FACTORS AFFECTING
THE WOUND HEALING

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.c...
FACTORS AFFECTING THE
WOUND HEALING
► LOCAL

► SYSTEMIC

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LOCAL FACTORS
► 1. Infection
► 2. Surgical Technique
► 3. Haematoma Formation
► 4.Foreign body reaction
► 5.Tissue ischaem...
► 6.Topical medications and dressings
► 7.Ionising

radiation

► 8.Ultraviolet light
► 9.Movement
► 10.Type, size, locatio...
SYSTEMIC FACTORS
► 1.Aging.
► 2.Radition.
► 3.Nutrition.
► 4.Systemic infection.
► 5.Uncontrolled diabetics.
www.indianden...
6.Disease states
A. Hereditary
  Ehlers-Danlos syndrome .
B. Coagulation disorders
Hemophilia,
Von Willebrand’s disease,
F...
► C.

Vascular disorders
Congestive heart failure.
Atherosclerosis.
Vasculitis.
Venous stasis.
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D. Metabolic
Chronic renal failure
Diabetes mellitus
Malnutrition
Cushing’s syndrome
Hyperthyroidism

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► E. Immunodeficiency diseases.
► F. Malignancy.
► G. Chronic illness.

Chronic pulmonary diseases.
Chronic liver diseases...
H. Medication
►

Glucocorticoids
Anticoagulants
Antineoplastic drugs
Cyclosporin A
Colchicine

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Wound infection
►The deposition and multiplication of

bacteria in tissue with an
associated host reaction

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INFECTIOUS AGENTS
Gram-positive cocci 

Beta Haemolytic Streptococci .
Enterococci .
Staphylococci.

Gram-negative aerobic...
►Gram-negative facultative rods 

Enterobacter species
Escherichia coli
Klebsiella species
Proteus species
► Anaerobes 

B...
Recognition of wound infection
► The

classic signs of infection
include :

► Localised erythema
► Localised pain
► Locali...
►Further

criteria include:

► Abscess
► Discharge which may be viscous in

nature, discoloured and purulent

► Delayed he...
►Friable, bleeding granulation tissue
►Unexpected pain and/or

tenderness either at the time of
dressing change or reporte...
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►Treatment
► Once a diagnosis of wound infection has

been confirmed and antibiotic sensitivities
identified, appropriate ...
Surgical Technique
The rough handling of tissue or the
use of inappropriately bulky
instrumentation can lead to crushed
sk...
Haematoma Formation
Excessive bleeding and the
formation of a hematoma within the
wound not only can mechanically
disrupt ...
Foreign body reaction
A foreign body in the wound serves as an
appropriate surface for the activation of the
alternate com...
Tissue ischaemia
Local factors such as foreign bodies,
infection or strangulating sutures
significantly slow healing by pr...
Topical medications and dressings
►Occlusive or semi occlusive dressings

promote faster reepithelization. They
may also a...
►Ionising

radiation: Delays granulation
tissue formation.

►Ultraviolet light: Facilitate wound healing.
►Movement
►Type,...
SYSTEMIC FACTORS
AGE
► The physiological changes that occur with
ageing place the older patient at higher risk
of poor wou...
DEHYDRATION
This leads to an electrolyte
imbalance and impaired cellular
function.
It is a particular problem in
patients ...
NUTRITION
► Vitamin

A is required for epithelial and
bone tissue development, cellular
differentiation, and immune system...
Levenson et al suggest vitamin A benefits
the wound by enhancing ;
1.The early inflammatory phase,
including increasing th...
Vitamin C
►Ascorbic acid is an essential cofactor
for the synthesis of collagen,
proteoglycans, and other organic
componen...
► Ascorbic acid is necessary for the

hydroxylation of proline and lysine residues in
procollagen, which is necessary for ...
►Clinical manifestations of ascorbic

acid deficiency include ;
bleeding gums,
poor immunity,
easy bruising ,

and slow he...
►Vitamin

E

►Vitamin E is popular among consumers

for skin care and to prevent scar
formation.

►It functions as the maj...
►Zinc
► Zinc is an essential trace mineral for DNA

synthesis, cell division, and protein synthesis,
all necessary process...
► Copper

is a required cofactor for the enzyme
lysyl oxidase, which plays a role in the crosslinking (and strengthening) ...
►Glucosamine.

► Hyaluronic acid is an important part of the

extracellular matrix and one of the main
glycosaminoglycans ...
►Protein

and Wound Healing

►Protein depletion appears to delay

wound healing by prolonging the
inflammatory phase; by i...
►Vitamin A 25,000 IU daily Enhances early

inflammatory phase of wound healing;
supports epithelial cell differentiation;
...
►Zinc 15-30 mg daily Required for DNA

synthesis, cell division, and protein
synthesis.

►Glucosamine

1,500 mg daily Enha...
DIABETES
► The effects of diabetes on wound healing

are diverse, multifactorial, complex and
inter-related.

► Thickening...
DIABETES
► Fibronectin is the major glycoprotein

secreted by fibroblasts during initial
synthesis of extracellular matrix...
Effects of Steroids on Wound
Healing
►Anti-inflammatory corticosteroids

significantly impair wound healing.

►Corticoster...
Factors that impede wound healing
►Local

factors

►Inadequate blood supply
►Increased skin tension
►Poor surgical apposit...
►Poor venous drainage
►Presence of foreign body and foreign

body reactions

►Continued presence of micro-organisms
►Infec...
Systemic factors
►Advancing age and general

immobility
►Obesity
►Smoking
►Malnutrition
►Deficiency of vitamins and
trace ...
►Chemotherapy and

radiotherapy
►Immunosuppressant drugs,
corticosteroids,
anticoagulants
►Inherited neutrophil
disorders,...
►Clinical

features of nonhealing wounds

►Absence of healthy granulation

tissue

►Presence of necrotic and unhealthy

ti...
►Failure of re-epithelialisation
►Cyclical or persistent pain
►Recurrent breakdown of

wound

►Clinical or subclinical inf...
Complications of chronic wounds
►Sinus formation
►Fistula

►Unrecognised malignancy

►Malignant transformation in the

ulc...
►Systemic amyloidosis
►Heterotopic calcification
►Colonisation by multiple drug

resistant pathogens, leading to
antibioti...
THANK YOU
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentalacademy.com
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Factors Affecting The Wound Healing /certified fixed orthodontic courses by Indian dental academy

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Factors Affecting The Wound Healing /certified fixed orthodontic courses by Indian dental academy

  1. 1. FACTORS AFFECTING THE WOUND HEALING INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. FACTORS AFFECTING THE WOUND HEALING ► LOCAL ► SYSTEMIC www.indiandentalacademy.com
  3. 3. www.indiandentalacademy.com
  4. 4. www.indiandentalacademy.com
  5. 5. LOCAL FACTORS ► 1. Infection ► 2. Surgical Technique ► 3. Haematoma Formation ► 4.Foreign body reaction ► 5.Tissue ischaemia www.indiandentalacademy.com
  6. 6. ► 6.Topical medications and dressings ► 7.Ionising radiation ► 8.Ultraviolet light ► 9.Movement ► 10.Type, size, location of injury. www.indiandentalacademy.com
  7. 7. SYSTEMIC FACTORS ► 1.Aging. ► 2.Radition. ► 3.Nutrition. ► 4.Systemic infection. ► 5.Uncontrolled diabetics. www.indiandentalacademy.com
  8. 8. 6.Disease states A. Hereditary   Ehlers-Danlos syndrome . B. Coagulation disorders Hemophilia, Von Willebrand’s disease, Factor XIII deficiency, www.indiandentalacademy.com
  9. 9. ► C. Vascular disorders Congestive heart failure. Atherosclerosis. Vasculitis. Venous stasis. www.indiandentalacademy.com
  10. 10. D. Metabolic Chronic renal failure Diabetes mellitus Malnutrition Cushing’s syndrome Hyperthyroidism www.indiandentalacademy.com
  11. 11. ► E. Immunodeficiency diseases. ► F. Malignancy. ► G. Chronic illness. Chronic pulmonary diseases. Chronic liver diseases. www.indiandentalacademy.com
  12. 12. H. Medication ► Glucocorticoids Anticoagulants Antineoplastic drugs Cyclosporin A Colchicine www.indiandentalacademy.com
  13. 13. Wound infection ►The deposition and multiplication of bacteria in tissue with an associated host reaction www.indiandentalacademy.com
  14. 14. INFECTIOUS AGENTS Gram-positive cocci  Beta Haemolytic Streptococci . Enterococci . Staphylococci. Gram-negative aerobic rods   Pseudomonas aeruginosa www.indiandentalacademy.com
  15. 15. ►Gram-negative facultative rods  Enterobacter species Escherichia coli Klebsiella species Proteus species ► Anaerobes  Bacteroides Clostridium ► Fungi  Candida www.indiandentalacademy.com
  16. 16. Recognition of wound infection ► The classic signs of infection include : ► Localised erythema ► Localised pain ► Localised heat ► Cellulitis ► Oedema. www.indiandentalacademy.com
  17. 17. ►Further criteria include: ► Abscess ► Discharge which may be viscous in nature, discoloured and purulent ► Delayed healing not previously anticipated ► Discolouration of tissues both within and at the wound margins www.indiandentalacademy.com
  18. 18. ►Friable, bleeding granulation tissue ►Unexpected pain and/or tenderness either at the time of dressing change or reported by the patient as associated specifically with the wound even when the wound dressing is in place ►Abnormal smell www.indiandentalacademy.com
  19. 19. www.indiandentalacademy.com
  20. 20. www.indiandentalacademy.com
  21. 21. www.indiandentalacademy.com
  22. 22. ►Treatment ► Once a diagnosis of wound infection has been confirmed and antibiotic sensitivities identified, appropriate management regimens should be considered, with a high priority given to reducing the risk of cross infection. ► The main treatment objective will be to reduce rather than eradicate the bacterial burden within the wound margins. www.indiandentalacademy.com
  23. 23. Surgical Technique The rough handling of tissue or the use of inappropriately bulky instrumentation can lead to crushed skin edges and subsequent devitalization of tissue, leading to increase in inflammatory reaction and risk of secondary infection with increased scarring. www.indiandentalacademy.com
  24. 24. Haematoma Formation Excessive bleeding and the formation of a hematoma within the wound not only can mechanically disrupt the wound closure but also can serve as an excellent culture medium for micro organisms. www.indiandentalacademy.com
  25. 25. Foreign body reaction A foreign body in the wound serves as an appropriate surface for the activation of the alternate complement pathway and the generation of a prolonged inflammatory response, which interferes with the subsequent stages of wound repairs. Wounds containing foreign materials are characterised by low pH and low PO2. These factors significantly slow down wound repair. www.indiandentalacademy.com
  26. 26. Tissue ischaemia Local factors such as foreign bodies, infection or strangulating sutures significantly slow healing by promoting tissue ischemia. Local hypoxia is detrimental to cellular proliferation, resistance to infection and collagen production. The cumulative effect is delayed healing. www.indiandentalacademy.com
  27. 27. Topical medications and dressings ►Occlusive or semi occlusive dressings promote faster reepithelization. They may also alter certain aspects of dermal repair. ►They also provide the moist environment needed for optimal wound repair, they may also help to prevent bacterial invasion and wound www.indiandentalacademy.com
  28. 28. ►Ionising radiation: Delays granulation tissue formation. ►Ultraviolet light: Facilitate wound healing. ►Movement ►Type, size, location of injury. www.indiandentalacademy.com
  29. 29. SYSTEMIC FACTORS AGE ► The physiological changes that occur with ageing place the older patient at higher risk of poor wound healing. ► Reduced skin elasticity and collagen replacement influence healing. ► The immune system also declines with age making older patients more susceptible to infection. www.indiandentalacademy.com
  30. 30. DEHYDRATION This leads to an electrolyte imbalance and impaired cellular function. It is a particular problem in patients with burns www.indiandentalacademy.com
  31. 31. NUTRITION ► Vitamin A is required for epithelial and bone tissue development, cellular differentiation, and immune system function. ► Ehrlich and Hunt have shown vitamin A reverses the corticosteroid-induced inhibition of cutaneous and fascial wound healing. ► Vitamin A has also corrected non-steroid www.indiandentalacademy.com
  32. 32. Levenson et al suggest vitamin A benefits the wound by enhancing ; 1.The early inflammatory phase, including increasing the number of monocytes and macrophages at the wound site, 2.Modulating collagenase activity, 3.Supporting epithelial cell differentiation, 4.Improving localization and stimulation www.indiandentalacademy.com
  33. 33. Vitamin C ►Ascorbic acid is an essential cofactor for the synthesis of collagen, proteoglycans, and other organic components of the intracellular matrix of tissues. ► Ascorbic acid deficiency causes abnormal collagen fibers and alterations of the intracellular matrix that manifests as cutaneous lesions, poor adhesion of endothelium cells, and decreased tensile strength of fibrous tissue. www.indiandentalacademy.com
  34. 34. ► Ascorbic acid is necessary for the hydroxylation of proline and lysine residues in procollagen, which is necessary for its release and subsequent conversion to collagen. ► Hydroxyproline also stabilizes the collagen triple-helix structure. ► In addition to collagen production, ascorbic acid enhances neutrophil function, increases angiogenesis, and functions as a powerful antioxidant. www.indiandentalacademy.com
  35. 35. ►Clinical manifestations of ascorbic acid deficiency include ; bleeding gums, poor immunity, easy bruising , and slow healing of wounds . www.indiandentalacademy.com
  36. 36. ►Vitamin E ►Vitamin E is popular among consumers for skin care and to prevent scar formation. ►It functions as the major lipophilic antioxidant, preventing peroxidation of lipids and resulting in more stable cell membranes www.indiandentalacademy.com
  37. 37. ►Zinc ► Zinc is an essential trace mineral for DNA synthesis, cell division, and protein synthesis, all necessary processes for tissue regeneration and repair. ► Zinc deficiency has been associated with poor wound healing and decreased breaking strength of wounds, which can result from decreased protein and collagen synthesis during healing found in zinc-deficient patients. www.indiandentalacademy.com
  38. 38. ► Copper is a required cofactor for the enzyme lysyl oxidase, which plays a role in the crosslinking (and strengthening) of connective tissue. ► A typical amount recommended is 2–4 mg per day, beginning two weeks prior to surgery and continuing for four weeks after surgery. ► Other trace minerals, such as manganese , copper , and silicon , are known to be important in the biochemistry of tissue www.indiandentalacademy.com
  39. 39. ►Glucosamine. ► Hyaluronic acid is an important part of the extracellular matrix and one of the main glycosaminoglycans secreted during tissue repair. ► Production of hyaluronic acid by fibroblasts during the proliferative stage of wound healing stimulates the migration and mitosis of fibroblasts and epithelial cells. ► Glucosamine appears to be the rate-limiting substrate for hyaluronic acid synthesis www.indiandentalacademy.com
  40. 40. ►Protein and Wound Healing ►Protein depletion appears to delay wound healing by prolonging the inflammatory phase; by inhibiting fibroplasia, collagen and proteoglycan synthesis, and neoangiogenesis (proliferation phase); and by inhibiting wound remodeling. www.indiandentalacademy.com
  41. 41. ►Vitamin A 25,000 IU daily Enhances early inflammatory phase of wound healing; supports epithelial cell differentiation; improves localization and stimulation of immune response. ►Vitamin C 1-2 g daily Synthesis of collagen, proteoglycan, and other organic components of the intracellular matrix; tissue antioxidant; supports immune response. www.indiandentalacademy.com
  42. 42. ►Zinc 15-30 mg daily Required for DNA synthesis, cell division, and protein synthesis. ►Glucosamine 1,500 mg daily Enhances hyaluronic acid production in the wound. ►Protein Minimum of Prevents delayed healing and 0.8 g/kg body surgical complications. weight daily www.indiandentalacademy.com
  43. 43. DIABETES ► The effects of diabetes on wound healing are diverse, multifactorial, complex and inter-related. ► Thickening of basement membrane in the microcirculation can lead to ischemia and decreased tissue perfusion, which in turn results in impaired wound healing (Cavallo et al, 1984). www.indiandentalacademy.com
  44. 44. DIABETES ► Fibronectin is the major glycoprotein secreted by fibroblasts during initial synthesis of extracellular matrix proteins. It serves important functions, being a chemoattractant for macrophages, fibroblasts and endothelial cells. It promotes reepithelialisation . ► Non-enzymatic glycation of fibronectin decreases its ability to bind to collagen, gelatin and heparin. www.indiandentalacademy.com
  45. 45. Effects of Steroids on Wound Healing ►Anti-inflammatory corticosteroids significantly impair wound healing. ►Corticosteroids lower transforming growth factor- (TGF-) and insulin-like growth factor-I (IGF-I) levels and tissue deposition in wounds. www.indiandentalacademy.com
  46. 46. Factors that impede wound healing ►Local factors ►Inadequate blood supply ►Increased skin tension ►Poor surgical apposition ►Wound dehiscence www.indiandentalacademy.com
  47. 47. ►Poor venous drainage ►Presence of foreign body and foreign body reactions ►Continued presence of micro-organisms ►Infection ►Excess local mobility, such as over a joint www.indiandentalacademy.com
  48. 48. Systemic factors ►Advancing age and general immobility ►Obesity ►Smoking ►Malnutrition ►Deficiency of vitamins and trace elements www.indiandentalacademy.com
  49. 49. ►Chemotherapy and radiotherapy ►Immunosuppressant drugs, corticosteroids, anticoagulants ►Inherited neutrophil disorders, such as leucocytes adhesion www.indiandentalacademy.com
  50. 50. ►Clinical features of nonhealing wounds ►Absence of healthy granulation tissue ►Presence of necrotic and unhealthy tissue in the wound bed ►Excess exudate and slough www.indiandentalacademy.com
  51. 51. ►Failure of re-epithelialisation ►Cyclical or persistent pain ►Recurrent breakdown of wound ►Clinical or subclinical infection www.indiandentalacademy.com
  52. 52. Complications of chronic wounds ►Sinus formation ►Fistula ►Unrecognised malignancy ►Malignant transformation in the ulcer bed ►Osteomyelitis ►Contractures and deformity in surrounding joints www.indiandentalacademy.com
  53. 53. ►Systemic amyloidosis ►Heterotopic calcification ►Colonisation by multiple drug resistant pathogens, leading to antibiotic resistance ►Anemia ►Septicaemia www.indiandentalacademy.com
  54. 54. THANK YOU Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com

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