Journal oj Clinical Periodontoiogy: 1979: 6: 3-14 Key words: Periodontal dressings - composinon - iherapeulic efjects - lisme irriiation. Accepted for publication: September 4, 197S.
Review Article
Periodontal dressing materials TREVOR L . P. WATTS AND EDWARD C. COMBE
Department of Oral Medicine and Dental Materials Science Unit, Turner Dental School, University of Manchester, England Abstract. A detailed review of periodonta) dressings is presented, covering physical, chemical and biological aspects. Areas requiring further research are outlined, particularly in the physico-chemical sphere; and some contra-indications to particular substances are described. It is concluded that there is a definite place for dressings, but that more knowledge is required before optimal properties can be deveioped.
Rationale for Usage
A wide variety of reasons has been given for the use of periodontal dressings. These reasons fall into two principal groups: a dressing may be employed as a physical adjunct to periodonta! surgery, or it may be used therapeutically with or without surgery. Physical effects Opinions vary as to the desirable physical effects of a dressing. Prichard (1972) states that a dressing is used to prevent postoperative haemorrhage and to protect the wound area from contact with food, concluding that a dressing "has no other virtue". Manson (1975) however, considers that a dressing is to protect a healing wound from saliva and trauma, thus producing comfort and speedier heahng, to prevent the proliferation of granulation tissue and to control haemorrhage. Held (1967), in addition, feels that the surgical wound must be protected from bacteria by the dressing which wiU also have an analgesic and anti-
haemorrhagic effect; whilst Goldman & Cohen (1973) emphasize the need for a "secure and rigid surgical dressing" with good adhesive properties. The advent of isobutyl cyanoacrylate has also led Bhaskar et al. (1966b) to consider instant haemostasis one of its main advantages. No other dressing material has this adhesion - dependent effect. Finally, the advent of flap repositioning led Ariaudo & Tyreli (1957) to state that the dressing should act as a stent. Many other writers have also stated the above points in textbooks and research papers, including some whose work is quoted elsewhere in this review. Thus we may conclude that wound protection and comfort, and some degree of hacmostasis and tissue stasis are generally considered to be desirable effects in a dressing. Therapeutic effects Dressings have been used in the absence of surgery for two principal effects: tissue destruction and tissue shrinkage. In the austere days of World War II, Orban (1943) described a technique of chemosurgery by
0303-6979/79/010003-12$02.50/0 © 1979 Munksgaard, Copenhagen
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using paraformaldehyde in a dressing. Gingival necrosis occurred in 4-8 days. It was noted that contact with bone would cause sequestration. This technique does not seem to have achieved much popularity. As regards tissue shrinkage, the limited use of saline and astringent packs for 20 minutes following scaling has been reported by Padgett (1959); this is a variation on the once popular technique of packing periodontal pockets with an inert substance (usually a paraffin wax formulation) for 1-2 days following subgingiva! scaling (Pincus 1944, Christensen 1944, McTntosh 1947). Isolation from tooth roots led to a rapid shrinkage of the gingiva, an effect which is produced today by the somewhat slower techniques of plaque control. The use of special pressure packs to produce gingival shrinkage has also been advocated in cases where surgery is medically or psychogically inadvisable (Weinreb & Shapiro 1964). Therapeutic effects after periodontal surgery have been the goal of many who have incorporated specific agents in dressings. These agents may be classified as having a primary effect eitber on oral bacteria or upon periodontal tissues. Eugenol has been shown to have antibacterial properties in several studies in vitro (Linghorne & O'Connell 1949, CoU man 1962, Persson & Thilander 1968a, O'Neil 1975, Haugen et al. 1977); in vivo, it has been noted that plaque composition is definitely altered, presumably as a result of selective inhibition (Coppes et al- 1967, Heaney et al. 1972). Pihlstrom et al. (1977) considered that the total number of microorganisms was not noticeably reduced by eugenol. None of the quoted authors has suggested that the antibacterial properties of eugenol in any way enhance healing. However, other antibacterial substances have been added to dressings with this object, notably tetracycHne (Fraleigh 1956,
Ariaudo & Tyreil 1957, 1960), zinc bacitracin (Baer et al. 1958, 1960, 1969) noneugenal phenol derivatives such as chlorothymol (Molnar 1962), oil of bergamot (Schach 1968), and chlorhexidine (AsboeJorgensen et al. 1974, Addy & Douglas 1975, Pliiss et al. 1975). It should be noted that chemical inactivation may occur: Baer et al. (1958) report that eugenol and tannic acid both affect bacitracin. Apart from haemostatics such as tannic acid, there have been two attempts to improve postoperative healing by means of substances with a primary effect on the tissues. Saad & Swenson (1965) reported on steroids; and Swann et al. (1975) reported on diiantin. The latter agent 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. It is unlikely that the present periodontai climate will be conducive to the widespread use of therapeutic agents other than antibacteriats in dressings. Emphasis on plaque control by the patient has largely replaced the earlier philosophies based on professional intervention. Material Aspects
The literature on periodontal dressings as materials is so sparse that Mjor (1977) was quite justified in complaining of its paucity. It is clear that manufacturers want to be free to vary the composition of their products and Smith (1970) gives Just such an example in relation to the reports of Persson & Thilander (1968 a, b) concerning Coe-Pak®. The limited factual information available will now be described and will highlight areas where knowledge is deficient. Setting systems With the exception of the zinc bacitracin/
PERIODONTAL DRESSING MATERIALS hydrogenated fat dressing described by Baer et al. (1960), most dressings are intended to set, though not necessarily to the point of rigidity. At least five different systems are discernible in presently available materials: (1) The reaction of zinc oxide with eugenol to form zinc eugenolate. The reaction is slow, and even with the use of accelerators such as zinc acetate, there will always be free eugenol available during the normal life of a periodontal dressing (Molnar 1967). The significance of this free eugenol will be discussed below (Biological side-effects). (2) Organic solvent loss is the basis of setting in Peripac® (Eberle & Miihlcniann 1959), and a physical hardening results. (3) The reaction between a metallic oxide and fatty acids is the basis of Coe-Pak (Molnar 1962). A requirement of water insolubility and suitable melting points limits the typs of acids which may be used. (4) Tissue conditioners have formed the basis for certain dressing materials (Frisch et al. 1968 b, Levin et al. 1969, Addy & Douglas 1975). Their setting is usually a physical process (Combe 1977), with an elastic gel as the result. (5) Cyanoacrylate tissue adhesives set by polymerisation in the presence of anions, such as OH- (Combe 1977). (6) In addition, an experimental polycarboxylate system was used on a limited basis by Smith (1970). These setting systems may therefore be categorised as chemical or physical, and at present there is no clear basis for choice of one or the other, except for individual preference in the clinical situation. If a particular system were acknowledged to be advantageous in other respects (for example, by not inactivating a useful antibacterial agent), then these factors would help determine choice.
Retention A considerable amount of ingenuity has been expended on the problem of how peri-
odontal dressings may be kept in place. Hirschfeld & Wasserman (1958) listed a whole battery of techniques, including the use of wire, floss, acrylic, adhesive tin foil and copper bands. At the other extreme. Gold (1964) preferred a cement type pack because, in his estimation, it could even splint mobile teeth. When flap repositioning techniques were established, Ariaudo & Tyreil (1957) wanted the dressing to act as a stent; but Seibert (1961) clearly had no faith in any dressing to achieve this, and advocated the use of cobalt-chromium tacks to hold flaps in place. Numerous splints and stents have been described, employing latex (Munns 1952), acrylic resin (McKenzie 1951, Gottsegen 1954, Hileman 1957, Holmes 1962, Reader 1970, Glcn^ dinning 1976) and a vinyl polymer (Frisch et al. 1968a, Kalkwarf et al. 3974). Some of these have been related to repositioning and grafting techniques. Other means of increasing retention which have been advocated include wiring (Cowan 1965, Larato 1967), interproximal usage of spiral saws and lengthwise cotton thread (Waerhaug & Aanerud 1953), foil (Berman et al. 1961, Nelson et al. 1977), and cotton tapes with interdental sutures if necessary (Castenfelt 1962). There is no experimental evidence that objects placed within a dressing are likely to contribute to its retention; on the contrary, they are likely to weaken the dressing material since they decrease its cross-sectional area and contribute to stress concentration phenomena, thus rendering it more liable to fracture. External retention with splints and stents is free from this criticism, but they are inconvenient to both patient and operator. Ideally the dressing should be sufficiently retentive without the need for extra devices. Smith (1970) reported on preliminary trials with polyacrylate dressing materials, and Addy & Douglas (1975) also attempted to incoiporate some degree of adhesion into
WATTS AND COMBE their chlorhexidine-carrying material, by employing polyacrylic acid. Two other research groups, Asboe-Jorgensen et al. (1974) and Pluss et al. (1975), decided to employ auxiliary methods of retention for their chlorhexidine-containing dressings. Other attempts at improving dressing retention have used frankly adhesive materials. The use of cyanoacrylate tissue adhesives is well attested to in the literature (Bhaskar et al 1966, Ewen 1967, Forrest 1974, Levin et al 1975). The production of haemostasis, flap immobilisation and possibly quicker healing are described as the principal advantages of the technique. No problems of removal have been described in the literature, since cyanoacrylates are apparently biodegradable and are gradually depolymerised and phagocytosed (CDA Council for Dental Materials and Devices 1977). From the variety of ideas, it is apparent that retention of dressings presents numerous problems. This is to be expected, since a periodontal dressing is intended to be removed after a short period of time. If retention were too good, removal might become a problem; therefore, an optimum level of retention should be specifiable. Biological and therapeutic compatibility Biological side-effects of dressings are considered below; certain authors have sought to ensure biological compability by using intermediate materials under dressings. Stern (195S) reported the use of Telfa®, the inner layer of which was a thin, perforated polyester film which was non-adherent and could be used to cover bone. The use of specially prepared fabrics has been advocated by Schultz (1962) and Chasens & Marcus (1963). These fabrics must be carefully cut to size and adapted to furcation and embrasure regions. Sullivan & Atkins (1968), referring to free mucosal grafts, suggested that rubber dam be
used under any zinc oxide and eugenol dressing for the first 6 days. Cleariy it would be simpler if intermediate materials were not needed; it is also possible that they might adversely affect retention of the, dressing. Therapeutic compatibility is important if an active pharmacological agent is incorporated in a dressing. It would seem from the results of Addy & Douglas (1975) that their dressing did not substantially interfere with chlorhexidine activity. The warning of Baer et al. (1960) regarding bacitracin has already been mentioned. Restorative material compatibility It is important that periodontal dressings should not damage permanent restorations in teeth. There are two possible problems which could arise. First, an interaction might take place between dressing and restoration leading to physical breakdown of the latter. The authors have heard one such report from a reliable periodontologist. Second, anterior restorations might be stained at their margins by substances such as chlorhexidine in dressings. Protection by a separating agent would be possible, but might affect retention. Further experimental data are required on this subject.
Biological Side-effects
It is essential that no risk should accompany the use of dressing materials. The patient should not suffer any side-effects, the surgical procedures should in no way be compromised, and there should be no health risks to the operator and his staff. In general, three methods of testing materials are used: tissue culture, animal experiments and human trials. Tissue irritation Culture studies with eugenol and noneugenol dressings show that with minor
PERIODONTAL DRESSING MATERIALS variations, both types of material can be cytotoxic when tested against HeLa cells (Kreth et al. 1966), fibroblasts (Hildebrand & DeRenzis 1974) and polymorphs (RiveraHildalgo et ai. 1977). It is possible that in vivo dilution may occur, as toxic substances leach into saliva (Rivera-Hidalgo et ai. 1977), and therefore these dressings may be better tolerated by a patient who is using frequent mouthrinses. Culture studies of cyanoacryiates (DeRenzis & Aleo 1970) 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 substanees tested showed definite cytotoxicily. Certain problems arise when experimental animals are used for tests of dressing materials. Most important of these is the animal's natural tendency to remove the dressing as an extraneous object. Thus Englcr et a!. {1966) decided no dressing was needed in their gingivectomy healing studies in rhesus monkeys, and Loe & Silness (1961) used acrylic splints as dressing retainers in mongrels. Other workers have used subdermal or paraperiosteal implantation (e.g. Mitchell 1959, Baer & Wertheinier 1961, Frisch & Bhaskar 1967). Eugcnol has been implicated as an irritant in some animal studies (e.g. Waerhaug & Loe 1957), though this is a relative effect For instance Mitchell (1959) found croton oil to be a more severe tissue irritant and Gugliani & Allen (1965) rated several materials to be more irritant, including bacitracin-containing dressings. Neither Triadan (3 965) nor Yokoyama (1976) could detect unfavourable effects of eugenol histologically, and Persson & Thilander (1968b) felt that the strong antibacterial substances in Coe-Pak at that time (but see Smith 1970) were also responsible for its greater tissue irritation. However, a recent study using a standardized technique of com-
parison is in agreement with these results (Haugen & Mjor 1978), even though the composition of Coe-Pak is now believed to be different. On the other hand, Baer & Wertheimer (1961) compared several dressings above and below periosteum, and concluded that a non-eugenol dressing was better, and that if possible the periosteum should be left intact. Ochstein ct al. (1969) agreed with the desirability of split flaps and the inferiority of eugenol dressings, but recommended isobutyl cyanoacrylate to Coc-Pak (presumably of the older formulation). This study involved actual gingival surgery on beagles, and was therefore closer to the clinical situation than that of Frisch & Bhaskar (1967) which found no difference in the response in rats to subperiosteai implants of eugenol and noncugenoi dressings. As regards cyanoacrylates, other studies have shown a generally moderate tissue response to the longer-chain molecules (Bhaskar et al. 1966a, Bhaskar et al. 1967, Binnie & Forrest 1974). If sub-epithehal leakage occurs, there is however a swift foreign body response (Miller et al. ]974, Ericksson 1976). Miller et al. (1974) also noted some bone resorption in response to cyanoacrylates, and considered that heat of polymerisation migbt also affect tissues. In human beings, Bernier & Kaplan (1947) studied the healing process after gingivectomy, and stated that surface contact of tbe dressing was of primary imporiance during the first 10 days, and that constituents were only of secondary importance. Orban & Arcber (1945) considered the blood clot of prime importance in the immediate post-operative period, a view shared by Radden (1962) with regard to extraction sockets. The latter author also pointed out the delayed healing associated with eugenoi contact in rhesus monkey experiments. Stahi et al. (1969) followed up a study of gingivectomy healing (Stah! et
WATTS AND COMBE al. 1968) by considering the effects of dressings. They concluded there was no detrimental effect detectable in either dressing used (Coe-Pak, Peripac), on the ground of biopsy examination. They also gave a figure of 7-14 days for complete epithelialisation to occur, and it is interesting that Ramfjord & Costich (1963) gave a figure of 6 days for epithelialisation after gingivectomy, but using Wondrpak® (Ward 1923, 1929), a eugenol-containing material. Finally, Levin et al. (1975) biopsied 350 out of 725 patients in whom isobutyl cyanoacrylate had been used after a variety of surgical procedures, and found that healing was excellent. On the basis of these studies, it would be reasonable to say that whilst eugenol and other strong antibacterials do have some irritant effect on healing tissues, it has yet to be shown that this effect damages the overall healing process. Tissue irritation is not a ground for the definite exclusion of any materials, except the short sidechain cyanoacrylates. However, factors such as patient comfort will play some part, and the irritant effects of eugenol are perhaps countered to some extent by its obtundent action. Tissue disturbance It is important that tissue flaps and grafts should remain precisely adapted and be undisturbed by dressing materials. Sutures are used for tissue retention with most dressing materials, but it is claimed that cyanoacrylates make sutures unnecessary. Binnie & Forrest (1974) observed more inflammation with sutures than cyanoacrylate, but Ericksson (1976), utilising the buccal mucosa, preferred sutures to adhesive, because of fistula formation and cyanoacrylate inclusion in wounds. Without doubt, the introduction of cyanoacrylate under a flap could impair healing, and in the case of a free graft prevent revas-
cularisation, but in the largest reported study (Levin et al. 1975), this did not seem a problem. However, these authors did note that overextension of the adhesive into the vestibule led to mucosal ulceration, and a tissue adhesive cannot be moulded like a conventional dressing. Allergy Contact ailergy differs from tissue irritation in several respects, such as the need for previous exposure to an antigen, a latency period following this, and the low antigen dose required to elicit a response in the subject (Magnusson et al. 1970). Where tissue is damaged, a very low dose of antigen may sensitize a person. It is therefore of great importance to minimise the antigenicity of periodontal dressings. Antibiotics are a well-known source of allergic reactions, but neither Fraleigh (1957) nor Baer et al. (1960) detected any true allergies in their respective studies with tetracycline and bacitracin. It is interesting that both of these studies used agents which have been implicated as allergens in later work: eugenol and colophony (rosin: abietic acid). Koch et al. (1971) were able to sensitize guinea pigs to both agents, and tested 18 patients who had clinical manifestations suggestive of allergy after periodontal surgery. Of these, about two-thirds were sensitive to eugenol and/or colophony. Subsequently, Koch et al. (1973) were able to produce a 10 % incidence of allergy to eugenol or colophony in a group of patients from which previously sensitized persons were excluded. Case reports of other workers have also appeared in the literature: Romanow (1957) may have been the first to indict eugenol and colophony: Lysell (1976) described a reaction to colophony alone, and Poulsom (1974) gave details of a severe reaction which occurred on the application of Coe-Pak 1 week after a eugenol-containing dressing. The trigger
PERIODONTAL DRESSING MATERIALS substance in this case appears to have been tannin (Poulsom 1977), which was incorporated in both dressings. In view of the possibility of rare and very serious allergic reactions, it seems wise to exclude substances with a well-known sensitizing potential from periodontal dressings. Indeed, it seems desirable to work with pure and fully-identified materials, in view of their application to wound areas. In this connection, it is of interest that bay oil has been suggested as a constituent of eugenoi-free materials (Molnar 1962): yet according to the Merck Index (Windholz et al. 1976) this oil contains 40-55 % eugenol. Asbestos-related disease Asbestos has been incorporated into numeous dressing materials as a binder and filler (Mcintosh 1947, Linghorne & O'Connell, 1949, Blanquie 1962, O'Neil 1975), but increasing knowledge regarding its possible side-effects has led to warnings that it should be avoided. 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. Otterson & Arra (1974) showed that it was possible to mix asbestos into a dressing and not infringe the stringent U.S. Department of Labor regulations, but advised against use of asbestos on the grounds that the patient would have a reservoir of the substance in any periodontal dressing. Liver toxicity Tannic acid was also used in some dressings (e.g. Box & Ham 1942) but absorption of this substance may lead to liver damage (Baer et al. 1969, CDA Council for Dental Materials and Devices 1977). Bacterial ecology In the complex oral microflora, variations
may easily occur where antibacterial dressings are used (Heaney et al. 1972). If an antibiotic is employed, two possible problems may occur: emergence of resistant organisms, and opportunistic infection. In the study quoted, organisms resistant to certain antibacterials predominated under the dressings used, but led to no adverse effect. However, Romauow (1964) found that clinical signs of candidiasis occurred when using tetracycline in dressings, and that bacitracin enhanced the growth of yeasts, though without clinical signs in this series. Gruber et al. (1966) showed in vitro that Candida would grow on tissue conditioners, but Frisch et al. (1968c) found no signs of candidiasis in patients using tissue conditioners as periodontal dressings. Thus, evidence suggests that antibacterials may lead to this problem, but not tissue conditioners. Critical Assessment
It has been asked whether periodontal dressings are necessary. The answer to this question surely depends on the type of surgery employed. For instance, Stahl et al. (1969) in a post-gingivectomy biopsy study found no marked differences between dressed and undressed sites; Greensmith & Wade (3974), using carefully sutured flaps in a controlled trial, found that patients healed more easily and more comfortably without dressings; but Prichard (1977) clearly considered the dressing an important and not-so-simiple aspect of the interdental denudation procedure. Furthermore, a dressing will play some part in the retention of an apically positioned flap, preventing undesirable coronal movement. As regards comfort, opinions are in conflict as to whether a dressing is required (e.g. Greensmith & Wade 1974, Addy & Dolby 1976), and this problem is not easily
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WATTS AND COMBE
studied because of the subjective phenomena involved. Comfort is at least partly involved in the question of whether biological agents are needed in dressings. Haugen .& Gjermo (1978) found that Peripac was less comfortable than either Coe-Pak or Wondrpak. However, O'Neil (1975) found that Peripac had better antibacterial properties than Coe-Pak, although the former has no specific antibacterial agent, and concluded that the physical properties of Coe-Pak were responsible for its clinical success. Oliver & Heaney (1970) on the other hand found that though a eugenol dressing was more easily fractured than Coe-Pak, there was no difference in comfort between the two. (This finding also highlights the difficulty of assessing materials for which the detailed formulation is not available: Did Oliver & Heaney (1970) use the low antibacterial post'Persson & Thiiander (1968b) formulation of Coe-Pak, or did they use the older formulation?) It seems that there is a dearth of evidence showing any definite advantage to biological agents. Of the three chlorhexidine studies quoted, two utilised auxiliary retention for the dressings as noted above, and one of these (Pliiss et al. 1975) used Peripac because it permitted a relatively large plaque accumulation. Only the study of Asboe-Iorgensen et al. (1974) concerned the direct tissue effects, and a high degree of professional attention yielded a moderate difference only. An effect was certainly demonstrated, but would it be worth-while under the normal conditions of periodontal practice? And to what extent was it related to the surgical techniques employed? No doubt the cyanoacrylates will continue to have their enthusiastic adherents, but they have two problems - difficulty in application in certain areas (Forrest 1974) and the impossibility of adjusting the dressing after application, leading for instance
to the ulceration observed by Levin et al. (1975). Many authors have indicated a need for specific physical properties in periodontal dressings, including Gottsegen (1954) Ariaudo & Tyreil (1957, 1960), Loe & Siiness (1961), Berman et al. (1961), Castenfelt (1962), Gold (1964), Kalkwarf et al. (1974), Addy & Douglas (1975), Heaney & Appleton (1976). This area is overdue for research, and new questions of chemical and biological compatibility will probably arise as a consequence. In conclusion, it appears that there are definite surgical indications for the use of periodontal dressings; that certain materials should be excluded because of toxic or other side-effects, that there is no definite indication for the use of biological agents; and that there is a need for research on the chemical and physical aspects of dressing materials. Zusammentassung
Parodontale Wundverbdnde. Eine Ubersicht Es wird eine eingehende Ubersicht tiber parodontale Wundverbande vermittelt, in der physikalisehe, chemiscbe und biologiscbe Ge.sichtspunkte beriicksichtigt werden. Weiterbin werden Gebiete umri^sen die weiterer Eorscbung bedurfen - vor allem handelt es sich hierbei um physikalisch-chemische Fragestellungen. Kontraindizierte Substanzen werden bescbrieben. Es wird gefolgert, dass der Wundverband seinen Platz in der parodonto-chirurgischen Bebandlung behauptet. Es ist jedoch eingehenderes Wissen erforderlich bevor Verbande mit optimal en Eigenschaften entwickelt werden konnen. Resume
Pansements parodontaux. Mise-au-point sur les matcriaux On trouvera iei une mise-au-point detaillee sur les pansements parodontaux et ieurs aspects physiques, chimiques et biologiques. Apergu de questions pour lesquelles des recherches ulterieures sont necessaires, particuli^remenl dans le domaine physico-cbimique; description
PERIODONTAL DRESSING MATERIALS de quelques eontre-indications concernant certaines subsiances particulieres. En eonciusion, les pansements parodontaux ont sans aueun doute un role a jouer, mais certaines connaissances necessaires manquent encore pour pouvoir realiser des produits ayant des proprietes optimales. Reierences Addy, M. & Douglas, W. H. (1975) A chlorhexidine containing metbacrylic ge! as a periodontal dressing. Journal of Periodontoiogy 46, 465-468. Addy, M. & Dolby, A. E. (1976) The use of chlorhexidine mouthwash compared with a periodontai dressing following the gingivectomy procedure. Journal of Clinical Periodonlology 3, 59-65. Ariaudo, A. A. & Tyreil, H. .\. (1957) Repositioning and increasing the zone of attacbted gingiva. Journal of Periodonlology 28, 106-
no. Ariaudo, A. A. & Tyreil, H. A. (1960) Elimination of pockets extending to or beyond the mucogingival junction. Dental Clinics of North America, 4, 67-74. Asboe-Jdrgerisen, V., Attstroni, R., Lang, N. P. & Loe, H. (1974) Effect of a chlorbexidine dressing on the healing after periodontal surgery. Journal of Periodontoiogy 45, ]3-17. Baer, P. N. & Wertheimer, F. W. (1961) A histologic study of the effects of several periodontal dressings on periosteal-covered and denuded bone. Journal of Dental Research 40, 858. Baer, P. N., Goldman, H. & Scigliano, J. (1958) Studies on a bacitracin periodontal dressing. Oral Surgery, Oral Medicine and Oral Pathology 11, 712-720. Baer, P. N., Sumner, C. F. & Scigliano, J. (1960) Studies on an bydrogenated fat-zinc bacitracin periodonta] dressing. Oral Surgery, Oral Medicine and Oral Pathology 13, 494498. Baer, P. N., Sumner, C. E. & Miller, A. (1969) Periodontal dressings. Dental Clinics of North America l3, 181-191. Berman, C, Beube, E., Odrich, R. & Kutscher, A. (1961) A new adhesive foil dressing for periodontal surgery. Journal of Periodontology 32, 14. Bernier, J, L. & Kaplan, H. (1947) Tbe repair of gingival tissue after surgical intervention. Journal of the American Dental Association 35, 697-705. Bhaskar, S. N., Jacoway, J. R., Margetis, P. M.,
Leonard, F. & Pani, K. C. (1966a) Oral tissue response to chemical adhesives (cyanoacrylates). Oral Surgery, Oral Medicine and Oral Pathology 22, 394-404. Bhaskar, S. N., Frisch, J., Margeds, P. M. & Leonard, F. (1966b) Application of a new chemical adhesive in periodontai and oral surgery. Oral Surgery, Oral Medicine and Oral Pathology 22, 526-535. Bhaskar, S. N., Frisch, J., Cutright, D. E. & Margetis, P. (1967) Effect of butyl cyanoacrylate on the heaiing of extraction wounds. Oral Surgery, Oral Medicine and Oral Pathology 24, 604-615. Binnie, W. H. & Forrest, J. O. (1974) A study of tissue response to cyanoacrylate adhesive in periodontal surgery. Journal of Periodontoiogy 45, 619-625. Blanquie, R. H. (1962) Fundamentals and technique of surgical periodontal packing. Journal of Periodontoiogy 33, 346-352. Box, H. K. & Ham, A. W. (1942) Necrotic gingivitis: its histopathology and treatment witb an adherent dressing. Oral Health 32, 721-736. Castenfeit, T. (1962) A dressing for major periodontoplastic operations. Journal of Periodontoiogy 33, 238-240. CDA Council for Dental Materials and Devices (1977) Status report: periodontal dressings. Journal of the Canadian Dental Association 43, 501-502. Chasens, A. I. & Marcus, R. W. (1963) Use of an inert syndietic gauze in periodontal surgery. Journal of Periodontoiogy 34, 23-26. Christensen, G. (1944) Paraffin packing and its application to periodontal treatment. Australian Journal of Dentistry 48, 188-194. Colman, G. (1962) A study of some antimicrobial agents used in oral surgery. Snti.vh Dental Journal 113, 22-28. Combe, E. C. (1977) Notes on Dental Materials, 3rd ed., pp. 28, 182. Edinburgh: Churchill Livingstone. Coppes, L., Grevers, A. &Hoogendiik, J. L. (1967) A comparison between a eugenol and a non-eugenol periodontal dressing. Nederlands Tijdschrift voor Tandheeikunde 74, 43^9. Cowan, A, (1965) Sulcus deepening incorporating mucosal graft. Journal of Periodontoiogy 36, 188-192. DeRenzis, F. A. & Aleo, J. J. (1970) An in vitro bioassay of cyanoacrylate toxicity. Oral Surgery, Oral Medicine and Oral Pathology 30, 803-808.
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WATTS AND COMBE
Dyer, M. R. (1967) The possible adverse effects of asbestos in gingivectomy packs. British Dental Journal 122, 507. Eberle, P. & MiJhlemann, H. R. (1959) Ein neuer Paradontalverband. Schweizerische Monatsschrift fiir Zahnheilkunde 69, 10951102. Engler, W. O., Ramfjord, S. P. & Hincker, J. J. (1966) Healing following simple gingivectomy. A tritiated thymidine radioautograpbie study. I. Epitbelialization. Journal af Periodontoiogy, 37, 298-308. Ericksson, L. (1976) Cyanoacrylate for closure of wounds in the oral mucosa in dogs. Odontohgisk Revy 27, 19-24. Ewen, S. J. (1967) Periodontal uses of a tissue adhesive. Journal of Periodontoiogy 38, 138-141. Forrest, I. O. (1974) The use of cyanoaerylates in periodontal surgery. Journal of Periodontoiogy 45, 225-229. Fraleigh, C. M. (1956) An assessment of topical terramycin in post-gingivectomy pack. Journal of Periodontoiogy 27, 201-208. Erisch, J. & Bbas!;ar, S. N. (1967) Tissue response to eugenol-containing periodontal dressings. Journal of Periodontoiogy 38, 402^08. Frisch, J., Levin, M. P. & Bbaskar, S. N. (1968a) Vinyl splint: a new method of dressing retention. Journal of Periodontoiogy 39, 24-26. Friscb, L Levin, M. P. & Bhaskar, S. N. (1968b) The use of tissue conditioners in periodontics. Journal of Periodontoiogy 39, 359-361. Erisch, J., Levin, M. P. & Bhaskar, S. N. (1968e) Ciinical study of fungal growth on tissue conditioners. Journal of the American Dental Association 76, 591-592. Giendinning, D. E. H. (1976) A method for retention of the periodontal pack. Journal of Periodontoiogy 47, 236-237. Gold, A. (1964) The current status of surgical gingivectomy. Dental Clinics of North America 8, 37-49. Goldman, H. M. & Cohen, 0 . W. (1973) Periodontal Therapy, 5th ed., p, 634. St. Louis: The C. V. Mosby Company. Gottsegen, R. (1954) Frenum position and vestibule deptb in relation to gingival healtb. Oral Surgery, Oral Medieine and Oral Pathology 7, 1069-1078. Greensmith, A. L. & Wade, A. B. (1974) Dressing after reverse bevel flap procedures. Journal of Clinical Periodontoiogy 1,97-106.
Gruber, R. G., Lucatorto, E. M. & Molnar, E. J. (1966) Fungus growth on tissue conditioners and soft denture liners. Journal of the American Dental Association 73, 641643. Gugliani, L. M. & Allen, E. E. (1965) Connective tissue reaction to implants of periodontal packs. Journal of Periodontoiogy 36, 279282. Haugen, £. & Gjermo, P. (1978) Ciinical assessment of periodontal dressings. Journal of Clinieal Periodonlology 5, 50-58. Haugen, E. & Mjor, I. A. (1978) Subcutaneous implants for assessment of dental materials with emphasis on periodontal dressings. Journal of Periodontal Research 13, 262269. Haugen, E., Gjermo, P. & 0rstavic, D. (1977) Some antibacterial properties of periodonta] dressings. Journal of Clinical Periodontoiogy 4, 62-68. Heaney, T. G. & Appleton, L (1976) The effect of periodonta] dressings on the healthy periodontium. Journal of Clinical Periodontoiogy 3, 66-76. Heaney, T. G., Melville, T. H. & Oliver, N. M. (1972) Tbe effect of two dressings on the flora of periodonta] surgical wounds. Oral Surgery, Oral Medicine and Oral Pathology, 33, 146-151. He]d, A. J. (1967) Les ciments chirurgicaux. Schweizerisehe Monatsschrift fiir Zahnheilkunde 77, 143-145. Hildebrand, C. N. & De Renzis, F. A. (1974) Effect of periodontal dressings on fibroblasts in vitro. Journal of Periodontal Research 9, 114-120. Hi]eman, A. C. (1957) Surgica] repositioning of vestibule and frenums in periodontai disease. Journal of the American Dental Association 55, 676-685. Hirschfeld, L. S. & Wasserman, B. H. (1958) Retention of periodontal packs. Journal of Periodontoiogy 29, 199-204. Holmes, C. H. (1962) Periodontal pack on singie tooth retained by acrylic splint. Journal of the American Dental Association 64, 831-832. Kalkwarf, K. L., Amerman, G. W. & Tussing, G. J. (1974) A vinyl stent for mucogingival graft procedures and post-surgical wound protection. Journal of Periodontoiogy 45, 797-800. Koch, G., Magnusson, B & Nyquist, G. (1971) Contact allergy to medicaments and materials used in dentistry (II): sensitivity to
PERIODONTAL DRESSING MATERIALS eugenol and colophony. Odontohgisk Revy 22, 275-289. Kocb, G., Magnusson, B., Nobreus, N. Nyquist, G. & Soderholm, G. (3973) Contact a]]ergy to medicaments and materia]s used in dentistry (IV): sensitizing effect of eugenol/ co]ophony in surgica] dressing. Kreth, K. K., Zimmermann, E. R. & Co]]ings, C. K. (1966) Effect of periodonta] dressings on tissue cu]ture ce]]s. Journal of Periodonlology 37, 48-53. Larato, D. C. (1967) Reinforcement of the periodontal pack. New York Dental Journal 33, 138-140. Levin, M. P., Friseh, J. & Bhaskar, S. N. (1969) Tissue conditioner dressing for free tissue grafts. Journal of Periodontoiogy 40, 271273. Levin, M. P., Cutright, D. E. & Bhaskar, S. N. (1975) Cyanaoerylate as a periodontai dressing. Journal of Oral Medicine 30, 40-43. Linghorne, W. J. & O'Conne]], D. C. (1949) The therapeutic properties of periodontal cement packs. Journal of the Canadian Dental Association 15, 199-205. Loe, H. & Siiness, J. (1961) Tissue reactions to a new gingivectomy pack. Oral Surgery, Oral Medieine and Oral Pathology 14. 13051314. Lysell, L. (1976) Contact allergy to rosin in a periodontal dressing. Journal of Oral Medicine 31, 24-25. Magnusson, B., Koch, G. & Nyquist, G. (1970) Contact allergy to medicaments and materials used in dentistry (I): General principles and diagnostic methods in contact aHergy. Identification of contact allergens by anima] testing. Odontologisk Revy 21, 287-299. Manson, J. D. (1975) Periodontics 3rd ed., p. 117. London: Henry Kimpton. Mclntosb, W. G. (1947) Periodonta! packs and their application. Journal of the Canadian Dental Association 13, 268-271. McKenzie, J. S, (3951) A method for postgingivectomy pack stabilization. Journal of Periodontoiogy 22, 201-205. Mi]]er, G. M., Dannenbaum, R. & Cohen, D. W. (1974) A pre]iminary bistologic study of the wound healing of mucogingival flaps when secured with the cyanoacrylate tissue adhesives. Journal of Periodontoiogy 45, 608-618. Mitchel], D. E. (3959) Tbe irritationai qualities of dental materia]s. Journal of the American Dental Association 59, 954-966. Mjor, I. A. (1977) Standardization of dental
and periodontal materials (Letter to the editor). Journal of Clinical Periodontoiogy 4, 69-70. Molnar, E. J. (1962) Dental composition and process of making same. U.S. Patent 3,028, 247. Molnar, E. J. (1967) Residual eugenol from zinc oxide-eugenol compounds, Journal of Dental Research 46, 645-649. Munns, D. (1952) Gingivectomy splint. British Dental Journal 92, 184-185. Nelson, E. H., Eunakoshi, E. & O'Leary, T. J. (1977) A comparison of the continuous and interrupted suturing techniques. Journal of Periodontoiogy 48, 273-281. Ochstein, A. J., Hansen, N. M. & Swenson, H. M. (1969) A comparative study of cyanoacryfate and other periodonta] dressings on gingival surgical wound healing. Journal oj Periodontoiogy 40, 515-520. Oliver, W. M. & Heaney, T. G. (1970) Sequelae following the use of eugenol or non-eugeno! dressings after gingivectomy and subgingiva] eurettage. Dental Practitioner and Dental Record 21, 49-52. O'Neil, T. C. A. (1975) Antibacterial properties of periodontal dressings. Journal of Periodontoiogy 46, 469-474. Orban, B. (1943) Gingivectomy by chemosurgery. Journal of the American Dental Association 30, 198-202. Orban, B. & Archer, E, A. (1945) Dynamics of wound bealing .following elimination of gingival pockets. American Journal of Orthodontics 31, 40-54. Otterson, E. J., & Arra, M. C. (1974) Potential hazards of asbestos in periodontal packs. Journal of the Wisconsin Dental Association 50, 435-438. Padgett, I. L. (1959) A comparative study of saline packs and astringent packs in reducing the depth of periodontal pockets. Northwestern University Bulletin 60: 4, 4-1]. Persson, G. & Thilander, H. (1968a) Experimenta] studies of surgical packs. 1. Jn vitro experiments on antimicrobial effect. Odontologisk Tidskrift 76, 147-155. Persson, G. & Tbilander, H. (1968b) Experimenta] studies of surgica] packs, 2. Tissue reaction to various packs. Odontologisk Tidskrift 76, 157-162. Pih]strom, B. L., Thorn, H. J. & Foike, L. E. A. (1977) The effect of periodonta] dressing upon supragingiva] microorganisms. Journal of Periodontoiogy 48, 440-445. Pincus, C. (1944) Dun]op wax pack treatment
14
WATTS AND COIVIBE
of pyorrhea. Australian Journal of Dentistry 48, 123. P]uss, E. M., Engelberger, P. R. & Rateitschak, K. H. (1975) Effect of chlorhexidine on dental plaque formation under periodonta] pack. Journal of Clinical Periodontoiogy 2, 136-142. Poulsom, R. C. (1974) An anaphylactoid reaction to periodontal surgica] dressing: report of case. Journal of the American Dental Association 89, 895-896. Pou]som, R. C. (1977) Persona] communication. Priehard, J. E. (1972) Advanced Periodontal Disease. 2nd ed., p. 348. Phi]ade]phia: W. B. Saunders. Prichard, J. F. (1977) Present state of the interdenta] denudation procedure. Journal of Periodontoiogy 48, 566-569. Radden, H. G. (1962) Mouth wounds. British Dental Journal 113, 112-119. Ramfjord, S. P. & Costicb, E. R. (1963) Healing after simple gingivectomy. Journal of Periodonlology 34, 401-415. Reader, E. G. (1970) Stabilisation of the periodontal pack. British Dental Journal 129, 283. Rivera-Hidalgo, F., Wyan, V. S. & Horton, J. E. (1977) Effect of soluble extracts from periodontal dressings on buman granulocytic ]eukocytes in vilro. Journal of Periodontoiogy 48, 267-272. Romanow, I. (1957) A]]ergic reaction to periodonta] pack. Journal of Periodontoiogy 28, 151-153. Romanow, I. (1964) Re]ationship of moniliasis to tbe presence of antibiotics in periodonta] packs. Periodontics 2, 298-300. Saad, L. I. & Swenson, H. M. (1965) Corticosteroid and periodonta] packs. Journal of Periodontoiogy 36, 407-412, Schacb, H. (1968) Vereinfachte Herste]]ungsweise des Zinkoxyd-bergamottol-Zabnf]eiscbverbandes. Zahndrtzliehe Welt 69, 482-483. Schu]tz, J. G. (1962) Method of using a fabric lining material under periodontal packs. Journal of Periodontoiogy 33, 172-175. Seibert, J. S. (1961) Technique for the stabilization of tissue flaps employing chromecoba]t a]]oy tissue tacks. Journal of Periodontoiogy 32, 283-289. Smith, D. C. (1970) A materialistic ]ook at periodontal packs. Dental Practitioner and Dental Record 20, 263-267. Stah], S. S., Witkin, G. J., Cantor, M. &
Brown, R. (1968) Gingiva] hea]ing. II. C]inica] and histo]ogic repair sequences following gingiveetomy. Journal of Periodontoiogy 39, 109-118. Stahl, S. S., Witkin, G. J., He]]er, A. & Brown, R. Jr. (1969) Gingiva] hea]ing. III. The effects of periodonta] dressings on gingivectomy repair. Journal of Periodontoiogy 40, 34-37. Stern, I. B. (1958) Tbe use of Teifa as a periodonta] surgica] dressing. New York State Dental Journal 24, 260-263. Su]livan, H. C. & Atkins, J. H. (1968) Free autogenous gingival grafts. 1. Principles of successful grafting. Periodontics 6, 121-129. Swann, W. P., Swenson, H. M. & Shafer, W. G. (1975) Effects of diiantin on tbe repair of gingival wounds. Journal of Periodontologv 46, 302-305. Triadan, H. (1965) Klinische und histologiscbe Untersuchungen liber einige Zahnfleischverbande im Tierex peri men t. Deutsche Zahndrtiliche Zeitschrift 20, 400-407. Waerhaug, J. & Loe, H. (1957) Tissue reaction to gingiveetomy pack. Oral Surgery,. Oral Medicine and Oral Pathology JO, 923937. Waerbaug, J. & Aanerud, A. (1963) Reinforcement and fixation of gingivectomy pack. Journal of Periodontoiogy 34, 464-465. Ward, A. W. (1923) Inharmonious cusp relation as a factor in periodontoclasia. Journal of the American Dental Association 10, 471^81. Ward, A. W. (1929) Postoperative care in tbe surgical treatment of pyorrhea. Journal of the American Dental Association 16, 635—640. Weinreb, M. M. & Shapiro, S. (1964) A clinical and bistological investigation of the pressure pack method in periodontia. Journal of Periodontoiogy 35, 167-J72. Windhoiz, M., Budavari, S., Stroumtsos, L. Y, & Eertig, M. N. (1976) The Merck Index 9th ed., p. 880. Rahway, N. L, U.S.A.: Merek & Co., Inc. Yokoyama, K. (1976) Periodontal dressing materials. Journal of the Osaka Odontologieal Society 39, 275-315. Address: Trevor L. P. Watts Department of Oral Medieine Turner Dental School Bridgeford Street Manchester M15 6FH England
Review Article
Periodontal dressing materials TREVOR L . P. WATTS AND EDWARD C. COMBE
Department of Oral Medicine and Dental Materials Science Unit, Turner Dental School, University of Manchester, England Abstract. A detailed review of periodonta) dressings is presented, covering physical, chemical and biological aspects. Areas requiring further research are outlined, particularly in the physico-chemical sphere; and some contra-indications to particular substances are described. It is concluded that there is a definite place for dressings, but that more knowledge is required before optimal properties can be deveioped.
Rationale for Usage
A wide variety of reasons has been given for the use of periodontal dressings. These reasons fall into two principal groups: a dressing may be employed as a physical adjunct to periodonta! surgery, or it may be used therapeutically with or without surgery. Physical effects Opinions vary as to the desirable physical effects of a dressing. Prichard (1972) states that a dressing is used to prevent postoperative haemorrhage and to protect the wound area from contact with food, concluding that a dressing "has no other virtue". Manson (1975) however, considers that a dressing is to protect a healing wound from saliva and trauma, thus producing comfort and speedier heahng, to prevent the proliferation of granulation tissue and to control haemorrhage. Held (1967), in addition, feels that the surgical wound must be protected from bacteria by the dressing which wiU also have an analgesic and anti-
haemorrhagic effect; whilst Goldman & Cohen (1973) emphasize the need for a "secure and rigid surgical dressing" with good adhesive properties. The advent of isobutyl cyanoacrylate has also led Bhaskar et al. (1966b) to consider instant haemostasis one of its main advantages. No other dressing material has this adhesion - dependent effect. Finally, the advent of flap repositioning led Ariaudo & Tyreli (1957) to state that the dressing should act as a stent. Many other writers have also stated the above points in textbooks and research papers, including some whose work is quoted elsewhere in this review. Thus we may conclude that wound protection and comfort, and some degree of hacmostasis and tissue stasis are generally considered to be desirable effects in a dressing. Therapeutic effects Dressings have been used in the absence of surgery for two principal effects: tissue destruction and tissue shrinkage. In the austere days of World War II, Orban (1943) described a technique of chemosurgery by
0303-6979/79/010003-12$02.50/0 © 1979 Munksgaard, Copenhagen
•WATTS AND COMBE
using paraformaldehyde in a dressing. Gingival necrosis occurred in 4-8 days. It was noted that contact with bone would cause sequestration. This technique does not seem to have achieved much popularity. As regards tissue shrinkage, the limited use of saline and astringent packs for 20 minutes following scaling has been reported by Padgett (1959); this is a variation on the once popular technique of packing periodontal pockets with an inert substance (usually a paraffin wax formulation) for 1-2 days following subgingiva! scaling (Pincus 1944, Christensen 1944, McTntosh 1947). Isolation from tooth roots led to a rapid shrinkage of the gingiva, an effect which is produced today by the somewhat slower techniques of plaque control. The use of special pressure packs to produce gingival shrinkage has also been advocated in cases where surgery is medically or psychogically inadvisable (Weinreb & Shapiro 1964). Therapeutic effects after periodontal surgery have been the goal of many who have incorporated specific agents in dressings. These agents may be classified as having a primary effect eitber on oral bacteria or upon periodontal tissues. Eugenol has been shown to have antibacterial properties in several studies in vitro (Linghorne & O'Connell 1949, CoU man 1962, Persson & Thilander 1968a, O'Neil 1975, Haugen et al. 1977); in vivo, it has been noted that plaque composition is definitely altered, presumably as a result of selective inhibition (Coppes et al- 1967, Heaney et al. 1972). Pihlstrom et al. (1977) considered that the total number of microorganisms was not noticeably reduced by eugenol. None of the quoted authors has suggested that the antibacterial properties of eugenol in any way enhance healing. However, other antibacterial substances have been added to dressings with this object, notably tetracycHne (Fraleigh 1956,
Ariaudo & Tyreil 1957, 1960), zinc bacitracin (Baer et al. 1958, 1960, 1969) noneugenal phenol derivatives such as chlorothymol (Molnar 1962), oil of bergamot (Schach 1968), and chlorhexidine (AsboeJorgensen et al. 1974, Addy & Douglas 1975, Pliiss et al. 1975). It should be noted that chemical inactivation may occur: Baer et al. (1958) report that eugenol and tannic acid both affect bacitracin. Apart from haemostatics such as tannic acid, there have been two attempts to improve postoperative healing by means of substances with a primary effect on the tissues. Saad & Swenson (1965) reported on steroids; and Swann et al. (1975) reported on diiantin. The latter agent 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. It is unlikely that the present periodontai climate will be conducive to the widespread use of therapeutic agents other than antibacteriats in dressings. Emphasis on plaque control by the patient has largely replaced the earlier philosophies based on professional intervention. Material Aspects
The literature on periodontal dressings as materials is so sparse that Mjor (1977) was quite justified in complaining of its paucity. It is clear that manufacturers want to be free to vary the composition of their products and Smith (1970) gives Just such an example in relation to the reports of Persson & Thilander (1968 a, b) concerning Coe-Pak®. The limited factual information available will now be described and will highlight areas where knowledge is deficient. Setting systems With the exception of the zinc bacitracin/
PERIODONTAL DRESSING MATERIALS hydrogenated fat dressing described by Baer et al. (1960), most dressings are intended to set, though not necessarily to the point of rigidity. At least five different systems are discernible in presently available materials: (1) The reaction of zinc oxide with eugenol to form zinc eugenolate. The reaction is slow, and even with the use of accelerators such as zinc acetate, there will always be free eugenol available during the normal life of a periodontal dressing (Molnar 1967). The significance of this free eugenol will be discussed below (Biological side-effects). (2) Organic solvent loss is the basis of setting in Peripac® (Eberle & Miihlcniann 1959), and a physical hardening results. (3) The reaction between a metallic oxide and fatty acids is the basis of Coe-Pak (Molnar 1962). A requirement of water insolubility and suitable melting points limits the typs of acids which may be used. (4) Tissue conditioners have formed the basis for certain dressing materials (Frisch et al. 1968 b, Levin et al. 1969, Addy & Douglas 1975). Their setting is usually a physical process (Combe 1977), with an elastic gel as the result. (5) Cyanoacrylate tissue adhesives set by polymerisation in the presence of anions, such as OH- (Combe 1977). (6) In addition, an experimental polycarboxylate system was used on a limited basis by Smith (1970). These setting systems may therefore be categorised as chemical or physical, and at present there is no clear basis for choice of one or the other, except for individual preference in the clinical situation. If a particular system were acknowledged to be advantageous in other respects (for example, by not inactivating a useful antibacterial agent), then these factors would help determine choice.
Retention A considerable amount of ingenuity has been expended on the problem of how peri-
odontal dressings may be kept in place. Hirschfeld & Wasserman (1958) listed a whole battery of techniques, including the use of wire, floss, acrylic, adhesive tin foil and copper bands. At the other extreme. Gold (1964) preferred a cement type pack because, in his estimation, it could even splint mobile teeth. When flap repositioning techniques were established, Ariaudo & Tyreil (1957) wanted the dressing to act as a stent; but Seibert (1961) clearly had no faith in any dressing to achieve this, and advocated the use of cobalt-chromium tacks to hold flaps in place. Numerous splints and stents have been described, employing latex (Munns 1952), acrylic resin (McKenzie 1951, Gottsegen 1954, Hileman 1957, Holmes 1962, Reader 1970, Glcn^ dinning 1976) and a vinyl polymer (Frisch et al. 1968a, Kalkwarf et al. 3974). Some of these have been related to repositioning and grafting techniques. Other means of increasing retention which have been advocated include wiring (Cowan 1965, Larato 1967), interproximal usage of spiral saws and lengthwise cotton thread (Waerhaug & Aanerud 1953), foil (Berman et al. 1961, Nelson et al. 1977), and cotton tapes with interdental sutures if necessary (Castenfelt 1962). There is no experimental evidence that objects placed within a dressing are likely to contribute to its retention; on the contrary, they are likely to weaken the dressing material since they decrease its cross-sectional area and contribute to stress concentration phenomena, thus rendering it more liable to fracture. External retention with splints and stents is free from this criticism, but they are inconvenient to both patient and operator. Ideally the dressing should be sufficiently retentive without the need for extra devices. Smith (1970) reported on preliminary trials with polyacrylate dressing materials, and Addy & Douglas (1975) also attempted to incoiporate some degree of adhesion into
WATTS AND COMBE their chlorhexidine-carrying material, by employing polyacrylic acid. Two other research groups, Asboe-Jorgensen et al. (1974) and Pluss et al. (1975), decided to employ auxiliary methods of retention for their chlorhexidine-containing dressings. Other attempts at improving dressing retention have used frankly adhesive materials. The use of cyanoacrylate tissue adhesives is well attested to in the literature (Bhaskar et al 1966, Ewen 1967, Forrest 1974, Levin et al 1975). The production of haemostasis, flap immobilisation and possibly quicker healing are described as the principal advantages of the technique. No problems of removal have been described in the literature, since cyanoacrylates are apparently biodegradable and are gradually depolymerised and phagocytosed (CDA Council for Dental Materials and Devices 1977). From the variety of ideas, it is apparent that retention of dressings presents numerous problems. This is to be expected, since a periodontal dressing is intended to be removed after a short period of time. If retention were too good, removal might become a problem; therefore, an optimum level of retention should be specifiable. Biological and therapeutic compatibility Biological side-effects of dressings are considered below; certain authors have sought to ensure biological compability by using intermediate materials under dressings. Stern (195S) reported the use of Telfa®, the inner layer of which was a thin, perforated polyester film which was non-adherent and could be used to cover bone. The use of specially prepared fabrics has been advocated by Schultz (1962) and Chasens & Marcus (1963). These fabrics must be carefully cut to size and adapted to furcation and embrasure regions. Sullivan & Atkins (1968), referring to free mucosal grafts, suggested that rubber dam be
used under any zinc oxide and eugenol dressing for the first 6 days. Cleariy it would be simpler if intermediate materials were not needed; it is also possible that they might adversely affect retention of the, dressing. Therapeutic compatibility is important if an active pharmacological agent is incorporated in a dressing. It would seem from the results of Addy & Douglas (1975) that their dressing did not substantially interfere with chlorhexidine activity. The warning of Baer et al. (1960) regarding bacitracin has already been mentioned. Restorative material compatibility It is important that periodontal dressings should not damage permanent restorations in teeth. There are two possible problems which could arise. First, an interaction might take place between dressing and restoration leading to physical breakdown of the latter. The authors have heard one such report from a reliable periodontologist. Second, anterior restorations might be stained at their margins by substances such as chlorhexidine in dressings. Protection by a separating agent would be possible, but might affect retention. Further experimental data are required on this subject.
Biological Side-effects
It is essential that no risk should accompany the use of dressing materials. The patient should not suffer any side-effects, the surgical procedures should in no way be compromised, and there should be no health risks to the operator and his staff. In general, three methods of testing materials are used: tissue culture, animal experiments and human trials. Tissue irritation Culture studies with eugenol and noneugenol dressings show that with minor
PERIODONTAL DRESSING MATERIALS variations, both types of material can be cytotoxic when tested against HeLa cells (Kreth et al. 1966), fibroblasts (Hildebrand & DeRenzis 1974) and polymorphs (RiveraHildalgo et ai. 1977). It is possible that in vivo dilution may occur, as toxic substances leach into saliva (Rivera-Hidalgo et ai. 1977), and therefore these dressings may be better tolerated by a patient who is using frequent mouthrinses. Culture studies of cyanoacryiates (DeRenzis & Aleo 1970) 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 substanees tested showed definite cytotoxicily. Certain problems arise when experimental animals are used for tests of dressing materials. Most important of these is the animal's natural tendency to remove the dressing as an extraneous object. Thus Englcr et a!. {1966) decided no dressing was needed in their gingivectomy healing studies in rhesus monkeys, and Loe & Silness (1961) used acrylic splints as dressing retainers in mongrels. Other workers have used subdermal or paraperiosteal implantation (e.g. Mitchell 1959, Baer & Wertheinier 1961, Frisch & Bhaskar 1967). Eugcnol has been implicated as an irritant in some animal studies (e.g. Waerhaug & Loe 1957), though this is a relative effect For instance Mitchell (1959) found croton oil to be a more severe tissue irritant and Gugliani & Allen (1965) rated several materials to be more irritant, including bacitracin-containing dressings. Neither Triadan (3 965) nor Yokoyama (1976) could detect unfavourable effects of eugenol histologically, and Persson & Thilander (1968b) felt that the strong antibacterial substances in Coe-Pak at that time (but see Smith 1970) were also responsible for its greater tissue irritation. However, a recent study using a standardized technique of com-
parison is in agreement with these results (Haugen & Mjor 1978), even though the composition of Coe-Pak is now believed to be different. On the other hand, Baer & Wertheimer (1961) compared several dressings above and below periosteum, and concluded that a non-eugenol dressing was better, and that if possible the periosteum should be left intact. Ochstein ct al. (1969) agreed with the desirability of split flaps and the inferiority of eugenol dressings, but recommended isobutyl cyanoacrylate to Coc-Pak (presumably of the older formulation). This study involved actual gingival surgery on beagles, and was therefore closer to the clinical situation than that of Frisch & Bhaskar (1967) which found no difference in the response in rats to subperiosteai implants of eugenol and noncugenoi dressings. As regards cyanoacrylates, other studies have shown a generally moderate tissue response to the longer-chain molecules (Bhaskar et al. 1966a, Bhaskar et al. 1967, Binnie & Forrest 1974). If sub-epithehal leakage occurs, there is however a swift foreign body response (Miller et al. ]974, Ericksson 1976). Miller et al. (1974) also noted some bone resorption in response to cyanoacrylates, and considered that heat of polymerisation migbt also affect tissues. In human beings, Bernier & Kaplan (1947) studied the healing process after gingivectomy, and stated that surface contact of tbe dressing was of primary imporiance during the first 10 days, and that constituents were only of secondary importance. Orban & Arcber (1945) considered the blood clot of prime importance in the immediate post-operative period, a view shared by Radden (1962) with regard to extraction sockets. The latter author also pointed out the delayed healing associated with eugenoi contact in rhesus monkey experiments. Stahi et al. (1969) followed up a study of gingivectomy healing (Stah! et
WATTS AND COMBE al. 1968) by considering the effects of dressings. They concluded there was no detrimental effect detectable in either dressing used (Coe-Pak, Peripac), on the ground of biopsy examination. They also gave a figure of 7-14 days for complete epithelialisation to occur, and it is interesting that Ramfjord & Costich (1963) gave a figure of 6 days for epithelialisation after gingivectomy, but using Wondrpak® (Ward 1923, 1929), a eugenol-containing material. Finally, Levin et al. (1975) biopsied 350 out of 725 patients in whom isobutyl cyanoacrylate had been used after a variety of surgical procedures, and found that healing was excellent. On the basis of these studies, it would be reasonable to say that whilst eugenol and other strong antibacterials do have some irritant effect on healing tissues, it has yet to be shown that this effect damages the overall healing process. Tissue irritation is not a ground for the definite exclusion of any materials, except the short sidechain cyanoacrylates. However, factors such as patient comfort will play some part, and the irritant effects of eugenol are perhaps countered to some extent by its obtundent action. Tissue disturbance It is important that tissue flaps and grafts should remain precisely adapted and be undisturbed by dressing materials. Sutures are used for tissue retention with most dressing materials, but it is claimed that cyanoacrylates make sutures unnecessary. Binnie & Forrest (1974) observed more inflammation with sutures than cyanoacrylate, but Ericksson (1976), utilising the buccal mucosa, preferred sutures to adhesive, because of fistula formation and cyanoacrylate inclusion in wounds. Without doubt, the introduction of cyanoacrylate under a flap could impair healing, and in the case of a free graft prevent revas-
cularisation, but in the largest reported study (Levin et al. 1975), this did not seem a problem. However, these authors did note that overextension of the adhesive into the vestibule led to mucosal ulceration, and a tissue adhesive cannot be moulded like a conventional dressing. Allergy Contact ailergy differs from tissue irritation in several respects, such as the need for previous exposure to an antigen, a latency period following this, and the low antigen dose required to elicit a response in the subject (Magnusson et al. 1970). Where tissue is damaged, a very low dose of antigen may sensitize a person. It is therefore of great importance to minimise the antigenicity of periodontal dressings. Antibiotics are a well-known source of allergic reactions, but neither Fraleigh (1957) nor Baer et al. (1960) detected any true allergies in their respective studies with tetracycline and bacitracin. It is interesting that both of these studies used agents which have been implicated as allergens in later work: eugenol and colophony (rosin: abietic acid). Koch et al. (1971) were able to sensitize guinea pigs to both agents, and tested 18 patients who had clinical manifestations suggestive of allergy after periodontal surgery. Of these, about two-thirds were sensitive to eugenol and/or colophony. Subsequently, Koch et al. (1973) were able to produce a 10 % incidence of allergy to eugenol or colophony in a group of patients from which previously sensitized persons were excluded. Case reports of other workers have also appeared in the literature: Romanow (1957) may have been the first to indict eugenol and colophony: Lysell (1976) described a reaction to colophony alone, and Poulsom (1974) gave details of a severe reaction which occurred on the application of Coe-Pak 1 week after a eugenol-containing dressing. The trigger
PERIODONTAL DRESSING MATERIALS substance in this case appears to have been tannin (Poulsom 1977), which was incorporated in both dressings. In view of the possibility of rare and very serious allergic reactions, it seems wise to exclude substances with a well-known sensitizing potential from periodontal dressings. Indeed, it seems desirable to work with pure and fully-identified materials, in view of their application to wound areas. In this connection, it is of interest that bay oil has been suggested as a constituent of eugenoi-free materials (Molnar 1962): yet according to the Merck Index (Windholz et al. 1976) this oil contains 40-55 % eugenol. Asbestos-related disease Asbestos has been incorporated into numeous dressing materials as a binder and filler (Mcintosh 1947, Linghorne & O'Connell, 1949, Blanquie 1962, O'Neil 1975), but increasing knowledge regarding its possible side-effects has led to warnings that it should be avoided. 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. Otterson & Arra (1974) showed that it was possible to mix asbestos into a dressing and not infringe the stringent U.S. Department of Labor regulations, but advised against use of asbestos on the grounds that the patient would have a reservoir of the substance in any periodontal dressing. Liver toxicity Tannic acid was also used in some dressings (e.g. Box & Ham 1942) but absorption of this substance may lead to liver damage (Baer et al. 1969, CDA Council for Dental Materials and Devices 1977). Bacterial ecology In the complex oral microflora, variations
may easily occur where antibacterial dressings are used (Heaney et al. 1972). If an antibiotic is employed, two possible problems may occur: emergence of resistant organisms, and opportunistic infection. In the study quoted, organisms resistant to certain antibacterials predominated under the dressings used, but led to no adverse effect. However, Romauow (1964) found that clinical signs of candidiasis occurred when using tetracycline in dressings, and that bacitracin enhanced the growth of yeasts, though without clinical signs in this series. Gruber et al. (1966) showed in vitro that Candida would grow on tissue conditioners, but Frisch et al. (1968c) found no signs of candidiasis in patients using tissue conditioners as periodontal dressings. Thus, evidence suggests that antibacterials may lead to this problem, but not tissue conditioners. Critical Assessment
It has been asked whether periodontal dressings are necessary. The answer to this question surely depends on the type of surgery employed. For instance, Stahl et al. (1969) in a post-gingivectomy biopsy study found no marked differences between dressed and undressed sites; Greensmith & Wade (3974), using carefully sutured flaps in a controlled trial, found that patients healed more easily and more comfortably without dressings; but Prichard (1977) clearly considered the dressing an important and not-so-simiple aspect of the interdental denudation procedure. Furthermore, a dressing will play some part in the retention of an apically positioned flap, preventing undesirable coronal movement. As regards comfort, opinions are in conflict as to whether a dressing is required (e.g. Greensmith & Wade 1974, Addy & Dolby 1976), and this problem is not easily
10
WATTS AND COMBE
studied because of the subjective phenomena involved. Comfort is at least partly involved in the question of whether biological agents are needed in dressings. Haugen .& Gjermo (1978) found that Peripac was less comfortable than either Coe-Pak or Wondrpak. However, O'Neil (1975) found that Peripac had better antibacterial properties than Coe-Pak, although the former has no specific antibacterial agent, and concluded that the physical properties of Coe-Pak were responsible for its clinical success. Oliver & Heaney (1970) on the other hand found that though a eugenol dressing was more easily fractured than Coe-Pak, there was no difference in comfort between the two. (This finding also highlights the difficulty of assessing materials for which the detailed formulation is not available: Did Oliver & Heaney (1970) use the low antibacterial post'Persson & Thiiander (1968b) formulation of Coe-Pak, or did they use the older formulation?) It seems that there is a dearth of evidence showing any definite advantage to biological agents. Of the three chlorhexidine studies quoted, two utilised auxiliary retention for the dressings as noted above, and one of these (Pliiss et al. 1975) used Peripac because it permitted a relatively large plaque accumulation. Only the study of Asboe-Iorgensen et al. (1974) concerned the direct tissue effects, and a high degree of professional attention yielded a moderate difference only. An effect was certainly demonstrated, but would it be worth-while under the normal conditions of periodontal practice? And to what extent was it related to the surgical techniques employed? No doubt the cyanoacrylates will continue to have their enthusiastic adherents, but they have two problems - difficulty in application in certain areas (Forrest 1974) and the impossibility of adjusting the dressing after application, leading for instance
to the ulceration observed by Levin et al. (1975). Many authors have indicated a need for specific physical properties in periodontal dressings, including Gottsegen (1954) Ariaudo & Tyreil (1957, 1960), Loe & Siiness (1961), Berman et al. (1961), Castenfelt (1962), Gold (1964), Kalkwarf et al. (1974), Addy & Douglas (1975), Heaney & Appleton (1976). This area is overdue for research, and new questions of chemical and biological compatibility will probably arise as a consequence. In conclusion, it appears that there are definite surgical indications for the use of periodontal dressings; that certain materials should be excluded because of toxic or other side-effects, that there is no definite indication for the use of biological agents; and that there is a need for research on the chemical and physical aspects of dressing materials. Zusammentassung
Parodontale Wundverbdnde. Eine Ubersicht Es wird eine eingehende Ubersicht tiber parodontale Wundverbande vermittelt, in der physikalisehe, chemiscbe und biologiscbe Ge.sichtspunkte beriicksichtigt werden. Weiterbin werden Gebiete umri^sen die weiterer Eorscbung bedurfen - vor allem handelt es sich hierbei um physikalisch-chemische Fragestellungen. Kontraindizierte Substanzen werden bescbrieben. Es wird gefolgert, dass der Wundverband seinen Platz in der parodonto-chirurgischen Bebandlung behauptet. Es ist jedoch eingehenderes Wissen erforderlich bevor Verbande mit optimal en Eigenschaften entwickelt werden konnen. Resume
Pansements parodontaux. Mise-au-point sur les matcriaux On trouvera iei une mise-au-point detaillee sur les pansements parodontaux et ieurs aspects physiques, chimiques et biologiques. Apergu de questions pour lesquelles des recherches ulterieures sont necessaires, particuli^remenl dans le domaine physico-cbimique; description
PERIODONTAL DRESSING MATERIALS de quelques eontre-indications concernant certaines subsiances particulieres. En eonciusion, les pansements parodontaux ont sans aueun doute un role a jouer, mais certaines connaissances necessaires manquent encore pour pouvoir realiser des produits ayant des proprietes optimales. Reierences Addy, M. & Douglas, W. H. (1975) A chlorhexidine containing metbacrylic ge! as a periodontal dressing. Journal of Periodontoiogy 46, 465-468. Addy, M. & Dolby, A. E. (1976) The use of chlorhexidine mouthwash compared with a periodontai dressing following the gingivectomy procedure. Journal of Clinical Periodonlology 3, 59-65. Ariaudo, A. A. & Tyreil, H. .\. (1957) Repositioning and increasing the zone of attacbted gingiva. Journal of Periodonlology 28, 106-
no. Ariaudo, A. A. & Tyreil, H. A. (1960) Elimination of pockets extending to or beyond the mucogingival junction. Dental Clinics of North America, 4, 67-74. Asboe-Jdrgerisen, V., Attstroni, R., Lang, N. P. & Loe, H. (1974) Effect of a chlorbexidine dressing on the healing after periodontal surgery. Journal of Periodontoiogy 45, ]3-17. Baer, P. N. & Wertheimer, F. W. (1961) A histologic study of the effects of several periodontal dressings on periosteal-covered and denuded bone. Journal of Dental Research 40, 858. Baer, P. N., Goldman, H. & Scigliano, J. (1958) Studies on a bacitracin periodontal dressing. Oral Surgery, Oral Medicine and Oral Pathology 11, 712-720. Baer, P. N., Sumner, C. F. & Scigliano, J. (1960) Studies on an bydrogenated fat-zinc bacitracin periodonta] dressing. Oral Surgery, Oral Medicine and Oral Pathology 13, 494498. Baer, P. N., Sumner, C. E. & Miller, A. (1969) Periodontal dressings. Dental Clinics of North America l3, 181-191. Berman, C, Beube, E., Odrich, R. & Kutscher, A. (1961) A new adhesive foil dressing for periodontal surgery. Journal of Periodontology 32, 14. Bernier, J, L. & Kaplan, H. (1947) Tbe repair of gingival tissue after surgical intervention. Journal of the American Dental Association 35, 697-705. Bhaskar, S. N., Jacoway, J. R., Margetis, P. M.,
Leonard, F. & Pani, K. C. (1966a) Oral tissue response to chemical adhesives (cyanoacrylates). Oral Surgery, Oral Medicine and Oral Pathology 22, 394-404. Bhaskar, S. N., Frisch, J., Margeds, P. M. & Leonard, F. (1966b) Application of a new chemical adhesive in periodontai and oral surgery. Oral Surgery, Oral Medicine and Oral Pathology 22, 526-535. Bhaskar, S. N., Frisch, J., Cutright, D. E. & Margetis, P. (1967) Effect of butyl cyanoacrylate on the heaiing of extraction wounds. Oral Surgery, Oral Medicine and Oral Pathology 24, 604-615. Binnie, W. H. & Forrest, J. O. (1974) A study of tissue response to cyanoacrylate adhesive in periodontal surgery. Journal of Periodontoiogy 45, 619-625. Blanquie, R. H. (1962) Fundamentals and technique of surgical periodontal packing. Journal of Periodontoiogy 33, 346-352. Box, H. K. & Ham, A. W. (1942) Necrotic gingivitis: its histopathology and treatment witb an adherent dressing. Oral Health 32, 721-736. Castenfeit, T. (1962) A dressing for major periodontoplastic operations. Journal of Periodontoiogy 33, 238-240. CDA Council for Dental Materials and Devices (1977) Status report: periodontal dressings. Journal of the Canadian Dental Association 43, 501-502. Chasens, A. I. & Marcus, R. W. (1963) Use of an inert syndietic gauze in periodontal surgery. Journal of Periodontoiogy 34, 23-26. Christensen, G. (1944) Paraffin packing and its application to periodontal treatment. Australian Journal of Dentistry 48, 188-194. Colman, G. (1962) A study of some antimicrobial agents used in oral surgery. Snti.vh Dental Journal 113, 22-28. Combe, E. C. (1977) Notes on Dental Materials, 3rd ed., pp. 28, 182. Edinburgh: Churchill Livingstone. Coppes, L., Grevers, A. &Hoogendiik, J. L. (1967) A comparison between a eugenol and a non-eugenol periodontal dressing. Nederlands Tijdschrift voor Tandheeikunde 74, 43^9. Cowan, A, (1965) Sulcus deepening incorporating mucosal graft. Journal of Periodontoiogy 36, 188-192. DeRenzis, F. A. & Aleo, J. J. (1970) An in vitro bioassay of cyanoacrylate toxicity. Oral Surgery, Oral Medicine and Oral Pathology 30, 803-808.
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WATTS AND COMBE
Dyer, M. R. (1967) The possible adverse effects of asbestos in gingivectomy packs. British Dental Journal 122, 507. Eberle, P. & MiJhlemann, H. R. (1959) Ein neuer Paradontalverband. Schweizerische Monatsschrift fiir Zahnheilkunde 69, 10951102. Engler, W. O., Ramfjord, S. P. & Hincker, J. J. (1966) Healing following simple gingivectomy. A tritiated thymidine radioautograpbie study. I. Epitbelialization. Journal af Periodontoiogy, 37, 298-308. Ericksson, L. (1976) Cyanoacrylate for closure of wounds in the oral mucosa in dogs. Odontohgisk Revy 27, 19-24. Ewen, S. J. (1967) Periodontal uses of a tissue adhesive. Journal of Periodontoiogy 38, 138-141. Forrest, I. O. (1974) The use of cyanoaerylates in periodontal surgery. Journal of Periodontoiogy 45, 225-229. Fraleigh, C. M. (1956) An assessment of topical terramycin in post-gingivectomy pack. Journal of Periodontoiogy 27, 201-208. Erisch, J. & Bbas!;ar, S. N. (1967) Tissue response to eugenol-containing periodontal dressings. Journal of Periodontoiogy 38, 402^08. Frisch, J., Levin, M. P. & Bbaskar, S. N. (1968a) Vinyl splint: a new method of dressing retention. Journal of Periodontoiogy 39, 24-26. Friscb, L Levin, M. P. & Bhaskar, S. N. (1968b) The use of tissue conditioners in periodontics. Journal of Periodontoiogy 39, 359-361. Erisch, J., Levin, M. P. & Bhaskar, S. N. (1968e) Ciinical study of fungal growth on tissue conditioners. Journal of the American Dental Association 76, 591-592. Giendinning, D. E. H. (1976) A method for retention of the periodontal pack. Journal of Periodontoiogy 47, 236-237. Gold, A. (1964) The current status of surgical gingivectomy. Dental Clinics of North America 8, 37-49. Goldman, H. M. & Cohen, 0 . W. (1973) Periodontal Therapy, 5th ed., p, 634. St. Louis: The C. V. Mosby Company. Gottsegen, R. (1954) Frenum position and vestibule deptb in relation to gingival healtb. Oral Surgery, Oral Medieine and Oral Pathology 7, 1069-1078. Greensmith, A. L. & Wade, A. B. (1974) Dressing after reverse bevel flap procedures. Journal of Clinical Periodontoiogy 1,97-106.
Gruber, R. G., Lucatorto, E. M. & Molnar, E. J. (1966) Fungus growth on tissue conditioners and soft denture liners. Journal of the American Dental Association 73, 641643. Gugliani, L. M. & Allen, E. E. (1965) Connective tissue reaction to implants of periodontal packs. Journal of Periodontoiogy 36, 279282. Haugen, £. & Gjermo, P. (1978) Ciinical assessment of periodontal dressings. Journal of Clinieal Periodonlology 5, 50-58. Haugen, E. & Mjor, I. A. (1978) Subcutaneous implants for assessment of dental materials with emphasis on periodontal dressings. Journal of Periodontal Research 13, 262269. Haugen, E., Gjermo, P. & 0rstavic, D. (1977) Some antibacterial properties of periodonta] dressings. Journal of Clinical Periodontoiogy 4, 62-68. Heaney, T. G. & Appleton, L (1976) The effect of periodonta] dressings on the healthy periodontium. Journal of Clinical Periodontoiogy 3, 66-76. Heaney, T. G., Melville, T. H. & Oliver, N. M. (1972) Tbe effect of two dressings on the flora of periodonta] surgical wounds. Oral Surgery, Oral Medicine and Oral Pathology, 33, 146-151. He]d, A. J. (1967) Les ciments chirurgicaux. Schweizerisehe Monatsschrift fiir Zahnheilkunde 77, 143-145. Hildebrand, C. N. & De Renzis, F. A. (1974) Effect of periodontal dressings on fibroblasts in vitro. Journal of Periodontal Research 9, 114-120. Hi]eman, A. C. (1957) Surgica] repositioning of vestibule and frenums in periodontai disease. Journal of the American Dental Association 55, 676-685. Hirschfeld, L. S. & Wasserman, B. H. (1958) Retention of periodontal packs. Journal of Periodontoiogy 29, 199-204. Holmes, C. H. (1962) Periodontal pack on singie tooth retained by acrylic splint. Journal of the American Dental Association 64, 831-832. Kalkwarf, K. L., Amerman, G. W. & Tussing, G. J. (1974) A vinyl stent for mucogingival graft procedures and post-surgical wound protection. Journal of Periodontoiogy 45, 797-800. Koch, G., Magnusson, B & Nyquist, G. (1971) Contact allergy to medicaments and materials used in dentistry (II): sensitivity to
PERIODONTAL DRESSING MATERIALS eugenol and colophony. Odontohgisk Revy 22, 275-289. Kocb, G., Magnusson, B., Nobreus, N. Nyquist, G. & Soderholm, G. (3973) Contact a]]ergy to medicaments and materia]s used in dentistry (IV): sensitizing effect of eugenol/ co]ophony in surgica] dressing. Kreth, K. K., Zimmermann, E. R. & Co]]ings, C. K. (1966) Effect of periodonta] dressings on tissue cu]ture ce]]s. Journal of Periodonlology 37, 48-53. Larato, D. C. (1967) Reinforcement of the periodontal pack. New York Dental Journal 33, 138-140. Levin, M. P., Friseh, J. & Bhaskar, S. N. (1969) Tissue conditioner dressing for free tissue grafts. Journal of Periodontoiogy 40, 271273. Levin, M. P., Cutright, D. E. & Bhaskar, S. N. (1975) Cyanaoerylate as a periodontai dressing. Journal of Oral Medicine 30, 40-43. Linghorne, W. J. & O'Conne]], D. C. (1949) The therapeutic properties of periodontal cement packs. Journal of the Canadian Dental Association 15, 199-205. Loe, H. & Siiness, J. (1961) Tissue reactions to a new gingivectomy pack. Oral Surgery, Oral Medieine and Oral Pathology 14. 13051314. Lysell, L. (1976) Contact allergy to rosin in a periodontal dressing. Journal of Oral Medicine 31, 24-25. Magnusson, B., Koch, G. & Nyquist, G. (1970) Contact allergy to medicaments and materials used in dentistry (I): General principles and diagnostic methods in contact aHergy. Identification of contact allergens by anima] testing. Odontologisk Revy 21, 287-299. Manson, J. D. (1975) Periodontics 3rd ed., p. 117. London: Henry Kimpton. Mclntosb, W. G. (1947) Periodonta! packs and their application. Journal of the Canadian Dental Association 13, 268-271. McKenzie, J. S, (3951) A method for postgingivectomy pack stabilization. Journal of Periodontoiogy 22, 201-205. Mi]]er, G. M., Dannenbaum, R. & Cohen, D. W. (1974) A pre]iminary bistologic study of the wound healing of mucogingival flaps when secured with the cyanoacrylate tissue adhesives. Journal of Periodontoiogy 45, 608-618. Mitchel], D. E. (3959) Tbe irritationai qualities of dental materia]s. Journal of the American Dental Association 59, 954-966. Mjor, I. A. (1977) Standardization of dental
and periodontal materials (Letter to the editor). Journal of Clinical Periodontoiogy 4, 69-70. Molnar, E. J. (1962) Dental composition and process of making same. U.S. Patent 3,028, 247. Molnar, E. J. (1967) Residual eugenol from zinc oxide-eugenol compounds, Journal of Dental Research 46, 645-649. Munns, D. (1952) Gingivectomy splint. British Dental Journal 92, 184-185. Nelson, E. H., Eunakoshi, E. & O'Leary, T. J. (1977) A comparison of the continuous and interrupted suturing techniques. Journal of Periodontoiogy 48, 273-281. Ochstein, A. J., Hansen, N. M. & Swenson, H. M. (1969) A comparative study of cyanoacryfate and other periodonta] dressings on gingival surgical wound healing. Journal oj Periodontoiogy 40, 515-520. Oliver, W. M. & Heaney, T. G. (1970) Sequelae following the use of eugenol or non-eugeno! dressings after gingivectomy and subgingiva] eurettage. Dental Practitioner and Dental Record 21, 49-52. O'Neil, T. C. A. (1975) Antibacterial properties of periodontal dressings. Journal of Periodontoiogy 46, 469-474. Orban, B. (1943) Gingivectomy by chemosurgery. Journal of the American Dental Association 30, 198-202. Orban, B. & Archer, E, A. (1945) Dynamics of wound bealing .following elimination of gingival pockets. American Journal of Orthodontics 31, 40-54. Otterson, E. J., & Arra, M. C. (1974) Potential hazards of asbestos in periodontal packs. Journal of the Wisconsin Dental Association 50, 435-438. Padgett, I. L. (1959) A comparative study of saline packs and astringent packs in reducing the depth of periodontal pockets. Northwestern University Bulletin 60: 4, 4-1]. Persson, G. & Thilander, H. (1968a) Experimenta] studies of surgical packs. 1. Jn vitro experiments on antimicrobial effect. Odontologisk Tidskrift 76, 147-155. Persson, G. & Tbilander, H. (1968b) Experimenta] studies of surgica] packs, 2. Tissue reaction to various packs. Odontologisk Tidskrift 76, 157-162. Pih]strom, B. L., Thorn, H. J. & Foike, L. E. A. (1977) The effect of periodonta] dressing upon supragingiva] microorganisms. Journal of Periodontoiogy 48, 440-445. Pincus, C. (1944) Dun]op wax pack treatment
14
WATTS AND COIVIBE
of pyorrhea. Australian Journal of Dentistry 48, 123. P]uss, E. M., Engelberger, P. R. & Rateitschak, K. H. (1975) Effect of chlorhexidine on dental plaque formation under periodonta] pack. Journal of Clinical Periodontoiogy 2, 136-142. Poulsom, R. C. (1974) An anaphylactoid reaction to periodontal surgica] dressing: report of case. Journal of the American Dental Association 89, 895-896. Pou]som, R. C. (1977) Persona] communication. Priehard, J. E. (1972) Advanced Periodontal Disease. 2nd ed., p. 348. Phi]ade]phia: W. B. Saunders. Prichard, J. F. (1977) Present state of the interdenta] denudation procedure. Journal of Periodontoiogy 48, 566-569. Radden, H. G. (1962) Mouth wounds. British Dental Journal 113, 112-119. Ramfjord, S. P. & Costicb, E. R. (1963) Healing after simple gingivectomy. Journal of Periodonlology 34, 401-415. Reader, E. G. (1970) Stabilisation of the periodontal pack. British Dental Journal 129, 283. Rivera-Hidalgo, F., Wyan, V. S. & Horton, J. E. (1977) Effect of soluble extracts from periodontal dressings on buman granulocytic ]eukocytes in vilro. Journal of Periodontoiogy 48, 267-272. Romanow, I. (1957) A]]ergic reaction to periodonta] pack. Journal of Periodontoiogy 28, 151-153. Romanow, I. (1964) Re]ationship of moniliasis to tbe presence of antibiotics in periodonta] packs. Periodontics 2, 298-300. Saad, L. I. & Swenson, H. M. (1965) Corticosteroid and periodonta] packs. Journal of Periodontoiogy 36, 407-412, Schacb, H. (1968) Vereinfachte Herste]]ungsweise des Zinkoxyd-bergamottol-Zabnf]eiscbverbandes. Zahndrtzliehe Welt 69, 482-483. Schu]tz, J. G. (1962) Method of using a fabric lining material under periodontal packs. Journal of Periodontoiogy 33, 172-175. Seibert, J. S. (1961) Technique for the stabilization of tissue flaps employing chromecoba]t a]]oy tissue tacks. Journal of Periodontoiogy 32, 283-289. Smith, D. C. (1970) A materialistic ]ook at periodontal packs. Dental Practitioner and Dental Record 20, 263-267. Stah], S. S., Witkin, G. J., Cantor, M. &
Brown, R. (1968) Gingiva] hea]ing. II. C]inica] and histo]ogic repair sequences following gingiveetomy. Journal of Periodontoiogy 39, 109-118. Stahl, S. S., Witkin, G. J., He]]er, A. & Brown, R. Jr. (1969) Gingiva] hea]ing. III. The effects of periodonta] dressings on gingivectomy repair. Journal of Periodontoiogy 40, 34-37. Stern, I. B. (1958) Tbe use of Teifa as a periodonta] surgica] dressing. New York State Dental Journal 24, 260-263. Su]livan, H. C. & Atkins, J. H. (1968) Free autogenous gingival grafts. 1. Principles of successful grafting. Periodontics 6, 121-129. Swann, W. P., Swenson, H. M. & Shafer, W. G. (1975) Effects of diiantin on tbe repair of gingival wounds. Journal of Periodontologv 46, 302-305. Triadan, H. (1965) Klinische und histologiscbe Untersuchungen liber einige Zahnfleischverbande im Tierex peri men t. Deutsche Zahndrtiliche Zeitschrift 20, 400-407. Waerhaug, J. & Loe, H. (1957) Tissue reaction to gingiveetomy pack. Oral Surgery,. Oral Medicine and Oral Pathology JO, 923937. Waerbaug, J. & Aanerud, A. (1963) Reinforcement and fixation of gingivectomy pack. Journal of Periodontoiogy 34, 464-465. Ward, A. W. (1923) Inharmonious cusp relation as a factor in periodontoclasia. Journal of the American Dental Association 10, 471^81. Ward, A. W. (1929) Postoperative care in tbe surgical treatment of pyorrhea. Journal of the American Dental Association 16, 635—640. Weinreb, M. M. & Shapiro, S. (1964) A clinical and bistological investigation of the pressure pack method in periodontia. Journal of Periodontoiogy 35, 167-J72. Windhoiz, M., Budavari, S., Stroumtsos, L. Y, & Eertig, M. N. (1976) The Merck Index 9th ed., p. 880. Rahway, N. L, U.S.A.: Merek & Co., Inc. Yokoyama, K. (1976) Periodontal dressing materials. Journal of the Osaka Odontologieal Society 39, 275-315. Address: Trevor L. P. Watts Department of Oral Medieine Turner Dental School Bridgeford Street Manchester M15 6FH England
