Periodontal Dressings

Presented by:Dr. Pfukrolo Koza

Dressings have no curatives properties

Assists healing by protecting tissue rather than providing “healing factors”

Pack serves the following functions:Controls postoperative bleedingTo enhance patients comfort, protect against

pain induced by contact of the wound with food or tongue during mastication

Minimizes the livelihood of postoperative infection

Provide some splinting of mobile teethFacilitates healing by preventing surface

trauma during mastication and irritation from plaque and food debris

Repositions soft tissueprotect suturesProtection of newly exposed root surface from

temperature changes

Types of periodontal dressingsMost common types of dressing areZinc oxide- eugenol Zinc oxide non-eugenol othersZINC OXIDE-EUGENOL PACKS:Based on the reaction of zinc oxide and eugenolInclude the Wonder-Pak developed by Ward in 1923 and several modified Ward’s original formula

Addition of accelerators, such as zinc acetate, gives a better working time

Other substances that are added include asbestos, used as binder and filler, and tannic acid.

Mostly supplied as a liquid and a powder that are mixed before use.

Some may be prepared ahead of time, wrapped in wax paper, and frozen for prolonged storage.

Eugenol may induce an allergic reaction that produces reddening of area and burning pain in some patients.

ZINC OXIDE NON-EUGENOLCoe-pakPeriocarePeriopacPerioputtyVocopacOTHERS

Photocuring periodontal dressing: BarricaidCollagen dressings

Methyacrylic gels(tissue conditioners)Cyanoacrylate

Gelatin-based dressing- Stomahesive ,excellent for use in soft tissue augmentation procedure, material has good stability properties and dissolve in 24 to 48 hours

Coe-pakReaction between metallic oxide and

fatty acids is the basis for Coe-Pak.Supplied in two tubes

One tube contains:Zinc oxidean oil(for plasticity), a gum (for cohesiveness), andLorothidol (a fungicide);Other tube contains :Liquid coconut fatty acids thickened with

colophony resin (or rosin)Chlorothymol (a bacteriostatic agent)

Antibacterial Properties of Packs

Improved healing and patient comfort with less odor and taste have been obtained by incorporating antibiotics in the pack.

Bacitracin,oxytetracycline (Terramycin),neomycin, and nitrofurazone have been tried, but all may produce

hypersensitivity reactions. The emergence of resistant organisms and opportunistic infection has been reported.

Incorporation of tetracycline powder in Coe-Pak is generally recommended, particularly when long and traumatic surgeries are performed

Reaction to DressingsContact allergy to eugenol and rosin has been

reported Allergic reactions to periodontal dressing

sometimes occurPatients wearing dressings over a prolonged

period of time due to multiple episodes of surgery or delayed healing

Sensitivity reaction is usually provoked by eugenol in the zinc oxide-eugenol type of dressings.

Very rarely with non-eugenol containing dressings

First symptom of a sensitivity reaction to dressing is burning sensation on the buccal mucosa and on the surface of the tongue where with the dressing is in contact.

If dressing is not removed, reaction progresses from erythema to vesicle formation and edema

If patient not treated, generalized allergic reaction may develop, including dermatitis.

Retentions of packs• In case of edentulous areas: with the help of splints, Hawley’s appliance

and stents• In case of dentulous areas:

mechanically by interlocking in interdental spaces and joining the lingual and facial portions of the pack

• In case isolated teeth- Tie dental floss or gauze loosely around the teeth and over which pack is applied

Preparation and Application of Dressing

A, Equal lengths of the two pastes are placed on a paper pad. B, Pastes are mixed with a wooden tongue depressor for 2 or 3 minutes until the paste loses its tackiness (C). D, Paste is placed in a paper cup of water at room temperature. With lubricated fingers, it is then rolled into cylinders and placed on the surgical wound.

Preparation and Application of Dressing

Zinc oxide packs are mixed with eugenol or noneugenol liquids on a wax paper pad with a wooden tongue depressor. The powder is gradually incorporated with the liquid until a thick paste is formed.

Coe-Pak is prepared by mixing equal lengths of paste from tubes containing the accelerator and the base until the resulting paste is a uniform colour .

A capsule of tetracycline powder can be added at this time.

The pack is then placed in a cup of water at room temperature .

In 2 to 3 minutes the paste loses its tackiness and can be handled and moulded; it remains workable for 15 to 20 minutes.

Working time can be shortened by adding a small amount of zinc oxide to the accelerator (pink paste) before spatulating.

The pack is then rolled into two strips approximately the length of the treated area. The end of one strip is bent into a hook shape and fitted around the distal surface of the last tooth, approaching it from the distal surface .

The remainder of the strip is brought forward along the facial surface to the midline and gently pressed into place along the gingival margin and interproximally.

The second strip is applied from the lingual surface. It is joined to the pack at the distal surface of the last tooth, then brought forward along the gingival margin to the midline

The strips are joined interproximally by applying gentle pressure on the facial and lingual surfaces of the pack

For isolated teeth separated by edentulous spaces, the pack should be made continuous from tooth to tooth, covering the edentulous areas

Inserting the periodontal pack. A, Strip of pack is hooked around the last molar and pressed into place anteriorly. B, Lingual pack is joined to the facial strip at the distal surface of the last molar and fitted into place anteriorly. C, Gentle pressure on the facial and lingual surfaces joins the pack interproximally.

  Continuous pack covers the edentulous space.

When split flaps have been performed, the area should be covered with tin foil to protect the sutures before placing the pack

The pack should cover the gingiva, but overextension onto uninvolved mucosa should be avoided.

Excess pack irritates the mucobuccal fold and floor of the mouth and interferes with the tongue. Overextension also jeopardizes the remainder of the pack because the excess tends to break off, taking pack from the operated area with it.

Pack that interferes with the occlusion should be trimmed away before the patient is dismissed .Failure to do this causes discomfort and jeopardizes retention of the pack.

Periodontal pack should not interfere with the occlusion.

The operator should ask the patient to move the tongue forcibly out and to each side, and the cheek and lips should be displaced in all directions to mold the pack while it is still soft. After the pack has set, it should be trimmed to eliminate all excess.

the patient may develop pain from an overextended margin that irritates the vestibule, floor of the mouth, or tongue. The excess pack should be trimmed away, making sure that the new margin is not rough, before the patient is dismissed.

If a portion of the pack is lost from the operated area and the patient is uncomfortable, it is usually best to repack the area.

The clinician should remove the remaining pack, wash the area with warm water, and apply a topical anesthetic before replacing the pack, which is then retained for 1 week.

As a general rule, the pack is kept on for 1 week after surgery. This guideline is based on the usual timetable of healing and clinical experience. It is not a rigid requirement; the period may be extended, or the area may be repacked for an additional week

POSTOPERATIVE INSTRUCTIONSAfter the pack is placed, printed instructions are

given to the patient to be read before he or she leaves the chair

The pack will harden in a few hours, after which it can withstand most of the forces of chewing without breaking off. For the first 3 hours after the operation, avoid hot foods to permit the pack to harden

try to chew on the nonoperated side of your mouth avoid hot liquids during the first 24 hoursDo not smoke.

Do not brush over the packDo not rinse on the day of pack application,

chlorhexidine oral rinses after brushing.The pack should remain in place until it is

removed at the next appointmentAfter the pack is removed, the gums most

likely will bleed more than they did before the operation. This is perfectly normal in the early stage of healing and will gradually subside. Do not stop cleaning because of it.

Findings at Pack Removal Gingivectomy : the cut surface is covered with a friable

meshwork of new epithelium, which should not be disturbed. If calculus has not been completely removed, red, beadlike protuberances of granulation tissue will persist. The granulation tissue must be removed with a curette, exposing the calculus so that it can be removed and the root can be planed. Removal of the granulation tissue without removal of calculus is followed by recurrence.

After a flap operation, the areas corresponding to the incisions are epithelialized but may bleed readily when touched; they should not be disturbed. Pockets should not be probed.

  The facial and lingual mucosa may be covered with a

grayish yellow or white granular layer of food debris that has seeped under the pack. This is easily removed with a moist cotton pellet.

The root surfaces may be sensitive to a probe or to thermal changes, and the teeth may be stained.

Fragments of calculus delay healing. Each root

surface should be rechecked visually to be certain that no calculus is present. Sometimes the color of the calculus is similar to that of the root. The grooves on proximal root surfaces and the furcations are areas where calculus is likely to be overlooked.

Removal of Pack and Return VisitWhen the patient returns after 1 week, the

periodontal pack is taken off by inserting a surgical hoe along the margin and exerting gentle lateral pressure.

Pieces of pack retained interproximally and particles adhering to the tooth surfaces are removed with scalers.

Particles enmeshed in the cut surface and should be carefully picked off with fine cotton pliers.

The entire area is rinsed with peroxide to remove superficial debris.

RepackingAfter the pack is removed, it is usually not

necessary to replace it. However, repacking for an additional week is advised for patients with (1) a low pain threshold who are particularly

uncomfortable when the pack is removed, (2) unusually extensive periodontal

involvement, or(3) slow healing.

• Clinical judgment helps in deciding whether to repack the area or leave the initial pack on longer than 1 week.