medicines
Review

Kampo Therapies and the Use of Herbal Medicines inthe Dentistry in Japan
Shuji Watanabe 1,2 , Toshizo Toyama 1 , Takenori Sato 1 , Mitsuo Suzuki 1,3 , Akira Morozumi 4 ,Hiroshi Sakagami 5 and Nobushiro Hamada 1, *
1

2
3
4
5

*

Division of Microbiology, Department of Oral Science, Kanagawa Dental University, 82 Inaoka-cho,
Yokosuka 238-8580, Japan; swatanabe2010@nifty.com (S.W.); toyama@kdu.ac.jp (T.T.); t.sato@kdu.ac.jp (T.S.);
suzuki@d2clinic.jp (M.S.)
Odoriba Medical Center, Totsuka Green Dental Clinic, 1-10-46 Gumizawa, Totsuka-ku,
Yokohama 245-0061, Japan
Dental Design Clinic, 3-7-10 Kita-aoyama, Minato-ku, Tokyo 107-0061, Japan
Morozumi Dental Clinic, 1-3-1 Miyamaedaira, Miyamae-ku, Kawasaki 216-0006, Japan;
morozumident@gmail.com
Meikai University Research Institute of Odontology (M-RIO), 1-1 Keyakidai, Sakado,
Saitama 350-0283, Japan; sakagami@dent.meikai.ac.jp
Correspondence: hamada@kdu.ac.jp; Tel./Fax: +81-46-822-8867

Received: 13 February 2019; Accepted: 25 February 2019; Published: 28 February 2019


Abstract: Dental caries and periodontal disease are two major diseases in the dentistry. As thesociety is aging, their pathological meaning has been changing. An increasing number of patientsare displaying symptoms of systemic disease and so we need to pay more attention to immunologic
aggression in our medical treatment. For this reason, we focused on natural products. Kampo consistsof natural herbs—roots and barks—and has more than 3000 years of history. It was originated in
China as traditional medicine and introduced to Japan. Over the years, Kampo medicine in Japan
has been formulated in a way to suit Japan’s natural features and ethnic characteristics. Based on
this traditional Japanese Kampo medicine, we have manufactured a Kampo gargle and Mastic Geldentifrice. In order to practically utilize the effectiveness of mastic, we have developed a dentifrice(product name: IMPLA CARE) and treated implant periodontitis and severe periodontitis.
Keywords: periodontitis; Kampo; traditional medicine; Jixueteng; Juzentaihoto; technical terms; gargle;
tongue diagnosis; mastic; pathogenic factors

1. Introduction
Kampo medicine in Japan is the Oriental medicine which was originally brought from China
through east Asia and the Korean peninsula as the ancient Chinese medicine. During the Nara periodof Japan (AD 710-784), Japanese envoys were sent to Tang Dynasty (AD616-907) under the nameof Kentoshi and it became a channel that Chinese medicine was directly brought to Japan. In the
Kamakura period (AD1185-1333), it made a progress to become more practical medicine by being
adopted more to Japan’s natural environment, rather than a simple copy of Chinese medicine. In the
Muromachi period (AD 1336-1573), a Japanese whose name was Sanki Tashiro studied in China during
its Ming dynasty (AD1368-1644) and created the academic foundation of the Japanese Kampo medicine.
Kampo was first used in higher social classes but since the 15th century it has provided general people
natural material-based medicine. In the Edo period (AD 1603-1867), Western medicine was introduced
to Japan from Netherland and was called Rangaku, innovating special characteristics such as abdominal
diagnosis and contributed to the developments of medical diagnosis and treatment [1–3]. On theother hand, the traditional medicine which was primarily using herbal medicines was called Kampo
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medicine. In 1883, the Japanese government promulgated the regulation of the medical license that
only those doctors who have mastered the Western medicine could prescribe the Kampo medicines
and the Kampo medicine declined since then except for the practice by some facilities or individuals.
In 1927, the book of Kokan Igaku (traditional Japanese and Chinese medicine) by Kyushin Yumoto
was published and it triggered the subsequent revival of Kampo medicine. Following that in 1950,
the academic society of “Japan Society of Oriental Medicine” of Kokan Igaku was established, whichbecame the association of Oriental medicine including acupuncture and moxibustion treatments.
Under the guidance of the Japan Medical Association, Kitasato University Oriental Medicine ResearchCentre was founded in 1972 and it has played a central role in the education of Oriental Medicine.
Further in 2001, the model curriculum of medical education newly incorporated a course of study for“being capable of explaining Japanese and Chinese medicines.” At present, all medical schools in Japan
have the courses of study for Kampo medicine or Oriental medicine as part of their education program.
Kampo medicine has a unique character, which is different from Western medicine. Kampo uses as
a combination drug of various herbal plants that have complementary physiological activities. In fact,
148 Kampo formulations are used for medicinal treatments and are covered by the Japanese National
Health Insurance Program [4]. Since 2012, seven kinds of Kampo formulations were approved by Japan
Dental Association within the National Health Insurance Drug Price Standard related with dental
treatment [5]. In 2015, Kampo Education Plan of Dentistry was sent from the Japan Dental Association
to all dental universities [6]. At the same time, the first author of this article (S.W.) established the
Yokohama Kampo Dentistry Study Group for the continuing education of Kampo. This group has held
18 research sessions and symposiums by calling a special lecturer of Kampo and is planning to publish
a side reader of 11 Kampo preparations for dental students from the Nanzando publishing company.
There are two academic societies on Kampo in Japan: The Japan Society for Oriental Medicine andJapan Dental Society of Oriental Medicine. The latter showed previously different direction about
qigong and massage but now changing to the same direction with the former.
Kampo prescriptions in dentistry has special characteristics due to the diverse symptoms suchas the pain caused by the bad bite alignment or malocclusion (exogenous cause) and unidentifiedcomplaints. For Kampo prescriptions, it is important to understand the symptoms, by considering
these special characteristics. It has also become known that the negative feedback functionality would
not work when malocclusion and occlusal destruction become chronic with the sympathetic-nerve
predominant state. We expect that Western medicine and the Oriental medicine will be used selectively
and in parallel in many of the clinical cases in dentistry to ensure the best results for primary cares andthat it would contribute to the dentistry medicine going forward.
In this review article, we firstly focus on the basic theory of Kampo medicine and then its biologicalactivities and clinical effects in the dental treatments.
2. Basic Theory of Kampo Medicine
2.1. Concept of Oriental Medicine
Western medicine is a proof medicine that is based on the medical evidence, while Oriental
medicine is a traditional medicine that has accumulated the evidence based on the experiences [7].
The modern medicine has made great advances by accumulating scientific evidences but it was at
the same time a challenge to the limit of the medicine and it has added a new dimension of problems
such as the side effects of medicines to cope up with the aggravation of diseases. In recent years,
medical evidences of Kampo prescription (traditional medicine in Japan based on the traditional
Chinese medicine), which is one of the pharmacotherapies of Oriental medicine, has become widely
known. It is making it possible to include Kampo in the pharmacotherapy of the modern medicine,in consideration of its role as biological response modifiers (BRMs) of the vital balance. Oriental
medicine was generated from the concept that the natural world consists of the opposing axis of Yin(Table A1) or “non-resistant” and Yang or “resistant,” where the relativity of these axes maintains theMedicines 2019, 6, x FOR PEER REVIEW
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medicine was generated from the concept that the natural world consists of the opposing axis of Yin(Table A1)balanceor “non-resistant”
and ofYangor “resistant,”
the relativityof theseaxesthemaintainsthequalitativeof the workings
mothernature [3]. where
This principle
is therefore
called“Yin-Yang
qualitativebalanceoftheworkings
ofmothernature[3].
Thisprincipleistherefore
calledthe“Yintheory.” In the Kampo therapy, the body state and each internal organ are divided into Yin or Yang andIn thetherapy,
the body
stateeach internalorgan are(Figure
divideditYangtreatstheory.”
the patient
so Kampo
the yin-yang
is balanced
andcanandmaintain
the homeostasis1).into Yin or
Yang and it treats the patient so the yin-yang is balanced and can maintain the homeostasis (Figure 1).

Fundamentals are thebalance of Yin and Yang

Yang
symptoms

Yinsymptoms

Powerof disease

Characteristics
of disease

Depthof disease

Jitus(excess)Netsu(heat)

Hyo(superficies)

Kyo(deficiency)Kan(chill)Ri(interior)

FigureFigure1.1.Concepts
ConceptsofofKampo
Kampotherapy.
therapy.Kampo
Kampotherapy
therapybegins
beginswith
withthetheknowledge
knowledgeofofconstitutional
constitutional
characteristics of patient’s body. In-Yo or Yin-Yang: When the switch-over between two representative
characteristics of patient’s body. In-Yo or Yin-Yang: When the switch-over between two representativeautonomic nerves, the sympathetic nerves (yang) and the parasympathetic nerves (yin), is good,autonomic nerves, the sympathetic nerves (yang) and the parasympathetic nerves (yin), is good, thethe yin-yang balance is kept well. Kyo-Jits or asthenia and sthenia show physical strength, constitutional
yin-yang balance is kept well. Kyo-Jits or asthenia and sthenia show physical strength, constitutional
characteristics of body and the strength of resistance against disease. The reaction differs, depending
characteristics of body and the strength of resistance against disease. The reaction differs, dependingon their Kyo-Sho or Jitsu-Sho. It is categorized into Jitsu-Sho (excess symptom), Kyo-Sho (deficiency
on their Kyo-Sho or Jitsu-Sho. It is categorized into Jitsu-Sho (excess symptom), Kyo-Sho (deficiency
symptom) and Chukan-Sho (symptom in-between the two). Kan-Netsu or chills and fever: Kan is Yin
symptom) and Chukan-Sho (symptom in-between the two). Kan-Netsu or chills and fever: Kan is Yin
while Netsu is Yang. They are always in a relative relation. When Yin deteriorates, Yang predominates,
while Netsu is Yang. They are always in a relative relation. When Yin deteriorates, Yang predominates,
called Netsu-sho (heat syndrome).
called Netsu-sho (heat syndrome).

2.2. Differences from the Western Medicine
2.2. Differences from the Western Medicine
Oriental medicine and Western medicine are both medical sciences, fundamentally and equally.
Oriental
medicineand Western
medicine
arebased
both medical
fundamentallyandequally.
Oriental
medicine
identifies
the disease
mainlyon the sciences,
pathologicalcondition at
thetime
Oriental
medicine
identifies
thediseasemainlybasedonthepathologicalcondition
at
the
time
of diagnosis. It understands that a part of the body appeals the problem and it spreads to theof
diagnosis.
understands
a part inof thatthe body
thetheproblemand aims
it spreads
to the entire
entirebody Itandshows the thatsymptom
part. appeals
Therefore,
treatment
at alleviating
the
body
and
shows
the
symptom
in
that
part.
Therefore,
thetreatmentaims
atalleviating
thesymptomsymptom while improving the pathological condition itself. This pathological condition is called Sho
improving
the pathological condition itself. This pathological condition is called Sho or Kampo
orwhileKampo
Diagnosis.
Diagnosis.
The Western medicine diagnoses based on the demonstrated symptom and it emphasizes the
The Western
diagnoses
basedon thesymptom
and it emphasizes
theimportanceof the medicine
examinations
in orderto findoutdemonstrated
the conditionof the appearing
symptoms,
importanceoftheexaminations
in
order
to
find
out
the
conditionoftheappearing
symptoms,
thenthen gives it a name and treats it accordingly. On the other hand, Kampo medicine improves thegives it a nameand treatsthe
it accordingly.
the otherpresented
hand, Kampo
medicine
symptomsymptomby improving
pathologicalOnconditionin theform ofimproves
Sho [2,8].theSho
is thebyimprovingthepathologicalcondition
presented
in
the
form
of
Sho
[2,8].
Shoisthemeasuremeasure to know the characteristics, size and depth of the disease, which would indicate the causeto
the characteristics,
size andisdepth
disease,
which
would
the causeconditionof the diseaseofknow
the disease
and the treatment,
givenofbythefindingout
the causeofindicate
the pathological
by
and
the
treatment,
is
given
by
finding
out
the
cause
of
the
pathologicalcondition
by
Sho.
From
this,
Sho. From this, Oriental medicine makes it possible to treat the patient as expressed in the phrase
Oriental treatments
medicine makes
possibleto treatthe patient
as expressed
in Itthephrase“Different
for one itdisease;identical
treatmentfor different
diseases.”
means
that“Different
different
treatmentswill
forbeone
disease;identical
treatment
different
It diagnosis)
means thatdifferent
treatments
given
for the samediseasename offor
patients
if thediseases.”Sho (Kampo
is different.
treatments
will
be
given
for
the
same
diseasenameofpatients
ifthe
Sho(Kampodiagnosis)
Likewise, the same treatment will be given to the different disease names of patients, if the Sho is theis
different.
the sametreatment
will
be givento theofdifferent
diseasenamesof patients,
if thesame.
HereLikewise,in this article,
the disease
name
means
the namethe disease
under
the modern
medicalSho is thesame.2).Here in this article, the disease name means the name of the disease under the modern
science(Figuremedical science (Figure 2).
2.3. The Categories of Sho
Shoko (Kampo medical conditions, symptoms in Western medical terms) consists of Yin-Yang
with Kyo-Jitsu, Kan-Netsu and Hyo-Ri. They reflect the current pathogenic condition. Table 1 shows
the definitions and classifications of Yin-Yang, Kyo-Jitsu (asthenia and sthenia) and Kan Netsu (chills
3Medicines 2019, 6, 34

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and fever). Table 2 shows the definitions of Yin-Kyo, Yo-Kyo, Yin-Jitsu and Yo-Jitsu. Figure 3 shows the
Medicines 2019,6, x FOR PEER
REVIEW Kyo-sho and Netsu-Kan in the body.
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conditioncategories
of Yin-Yang,
Sho
Oriental medicine = symptom = location of the disease (systemic)

Treatment plan
Western medicine =examination = disease name (local)

Figure 2. Characteristics of Oriental medicine and Western medicine therapy. Sho (Kampo Diagnosis):
Figure 2. Characteristics
of Oriental
medicineand Western
medicine
therapy.
(KampoDiagnosis):
Capturing
the Shoko (yin-yang,
Kyo-Jitsu
or deficiency
and excess,
Kan-Netsu
orShochillsand fever,Hyo-RiCapturingtheShoko(yin-yang,
Kyo-Jitsu
ordeficiency
andexcess,Kan-Netsu
orchillsandfever,
Hyoor superficies and interior) as the holistic symptom caused by the pathological condition andit shows
Riorsuperficies
andinterior)astheholistic
symptomcausedbythepathologicalconditionandthe condition of the patient at the time of diagnosis. Sho changes depending on the bodily sensation.it
shows the condition of the patient at the time of diagnosis. Sho changes depending on the bodily
sensation. Table 1. Definitions and classifications of Yin-Yong, Kyo-Jitsu and Kan-Netsu.
Categories
2.3. The
Categories of Sho

Kyo-Jitsu(Asthenia and Sthenia)

Yin-Yang

Kan-Netsu(Chills and Fever)

Shoko(Kampo medical
conditions,inThe
Western
consistsof Yin-Yang
Definitions
Ability
to resist thesymptoms
disease.
state ofmedical
deficiencyterms)
isActualfeelingof chill
The treatment
differs,
or asthenia
and condition.and
heat1 showswith Kyo-Jitsu, Kan-Netsu and
Hyo-Ri. They
reflect thekyo-sho
current
pathogenic
Table
depending on whether the sho isis jitsu-sho or
Kyo-netsu (asthenic
the definitions and classificationsof Yin-Yang, Kyo-Jitsuexcess(asthenia
and sthenia) and
Kan Netsu (chills
yang and yin.
sthenia.
heat): Heat coming
and fever). Table 2 showsthedefinitionsof
Yin-Kyo,Yo-Kyo,Yin-Jitsu
andYo-Jitsu.
Figure3 shows
Yin disease: The resistant power
Kyo (Asthenia):
from poor
metabolism
the condition categoriesagainstof Yin-Yang,
Kyo-shoand Netsu-Kan
in thethe disease
is weak.
Deficiency
ofbody.
what isand retained inside theTreatment is given to recover therequired for the bodybody, slight fever,exhaustion
of
the
body.
It
is
and
shows
the
sho
of
internal
Table 1. Definitions and classifications of Yin-Yong, Kyo-Jitsu and Kan-Netsu. fever, showing
called honchi or the systemic
Yin-kyo syndrome or
yin-syndrome.
Kyo-Jitsu
Kan-Netsu
meridian treatment
yang-kyosyndrome
Categories
Yin-Yang(Asthenia
andSthenia)(Chillsand Fever)Classification
Ability toYang
resistthe disease.
The The stateJitsu
of deficiency
kyoActual
feelingof chill(According to thedisease:
The resistant(Sthenia): is
Low
Jitsu-netsu(sthenic
treatment
differs,
dependingon is sho ormetabolic
asthenia andandChills
heat that
Orthodox Theory)
power
againstthe disease
rate excess
due to istheheat):
strong.
accumulationof toxic
occursby (asthenic
increasing
whether the
sho isTreatmentyang and whichyin.
jitsu-shoor sthenia.
Kyo-netsu
positivity
disease Kyois (Asthenia):
substanceDeficiency
in the bodytheHeatheat inthe body.
Yin disease:
The attacks
resistantthe
power
of heat):comingfromeffective.
It is calledhyochi orwhat is andshowsofObserves
pyrexiaand
andDefinitions
againstthe disease
is weak.
required
forthetheshobody
poor
metabolism
local
and
symptomatic
yin-jitsu
oryang-jitsu.
showing
Treatment is given to recoverand shows the sho of Yin-kyo
retained inside thetreatment.
Yang-syndrome.
the exhaustion of the body. It is
syndrome or yang-kyo
body, slight fever,called honchi or the systemic
syndrome
internal fever, showing
Table 2. Definitions
meridiantreatment of Yin-Kyo, Yo-Kyo, Yin-Jitsu and Yo-Jitsu.
yin-syndrome.
Yang disease: The resistant
Jitsu (Sthenia): Low
Jitsu-netsu (sthenic
Categories
Yin-KyoYo-KyoYin-Jitsu
Yo-Jitsu
Classification
power against the disease ismetabolic rate due to theheat): Chills that occurs(yin deficiency)(yang deficiency)(Yin excess)(Yang excess)(According
strong. Treatment whichaccumulation of toxic
by increasing the heat in
Definitions
Yin is insufficient
Yang is insufficient
Coldnesscomesand
from
Heat
comes
from
to thepositivity
attacks the diseaseissubstancein the body
the
body.
Observes
and yan becomesand yin relatively
outside to constantly
outside to constantly
Orthodox
effective. It is called hyochi orshows the sho of yin-jitsu or
pyrexia and showing
relatively
becomesmaintain themaintain the
Theory)local
andsymptomaticyang-jitsu.
Yang-syndrome.
overactive; shows
overactive;
homeostasis of yin and homeostasisof yin andtreatment.
fever called
asthenia cold;yang and shows theyang; and shows theasthenic fever;feeling chills.
state of chills, calledstate of heat, called
feverishsymptom.
sthenic
Table
2. Definitions of Yin-Kyo, Yo-Kyo,Jitsu-Kan
Yin-Jitsuorand
Yo-Jitsu. Jitsu-Netsu or sthenic
cold; body is chilled
heat; feeling hot andand feeling cold.
excessivesw eating.
Yin-KyoYo-KyoYin-Jitsu
Yo-Jitsu
Categories(yin deficiency)(yang deficiency)(Yin excess)(Yang excess)Definitions
Yin is Hyo-Ri (superficies
Yang is and interior)
Coldnesscomes fromcomes fromoutsideOn the other hand,indicates
where Heat
the disease
existsin theinsufficient andinsufficient andoutside to constantly
to constantly maintain the
body and shows the depth of Sho, depending on the part of the body. Hyo-ri is a unique concept ofyan becomesyin relatively
maintain the
homeostasis of yin andKampo medicine, which indicates the seriousness of the disease, based on the location and depth
relatively
becomeshomeostasis of yin andyang; and shows the stateof the disease. According
literature “Shokan-ron,”arecalled
further
dividedoveractive; to the classic
overactive;yang and showsYin
theand Yangof heat,Jitsu-Netsu
into 3 layers by shows
the degree
and it calls
the called“Three Yin”
and the“Threefever of development
asthenia cold;statethemof chills,
or sthenic
heat;feelingYang”
hotcalled asthenic
feeling chills.
Jitsu-Kan or sthenicand excessive sw eating.
fever; feverish
cold; body is chilled
symptom.
and feeling cold.

4Medicines 2019, 6, 34

5 of 31of diseases [8]. The Three Yang stage indicates Hyo or the surface of the body such as skin but also
includes the parts of the body that show the Hyo symptoms such as chill, fever, headache, joint pain
and sweat. The three Yin stage indicates Ri. Mostly Sho’s of the internal organs, including heart,lungs and digestive apparatus, are shown, where the symptoms are, for example, abdominal pain,
constipation, diarrhoea, fullness of the abdomen, stomach tension. The middle part between the Hyo-Ri
is called
Han-Hyo-Ri
or REVIEW
mesodermal.
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Yin-Yang, Kyo-Jitsu, Netsu-Kan
Yin

Jitsu-sho Yang

Homeostasis
Kyo-sho

Yin

Yang
Yang

Yin
Yin

Jitsu-Netsu

Jitsu-Kan

Kyo-Netsu

Yang

Kyo-KanFigure 3. Condition categories of Yin-Yang, Kyo-sho and Netsu-Kan in the body.

Figure 3. Condition categories of Yin-Yang, Kyo-sho and Netsu-Kan in the body.

2.4. Cause of Illness

On the other hand, Hyo-Ri (superficies and interior) indicates where the disease exists in the
Disease in Kampo medicine is the disorder of harmony of spirit and body. The living body has
body and shows the depth of Sho, depending on the part of the body. Hyo-ri is a unique concept ofphysiological functions to maintain the homeostasis of the organism against the changes of internal
Kampo medicine, which indicates the seriousness of the disease, based on the location and depth ofand external environment. This function is called Shoki or healthy Ki. Shoki is a function which would
the disease. According to the classic literature “Shokan-ron,” Yin and Yang are further divided into 3
defend the body against disease and would induce natural healing ability, where the natural healing
layers by the degree of development and it calls them the “Three Yin” and the “Three Yang” ofability would seek for the harmony of Ki, Ketsu and Sui (vital energy, blood circulation and aqua).
diseases[8]. The Three Yang stage indicates Hyo or the surface of the body such as skin but also
In contrast, the factor that attempts to destroy the homeostasis is called Ja or Byoja or stress or pathogen.
includesthe thepartsof theemotion
body thatshowtothe
Hyovarious
symptoms
suchabnormalities
as chill, fever,headache,
It induces
climate,or virus
cause
physical
which
wouldjoint
lead paintoandsweat.
The
three
Yin
stage
indicates
Ri.
MostlySho’softheinternalorgans,includingheart,
lungs
diseases. Causes of disease are categorized into endogenous, exogenous and other factors.
and digestive
apparatus,
are shown,thesymptoms
abdominal
Endogenous
factor meansthat thewhere
cause ofdiseasecomes are,fromforthe example,
inside of body.
It may pain,beconstipation,
diarrhoea,
fullnessof thestomachtension. The
between the
Hyocommon emotionsof humanbeings.
It abdomen,
is a physiologicalphenomenon
andmiddle
may bepartquintessential
in life.
Ri However,is called Han-Hyo-Ri
mesodermal.
it can cause orabnormality
in the functions of internal organs, when mental stress persists orwhen a sudden strong shock hits us, because it would collapse the balance of Yin, Yang, Ki and Ketsu on

2.4.such
Causeof IllnessIt is called the Seven Emotions –joy, anger, anxiety, worry, grief, apprehension and fear.
occasions.
Exogenous
factor medicine
means thatisjathe
invadesthe ofbodyfrom outside.
Diseasesoccur
influenced
by theDiseasein Kampo
disorderharmonyof spiritand body.
Theliving bodyhasmental or physical changes when the body cannot accept the natural environment such as pathogens,physiological functions to maintain the homeostasis of the organism against the changes of internal
severe natural environment and sudden climate changes. It is called the Six Pathogenic Agents - wind,and external environment. This function is called Shoki or healthy Ki. Shoki is a function which would
cold, heat, humidity, dryness and fire (fever).
defend the body against disease and would induce natural healing ability, where the natural healing
These are other factors, which would cause diseases due to other causes such as inadequate
ability would seek for the harmony of Ki, Ketsu and Sui (vital energy, blood circulation and aqua). In
eating-drinking, fatigue, overwork, injury, poisoning, parasite and heredity.

contrast, the factor that attempts to destroy the homeostasis is called Ja or Byoja or stress or pathogen.
It induces
the climate,or virus
to cause various physical abnormalities which would lead to
2.5. Explanationof Ki, emotion
Ketsu, Oketsu
and Suidiseases. Causes of disease are categorized into endogenous, exogenous and other factors.
The concept of Ki (vital energy), Ketsu (blood/blood circulatory function) and Sui (aqua) is theEndogenous factor means that the cause of disease comes from the inside of body. It may befundamental concept to understand the Kampo medicine [2,8] (Figure 4).
commonof humanbeings.
It isindicate
a physiologicalphenomenon
and Jitsu-Sho
may be quintessential
Ki emotions
indicates yang
and Ketsu
and Suiyin. Patients
reversibly show
(excessive) and inlife.
However,
it
can
cause
abnormality
inthefunctionsofinternalorgans,whenmentalstress persists
Kyo-Sho (deficiency) (Table 3).
or when a sudden strong shock hits us, because it would collapse the balance of Yin, Yang, Ki and
Ketsu on such occasions. It is called the Seven Emotions –joy, anger, anxiety, worry, grief, apprehension
and fear.
Exogenous factor means that ja invades the body from outside. Diseases occur influenced by themental or physical changes when the body cannot accept the natural environment such as pathogens,severe natural environment and sudden climate changes. It is called the Six Pathogenic Agents - wind,cold, heat, humidity, dryness and fire (fever).
These are other factors, which would cause diseases due to other causes such as inadequate

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「Sho」
Ki

Ketsu

Sui

Figure 4. Diagrams of biological factors in Sho.
Table 3. Classifications of Ki, Ketsu and Sui.

Ki indicates yang and Ketsu and Sui indicate yin. Patients reversibly show Jitsu-Sho (excessive)
and Kyo-Sho (deficiency) (Table 3).
Yin
Yang
Ketsu Sui
Ki
Table 3. Classifications of Ki, Ketsu and Sui.

Yin
Yang
Ketsu Sui
Ki
Ki is the source of energy of the entire biological activities and it circulates blood and bodily fluidin the whole body [8]. Therefore, the inhibition of the workings of Ki would inhibit the workings of
2.5.1. Ki, Vital Energy
Ketsu (blood circulation) and Sui (bodily liquid) and thus a disease would occur. Ki belongs to yang.
is theelements
source ofare
energyof the entire
biologicalactivities
it circulates
bloodKyo
andorbodily
fluid
WhenKitheseexcessively
active,it is called
Jitsu orandexcessand is called
deficiency
in the thesewholearebody[8]. Therefore,
theof the workings
would inhibit
workingsofwhen
deficient.
Excessive
Kiinhibitionis called Ki-Gyaku(ki-Jitsu)oforKi
hyperactive
ki. Itthe
is called
Ki-TaiKetsu(bloodcirculation)
andSui(bodilyliquid)andthusadiseasewould
occur.
Ki
belongs
toyang.
when stagnated due to over excess, while Ki-Kyo when under hypersecretion.
When these elements are excessively active, it is called Jitsu or excess and is called Kyo or deficiency
2.5.2.
Blood
Circulation
whenKetsu,
these aredeficient.
Excessive Ki is called Ki-Gyaku (ki-Jitsu) or hyperactive ki. It is called Ki-Tai
whenBloodstagnated
due
to
over
excess,whileandKi-Kyowhennutrition
under hypersecretion.
circulates throughthe body
suppliesto the five parenchymatous viscera
2.5.1. Ki, Vital Energy(heart, liver, spleen, lung and kidney) and the six hollow viscera [gallbladder, stomach, small intestine,
2.5.2. Ketsu, Blood Circulation
large intestine, urinary bladder and triple heater (sansho, a passage that controls the flow of air, blood
and water)].
Ki and ketsu
are interdependent
each other–Ki warms
theparenchymatous
body in Yang andketsu
Blood circulates
throughthe body and supplies
nutrition
to theup
fivevisceranourishes
the bodyin Yin.
three statesof Ketsu,
namely,viscera
Ketsu-Netsu(Ketsu-Jitsu)(blood-heat),(heart, liver,spleen,lungThere
and arekidney)and thesix hollow[gallbladder,stomach,small
Oketsu(Ketsu-Tai)(blood stagnation)
and Ketsu-Kyo
Symptoms
blood-heatshowsintestine,large intestine,urinary bladderand triple(bloodheaterdeficiency).
(sansho, a passage
thatofcontrols
the flowofhematemesis,
for example andbleeding
tissue,air, blood and bloody
water)].stools,
Ki andnose
ketsubleeds,
are interdependent
eachshowsother –Ki
warmsfromup thebodyconstipationin Yang and
and
urine
When
heatedblood
up to theupperKetsu-Netsu
body, it causes
not only
ketsuyellowish
nourishes
the [8].
bodyin Yin.
Thereare(ketsu-netsu)
three statesgoesof Ketsu,
namely,(Ketsu-Jitsu)
oketsu(bloodstagnation)butalso
affects
emotionssuch
as
irritation.
Blooddeficiency
is
the
decay
(blood-heat), Oketsu (Ketsu-Tai) (blood stagnation) and Ketsu-Kyo (blood deficiency). Symptomsofofthe recuperation
ability of blood.
It causes
anaemia
but also and
shows
other
dysfunction
blood-heatshows hematemesis,
bloodystools,so-called
nose bleeds,
for example
shows
bleedingfromsuchanorexia andand
weakeningdigestion
and absorption
and(ketsu-netsu)
these are governed
Ki. Bloodtissue,asconstipation
yellowishofurine[8]. Whenheated blood
goes up by
to theupper
will
notit circulatetheonlybody
if Ki (bloodis insufficientto operatetheaffects
blood vessels.
Kias
in irritation.
each part Bloodof thebody,causes not
oketsustagnation)
but also
emotionsThis
such
body
is called
Ei-ki
or Yin-energy.
Ki initiates
functionsofIteach
organof the anaemia
body. Ketsu
belongs
todeficiency
is thedecayof the recuperation
abilityof blood.
causesso-called
but also
shows
Yin.
concept of Oketsu
blood stagnationis the mostOketsu is anda pathologicalotherThe
dysfunction
such asor anorexia
and weakening
ofimportant
digestion concept.
and absorption
these arechangethat
causewhenthethebodybloodin thebodyor in avessels.
local tissue
governedbywould
Ki. Blood
willdiseases
not circulate
if is
Kistagnatedis insufficient
to entire
operatethe bloodThis(Figure5). part of the body is called Ei-ki or Yin-energy. Ki initiates functions of each organ of theKi in each
one conceptof the 12channelsisin
body,
responsibleforbody.Sansho
Ketsu (triple
belongsheater),to Yin. The
ofmainOketsuacupunctureor blood stagnation
thethemostimportantconcept.
movingbetween change
the upper
body
andcause
the lower
body.
Oketsu isenergy
a pathological
that
would
diseases
when the blood is stagnated in the entire
body or in a local tissue (Figure 5).
2.5.3.Sansho
Oketsu(triple heater), one of the 12 main acupuncture channels in the body, responsible formovingenergy between
the upper
body
and thelower body.
Pathologicalconditionof Oketsu(bloodstagnation)is expressed in a unique way to Kampo
medicine and it is the most important concept [8]. In the modern medicine, it is perhaps morecommonly understood as one of the syndromes of disability of microcirculation mechanism (Figure 6).
However, Kampo medicine does not simply diagnose the symptoms but it considers important to
identify the pathological condition which caused the symptom and the following are considered the6Ketsu-Netsu
Kitai (Ki-Jitsu)
Kitai (Ki-Jitsu)
Stagnation of Ki• Mental stress
Ki-KyoRise of Ki• Tension ofautonomic
nervesMedicines
2019,
6, 34
• Abnormal
accentuation•••

Anxiety
Headache,
Facial flush
Anger

Bleeding, Inflammation, Rush

OketsuStagnation of blood

Fall of Ki•••

invation of wet/heat Ja

Pain, Swelling, Dark tongue7colorof 31

Loss ofappetite
Exhaustion
Chill, Swelling

Ketsu-Kyo

Insufficient
production of blood

Insomnia, Sweat fromthe head, Pallor
pathogenic
Sho
ofFOR
Oketsuas the changes in the blood vessels due to inflammation,
accentuationofMedicines 2019,
6, x
PEERsuch
REVIEW
7 of 32
blood coagulation factors, blood congestion, polycythaemia, menstruation, pregnancy or child-delivery.

Figure 5. The concepts of Ki and Ketsu.

2.5.3. Oketsu

Ketsu

Ki

Ketsu-Netsu

invation of wet/heat Ja

Pathological Kitai
conditionof Oketsu (blood stagnation) is expressed in a unique way to Kampo(Ki-Jitsu)
Bleeding, Inflammation, Rush
medicineand
it is the mostKitaiimportant(Ki-Jitsu) concept [8]. In the modern medicine, it is perhaps more
Stagnationof Ki• Mental stress
Stagnationmechanismof bloodcommonly
understood
asofonesyndromes of disability ofOketsu
microcirculation(FigureRise
Ki of the Ki-Kyo• Tension of• Anxiety
Fall
of
Ki
6). However,Kampo
medicine
does
notsimplydiagnosethesymptoms
butitconsiders
importantPain, Swelling, Dark tongue colorto
autonomic nerves• Headache,• Loss of• Abnormal
Facialflush
identify
the pathological condition which
are considered theappetite caused the symptom and the following
Insufficient
accentuation
Ketsu-Kyo• Anger
production of blood
pathogenic Sho of Oketsu such as ••theExhaustionchanges
in
the
blood
vesselsdue
toinflammation,
accentuation
Chill, Swelling
Insomnia, Sweat from the head, Pallorof blood coagulation factors, blood congestion, polycythaemia, menstruation, pregnancy or childdelivery.
Figure 5. The concepts of Ki and Ketsu.
Figure 5. The concepts of Ki and Ketsu.

2.5.3. Oketsu

Abnormal Ketsu

Normal circulation of blood
Pathological condition of Oketsu (blood stagnation) is expressed in a unique way to Kampo
medicine and it is the most important concept [8]. In the modern medicine, it is perhaps more
Ketsu-kyocommonly understood as oneof the syndromes of disability of microcirculation mechanism (Figure6). However, Kampo medicine does not simply diagnose the symptoms but it considers important toOketsuidentify the pathological condition which caused the symptom and the following are considered thepathogenic Sho of Oketsu such as the changes in the blood vessels due to inflammation, accentuationof blood coagulation factors, blood congestion, polycythaemia, menstruation, pregnancy or childFigure 6. The Symptoms of Oketsu, in blood stagnation.
delivery.
Figure 6. The Symptoms of Oketsu, in blood stagnation.
When the following symptoms are observed, we diagnose them Oketsu; the patient feels mouth
When the following symptoms areAbnormal
observed, we Ketsu
diagnose them Oketsu; the patient feels mouthdryness and would moisten the mouth with water but does not want to drink water; the patient feels
dryness and would moisten themouth withwater but
does not want to drink water; the patient feels
stomach fullness though theNormal
abdominal
distension
is not observed; burning fever is felt locally or
circulationof blood
stomach fullness though the abdominal distension is not observed; burning fever is felt locally oruniversally; purple spots appear on the skin or membrane; purple spots are appearing on the skinuniversally; purple spots appear on the skin or membrane; purple spots are appearing on the skin oror membrane; dark purple spots
appear on the edge of the tongue and lips are pale; stool is black;
Ketsu-kyomembrane; dark purple spots appear on the edge of the tongue and lips are pale; stool is black; easy
easy bleeding. The endogenous factor is in imbalance of autonomic nerve and the exogenous factor is
bleeding. The endogenous factor
is in imbalance of autonomic nerve and the exogenous factor is
Oketsucoldness and bruise.
coldness and bruise.
2.5.4. Sui, Aua
2.5.4. Sui, Aua
Sui is also called Shin-Eki.
the relatively
thininandpure
fluids such as fluid component
Figure Shin
6. TheisSymptomsof Oketsu,
bloodstagnation.
Sui
is
also
calledShin-Eki.
Shin
is
the
relatively
thin
and
pure
fluidssuch
as fluidcomponentofof blood, tissue fluids, sweat and urine, while Eki is relatively thick andstickyfluidsamong theblood,
tissuefluids,sweat
andurine,
whileEki
isrelatively
thick
and
stickyfluidsamong
theintracellular
andfollowing
secretorysymptoms
fluids [8]. are
Eachshows Sho
Sui-Tai (Sui-Jitsu)
andtheSui-Kyo.
means
When theobserved,
weofdiagnosethem Oketsu;
patientSui-tai
feels mouth
intracellularandsecretory
fluids
[8].
Each
shows
Sho
of
Sui-Tai(Sui-Jitsu)
andSui-Kyo.
Sui-taistagnation
of
the
body
fluid
(Figure7).
dryness and would moisten the mouth with water but does not want to drink water; the patientmeans
feels
stagnationof thebody
fluid(Figure7). causes
Unevenly
distributedSuior aquaa localWhen
it is linked
stomachfullnessthoughtheabdominal
distension
is oedema.
not observed;
burning
fever withis feltblood-heat,
locally or
purple spots appear
the skinor membrane;
purpleAs
spots
appearingon the skin or
ituniversally;
becomes Tan-In-diseases
and theonfluid
becomes
sticky phlegm.
the areblood-heat
is understoodasmembrane;darkpurplespots
appear
on
the
edge
of
the
tongue
and
lips
are
pale;
stool
is
black;easy
the inflammatory blood, it can appear when physical infection control is conducted. Ko-Katsu or mouth
bleeding.
endogenous
factorwhen
is in water
imbalanceof autonomic
nerve andexogenous intake
factor isdryness
is aThesymptomappearingis temporarily
exhausted
duetheto insufficientofcoldness
andthirst
bruise.
water.
Fever,and tongue dryness are also systemically observed. It is called Sui-Kyo or aqua
deficiency, which occurs from the temporal water7 exhaustion and shows dehydration. Xerostomia
Sui, Auaof chronical insufficiency of water. Patients would feel mouth dryness and appeal lip
is2.5.4.
a symptom
dryness
cracksbutShin-Eki.
would notwant
to drink
water.
It andis mainly
causedsuch
by theendogenous
factors
Suiandis alsocalledShinis therelatively
thinpure fluids
as fluidcomponentofandsystemicallyshowing
Yin-Kyoor Yin-deficiency
andis diagnosed
Oketsu-Sho.
It alsoshowsthetheblood,
tissue fluids,
sweat
and urine,
while Eki isrelatively
thickasandsticky fluids
amongdeterioration
kidneyfunctionsis theshows
symptomof Sui-Tai
deteriorationof Ki.
intracellular of
andsecretory
fluids that[8]. Each
Sho of(Sui-Jitsu)
and Sui-Kyo. Sui-tai means
stagnation of the body fluid (Figure 7).

7

Yin deficiency,
renal failureJin-Kyo)polyuria,
diarrhea)

Medicines 2019, 6, 34
Medicines 2019, 6, x FOR PEER REVIEW

Suo-Kyo(temporary
insufficiency)

Insufficientcy(Chronicalinsufficiency)

Stagnation(Sui-Tai)

Wet(Sui-Tai)

8 of 31
8 of 32

Sui (Shin-Eki)

Retention
Dry
Mouth(mucus,phlegm)(hyperhidrosis
oliguria,
polyuria,
constipation
diarrhea)

Xerostomia
Localization(internal
heatYin(swelling,
deficiency,
edema)
renal
failureJin-Kyo)

Suo-KyoFigure7. The conceptsInsufficientcy
of Sui (Shin-Eki).
(temporary(Chronicalinsufficiency)
insufficiency)

Unevenly distributed Sui or aqua causes a local oedema. When it is linked with blood-heat, it
becomes Tan-In-diseases and the fluid becomes stickyWet
phlegm. As the blood-heat is understood as
Stagnation
the inflammatory blood, it can appear
when
physical
infection control is conducted. Ko-Katsu or(Sui-Tai)(Sui-Tai)
mouth dryness is a symptom appearing when water is temporarily exhausted due to insufficient
intake of water. Fever, thirst andtongue dryness are also systemically observed. It is called Sui-Kyo
Retention(mucus,or aqua deficiency, which occursphlegm)
from the temporal waterLocalization
exhaustion and shows dehydration.
(swelling,oliguria,
Xerostomia is a symptom of chronical insufficiency of water. Patientswould feel mouth dryness andedema)
constipation
appeal lip dryness and cracks but would not want to drink water. It is mainly caused by theendogenous factors and systemically showing Yin-Kyo or Yin-deficiency and is diagnosed as OketsuFigure
7. The conceptsof thatSui (Shin-Eki).
Sho. It also shows the deteriorationof kidneyfunctionsis the symptom of deterioration of Ki.
2.5.5.Unevenly
Views on PeriodontalSui
Diseaseandcauses
Toothacheor aquaa local oedema. When it is linked with blood-heat, it
2.5.5. Views on distributed
Periodontal Disease
and Toothache
becomesTan-In-diseases
and
the
fluid
becomes
stickycirculationphlegm. As
the blood-heat
understoodasIn the progress of periodontitis, the gingival blood
inducesthe loss ofiscapillary
vessels
In the progressof periodontitis,thegingival
blood
circulationinducesthe loss ofcapillarytheinflammatory
blood,
itcanappearwhen
physical
infection
controlisconducted.
Ko-Katsuorand become anaemia. This status is so-called Ketsu-Kyo (blood deficiency) in Kampo. Ketsu-Kyo affects
vessels
and becomeThisstatus is
so-called
Ketsu-Kyo(bloodexhausted
deficiency)due
in Kampo.
Ketsumouthdryness
is a anaemia.
symptomappearing
when
water
is temporarily
to insufficientthenutritional
disorderof gingiva
and reduces
oral
immunesystem. Consequently,
microcirculatory
Kyoaffects
thenutritional
disorderofgingiva
andreducesoral
immunesystem.
Consequently,
intake of water.
Fever,
andtonguedryness
are also
systemicallyobserved.
It is called Sui-Kyo
dysfunction
inducesthethirst
loss oforal
biologicalactivity,
increasing
the numbersof compromised
hosts.
microcirculatory
dysfunction
inducesthethelosstemporalof oral biologicalactivity, increasing
thedehydration.
numbers oforaqua
deficiency,
which
occursfromwater
exhaustion
and
shows
This status is called Oketsu (blood stasis) in Kampo. Oketsu was observed in 70% to 80% of therandomly
compromised
This status
is called
Oketsu (blood stasis) in Kampo. Oketsu was observed in 70%
Xerostomia
is ahosts.
symptomof abovechronical
chosenperiodontal
patients
age insufficiency
40 (Figure 8).of water. Patients would feel mouth dryness and
to
80%
of
the
randomly
chosenperiodontal
above
age 40water.
(FigureIt8).
appeal lip dryness and cracks but would patients
not want
to drink
is mainly caused by theendogenous factors and systemically showing Yin-Kyo or Yin-deficiency and is diagnosed as OketsuSho. It also shows the deterioration of kidney functions that is the symptom of deterioration of Ki.

2.5.5. Views on Periodontal Disease and Toothache
In the progress of periodontitis, the gingival blood circulation induces the loss of capillary
vessels and become anaemia. This status is so-called Ketsu-Kyo (blood deficiency) in Kampo. KetsuKyo affects the nutritional disorder of gingiva and reduces oral immune system. Consequently,
microcirculatory dysfunction induces the loss of oral biological activity, increasing the numbers ofcompromised hosts. This status is called Oketsu (blood stasis) in Kampo. Oketsu was observed in 70%
to 80% of the randomly chosen periodontal patients above age 40 (Figure 8).

Figure 8. The proportions of poor blood circulation (Oketu) in the ages of the periodontal patients.
Cited from [9] with permission.
8

Although there are Kampo medicines which contain analgesic effect but they are not comparable to
the western medicines. In oriental medicine, pain is understood as the change of symptom to maintainthe homeostasis of organism. The flows of ki, ketsu, sui (vital energy, blood circulation function andaqua) deteriorate and it causes the unwell condition from stagnation. Therefore, Kampo medicine
emphasizes to recuperate the body condition to normal. The background of pain would include not
only infections and injuries but also the environmental and mental stress, where psychological factor
would cause anxiety and anger and can go back to the emotions in the past. Chinese proverb says that
good circulation brings no pain (= stagnation), meaning that if it flows, no pain.
8

maintain the homeostasis of organism. The flows of ki, ketsu, sui (vital energy, blood circulation
function and aqua) deteriorate and it causes the unwell condition from stagnation. Therefore, Kampo
medicine emphasizes to recuperate the body condition to normal. The background of pain would
include not only infections and injuries but also the environmental and mental stress, where
Medicines
2019, 6, 34factor would cause anxiety and anger and can go back to the emotions in the9 past.
of 31
psychological
Chinese proverb says that good circulation brings no pain (= stagnation), meaning that if it flows, nopain.
Occlusal trauma, occlusal destruction and traumatic occlusion are intraoral fragility and could
Occlusal trauma, occlusal destruction and traumatic occlusion are intraoral fragility and could
cause systemic symptoms (Figure 9).
cause systemic symptoms (Figure 9).
Toothache
Periodontal
diseaseGingiviti
Periodontitis

Occlusal trauma

Xerostomia
ThirstMouth dryOcclusal destruction
Malocclusion
Stomatitis
Intractable stomatitis
Recurrent aphtha

Traumatic occlusion
Inadaptation of denture

Oral malaisis
Unidentifiedcomplaint

Vegetative syndrome

Climacteric disturbance

Oral Psychosomatic
diseases
TMJ arthrosis

Jaw displacement
Bruxism
Clenching

Figure 9. The correlations between occlusal-related troubles and oral diseases. (Watanabe S,
Figure 9. The correlations between occlusal-related troubles and oral diseases. (Watanabe S,
unpublished data)
unpublished data)

3. Tongue Diagnosis
3. Tongue Diagnosis
Clinical tongue conditions reflect the diseases of internal organs. The important points of clinical
Clinical are
tongueconditions
reflectdiseasesof internal
importantof(shapeclinicalobservations
colours,
coatings
andthevolumeof thetongue organs.
[8]. TheThetensionof thepoints
tongueobservations
arecolours,
coatings
andvolumeofthetongue[8].
Thetensionofthe
tongue(shapeandand lustre) change to the depending on the fall and rise of Ki-Ketsu and the location and the depth
lustre)change tointhe
dependingand riseof Ki-Ketsu
andthelocationcondition,and the depthof theofthe pathogen
body.
Coatingon
ofthe
thefall
tonguemostlyindicatesthestomachespecially,
pathogen in body.coldness-heat
Coating of ofthemostly andindicates
theconditions
stomach arecondition,
especially,
dampness-dryness,thetongue
body. Normal
abnormalshown in
Tables 4
dampness-dryness,coldness-heat of the body. Normal and abnormal conditions are shown in Tables
and
5.
4 and 5.
Table 4. The correlations between the colours and shapes in tongue.

Table 4. The correlations between the colours and shapes in tongue.
Colour Tone•
Pale tongue: Paler colour than normal tongue; showing deficiency of Ki and Ketsu.
Colour Tone
Pale tongue: Paler colour than normal tongue; showing deficiency of Ki and Ketsu.
•
Reddish tongue: Netsu-Sho (heat) symptom; redder than normal tongue colour and often
Reddish tongue: Netsu-Sho (heat) symptom; redder than normal tongue colour
shows dryness of mouth and lips.
and often shows dryness of mouth and lips.
•
Purplish tongue: Systemic Oketsu due to stagnation of Ki and Ketsu; especially it is very
likely when the dorsal lingual veins are over swelling.
9•
If the tongue is wet, it is Kan-Sho (cold)
symptom and the body is chilled. If dry, it shows
Netsu-Sho.
Shape

•
•
•

Swelled tongue: Tongue is swollen and shows tooth marks on peripheral; showing
Ki-Kyo and Sui-Tai (deficiency of Ki and fluid stagnation).
Thin tongue: Tongue is dry and in deep purple colour; shows Sui-Kyo, Yin-Yo-Kyo(deficiency of Sui, Kyo of both Yin and Yang.
Trembling tongue: When moving the tongue, it trembles; it vibrates; showing Netsu-Sho
and Ki-Kyo (Ki deficiency).

Medicines 2019, 6, x FOR PEER REVIEW

10 of 32



Purplish tongue: Systemic Oketsu due to stagnation of Ki and Ketsu; especially it isvery likely when the dorsal lingual veins are over swelling.

If the tongue is wet, it is Kan-Sho (cold) symptom and the body is chilled. If dry,
Medicines 2019, 6, 34
10 of 31
it shows Netsu-Sho.
ShapeSwelled tongue: Tongue is swollen and shows tooth marks on peripheral;showing Ki-Kyo and Sui-Tai (deficiency of Ki and fluid stagnation).
 TableThin
tongue:Tongue isbetween
dry andthe
in deep
purplecolour; shows
Sui-Kyo, Yin-Yo-Kyo
5. Thecorrelations
colours
and volumes
in tongue.
(deficiency of Sui, Kyo of both Yin and Yang.
Colour ToneTrembling tongue: When moving the tongue, it trembles; it vibrates; showing(Ki deficiency).
Netsu-ShoandKi-KyoPale•White
tonguecoating:
white colour is considered normal but shows the changes inbody condition, depending on the wetness
Shows stomach/intestinefunction in
deficiency;• TableYellow
tonguecoating: between
5. Thecorrelations
the colours and volumes
tongue. fever; lack of water
due to fever
White black
tonguecoating:
Pale Yellow
white colour
considered
normalbut showstheColour Tone •  Greyish
tonguecoating:
tongue iscoating
symptomprogressedand diseasechangesinbodycondition,
dependingonthewetness
worsened; related to infectious disease, high fever, dehydrationYellow tongue coating: Shows stomach/intestine function deficiency; fever; lackof water due to fever
Volume•  Thintongue coating: Normal
Greyish black tongue coating: Yellow tongue coating symptom progressed and•Nodisease
tongueworsened;coating: Abnormal;
chronical disease;dehydration
related to infectious
disease, protracted
high fever,illness•
Thicktonguecoating:Abnormal;exacerbationof
disease,growth of bacteria due toVolume
Thin tongue coating: Normal
metabolism
of tongue coating
 defective
No tongue
coating: Abnormal;
chronical disease; protracted illnessThick tongue coating: Abnormal; exacerbation of disease, growth of bacteria due
to defective metabolism of tongue coating

Kampo promotes the metabolism involved in the physical growth, development and physiologicalKampo
promotes
theKetsu
metabolism
in theruns
physicaldevelopment
andactivity.
Kampo
moderateand Sui, soinvolvedthat the bloodin bloodgrowth,
vessels andprevents bloodphysiologicalactivity.
Kampo
moderate
Ketsu
and
Sui,
so
that
the
blood
runs
in
blood
vesselsandfrom leaking outside. Kampo produces Ki that works to produce Ketsu and Sui, thus converting fluids
prevents
bloodfromleaking
outside.
Kampo
produces
Ki
that
works
to
produce
Ketsu
and
Sui,
thus
into sweat and urine.
converting
fluidsintointernalsweat andurine.
Changesin theorgans(liver, heart, lienogastric, lung and kidney) are reflected on the
Changesintheinternalorgans(liver,heart,
lienogastric,
are diagnosis
reflected onthetongue (Figure 10). It tells the Sho of disease,namely,Kyo, Jitsu,lung
Hyo andand kidney)
Ri. Tongue
is very
tongue(Figure10).theIt tells
the Shodiagnostic
of disease,techniques.
namely, Kyo,
Jitsu, Hyodiagnosis
and Ri. Tongue
is veryimportantamongempirical
Systematictheory diagnosis
has been formed
importantamong
the empirical
techniques.
diagnosis
been formed
based on theempirical
evidencesdiagnostic
over several
thousandsSystematicof years. The
rise andtheory
fall ofhas
Ki, Ketsu
and Sui
based
empirical
evidences
over several
thousandsof years.
Theseenriseonandof Ki, Ketsu
andreflecton
thetheadvanceor retreatof illness.
Severityof the diseasecan bethefall
tongue.
Therefore,
Sui
reflect theadvanceretreatareofshown
illness.inSeverityof thediseasebeearly
seen stage.
on thetongue.
pathologicalchangesof aordisease
the changeof thetonguecan
at itsIt iscalledTherefore,
pathologicalchangesofadisease
are
shown
in
the
changeofthetongueatits
earlystage.
Mibyo or pre-symptomatic in Kampo medicine. It is important diagnostic criteria and is recognized asItis called
Mibyo
or pre-symptomatic
medicine.
It is importanta clueto findthe causeof the illness atin
anKampoearly stage
in the primarycare. diagnostic criteria and isrecognized as a clue to find the cause of the illness at an early stage in the primary care.

Figure 10. Tongue diagnosis of patients. (A) Clinical observation of Healthy tongue. Properly moistened:
Figure 10. Tongue diagnosis of patients. (A) Clinical observation of Healthy tongue. Properly moistened:
tongue coating white colour, thinly spread across the tongue. Light pink colour, Shape: fitting within
tongue coating white colour, thinly spread across the tongue. Light pink colour, Shape: fitting within
the mouth. Back of tongue: sublingual vein is not over swelling. (B) Abnormal tongue (Sui). Tongue
the mouth. Back of tongue: sublingual vein is not over swelling. (B) Abnormal tongue (Sui). Tongue
peripheral impression, swelling tongue (oedema). Left: Sui-Tai or water stagnationis oedema, tongue
peripheral impression, swelling tongue (oedema). Left: Sui-Tai or water stagnationis oedema, tongue
peripheral impression. Pressure impression by the teeth on the edge of the tongue where water isperipheral impression. Pressure impression by the teeth on the edge of the tongue where water issustained. Right: Sui-Kyo (insufficient water): oedema, water is not flowing well; big and swollen.
sustained. Right: Sui-Kyo (insufficient water): oedema, water is not flowing well; big and swollen. (C)(C) Abnormal Ki (vital energy). Map-like tongue, insufficient Ki, slow circulation of Ki. Warming:
Abnormal Ki (vital energy). Map-like tongue, insufficient Ki, slow circulation of Ki. Warming: Workings
Workings of warm-up and circulation; central of Ki. Defence: Workings to promote natural healing;of warm-up and circulation; central of Ki. Defence: Workings to promote natural healing; protects
protects skin and membrane and defends the body from the cause of disease. (D) Abnormal tongue(Ketsu-Kyo and Kyo-Netsu). Ketsu (blood circulation)10indicate the body of the tongue and sublingual veinthat are in reddish purple, colour change of the tongue coating (Ketsu-Kyo, Kyo-Netsu). Left: Ketsu-Kyo:
Tongue is thin and lean; Nutrition, water and blood circulation were insufficient. Right: Kyo-Netsu:
Sticky blood; stagnated; Nutrition. water and blood body fluids were insufficient. Body is dry, sinceMedicines 2019, 6, x FOR PEER REVIEW

11 of 32

skin and membrane and defends the body from the cause of disease. (D) Abnormal tongue (Ketsu-Kyo
and Kyo-Netsu). Ketsu (blood circulation) indicate the body of the tongue and sublingual vein that are
Medicinesin2019,6, 34 purple, colour change of the tongue coating (Ketsu-Kyo, Kyo-Netsu). Left: Ketsu-Kyo: Tongue
11 of 31
reddishis thin and lean; Nutrition, water and blood circulation were insufficient. Right: Kyo-Netsu: Sticky
blood; stagnated; Nutrition. water and blood body fluids were insufficient. Body is dry, since the heatremains to circulate internally. (E) Abnormal tongue (Okesu). Blood heat condition in tongue. Ischemia
theheat remains
to circulateinternally.of(E)sublingual
Abnormal veins.
tongueSystemically(Okesu). Bloodheat condition
in tongue.
(tongue:cyanosis)and over-swelling
impairedflow of blood.
These
Ischemia(tongue:cyanosis)andover-swellingofsublingualveins.
Systemically
impairedflow ofphotos were taken, after obtaining the informed consent from the patients, under the conditionthatblood. These photos were taken, after obtaining the informed consent from the patients, under thethe patients are not identified. (Watanabe S, unpublished data)
condition that the patients are not identified. (Watanabe S, unpublished data)

TherapeuticEffect
EffectJuzentaihoto
4.4.Therapeutic
ofof
Juzentaihoto
Periodontitis
themostcommonchronic
inflammatory
diseasehumansandcharacterized
Periodontitis
is is
the
most
commonchronic
inflammatory
diseaseininhumansandis ischaracterized
alveolar
bone
loss
and
connective
tissuedestruction.Periodontitis
Periodontitisisisexacerbatedexacerbatedbybyrisk
risk
factorsbyby
alveolar
bone
loss
and
connective
tissuedestruction.
factors
includingage,
gender,smoking,systematic
diseasesandpsychologicalstress[10].
The
stressresponse
including age, gender, smoking, systematic diseases and psychological stress [10]. The stress response
mediatesinteraction
betweenunfavourable
psychologicaland inflammatory
mediates
the theinteraction
betweenunfavourable
psychologicalconditions conditions
and inflammatory
periodontal
periodontal
Thereprevalence
is a higherof prevalenceof chronicperiodontal
destructivedisease
periodontal
disease indisease.
Theredisease.
is a higher
chronic destructive
in individuals
individuals
withpsychologicalstress,
which
may
be
associated
with
acute
necrotizing
periodontal
with psychological stress, which may be associated with acute necrotizing periodontal disease [11].
disease [11]. Psychologicalstress downregulates
the cellularimmuneresponse,maylink tothePsychologicalstress downregulates
the cellular immune
response,
which
may whichlink thestressstresstoperiodontal
disease[12].
Herbalmedicines,such
asJuzentaihoto(JTT),
have
good
therapeutic
periodontal disease [12]. Herbal medicines, such as Juzentaihoto (JTT), have good therapeutic effects
for stress-related
systematicand minimal
sideJTTeffects.
JTT consistsof 10Ginseng
herbs: Ginseng
foreffects
stress-related
systematic
diseases diseases
and minimalside effects.
consistsof 10 herbs:
radix,
radix, Astragali
radix, Angelicae
radix, Rehmanniae
radix, Atractylodis
lanceae rhizoma,
Cinnamomi
cortex,Astragaliradix, Angelicae
radix, Rehmanniae
radix, Atractylodis
lanceae rhizoma,
Cinnamomi
cortex, Poria,
Poria,
Paeoniae
radix,
Ligustici
rhizomeand
Glycyrrhizae
radix.
JTT
istraditionallyusedforanaemia,
Paeoniae radix, Ligustici rhizome and Glycyrrhizae radix. JTT is traditionally used for anaemia, rheumatoid
rheumatoid
arthritis,
chronic
fatigue
syndrome
and inflammatorybowel
is widelyused toarthritis,
chronic
fatigue
syndromeandinflammatory
bowel disease.
It isdisease.
widelyItused
to prevent
prevent
cancer metastasis
andin
infectionin immunocompromised
patients[13].examined
We had examinedthecancermetastasis
and infection
immunocompromised
patients [13].
We hadthe efficacy
efficacyofJTT
toprevent
periodontitis.
of JTT to prevent periodontitis.
4.1.
4.1.Biological
BiologicalActivity
Activity(in(inVitro)
Vitro)
4.1.1.
ofof
JTT
onon
P. P.
gingivalis
4.1.1.Bactericidal
BactericidalEffect
EffectJTT
gingivalisWe
evaluatedthebactericidal
gingivalis.
gingivalis
with0.10.1
toto
WeevaluatedthebactericidaleffecteffectofofJTT
JTTononP.P.
gingivalis.Treatment
TreatmentofofP.P.
gingivalis
with
1010
mg/mL
mg/mLJTT
JTTreduced
reducedthe
thenumbernumberofofviableviablecells
cellsininaadose-dependentdose-dependentmanner.
manner.InInparticular,
particular,bacterial
bacterial
reduction
by
10
mg/mL
JTT
was
greater
than
that
of
0
(control),
0.1
and
1
mg/mL
JTX
treatment
reduction by 10 mg/mL JTT was greater than that of 0 (control), 0.1 and 1 mg/mL JTX treatment at 60
atminutes
60 minutes(Figure11),suggestingsuggestingthat
thatJTT
JTT may
may suppress[14][14](Figure11),
suppress virulence
virulence factors
factorsfrom
fromperiodontal
periodontal
bacteria
andprevent
thetheprogressionof periodontitis.
SomeSome
herbsherbs
from JTT
have
bacteria
andprevent
progressionof periodontitis.
fromand
JTTtheirandingredients
their ingredients
antimicrobial
effects[15].
Compounds
from
Glycyrrhizae
radix
inhibitthegrowthofP.
gingivalis[16].
have antimicrobial effects [15]. Compounds from Glycyrrhizae radix inhibit the growth of P. gingivalis
Glycyrrhizae
radix mayhave
importantrole in theeffect ofeffect
JTT onP. gingivalis.
[16]. Glycyrrhizae
radixmayanhavean importantrolebactericidal
in the bactericidalof JTT
on P. gingivalis.

Figure 11. Antibacterial effect of JTT on P. gingivalis. Bacterial cells were treated with 10 mg/mL (N),Figure 11.
effectof JTT
on0P.mg/mL
gingivalis.
Bacterial
cells
treatedwith 10
1 mg/mL(4Antibacterial) or 0.1 mg/mL
of JTT(•) orof JTT(# ) forthewereindicatedperiod.
At mg/mL
the end (▲),
of1 incubation
mg/mL (△)period,
or 0.1 mg/mL
ofserial
JTT (●)or 0 mg/mL
of JTT (〇)infor
the indicated period.
At(PBS;the endthea 10-folddilution
was performed
phosphate-bufferedsalinepHoftheandincubation
period,a 10-foldserialplate
dilutionwas
performed inwith
phosphate-bufferedsaline(PBS;KpH
7.4)
spread ontoa BHI
blood agar
broth
supplemented
hemin (5 µg/mL),vitamin1(0.2 µg/mL) and yeast extract (5 mg/mL). The number of CFU (colony forming unit) was determined
11
after 7 days of incubation under anaerobic conditions (CO2 : 10%, H2 : 10%, N2 : 80%) at 37◦ C. Cited
from [14] with permission.

Medicines 2019, 6, x FOR PEER REVIEW

12 of 327.4) and spread onto a BHI blood agar plate broth supplemented with hemin (5 µg/mL), vitamin K1(0.2 µg/mL) and yeast extract (5 mg/mL). The number of CFU (colony forming unit) was determined
Medicines
6, 34of incubation under anaerobic conditions (CO2: 10%, H2: 10%, N2: 80%) at 37°C. Cited
12 of 31
after2019,
7 daysfrom [14] with permission.

4.1.2. Anti-osteoclastogenesis Effect of JTT
4.1.2. Anti-osteoclastogenesis Effect of JTT
We investigated whether JTT inhibits the osteoclast differentiation using a mouse co-culture
We investigated whether JTT inhibits the osteoclast differentiation using a mouse co-culture
system, according to the guideline of the intramural Committee of Ethics on Animal Experiments.
system, according to the guidelineof the intramural Committee of Ethics on Animal Experiments.
Bone marrow cells (1.5×105 cells/well) obtained from the tibiae of 5–8-week-old BALB/c mice andBone marrow cells (1.5×105 cells/well) obtained from 4the tibiae of 5–8-week-old BALB/c mice and prepre-adipose cell line MC3T3-G2/PA6 cells (1.5×10 cells/well) were co-cultured for 7 days in the
adipose cell line MC3T3-G2/PA6 cells (1.5×104 cells/well) were co-cultured for 7 days in the presence
presence of 10 nM 1a,25-(OH)2 D3 (calcitriol) and 10 nM dexamethasone in α modification of Minimumof 10 nM 1a,25-(OH)2D3 (calcitriol)and 10 nM dexamethasone in α modification of Minimum
Essential Medium (α-MEM) supplemented with 20% FBS (foetal bovine serum) in 48-well plates under
Essential Medium (α-MEM) supplemented with 20% FBS (foetal bovine serum) in 48-well plates
a 5% CO2 atmosphere. Osteoclast was defined as tartrate-resistant acid phosphatase (TRAP)-positive
under a 5%
CO2 atmosphere. Osteoclast was defined as tartrate-resistant acid phosphatase (TRAP)multinucleated cells containing three or more nuclei. Treatment with JTT at concentrations of 10,
positive multinucleated cells containing three or more nuclei. Treatment with JTT at concentrations
1 and 0.1 µg/mL significantly inhibited osteoclast formation (Figure 12A) [14]. A low concentrationof 10, 1 and 0.1 µg/mL significantly inhibited osteoclast formation (Figure 12A) [14]. A low(0.1 µg/mL) of JTX significantly inhibited the osteoclast formation compared to control (Figure 12B).
concentration (0.1 µg/mL) of JTX significantly inhibited the osteoclast formation compared to control
Angelicae gigantis radix, one of the components in JTT, significantly decreased osteoclast formation [17].
(Figure 12B). Angelicae gigantis radix, one of the components in JTT, significantly decreased osteoclast
Therefore, JTT can be a therapeutic drug that prevents periodontitis.
formation [17]. Therefore, JTT can be a therapeutic drug that prevents periodontitis.

Figure 12. JTT inhibits osteoclast differentiation of BALB/c mouse bone marrow cells co-cultured with
Figure12. JTT inhibits
differentiationof BALB/cmousecells
boneweremarrowcellsforco-cultured
MC3T3-G2/PA6
cells.osteoclast
After incubationfor 7 days,
co-cultured
stained
TRAP (A)with
and
MC3T3-G2/PA6
cells.
After
incubation
for
7
days,
co-cultured
cells
were
stainedfor
TRAP(A) anddetermination of TRAP-positive multinucleated cells containing three or more nuclei (B). Results
aredeterminationofTRAP-positive
multinucleatedcells
containing
three
or
more
nuclei(B).
Resultsareexpressed as the mean ±SD of triplicate cultures. **p < 0.01, *p < 0.05. Cited from [14] with permission.
expressed as the mean ±SD of triplicate cultures. **p < 0.01, *p < 0.05. Cited from [14] with permission.

4.2. Clinical of JTT
4.2. Clinical of JTT
Kampo medicine and adjustment of denture were effective for a patient (80 years old, female,
Kampo
medicineandof denture
were effective
a patientof(80years
old,stenosis,
female,cervicalcanceroperated
25adjustment
years ago withgood prognosis),
withforsymptomspinalcanalcervicalcanceroperated
25
years
ago
with
good
prognosis),
withsymptomofspinalcanalstenosis,
cervical vertebra stenosis, dizziness, unsteadiness and oppression on the chest. She was diagnosed
cervicalvertebra ofstenosis,dizziness,and oppression
chest. Sheand
wasxerostomia.
diagnosed
as inadaptation
the denture,oral unsteadinessmalaise (tongue),
dysfunctiononofthe
masticatoryasinadaptationof thedenture, wasoral improved
malaise (tongue),
dysfunctionof masticatory
and xerostomia.
HerHer
oketsu (blood
stagnation)
by taking
JTT mornings
and evenings– 2 doses before
oketsustagnation)
was improvedby taking
JTT mornings
and evenings
2 doses
beforemeals.
meals.(blood
Swellingand oedemaof the tongue
was improvedby takingGoreisan–(GRS)
beforegoing
toSwelling
and consultation
oedema of the
tongueinwas
improved by oftakingGoreisan(GRS)
beforegoing
to bed.
bed. Medical
resulted
the improvement
mentalcondition.
Two
Kampo
medicines,
Medicalconsultation
resulted
theretention
improvementof mental
condition.
Two Kampoofmedicines,
GRS (that
improves Sui-Tai
or in
fluid
symptomcausedby poor metabolism
water) andGRS
JTT
(that
fluid retention
symptomcaused by function)
poor metabolism
of water)and JTT[that[that improves
enhances Sui-Tai
ki (vitalorenergy)
and ketsu(blood circulationand improve
fatigue,anaemia,enhanceski (vitaland hands
ketsu (blood
circulation
function)theandimprove fatigue,anaemia, low
low appetite,nightenergy)
sweat, coldand feetwhich accompany
decondition]
were administeredinappetite,night
sweat,
cold
hands
and
feet
which
accompany
thedecondition]
were
administeredinthis case. In the initial diagnosis, prescription of GRS showed no progress in 2 weeks, then additionally
this
case.
In the initialdiagnosis,
GRS
no whenprogressin 2 withweeks,
then
JTT wasadministered.
After
1 monthprescription
later (Figure of
13A),
theshowed
filling pain
chewing
dentureadditionally
was administered.
After
1 monthlatersleeping.
(Figure 13A),
the filling
pain
when
chewing
stopped jawsJTT
glidingand oppression
on throat
while
Two months
later,
she
could
bite off
withdenturegliding andoppression
on throat
while
sleeping.
monthssheand eatfood.stopped
She hadjaws
no sensationof tongue
torsion,stoppedwakingup atTwonight
due tolater,
the neck
could
bite off and eat offood.
had nosensationof tongue
torsion,up at13B),
nightupondue
pain. Administration
GRSShestoppeddue
to frequenturination.
Fourstopped
monthswaking
later (Figure
toneck pain.
ofneckGRS strain
stoppeddue
to frequenturination.
Four months
later (Figure
thethemounting
of Administration
dentures, she felt
andtorsionof denture
and tongue.
The administration
13B),
upon
mountingof dentures,she feltneck 13C),
strainshe
andbecame
torsionableof denture
Theof GRS
wastherestarted.
Eightmonths later(Figureto chewand
anytongue.
food, withno sensation of tongue swells. She did not wakeup
atnight.
Twelvemonthslater(Figure13D),
12
the administration of GRS was stopped but that of JTT was continued (Figure 13).

Medicines 2019, 6, x FOR PEER REVIEW

13 of 32

administration of GRS was restarted. Eight months later (Figure 13C), she became able to chew any
Medicines 2019, 6, 34
13 of 31
food,with no sensation of tongue swells. She did not wake up at night. Twelve months later (Figure13D), the administration of GRS was stopped but that of JTT was continued (Figure 13).

Figure 13.
13. Changes
Changes ofof thethe tongue
tongue surfaces
surfaces at
at 11 (A),(A), 44 (B),(B), 88 (C)(C) oror 12
12 (D)
JTT
Figure(D) months
months after
after GRS
GRS +
+ JTT
treatment. (Presented(Presented inin Kanagawa
Kanagawa Dental
Dental College
College Society
Society 53rd
53rd General
General Assembly:
Assembly: A
A casecase in
in whichwhich
treatment.
Kampo andand denture
denture adjustment
was successful
Photos were
were
Kampo
adjustment was
successful forfor patientspatients complaining
complaining ofof denture).
denture). Photos
taken,
after
obtainingtheinformed
consentfromthepatient.
(WatanabeS,
unpublisheddata)taken, after obtaining the informed consent from the patient. (Watanabe S, unpublished data)

When making dental prosthesis, it is necessary to pay attention to the intraoral environment. In the
When making dental prosthesis, it is necessary to pay attention to the intraoral environment. In
case above, we observed the lower jaw denture floated due to tongue oedema and swelling and that thethe case above, we observed the lower jaw denture floated due to tongue oedema and swelling anddenture instability caused the occlusal pain and dysfunction of masticatory. We therefore prescribedthat the denture instability caused the occlusal pain and dysfunction of masticatory. We therefore
Kampo medicines that would improve these symptoms. In this clinical case, we considered that theprescribed Kampo medicines that would improve these symptoms. In this clinical case, we
improvement
sui-tai(fluid stagnation)
be the targetof Hyo-Chi,local ofandsymptomaticconsidered
thatofthe
improvementof sui-taishould(fluid stagnation)
shouldbe the atarget
Hyo-Chi,a localtreatment,
to improve
the tongue
oedema,so GRSoedema,
was administered.
we could
not getandsymptomatic
treatment,
to improve
the tongue
so GRS was However,administered.
However,
wethe expected
so JTT
was also
administeredin the morning
andbefore andgoing
to bed
andto
it
could
not get results,
the expected
results,so JTT
was also administeredin themorning
beforegoing
presented
the
trend
of
improvements
from
the
next
day.
JTT
is
a
Kampo
medicineforhon-chi,thatis,bed and it presented the trend of improvements from the next day. JTT is a Kampo medicine for honthe thatsystemic
the fundamental
cause of thedisease.
is often It
observedin the dentistrychi,is, thetreatment
systemic oftreatmentof the fundamental
cause
of theItdisease.
is often observedin theandintraoral
medicinethat
patient’s
conditions
changeuntil
thesymptom
finally
surfacesdue todentistry and intraoral medicine that patient’s conditions change until the symptom finally surfaces
the chronicaldeficiencies.
Especially,
the entire
psychologicallyand mentallyaffectedwhen
due
to the chronicaldeficiencies.
Especially,
the body
entireisbody
is psychologicallyand mentallyaffected
malocclusion
exists.
Underthesituationthatmalocclusion
lasts
long,
it
is
known
that
glucocorticoid
when malocclusion exists. Under the situation that malocclusion lasts long, it is known thatappears in blood
chronically
duechronicallyto the chronicalfrom thestressmalocclusion
would induce
glucocorticoid
appearsin blood
due tostressthe chronicalfrom thewhich
malocclusion
which
the malfunctionof negative
feedback.
The Oriental
medicine
explains thatthe symptoms
Ki andwould
induce themalfunctionof negative
feedback.
The Oriental
medicine
explains ofthattheKetsu occur ofandas the andtime they
elapses.
In ourGRS manifested
its effectat early
symptoms
Kitheyandworsen
Ketsu occur
worsenascasethe above,time elapses.
In our caseabove,
GRS
timing by theof JTT. It not only
cured the oedema
but also
manifested
itssimultaneous
effect at earlyadministration
timing by the simultaneousadministrationof JTT.of
It thenottongue
only cured
thementallyofstabilized
thebutpatient.
oedemathe tongue
also mentally stabilized the patient.
JTT isis known
known toto improve
improve thethe pathologicalpathological condition
condition ofofthe
theblood
bloodcirculation
circulationand
andmental
mentalstability.
stability.
JTT
When thethe condition
condition ofof thethe diseasedisease isis foundfound difficult
difficult toto improve,
improve, Kampo
Kampo medicine
medicine ofof hon-chi
hon-chi (treatment(treatment
Whenoffundamental
cause),
incombination
would
relievethesymptoms.
of fundamental cause), in combination would relieve the symptoms.
5. Therapeutic Effects of Jixueteng
5. Therapeutic Effects of Jixueteng5.1. Bactericidal Effect of Jixueteng5.1. Bactericidal Effect of Jixueteng
Jixueteng is prepared from the dried stems of Spatholobus suberectus (S. suberectus) Dunn of the
Jixuetengis preparedfromhasthebeneficial
dried stemsof Spatholobus
suberectus(S. assuberectus)
Dunnof thefamily Leguminosae.
Jixueteng
pharmacologicalproperties
such
increasing
circulation,familyLeguminosae.
Jixuetenghasbeneficial
pharmacologicalproperties
suchasincreasing
analgesia and the number of red and white blood cells [18]. Jixueteng contains various types ofcirculation,
analgesia
and thenumber offlavanones,
red and whiteblood cells
Jixueteng
variousflavonoids suchas flavone,isoflavones,
flavanonols
and[18].
chalcone[19].contains
Flavonoids
are
types
flavonoids
flavone, isoflavones,
flavanones,
flavanonols
and chalcone[19].
naturalofproductsthat suchshow asantibacterial[20] and antioxidant
activities[21]. Productionof reactive
Flavonoids
are(ROS)naturalproductsbythatshow[20]mannerand antioxidant
activities[21].
oxygen species
is decreased
Jixuetengin aantibacterial
dose-dependent[22]. Therefore,
we focused
Productionof reactive
oxygenspeciesis decreased
by Jixueteng inspecies,
a dose-dependent
on the bactericidal
effectof Jixuetengon(ROS)
oral bacteria.
The gram-positive
Streptococcusmanner
mutans[22].
Therefore,
we
focusedonthebactericidal
effectof
Jixuetengonoralbacteria.
The gram-positive
Ingbritt (S. mutans) and the gram-negative species, Aggregatibacter actinomycetemcomitans
ATCC 29523
species,
Streptococcus mutans
Ingbritt (S.
mutans)ATCC
and thegram-negative
Aggregatibacter(A. actinomycetemcomitans),
Fusobacterium
nucleatum
25586(F. nucleatum), species,
Porphyromonas
gingivalis
actinomycetemcomitans
ATCC
29523
(A.
actinomycetemcomitans),
Fusobacterium
nucleatum
ATCC
25586
ATCC 33277 (P. gingivalis) and Veillonella parvula GAI-0580 (V. parvula), were grown in BHI brothand(F.
nucleatum),
Porphyromonas
gingivalis
ATCC
33277
(P.
gingivalis)
andVeillonella
parvulaGAI-0580
suspended in PBS to an optical density of 1.0 at 600 nm. Fifty µL of bacterial suspension was exposed
(V.
grown
BHI brothin PBS toextract.
an opticalof 1.0 of
at PBS
600 nm.
for parvula),
1, 15 and were
60 minin theinpresenceof 0,and0.2,suspended
2.0 or 8% Jixueteng
The density
same volume
was
Fifty
bacterial
exposed forperiod,
1, 15 and60 minserial
in thedilution
presenceof inoculated
0, 0.2, 2.0 oronto
8%
used µL
as aofcontrol.
Atsuspension
the end of was
the incubation
a 10-fold
was◦
BHI sheep blood agar plates and incubated anaerobicallyat 37 C for 7 days. The bactericidal effect13of Jixueteng was determined by counting the number of bacterial cells. Jixueteng extract reduced theMedicines 2019, 6, x FOR PEER REVIEW

14 of 32

Jixueteng extract. The same volume of PBS was used as a control. At the end of the incubation period,
14 of 31
a 10-fold serial dilution was inoculated onto BHI sheep blood agar plates and incubated anaerobicallyat 37°C for 7 days. The bactericidal effect of Jixueteng was determined by counting the number ofbacterial
cells.bacterial
Jixuetengcells,
extract
reducedthe numberof viable
cells,(Figuresuch as14B),
S. mutans(Figurenumberof viable
such
as S. mutans(Figure14A),bacterial
P. gingivalis
V. parvula
14A),
gingivalis(Figure(Figure
14B), V.
parvula(Figure14C)
and F. nucleatum(Figureeffects
14D) (Figure14). In(Figure14C)P.andF. nucleatum
14D)(Figure14). In
particular,
the bactericidalof Jixuetengparticular,
thebactericidal
effectsof
JixuetengagainstF.
nucleatum(Figure14D)
washigherthan
against F. nucleatum (Figure 14D) was higher than those of other oral bacteria. After treatment with those8%
9 to 2.90
6 perof otheroralforbacteria.
treatment
with
8% Jixuetengextract forfrom
60 min,numberof ×
P. 10
gingivalis
Jixueteng
extract
60 min,Afterthe numberof P.
gingivalis
was decreased
4.61the× 10
was(Figure
decreasedfrom× 109 to 2.90 ×periodontal
106 per millilitre(Figureare
14B)
[23].
Gram-negative
periodontal
millilitre
14B)[23].4.61
Gram-negative
pathogenslatecolonizers
of dental
plaquepathogensarelatecolonizersofdentalplaqueandpromoteinflammatory
tissuedestruction
and promote inflammatory tissue destruction in the oral cavity [24]. Thus, Jixueteng extract mayin
acttheoral
cavity[24].
Thus,
Jixueteng
extractmay
act
selectively
onperiodontal
bacteria
and
break
down
selectively on periodontal bacteria and break down dental plaque accumulation.
dental plaque accumulation.
Medicines 2019, 6, 34

100△

○

○

○： PBS (control)△

10△： 0.2％ Jixueteng

S. mutans

1.0△□： 2.0％ Jixueteng□

0.1

Viability (%)

0.01
100△

×： 8.0% Jixueteng

□

A

×

Gram-positive bacteria

×
○
△
□

○
△
□

×

10

△

○
△

○
△

□
×

□

1.0

V. parvula,

P. gingivalis

0.1
0.01
100△

×

B

○

○

C
△

△
○
□

□
×
○
△

□
△

10
1.0

×
△

F. nucleatum

A. actinomycetemcomitans

0.1
0.01

×

0

Gram-negative bacteria

E

D
10

×

20

30

40

50

□
×

60

0

10

20

30

40

50

60

Time (minutes)

FigureFigure
14. Bactericidal
effecteffectof JixuetengagainstGram-positive
andand-negative
bacteria.
Gram-positive
14. Bactericidalof JixuetengagainstGram-positive-negative
bacteria.
Gram-positivebacteria(S.
mutans)(A)
andgram-negative
bacteria(B:P.
gingivalis,C:V.
parvula,D:bacteria (S. mutans) (A) and gram-negative bacteria (B: P. gingivalis, C: V. parvula, D: F.
F. nucleatum,
nucleatum, E:
E: A. actinomycetemcomitans.)
weretreatedbyby
0.2,0.2,
2 and
8%8%
of of
thetheJixueteng
extract
forfor
1, 1,
1515
or or
60 60
min.
A. actinomycetemcomitans.)
weretreated
2 andJixueteng
extractmin.
The suspensions
were weretreatedby PBSa control.
Cell Cell
viability
waswasexpressed
as aaspercentage
relative
The suspensions
treatedbyas
PBS
as a control.
viability
expressed
a percentage
relativeto control.
CitedCited
from from[23] withpermission.
to control.
[23] withpermission.

5.2. Inhibitory Effect of Jixueteng on Osteoblast Differentiation
5.2. Inhibitory Effect of Jixueteng on Osteoblast Differentiation
In periodontitis, several cytokines, such as interleukin (IL)-1, prostaglandin (PG) E2 andIn periodontitis, several cytokines, such as interleukin (IL)-1, prostaglandin (PG) E2 and RANKLRANKL (receptor activator of NF-κB ligand), promote osteoclast differentiation. RANKL, a tumour(receptor activator of NF-κB ligand), promote osteoclast differentiation. RANKL, a tumour necrosis
necrosis factor (TNF)-family member, binds to its receptor RANK, which is on the surface offactor (TNF)-family member, binds to its receptor RANK, which is on the surface of osteoclasts andosteoclasts and preosteoclasts. The interaction between RANK and RANKL signalling is important forpreosteoclasts. The interaction between RANK and RANKL signalling is important forosteoclastogenesis[25]. To examine the influence of Jixueteng on osteoclastogenesis, we used mouse
osteoclastogenesis [25]. To examine the influence of Jixueteng on osteoclastogenesis, we used mouse
co-cultured
cells
in
theinpresenceof 1α,25-(OH)dexamethasone.
Jixueteng
extracts
wereadded
2 D3 2andco-cultured cells
the presenceof 1α,25-(OH)D3 anddexamethasone.
Jixueteng
extracts
were
added
to co-cultured
cells cells
at a final
concentrationof 0.1%,
0.01%,
0.001%
andand0.0001%andandcultivatedforfor7 7
to co-cultured
at a final
concentrationof 0.1%,
0.01%,
0.001%
0.0001%
cultivateddays days
underunder
5% CO
atmosphere.
After
7
days,
cells
were
fixed
and
stainedfor
TRAP.
TRAP-positive
5%2 CO2 atmosphere. After 7 days, cells were fixed and stained for TRAP. TRAP-positive
multinucleatedcells cells
containing
threethreeof morenucleiwere
countedas osteoclasts.
The
treatmentof ofmultinucleatedcontainingof morenucleiwere
countedas osteoclasts.
The
treatment
Jixueteng
extract(atconcentrations
of
0.1%
and
0.01%)
significantly
inhibitedosteoclast
formation
Jixueteng extract (at concentrations of 0.1% and 0.01%) significantly inhibited osteoclast formation (P(P < 0.01).
Additionof of
0.1%
extract
completely
inhibited
TRAP-positive
cells
and
multinucleated< 0.01).
Addition
0.1%
extract
completely
inhibited
TRAP-positive
cells
and
multinucleatedosteoclasts.
In addition,
the inhibitory
effectof Jixuetengon osteoclast
survival
wasdeterminedbyby
osteoclasts.
In addition,
the inhibitory
effectof Jixuetengon osteoclast
survival
wasdeterminedmouse
co-cultured
cells incells
the presenceof RANKL
PGE2 .and
ThePGE
numberof osteoclasts
decreased
mouse
co-cultured
in the presenceof andRANKL
2. Thenumber ofwas
osteoclasts
waswith 0.001
to
0.1
mg/mL
Jixuetenginadose-dependent
manner[26].
Theseresultssuggestthat
Jixueteng
decreased with 0.001 to 0.1 mg/mL Jixueteng in a dose-dependent manner [26]. These results suggest
inhibits
and reduces osteoclast
activityosteoclast
in periodontitis.
thatosteoclastogenesis
Jixueteng inhibits osteoclastogenesis
and reduces
activity in periodontitis.
5.3. Inhibitiory Effect of Alveolar Bone Resorption by Jixuetengon Mice Experimental Periodontitis
14
Flavonoids are effective ingredients for the inhibition of inflammatory bone resorption [27].
We evaluated the inhibitory effect of alveolar bone resorption by Jixueteng using an experimental

Medicines 2019, 6, 34

15 of 31

periodontitis model, under the guideline of the intramural Committee of Ethics on Animal Experiments.
Fifty-four male C57BL/6N 4-week-old mice were used. Mice were given sulfamethoxazole (1 mg/mL)
and trimethoprim (200 mg/mL) in their drinking water for 4 days to reduce original oral flora followedby 3 days of an antibiotic-free period before bacterial infection. The bacteria used was P. gingivalis A,
which was inoculated in BHI broth under anaerobic conditions. Animals were randomly divided into
the following three groups: Group A received only 5% carboxymethylcellulose (CMC) (sham-infectedgroup), group B was infected orally with P. gingivalis and group C was administered Jixueteng extract
in drinking water and was infected orally with P. gingivalis. Each mouse in group B and group
C was infected orally with P. gingivalis, which was suspended in 5% CMC and received 0.1 ml(1.0 × 1010 cells/mL) of bacterial suspension. The bacterial infection was given by oral gavage (threetimes) at 48 h intervals. The mice were sacrificed 2, 4 and 6 weeks after the final bacterial infection to
examine the change in alveolar bone resorption every 2 weeks. The left sides of the horizontal alveolarbone resorption around the maxillary molars were evaluated morphometrically as dry specimens
to measure horizontal alveolar bone loss. The distance between the cemento-enamel junction (CEJ)and the alveolar bone crest (ABC) was measured at seven palatal sites per mouse. Measurements
were made under a dissecting microscope (40× magnification) fitted with a digital high-definition
system, standardized to provide measurements in millimetres. The right sides of the upper jaws wereanalysed for histology. The samples were fixed, decalcified and embedded in paraffin. The paraffin
section was cut serially into 5-mm sections in a mesial–distal direction. The sections were stainedfor haematoxylin–eosin (H–E) and TRAP. In particular, TRAP-positive multinucleated cells were
defined as osteoclasts and examined under an optical microscope (40× magnification). The number ofosteoclasts was counted in the area of the periodontal tissue between the mesial root of the first molar
and the distal root of the third molars. We found apparent horizontal bone loss in C57BL/6N micechallenged with P. gingivalis (group B) but not in the control (group A) or the Jixueteng-administeredgroup (group C) (Figure 15A). Figure 15B shows the mean values ± standard error (SEM) of the
CEJ to ABC derived from seven measurement sites in weeks 2, 4 and 6 after infection. Induction ofalveolar bone loss was more reproducible with an infection by P. gingivalis by oral gavage (group B)(p < 0.01) than in the sham-infected control (group A) 4 weeks after infection, whereas no difference
was observed 2 weeks after infection. In all experimental groups, the maximum resorption of alveolarbone was observed at the end of the experiment and the mean bone levels of the sham-infected control(group A) and P. gingivalis infection group (group B) were 0.194 ± 0.001 mm and 0.228 ± 0.010 mm,
respectively. Alveolar bone loss was significantly lower in the Jixueteng group (group C) (p < 0.01) thanthat of group B in weeks 4 and 6. The mean bone level of group C in week 6 was 0.188 ± 0.003 mm,
which was comparable to that of the control group A (Figure 15) [28].
By histopathological examination, osteoclasts were observed along the alveolar septum in mice
periodontal tissues (Figure 16). Table 6 shows the number of osteoclasts in the alveolar bone crest. No
significant difference in the number of osteoclasts was observed among the experimental groups 2
weeks after infection.
Table 6. Effects of Jixueteng on osteoclast formation in periodontal tissues.
Number of Osteoclasts

GroupsControlP. gingivalis
Jixueteng + P. gingivalis

2W

4W

6W

14.25 ± 1.71
18.50 ± 5.45
15.75 ± 7.41

16.00 ± 1.00
29.00 ± 8.25 **17.00 ± 2.94

10.33 ± 0.58
23.33 ±1.53 **12.33 ± 3.21** Significantly different (p < 0.01) from Group A and C. The number of osteoclasts was examined in the section
from right maxillary specimen stained of tartrate-resistant acid phosphatase. The results were expressed as mean ±standard deviation. Group A, control (non- infected with P. gingivalis); group B, orally infected with P. gingivalis;group C, administered Jixueteng and orally infected with P. gingivalis. Cited from [28] with permission.

Medicines
Medicines2019,2019,6,6,34x FOR PEER REVIEW

16 16
of of
3231

Figure 15. Morphometric bone levels of 6 week after P. gingivalis infection (left) and alveolar bonelevels at 2, 4 and 6 weeks after P. gingivalis infection (right). A, non-infected control; B, infected with
P. gingivalis; C, Jixueteng administered group along with P. gingivalis infection. Bone levels were
evaluated by measuring the distance from the cemento-enamel junction (CEJ) to the alveolar bone
crest (ABC) at seven palatal sites per mouse. Values indicate the mean bone loss levels ± standard
FigureMorphometricbone levelsof 6 week afterP. gingivalis(left)
andalveolarboneerror15.
of themean (n = 6/group).
**: significantly
different(p < 0.01).infection
Cited from
[28]
with
permission.
levels
at
2,
4
and
6
weeks
after
P.
gingivalis
infection(right).
A,
non-infected
control;B,
infected
withFigure 15. Morphometric bone levels of 6 week after P. gingivalis infection (left) and alveolar bone
P.levelsgingivalis;
C,
Jixuetengadministered
group
along
with
P.
gingivalis
infection.
Bonelevelswere
at 2, 4 and 6 weeks examination,
after P. gingivalis
infection (right).
A, non-infected
B, infected
within mice
By histopathologicalosteoclasts
were observed
alongcontrol;
the alveolar
septumevaluatedbytissuesmeasuring
the administereddistancefromthe cemento-enamel
(CEJ)
toin
thethealveolarbone
crestcrest.
P. gingivalis;C, Jixuetengalongwith P. junction
gingivalis
infection.
Bonelevelswere
periodontal(Figure16). Table
6 groupshows
the numberof osteoclasts
alveolar
bone
(ABC)
at
seven
palatalsites
permouse.
Valuesindicate
the
mean
bone
loss
levels±standarderror
ofevaluatedbymeasuringthe
distancefromthecemento-enamel
junction
(CEJ)
to
the
alveolarbone
No significant difference in the number of osteoclasts was observed among the experimental groups
the
mean
(n
=
6/group).
**:significantly
different(p<0.01).
Cited
from
[28]
with
permission.
crest
(ABC)
at
seven
palatalsites
permouse.
Valuesindicate
the
mean
bone
loss
levels±standard
2 weeks after infection.
error of the mean (n = 6/group). **: significantly different (p < 0.01). Cited from [28] with permission.

By histopathological examination, osteoclasts were observed along the alveolar septum in mice
periodontal tissues (Figure 16). Table 6 shows the number of osteoclasts in the alveolar bone crest.
No significant difference in the number of osteoclasts was observed among the experimental groups
2 weeks after infection.

Figure 16. Histopathological examination of mice periodontal tissues. Specimens obtained from themaxillary bone of mice were evaluated with TRAP staining. Osteoclasts (arrows) were observed along
the alveolar septum of the maxillary molars. A, con-infected
control; B, infected with P. gingivalis;
16C, administered Jixueteng and infected with P. gingivalis. Original magnification: × 10 and × 40. Bars:
100 µm. Scanning electron microscopy shows that compared to the normal group (A), morphologicaldegeneration of vessels in vascular networks and abnormality of the vascular lumen caused by
P. gingivalis infection were observed (B). However, improvement in degeneration of these vascular
networks and prolongation of the vascular plexus were observed by administration of Jixueteng (C).
16
Cited from [28] with permission.

Medicines 2019, 6, 34

17 of 31After 4 weeks, the number of osteoclasts in the P. gingivalis-infected group B was significantly
higher than that of sham-infected group (group A) and the Jixueteng-administered group (group C)(p < 0.01) [28]. P. gingivalis has virulent factors that induce inflammatory responses and alveolarbone resorption [29]. This bacterium also invades and survives in host cells, inducing a network of
inflammatory responses [30]. P. gingivalis also increases the likelihood of systemic diseases such as
diabetes and cardiovascular disease [31]. We previously reported that Jixueteng improves gingival
vascular networks in a P. gingivalis-induced periodontitis [28] (Figure 15). Jixueteng may inhibit theadherence and colonization of P. gingivalis in mice oral cavities. Therefore, our findings suggest that
Jixueteng reduces the inflammatory destruction in periodontitis. Jixueteng has bactericidal effects
against oral bacteria, inhibits the osteoclastogenesis and reduces the alveolar bone resorption inducedby P. gingivalis. Jixueteng reduces the inflammatory tissue destruction in periodontitis and Jixueteng
may be a useful ingredient to prevent periodontitis.
6. Therapeutic Effects of Mastic
6.1. History of Mastic (Kampo Name: Yo-Nyuko olibanum)
Mastic is the resin collected from the naturally growing trees in only Chios Island in southeast
Aegean Sea of Greece. It was initially called frankincense. Mastic has a long history, it is written in the
Old Testament (Genesis 37:25) and many ancient Greek literatures mentioned the medical effect ofmastic. Christopher Columbus, before he stayed in Portugal, visited Chios Island during his voyage to
the Orient as recorded in his diary in 1474–1475 and he described about mastic; it is sticky sap extracted
from tree and becomes resin when solidified. There has been a habit of chewing this in Greece sincemore than 5000 years ago and it was known that those people who had this habit rarely had digestive
diseases. In China’s classical Kampo medicine masterpiece of “Zu-Kei Honzo” (masterpiece of plant
diagrams) also described it as Kun-roku-ko, kuduruka. The substance called frankincense today is theresin from the trees of Boswellia genus of the Burseraceae family that grow in north-eastern Africa or
Arabian coast and it is different from the mastic from Greece. Traditional frankincense to present is the
Medicines
2019, 6, x FOR
PEER
REVIEW
18 ofthe32
samekudurukain thebookof Honzo and they grow in the Mediterranean coast areas. Resin fromtree that belongs to the Anacardiaceae family is considered MASTICHE RESINA. This is called “mastic”
MASTICHERESINA.
or Yo-Nyuko
in Kampo
and17).
is known as Pistacia lentiscusor
Yo-Nyuko in
KampoThis
andisiscalled
known“mastic”
as Pistacia
lentiscus locally(Figurelocally (Figure 17).

Figure 17.
Mastic tree
tree (Pistacia(Pistacia lentiscus).
(photos taken
taken at
at Chios
Chios island,
Figure17. Mastic
lentiscus). (photos
island, Greece,
Greece, 2007)
2007)

It is empirically proven that herbs that are used in folk therapies, including the herbal medicines
It is empirically proven that herbs that are used in folk therapies, including the herbal medicinesconstituting Kampo, have multifunctional medicinal effects. Mastic resin has a unique shape andconstituting Kampo, have multifunctional medicinal effects. Mastic resin has a unique shape andvarious efficacy and has been used to promote health from old time. In addition, mastic resin has beenvarious efficacy and has been used to promote health from old time. In addition, mastic resin has
used in chewing gums as a material for oral health and hygiene and indicated antiplaque activities.
been used in chewing gums as a material for oral health and hygiene and indicated antiplaqueRecently in Japan, mastic has been receiving attention as material for oral cares and many companies
activities. Recently in Japan, mastic has been receiving attention as material for oral cares and many
are developing and selling mastic-formulated oral gels for toothbrushing paste.
companies are developing and selling mastic-formulated oral gels for toothbrushing paste.
Mastic has been forming a market of high-end products of oral cares. Also, dentists have been
Mastic has been forming a market of high-end products of oral cares. Also, dentists have been
paying attentions to its effect and mastic is securing its position in the clinical medicine as the primary
paying attentions to its effect and mastic is securing its position in the clinical medicine as the primarycare product for oral cavity cares. To cope with the improvements of adult diseases and systemiccare product for oral cavity cares. To cope with the improvements of adult diseases and systemic
diseases associated with the oral hygiene in the aging society of Japan and further to improve the oraldiseases associated with the oral hygiene in the aging society of Japan and further to improve the oral
health in Asia, a group of dentists launched an NPO called “Mastic Clinical Study Group.” It has
been running the public awareness building programs of the oral hygiene including preventive
dentistry. Presently, many dentists are making use of mastic in the clinical studies and are promoting
its use in the treatment of patients and to spread the awareness of the primary cares.

Medicines 2019, 6, 34

18 of 31

health in Asia, a group of dentists launched an NPO called “Mastic Clinical Study Group.” It has beenrunning the public awareness building programs of the oral hygiene including preventive dentistry.
Presently, many dentists are making use of mastic in the clinical studies and are promoting its use in
the treatment of patients and to spread the awareness of the primary cares.
6.2. Component of Mastic
Essential oils, obtained by hydrodistillation of aerial parts of Pistacia lentiscus var chia, were
determined for their oil composition using gas chromatography-mass spectrometry (GC/MS). Most
abundant component was α-pinene (72.93% of the total oil composition), followed by β-myrcene(13.57%) > β-pinene (2.58%) > limonene (0.89%) > linalool (0.73%) > camphene (0.58%), methylanisol(0.58%) > α-pinene oxide (0.56%) > sabinene (0.30%), β-caryophyllene (0.30%) > verbenone (0.26%) >pinocarveol (0.21%) > myrtenol (0.18%) > pinocarvone (0.10%) [32].
6.3. Biological Activity of Mastic Gum (Resin)
6.3.1. Antimicrobial Activity
Compared with the group, which used the PBS mouthwash, the group that used themastic-formulated gums showed the significant inhibition of the increase of oral bacteria (Figure 18).
Compared with the group that used the gums without mastic formulation, it inhibited the increase of
2019, 6,x FOR PEER
19 of 32
theMedicines
pathogenic
bacteria
andREVIEW
the effect was equivalent of benzalkonium chloride.
350○

CFU/ml

300
250
200

○

150

○

100
50
0

1

2

△
□
×

□
×

△
□
×

△
□
×

○
△

3

○ ： PBS (control)△ ： non-mastic-formulated gums
□ ： mastic-formulated gums
× ：0.2% benzethonium chloride solution（Neostelin Green®）

4

5

Treatment time (hours)

Figure 18. Bactericidal effect of mastic gum against oral bacteria. (Hamada N, unpublished data)
Figure 18. Bactericidal effect of mastic gum against oral bacteria. (Hamada N, unpublished data)

Stick examined the antibacterial effect against gram-negative bacteria. The result of the
Stick examined the antibacterial effect against gram-negative bacteria. The result of theexamination of the minimum inhibitory concentration (MIC) of mastic resin oil against the oral
examination of the minimum inhibitory concentration (MIC) of mastic resin oil against the oral
bacterial groups showed it had antibacterial effect (< 0.05%) for adult periodontal bacteria, P. gingivalis.
bacterial groups showed it had antibacterial effect (< 0.05%) for adult periodontal bacteria, P.
Mastic rein oil also showed great selective effect at < 0.05% against Fusobacterium nucleatum (Tables 7
gingivalis. Mastic rein oil also showed great selective effect at < 0.05% against Fusobacterium nucleatumand 8). F. nucleatum is an important periodontal bacterium that derives the bacterial agglutination on(Table 9). F. nucleatum is an important periodontal bacterium that derives the bacterial agglutination
the dental plaque formation. Mastic rein oil can reduce the dental plaque and promote the prevention
on the dental plaque formation. Mastic rein oil can reduce the dental plaque and promote theof periodontitis.
prevention of periodontitis.
Mastic showed selective antimicrobial activity against Porphyromonas gingivalis and Prevotellamelaninogenica,
as compared with that against the growth of Actinomyces viscosus, Streptococcus
Table 7. Minimum inhibitory concentration (MIC) of mastic resin oil. (Hamada N, unpublishedgordonii, Streptococcus mutans, Capnocytophaga ochracea,data)Fusobacterium nucleatum, Prevotella intermedia,
Staphylococcus aureus, Escherichia coli and Candida albicans [33]. When mastic gum was fractionatedOral solvents
Bacteria with increasing water-solubility
MIC (%)
with successive extractions with organic
into hexane, ethyl
Streptococcus
mutans0.4extractable fraction showedacetate, n-butanol extracts and remainingwaterlayer, the ethyl acetate
Streptococcus
sanguinis
eight or nine times higher anti-bacterial
activity
against Streptococcus0.4mutans (IC50 = 104 µg/mL),
Streptococcus
mitis
0.4 bacterium was P. gingivalis
as compared with other fractions (831–936 µg/mL). The most sensitive(IC50 = 32.7 µg/mL), followed byLactobacillus
S. mutans species(IC50 = 104 µg/mL), S. 0.2
aureus (IC50 = 609.4 µg/mL),
Staphylococcus aureus
F. nucleatum (IC50 = 759.6 µg/mL) and E. coli (IC50 = 907.4 µg/mL) 0.8[34]. Ethyl acetate extract ofBacillus species
Actinomyces species
Porphyromonas gingivalis
Porphyromonas endodontalis
Prevotella intermedia
Fusobacterium nucleatum
Aggregatibacter actinomycetemcomitans

0.2
0.2< 0.051.6
1.6< 0.050.2

Medicines 2019, 6, 34

19 of 31

mastic, which has higher antibacterial activity than unfractionated mastic, may be appropriate for thetreatment of periodontal diseases.
Table 7. Minimum inhibitory concentration (MIC) of mastic resin oil. (Hamada N, unpublished data).
Oral Bacteria

MIC (%)

Streptococcus mutans
Streptococcus sanguinis
Streptococcus mitis
Lactobacillus species
Staphylococcus aureus
Bacillus species
Actinomyces species
Porphyromonas gingivalis
Porphyromonas endodontalis
Prevotella intermedia
Fusobacterium nucleatum
Aggregatibacter actinomycetemcomitans

0.4
0.4
0.4
0.2
0.8
0.2
0.2
< 0.051.6
1.6< 0.05
0.2

Table 8. Plaque formation on the tooth surface and effect of inhibition of gingivitis of mastic gums.
(Hamada N, unpublished data).
Group
Mastic gum (n = 10)
Placebo gum (n = 10)

Plaque Index

Gingivitis Index

Baseline

1 weekBaseline

1 week

1.06 ± 0.29
1.19 ± 0.19

2.69 ± 0.29 **3.15 ± 0.24 **000.44 ± 0.15*
0.66 ± 0.23*

These data are represented as mean ± standard deviation. No statistical difference was observed between thegroups at baseline. p < 0.05* p < 0.001** comparison with the baseline using Student’ test. The data are determinedas the lowest concentrations of mastic resin oil.

The MIC of polymers from mastic gum of Pistacia lentiscose (MW: 50-130 kD), isolated bygel permeation chromatography against gram-negative bacteria (Escherichia coli type 1, Salmonella
typhimurium, Serratia marscens. Pseudomonas aeruginosa, Alcaligenes faecalis, Enterobacter aerogenes,
Pseudomonas fluorescens, Proteus vulgaris, Porphyromonas. gingivalis) and gram-positive bacteria(Bacillus cereus, Staphylococcus aureus, Streptococcus faecalis, Staphylococcus epidermidis, Bacillus subtilis,
Corynebacterium sp) was 200–250 and 1000 µg/mL, respectively. The MIC of polymer of β-myrcene(MW 50–500 kD), synthesized by incubation with cyclohexane and sec-butyl lithium, against
gram-negative and -positive bacteria was 100 and 1000 µg/mL, respectively [35]. Chewing mastic
gum decreased the total viable bacteria, S. mutans and lactobacilli in saliva in orthodontically treatedpatients with fixed appliances, suggesting the usefulness of chewing mastic gum in preventing caries
lesions [36].
6.3.2. Antiviral Activity
Anti-HIV activity was determined by the selectivity index (SI), based on the ratio of 50%
cytotoxic concentration (CC50 ) against mock-infected CD4-positive human T-cell line MT-4 cells
to 50% protective concentration (EC50 ) against HIV-infected MT-4 cells. All mastic extracts did
not prevent HIV-induced cytopathic effects on MT-4 cells (SI <1), whereas three anti-HIV agents(azidothymidine, dideoxycytidine, curdlan sulphate) showed excellent anti-HIV activity (SI = 5624,
3868, 7142). All mastic extracts partially but significantly reduced the HSV-induced cytopathic effects
on Vero cells, recovering the cell viability up to 43.2 ± 5.3% of mock-infected cells [34].
6.3.3. Anti-tumour Activity
Mastic showed very low antitumor activity against four human oral squamous cell carcinoma
cell lines (Ca9-22, HSC-2, HSC-3, HSC-4) (CC50 = 13.5–24.4 µg/mL) as compared with three humanMedicines 2019, 6, 34

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normal oral cells (gingival fibroblast HGF, periodontal ligament fibroblast HPLF, pulp cells HPC)
(CC50 = 28.1–84.8 µg/mL), with the tumour-specificity value (TS, determined by the ratio of CC50
against normal cells to CC50 against tumour cells) of only 1.4 to 2.4. Among 5 extracts, ethyl acetate
extract showed the highest TS values (TS = 2.6), although its values were two-order lower than thatof doxorubicin (TS = 244.7) [34]. However, mastic showed approximately 5-fold higher cytotoxicity
against human leukemic cell lines: promyelocytic HL-60 (19 µg/mL), myeloblastic ML-1 (25 µg/mL ),myeloblastic KG-1 (27 µg/mL), erythroleukemia K-562 (30 µg/mL), as compared with normal cells(HGF, HPLF, HPC) (93–155 µg/mL). Mastic induced apoptotic cell death (internucleosomal DNA
fragmentation, caspase-3 activation, decline in the intracellular concentration of putrescine) in HL-60
promyelocytic leukaemia, while it inhibited the spontaneous apoptosis of oral polymorphonuclear
leukocytes. Mastic showed hydroxyl radical scavenging activity, suggesting the beneficial effects
of mastic on oral health [33]. Mastic gum (200 mg/kg) inhibited the growth of colorectal tumour
xenografts by approximately 35%, when the optimal experimental conditions were chosen [37].
Recently, apoptosis induction by mastic in COLO205 human colonic adenocarcinoma [38], MCF-7
human breast cancer cells [39], LT97 human colon adenoma cells [40], FTC-133 (human follicularthyroid carcinoma) [41], H-SY5Y, SK-N-BE(2)C human neuroblastoma [42] and YD-10B human oral
squamous carcinoma [43] has been reported, however, most of these studies have not mentioned thetumour-specificity of mastic.
6.3.4. Anti-inflammatory Activity
Essential oil of mastic showed a strong iron chelating activity (IC50 = 20 µg/mL) and actively
scavenged hydroxyl radical (IC50 = 3 µg/mL) and protected tert-butyl hydroperoxide-treatedlymphocyte [44]. Mastic inhibited the production of nitric oxide (NO) and prostaglandin (PG)E2 ,as well as expression of inducible NO synthase (iNOS) and cyclooxygenase (COX)-2 protein andmRNA, induced by lipopolysaccharide (LPS)-activated mouse macrophage-like RAW264.7 cells.
Mastic scavenged hydroxyl radical more potently than NO and superoxide radicals. The narrow
range of effective concentration of mastic due to its cytotoxicity may limit its potential application as
an anti-inflammatory agent [45].
6.3.5. Inhibition of CYPs
Five days oral treatment with Pistacia lentiscus oil 100 µL per mice did not show any undesirable
effect on the function of kidney and liver but significantly inhibited the enzyme activity and expressionof CYP1A1, CYP1A2, CYP2E1 and CYP3A4, especially in the liver tissue [46]. The result suggests thepossibility that when mastic is used in combination with other pharmacological agents, the biologicalaction of the latter may be more enhanced.
Among five masic fractions, n-hexane extract exhibited the highest CYP3A4-inhibitory activity(IC50 = 3.1 µg/mL), followed by methanol extract (macerated) (IC50 = 4.1 µg/mL), n-butanol extract(IC50 = 12.1 µg/mL), unfractionated sample (IC50 = 14.3 µg/mL), ethyl acetate extract (IC50 =14.8µg/ml) (C) and, finally, methanol extract (refluxed) (IC50 = 24.4 µg/ml). Washing out these CYP3A4
inhibitory substance with n-hexane may reduce these pharmacological action or side-effects ofcombined drugs [34].
6.3.6. Oral Application of Mastic Gel
Salivary bacteria create healthy microbiomes when the intraoral condition becomes good. In orderto maintain the good intraoral environment, we developed a gel toothpaste with mastic (Boswellia
carterii, Kampo name: Yo-Nyuko), a mouthwash with Kampo herbs formulated (Figure 19).
Since the patient had lost the freedom of his hands thus the prevention infection control after
treatment would be difficult, it was decided to try treatments using dental laser and Kampo mouth
wash and mastic gel to improve the gingival tissue [47–49]. Then, we show a clinical case using themastic gel in oral cavity. The following is the clinical report of patients treated with mastic in our dental

= 12.1 µg/mL), unfractionated sample (IC50 = 14.3 µg/mL), ethyl acetate extract (IC50=14.8 µg/ml) (C)and, finally, methanol extract (refluxed) (IC50 = 24.4 µg/ml). Washing out these CYP3A4 inhibitory
substance with n-hexane may reduce these pharmacological action or side-effects of combined drugs[34].
Medicines 2019, 6, 34

21 of 316.3.6. Oral Application of Mastic Gelbacteriathe
createhealthy
microbiomes
when theintraoral
condition
becomesgood.
Inclinic,Salivary
after obtaining
informed
consent
from the patient,under
the conditionthatthe patient
is notorder
to maintainthe good intraoral environment, we developed a gel toothpaste with mastic
identified(Figure 20).
(Boswellia carterii, Kampo name: Yo-Nyuko), a mouthwash with Kampo herbs formulated (Figure 19).

Medicines
2019,19.
6, xToothpaste
FOR PEER REVIEW
Figureand mouth-rinse including mastic and IMPLA CARE. (unpublished data) 22 of 32

Figure 19. Toothpaste and mouth-rinse including mastic and IMPLA CARE. (unpublished data)

Since the patient had lost the freedom of his hands thus the prevention infection control after
treatment would be difficult, it was decided to try treatments using dental laser and Kampo mouth
wash and mastic gel to improve the gingival tissue [47–49]. Then, we show a clinical case using themastic gel in oral cavity. The following is the clinical report of patients treated with mastic in ourdental clinic, after obtaining the informed consent from the patient, under the condition that thepatient is not identified (Figure 20).

21

FigureThe
clinicalobservationof periodontal
tissuearoundthe upper
4th 5thandteeth
5th teeth
Figure20.20.
The
clinicalobservationof periodontal
tissuearoundthe upper
4th andbeforebefore
andandtreatment
after treatment
withandlaser
and mastic(A) Before
treatment
thefirst visited(B)timeFirst
afterwith laser
masticgel. (A)gel.
Beforetreatment(at the(atfirstvisitedtime); time);(B) First
timelaser treatment.
Masticgel wasafter
appliedafter carbonizedlaser (C)treatment.
(C) Second
after
theafterlaserthetreatment.
Mastic gel
was applied
carbonizedlaser treatment.
Second times
after
the laser
treatment.
the laser
treatment, chlorhexidine
was used
to prevent
bacterial
thetimeslaserafter
treatment.
Afterthe laserAfter
treatment,
chlorhexidine
was used to prevent
bacterial
infectionandinfection
andapplied
mastic gel
wasapplied(D)at Third
the gingiva.
(D) Third
times
after theMastic
laser treatment.
Masticmasticgel wasat thegingiva.
times after
the laser
treatment.
gel was appliedgellight
was coagulation
applied after
lightwascoagulation
addedtimes
by laser.
times after
the laser
after
layer
added by layer
laser. was(E) Fourth
after(E)the Fourth
laser treatment.
Masticgeltreatment.
Mastic gel
applied aroundthearea.
inflammatory
gingivalgingival
area. (F)Inflammatory
gingival
wasapplied aroundthe wasinflammatory
gingival(F) Inflammatory
area
between upper
4tharea
upperby4th
andthe5thmastic
are improved
bywereusing
the after
masticgel. Photos
were taken,
after
and
5thbetween
are improved
usinggel. Photos
taken,
obtaining
the informed
consent
obtaining
the informed
consent
from the patient.
fromthe patient.
(Watanabe
S, unpublisheddata) (Watanabe S, unpublished data)

TheThepatient
waswasa 66a years
old old
male.
Showing
bleeding
due dueto theof upperright right
4th andpatient
66 yearsmale.
Showing
bleeding
tomobility
the mobilityof upper4th
5th
teeth.
He
visited
us
due
to
his
chief
complaintofmastication
disorder.
He
hadastroke3
years
and 5th teeth. He visited us due to his chief complaint of mastication disorder. He had a stroke 3
agoandagois currently
seeing thephysicianonce a month.
conditionis stable. is
Asstable.
his hands
tremble,years
and is currently
seeingthe physician
once aThemonth.
The condition
As hishands
themouth thecleaning
poor wasand poor
the breathwasbad. was
Poor
oralPoorhygiene,bleedingbleedingfrom thegums
tremble,mouthwascleaning
and thebreathbad.
oral hygiene,fromthe(+++),
redswelling
on
the
gums
and
inflammationwere
observed.
As
itwasnecessarytocreatethegums (+++), red swelling on the gums and inflammation were observed. As it was necessary to create
environmentthat treatment
can be done,
Kampo
and applicationof mastic gel
the environmentthat treatment
can bedone,mouthwash
Kampo mouthwash
and applicationof toothpaste
mastic gel
wasconducted
forconducted
three timesfor
a day
beforeafter
the treatment.
Next,
we showed
theweimprovement
toothpaste
was
three
timesanda day
beforeand after thetreatment.
Next,
showed theofimprovement
the chief complaintby theinitial treatment.
Whenthe patientcame
the clinic,
4thclinic,
and 5thof the chiefcomplaintby the initial
treatment.
When
the topatient
camehisto the
his
teeth
in
upper
right
were
showing
mediumlevelofmobilitybut
itwas
judgedfromtheobservation
4th and 5th teeth in upper right were showing medium level of mobility but it was judged from theusing
X-ray that
the X-raybone absorption
wasnot bad. was not bad.
observation
using
that the boneabsorption
We used the dentifrice that mastic was formulated and expected the effect of preventing the
fixation of pathogen bacteria before and after the treatment. Considering that the oral hygiene
significantly influences the management of the entire body, the biological study of the natural
products is critically important from now on [50–52].

Medicines 2019, 6, 34

22 of 31

We used the dentifrice that mastic was formulated and expected the effect of preventing the
fixation of pathogen bacteria before and after the treatment. Considering that the oral hygiene
significantly influences the management of the entire body, the biological study of the natural products
is critically important from now on [50–52].
7. Development of A Dentifrice Gel Containing A Mastic Resin and Jixueteng
Periodontitis is the second most common dental disease worldwide after dental decay.
Periodontitis is caused by microorganisms that adhere and grow on tooth surfaces and by an aggressive
immune response against these microorganisms. The mouth contains a wide variety of oral bacteria,
which is an ideal environment for their growth. Nutrition is supplied from food residues and saliva,
nitrogen and amino acids mix in gingival crevicular fluids. Periodontitis is triggered by a complex
microbial biofilm in the subgingival area that houses over 700 bacterial species and phylotypes [47].
Bacteria from the red complex group, such as P. gingivalis, predominate in gingivitis and periodontal
disease patients by PCR analysis. Three microorganisms are mainly associated with periodontal disease,
Treponema denticola, Tannerella forsythia and P. gingivalis and they usually form a complex called red
complex bacteria (RCB). These bacteria are Gram negative, non-spore-forming anaerobic organisms
and they may be found as pure or mixed infections [48]. RCB possess several virulence factors
including fimbriae, proteinases, exopolysaccharides and hemin-binding proteins [49]. RCB have been
detected in both subgingival plaque and in the apical root canal and cause periodontal and endodontic
diseases [48,53,54]. P. gingivalis is a pathogen that causes periodontal disease, which is a common
chronic inflammatory disease [55–57].
Jixueteng is a herbal medicine with pharmacological properties, such as increasing circulation,
analgesia and the number of red and white blood cells and is composed of the dried stems of Spatholobus
suberectus Dunn and Millettia dielsiana Harms, both family Leguminosae [58,59]. Jixueteng has potent
local anti-infection effects on oral indigenous bacteria and inhibits alveolar bone loss [23,39]. Thesefindings suggest that Jixueteng is a safe and effective therapeutic agent for periodontal disease becauseof its antibacterial and immune activities and its ability to improve circulation. However, Jixueteng has
not been clinically used in the oral field and its effects on reactive oxygen species (ROS) in inflamed
regions and the detailed mechanisms underlying these pharmacological actions remain unclear. ROS
is involved in various physiological and pathological events. Overproduction of ROS causes oxidative
damage to biomolecules, such as lipids, proteins and DNA, which ultimately results in many chronic
diseases in humans such as atherosclerosis, cancer, diabetes, rheumatoid arthritis, post-ischemic
perfusion injury, myocardial infarction, cardiovascular diseases, chronic inflammation, stroke, septic
shock, aging and other degenerative diseases [60,61].
Because, Jixueteng extract inhibits osteoclast differentiation and survival in a dose-dependent
manner, neutralizes oxygen species and improves blood flow, we developed a dentifrice containing
Jixueteng in this study. However, Jixueteng alone did not have a satisfactory bactericidal effect on
periodontopathic bacteria and fungi. Therefore, the antimicrobial effect was supplemented witha mastic, which effectively suppresses pathogenic bacteria. Furthermore, as a result of searchingfor plant-derived components that suppress periodontopathic bacteria, we found that antibacterial
lotuses had comprehensive and effective antibacterial effects on pathogenic bacteria and fungi. We arecommercializing a dentifrice containing these ingredients and named it "IMPLA CARE" (Figure 19).
At our hospital, dental hygienists do not invasively remove dental calculus in primary care.
Patients were supplied with an IMPLA CARE at night-time and the dental calculus was removed
after the gums were healthy and tight. Improving gingiva before treatment with IMPLA CARE
reduced the risk of bacteraemia. IMPLA CARE was important for subsequent treatment, postoperative
management and may help prevent systemic diseases such as diabetes, cerebral infarction andmyocardial infarction. We investigated natural products with antimicrobial activity. First, the minimum
inhibitory concentrations (MIC) of Jixueteng, Sasa veitchii and lotus on oral bacteria were measured.
The natural products were dissolved in sterilized phosphate-buffered saline (PBS; pH 7.4) and two-foldMedicines 2019, 6, 34

23 of 31

serial dilutions were aliquoted in small volumes in microwell plates. Bacterial cells were grown inbrain heart infusion (BHI) broth supplemented with hemin (5 µg/mL), vitamin K1 (0.2 µg/mL) andyeast extract (5 mg/mL) under anaerobic conditions (CO2 : 10%, H2 : 10%, N2 : 80%) at 37◦ C for 18 h.
Bacterial cells were washed and suspended in PBS to an optical density of 1.0 at 600 nm. The bacterial
suspension was exposed for 40 h to two-fold serial dilutions of the natural products. The same volumeof PBS was used as a control. Jixueteng had bactericidal effects on S. mutans, L. casei, S. gordonii,
F. nucleatum and S. aureus. Sasa veitchii had a strong bactericidal effect on the fungus C. albicans (Table 9).
Therefore, the IMPLA CARE contained a mixture of Jixueteng, Sasa veitchii, grapefruit and lotus in themastic resin.
Table 9. Minimum inhibitory concentration (MIC) of five natural products. (Hamada N, unpublisheddata).
Tested bacteria

Jixueteng

Sasa Veitchii

Grapefruit

Propolis

Lotus

Streptococcus mutans
Streptococcus gordonii
Lactobacillus casei
Staphylococcus aureus
Actinomyces viscosus
Porphyromonas
gingivalis
Prevotella nigresecens
Fusobacterium
nucleatum
Escherichia coli
Candida albicans

4
8
4
32
32

> 8192
4> 8192> 8192
4

512
2048
512
4096
4096

256
8192
256
> 8192256

8192> 81928192> 81928192> 81925124096> 8192> 8192> 8192128> 8192> 8192> 8192

16

8

4096

2048

> 8192> 819264> 8192
8

1024
8192

16
2048

8192
> 8192Six patients with periodontal disease, peri-implant inflammation or both were examined. Results
were measured after using IMPLA CARE and 1–3 times daily tooth brushing and 1–3 months of light
Medicinesof
2019,
x FOR PEER
26 of 32
massagethe6,affected
partREVIEW
with fingers (Tables 9 and 10). Periodontal disease improved in all patients(Table 11, Figure 21).

Figure 21. Effects of the IMPLA CARE. (Watanabe S, unpublished data)
Figure 21. Effects of the IMPLA CARE. (Watanabe S, unpublished data)

We evaluated patients who were not examined by dentists and found a self-reported
improvement (Figure 22). Patient satisfaction also increased, which suggests that IMPLA CARE canbe used as a primary care tool after treatment.
Case 1: A patient who was developing diabetes and hypertension. The patient had an implantin the anterior teeth of the maxilla and had teeth cleaned regularly at a dental clinic but gingivitis
persisted. The doctor instructed the patient to use the IMPLA CARE before going to bed every night.
Gingivitis improved gradually (Figure 22A).
Case 2: A patient with peri-implantitis. After insertion of an implant at 65 years old, a secondary
operation was performed but peri-implantitis developed after the second operation. The doctor
instructed the patient to use the IMPLA CARE himself before going to bed every night. Conditions
gradually improved and a superstructure was formed after one month (Figure 22B).
Case3: A patient with an ulcer from sleep deprivation and work stress. A patient developed anMedicines 2019, 6, 34

24 of 31

Table 10. Scores showing the progress of periodontal disease.
Examination Criteria
Score

Swollen Pus

Redness

Bleeding

Pus Discharge

Gingival Colour

Mobility

Patient’s Opinion

5

Papilla andadhering togingiva

Extending to thepapilla andgingival gums

Naturally bleeding

Naturally draining

Dark red purple

Upper and lower lip andtongue immobile

No change

3

Papilla andextending to thegingival margin

Papilla and toothinflammation

Bleeding by
acupressure

Acupressure-induced
draining

Dark redStrongly immobile

Improved a little

1

Part of the papilla

Part of the papilla

Slight bleedingwith acupressure

Slight draining
with acupressure

Brilliant

Slightly immobile

Tightened0

None at all

No redness

None at all

No discharge at all

Light pink

Within a physiologicalrange

Improved a lot

Table 11. Improvement of periodontal disease after administration of the IMPLA CARE. (Watanabe S, unpublished data).
Scores at 0, 1, 2 or 3 Months Later
Examination
Items

Patient A

Patient B

Patient C

Patient D

Patient E

Patient F

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

Swollen pus
Redness
Bleeding
Pus discharge
Gingival colour
Mobility
Patient’s opinion

1
5
5
1
3
3

0
3
3
0
1
1
3

0
1
1
0
0
0
1

0
0
0
0
0
0
0

1
3
3
1
3
1

0
2
2
0
2
0
3

0
1
1
0
1
0
1

0
0
0
0
0
0
0

3
3
2
3
2
0

2
2
1
2
1
0
1

1
1
1
1
1
0
0

0
0
0
0
0
0
0

3
3
2
3
2
0

0
0
0
0
3
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

5
3
3
1
3
1

3
1
0
0
1
0
1

0
0
0
0
0
0
0

0
0
0
0
0
0
0

1
3
1
1
3
1

1
1
0
0
1
1
1

0
1
0
0
1
1
0

0
0
0
0
0
0
0

Total score

18

11

3

0

12

9

4

0

13

9

5

0

14

3

0

0

16

6

0

0

10

5

3

0

persisted. The doctor instructed the patient to use the IMPLA CARE before going to bed every night.
Gingivitis improved gradually (Figure 22A).
Case 2: A patient with peri-implantitis. After insertion of an implant at 65 years old, a secondary
operation was performed but peri-implantitis developed after the second operation. The doctor
instructed
patient to use the IMPLA CARE himself before going to bed every night. Conditions
Medicines
2019,the6, 34
25 of 31
gradually improved and a superstructure was formed after one month (Figure 22B).
Case3: A patient with an ulcer from sleep deprivation and work stress. A patient developed anevaluatedpatients
were
not examinedby dentists
andwasfound
a self-reported
ulcerWefromwork stressandwhosleep
deprivation.
An IMPLA
CARE
used
daily in the improvement
morning and(Figure22).
Patient
satisfaction
also
increased,whichsuggests
that
IMPLA
can
be usedas aevening and improvements were observed with a week, which suggests CARE
that the
IMPLA
CARE
primarycare
tool after Chinese
treatment.
containing
traditional
medicines did not cause gingival recession (Figure 22C).

Figure 22. Case 1: A patient who was developing diabetes and hypertension (A), Case 2: A patient
Figure22. Case 1: A (B),patient
whoAwasdeveloping
diabetes
andhypertension(A),
2: stress
A patientwith
peri-implantitis
Case3:
patient
with an ulcer
from
sleep
deprivation
andCase
work
(C).
with
peri-implantitis(B),
Case3:
A
patient
with
an
ulcer
from
sleep
deprivationandwork
stress(C).
(Suzuki M, unpublished data)(Suzuki M, unpublished data)

Case 1: A patient who was developing diabetes and hypertension. The patient had an implant
8. Conclusions
and FutureStudies and had teeth cleaned regularly at a dental clinic but gingivitis
inthe anterior teethof the maxilla
persisted. The doctor instructed the patient to use the IMPLA CARE before going to bed every night.
Kampo is a historic traditional medicine that has been adjusted to Japanese culture. The concept
Gingivitis improved gradually (Figure 22A).
of Kampo emphasizes the relationship between the human body and its social and natural
Case 2: A patient with peri-implantitis. After insertion of an implant at 65 years old, a secondary
environments [2]. Our experiments concluded that Kampo (JTX and Jixueteng) reduce a great effectoperation was performed but peri-implantitis developed after the second operation. The doctor
on oral bacteria and inhibited the bacteria-induced alveolar bone loss. Kampo also suppressed the
instructed the patient to use the IMPLA CARE himself before going to bed every night. Conditions
osteoclast differentiation. Furthermore, Kampo improved the inflammatory response in thegradually improved and a superstructure was formed after one month (Figure 22B).
periodontal tissues of patients. These findings suggest that Kampo is an effective agent for theCase3: A patient with an ulcer from sleep deprivation and work stress. A patient developed
prevention of dental caries and periodontitis. The administration of Kampo may ameliorate toan ulcer from work stress and sleep deprivation. An IMPLA CARE was used daily in the morning
infected oral tissue environment.
and evening and improvements were observed with a week, which suggests that the IMPLA CARE
containing traditional Chinese medicines did not cause
gingival recession (Figure 22C).
26
8. Conclusions and Future Studies
Kampo is a historic traditional medicine that has been adjusted to Japanese culture. The conceptof Kampo emphasizes the relationship between the human body and its social and naturalenvironments [2]. Our experiments concluded that Kampo (JTX and Jixueteng) reduce a great effecton oral bacteria and inhibited the bacteria-induced alveolar bone loss. Kampo also suppressed
the osteoclast differentiation. Furthermore, Kampo improved the inflammatory response in the
periodontal tissues of patients. These findings suggest that Kampo is an effective agent for theprevention of dental caries and periodontitis. The administration of Kampo may ameliorate to infectedoral tissue environment.
Oral health is related to life-style such as diet in many ways. The development of dental caries
requires high sugar intakes [62]. On the other hand, the high consumptions of smoking and alcoholand the loss of vitamin D affects metabolic functions of periodontal tissue and induce periodontitis.
Previous review has been reported that psychological stress reduces human immune system andpromotes chronic inflammation in periodontal tissue [63]. Our result demonstrated that JTX affected
the correlation between restraint stress and bacteria-induced periodontal destruction [6,14]. Recently,
psychological stress is a risk factor of toothache, especially non-odontogenic pain [64]. Odontogenic
pain is generally derived from pulpal or periodontal tissue. However, non-odontogenic pain is not often
originated from the orofacial regions. The characteristics of non-odontogenic pain indicate various
types of symptoms; very mild, intermittent and severe, sharp pain and continuous. The general
dentists are difficult to be specified the pain regions, that confuse the exact pain control in any
case. In the clinical suggestion of effective pain control, the use of Kampo is expected to reduce thenon-odontogenic pain [65]. In the future, the mixed concept of Western medicine and Kampo medicine
will contribute in the treatment and prevention of several oral diseases.

pain is generally derived from pulpal or periodontal tissue. However, non-odontogenic pain is notoften originated from the orofacial regions. The characteristics of non-odontogenic pain indicate
various types of symptoms; very mild, intermittent and severe, sharp pain and continuous. The
general dentists are difficult to be specified the pain regions, that confuse the exact pain control in
Medicines2019,
34 clinical suggestion of effective pain control, the use of Kampo is expected to reduce
26 of 31any case.
In 6,
thethe non-odontogenic pain [65]. In the future, the mixed concept of Western medicine and Kampo
medicine will contribute in the treatment and prevention of several oral diseases.
Supplementation of alkaline extract of Sasa sp.
leaves (SE), which can alleviate theSupplementation of alkaline extract of Sasa sp. leaves (SE), which can alleviate the deoxorubicindeoxorubicin-induced keratinocyte cytotoxicity [66] and paclitaxel-induced neurotoxicity [67] by
induced keratinocyte cytotoxicity [66] and paclitaxel-induced neurotoxicity [67] by promoting
promoting hermetic cell growth. and have anti-HIV activity [68], may enhance the potential of mastic
hermetic cell growth. and have anti-HIV activity [68], may enhance the potential of mastic gel tooth
gel tooth paste (Figure 23).
paste (Figure 23).

Cytoprotective substance
Antiviral agent
Mastic gel tooth paste

More active form

Figure 23. Manufacturing of advanced mastic gel tooth paste.
Figure 23. Manufacturing of advanced mastic gel tooth paste.
Authorcollecting
the
data.
Author Contributions:Contributions: S.W.,
S.W., N.H.
N.H. andand H.S.
H.S. writing
writing thethe paper;
paper;T.T.,
T.T.,T.S.,
T.S.,M.S.
M.S.andandA.M.
A. M.
collecting
the
data.
Funding:
Funding: This
This work
work was
was partiallypartially supported
supported byby KAKENHI
KAKENHI fromfrom thethe Japan
Japan Society
Society forfor thethe Promotion
Promotion ofof Science
Science(JSPS):
SakagamiH,
16K11519.
(JSPS): Sakagami H, 16K11519.
Acknowledgments: The authors acknowledge Tsumura Co. Ltd for the supply of Kampo and Katsushi Tamaki
Acknowledgments:
The
acknowledge
Tsumuradentistry
Co. Ltd forthe supplyof andKampo
and Drs.
KatsushiandAtsushi Shimada
of authors
the Divisionof Prosthodontic
functionof TMJ
Occlusion,
Kanagawa
TamakiandAtsushiShimadaoftheDivisionof
Prosthodontic
dentistryfunctionofTMJ
andOcclusion,
Dental University and Atsushi Ishige and Jing Yu of Herbal medicine biology laboratory, Chinese herbal medicine
department,
Yokohama
Collegeandof Pharmacy
for thesupporttheYu
research.
Kanagawa Dental
University
Drs. Atsushi
Ishigeand forJing
of Herbal medicine biology laboratory,
Chineseherbalmedicine
department,
Yokohama
CollegeofPharmacy
for the support for the research.
Conflicts of Interest: The authors declare no conflict of interest.

Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations

Abbreviations
ABC
alveolar bone crest
ABC
alveolar bone
crest
CC
50% cytotoxic
concentrations
50
CC
50
50%
cytotoxic
concentrations
CEJ
cemento-enamel junction
CEJ
cemento-enamel
CFU
colonyforming unit junction
CFU
colony forming unit
CMC
carboxymethylcellulose
CMC
carboxymethylcellulose
COX
cyclooxygenase
COX
cyclooxygenase
CYP
cytochrome
P450
EC
50%
effective
concentration
CYP
cytochrome
P450
50
FBS
foetal50%
bovineserum
effective
concentration
EC50
GC/M
gas chromatography-mass
FBS
foetal bovine serum spectrometry
GRS
goreisanGC/M
gas chromatography-mass spectrometry
HGF
human
gingival fibroblast
GRS
goreisanHIV
humanimmunodeficiency
virus
HGF
human
gingival fibroblast
HPC
human
pulp
cell
HIV
human immunodeficiency virus
HPLF
human periodontal ligament fibroblast
HPC
human pulp cell
HSV
herpes simplex virus
HPLF
human periodontal ligament fibroblast
IC50
50% inhibitory concentration
HSV
herpes simplex viruskDkilo dalton
27
LPS
lipopolysaccharide
MIC
minimum inhibitory concentrationNO
nitric oxide
PGE2
prostaglandin E2
RANKL
receptor activator of NF-κB ligand
RCB
red complex bacteriaSI
selectivity index, determined by the ratio of CC50 /EC50
TNF
tumour necrosis factor
TRAPtartrate-resistant acid phosphataseTStumour specificity, determined by ratio of CC50 for normal cells to CC50 for tumour cells

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Appendix A
Table A1. Kampo terminology.
Byo-jaPathogen, disease inducing factor

Ei-ki

Ying energy, Ki which operates the blood flows in the blood vessels. Without ki, blood does not
circulate

Honchi

Systemic meridian treatment for systemic route cause of the disease

Hyo

Superficies, Surface of the body

Hyochi

Local and symptomatic treatment for symptoms derived by the rout cause

Hyo-sho

Pathological condition which appears on the surface of the boy

In

Yin, the state opposite of Yang, including ri, kan, kyo, shuren (convergence) and yukei (tangible)

In-Yo

Yin-Yang, Bipolar nature of all phenomena or viewing the phenomena from bipolar aspect

Ja

Stress/pathogenic factor, disease-inducing factor that is harmful to the body; endogenous
factor, exogenous factor, neither endogenous or exogenous factor

Jitsu

Excess of required substance of body being a disease inducing factor or its pathologicalcondition

Jitsu-kan

Sthenic chill; Kan-ja inhibits yang-ki (heat energy) in body and deteriorates body functions

Jitsu-netsu

Sthenic heat/excess heat, affected by the exogenous cause of heat; or heat from dental stressand intemperance

Jitsu-sho

Robust/excess constitution, condition or characteristics of over-reaction caused by byo-ja

Kan

Chill, symptom showing coldness

Kan-netsu

Chills and fever, pathological condition of chill and heatKan-shoKan-sho, pathological condition showing chilly feeling

KekkyoKetsu-kyo, pathological condition of ketsu insufficiency

Ketsu-netsu

Blood-heat, ketsu (blood) affected by heat-ja and shows kyo-netsu

Ki

Vital energy that operates body functions

Ki-gyaku

Pathological condition of ki regression

Ki-kyoKi deficiency, state of insufficient or deficient ki

Ki-kyoKi deficiency, state of insufficient or deficient ki

Ki-taiKi stagnation, pathological condition of ki stagnation

Ko-kanXerostomia, feeling mouth dryness but not wanting to drink water; tends to occur with mental
strainKo-katsu

Mouth dryness, feeling thirst and wanting to drink water

Kyo

Deficiency/asthenia, insufficiency of functions or physiological substance that physical bodyrequires
Asthenia-cold, kyo-sho symptom and belongs to Kan; insufficient yang-ki (heat) to warm up thebody

Kyo-kan
Kyo-netsu

Asthenic heat-syndrome, where yin-eki is insufficient and relatively yang becomes overactive
feeling feverish

Kyo-shoasthenia constitution; Pathological condition of insufficiency of fundamental substances that
operate body functions

Nai-netsu

Internal heat-syndrome, generated as a relative result of the imbalance of yin-yang; jitsu-netsu,
kyo-netsu

Okets

Blood stagnation, symptom caused by the stagnation of the blood flow

Ri

Interior of the entire body

Sanshoa passage that controls the flow of air, blood and water, called “triple heater “Medicines 2019, 6, 34

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Table A1. Cont.
Shin-eki

Bodily transparent fluid which constitutes the human bodyShitsuDampness of morbidly sustained fluid in the body as a disease inducing factor

Sho

Kampo diagnosis, set of holistic pattern of a patient’s pathological symptoms that cause
diseaseShoko

Kampo medical conditions, symptoms in Western medical terms

Tanphlegm, sticky fluid locally pooled due to poor water metabolism

Tan-inDiseases due to pathological accumulation of fluids in the bodyTonguecoating

Mossy substance covering the surface of the tongueyang

Chinese term for Yo

Yin

Chinese term for In

Yin-ekiFluid consisting of human body and composed of transparent shin-eki and red blood

Yang

Yin-deficiency Symptom of heat due to insufficient Yin-eki

YoYang, the state opposite of Yin, including hyo, netsu, jitsu, hassan (divergence) and mukei(intangible)

Yo-kyoYang-deficiency, pathological condition that chill of ki-kyo is worsened

Yo-shoYang-sho, condition that has characteristics of excitement, activity and warm-heat

Shokan-ron

A treatise on Shang han, a form of an acute infectious disease

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