Here’s the TIP (Tri-Immuno – Phasic periodontal therapy) –A dive to thrive!

Introduction

Periodontitis is a chronic immune-inflammatory disease characterized by the destruction of tooth-supporting structures leading to loss of clinical attachment and bone loss and eventually leading to loss of the tooth. Periodontitis may occur as an extension and spread of inflammation from the gingiva into the underlying deeper tissues. However, not all gingivitis lesions necessarily lead to periodontitis.¹ Various studies have demonstrated that periodontitis is mainly caused by biofilm containing certain pathogenic species of microorganisms that are mostly gram-negative, anaerobic, and motile.² Hence to remove the biofilm, non-surgical periodontal therapy involving scaling and root planing (SRP) is considered as the gold standard treatment. The benefits of SRP are well recognized, but few limitations can occur with SRP which includes improper removal of all the pathogenic organisms, resulting in re-growth of the biofilm which in turn requires repetitive mechanical debridement procedures which also increases the chances of bacteremia.³ Therefore, U.S. periodontal therapist William Hoisington in the year 2006 introduced a new minimally invasive non-surgical technique to treat periodontal diseases in an entirely new way, called the Tri-Immuno – Phasic periodontal (TIP) therapy. In this technique, the dentist can reach the deepest part of the periodontal pocket up to the crest of the alveolus with the help of appropriate instruments to remove all the anaerobic aggressive periodonto-pathogenic bacteria, which otherwise would have not only caused further periodontal destruction, but would have also caused systemic complications such as coronary heart disease (CHD), osteoporosis, pre-term low birth weight, and infertility by penetrating the body’s circulation from the periodontium. TIP therapy also attempts to regenerate alveolar bone via three immune phases.⁴

The rationale of TIP therapy⁵

Like as in other parts of our body, the periodontium also can heal and repair. Hence, when there is proper removal of the etiologic factors and the causes for the periodontal destruction are controlled, the alveolar bone which was damaged due to periodontal diseases can heal like other bones in our body.

Phases of TIP therapy^5,6

TIP therapy influences the etiological factors of the disease and aids in healing by three immune phases. It changes the defensive phase against the periodontopathogenic bacteria and other pathogenic microorganisms in the periodontitis sites into a regenerative phase, thereby altering the pathway of pathogenesis and progression of the disease to achieve a new attachment and to some extent cause regeneration of the alveolar bone. The three immune phases are:

• Vigilant readiness

• Defense phase

• Repair and regeneration

TIP periodontal therapy methods^5-7

• Bone One Session Treatment (BOST)

• Controlling the occlusal forces

• Oral hygiene reinforcement with adjuvant modalities

• Lifestyle modification

• Enhancing nutrition and exercise

Bone one session treatment (BOST)^5,6,8

BOST is an aerobic method of treatment that eliminates periodontal disease in the deepest pockets and supporting alveolar bone. BOST treatment of full mouth can be done in a single appointment and usually takes about 4 to 5 hours to complete. BOST minimizes damage to the gingiva, bone, and periodontal apparatus during treatment which in turn improves post-operative healing, reduces complications, and also improves the clinical outcome. It uses a technique called “The stretch flap”. This new technique allows access to the deepest parts of the root and periodontal pocket up to the crest of alveolar bone, without giving any incision.

Stretch flap technique

First step: In this step, a Universal or a Gracey curette is inserted into the deepest part of the periodontal pocket keeping the working end facing towards the tooth surface and the blunt non-working end facing the tissues. While removing the local etiologic factors, the tissues are stretched by applying slight finger pressure laterally (Figure 1). ⁵

Second step: In this step, mobilization of the tissues begins at the corners by directing the curette in a more circumferential motion. The operator must avoid pulling the papilla free and eventually creating an incisional flap.⁵

Third step: In this step, the dentist plasty the surface of the alveolar bone and removes any attached granulation tissue or degenerated attachment with the rounded tip of the curette which is done by inverting the curettes.6,8 This induces fresh bleeding from the porosities of the alveolar bone which in turn physically removes the pathogenic organisms and their toxins present in the deepest part of the pocket.⁵ The main aim is to achieve a smooth, regular bone surface and eliminate bacteria and toxins from the deepest part of the pocket and porosities of the bone (Figure 2). ^6,8

Healing phases after BOST⁷

• Defensive phase

• Regenerative phase

• The phase of new attachment formation

Defensive phase: It is also called the phase of ‘stem cell migration’. After BOST, a clot that is formed and attached to the clean and smooth bone surface acts as a scaffold. In this phase, the stem cells migrate coronally along the surface of the root at the rate of 0.5 mm per day for 8 days and make the clot layer thicker (Figure 3). ⁷

Regenerative phase: It is also called the phase of ‘maturation of attachment’. The periodontal pockets gradually start filling from the bottom with very dense, partially mineralized connective tissue during a healing period of four to six weeks, which then becomes acellular.^5-8 After (4–6) weeks of initial healing, further treatment if required can be carried out, whether elective surgeries, implant placements, orthodontic, restorative, or prosthetic treatment (Figure 4). ⁶

The phase of new attachment formation: The healing of alveolar bone takes place naturally below the newly formed mineralized acellular connective tissue attachment which was in place for about one month. In about eight more months, a dense layer of cortical bone is formed above the healed inner cancellous.^5,7,8 In about nine months, the final healed result is visible on the radiograph as a reformed cortical layer over the alveolar bone crest (Figure 5). ⁶

Controlling the occlusal forces^5,6,8

Periodontal disease causes destruction and weakening of the supporting structures, and the inability to withstand normal occlusal forces which may lead to the shifting of bite, increased tooth mobility, and further tissue damage. Occlusal forces can be controlled by the following methods – enameloplasty, coronoplasty (Figure 6), and splinting (Figure 7), which redistributes the forces among the entire dentition and improves the stability of the mobile teeth as well as provide patient comfort.

Oral hygiene reinforcement with adjuvant modalities^5,6,8

The biggest advantage of BOST therapy is that it allows the patient to start their oral hygiene from the 2nd day after the BOST therapy. In addition to the conventional methods of dental hygiene, i.e., brushing and flossing, an aerobic oral hygiene kit (Perio-aid) is advised which specifically cleans the inaccessible areas of the gingiva and eliminates the disease-causing anaerobic bacteria from the deepest part of periodontal pockets and root concavities where bristles of brush and floss cannot reach (Figure 8).

Lifestyle modification, enhancing nutrition and exercise^5,6,8

A local periodontal inflammatory response may also adversely affect the systemic immune responses of the host and the general health of the individual. Hence eating a balanced diet at regular meals, avoiding intake of excessive sugar, snacks, granular food like nuts, seeds, chips, whole grain, bread, etc. improves the overall health condition of an individual. An increased intake of vitamins and minerals is advised to boost the overall health of an individual. Most importantly, adequate intake of vitamin-C and zinc is advised. Avoid smoking as it reduces circulation, depresses certain immune cells, and delays any healing processes. Exercise should be regular because its increases circulation and permits proper uptake of nutrients and oxygen by the tissues.

The recovery process of TIP therapy^5,7,8

Day 1: Bone One Session Treatment

Day 2: Patient restart oral hygiene

Day 3: Stoppage of bleeding

Day 4: Filling of the periodontal pocket starts

Day 5: Inflammation continues to subside

Day 8: Periodontal pocket starts to seal Day 14: Normal chewing is resumed

Day 15: Checkup and re-evaluation

Day 30: Periodontal pockets are filled

Day 35: Esthetic restorations if required can start

Day 45: Healing of Bone begins

3 months: Check-up and re-evaluation

9 months: Healing of bone is completed

Advantages of TIP therapy^5-8

• No incisions or sutures mean less discomfort

• Performed without invasive surgery

• No much gingival damage

• The gingival margins tend to stay near their original height, thus preserving the esthetics and minimizing tooth sensitivity

• No necrosis of bone

• Faster recovery from inflammation

• Patients can restart their oral hygiene the next day after BOST therapy

• Any minor retreatment needed later can be easily accomplished by stretching open the tissues again

• Less complications and patience compliance is good

Conclusion

Tri-Immuno – Phasic periodontal (TIP) therapy has led to the rise of a novel method for treating periodontal diseases. It overcomes the disadvantages of traditional treatment modalities. It is a minimally invasive, costeffective procedure that not only eliminates the local etiologic factors like plaque and calculus from the deepest part of the diseased periodontal pocket, but also helps to form a new attachment and attempts to regenerate the alveolar bone as well. It creates a condition that helps the body to get out of the defensive phase against bacteria and other micro-organisms into a regenerative phase to heal back, thereby leading to a new attachment formation

Conflict of Interest

None.