pack or no pack

1. CONTROVERSIES IN THE
APPLICATION OF PERIODONTAL
DRESSINGS
Dr. Rinisha Sinha
MDS III Postgraduate trainee

2. TS
o Introduction
o Definition
o Rationale for Use
o Ideal Properties
o Types of Dressings
o Application of Dressing
o Removal and Replacement
o Controversial Articles
o Conclusion
o References

3. o The main objectives following periodontal surgery, are to obtain optimal healing and to ensure
minimum amount of discomfort to the patient.
o Periodontal dressings are being used to aid in these objectives since the early 1920s.
o Since the introduction of first practical periodontal dressing by Dr. A.W Ward in 1923, numerous
investigations on all aspects of the effects have been carried out.
ON

4. Periodontal dressing is defined as a surgical dressing applied over and
protecting the surgical wound produced by periodontal surgical
procedures.
N
- American Academy of
Periodontology 1986

5. USE
o Maintenance of debris free area.
o Protection of newly exposed root surfaces from temperature changes and protection of sutures.
o Protection of the wound area.
o Enhancement of patient comfort.
o Control of bleeding.
o Prevent salivary contamination.
o Prevent coronal displacement of an apically positioned flap.
Bernier & Kaplan 1947

6. TIES…
1. The dressing should be soft, but still have enough plasticity and flexibility to facilitate its
placement in operated area and to allow proper adaptation.
2. Should harden within a reasonable period of time.
3. After setting the dressing should be sufficiently rigid to prevent fracture and dislocation.
4. The dressing should have a smooth surface after setting to prevent irritation to cheeks and lips.
5. It should not interfere with healing.
Jan Lindhe; 1995

7. TIES
6. The dressing should preferably have bactericidal properties to prevent excessive plaque formation.
7. The dressing should have dimensional stability to prevent salivary contamination.
8. It should not induce possible allergic reactions.
9. It should have an acceptable taste.
10. It should be economical and easily available.
11. The material should have a good shelf life.

8. GS
Eugenol dressings
Non-eugenol dressings
Light-curing dressing materials
Tissue conditioners
Cyanoacrylates

9. NAME, TYPE AND
COMPOSITION OF
EACH COMMERCIALLY
AVAILABLE
DRESSING

10. S.
No.
Name Type Composition
1. Ward’s Wondipak Eugenol Powder: ZnO, Powdered pine resin, talc and asbestos
Liquid: Isopropyl alcohol 10%, clove oil, pine resin, pine oil,
peanut oil, camphor and coloring material
2. Kirkland formula Eugenol ZnO, resin, Zinc acetate, eugenol, tannic acid and olive oil
3. Coe-pak Non-
Eugenol
First paste – ZnO, added oils, gums and lorothidol
Second paste – Unsaturated fatty acids and chlorothymol
4. Cross Pack Non-
Eugenol
Colophony powder, ZnO, tannic acid bentonite and powdered
neomycin sulphate
5. Peripac Non-
Eugenol
Calcium sulphate, ZnO, ZnS, acrylic type of resin and glycol
solvent
6. Septopack Non-
Eugenol
Amyl acetate, dibutyl phthalate, butyl polymetacrylate, ZnO,
ZnS
7. PerioCare Non-
Eugenol
First paste – paste of metal oxides in vegetable oil
Second paste – gel of rosin suspended in fatty acids

11. S.
No.
Name Type Composition
8. Perio Putty Non-
eugenol
Methylparabens, propylparabens, benzocaine
9. Periogenix TM Non-
eugenol
Perfluorodecalin, purified water, glycerin, hydrogenated
phosphatidylcholine, cetearyl alcohol, polysorbate 60,
tocopheryl acetate, benzyl alcohol, methylparaben,
propylparaben and oxygen
10. Cyanoacrylate
dressings
Other N-Butyl cyanoacrylate
11. Light cure
dressings
Other Silicon dioxide crystalline – quartz, hydrophobic amorphos
fumed silica, urethane dimethacrylate resin
12. Collagen dressing Other Type I collagen derived from bovine tendon mixed with
cancellous granules
13. Stomato adhesive
dressing
Other Gelatin pectin, sodium carboxymethylcellulose and polusio
polysiobutylene

12. COMPOSITION
AND
INGREDIENTS OF
COE-PAK AND
THEIR
FUNCTIONS

13. Lesher 1949; Zwemer TJ 1993; Haugen E 1978; Newman, Takei, Carranza 2006; Philstorm, Thorn 1977

15.  Ensure that the bleeding from operative area has ceased before the dressing
material is applied.
 Carefully dry teeth and soft tissues before the application for optimal adherence of
dressing.
 Moisten the surgical gloves to avoid the material sticking to finger tips.
 Zinc oxide packs are mixed with eugenol or non eugenol liquids on a wax paper
pad with a wooden spatula.
 The powder is gradually incorporated with the liquid until a thick paste is formed.
ION

16. Loosen the lingual
and buccal packs
Remove the lingual
pack
Cut the sutures
from lingual portion
if necessary
Remove the
buccal pack
Cleanse the area
with normal saline
and betadine
Remove
remaining
sutures
Re-cleanse the
area
Gently remove any
debris or granulation
tissue.
DRESSING

17. DRESSING
It is advisable to replace the
dressing for an additional week
for patients with:
A low pain threshold who are
particularly uncomfortable when
the pack is removed
Unusually extensive periodontal
involvement
Slow healing. Clinical judgement
helps in deciding whether to
repack the area or leave the initial
pack on longer than a week.

18. Clinical trials supporting
the use of periodontal
dressings

19. Increasing the Amount of Attached
Gingiva Using a Modified Apically
Repositioned Flap
• Name of the Authors: Arnold A. Ariaudo,Howard A. Tyrrell
• Year of Publication: 1957
• Name of the Journal: The Journal of Periodontology
• Results:
They supported the use of a periodontal pack incorporated with Terramycin (or any brand
of tetracycline Hydrochloride) 125 mg to 6 drops of liquid)
• Reason:
Protection of wound from mechanical trauma, and stability of the surgical site during
healing process.

20. Significance of early healing events
on periodontal repair: a review
• Name of the Authors: Wikesjö UM, Nilvéus RE, Selvig KA.
• Year of Publication: 1992
• Name of the Journal: The Journal of Periodontology
• Reason:
Prevention of flap displacement in apically repositioned flaps, additional support in free
gingival grafting procedures.

21. Periodontal dressing (Vocopac)
influences outcomes in a two-step
treatment procedure
• Name of the Authors: Sigusch BW, Pfitzner A, Nietzsch T, Glockmann E.
• Year of Publication: 2005
• Name of the Journal: The Journal of Clinical Periodontology
• Reason:
Periodontal wound dressing has a positive effect on clinical long-term results.

22. The etiology, diagnosis and
treatment of the
intrabony defect.
• Name of the Authors: Prichard JF
• Year of Publication: 1967
• Name of the Journal: The Journal of Periodontology
• Reason:
Patient comfort during healing, good adaptation to underlying gingival and bony tissue,
prevention of postoperative hemorrhage or infection, decreasing tooth hypersensitivity,
protecting the clot from forces applied during speaking or chewing, preventing gingival
detachment from the root surface.

23. Clinical trials NOT IN
FAVOR OF the use of
periodontal dressings

24. CLINICAL TRIALS: AUTHORS REASONS
Loe and Silness; 1961 Dressing has little effect
Stahl et al.; 1969 Dressing accumulates plaque
Harpenau; 1972 No difference in clinical parameters
Greensmith; 1974 No differences in healing
Kidd and Wade; 1974 Greater pain experience; Plaque accumulation; Subsequent microbial
invasion; Nonpack areas showed better wound healing; Lesser pain
scores
Jones and Cassingham; 1979 Irritates healthy tissue increases chances of infection
Allen and Caffesse; 1983 No difference in PD, CAL and gingival inflammation
Checchi and Trombelli 1993 No statistical differences in pain scores and number of analgesics
consumed between the pack and non-pack groups. Postoperative pain
with dressing
Bose et al.; 2013 Pronounced swelling increases plaque accumulation; Increases
inflammation and GCF; Difficult in eating

25. STUDIES ASSESSING
ANTIBACTERIAL
PROPERTIES OF
PERIODONTAL
DRESSING AGAINST
Baghani Z, Kadkhodazadeh M. Periodontal
dressing: a review article. J Dent Res Dent Clin
Dent Prospects. 2013; 7(4): 183-191

26. Coppes et al. 1967 - in comparison of microorganism types between eugenol and non-
eugenol dressings, revealed the frequency of Bacteroides melaninogenica to be higher
under eugenol-free dressings.
Heaney et al. 1972 - took a bacterial sample from the areas under two periodontal dressings. They revealed that the
most frequent microorganisms under Coe-Pak were gram-negative rods, although the incidence of yeasts was
higher under ZOE dressing.
Plüss 1975 - showed that significantly less plaque formed under periodontal packs with chlorhexidine powder than
under control packs.
In evaluation of healing process, O’Neil 1975 - revealed that tested periodontal dressings (Coe-Pak, Cross-Pak, Peripac,
Septo-Pak, ZOE) had no antibacterial properties, and ZOE had minimal antifungal properties.
In some in vitro studies (O’Neil 1975, Pihlstrom 1977, Oliver et al. 1972, Appleton 1976), antibacterial properties of
periodontal dressings against bacterial plaque have been reported to be inconsistent.

27. Haugen and Gjermo 1978 - revealed that the tested periodontal dressings (Wondrpak, Coe-Pak and Peripac) had
antibacterial effects on salivary microorganisms.
The effect of chlorhexidine supplementation on periodontal dressing was assessed by Othman et al 1989. They
showed that the durability of chlorhexidine efficacy in periodontal dressing depends on its concentration.
Sustained-release varnish of chlorhexidine as an inhibitor of plaque accumulation under periodontal dressings was
evaluated by Zyskind et al 1992. The application of chlorhexidine varnish under tested dressings caused less plaque
accumulation compared with the control group.
Volozhin et al 2004 showed that the frequency of aggressive microorganisms in periodontal pockets of patients with
generalized chronic periodontitis reduced when the periodontal dressing consisting of collagen and Lactobacillus
casei 37 cell suspension was used.
Ikeda T et al 1984 and Woodcock 1988 in their studies revealed that biguanides like 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

28. STUDIES ASSESSING
PERIODONTAL
DRESSING
CYTOTOXICITY
Prichard JF. The etiology, diagnosis and
treatment of the intrabony defect. J Periodontol.
1967; 38(6): 455-465.

29. An in vitro cell culture technique suggested that the solubility of the leachable toxic
substances in cell culture medium is an important factor responsible for various
behaviors of dressings. – Haugen; 1978
Haugen et al 1978 - introduced Wondrpak as the most irritating product, followed
by Coe-Pak and Peripac.
Haugen et al 1979 - Under laboratory conditions, fresh samples of Coe-Pak and
Wondrpak cause more hemolysis than other products, and the cytotoxicity of Coe-
Pak increases with time.
Nezwek et al 1980 and Wennberg et al 1983 in their in vitro studies, investigated tissue reactions to some
periodontal dressings. They reported that the greatest inflammatory reaction was caused by Wondrpak. Also,
Wennberg et al showed that when the contact period increased to 3 days, Peri-pac showed a more severe tissue
reaction than Wondrpak.

30. Smeekens et al 1992 in an animal study, suggested that the products that contain
eugenol trigger greater inflammatory reactions, although this increase was not
significant in other studies.
By using scanning electron microscopy and L-929 cell media, the cytotoxicity of some periodontal dressings was
assessed. They showed that all of the materials had an insignificant toxic effect on L-929 cell lines, and Sne-Pack
and Coe-Pak dressings were smoother than ZOE. – Baer et al. 1961
By using cell culture medium, Barricaid was introduced as a cyto-compatible
dressing, where human gingival fibroblasts, 3T3 mouse fibroblasts and human
osteoblast-like cells (HOBI) were used. – Alpar et al. 1999
Baer and Wertheimer 1961, Haugen and Mjör 1979 and Saito et al. 2008 in their studies showed that periodontal
dressings can cause greater inflammatory infiltration on the bone and the inflammatory reaction is greater when
the dressing is directly placed on the bone compared with the time when it is placed on the periosteum.

31. CONCLUSION
• The question of whether we need to use a dressing for all surgical procedures still remains open !!!
• First school of thought - complete healing can take place even without a dressing, provided the surgical
area is kept clean, and that there is no difference in healing between dressed and non-dressed wounds,
lends support to the theory that NOT ALL SURGICAL AREAS NEED TO BE “PACKED”. The use of a
dressing accumulates
• plaque-causing inflammation
• irritates the healing tissues,
• produces transient bacteremia during postoperative dressing change,
• causes more pain and swelling but less sensitivity and difficulty in eating.
• Despite these, healing is slightly more rapid in the dressed segments.
• According to patients’ preference and comfort point-of-view, 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.

32. THE CHOICE OF USE OF A PERIODONTAL
DRESSING IS A MATTER OF INDIVIDUAL
PREFERENCE AND THE JUDGMENT OF THE
OPERATOR.
• However, it is prudent to use a dressing for stabilization of free gingival grafts and
protection of donor site, retention of an apically positioned flap, protection of the
denuded bone from further injury, protection of the graft site in periodontal regeneration
and to facilitate retention of drugs delivered locally in the sub-gingival sites.
There appears to be 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

33. REFEREN
CES
o Carranza’s Clinical Periodontology : 10th Edition
o PerioBasics – A textbook of Periodontics and
Implantology
o Periodontal Dressing: A Review Article –
Zahra Baghani and Mahdi Kadkhodazadeh
o Antibacterial properties of periodontal dressings – T. C
. A . O 'NEIL
o To Pack or Not to Pack: The Current Status of
Periodontal Dressings – Dr. Rahul Kathariya, Hansa
Jain and Tanya Jadhav (Journal of Applied Biomaterials
and Functional Biomaterials)