To pack or not to pack: the current status of periodontal dressings

Role of eugenol

Eugenol-based dressings were formerly popular, especially following gingivectomy (11), due to their property of obtunding pain and rendering sites less sensitive. Waerhaug and Löe in 1957 (12) commented that zinc oxide–eugenol dressings seemed to prevent or retard bacterial growth based on their antiseptic properties. However, eugenol was found to irritate oral mucosal tissues, induce allergic reactions and cause tissue necrosis, particularly of bone, which led to delay in healing (13). Furthermore, it presents difficulties in manipulation and has a rough surface after setting. Histological evidence has also shown that eugenol-containing dressings produce greater tissue destruction, with more inflammatory cell infiltration and connective tissue response (14, 15). Eugenol has proven to be cytotoxic at higher concentrations and has an adverse effect on fibroblasts and osteoblast-like cells (16). All of these reasons lead to the development of noneugenol dressings in the late 1950s.

Coe-Pak^TM

Coe-Pak is the most widely used noneugenol intraoral dressing in the United States, and is manufactured by Coe Laboratories (Alsip, IL, USA). It consists of 2 pastes (Tab. II): the base paste which contains zinc oxide with added oils and gums, and lorothidol which is a fungicide related to hexachlorophene. The catalyst paste contains coconut fatty acids thickened with colophony resin or rosin and chlorothymol as an antibacterial agent. Equal lengths of material are placed on a waxed paper pad and mixed using a wooden tongue depressor until a thick consistency and uniform color is reached. The setting time can be altered by adding a few drops of warm water during mixing or by immersing the pack into a bowl of warm water just after mixing. Once the paste loses its tackiness, it can be handled and molded using gloves lubricated with water or petroleum. The pack is then formed into pencil-sized rolls that are then mechanically interlocked in the facial and lingual interproximal areas (Fig. 1) (19). The Coe-Pak is available in regular set and hard and fast set formulations, based on its setting time and consistency, and it is supplied commercially both in manual mix and automix varieties.

Cross Pack

Cross Pack was formerly the powder part of a zinc oxide–eugenol dressing in use in the late 1940s (W.G. Cross, personal communication, 1974). It consists of colophony powder, zinc oxide, tannic acid, bentonite and powdered neomycin sulphate. Cross Pack is added as a filler to Coe-Pak to give more body to the material. Zinc oxide alone can be used instead of Cross Pack if desired (11).

Peripac®

Peripac (Dentsply, Konstanz, Germany) is a paste containing calcium sulphate, zinc sulphate, zinc oxide, polymethyl methacrylate, dimethoxy tetraethylene glycol, ascorbic acid, flavor and iron oxide pigment. It reacts on exposure to air or moisture through loss of the glycol, dimethoxy tetraethylene glycol. Peripac is indicated as a dressing following gingivectomies and papillectomies, deep curettage, reattachment surgery and gingival repositioning. It can also be used in treatment of necrotic gingivitis and ulcers; protection of nonspecific lesions or sutured margins, fixation of desensitizing medicaments to cervical areas and temporary rebasing of immediate dentures in periodontal surgery (11).

Septo-Pack

Septo-Pack (Septodont, Saint Maur-des-Fosses, France) contains amyl acetate, dibutyl phthalate, butyl polymetacrylate, zinc oxide, zinc sulphate and excipient. It is a self-hardening plastic paste containing fibers in its mass. It can also be combined, as a neutral medium, with some medicines so that they can be kept in place easily on the gingiva or tooth or at the alveolar ridge level. Neither Peripac nor Septopack contains any specific antibacterial agent (11).

PerioCare

PerioCare (Pulpdent Corp., Watertown, MA, USA) is a highly elastic periodontal dressing and sets resiliently hard. It comes in a 2-paste system: 1 contains a paste of metal oxides in vegetable oil, and the other contains a gel of rosin suspended in fatty acids. Equal amounts of the pastes are dispensed, mixed and applied.

Perio Putty

Perio Putty (Cadco Dental Products Inc., Los Angeles, CA USA) is another noneugenol dressing containing methylparabens and propylparabens for their effective fungicidal properties and benzocaine as a topical anesthetic (10).

Periogenix^TM

Periogenix^TM is a noneugenol dressing manufactured by OroScience (New Line Medical Inc., Lafayette, LA, USA). It contains perfluorodecalin, purified water, glycerin, hydrogenated phosphatidylcholine, cetearyl alcohol, polysorbate 60, tocopheryl acetate, benzyl alcohol, methylparaben, propylparaben and oxygen. It has been said that this dressing accelerates healing of postoperative surgical wounds. It was also observed that wounds treated with Periogenix^TM demonstrated an up-regulation of vascular endothelial growth factors, collagens I and III, and matrix metalloproteinase levels. Periogenix^TM allows for the exchange of oxygen and carbon dioxide into and out of injured tissues. This property has been shown to promote wound healing by stimulating several processes, including neovascularization, collagen production, epithelization, phagocytosis neutrophil-mediated oxidative microbial killing, and degradation of necrotic wound tissue (20).

The main advantages of noneugenol dressings are minimal irritation of the mucous membrane, pleasant odor, neutral taste, ease of manipulation, pliability which facilitates easy removal from undercut areas and elimination of the objectionable taste of eugenol. Although they possess neither the analgesic nor antibacterial properties of eugenol dressings, they are less irritating and form a closely adapted adhesive barrier to saliva and oral bacteria (21).

Cyanoacrylate

The cyanoacrylate alkyls were obtained for the first time in 1949 by A. E. Ardis (22). It was in 1959 that Coover et al (23) synthesized tissue adhesive materials and suggested their possible use as surgical adhesives. Their chemical formula is H₂C = C(CN)COOR, where R- can be substituted for any alkyl group ranging from methyl to decyl. The earlier methyls were found to be histotoxic and thus were discontinued in clinical practice. Only n-butyl cyanoacrylate was found to be biocompatible and therefore was suggested to be used in surgical procedures (e.g., Histoacryl®; B. Braun Biosurgicals, Germany and PeriAcryl®; Glustitch Inc, Delta, Canada). As a dressing it has been evaluated clinically and histologically following procedures such as gingivectomy, mucoperiosteal flaps, excisional biopsies, free mucosal grafts, frenectomies and for oral mucosal ulcers (24). It is useful because it provides rapid hemostasis in the presence of moisture due to polymerization. It accelerates initial healing by acting as a protective barrier maintaining precise positioning of a flap or free gingival graft and also possesses antimicrobial properties (10).

Light cure dressings

Light cure dressings (e.g., Bucrylate; Ethicon Inc., Somerville, NJ, USA) is a novel concept for the protection of periodontal surgical sites. It is a single-component, light-activated dressing material supplied in a syringe for direct placement. It is cured in increments with a visible light curing unit and retains its elasticity on setting. It is tasteless and has a tinted pink translucent color, and is thus usually preferred in the anterior segment (25).

Collagen dressings

Collagen dressings (e.g., Colla products from Zimmer Dental, Carlsbad, CA, USA) are biological dressings which create a physiologic interface between the wound and the environment and encourage healing by deposition and organization of the fibers in granulation tissues formed freshly in the wound bed. The advantages over other dressings include ease of application, nonimmunogenic, nonpyrogenic, hypoallergenic properties. Moreover, an inherent property of native collagen is the ability to promote hemostasis by facilitating aggregation of platelets and subsequently, the coagulation cascade. Additionally, the structure of absorbable collagen provides a 3-dimensional matrix for strengthening the blood clot. Commercially available collagen dressings have three forms: tape (CollaTape; Zimmer Dental, Carlsbad, CA, USA), cote (CollaCote, Zimmer Dental, Carlsbad, CA, USA) and plug (CollaPlug; Zimmer Dental, Carlsbad, CA, USA). Tape is used for localized ridge defects, socket grafting, Schneiderian membrane tears, subantral augmentations and protection of soft tissue donor sites. Cote is used in procedures like soft tissue recontouring, sinus graft containment, guided bone regeneration and sinus membrane perforations, whereas, a plug is used as a dressing for biopsy sites (26).

Some surgeons reported the use of mucoadhesive/stomahesive dressing (CovaTec, Middlesex, UK), whenever mucosal coverage is required for a short period of time. It is an adhesive, nonsensitizing wound dressing which was patented by Peter L. Steer and Howard Mathew in 1982 (US Patent 3,339,546). It is a multilayered dressing including a layer of curative and absorbent material which makes contact with the wounds, a layer of deodorizing material and an outer layer which secures the bandage to the tissues. The contents include gelatin, pectin, sodium carboxymethylcellulose and polyisobutylene. The longevity of the dressing is minimal (dissolves in 8-24 hours) (see Hall (19) p. 208). However, some surgeons find this short time adequate for protecting the donor and recipient sites of a soft tissue graft or for gingivoplasty procedures (19, 27).

Dressing and chlorhexidine

Chlorhexidine is an established antibacterial agent with long-term activity in the oral cavity owing to its substantivity and slow-release properties. In 1989, most commercial periodontal dressings claiming to have initially good antimicrobial activity, lost this activity shortly after application. Thus the addition of chlorhexidine to dressings to improve their properties was proposed.

As early as 1975, Addy and Douglas (27) tested the antibacterial properties of a chlorhexidine-containing gel in vitro and in vivo, and found that methacrylate gel is a good medium for carrying chlorhexidine to the wound area and releasing it slowly.

Chlorhexidine salts were also incorporated into the dressings in the form of a powder mixed along with the dressing material. Plüss et al in 1975 incorporated 15-20 mg of chlorhexidine dihydrochloride in a periodontal dressing (Peripac) and documented a significant reduction in the amount of plaque formation (28). They attributed this to the direct contact of the powder with the teeth. In another similar study, Othman et al found that surgical dressings containing antimicrobial agents, having high retention and and slow release properties are advantages (29, 30).

Other chlorhexidine formulations such as mouth rinses and varnishes were also used adjunctively with periodontal dressings. Numerous studies in which chlorhexidine mouth rinses have been prescribed have reported significantly less plaque accumulation and less sulcular bleeding and exudate (31, 32). In a study by Zyskind et al, chlorhexidine varnish was applied prior to the application of a periodontal dressing (33). Significantly less plaque was found on teeth pre-coated with the slow-release varnish.

Numerous reports have published data regarding the benefits of addition of various chlorhexidine formulations to periodontal dressings (28-29-30-31-32, 34). Clinical trials supporting the use of periodontal dressing are tabulated in Table III. In contrast, there were trials which demonstrated no additional plaque inhibitory effects (32) and refuted the use of periodontal dressing are tabulated in Table IV. A review of the literature seems to suggest that the addition of chlorhexidine is a valuable asset in postsurgical care as it inhibits plaque growth. However, since the use of chlorhexidine mouth rinses is preferred by patients, the practice of direct incorporation of chlorhexidine powder in the dressing seems to have waned. Additionally, mouth rinses have a rinsing and washing off effect against the bacteria from the potential infection site and can reach more surfaces compared with any hard or semirigid materials.

Dressing and antibacterial agents

To enhance healing and prevent infections, the addition of antibiotics to dressings has been evaluated (Tab. V). The earliest reports outlining the use of tetracycline are by Fraleigh (55) and of zinc bacitracin, by Baer et al (56). In 1972, Grant et al discussed this subject and stated that the possible advantages of the use of bactericidal and bacteriostatic drugs in periodontal dressings had not been fully investigated and pointed out the possibility of sensitization and allergy, and the potential development of candidiasis with the use of these drugs (57).

Though the addition of these agents is beneficial, there are a few authors who claim that their addition may be harmful. Heaney et al (50) suggested the removal of the dressing within 7 days of application, as antimicrobial agents used in conjunction with dressings may allow for selective inhibition of microorganisms and bring about variations in complex oral microbiota. Two possible problems may occur: emergence of resistant organisms and opportunistic infections. In the study cited, organisms resistant to certain antibacterials predominated under the dressings used, but led to no adverse effect. Romanow (58) found that clinical signs of candidiasis occurred when using tetracycline in dressings and that bacitracin was found to enhance the growth of yeasts. In 1983, Breloff and Caffesse (59) tested the effect of Achromycin applied underneath a dressing and showed that topical Achromycin had no beneficial effect on healing.

In light of the current trend toward overuse of antibiotics, we emphasize that the antibiotics should be used only after the antibiogram (except in some acute cases such as acute necrotizing ulcerative gingivitis (ANUG)) and should not be used with all periodontal dressings for every periodontal treatment.

Other medicaments and dressings

The addition of noneugenol phenol derivatives such as chlorothymol and oil of bergamot was described by Molnar (60) and by Schach (61), respectively. To improve postoperative healing, Saad and Swenson (62) and Swann et al (63) added steroids and Dilantin to dressings. Such agents had been previously reported to increase the rate of healing in skin wounds of rats and humans, but neither agent showed any advantage in these periodontal studies.

In 2011, a study conducted by Srakaew et al (64) evaluated the possibility of metal complex formation between sodium-phosphorylated chitosan and zinc oxide. The polymer-metal complex formation was investigated in terms of thermal degradation. Indications of cytotoxicity, evaluated by a direct contact test with primary human gingival fibroblast cells, revealed that sodium-phosphorylated chitosan was biocompatible and reduced the cytotoxicity of zinc oxide by complexation, making sodium-phosphorylated chitosan/zinc oxide complexes potentially biocompatible. The authors concluded that sodium-phosphorylated chitosan could be used as a reaction rate-modifying agent (reacting speed controlling agent) in periodontal dressings.

Physical effects

With the advent of flap repositioning, advocated by Ariaudo and Tyrell (35), it was established that the periodontal dressing could be used as a stent. It was Prichard (65) who stated that a dressing was to be used to prevent postoperative hemorrhage and to protect the wound area from contact with food, concluding that a dressing “has no other virtue.” Later, Manson (66) said that a dressing is applied to protect a healing wound from saliva and trauma, thus producing comfort and enhancing healing. Ramfjord (67) stated that closed curettage causes a periodontal trauma – i.e., it often results in a relatively wide dehiscence of the buccal and lingual papillae. He advocated that after completion of the treatment, the soft tissue should be brought into close contact with the tooth again, either by interproximal sutures or by a firm dressing for better postoperative results. Wikesjo et al (37) also described elevated sensibility of healing during the first few hours and days, especially in the process of fibrin attachment to the root surface. They stated that a dressing protected the coagulum from forces exerted during talking and chewing and prevented its detachment from the root surface. Subsequently, Plagman (68) 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 so that movements of the healing epithelium were prevented and an untroubled attachment to hard tissues was guaranteed.

Recently a study was carried out by Genovesi et al (69) to 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. Their results evidently suggested that 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.

To summarize, we can say that the list of physical benefits of a periodontal dressing includes protection of the postsurgical wound from postoperative trauma, saliva, and food debris and stabilization of the blood clot. Secondly, it limits the entry of bacteria and other microorganisms which may cause infection and other complications. Furthermore, it has been suggested that it acts as a splint for loose teeth and to immobilize newly positioned grafts and flaps. We find it imperative here to mention that only the light cure dressings have this ability, and stabilization of loose teeth is not a principal goal of a dressing. The splinting of loose teeth should be done by composite- or glass fiber–reinforced composite materials prior to the nonsurgical or surgical periodontal treatment. Although none of the current studies confirm the hypothesis that splinting itself causes better healing after the periodontal treatment, they seem to suggest that the stabilization of the teeth brings better results because of the stable environment around the blood clot and dispersion of the occlusal forces to the surrounding teeth. Finally, a dressing may control postoperative discomfort in the early stages of healing.

Therapeutic effects

Ward (5) advocated the use of a periodontal dressing to bypass pain, infection and root sensitivity and to prevent formation of caseous deposits on the root surface. He felt a dressing would also act to provide temporary support after gingivectomy. Orban (70) used a zinc oxide eugenol dressing and observed that better healing occurred after gingivectomy if the dressing was changed every 2 to 4 days for 10 to 14 days. However, he also noted that if the dressing was left in place in excess of 12 days, delayed healing occurred. Box and Ham (71) described the use of a zinc oxide eugenol dressing after performing a chemical curettage for the treatment of necrotizing ulcerative gingivitis. This significantly improved the clinical parameters. Bernier and Kaplan (72) reported that the use of a dressing facilitates the healing process. They indicated that the dressing’s function as a surface barrier provided the primary benefit, while the constituents of the dressing appeared to be of secondary importance. Blanqui (73) stated that the purpose of a periodontal dressing was to control postoperative discomfort, allowing tissue healing under aseptic conditions, preventing reestablishment of a periodontal pocket and desensitizing denuded cementum.

Loe and Silness (39) reported that exposed tissue will heal irrespective of the application of a protective dressing. However, they felt that the dressing provided an environment more favorable for optimum healing. The use of isobutyl cyanoacrylates, self curing and light curing packs led Bhaskar et al (74) to consider instant hemostasis as one of its main advantages. Greensmith and Wade (42) using a split mouth surgical technique, evaluated healing after reverse bevel flap procedures with or without a dressing. They concluded that the application of a dressing led to statistically slightly better results, as indicated by a shallower pocket and lower gingival index in spite of a slight increase in inflammation. In the same year Asboe-Jörgensen et al (30) discussed the use of dressings after periodontal surgery in terms of improved patient comfort. Linsky et al (75) said that if a wound was provided with a dressing and was thereby “closed,” the inflammatory response produced was significantly lesser than that in open wounds. Eaglstein (17) mentioned that “wounds of the skin that had been provided with a dressing healed significantly faster.”

Regarding the improvement in clinical periodontal parameters, clinical probing depth and probing attachment level using a dressing following nonsurgical periodontal therapy have also been documented (17, 69).

A literature review thus 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.

Postoperative pain and dressing

One of the purposes of periodontal dressings is to aid in reducing postoperative discomfort. In earlier reports, measuring the degree of pain experienced by the patient was done based on the consumption of analgesic tablets. Such 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. Also, when sensitivity was observed, it was seen that the highest proportion of sensitive teeth was found after the use of Coe-Pak, and the lowest with Peripac (43). 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 (104). The same authors, in another study, compared pain experience after gingivectomy when using a local anesthetic agent. They reported that pain was masked when using a eugenol-based periodontal dressing, thus proving that eugenol dressings cause less pain than noneugenol ones (105).