TRI-IMMUNO-PHASIC PERIODONTAL THERAPY A

New Practical Approach

Dr Vivek Kr Sharma, Consultant PeriodontistDental College & Hospital Aligarh Muslim University Aligarh.UP

PERIODONTAL DISEASEOutcome of• Lowered immune response• Presence of disease causing

pathogens

Damage to connective tissue attachment

Pocket Formation

TRADITIONAL TREATMENT MODALITIES

• Non-surgical

• SurgicalScaling, root planing, home oral hygiene measures

Invasive periodontal incisional flap

After the surgery, due to the nature of the incision and the damaged state of the tissue, the gums, bone, and

attachment are left in a very weak state. Thus,In addition to fighting the infection from the gum disease, the body is now also burdened with trying to

repair the damage done from the surgery

TRI-IMMUNO-PHASIC (TIP) :PERIODONTAL DISEASE THERAPY BASED ON INFLUENCING IMMUNE RELATED RISK FACTORS

WILLIAM HOISINGTON , D.D.S.

TRI-IMMUNO-PHASIC PERIODONTAL THERAPY

• The Tri-Immuno-Phasic therapy, (TIP), philosophy assumes that the body is capable of healing periodontal disease just as other forms of repair. Damaged periodontal bone can heal like broken bones heal if all the right conditions are met .

• TIP periodontal therapy with its immune point of view seeks to influence personal as well as local factors in the disease picture to improve the conditions for healing by aiding the body in all three immune phases

IMMUNE SYSTEM PHASES

• Vigilant readiness • Defense Phase• Repair and Regeneration

.TIP sets up all the conditions where the body can get out of the defensive phase against bacteria and other microorganisms and enter into a regeneration phase to heal back a new attachment

TIP- PERIODONTAL THERAPY METHOD

• BONE ONE SESSION TREATMENT(BOST)• CONTROLLING BITING FORCES• NEW ORAL HYGIENE ROUTINE• LIFESTYLE, NUTRITION AND EXERCISE

ATTACHMENT

• Connective tissue attachment• Epithelial attachment • Scar tissue attachment • Mineralized acellular connective tissue

(MAC ) attachment

4 Types of attachment from the gum tissue to the teeth roots :

BONE ONE SESSION TREATMENT (BOST)

A Non-invasive microsurgery aims to REMOVE LOCAL OBSTACLES to healing (i.e. plaque bacteria and their immune provoking acids, toxins, enzymes, and calculus) that contaminate the teeth roots and or surfaces of the bone and MINIMIZE DAMAGE to the gums, bone, and attachment during the course of the treatment. In doing so, it sets up optimal conditions for healing.. It uses technique, called “STRETCH FLAP” that allows access all the way down to the deep areas of the roots and the surface of the bone.without giving incision..

First step: A universal 4R-4L curette, penetrating the rounded back first to open the sulcus, the working blade begins cleaning the superficial portion of the root of plaque and calculus and backward pressure is applied to the tissue to begin stretching it open.Second step: The direction changes to a circumferential motion starting at the corner to mobilize the tissue and avoid pulling the papilla free and in essence creating an incision flap.

Step three: With the tip of the curette advancing first’ the surface of the bone can begin to be instrumented to remove attached granulation tissue and expose and plasty the surface porosities to help physically remove and flush out with fresh bleeding the bacteria and chemicals trapped there

STRETCH FLAP

Concepts that separate BOST from traditional periodontal therapy

BOST aims to minimize damage to the gums, bone, and attachment during the course of the treatment. The micro-surgery procedure is non-invasive; protecting the tissue that has not been damaged by the periodontal disease.

BOST creates a strong attachment, which is necessary to heal the gums and bone and prevent further outbreaks of periodontal disease.

The recovery process after BOST is quick and easy.

BOST is performed in a single session of treatment.

HEALING AFTER BOSTThe clot that is firmly attached to the clean bone serves as a scaffold. The stem cells can move on along it and up the root surfaces at the rate of 0.5mm per day for eight days and thicken the layer on the clot. As healing time increases, the pockets gradually fill in from the bottom with very dense, partially mineralized connective tissue in about four to six weeks, and finally will become acellular.Once the new mineralized acellular connective tissue (MAC) attachment is in place in about a month, the bone naturally heals in under it. A new, dense layer of cortical bone forms over the healed inner (cancellous) bone in about 8 more months.

CONTROLLING BITING FORCES AND SAVING LOOSE TEETH

• With inflamed weakened bone, the teeth may become loose with a shifting bite. This can cause grinding to try to self adjust the bite. That further stresses the bone. Chronic inflammation with stagnant blood can cause clenching and grinding of the teeth to try to promote some circulation

• So loose the teeth may need to be stabilized with a "cast" called a splint .

NEW ORAL HYGIENE ROUTINE

Along with Brushing, flossing, and other conventional methods of dental hygiene, Aerobic Oral Hygiene Kit (PERIO-AID) that is created specifically to clean the area under gums and eliminate the disease-causing bacteria all the way down to the attachment and into root concavities where brush and floss don't reach , is used.

Use of perio-aid stops the suction cup like cells called epithelium on the inner tissue wall from attaching to the roots. The epithelial cell's job is to seal things up quickly. Their fast but weak connection (WC), would shut down slower healing from the bottom up that is best.

LIFESTYLE, NUTRITION & EXERCISE

• Eat a BALANCED DIET which includes plenty of protein and a moderate intake of unsaturated fat

• Eat REGULAR MEALS• AVOID EXCESSIVE SUGAR AND SNACKS• AVOID GRANULAR FOOD like nuts, seeds, chips, whole

grain breads etc. for a couple weeks while the tissue seals up,• Increase your intake of vitamins and minerals. VITAMIN C

and ZINC are the most important.

LIFESTYLE, NUTRITION & EXERCISE

• AVOID SMOKING. Smoking promotes anaerobic conditions, slows down healing, reduces circulation, and depresses certain immune cells

• EXERCISE REGULARLY. Exercise increases circulation to bring in building blocks and oxygen to the tissues as well as the vitamins and minerals that permit proper uptake.

RECOVERY PROCESS OF TIP

Day 1: BOST treatment  Day 2: Patient restarts oral hygiene  Day 3: Bleeding stops, follow-up check   Day 4: Pockets start to fill in  Day 5: Inflammation continues to recede Day 8: Pocket is sealing up  Day 14: Resume normal chewing  Day 15: Check-up  Day 30: Pockets have filled-in  Day 35: Esthetic restorations can start  Day 45: Bone is beginning to heal  3 months: Check-up  9 months: Bone is completely healed

The principal points in relation to the patient acceptance and active

participation are : • minimize extractions in the initial phase,

giving their healing potential a chance to save teeth,

• rapid, comfortable full mouth treatment not painful,

• fast healing that restores comfort • moving on to restoration and esthetic

phase quickly.

ADVANTAGES OF TIP OVER TRADITIONAL FLAP SURGERY

• No incisions or sutures• Hygiene restarts the next day • No Necrosis of bone as With incisional flaps, because

bone surface stays covered with fluid , protected and retains its circulation.

• The gingival tissue tends to stay near it's original height thus preserving esthetics and minimizing sensitivity

• No wound from cutting and bone surface death means the immune reaction is fast regeneration healing rather than slow wound healing with scarring and bacterial colonization of dead tissue (by spirochetes). With regeneration healing, inflammation quickly leaves..

TIP sets up all the conditions where the body can get out of the defensive phase against bacteria and other microorganisms and into a regeneration phase to heal back a new attachment .