This document discusses the history and types of periodontal dressings. It begins by outlining key studies from the 1940s-1960s that established the primary purposes of dressings as wound protection and patient comfort. It then categorizes the main types of dressings as those containing zinc oxide and eugenol, zinc oxide without eugenol, or neither ingredient. Specific dressings like Coe-Pak, Periocare, and collagen are described. The document concludes by discussing alternatives to traditional dressings like methacrylate gels and cyanoacrylate glues.

1. DR JEETHU JOHN JERRY
READER
MALABAR DENTAL COLLEGE AND RESEARCH CENTRE

2. Dressing
Immobilize
soft tissue
grafts
Wondr
Pak
Stabilize
flaps
Desensitiz
ation
↓Proliferati
on of
Granulation
tissue
Trauma,
Contami-
nation

3. (1942) -zinc oxide eugenol dressing / chemical curettage in
treatment of NUG.
(1941) ZOE dressing/ Paraformaldehyde to perform gingivectomy by
chemosurgery.
Pocket depth reduction extensive necrosis of gingiva and bone, and was
susceptible for abscess formation.

4. (1947) - primary purpose of periodontal dressing was
wound protection, and constituents of healing - secondary importance.
(1957) - dressing to an apically positioned flap.
(1958) - dressing could be used to splint teeth as long as it was a cement
dressing that set hard.
(1962) - 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.

5. (1961) 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.
• Thus from these studies it can be concluded that wound protection,
patients comfort, and some degree of hemostasis are considered to be
desirable effects in dressings.
• The first surgical dressing was patented by E. P. Lesher (1953)

6. • Protection – irritation.
• Enhancement - comfort
• Debris free area.
• Reposition of soft tissue/ Retention; additional stabilization of a soft-tissue
graft, protection of suture.
• Control bleeding

7. • Act as template 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.

8. • Should be soft, 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.

9. • Should have bactericidal 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.

10. Periodontal dressings are generally 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

11. • Powder and liquid form
• Paste form
• Ward’s Wondr pack

12. • The powder -- Zno, powdered pine, resin, talc and asbestos and
• Liquid -- isopropyl alcohol 10%, clove oil, pine oil, peanut oil, camphor and
coloring agents.

13. •a) Powder and liquid form/ Krikland pack- dressing material is obtained by
mixing powder and liquid.
Powder Liquid
Zinc oxide
Tannic acid
Rosin
Kaolin
Zinc-sterate
Asbestos
Eugenol
Organic oil
Rosin
Antiseptic & Astringent
Haemostatic
Filler, speed reaction
Anesthetic and
astringent
Setting time
+ Zinc
Acetate

14. Powder
Liquid
Zinc
eugenolate

15. • Can be mixed in large quantity-wrapped in aluminium foil and refrigerated
(Newman et.al, - 2006)
• Splinting since its stiff
• The haemostatic effects -- tannic acid.
• Firm, heavy and easy to manipulate --do not stick to the clinician finger.

16. • Material is firm-- more pressure to manipulate and adapt the dressing to the soft
tissue.
• Rough surface - bacterial proliferation (Kreth et. al, -1966; Rivera et.al,- 1977)
• A hard setting consistency that may complicate removal if engaged in an undercut
• Eugenol has proven to be cytotoxic at higher concentrations and has an ad- verse
effect on fibroblasts and osteoblast-like cells (Alpar- 1999)
• The distinct taste of eugenol while the pack is in place
• Possible allergic reaction to eugenol -- burning pain and reddening of the treated
area, induce allergic reactions and cause tissue necrosis, particularly of bone, which

17. 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.

18. Advantages: -
• Pleasant color 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.

19. Disadvantages: -
• Inability to adhere to mucosa; premature loss
• Minimal splinting ability due to its soft, rubbery consistency
• Absence of tannic acid in the material.

20. • 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.

21. A) Automix B) Manual Mix

22. Base contains Accelerator contains
Rosin,Oils Zinc oxide
Cellulose Vegetable oil
Natural gums and waxes,
Fatty acids
Chlorothymol
Chlorothymol Magnesium oxide,
Silica
Zinc acetate Synthetic resin,
Coumarin
Alcohol. Lorothidol
Principal ingr.
viscosity
Manipulation
Lubrication
Strength, Acc
Bacteriostatic
P.I ,Acc, fillers
Plasticizers
fungicides
Plasticizers

23. • It is available in form of paste & gel and sets resiliently hard by chemical
reaction.
• Its highly elastic.
Paste: Zinc oxide, magnesium
oxide, calcium hydroxide,
vegetable Oils.
Gel: Resins, fatty acids,
ethyl cellulose, lanolin,
Calcium hydroxide.

24. • It is a 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.
• used in treatment of necrotic gingivitis and ulcers; protection of nonspecific
lesions or sutured margins, fixation of desensitizing medicaments to cervical
areas

25. • It contains 90 gms 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.

26. • Methyl- and propyl - parabens for their effective bactericidal and fungicidal
properties
• Benzocaine as a topical anesthetic.
• ( Sachs et.al, 1984)

27. Contain neither zinc oxide nor eugenol

28. • It is a light cure periodontal dressing with a single component.
• Less time consuming.
• Syringe -single time usage.
• Curing is done using a visible light curing unit resulting in a firm elastic
covering.
• It might be tinted for esthetics.
• Polyether urethane dimethacrylate 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.

29. Advantages: -
• Colour more 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.

30. • Absorbable collagen-- promote 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.

31. • Primarily these dressings are used as tissue
conditioners as they have elastic like consistency
that is soft and resilient i.e, 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.

32. • Lot of studies 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

33. • In 1960’s Surindar 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

34. • He also demonstrated 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.

35. • Cyanoacrylates is either 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.

36. Advantages
• Easy adherence to 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,

37. Disadvantages
• Difficulty in application around posterior teeth
• Rapid polymerization upon contact with small amounts of
moisture.

38. • Antibiotics and other 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.
(1956) 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.
• According to (1965) incorporation of Corticosteroids and
Dilantin into a dressing was of no value in healing.

39. (1974) , a dressing containing chlorhexidine promoted
healing , ↓ bacterial colonization of wound.
• 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.
• When the dressings 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.

40. • 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.

41. • A non-eugenol-containing periodontal dressing.
• It contains of ZnO, rosin and Zinc Bacitracin 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.

42. Ideal dressing
• Does not move and does not require removal / no tug on sutures.
• Provide stability for the graft
• Minimize bleeding and
• Prevent blood from collecting between the graft and receptor.
• Cyanoacrylate dressings such as isobutyl cyanoacrylate or trifluor
isopropyl cyanoacrylate are excellent for these purposes

43. 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.

44. • Coe Pak or 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

45. • 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 favoured
• Colycote or Surgicel, both of which minimize bleeding (↑Stomahesive).
• Still others may favour placing Coe Pak and suture (↑tedious, bleeding),
• A palatal stent is favoured by others.

47. Preparing the patient:
• 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.

49. A properly placed and adapted periodontal dressing

50. •After placing the dressing patient is instructed for proper care of dressing
and oral hygiene procedures.
•Patient should be cautioned for first few hours.
•Spicy and hot food should be avoided immediately after surgery.
•Patient should gently rinse mouth after eating and floss only other areas
of mouth.

51. • Pt should be 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 5 days for dressing removal and tissue evaluation.
• Dressing may be replaced when the healing is still taking place.

52. • Interlocking in interdental 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.

53. • If the dressing becomes dislodged before the removal appointment, the
healing has to be evaluated.
• When dressing remains intact for 4 or 5 days, replacement may not be
necessary.
• When replacement is indicated, the dressing should be replaced in its
entirety rather than in patches.
• Instruct the patient to continue with daily frequent biofilms removal and
rinsing using antimicrobial agent.

54. • Gingivectomy
• The cut 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.

55. • Tissue irritation : ( 2/3rd patients allergic to eugenol)
• Culture studies with eugenol and non-eugenol dressings show that
with minor variations, both can be cytotoxic against fibroblasts, and
polymorphs. (Haugen- 1978, Baer- 1961, Saito- 2008)
• 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

56. • 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 couldn’t be moulded like a
conventional dressing.

57. • 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.

58. • Bacterial ecology :
• If an antibiotic is employed, two possible problems may occur:
emergence of resistant organisms, and opportunistic infection.
• However, (1964) found the clinical signs of candidiasis
occurred when using tetracycline in dressings and that bacitracin
enhanced the growth of yeasts.

59. • Effects on wound 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.

60. • Therefore the dressing should be removed whenever possible within one
week of application
• Although (1947) 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.

61. • Disadvantages of using 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.

62. • Mandibular anterior segments-
• 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

63. (1957)
protection, Site
Stability
(1961) Comfort, clot
protection,
adaptation, ↓
haemorrhage,
infection
(1969)
↓ flap
displacement,
Graft support
(1992)
Improved long
term Results
( 1961) little effect
( 1969) Dressing accumulates plaque
( 1972) No difference in clin parameters
( 1974) No diff in healing
( 1974) ↑ plaque, subs microbes, ( non pack
= better pain scores)
( 1979)
↑ irritation, infection
( 1983) No diff in clin parameters
( 1993)
No diff in pain scores, num of
analgesics consumed
(2013) ↑ plaque, infl, discomfort on
chewing

64. Use of periodontal dressing has been wide
spread for many years. There has been 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 conflicting reports exist.
Placing the periodontal dressing
depends on the post surgical
conditions and the
priorities of the
clinician.

65. • Critical decision making in periodontics-4th Ed Hall.
• Clinical practice of the dental hygienist- 9th Ed Esther M. Wilkins.
• Clinical Periodontology 10th edition - Carranza
• Clinical Periodontology & Implant Dentistry 5th edition - Jan Lindhe
• Atlas of cosmetic & reconstructive periodontal surgery – 3rd Ed Edward S.
Cohen
• Addy, M. and Douglas, W.H., 1975. A chlorhexidine-containing methacrylic
gel as a periodontal dressing. Journal of periodontology, 46(8), pp.465-468.
Baer PN, Wertheimer FW. A histologic study of the effects of several
periodontal dressing on periosteal-covered and denuded bone. J Dent Res.
1961; 40(4): 858.
• Concise encyclopedia of Periodontology- David C. Vandersall. Singh, O.,
Gupta, S.S., Soni, M., Moses, S., Shukla, S. and Mathur, R.K., 2011. Collagen
dressing versus conventional dressings in burn and chronic wounds: a
retrospective study.

66. • Kathariya, R., Jain, H. and Jadhav, T., 2015. To pack or not to pack: the
current status of periodontal dressings. Journal of applied biomaterials &
functional materials, 13(2).
• Saad, L.J. and Swenson, H.M., 1965. Corticosteroid and periodontal
packs. Journal of periodontology, 36(5), pp.407-412.tudy. Journal of
cutaneous and aesthetic surgery, 4(1), p.12.
• Sachs, H.A., Famoush, A., Checchi, L. and Joseph, C.E., 1984. Current
status of periodontal dressings. Journal of periodontology, 55(12),
pp.689-696.
• Watts, T.L. and Combe, E.C., 1979. Periodontal dressing
materials. Journal of clinical periodontology, 6(1), pp.3-14.