Periodontal pack

The periodontal dressing is a physical barrier that is placed in the surgical site to protect the healing tissues from the forces produced during mastication, for comfort and close adaptation.

1. Periodontal Pack Dr. Nithin Markose Reji 1 st year PG PMS Dental College

2. Contents Introduction Rationale Classification of dressing Modification Properties of Dressing Periodontal dressing for all? conclusion

3. Introduction Wound healing -complex & dynamic process 4 phases Hemostasis Inflammation Proliferation Remodeling

4. “The germ is nothing. It is the terrain in which it is found that is everything .” Holistic fashion Terrain- plays a critical role ( Orsted HL 2011 )

5. A surgical dressing The periodontal dressing is a physical barrier that is placed in the surgical site to protect the healing tissues from the forces produced during mastication, for comfort and close adaptation.

6. These dressings are applied around the necks of the teeth and adjacent tissue to cover and protect the surgical wound after periodontal surgery ( Zwemer TJ et al in 1993)

7. Rationale Bandage over the surgical site Holding the flap in place Postoperative pain, infection & hemorrhage Protecting the surgical site from trauama during eating and drinking supporting mobile teeth

8. History of Pack Zentler in 1918 -1 st periodontal dressing - iodoform gauze.- A. W. Ward in 1923 - Wondrpak -word pack ---1 st time Bernier and Kaplan in 1947 – for wound protections. Box and Ham in 1942 – Zno Eugenol dressing - chemical curettage - NUG

9. Ideal requisites of periodontal dressings   Plasticity Reasonable setting time. Sufficient rigidity Smooth surface Bactericidal

10. Dimensional stability Should not induce allergic reactions. Acceptable taste. Economical and easily available. Good shelf life.

11. TYPES OF PERIODONTAL DRESSINGS 3 categories ( i ) Those containing zinc oxide and eugenol , (ii) Those containing zinc oxide without eugenol and (iii) Those containing neither zinc oxide nor eugenol

12. Eugenol dressings

13. Wondrpak The first periodontal dressing introduced containing eugenol ( Ward AV in 1923 ) 2-component system

14. Powder – zinc oxide, powdered pine resin, talc & asbestos Liquid – isopropyl alcohol 10%, clove oil, pine resin, pine oil, peanut oil, Camphor & coloring materials( Haugen E in 1978 )

15. Kirkland Formula A modified form of a eugenol dressing was introduced by Kirkland It consisted of zinc oxide, resin, zinc acetate, eugenol , tannic acid and olive oil.

16. Evoluttion of ZnOE Dressing Products-eliminated Products such as asbestos and tannic acid -eliminated Asbestos- asbestosis, lung cancer and mesothelioma ( Dyer MRY in 1967 ) Tannic acid- potential liver damage (systemically) ( Baer PN 1969 )

17. Products-Added Zinc acetate- accelerator- working time ( Newman MG et al 2006 ) ( Sachs et al 1984 )

18. Preparation of ZnOE dressing Powder & liquid are mixed -waxed paper pad - wooden tongue depressor or spatula Powder or paste -incorporated into the liquid –dough like stage used immediately/ wrapped in aluminum foil and refrigerated for up to 1week ( Newman 2006 )

19. Advantages Eugenol -based dressings - gingivectomy ( O Neil 1975 ), due to -obtunding pain & sites less sensitive. zinc oxide– eugenol dressings prevent or retard bacterial growth (antiseptic properties) ( Waerhaug and Löe in 1957 )

20. Disadvantages Irritate oral mucosal tissues Allergic reactions -tissue necrosis(bone)- healing ( Sarrami et al 2002 ). Difficulties in manipulation Rough surface after setting.

21. Histological evidence - inflammatory cell infiltration and connective tissue response ( Kreth et al 1966 ). Eugenol has proven to be cytotoxic effect on fibroblasts and osteoblast -like cells ( Alpar et al 1999 ).

22. Noneugenol dressings

23. Noneugenol dressings Most widely used periodontal dressings. Commercially available – Coe-Pak Cross Pack Peripac Septopack PerioCare Perio Putty Periogenix .

24. Coe- Pak TM Coe-Pak is the most widely used -United States, - Coe Laboratories (Alsip, IL, USA) Consists of 2 pastes First paste – zinc oxide, added oils, gums & lorothidol Second paste – unsaturated fatty acids & chlorothymol

25. Base paste

26. Catalyst paste(accelerator)

27. Preparation Equal lengths of material -waxed paper pad -wooden tongue depressor - thick consistency & uniform colour Setting time-few drops of warm water/ immersing in a bowl of warm water

28. Handled and molded - gloves lubricated with H2O or petroleum (Tackiness is lost) Formed into pencil-sized rolls Mechanically interlocked in the facial and lingual interproximal areas

29. Cross Pack Cross Pack - formerly the powder part – ZnOE – in late 1940s ( W.G. Cross 1974 ) Consists of Colophony powder Zinc oxide Tannic acid Bentonite Powdered neomycin sulphate

30. Cross Pack - filler to Coe-Pak -more body. ZnO alone can be used instead of Cross Pack if desired ( O Neil 1975 ).

31. Peripac ® ( Dentsply , Konstanz, Germany) It contains Calcium sulphate Zinc oxide Zinc sulphate Acrylic type of resin Glycol solvent Ascorbic acid Flavor & Iron oxide pigment.

32. It reacts on exposure to air or moisture through loss of the glycol, dimethoxy tetraethylene glycol Indications Gingivectomies Papillectomies , Deep curettage,

33. Reattachment surgery and gingival repositioning. Rx of necrotic gingivitis and ulcers Protection of nonspecific lesions / sutured margins, Fixation of desensitizing medicaments to cervical areas Temporary rebasing of immediate dentures in periodontal surgery ( O Neil 1975 ).

34. Septo -Pack ( Septodont , Saint Maur -des-Fosses, France) Contains- Amyl acetate Dibutyl Phthalate Butyl polymetacrylate Zinc oxide Zinc sulphate

35. It is a selfhardening plastic paste containing fibers Used as a neutral medium with some medicines for application on gingiva , tooth or at the alveolar ridge level. Neither Peripac nor Septopack contains any specific antibacterial agent ( O Neil 1975 ).

36. PerioCare ( Pulpdent Corp., Watertown, MA, USA) Highly elastic dressing & sets resiliently hard Two paste system 1 st paste – paste of metal oxides in vegetable oil 2 nd paste – gel of rosin suspended in fatty acids

37. Perio Putty ( Cadco Dental Products Inc., Los Angeles, CA USA) Contains Methylparabens , propylparabens & benzocaine Effective fungicidal properties and benzocaine as a topical anesthetic ( Sachs 1984 ).

38. Periogenix TM Manufactured by OroScience (New Line Medical Inc., Lafayette, LA, USA) It contains Perfluorodecalin Purified water Glycerin Hydrogenated phosphatidylcholine , Cetearyl alcohol

39. Polysorbate 60 Tocopheryl acetate Benzyl alcohol, Methylparaben Propylparaben oxygen

40. Advantages Accelerates healing – postoperative wounds. vascular endothelial growth factors, collagens I and III, and matrix metalloproteinase levels

41. Allows exchange of O 2 &CO 2 into and out of injured tissues. Promote wound healing -several processes Neovascularization , Collagen production,

42. Epithelization , Phagocytosis Neutrophil -mediated oxidative microbial killing Degradation of necrotic wound tissue ( Li KK 1995 ).

43. Advantages Of Noneugenol Dressings Minimal irritation of the mucous membrane, Pleasant odor , Neutral taste, Ease of manipulation, Pliability -easy removal from undercut areas

44. Elimination of the objectionable taste of eugenol . They are less irritating Form a closely adapted adhesive barrier to saliva and oral bacteria ( Singer and Thode 2004 )

45. Dressings Containing Neither Zinc Oxide Nor Eugenol

46. Cyanoacrylate Dressing, Light Cure Dressing, Collagen Dressing And Mucoadhesive / Stomahesive Dressing.

47. Cyanoacrylate The cyanoacrylate alkyls -obtained 1 st time ( 1949 by A. E Ardis ) Coover et al in 1959 synthesized tissue adhesive materials and suggested their use as surgical adhesives. Their chemical formula is H2C = C(CN)COOR, where R- any gp . From methyl to decyl

48. Only n-butyl cyanoacrylate -biocompatible -suggested in surgeries Rapid hemostasis with moisture -polymerization. It accelerates initial healing - acting as a protective barrier Maintaining precise positioning of a flap or free gingival graft Possesses antimicrobial properties ( Sachs 1984 ).

49. Light cure dressings Novel concept It is a single-component light-activated dressing material supplied in a syringe for direct placement.

50. Cured in increments -visible light curing unit It retains its elasticity on setting. It is tasteless Has a tinted pink translucent color (preferred in the anterior segment) ( Singh et al 2011 ).

51. Collagen dressings Colla products from Zimmer Dental, Carlsbad, CA, USA- egs Create a physiologic interface b/w wound and the environment Encourage healing by deposition and organization of the fibers in granulation tissues formed freshly in the wound bed.

52. Advantages Ease of application, Nonimmunogenic , Nonpyrogenic , Hypoallergenic properties. Ability to promote hemostasis by facilitating aggregation of platelets resulting incoagulation cascade.

53. The structure of absorbable collagen has a 3-D matrix for strengthening the blood clot.

54. Available as Colla tape- (Zimmer Dental, Carlsbad, CA, USA) Colla - Cote CollaPlug

55. Colla tape Used in localized ridge defects Socket grafting Schneiderian membrane tears Subantral augmentations Protection of soft tissue donor sites.

56. Colla - Cote Used In Soft Tissue Recontouring Sinus Graft Containment Guided Bone Regeneration Sinus Membrane Perforations.

57. CollaPlug Used As Dressing For Biopsy Sites ( Steer and Mathews ).

58. Mucoadhesive / Stomahesive Dressing An adhesive, nonsensitizing wound dressing –patented Peter L. Steer and Howard Mathew in 1982 Used whenever mucosal coverage is required for a short period of time.

59. It is a multilayered dressing i - a layer of curative and absorbent material contact with the wounds, a layer of deodorizing material and an outer layer which secures the bandage to the tissues.

60. It includes Gelatin Pectin Sodium Carboxymethylcellulose Polyisobutylene . The longevity -is minimal (dissolves in 8-24 hours).

61. Modifications

62. Dressing and chlorhexidine Chlorhexidine - antibacterial agent with long-term activity ( substantivity ) and slow-release properties

63. In 1975, Addy and Douglas tested the antibacterial properties of chlorhexidine -found that methacrylate gel is a good medium for carrying chlorhexidine to the wound area and releasing it slowly

64. Chlorhexidine salts incorporated dressings Pluss et al in 1975 incorporated 15- 20 mg of chlorhexidine dihydrochloride in a periodontal dressing ( Peripac )– documented in the amount of plaque formation. –due to direct contact of the powder with the teeth.

65. Othman et al 1989 found that surgical dressings containing antimicrobial agents, having high retention and slow release properties.

66. Chlorhexidine mouthrinses and varnishes Chlorhexidine mouth rinses - less plaque accumulation and less sulcular bleeding and exudate ( Addy and Dolby 1976 , Zyskind et al 1992 ).

67. In a study by Zyskind et al 1992 , chlorhexidine varnish was applied prior to the application of a periodontal dressing -Significantly less plaque was found on teeth pre-coated with the slow-release varnish.

68. Studies -Favour Of Addition Of Chlorhexidine To Periodontal Dressings Pluss et al 1975 Othman et al 1989 Asboe – Jorgensen et al 1974 Addy M, Dolby AE 1976 Newman 1978 Bay LM 1978

69. Addition of chlorhexidine -postsurgical care as it inhibits plaque growth. Chlorhexidine powder in the dressing seems to have waned due to the use of chlorhexidine mouth rinse

70. Mouth rinses have rinsing and washing off effect against the bacteria -can reach more surfaces compared to chlx incorporated dressing

71. Dressing and antibacterial agents To enhance healing and prevent infections, The earliest reports outlining the use of tetracycline are by Fraleigh (1956) and of zinc bacitracin , by Baer et al (1958).

72. In 1972, Grant et al stated that the possible advantages of the use of bactericidal and bacteriostatic drugs in periodontal dressings -not been fully investigated There is possibility of sensitization and allergy, development of candidiasis with the use of these drugs.

73. Studies Showing Antibacterial Properties Of Periodontal Dressing Coppes et al (1967) in comparison presence of microorganism in eugenol and non- eugenol dressings, - Bacteroides melaninogenica are higher under eugenol -free dressings.

74. Heaney et al (1972) took a bacterial sample from the areas under two periodontal dressings.- microbes under Coe-Pak were gram-negative rods, & incidence of yeasts was higher under ZOE dressing

75. In evaluation of healing process, O’Neil (1975) revealed Coe-Pak, Cross-Pak, Peripac , Septo -Pak, ZOE had no antibacterial properties, and ZOE had minimal antifungal properties. Haugen and Gjermo (1978) revealed that Wondrpak , Coe-Pak and Peripac had antibacterial effects

76. Ikeda T et al (1984) and Woodcock (1988) in their studies revealed that polyhexamethylene biguanide (PHMB) have better physical properties than chlorhexidine . PHMB has extensive antibacterial activity against a wide range of gram-positive bacteria and fungi and causes destabilization of the bacterial cell membrane.

77. Problems associated with the addition of antibiotics Emergence of resistant organisms and opportunistic infections. Romanow (1964) signs of candidiasis occurred when using tetracycline in dressings and that bacitracin was found to enhance the growth of yeasts.

78. In 1983, Breloff and Caffesse tested the effect of Achromycin applied underneath a dressing and showed that topical Achromycin had no beneficial effect on healing.

79. Other medicaments and dressings The addition of noneugenol phenol derivatives such as Chlorothymol - Molnar E J Oil of bergamot - Schach 1968 Steroids and Dilantin - Saad and Swenson (1965 ) and Swann et al (1975) increase in the rate of healing in skin wounds of rats and humans, but neither agent showed any advantage in these periodontal studies.

80. Srakaew et al 2011 evaluated the possibility of metal complex formation between sodium- phosphorylated chitosan and zinc oxide. sodium- phosphorylated chitosan could be used as a reaction rate-modifying agent in periodontal dressings.

81. Substitutes for dressings In 1975, the modification of a methacrylic gel for use as a periodontal dressing was attempted, and the results suggested that the modified methacrylic gel fulfilled the requirements of a periodontal dressing. However, further research was proposed for the use of this gel as a dressing ( Pluss 1975).

82. Solcoseryl dental adhesive paste In 1990, a study was carried out with the aim of evaluating the healing of the gingival grafts covered with Solcoseryl dental adhesive paste in comparison with the grafts covered with Peripac . The results indicated that the adhesive paste can be used as a periodontal dressing ( Steer PL ). Thus, the use of adhesive pastes was also considered as a substitute for conventional dressings ( Ariaudo and Tyrell 1967)

83. Benefits of a dressing physical benefits and therapeutic benefits

84. Physical benefits could be used as a stent- Ariaudo and Tyrell (1957) Prichard (1972) stated that a dressing can use to prevent postoperative hemorrhage and to protect the wound area from contact with food,and concluded that a dressing “has no other virtue.”

85. Manson (1975) said that a dressing is applied to protect a healing wound from saliva and trauma, thus producing comfort and enhancing healing

86. Wikesjo et al (1992) described elevated sensibility of healing during the first few hours and days, especially in the process of fibrin attachment to the root surface in presence of dressing

87. Plagman (1998) recommended the covering of the wound area for 3-4 days with a periodontal pack in addition to suturing, because the dressing prevented food debris from impacting in the interdental spaces. He assumed that the coagulum had to be stabilized

88. Genovesi et al (2012) test the hypothesis that the placement of a periodontal dressing would be able to prevent detachment of coagulum, inducing proper healing and improving periodontal parameters, after nonsurgical periodontal therapy.

89. RESULTS the use of a periodontal dressing improved the periodontal parameters even after scaling and root planing . This was attributed to clot stabilization and prevention of bacterial colonization during wound healing.

90. Physical effects Protection of the postsurgical wound stabilization of the blood clot. Limits the entry of bacteria and other microorganisms Acts as a splint for loose ,newly positioned grafts and flaps. Postoperative discomfort in the early stages of healing.

91. Therapeutic effects A literature review suggests that the therapeutic effects of a dressing include control of bleeding or hemostasis , improvement in clinical periodontal parameters, desensitization of denuded root surface and prevention of reestablishment of periodontal pockets

92. Ward (1923) Orban (1941) Box and Ham (1942) Bernier and Kaplan (1947) Blanqui (1962) Loe and Silness (1961)

93. Retention of packs 1950s - numerous splints and stents were used to stabilize acrylic resin, advocated by McKenzie (1951) and later by Munns (1952). spiral saws and lengthwise cotton thread- 1953, Waerhaug and Anerud use of wire, floss, acrylic, adhesive tin foil and copper bands- Hirschfeld and Wasserman (1958)

94. cotton tapes with interdental sutures.- 1952, Castenfelt custom-made vinyl splint sealed at the periphery by a thin ring of Coe-Pak- Plüss et al (1975)

95. The ideal dressing is the one which does not require any retention. In 1992, Ferguson utilized a light-cured periodontal dressing – i.e., Barricaid in conjunction with the surgical exposure of palatally displaced maxillary canines. The procedure was very quick and simple to perform.

96. Techniques For Retention Circumdental wire buttons – the Kazanjian button (1918) Use of interdental wires in which circumdental wire was wrapped like a chord from an anterior tooth to a posterior tooth on the opposite side of the palate, across the wound. Use of bonded brackets,

97. Kondoh et al In 2003 , cotton gauze with α- cyanoacrylate was used for alveolopalatal wound dressing after alveolar bone grafting in alveolar cleft patients. It helped reduce mechanical injuries, tension from wound dehiscence and adhesion of food remnants. T-shaped cotton gauze was placed on the gingivoperiosteal flaps and was impregnated with cyanoacrylate .

98. Lisa Harpenau 2003 recommended the use of a surgical absorbable hemostat such as Surgicel , CollaCote or Avitene , applied over the wound bed over which the periodontal dressing or palatal stent can be placed.

99. Physical properties of various dressings von Fraunhofer and Argyropoulos (1979) examined Two chemically cured (Coe-Pak and PerioCare ) and 1 photocured dressing ( Barricaid ) All materials absorbed water, both Coe-Pak and PerioCare acted in a similar manner at 23˚C,

100. but PerioCare absorbed far more water at 37˚C. For Barricaid , increased light exposure had little effect on its water sorption or solubility. It was also shown that there was no difference in the solubility of each material when immersed at 23˚C and 37˚C.

101. When immersed in 0.9% KCl solution, Barricaid had no effect on solution conductivity or pH, however Coe-Pak and PerioCare were found to increase conductivity slightly and increase pH notably.

102. Adhesion Adhesion of Coe-Pak to a single tooth at 1 hour was about 7 kg, but this decreased to about 6.5 kg at 24 hours and to 5 kg at 7 days. The adhesion of PerioCare was 2 kg at 1 hour and 8.5 kg at 24 hours, but it decreased to 7.5 kg at 7 days. The adhesion of Barricaid was about 5 kg at 1 hour, which decreased to 3.5 kg at 24 hours and 1.5 kg at 7 days

103. The mechanism of adhesion of Barricaid appeared to involve mechanical locking, which differs from that of Coe-Pak and PerioCare .

104. Biological properties Effects on wound healing. Contradictory results regarding the tissue effects and intensity of inflammatory reaction with the use of a eugenolbased dressing Adverse effects ( Waerhaug and Loe 1957 ) eugenol -based dressings may cause less growth inhibition of permanent cells and primary human leukocytes than some noneugenol products

105. Haugen et al (1978) found Wondrpak as the most irritating product, followed by Coe-Pak and Peripac . noneugenol dressings are more biocompatible than their eugenol counterparts.

106. Therapeutic effects of antimicrobial agents in dressings Eugenol -based dressings were found to have a bacteriostatic effect in vitro ( Linghorne 1949 ) and were also found to alter the plaque composition as a result of selective inhibition. A comparative evaluation of periodontal dressings revealed that the antimicrobial activity of Coe-Pak was greatest, while that of Peripac was the least ( Persson 1968

107. Postoperative pain and dressing studies reported that the experience of pain was significantly more frequent after the use of Peripac than Coe-Pak and Wondrpak , based on higher tablet consumption in the Peripac group. Sensitivity highest proportion of sensitive teeth was found after the use of Coe-Pak, and the lowest with Peripac ( Kidd EA 1974).

108. Pain measurements using visual analogue scale (VAS) studies have reported that pain scores with Coe-Pak were higher than with Wondrpak after a gingivectomy procedure ( Jorkjend 1990 ). eugenol dressings cause less pain than noneugenol ones ( Skoglund 1991).

109. PERIODONTAL DRESSINGS FOR ALL? Having discussed at length the biologic and therapeutic benefits of a periodontal dressing, the question of whether we need to use a dressing for all surgical procedures remains open.

110. Sites where pack not indicated complete healing can take place even without a dressing, provided the surgical area is kept clean. no difference in healing between dressed and nondressed wounds.( Loe and Silness 1961 ) the presence of inflammation seemed to influence the rate of wound healing to a larger extent than the use of a dressing ( Stahl 1969).

111. the use of a dressing accumulates plaque-causing inflammation ( Haeney TG and Apleton 1976, Newman 1982 ), Despite these drawbacks, it appears that healing is slightly more rapid in the dressed segments.

112. Trials Supporting Pack Ariaudo and Tyrell Protection of wound from mechanical trauma, stability of the surgical site during healing process Prichard Patient comfort during healing, good adaptation to underlying gingival and bony tissue, prevention of postoperative hemorrhage or infection

113. Wikesjo et al Prevention of flap displacement in apically repositioned flaps, additional support in free gingival grafting procedures Sigusch et al Periodontal wound dressing has a positive effect on clinical long-term results

114. CLINICAL TRIALS NOT IN FAVOR OF USE OF PERIODONTAL DRESSINGS Loe and Silness - Dressing has little effect Stahl et al - Dressing accumulates plaque Harpenau - No difference in clinical parameters Greensmith -No differences in healing

115. Jones and Cassingham -Irritates healthy tissue increases chances of infection Allen and Caffesse -No difference in PD, CAL and gingival inflammation Kidd and Wade -Greater pain experience,Plaque accumulation,Subsequent microbial invasion,Nonpack areas showed better wound healing,Lesser pain scores

116. Checchi and Trombelli -No statistical differences in pain scores and number of analgesics consumed between the pack and nonpack groups. Postoperative pain with dressing Bose et al (2013) -Pronounced swelling increases plaque accumulation Increases inflammation and GCF Difficult in eating

117. Patient response Conflicting reports exist in the literature The use of chlorhexidine mouth rinse instead of a dressing has been found to reduce postoperative plaque accumulation and surgical inflammation (Newman and Addy 1982)

118. many patients experienced discomfort when a periodontal dressing was used and preferred to use a mouth rinse. Conversely, some patients exhibited a psychological feeling of protection and well-being when a periodontal dressing was put in place ( Sigusch 2005, Checchi and Trombelli 1993

119. The answer to this controversy, though still open to debate, is probably that the choice of use of a periodontal dressing is a matter of individual preference and the judgment of the operator.

120. CONCLUSION No consensus regarding the absolute indication for the use of periodontal dressings after a surgical procedure. However, the literature does elaborate on the benefits of application of a dressing postsurgically . Moreover, no periodontal dressing material has been shown to exhibit all the ideal properties – both physical and biologic.

121. Reference Rahul KathariyaHansa Jain, Tanya Jadhav J Appl Biomater Funct Mater 2014; Vol. 0 no. 0, 000-000 Dr. Triveni Kale, Dr.Nitin Dani , Dr.Tejas Patange IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 3 Ver. IV. (Mar. 2014), PP 94-98 Jan Lindhe – Clinic Periodontology & Implant Dentistry, Fourth Edition Carranza’s Clinic Periodontology , 11 th Edition. .