1. INTRODUCTION:

1.1 Periodontal Surgery:

Surgery for periodontitis requires tissue manipulation. A type of protection is needed to combat post-surgical swelling, inflammation, and bleeding¹. The purpose of periodontal surgery is to remove pockets and restore a gingival morphology that allows the patient to effectively control plaque.

If the local environment is managed, surgical removal of pockets, plaque, and calculus, and development of a good fundamental morphology will provide the groundwork for periodontal health².

1.2 Surgical procedures^3,4

The surgical procedures performed in dental clinics are as follows:

· Tooth Extraction.

· Periodontal Flap Surgery.

· Regenerative Periodontal Surgery or periodontal tissue regeneration.

Laser therapy has been used to treat periodontal pockets and mechanical debridement of subgingival root surfaces in recent years. Lasers are also employed in other fields of periodontics, such as curettage, depigmentation, hemostasis, soft tissue ablation, soft tissue recontouring, frenectomy, operculectomy, soft tissue recontouring, removal of huge masses of tissue, and bactericidal effects in the pockets.

1.3 Periodontal dressing:

One of the items that periodontists use the most frequently is periodontal dressings. To cover and protect the surgical wound surface caused by periodontal therapy following surgery, a periodontal dressing is employed⁵.

The main goals of periodontal dressings are to achieve optimal healing and guarantee that the patient experiences the least amount of discomfort⁶. There are several different types of periodontal dressings available. Clinical research has shown that the type of dressing used following periodontal surgery may affect how quickly the wound heals⁷.

Fig 1: Periodontal dressing⁸.

1.3.1 History of periodontal dressing:

In the form of iodoform gauze, periodontal treatments were initially introduced by Zentler in 1918¹. Dr. A.W. Ward introduced periodontal dressings called “wonder pack” for the first time in 1923, recommending their usage after periodontal surgery⁹.

1.1.2 Purpose of periodontal dressing^2,10:

The following is the primary purpose of the dressing:

· To protect the healing wound from saliva and trauma.

· To prevent the formation of granulation tissue.

· To control hemorrhage.

· To provide patient comfort and

· To protect the wound from injury during healing,

· To hold a flap in position after it has been sutured.

1.1.3 Properties of Periodontal Dressings^5,6:

The following are the ideal properties of periodontal dressing:

· It should be set within a reasonable amount of time.

· It should have enough stiffness to shield against fracture and dislocation

· After setting, the surface must be smooth to avoid irritating the cheeks and lips.

· To stop excessive plaque formation, it must have bactericidal characteristics.

· The healing process shouldn't be hampered.

· To avoid salivary leakage, it should have dimensional stability.

· It shouldn't cause any potential adverse systemic effects or allergic reactions.

· It should be of palatable taste.

· It must be economical and easily available.

· It must possess a good shelf life.

· It should have an acceptable smell.

· It should be soft with enough plasticity and flexibility to facilitate its placement in the operated area and to allow proper adaptation.

· It should be non-irritant to the tissues of the patient and the operator.

1.1.4 Functions of periodontal dressings⁶:

The following are the functions of periodontal dressing:

· It provides comfort to the patient and also gives a psychological feeling of healing to the patient.

· It helps to obtain and maintain a close adaptation of the mucosal flaps to the underlying bone.

· It provides additional support to stabilize the free gingival graft.

· It protects the suture.

· It protects the wound post-operatively from irritation.

· It helps to minimize post-operative infection and hemorrhage by maintaining pressure after it becomes hard.

· It helps to desensitize the root surface and protect the exposed root surface from temperature changes.

· It helps to obtain debris area

· It helps in the maintenance of oral hygiene which helps the patients to brush their remaining teeth.

1.2 Classification of periodontal dressing^{1,5,6,11–16}:

In general, there are three categories of periodontal dressings: (i) those containing zinc oxide and eugenol, (ii) those containing zinc oxide without eugenol, and (iii) those containing neither zinc oxide nor eugenol.

2. COMMERCIALLY AVAILABLE PERIODONTAL DRESSINGS:

The following dressings are available in the market for use:

2.1 Ward’s Wonder Pack

· Type: Eugenol dressing^6,16.

· Composition: it is available in two forms containing several ingredients⁶.

i. Powder and liquid form:

The powder comprises asbestos, talc, resin, powdered pine, and zinc oxide. The liquid contains coloring pigment, clove oil, peanut oil, pine oil, camphor, and 10% isopropyl alcohol¹⁶.

The primary component is zinc oxide powder, which undergoes a chelation reaction with eugenol to produce zinc eugenolate. Strength and hardness are provided by polymerized rosin, while zinc acetate and stearate serve as accelerators. To lessen the irritation caused by the eugenol, cottonseed oil is employed. The pack is prepared to a putty consistency to facilitate easy molding.

ii. Paste form:

it includes two tubes that are mixed in equal amounts the composition of the tubes is given below:

Base: 87% zinc oxide and 13% fixed vegetable oil are found in Tube 1.

The contents of Tube 2 include an accelerator solution consisting of calcium chloride (5 percent), coloring agent Canada and Peru balsam, gum or polymerized rosin (50 percent), filler (silica type) (20 percent), lanolin (3 percent), resinous balsam (10 percent), and oil of clove or eugenol (12 percent)¹⁶.

· Advantages: Prepared in advance, Immobilize the surgical area for the desired time

· Disadvantages: Attributed to allergic reactions due to the presence of free eugenol, Spicy taste, Lack of smoothness, Difficulty with adaptation, Frequency of fracture, and Cracking of acrylic material.

· Manufactured by: Westword Dental Products. Co.San. Francisco; USA^6,10

2.2 Kirkland formula:

· Type: Eugenol dressing^6,16.

· Composition: Supplied as,

i. Paste form: Two distinct pastes are administered for each. This tube 1 has a base consisting of 87 percent zinc oxide and 13 percent mineral oil, which serves as a plasticizer and helps counteract the irritating effects of eugenol. Accelerator oil of clove or eugenol (12 percent), gum or polymerized rosin (50 percent), silica type filler (20 percent), lanolin (3 percent), and resinous balsam (10 percent) are all present in tube 2 and aid in improving mixing qualities and flow. It also includes 5% coloring pigment and an accelerator solution (calcium chloride).

ii. Power and liquid: The powder is composed of tannic acid, rosin, zinc oxide, kaolin, zinc stearate, and asbestos; the liquid is composed of rosin, peanut oil, and eugenol. The powder and liquid are combined to make the dressing.

· Manufactured by: Kirkland Pack, Prudent, Corporation of America-, Brookline, Maes⁶.

2.3 Coe-pak:

Coe-Pak is the most commonly used product^{1,5,10,14,16,17}.

· Type: Non eugenol dressings^1,6,10,16.

· Composition: Supplied as i) two pastes and ii) auto-mixing system in a syringe.

i. Paste form: developed by Smith D C 1970¹⁰.

(Accelerator)

a. Zinc oxide: an antiseptic and astringent;

b. vegetable oil: flexible

c. Lorothidol-Fungicide

d. Magnesium oxide: Aids in reaction setup;

e. Gum: Cohesiveness

(Base paste)

a. Liquid coconut fatty acid-Helps in the chemical reaction

b. Colophony resin-Regulates the setting time

c. Chlorothymol- Bacteriostatic ^1,5,6,10,16.

ii. The Auto-mixing system:

It is kept inside the syringe. There are two distinct cylinders in this syringe. One of the pastes is present in each. Mixing happens inside the syringe tip as the trigger is pressed. After being placed in a mixing pad, the dressing material is applied to the surgical site in 30 seconds, taking the proper shape. The manually mixed system will not be set as hard as this one^6,10.

· Setting reaction: The primary mechanism behind Coe-Pak is the interaction between metallic salts and fatty acids^5,10. The two pastes react through a process called saponification⁶. The absence of eugenol and asbestos in the dressing prevents issues related to these substances ¹⁰.

· Improper adaptation- overextension

i. Tend to dislodge the dressing.

ii. Irritates the soft tissue.

iii. Interferes with occlusion and movement of the tongue.

iv. Disturbs the wound healing- rocking motion.

· Advantages

i. Smooth, non-brittle, and cohesive dressing material with a pleasant taste.

ii. Germicidal activity

· Disadvantages

i. Poor appearance,

ii. Ill-defined setting time;

iii. Poor flow properties during manipulation

iv. Microbial colonization

v. Does not stay for a longer time and is pushed up as tissue shrinks⁶.

· Manufactured by: Coe Laboratories Inc., Chicago, I1, USA¹⁰.

2.4 Peripac:

Peripac was introduced by Eberle and Muhleman. The paste is a zinc oxide dressing that has been premixed.^6,10.

· Type: Non eugenol dressings^1,6,10,16.

· Composition: Calcium sulfate, zinc oxide, zinc sulfate, acrylic type of resin, glycol solvent, flavoring agents, coloring agents^6,10,16.

· Setting reaction: When exposed to moisture or air, it solidifies into a hard condition. It sets in the mouth because of the saliva's water content and glycol loss.⁶.

· Description: Using a dry, sterile spatula, remove a tiny amount of the material from the jar and place it on a paper napkin to use. Peripac starts to harden as soon as it comes into contact with water and takes around 20 minutes to finish. Applying the dressing shouldn't take longer than two to three minutes. A well-applied dressing lasts for eight to ten days without changing.¹⁰. Following several minor periodontal surgical procedures, Peripac is recommended as a dressing. It is also used as a temporary rebasing material for dentures that are placed right before periodontal surgeries.^1,2.

· Manufactured by: GC America Inc., Chicago, USA¹⁰.

2.5 Septopack:

It is a plastic paste that self-hardens and has fibers mixed into its mass.

· Type: Non eugenol dressings.

· Composition: Its ingredients include zinc oxide, sulfate, butyl polymethacrylate, amyl acetate, and dibutyl phthalate. The excipient is a plastic paste that serves as a vehicle for administering medication to the gingiva, teeth, or alveolar ridge level to promote faster wound healing.

· Manufactured by: Septodont, Saint Maur-des-Fosses, France^1,16.

2.6 PerioCare:

PerioCare is a resiliently strong periodontal dressing that is extremely elastic¹⁶.

· Type: Non eugenol dressings.

· Available in paste-gel form.^1,5,6,10,16

· Composition:

Paste: Zinc oxide, Magnesium oxide, calcium hydroxide, and vegetable oils.

Gel: Resin, fatty acids, ethyl cellulose, lanolin, and calcium hydroxide^6,10,16.

· Properties:

i. It is a highly elastic periodontal dressing and does not chip

ii. It provided durable protection of tissue

iii. It does not support the growth of bacteria

iv. It is patient-pleasing and has a neutral odor and taste.

v. It contains no eugenol or asbestos

· Procedure: Leave the same amount of gel and paste on the mixing pad. until a consistent shade is achieved, use an appropriate spatula mix. Use Wonder-Orange Organic Solvent to clean the spatula.

· Mixing time: 30 seconds.

· working time: 7 minutes

· Setting time: 15 minutes⁶.

· Manufactured by: Pulpdent Corp. Brookline Watertown, MA, USA^1,6.

2.7 Vocopac:

It is a recently developed product. Neither coumarin nor eugenol is present.⁶. It is provided as two chemically reactive pastes, base and catalyst^6,10.

· Type: Non eugenol dressings^6,10

· Manufactured by: Voco, Cuxhaven, Germany.

· Composition: includes natural resin, natural oils, colorant, fatty acids, zinc oxide, zinc acetate, magnesium oxide, and pure columbium.

· Mixing time: 20 – 30 secs¹⁰.

· Working time: 10-15 minutes⁶.

· Advantage: This substance is not fragile and maintains its flexibility in the patient's mouth. does not irritate the gingiva effectively sticks to teeth and aids in the healing process^6,10.

· Contraindication: Avoiding contact with the bone is also advised for people who have allergies to these substances. Additionally, synthetic materials may slightly discolour¹⁰.

2.8 Cyanoacrylate dressings:

Synthesized by Coover et al in 1959. The chemical formula– H 2 C = C (CN) COOR, where R-can be substituted for any alkyl group ranging from methyl to decyl. In 1965 Dr. S.N. Bhaskar conceived of the idea of the potential of cyanoacrylates as periodontal dressings^10,16.

· Type: Other^6,10,15,16.

· Composition: n-Butyl cyanoacrylate^1,16.

· Manufactured by: Histoacryl®; B. Braun Biosurgicals, Germany and PeriAcryl®; Glustitch Inc, Delta, Canada¹⁶.

· Properties¹⁰

i. Strong adhesion: to the tissues in the presence of moisture

ii. Workable polymerization time

iii. Biodegradability- is eliminated in the feces and urine inhibits bacterial growth

iv. Bacteriostatic

v. Hemostasis.

vi. Reduction in post-operative pain

· Advantages^6,10,16: It is easy to apply, and less bulky than others. No manipulation is required. It is easy to take out and easy to repair. It does not require chair assistance. It is transparent- so can see the healing of the wound.

· Application¹⁰: Cyanoacrylate as the dressing has been specified for post-operative use following an array of periodontal procedures¹.

2.9 Light cure dressings:

It is offered in a syringe for intraoral administration or for dispensing on a mixing pad. Barricaid is currently the most widely used light-cured periodontal dressing⁵.

· Type: Other¹⁶.

· Composition: The main components of these materials are silanated silica, polyether urethane di-methacrylate resin, hydrophobic amorphous fumed silica, silicon dioxide crystalline quartz, stabilizer, colorant, and visible light cure (VLC) photoinitiator and accelerator^5,10,16.

· Manufactured by: Barricaid®, Caulk, Dentsply¹⁸.

· Placement Of Barricade: Barricade is designed for both direct and indirect placement.

i. Direct placement: Dry the buccal or lingual tooth surfaces next to the surgery site using sterile, dry 2 x 2 gauze. Take off the disposable syringe's tip. Apply the substance at the intersection of the cervical third of the teeth.

ii. Indirect placement: Spread a small amount of lubricant onto a spotless mixing pad. Using a gloved finger that has been mildly greased, roll the dressing ribbon off the pad. The material can be shaped with a carver, muscle mold, plastic tool, or finger pressure. Place the barricade under a visible light source for a minimum of 10 seconds on each side of each tooth (buccal or lingual)⁵.

· Clinical significance: The following circumstances allow for the short-term temporization of light-cured periodontal surgical dressing material:

i. when the patient must return at a later time to receive an indirect provisional.

ii. when abutment preparation is combined with periodontal surgery.

iii. If significant bleeding or gingival damage necessitates delaying the final imprint following tooth preparation¹⁸.

· Advantages

i. Non brittle and very elastic

ii. No mixing- component, light-activated periodontal dressing eliminates the time-consuming mixing of pastes.

iii. Curing with a visible light-curing unit to form a non-brittle, but firm, protective elastic covering

iv. Incremental additions of the material, which bond adherently, can be made in the mouth without any special prior surface preparation.

v. The dressing is tinted pink, tasteless, and has a translucent character which allows for superior esthetics.

vi. Designed for both Direct and Indirect Placement. If the syringe is used in direct intra-oral placement, the syringe must be discarded to avoid any potential patient cross-infection¹⁰.

2.10 Collagen dressing:

· Type: Other.

· Composition: Type I collagen derived from bovine tendon mixed with cancellous granules.

· Description: This dressing sponge is absorbent, with a thickness of around 3 mm. It may be sliced to fit the graft site, stopping bleeding immediately. It can absorb 30–40 times its weight in fluid without swelling¹⁰. It serves to conceal and safeguard the site of the palatal transplant. Compared to conventional non-eugenol dressing, collagen band dressing may have far more benefits⁶.

Three types of collagen dressings are sold commercially:

i. Tape: it can be utilized for substantial augmentations, socket grafting, Schneiderian membrane rips, localized ridge deficiencies, and soft tissue donor site protection.

ii. Cote: it is utilized in directed bone regeneration, sinus membrane perforations, sinus graft containment, and soft tissue recontouring.

iii. Plug: it is applied to biopsy sites as a dressing.

· Advantages: The dressings have several advantages over other types, such as being hypoallergenic, nonpyrogenic, immune-stimulating, and easy to apply. Furthermore, natural collagen has the innate capacity to support hemostasis through platelet aggregation and the subsequent coagulation cascade. Furthermore, the blood clot is strengthened by the three-dimensional matrix that the absorbable collagen's structure offers¹⁶.

· Manufactured by: Colla products from Zimmer Dental, Carlsbad, CA, USA.

Commercially available collagen dressings have three forms: tape (CollaTape; Zimmer Dental, Carlsbad, CA, USA), cote (CollaCote, Zimmer Dental, Carlsbad, CA, USA) and plug (CollaPlug; Zimmer Dental, Carlsbad, CA, USA)^1,16.

CONCLUSION:

As part of the survey, several commercially available dressings were examined, and it was determined regarding the precise indication for using periodontal dressings following surgery, there doesn't seem to be much agreement. The literature does, however, go into further detail regarding the advantages of using dressing after surgery. Furthermore, it has not been demonstrated that any periodontal dressing material possesses all of the ideal biological and physical characteristics. We think that greater investigation into enhancing the qualities of biomaterials could result in a more broadly applicable use. Periodontal dressings for everyone, for the time being? Maybe not yet!

REFERENCES:

1. Bezawada, N. R., Bali, S., Aggarwal, P. and Arora, S. Periodontal dressings: A review. Santosh University Journal of Health Sciences. 2020; 6(1): 5–9 doi: 10.18231/j.sujhs.2020.002.

2. O’Neil, T. C. A. Antibacterial Properties of Periodontal Dressings. J. Periodontol. 1975; 46: 469-474.

3. Cho, Y.D., Kim, K.-H., Lee, Y.M., Ku, Y. and Seol, Y.J. Periodontal Wound Healing and Tissue Regeneration: A Narrative Review. Pharmaceuticals. 2021; 14: 456.

4. Christeena Abraham, Sankari M. An Assessment of knowledge, Attitude and Practice of Lasers among periodontists in India. Research J. Pharm. and Tech. 2018; 11(12): 5458-5460. doi: 10.5958/0974-360X.2018.00995.2

5. Baer, P. N., Sumner, C. F. and Miller, G. Periodontal dressings. Ariz Dent J. 1970; 16: 10–19.

6. Malathi, K., Sandhya, G. and Srividya, N. Integrated Review of The Periodontal Dressing. World Journal of Pharmaceutical Research. 2022; 11(5): 440-59 doi: 10.20959/wjpr20225- 23803

7. Gjerdet, N. R. and Haugen, E. Dimensional Changes of Periodontal Dressings. Journal of Dental Research 1977 dec 56(12), 1507-1510

8. Ahad, A. Semilunar Coronally Repositioned Flap: A Minimally Invasive Technique for Predictable Management of Gingival Recession. https://www.researchgate.net/publication/325973662 | 30-33 (2018)

9. Baghani Z, Kadkhodazadeh M. Periodontal Dressing: A Review Article. Journal of Dental Research, Dental Clinics, Dental Prospects. 2013; 7(4) 183-90. Doi; 10.5681/joddd.2013.040

10. Dr. Bhusari, B. M. et al. Periodontal Dressing. International Journal of Current Research. 2015; 7(7): 18578-81.

11. Meenakshi, S. S. and Malaiappan, S. Knowledge, Attitude and Practice of Placing Periodontal Dressing (to pack or not to pack) among Periodontists. Research Journal of Pharmacy and Technology. 2019; 12(2): 799-804 doi: 10.5958/0974-360X.2019.00139.2

12. Kumar, M. B. V. et al. Assessment of clinical efficacy of different periodontal dressing materials on wound healing: A comparative study. Journal of Contemporary Dental Practice. 2019; 20(8): 896–900 doi: 10.5005/jp-journals-10024-2631.

13. Subramanya, A. P., Vardhan, K. B. and Prabhuji, M. Current Trends and Controversies in Periodontal Dressing – A Narrative Review. RGUHS Journal of Dental Sciences. 2022; 14(2): 32–40 doi: 10.26715/rjds.14_2_7

14. Garg, S. et al. Periodontal Dressing: A Mini Review. Acta Scientific Dental Sciences. 2023; 7(2): 59–60 doi: 10.31080/ASDS.2023.07.1555

15. Anitha S. Topic: General Principles of Periodontal Surgery. Theory hand-out, Dept of Periodontics, Dept of Periodontics, JSSDCH, JSSU: 1-61

16. Kathariya, R., Jain, H. and Jadhav, T. To pack or not to pack: The current status of periodontal dressings. Journal of Applied Biomaterials and Functional Materials. 2015; 13(2): e73-e86 doi: 10.5301/jabfm.5000215

17. Kadkhodazadeh, M., Baghani, Z. and Torshabi, M. In Vitro Comparison of Biological Effects of Coe-Pak and Reso-Pac Periodontal Dressings. Journal of Oral and Maxillofacial Research. 2017; 8(1), 1-11 doi: 10.5037/jomr.2017.8103

18. Singh, W. B. L., Singh, S. V., Pandey, W. P. and Solanki, N. Use of a light cured periodontal surgical dressing material in temporization: A convenient approach. Journal of Oral Biology and Craniofacial Research. 2015; 5(2): 117–119 doi: 10.1016/j.jobcr.2015.03.002

19. Dental express upgrading dentistry https://dentalexpress.in/products/gc-coe-pak-periodontal-dressing-standard-pkg-new-pack-1 27-02-2024.

20. Pulpdent https://www.pulpdent.com/product/periocare-periodontal-dressing-ref/ 27-02-2024.

21. Septo-pack https://www.indiamart.com/proddetail/septopack-6772435288.html 27-02-2024.

22. peripac https://periobasics.com/periodontal-dressing/ 27-02-2024.

23. Indiamart https://www.indiamart.com/proddetail/voco-pac-3024132962.html 27-02-2024.

24. glu stitch inc. Cyanoacrylate dressing https://periacryl.com/ 27-02-2024.

25. Indiamart https://www.indiamart.com/proddetail/dentsply-barricaid-periodontal-surgical-dressing-21489697191.html 27-02-2024.

26. MBI Maxigen Biotech inc. https://mbi-bio.com/medical-device/healiaid-collagen-wound-dressing-for-dental/ 27-02-2024.

27. Woundcare mart https://woundcaremart.com/product/synerheal-sterile-collagen-sponge-dressing/ 27-02-2024.

Received on 29.02.2024 Revised on 12.07.2024

Accepted on 17.10.2024 Published on 10.12.2024

Available online on December 17, 2024

Asian J. Res. Pharm. Sci. 2024; 14(4):384-390.

DOI: 10.52711/2231-5659.2024.00061

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Sr. No.	Name of the dressing	Type	Composition	Manufactured by
1	Ward’s Wonder Pack	Eugenol dressing	Powder – zinc oxide, powdered pine resin, talc & asbestos Liquid – isopropyl alcohol 10%, clove oil, pine resin, pine oil, peanut oil, camphor & coloring materials	Westword Dental Products. Co.San. Francisco; USA
2	Kirkland formula	Eugenol dressing	Zinc oxide, resin, zinc acetate, eugenol, tannic acid and olive oil.	Kirkland Pack, Prudent, Corporation of America, Brookline, Maes
3	Coe-Pak	Non-eugenol dressing	Two pastes First paste – zinc oxide, added oils, gums & lorothidol Second paste – unsaturated fatty acids & chlorothymol	Coe Laboratories Inc., Chicago, I1, USA
4	Septopack	Non-eugenol dressing	Calcium sulphate, zinc oxide, zinc sulphate, acrylic type of resin & glycol solvent	Septodont, Saint Maur-des-Fosses, France
5	PerioCare	Non-eugenol dressing	Two pastes First paste – paste of metal oxides in vegetable oil Second paste – gel of rosin suspended in fatty acids.	Pulpdent Corp. Brookline Watertown, MA, USA
6	Perio Putty	Non-eugenol dressing	Methylparabens, propylparabens, benzocaine	Cadco Dental Products Inc., Los Angeles, CA USA
7	Peripac	Non-eugenol dressing	calcium sulphate, zinc sulphate, zinc oxide, polymethyl methacrylate, dimethoxy tetraethylene glycol, ascorbic acid, flavor and iron oxide pigment.	GC America Inc., Chicago, USA
8	Cyanoacrylate dressings	Others	n-Butyl cyanoacrylate	PeriAcryl®; Glustitch Inc, Delta, Canada
9	Light cure dressings	Others	Silicon dioxide crystalline – quartz, hydrophobic amorphous fumed silica, urethane dimethacrylate resin	Barricaid®, Caulk, Dentsply
10	Collagen dressing	Others	type I collagen derived from bovine tendon mixed with cancellous granules	Colla products from Zimmer Dental, Carlsbad, CA, USA