the tooth development.

Periostin in Angiogenesis:

Periostin facilitates angiogenesis by its Fas1-2

domain  which  helps  in  cell  adhesion.  It  promotes
capillary  formation  in  a  concentration  dependent  manner
by  significantly  enhancing  vasculo  endothelial  growth
factor receptor -2. Periostin regulates angiogenesis by up-
regulation  of  Matrix  metalloproteinase’s  MMP-2,  which
also stimulates VEGF receptor – 2. Thereby periostin aids
in  wound  healing  and  repair  during  periodontal
remodelling,  post  periodontal  surgery  and  regenerative
procedures.

ROLE OF PERIOSTIN IN PERIODONTAL

HEALTH:

Periostin in collagen formation:

Collagen fibrillogenesis is a complex multi-step

process  and  matricellular  proteins  play  a  major  role  in
collagen  assembly.  Many  studies  confirm  the  co-
localisation  and  molecular  interaction  between  periostin
and  Type  I  collagen.  Periostin  interacts  with  BMP-1  and
aids  in  the  formation  of  high  stiffness  collagen  by
enhancing collagen cross-linking by proteolytic activation

of  lysosyl  oxidase  (LOX).  It  also  helps  in  maintaining
collagen  fibrils  diameter,  collagen  maturation  and
assembly  and  preserves  the  biomechanical  properties  of
connective tissue.

Periostin in gingiva:

Immunohistochemical studies show that Periostin is

present  in  relatively  higher  levels  around  the  gingival
collagen  fibres  of  the  non-bone  attached  portion  of  the
periodontal  ligament.  It  is  also  present  just  beneath  the
epithelium  as  it  is  associated  with  some  basement
membrane  components  and  it  is  co-localised  with  type  I
collagen.  It  was  not  found  within  the  cytoplasm  of  basal
epithelial  cells.  Periostin  plays  a  major  role  in  the
interactions  of  the  connective  tissues  with  the  epithelial
cells.

Periostin in bone formation:

Periostin is known to play a vital role in osteoblast

adhesion, differentiation, and survival, recruitment and
attachment.

Periostin promotes the expression of type I

collagen,

osteocalcin,

osteopontin

and

alkaline

phosphatase  by  osteoblast.  Thus,  Periostin  has  a  role  in
maintaining  bone  microarchitecture  and  bone  strength.
There is currently no evidence that Periostin is expressed
in  osteoclasts  of  alveolar  bone.  In  osteocyte  it  is  an
immature  osteocyte  marker.  In  periostin  null  mice,  there
is an increased secretion of  sclerostin  which causes bone
loss  and  increased  apoptosis  of  osteoblast  and  osteocyte.
Thereby, Periostin acts as an anti-apoptotic factor.

Periostin in Mechanical loading and force

transmission:

Periodontal ligament transmits force resulting from

mastication. This mechanical strain activates transforming
growth  factor  beta  which  in  turn  increases  periostin
mRNA  levels  and  activates  periostin  which  helps  in
maintaining  the  integrity  of  PDL  fibre  in  response  to
mechanical  stress.

Periostin is involved in periodontal

remodelling  in  response  to  mechanical  stress  by
orthodontic  tooth  movement.  Divergent  expression  of
Periostin mRNA is seen strongly in the pressure sites than
in  tension  sites  after  3  to  96hrs  of  tooth  movement.
Sclerostin  levels  also  increases  after  tooth  movement  in
the  pressure  sites.  This  suggests  that  there  is  an
interaction  between  Periostin  and  Sclerostin  during  tooth
movement which aids in bone remodelling.

ASSESSMENT OF PERIOSTIN LEVELS:

Periostin is expressed in serum, saliva and GCF

which can be used to determine disease and health. It can
be quantitatively and qualitatively measured by various
diagnostic methods such as ELISA, quantitative real time
PCR, mRNA analysis.

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PERIOSTIN IN PERIODONTAL DISEASE:

Periostin in gingivitis:

Studies

shows

that

the

total

amount

and

concentration of periostin decreased in gingival crevicular
fluid  with  the  progression  and  severity  of  the  disease.
Periostin  levels  declined  from  healthy  controls  to
gingivitis  and  to  chronic  periodontitis  groups.  However,
there  was  no  significant  difference  in  serum  periostin
concentration within all groups.

Periostin in gingival enlargement:

Studies show that periostin up-regulation is

associated with gingival enlargement in patients on
systemic administration of nifedipine.

Similarly,

elevated levels of periostin were seen in Phenytoin
induced gingival enlargement

where it enhances the

accumulation  of  ECM  rather  than  fibrosis.  In  Drug
induced  enlargement,  there  is  an  up-regulation  of  TGF-β
which  in  turn  increases  periostin  levels  despite  the
inflammation.

Periostin in Chronic Periodontitis:

Periodontitis is caused by bacteria acting in a

preferentially  susceptible  host.  Inflammatory  mediators
and  cytokines  released  causes  attachement  loss  and  bone
loss by collagen destruction. This affects the matricellular
proteins and the PDL integrity. Tumour Necrosis Factor –
α (TNF- α) and LPS initially might increase the periostin
levels  in  fibroblasts,  but  chronic  exposure  leads  to
decreased levels of periostin.

Periostin levels negatively

correlated  with  all  the  site-specific  clinical  paramters
whereas  TNF-  α  positively  correlated  in  patients  with
both  chronic  periodontitis  and  diabetes.

Similarly,

periostin levels in saliva was evaluated and the results
showed that the level of periostin in saliva in patients with
chronic periodontitis was significantly lower than healthy
controls and Periostin was detectable in all samples. They
concluded that there is a significant relationship between
the level of periostin in saliva and chronic periodontitis.

Periostin in Aggressive Periodontitis:

Aral et al.

evaluated the levels of POSTN in

Chronic  Periodontitis  (CP)  and  Aggressive  Periodontitis
(AgP)  compared  to  non-periodontitis.  Individuals  were
submitted  to  GCF  and  saliva  sampling.  The  mean  GCF
level  of  POSTN  was  lowest  in  the  AgP  group  as
compared  to  the  other  groups  and  was  lower  in  the  CP
group  as  compared  to  the  healthy  group.  Periostin  levels
were  increased  in  the  saliva  of  patients  with  AgP  as
compared  to  the  CP  and  healthy  groups.  Study  by
Jamesha  et  al

also showed similar results where GCF

Periostin levels decreased with increased severity of the
disease. Subjects with Aggressive periodontitis had the

lowest level of periostin in GCF followed by Chronic
periodontitis subjects and healthy controls.

Periostin in Peri-implant sulcular fluid:

Analysis of periostin levels in Peri-implant sucular

fluid and gingival crevicular fluid showed that there was
no significant difference between implant and natural
teeth groups respectively.

PERIOSTIN IN PERIODONTAL

REGENERATION:

Bacterial products and inflammatory cytokines may

reduce periostin levels, which in turn compromise the
structure and function of the periodontium by reducing its
structural and biomechanical properties. Periostin
increases cell migration, recruitment, and attachment into
the healing areas of different tissues.

High expression of Periostin in GCF samples of

chronic periodontitis patients after 2 weeks of scaling and
root planning was found.

Furthermore, Periostin levels

were  used  to  assess  the  outcome  of  Non-surgical
periodontal  therapy.  Studies  shows  that  periostin  levels
increased  after  Low  level  laser  therapy  (LLLT).

Also,

Periostin levels increased after periodontal surgery in
GCF of periodontitis patient. This is due to the decrease
in the inflammatory stimuli and bacterial challenge which
enhances

periostin

production

thereby

promoting

periodontal healing and regeneration. Bone formation
during mechanical loading is added by periostin and has
direct implication on the immediate functional loading of
dental implants.

Periostin may function as an intermediate regulator

of  mechanotransduction  that  controls  stem  cell  fate  by
upregulating  stem  cell  markers  like  NANOG  and  OCT4
in response to force. It is also proposed that light optimal
compressive  force  plays  a  role  in  maintaining
homeostasis in periodontal tissue. These findings support
the  orthodontic  tooth  movement  theory,  which  suggest
that  an  optimal  force  can  induce  maximum  tooth
movement  by  promoting  healing  without  damaging
periodontium.

Periostin acts a critical modulator of cell

proliferation  and  remodeling  during  would  healing  in
Periodontal  ligament  by  inducing  the  proliferation  of
human Periodontal ligament stem cells (hPDSC). It shows
that  sufficient  concentration  of  POSTN  may  effectively
promote  would  healing  in  both  periodontal  tissues  and
around dental implants.

FUTURE DIRECTIONS:

Since periostin is essential for cardiac repairing after

an acute myocardial infarction, a trial of treatment with
recombinant periostin in a preclinical infarct model was

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Reshmaa et al:

Periostin – A Forward Step In Periodontal Biomarkers – A Narrative Review

ISSN No: 2582-0559

initated.

Transfer

periostin-overexpressing

mesenchymal cells, resulted in the improved cardiac
function.

Recently, biomimetic scaffolds loaded with

recombinant Periostin has also been used in the treatment
of tendonitis where periostin helped in tissue repair and
regeneration.

Thus, diagnostic or clinical applications of

anti-periostin  antibody  or  recombinant  periostin  may
promote  further  development  of  periostin  for  these
applications  in  the  dental  field.  Particularly  in
Periodontitis,  application  of  recombinant  periostin  might
serve as a healing factor or promoter.

CONCLUSION:

Periostin plays a fundamental role in postnatal

development  and  repair  of  bone  and  tooth-related
structures.  Periostin  may  be  involved  in  healing  after
post-periodontal  surgery,  regenerative  procedures,  or
even  after  placement  of  dental  implants.  By  promoting
the migration of fibroblasts and osteoblasts, periostin may
play a key role in remodeling of the PDL and surrounding
bone  after  periodontal  surgery  with  (or  without)  various
biomaterials  used for regeneration. Expression of protein
levels  of  periostin  may  help  in  identifying  various
pathways  in  healing  and/or  disease  pathogenesis  in  the
periodontium.  Periostin  can  act  as  a  novel  biomarker  in
the  near  future  with  respect  to  the  pathogenesis  of
periodontitis.  Usage  of  an  anti-periostin  antibody  or
mainly  recombinant  periostin  may  be  considered  for
therapeutic  applications  in  dentistry  and  for  periodontal
regeneration.  More  studies  are  needed  to  confirm  this
hypothesis  and  develop  treatment  protocols  based  on
these scientific evidences.

FINANCIAL SUPPORT AND SPONSORSHIP

Nil

CONFLICTS OF INTEREST

There are no conflicts of interest.

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