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PERIODONTAL DRESSINGS AND RECENT ADVANCES
- 2. Def: -covering, protective or supporting aid for diseased or injured part of body.
- 3. Periodontal dressingswere first introduced in 1923 by - To protect surgical sites from trauma, which also increased the patients comfort, prevented wound contamination by oral debris.....
- 5. Box andHam described the use of a zinc oxide eugenol dressing to perform a chemical curettage in treatment of NUG. Orban described a zinc oxide eugenol dressing with Paraformaldehyde to perform gingivectomy by chemosurgery. Pocket depth reduction extensive necrosis of gingiva and bone, and was susceptible for abscess formation.
- 6. Bernier andCaplen stated that the primary purpose of periodontal dressing was wound protection, and that constituents which may aid in healing are of secondary importance. Ariaudo and Tyrell recommended using a dressing to position and stabilize an apically positioned flap. Blanquie felt that the purpose of a dressing was to control post operative bleeding, decreased post operative discomfort, splint loose teeth, allow for tissue healing under aseptic conditions, prevent reestablishment of pockets and desensitize cementum.
- 7. Gold feltthat a dressing could be used to splint teeth as long as it was a cement dressing that set hard. Shapiro packed zinc oxide eugenol impregnated cords into periodontal pockets but found them less effective than gingivectomies in reducing pocket depth.
- 8. Baer etal stated that the primary purpose of the dressing was to provide patient comfort and protect the wound from further injury during healing. They pointed out that a dressing should not be used to control post operative bleeding, which should be controlled during the surgery, nor should be used to splint teeth, which should be done prior to surgery.
- 9. Protection –irritation. Enhancement - comfort Debris free area. Reposition of soft tissue/ Retention; additional stabilization of a soft-tissue graft, protection of suture. Control bleeding
- 10. Act astemplate and prevent excessive formation of granulation tissue. Protects newly exposed root surface from temperature changes and Stabilizes /Splinting of postsurgically mobile teeth Psychological comfort provided to the patient after surgery.
- 11. Should besoft, but still enough plasticity and flexibility to facilitate its placement & adaptation. Harden within reasonable time. Sufficiently rigid to prevent fracture and dislocation. Smooth surface - prevent irritation to the cheeks and lips.
- 12. Should havebacteriacidal property to prevent excessive plaque formation. Not interfere with healing. Dimensional stable to prevent salivary leakage and accumulation of plaque debris It should have acceptable taste.
- 13. Periodontal dressings aregenerally divided into the following three categories: (1) Those containing zinc oxide and eugenol (2) Those containing zinc oxide without eugenol Coe pack Periocare Periopac Perioputty Vocopac (3) and Those containing neither zinc oxide nor eugenol/Others. Photocuring periodontal dressing: Barricaid Collagen dressing Methaccrylic gel Cyanoacrylate
- 14. Powder andliquid form Paste form Ward’s wonder pack
- 15. The powder-- Zno, powdered pine, resin, talc and asbestos and Liquid -- isopropyl alcohol 10%, clove oil, pine oil, peanut oil, camphor and coloring agents.
- 16. a) Powderand liquid form/ Krikland pack- dressing material is obtained by mixing powder and liquid. Powder Liquid Zinc oxide Tannic acid Rosin Kaolin Zinc-sterate Asbestor Eugenol Peanut oil Rosin Antiseptic & Astringent Haemostatic Filler, speed reaction Anesthetic and astringent Setting time
- 17.
- 18. Can bemixed in large quantity--wrapped in aluminium foil and (frozen) refrigerated. Splinting since it adheres to the teeth and The haemostatic effects -- tannic acid. Firm, heavy and easy to manipulate --do not stick to the clinician finger.
- 19. Material isfirm-- more pressure to manipulate and adapt the dressing to the soft tissue. Rough surface-- plaque accumulation and bacterial proliferation A hard setting consistency that may complicate removal if engaged in an undercut
- 20. The inabilityto adhere to mucosal surfaces The distinct taste of eugenol while the pack is in place Possible allergic reaction to eugenol -- burning pain and reddening of the treated area.
- 21. Paste form: - Available in base and accelerator pastes: Base Accelerator Zinc oxide 87% Oil of clove or eugenol12% Vegetables or mineral oil gum or polymerized resin 50% 13%- Plasticizers Filler (silica type) 20% lanolin 3%, resinous balsam 10% Cacl2-accelerator solution. Canada balsam and peru balsam – increase flow and improve mixing properties.
- 23. Advantages: - Pleasantcolor and neutral taste Pliability, which facilitates removal from undercut areas Absence of eugenol and asbestos. Smooth surface- comfortable to the patient, resists biofilms and debris deposits.
- 24. Disadvantages: - Inabilityto adhere to mucosa; premature loss Minimal splinting ability due to its soft, rubbery consistency Absence of tannic acid in the material.
- 25. Coepak: -most common Two paste or auto-mixing system containing in syringe. Working time is approximately 15 to 20 minutes. Few drops of warm water during mixing or by immersing the pack into a bowl of warm water just after mixing.
- 27. Base contains Acceleratorcontains Rosin Zinc oxide Cellulose Vegetable oil Natural gums and waxes, Fatty acids Chlorothymol Chlorothymol Magnesium oxide, Silica Zinc acetate Synthetic resin, Coumarin Alcohol. Lorothidol (a fungicide)
- 28. It isavailable in form of paste & gel and setting occurs by chemical reaction. Paste: Zinc oxide, magnesium oxide, calcium hydroxide, vegetable Oils. Gel: Resins, fatty acids, ethyl cellulose, lanolin, Calcium hydroxide.
- 29. It isa pre-mixed zinc oxide non eugenol dressing. It contains Calcium phosphate, Zinc oxide, acrylate, organic solvents, flavoring and coloring agents. When exposed to air or moisture, it sets by loss of organic solvent. After it is set, this dressing becomes quite brittle.
- 30. It contains 90gms base and 90 gms catalyst. No gingival irritants. Retains its tough elastic qualities. Does not become brittle. Adheres excellently to the teeth. Promotes healing. Mixing time is about 20 to 30 sec Applicable for approx 10-15 minutes.
- 31. Dressing incurrent use Methyl- and propyl - parabens for their effective bactericidal and fungicidal properties Benzocaine as a topical anesthetic.
- 33. It isa light cure periodontal dressing with a single component. Less time consuming. Syringe form for direct application--single time usage. Curing is done using a visible light curing unit resulting in a firm elastic covering. It might be tinted for esthetics.
- 34. Polyether urethanedimethacrylate resin, silanated silica. Visible light cure(VLC) photo initiator and accelerator, stabilizer, colorant. The polymerisable monomer - may cause skin sensitization in susceptible persons. Discontinued if skin sensitization occurs or known history of allergy from methacrylate.
- 35. Advantages: - Colormore like gingiva than other dressing material. Setting does not begin until activated by light curing unit. Removal easy, often comes in one piece. Disadvantage: - Exposure before placement should be limited as daylight in a room may begin the activation process.
- 36. Absorbable collagen--promot wound healing ex. Collacote Type-1 collagen derived from bovine Achilles tendon. 3mm thick; absorb fluid 30 to 40 times its weight. Available in sterilized unit package. It is used to cover palatal graft site during healing. Bullet shape to use for deep biopsy. Dressing may be placed on clean moist or bleeding wounds.
- 37. Primarily thesedressings are used as tissue conditioners as they have elastic like consistency that is soft and resilient ie thixotropic in nature Cannot be used alone as dressings because of their poor retention-- conjunction with a zinc oxide non - eugenol dressings. More stiffness has been obtained by the inclusion of zinc oxide powder. Ability to carry and release medicaments to the soft tissues.
- 38. Lot ofstudies have been reported regarding the modification of methacrylic gel with special emphasis on the ability of the material to carry and release Chlorhexidine acetate. Studies demonstrated effective release of the chlorhexidine from the dressing
- 39. In 1960’sSurindar N. Baskar studied the ability of certain chemical substance to adhere to and cement moist, living tissue. Cyanoacrylate They eliminated the need for suture, provided haemostasis and were biodegradable in 7 to 10 days. Cyanoacrylate compound that proved acceptable to living tissues were iso-butyl or n-butyl periodontal dressings used as alternative to suturing and as a surface adhesive. Orofacial wounds Periodontal wounds
- 40. He alsodemonstrated that n-Butyl cyanoacrylate is more tissue tolerant than conventional periodontal dressings. In comparison to the conventional dressings the material can be easily applied, produced quick hemostasis, had minimal bulk, reduced post operative pain allowed faster wound healing, stimulated less granulation tissue proliferation and is the replacement for sutures.
- 41. Cyanoacrylates iseither applied in drops or sprayed on the tissue. Cyanoacrylates have been used for surface application only; adhesive that becomes trapped under the soft tissue flap will delay wound healing.
- 42. Advantages Easy adherenceto living tissues, Lack of evidence of systemic toxicity or sensitivity, Excellent healing results, Precision placement of flaps, Decreased suturing time, Reapplication over existing material and Patient preference over bulky dressings. Lack of apparent side effects,
- 43. Disadvantages Difficulty inapplication around posterior teeth Rapid polymerization upon contact with small amounts of moisture.
- 44. Antibiotics andother anti-bacterial agents are added to periodontal dressings in order to reduce infection and promote healing. Antibiotics like Terramycin, Tetracycline in dressings following gingivectomies have been used. Fraleigh using Terramycin in dressings following gingivectomies, showed a definite antimicrobial effect and accelerated healing and also patients experienced less odour unpleasant taste and were more comfortable, however some patients developed allergic reactions.
- 45. Inclusion ofantibiotics in periodontal dressings encourages the growth of Candida albicans and yeasts. According to Sadd & Swenson incorporation of Corticosteroids and Dilantin into a dressing was of no value in healing. The addition of Chlorhexidine gluconate to methacrylic gel dressing has an effective antibacterial activity.
- 46. Asbo-Jorgensen etal, a dressing containing chlorhexidine promoted healing because of decreased bacterial colonization of wound. The efficacy of chlorhexidine appears to be related to its mode of application. When chlorhexidine was used with a dressing i.e when patients were instructed to rinse with 0.2% chlorhexidine, no significant reduction in plaque was observed.
- 47. When thedressings were rolled in 15-20 mgs of chlorhexidine, a significant reduction of plaque was observed. The overall results of the studies indicate that chlorhexidine is a valuable asset in post surgical care as it inhibits the plaque growth.
- 48. Mucosal coverage- for a short time (24 to 36 hours). Stomahesive is a gelatin like material with an adhesive surface protected by a paper coating. After the paper is removed, the product may be placed on mucosal surfaces, and it will adhere if it is slightly warmed by gloved hands and the warmth of the oral environment. The longevity - minimal; adequate for protecting the donor and recipient sites of a soft-tissue graft or a gingivoplasty procedure.
- 49. A non-eugenol-containingperiodontal dressing. It contains of ZnO, rosin and Zinc Bacitracin in mixed in an ointment of zinc oxide and hydrogenated fat. The purpose is to aveliate pain in surgical areas where bone is exposed, which requires two or more weeks for maturation.
- 50. Mucogingival surgical--Necessary or not Ideal dressing Does not move and does not require removal procedures that would tug on sutures. Provide stability for the graft Minimize bleeding and Prevent blood from collecting between the graft and the receptor site.
- 51. Cyanoacrylate dressingssuch as isobutyl cyanoacrylate or trifluor isopropyl cyanoacrylate are excellent for these purposes Free gingival graft receptor sites and connective tissue sites Dressing may not be necessary Stomahesive bandage has the advantages of maintaining the adaptation of the graft to the receptor bed and minimizing bleeding or blood pooling. The simplicity of placement -- dressing of choice.
- 52. Coe Pakor an alternative has the disadvantages of difficulty of stabilization when papillae completely fill interproximal spaces and Movement of the pack during healing will disrupt the tenuous, developing union of graft and receptor site. Mucogingival osseous- Coe Pak or an alternative becomes the dressing of choice because the opening of interproximal spaces permits solid, stable pack application
- 53. To minimizebleeding and protect the donor area from the tongue and food. Isobutyl cyanoacrylate and trifluor isopropyl cyanoacrylate work well for this purpose Otherwise the selection of a dressing seems to be the dentist’s choice. Use of a Stomahesive bandage is favored
- 54. Colycote orSurgicel, both of which minimize bleeding- - not as well as Stomahesive bandage does. Still others may favor placing Coe Pak and suturing it in place; this is a tedious process that results in poorer control of bleeding, Coe Pak does not require replacement. A palatal stent is favored by others.
- 56. Interlocking ininterdental spaces and joining the lingual and facial portions of the pack. In isolated teeth or when several teeth in an arch are missing, splints and stents or dental floss tied loosely around the teeth enhances retention of the pack. To keep dressings stabilized or reinforced various devices have been used. These include ligature wires, cotton tapes, stents & splints. However they add to plaque accumulation.
- 57. Preparing thepatient: The purpose of periodontal dressing should be discussed with the patient and Describe how it will be placed as well as how it will taste, feel and look in the mouth. In order to prevent adhering -- petroleum jelly is applied.
- 58. Pic ofmixing and apllication Homogenous mix
- 59. A properly placedand adapted periodontal dressing
- 60. After placingthe dressing patient is instructed for proper care of dressing and oral hygiene procedures. Patient should be cautioned not to get his periodontal pack dislodged within first few hours. Spicy food should be avoided immediately after surgery. Patient should thoroughly rinse mouth after eating and floss only other areas of mouth.
- 61. Pt shouldbe given instruction to avoid eating and drinking within first few hours after surgery. Pt should brush carefully on occlusion i.e. uncovered surface of the tooth. Pt recalled after 3-5 days for dressing removal and tissue evaluation. Dressing may be replaced when the healing is still taking place.
- 62. If thedressing becomes dislodged before the removal appointment, the healing has to be evaluated. When dressing remains intact for 4or5 days, replacement may not be necessary. When replacement is indicated, the dressing should be replaced in its entirety rather than in patches. Instruct the pt to continue with daily frequent biofilms removal and rinsing using antimicrobial agent.
- 63. Gingivectomy Thecut surface is covered with a friable meshwork of new epithelium If calculus has not been completely removed, red, beadlike protuberances of granulation tissue will persist. The granulation tissue must be removed with a curette Flap operation- the areas corresponding to the incisions are epithelialized but may bleed readily when touched.
- 65. Tissue irritation: Culture studies with eugenol and non-eugenol dressings show that with minor variations, both can be cytotoxic against fibroblasts, and polymorphs. Culture studies of cyanoacrylates on mouse fibroblasts show that a short side-chain molecule (methyl cyanoacrylate) is considerably more toxic than one with a long side chain (isobutyl or n-octyl cyanoacrylates). However, all substances tested showed definite cytotoxicity
- 66. Tissue disturbance: Dressings do contribute to plaque retention and may promote bacterial proliferation at the surgical sites. It is important that tissue flaps and grafts should remain precisely adapted and be undisturbed by dressing materials. Introduction of cyanoacrylate under a flap could impair healing It was also noted that overextension of the adhesive into the vestibule led to mucosal ulceration, and a tissue adhesive cannot be moulded like a conventional dressing.
- 67. Allergy : About two-thirds of patients were sensitive to eugenol. Antibiotics are a well-known source of allergic reactions, but neither Fraleigh (1957) nor Baer et al. (I960) detected any true allergies in their respective studies with tetracycline and bacitracin.
- 68. Asbestos-related disease: Asbestos has been incorporated into numerous dressing materials as a binder and filler. Dyer (1967) pointed out that asbestos had not only been incriminated in chronic destructive lung disease, but also in carcinoma of the lung and mesothelioma. Liver toxicity : Tannic acid was also used in some dressings but absorption of this substance may lead to liver damage.
- 69. Bacterial ecology: If an antibiotic is employed, two possible problems may occur: emergence of resistant organisms, and opportunistic infection. However, Ramanow (1964) found the clinical signs of candidiasis occurred when using tetracycline in dressings and that bacitracin enhanced the growth of yeasts.
- 70. Effects onwound healing : Although it has been customary for many years to apply dressing following periodontal surgical procedures, there is still confusion concerning the influence of such preparations on wound healing process. As setting occurs dressing undergoes dimensional changes leading to the movements of its deep surface over the surface of the gingiva and alveolar mucosa. The bacteria were found in groups of varying size, consistent with appearance of bacterial plaque, and vitality was evidenced by the frequent presence of actively dividing organisms- cocci or rods.
- 71. Therefore thedressing should be removed whenever possible within one week of application Although Dernier and Kaplan concluded that the use of a dressing following periodontal surgery facilitated healing, majority of the human studies published generally agree that the use of a dressing does not influence the healing. These data seem to support the current concept that a dressing functions primarily by assisting healing indirectly through protection of the wound from further injury and secondarily by providing patient comfort.
- 72. Disadvantages ofusing dressings include compromised esthetics and delay in healing after the first few postoperative days. Great variability in determining the need for a dressing and choosing the appropriate one exists. Conservative guidelines: - Anterior segments - esthetic problems… not placing a dressing is a reasonable option Stomahesive bandage - minimizes early postoperative bleeding and further stabilizes the flaps.
- 73. Mandibular anteriorsegments- Mobility with considerable bone loss- Coepack or non-dissolvable pack. Complete closure & little mobility - Stomahesive bandage. Posterior segment- incomplete closure - Coe pack/ alternative pack. Complete closure- no pack
- 74. Checchi (JP 94)24 APF; 1 quadrant dressing other no dressing. No additional relief of discomfort. Loe and silness With and without dressing In absence of dressing complete healing Stahl et al With and without dressing – gingivectomy Dependent on the rate of healing Smeekens et al (92) Barricaid and eugenol dressing No difference in wound healing- microulcer in eugenol dressing.
- 75. Use ofperiodontal dressing has been wide spread for many years. Recently, however, there is a great deal of debate over the value, of usefulness and their effects on periodontal wound healing. The primary purpose of dressing was to provide comfort and protect wound from further injury during healing. However conflict reports exist in literature. Studies based on effect of periodontal dressing on wound healing indicated that periodontal dressing do-not improve post-operative healing
- 76. Placing the periodontaldressing depends on the post surgical conditions and the priorities of the clinician.
- 77. Clinical Periodontology10th edition - Carranza Clinical Periodontology & Implant Dentistry 5th edition - Jan Lindhe Atlas of cosmetic & reconstructive periodontal surgery – 3rd Ed Edward S. Cohen Sources from net
- 78. Critical decisionmaking in periodontics-4th Ed Hall. Clinical practice of the dental hygienist- 9th Ed Esther M. Wilkins. Concise encyclopedia of Periodontology- David C. Vandersall.
Editor's Notes
- #4 The use of periodontal dressing arose from the desire to stabilized periodontal flaps and immobilized soft tissue grafts. Other advantage includes tooth desensitization, tooth splinting and attempt to prevent excessive proliferation of granulation tissues.
- #6 All though pocket depth reduction was achieved, this dressing caused extensive necrosis of gingiva and bone, and was felt to promote abscess formation by the blockage of exudate.