PERIODONTAL REGENERATION - start 06-27-12 = = = DEMINERALIZED BONE MATRIX - DBM -  INJECT-ABLE BONE FILLER - This appears to be the real stuff. Find a void that just happens to be surrounded by viable epithelial tissue and lack of infection and stick it in. Dilute with HA? 16g needle? - questions questions issues issues - real life is it is not so easy. In particular if it is thin enough to flow through a needle it is probably not thick enough to actually help. If you look at the pictures the surgeon mostly cuts things open don't they and uses a spatula. They don't just stick the stuff in with a needle.  Plus the DBM is expensive and also happens to be a controlled substance. Can you fill an abscess void with this stuff? - NO TO HIGHLY DOUBTFUL - So where could this possibly be pulled off? Possibly between the front teeth with cratered regressive gums where the epithelias tissue looks perfectly healthy and where the periodontal disease has been eliminated. Here you can imagine the regressed gum like a balloon. Just fill it up Jack! - TRY IT YOURSELF? DUMB IDEA - Why not just find a periodontist who believes in injectable bone? How about trying that instead? "Here Mr Surgeon, you just take your needle and stick the stuff it in okay? And save your stories for your next patient, ok?" WHY WON'T THIS WORK WITH ABSCESSES? Because the hole is open, that is why. You have a pocket that goes down real deep real deep and you want the hole to fill in with bone, right? But what is on the bottom of the hole? Some cheap crappy BS epithelial tissue? If you are lucky! But more likely you have what is known as..  ESCHAR ...  What is eschar? - ESCHAR IS BASICALLY A SCAB - DEAD END - NO FUTURE -  Eschar is basically dead dry crappy crud that got de-hydrated. Is it going to regenerate? NO. Is it easy to get the eschar to come loose so it can get replaced with real life epithelial tissue? Again the answer is NO. Eschar turns into a sort of permanent scab. WHAT ARE YOUR OPTIONS? - Don't want to sound pessimistic, but largely you are SOL unless you can get the eschar to heal and form some type of healed periodontal epithealial (real live skin) layer. Though alternately the surgeon may be able to somehow "flap over" some nearby real life epithelial tissue skin-like membrane and somehow seal in a pseudo-bone filled chamber. But if everything is destroyed where is the surgeon going to get the flap from? Plus if the epithelial tissue is only a few layers thick how can anybody flap it? NOT GOING TO HAPPEN. ANY OTHER POSSIBILITIES? - Yes, if somehow the underneath part of the hole can be made perfectly clean, like perfectly clean, which is almost impossible, then over a period of time the upper areas will tend to remodel. So maybe you can grow some epithelial tissue back well enough that a hole can be sealed in. GFL. But if things are destroyed too bad then there is too much remodeling to do. But otherwise you may be able to retain a clean hole for years and years and might get better luck later, if the infection has not burrowed in even deeper and destroyed your wonderful project in the meantime. = = = WHAT ABOUT THE OTHER STUFF? Yes there may be a few other possibilities. Hydro-X or whatever it is called, TCP etc. Again the logic is to stick the stuff into a closed clean space. BUT also consider that if mineral gets into the presence of nerves it can damage them or even destroy them. SO YOU JUST KILLED YOUR TOOTH or YOU JUST DAMAGED ONE OF YOUR FACIAL NERVES! BRIGHT IDEA HUH? - Yes, so best to stay away from any crazy regeneration ideas. WHAT ABOUT PLAIN OLD GELATIN? - LIKE KNOX GELATIN? WHICH IS JUST COLLAGEN ISN'T IT? - Yes, there is some possibility that in a perfectly clean environment, essentially lacking much of any infection at all, that gelatin-collagen irrigation could get absorbed by the cheesy epithelial tissue and get absorbed by the bone and help fatten it up. Or likewise get absorbed by the cheesy epithelial tissue itsself. However, the gelatin is too wide to pass through the spaces between the cells. So this so-called "vision" may just be a fantasy, not real at all. But who knows, maybe some of it can get through. Like those collagen advertisements for beautiful skin, sort of like that. Maybe not pure fantasy. WHAT IS THE PROBLEM WITH GELATIN?  The basic problem with gelatin is it is food for the bacteria. But maybe not. Maybe it isn't really food. Or maybe the gelatin will get turned into a protein slime layer of some type that is counterproductive. In any case haven't read anything about collagen treatments for periodontal disease, so there is no reason to think it would be helpful. And could cause some minor harm. Personally I have thought about it a lot but have never tried it, mostly due to active infection. Plus for areas that are perfectly clean it is not necessary. The body gets all the collagen it needs internally. So could it help? Who knows? Maybe yes, but probably no. MAYBE YOU ARE JUST TOO LAZY TO TRY THE GELATIN AND ARE LOOKING FOR AN EXCUSE FOR YOUR OWN LAZINESS? - Maybe. Maybe gelatin has potential, maybe. And with some generous ambitious plan the body will just suck it right up. Maybe. But if you are going to be ambitious try HA instead. Since it has proven merit and seems likely to be able to get through the epithelial membrane. Knock yourself out. = = = - NATURAL REGENERATION - 1 - BONE FILL - It is generally recognized by the dental community that natural regeneration is theoretically possible, but very difficult to achieve. In simple terms you can imagine two different types of regeneration. The first is related to teeth tightening up after SRP. Do they tighten? Of course they do!! So what does this mean? What it means is that some of the diseased empty areas that get hygienically cleaned then fill in with bone. So bone does grow back, in spite of all the myriad of claims you have heard otherwise. It fills in! Likewise you can imagine the experience of orthodontics. The tooth is pushed back. The bone fills in behind the tooth. So does bone grow back? Of course it does. So when people say bone does not grow back they only mean it doesn't grow vertically, past its fill level. BTW the tales about how bone doesn't grow are similar in intent to the tales about how teeth drift and bone shrivels away unless you get an implant right away. There is some truth, but largely the tale is a sales pitch. Designed to convince you to part yourself from your money sooner rather than later. While you are still warm in the chair. = = = -NATURAL BORDERS TO NATURAL REGENERATION - FINALIZED AT LEVEL OF RESULTING BONE HEIGHT - So what do these folks mean when they claim bone won't grow back? What they mean is that you won't get vertical growth beyond the natural height boundaries of the teeth. For simplicity you can imagine your bone like an above ground swimming pool. Naturally you can toss in sand up to the height of the walls, but no higher. So can the bone grow back all the way up to the height of the walls? Theoretically yes, but in practical terms it is more like a mountain valley. Where the valley fills in a little bit and gets rounder but doesn't fill in completely. Unless you are really super hygienic and real lucky it will stay a valley. And you can figure the hole will fill in roughly 1-3 mm. Or up to around 1/8th inch. Which isn't bad really. Not bad at all. Though 1mm does sound miserly. But still if it is preventing a hole into your sinus it is still a very valuable 1mm. - NATURAL REGENERATION - 2 - NORMALIZED PERIODONTAL MEMBRANE - The second part of regeneration is more complicated. It relates to how teeth are originally formed. Salamander like. Here, in simple form, presuming perfect health and perfect hygiene, there is a clean healthy junction between the existing bone, the periodontal membrane and an outer coating of the tooth called the cementum. Living cementum. If it is dead it is bad. Here if everything is perfectly clean new cementum will deposit itself onto the lowest edge of the tooth right next to the lower layer of existing living cementum. Hairs from the periodontal membrane will then insert themselves into the cementum creating a balloon-like space right above the bone-level that will fill in with cartilage and then magically transform itself into bone. Or alternately, never transform back into real bone, but survive only as immature cartilage, if the infection persists, only to get debrided out when the infection returns in full force. Like what happened to me. - HOW COME THIS DOESN'T HAPPEN? - Three reasons. The first reason is that reasonable healing cannot take place in the presence of infection. Hello? So as long as the periodontal disease is active complete healing cannot take place. The second reason is there is almost always a layer of dead cementum covering the tooth, plus latent calculus that blocks the way. So first this debris has to be removed. Which is close to impossible to do. Third is the cementum has to have stimulation to grow back from open tubules leading into the tooth. On some primitive biological level. But the tooth is covered in what is called the "slime layer." Which is a combination of slime and debris. - HOW WOULD THE NATURAL REGENERATION HAPPEN, THEORETICALLY SPEAKING? - First step would be to get rid of virtually all of the obvious periodontal infection on all the obviously exposed surface of the tooth. Second step is the so-called "de-trenching" where even more calculus is removed from below bone level, including the dead cementum. So the tooth is in fact perfectly clean, 100% clean, which is an almost impossible goal and largely is just theoretical unless somebody is a total maniac clean freak. Third step is removal of the slime layer through some sort of chemical cleaning process, called "conditioning." Typicaly using EDTA or citric acid. The fourth step might involve some sort of protein stimulation, using amelogenin, brand-name Emdogain, which stimulates the edge of bone, tooth and periodontal membrane to lay down fresh cementum and regenerate. CAN THIS HAPPEN IN A LESS COMPLICATED WAY? - Yes it can. If you can get the tooth close to perfectly clean the bone will tend to grow back even without the extra stimulation, forming the "long epithelial junction" etc. Which is not as good. But which still leaves the door open for the more advanced regeneration. Similarly it may be possible to condition teeth roots down under a closed gum, but usually it is done as a surgical process, so the dentist can see what he is doing. Same goes for the Emdogain. Only a highly skilled operator would be able to do either process successfully. = = = - EPITHELIAL CELLS FORM THE LONG-JUNCTIONAL-EPITHELIUM - Primary issue is that skin-like epithelial cells migrate into any infected areas that have been relieved of infection. These skin-like cells then form a skin-like membrane that will eventually turn into something resembling inside skin. But highly inferior. And really just a thin membrane to help the body provide security to itself. It would be the equivalent of using plastic dropcloth material to protect your home from poison gas attack. You can also think of The Epithelium as a form of interior empire of relatively modest fortifications inside the greater empire of your teeth, gums and jawbone. Protecting the perimeter from the enemy infection. Ready to move in at a moments notice to secure any areas that have been cleansed of enemy combatants and associated materiel and detritus. = = = - IS THIS SORT OF LIKE DEAD SPACE? YES IT IS PRETTY CLOSE  - WHAT IS DEAD SPACE? - For simplicity can imagine somebody with a fairly deeply open infected wound. Which then gets debrided. Essentially what happened was that the infection broke through the perimeter of the body and attempted to invade deeper portions. Meanwhile the body created various layers and membranes to attempt to stave off the infection. One of these types of layers called eschar is basically dried crud. Another type is called the extra-cellular-matrix - ECM - which is basically a series of chains that turn into nets and then fabrics and then full-fledged layers over a period of days. The ECM is how normal healing takes place.  Anyway... just to finish this off at the end of the day after all the infection is removed the area destroyed by the infection gets walled off with skin-like stuff. If it is the body it is called dead-space. But the teeth are open to the outside world at the gumline. So when the infection is relieved this is what is left behind. - WHAT IS WRONG WITH THIS? WHY CAN'T THE GUMS AND UNDERLYING BONE STILL REGENERATE? - Several reasons. First is that any latent infection will put the kibosh on any but the most rudimentary healing. But the main reason is that the skin-like material perimeter  will only allow fairly small molecules to travel between the outside world and the inside world of the body. So anything outside the perimeter is outside the body. So that obviously cannot turn into bone. Meanwhile if you try to feed the area with beneficial chemicals, such as hyaluronic acid, tri-calcium phosphate, gelatin, lactoferrin and other nice things that bone likes to eat to grow up strong and healthy the chemicals won't be able to travel through the membrane so easily either. DO I HAVE TO BELIEVE THIS? -  NO YOU DO NOT HAVE TO BELIEVE THIS - INSTEAD YOU CAN ENGAGE IN MAGICAL THINKING AND HOPE THAT MAGIC TRULY CAN HAPPEN - What does this mean? You can magically believe that the epithelial layer is not such an absolute barrier. And instead that it occasionally feels nice and friendly and will let friendly chemicals pass through into the bony portion to help it grow back. IS THIS MAGICAL THINKING TRULY JUST A BUNCH OF NONSENSE OR NOT? - Well, if you think about it, there is the entire skin care business, worth billions and billions of dollars, whose basic premise is that magical substances and concoctions can indeed travel through the barrier and do magical things. Like restore lost youth. Is the entire industry full of it? NO - the reality is most likely somewhere in between the NO of the scientists and the YES of the beauty industry. WHAT ABOUT THE NICOTINE SUBSTITUTES - DON'T THEY TRAVEL THROUGH THE EPITHELIAL BARRIER? - Yes they do. But the molecules are small. The epithelial barrier largely pertains to larger molecules. SO WHAT ABOUT HYALURONIC ACID - CAN THEY PASS THROUGH? - Most likely YES - But HA also forms chains which won't pass through so easily. = = = WHAT ABOUT TRI-CALCIUM PHOSPHATE? - These molecules also would seem small enough to pass through. But TCP also helps form calculus. So without a regenerative environment result would also include calculus. Also...  WATCH OUT! RECOMMEND STAY AWAY FROM NERVES!! - Actually don't know about TCP - Tri-Calcium Phosphate - but do know that - bone hydroxyapatite - is considered dangerous to nerves. So I would tend to avoid any wishful thinking with minerals. HOWEVER... There is what is called - Liquid Calcium - Novamin - plus several other compounds that are supposed to help rejuvinate tooth enamel. Which I largely ignore. But do use from time to time. And did have a little scare with some liquid calcium around my lower alveolar nerve, when it was wide open for the taking. So would avoid around open nerves. But if things are sealed up at least a little bit and you aren't too aggressive then can probably use these things in moderation without much issue. = = = AVOID FRANKENSTEIN STUFF UNLESS YOU KNOW EXACTLY WHAT YOU ARE DOING - Like I said, regeneration will not happen with infection. Without infection regeneration will happen spontaneously. So what is the point of Frankenstein stuff?? Sounds like a wasted effort at best and quite stupid and foolish at worst, especially if you cause damage or are wasting effort pointlessly. BUT there is room for some Frankenstein activity. The issue is where and when. Plus some mild Frankenstein is okay. Like Hyaluronic Acid! What is the harm? Nothing! What is the benefit? Could be considerable and you never know. Likewise honey is not really Frankenstein at all, just drilling mud and an infection suppressant. Nothing magical about it at all. It's just honey. = = = WHAT ABOUT GELATIN? - Personally gelatin sounds like the Holy Grail. Since it would seem to help create zombie bone which can then grow into real bone. BUT the molecules are definitely too big to pass through without some special biological function which may or may not exist. But which likely does no exist. NOTE ON COLLAGEN - 09-12-13 - For periodontal abscess complex on teeth #3(4)5 just recently discovered a deep deep abscess with dead rat smell that I am clearing out and may finally be getting to bottom. With exposed nerves and lots of hopelessness. Was going to use Knox Gelatin or Violin Gelatin Pig Glue or try to cop some bone fill on the sly. AND still feel any effort is a waste as long as any infection is left. ALSO the collagen could just feed the infection, so it could be counter-productive, don't know the answer and can't find it anywhere. But if the infection is minimized then a little collagen probably won't hurt. ANYWAY... Just bought some Fish Skin Collagen!! And what is particularly cool about this stuff is it may have some amelogenin precursors in it. Since fish scales are supposed to be a good source. But the amelogenin is probably denatured so it won't help. But nonetheless the fish skin collagen is probably just as good as the pig stuff. Alternately could use the Knox Gelatin. Idea will be to make a really thick mixture that slightly solidified at body temperature. So it doesn't leak out too fast. Which it will probably do anyway. Or could go back to the pig stuff. Since it comes in pieces. Or whatever!! Will figure something out. Idea is that there is a big hole in there, soon to hopefully be a big clean hole. With exposed nerves etc. So want it to regenerate and it is now time to do something. = = = WHAT ABOUT LACTOFERRIN? Lactoferrin also sounds like great stuff. Plus it is known to stimulate bone growth. But one treatment is not likely to help much. Think it might do well to add it to the hyaluronic acid. Dissolve the lactoferrin first. Then add the HA. Plus repeat the treatment. But don't go crazy until you already have the area close to perfectly clean anyway. Since effort in presence of infection may not do much. But I could be wrong and just being too lazy. Since irrigation programs take considerable effort and may mostly be wishful thinking.

www.diyperio.com tom@diyperio.com - - - - - -