Current Trends and Controversies in Periodontal Dressing – A Narrative Review

Introduction

Surgical dressings have been used for centuries to protect the surgical sites, prevent postoperative infection, and aid in faster healing. Similar benefits were observed after periodontal surgeries by using periodontal dressings or packs.¹ Dr. A W Ward introduced and suggested the use of a periodontal pack following periodontal surgery in 1923. Although Zentler in 1918 was the first to suggest the use of iodoform gauze as a periodontal dressing, Ward has been noted as a pioneer for the periodontal dressing used in current times as he introduced Wondrpak and the word pack in this context for the first time.² Since then, periodontal pack is used in various clinical situations by dental professionals.³

It is suggested that periodontal dressings protect the area of wound healing from mechanical trauma, stability of surgical site, fibrinolytically active saliva and control hemorrhage.^2,4 Despite several advantages and applications, their effects and value on periodontal wound healing has been questioned.⁵ There are reports of complications such as erythema, edema, and allergic reactions supposedly caused by various agents incorporated in periodontal dressings.⁶

Periodontal dressings are conventionally grouped as eugenol based or non-eugenol based periodontal packs.² Another group, recognized as non- zinc oxide, noneugenol are also in use.¹ The original product comprised of zinc-oxide eugenol-based with alcohol, pine oil, and asbestos fibres as additives.⁷ To achieve desired physical and chemical properties several additives to zinc oxide eugenol has been tried by manufacturers. For instance, tannic acid to control bleeding and corticosteroids to reduce inflammation are a few modifications.⁷ Chemical constituents of the periodontal pack should not lead to tissue damage. Studies have shown inhibition of human fibroblast by eugenol dressings. However, literature shows conflicting reports on the same.⁸ Hence, newer materials to overcome the shortcomings of conventional periodontal dressings have been introduced.

Despite nine decades of inception, there appears to be no proper consensus on the universal application of periodontal dressing following periodontal surgeries. Meanwhile the search for materials with better properties and optimum results continue. This review aims to explore the current trends and advances in periodontal dressing and also throw light on the controversies on periodontal dressings.

Current trends in Periodontal Dressings

In the past few years, there has been growing interest towards biologic or biomaterial based periodontal dressings which are found to be more tissue friendly, biocompatible and patient friendly. Muco-adhesive patches, Platelet rich fibrin, Hyaluronic acid gel, Curcumin gel, Propolis extract, Amniotic membrane are a few materials that have been reported to be promising. Table 1 provides details on the newer commercially available products that have been used as periodontal dressing.

Muco-adhesive patches

Muco-adhesive patches can be used when wound protection is needed for a shorter period.

TBM Ora-Aid

It is an intra-oral patch to protect the affected or treated area. It is indicated to be used post periodontal surgeries like periodontal flap surgery, connective tissue grafts, dental implants, crown lengthening and other situations such as traumatic ulcers. Han-Seul et al. reported a clinical study on the effect of attachable periodontal wound dressing on post-operative pain and healing.⁹ Less bleeding, post operative pain and discomfort, difficulty in eating was noted among patients with attachable periodontal wound dressing.

Advantages:

• Easy to apply

• Adheres to tissue surfaces

Disadvantage:

• Lasts only for 6-12 hours

TBM Curatick

It is a mouth-adhesive, transparent wound dressing. In a clinical trial by Chungnam National University, Korea using oral wound model, it was observed that Curatick group had a higher amount of collagen fiber compared to the control group on 3rd, 7th and 14^th day.¹⁰

Advantages:

• Easy to apply

• Adheres to tissue surfaces

Disadvantage:

• Loses adhesion by itself over time

Platelet Rich Fibrin

Platelet concentrates accelerates wound healing by excellent neovascularization and promoting fast cicatricle tissue remodelling. Choukroun’s platelet-rich fibrin (PRF) is a second-generation platelet concentrate. Wound healing is stimulated by this platelet concentrate as it contains many growth factors such as fibroblast growth factor, platelet derived growth factor and epidermal growth factor. Also, it is shown to provide excellent scaffold for angiogenesis and epithelization. It has been used and explored in various aspects of periodontal treatment.¹¹

Beneficial role of PRF in the healing of free gingival graft (FGG) donor sites has been reported. The notable results of using PRF were observed at FGG donor sites; nearly total closure of the wound at 1 week, lack of inflammation at the periphery of the healing wound and good control of bleeding at the time of the surgery were noted. As the morbidity of donor site is a major concern of free gingival graft procedure, use of PRF which results in better and faster healing is definitely a boon.¹¹ A comparative evaluation of PRF and Gelatin sponge in the management of palatal wound following epithelialized free gingival graft showed that PRF bandage group had a significantly faster complete re-epithelisation of wound with participants reporting significantly less discomfort, changes in feeding habit and lower dose of analgesics. Further randomized controlled trial on PRF for palatal wound due to FGG has stated PRF as an efficient biological wrapping material (bandage) that reduces pain and discomfort.¹²

Debnath and Chatterjee evaluated clinically and histologically the effect of platelet concentrates (platelet‑rich fibrin [PRF] membrane and PRF matrix [PRFM] gel) after depigmentation.¹³ The report suggests this method to be successful in protection of raw wound area of sites that underwent depigmentation procedures thereby aiding in quicker healing and better patient comfort when compared with utilisation of periodontal pack alone. Use of platelet concentrates is necessary to cover the exposed lamina propria as healing occurs with secondary intention. Delay in healing occurs when surgical site is left exposed.

In a comparative study, Belkhede et al., reported that Gelatin sponge showed better results than PRF at palatal donor site.¹⁴ Gelatin sponge is suggested as an alternative material of choice as it is economical, effective and biocompatible.

Collagen based periodontal dressing

They adhere to the underlying tissue and provide coverage. It is said to resorb in 90 days of application. Clinical and histological evaluation of a non-eugenol dressing (Coe-pak) and Collagen dressing (Colla Cote) in healing of palatal wounds was studied. The group with collagen dressing demonstrated greater connective tissue turn over with more mature collagen resulting in firmer connective tissue in the palate. Palatal donor site might be required again for revision surgery or when multiple teeth are in need of treatment. Hence, quality of healing that results in firm and abundant connective tissue formation is crucial for further intervention. Overall, when compared to Coe-pak dressing sites treated with CollaCote showed better and faster healing with significantly less pain experiance.¹⁵

Clinical efficacy on wound healing of collagen dressing (CollaCote), non-eugenol dressing (Coe-pak) and light cured dressing (Barricaid) was assessed. The results showed periodontal wound covered with the collagen dressing showed evidence of better healing and provided better symptomatic relief to the patients when compared to those covered with a light-cured and non-eugenol dressing. Colla Cote is a type 1 collagen, which is derived from the bovine Achilles tendon. Collagen is a natural extracellular matrix substrate that has a chemotactic effect on many types of cells such as fibroblasts, osteoblast, and endothelial cells. Therefore, collagen dressings contribute to reducing the process of inflammation occurring during the process of healing. The inflammation of a lesser degree may directly lead to the reduction of pain and sensation of burning.¹⁶

Advantages:

• Nonimmunogenic

• Antipyrogenic

• Hypoallergenic

• Enhances strength of blood clot by providing a 3-dimensional matrix

• Promotes hemostasis by aiding aggregation of platelets and subsequently coagulation cascade

Disadvantages:

• Its hydrophilic properties can act as a disadvantage, leading to rapid enzymatic degradation and swelling.

Hyaluronic-Acid (HA)

HA is a high molecular weight, non-sulphated polysaccharide component of the family of the glycosaminoglycans, present in various body fluids such as synovial fluid, serum, saliva and gingival crevicular fluid. Presence of HA has been noted in all periodontal tissues, particularly abundant in non-mineralised tissues like gingiva and periodontal ligament. Mineralised tissues like cementum and alveolar bone contains only less quantity of HA. Primarily mesenchymal cells with most cells of the human body such as fibroblasts, chondrocytes and osteoblasts synthesize HA in the cell membrane.¹⁷

HA is highly biocompatible and non-immunogenic in nature, has bacteriostatic, fungistatic, anti-inflammatory, anti-oedematous, osteoinductive and proangiogenic properties. These properties have been utilised to promote wound healing. It is hygroscopic and allows to maintain its conformational stiffness retain water. HA has viscoelastic property that provides stability and elasticity to tissues and delay the penetration of viruses and bacteria. A randomised controlled clinical trial evaluated the effect of topically applied HA on pain and palatal epithelial wound healing. 0.2% and 0.8% HA gels were used in two test groups and a control group with only periodontal dressing was used. The results reveal better in terms of wound healing by means of epithelisation and colour match of the tissue. In addition, there was positive result with regard to post-operative pain and burning sensation.¹⁸

Curcumin gel

Curcumin is used as a topical application and for its wound healing properties, such as anti-inflammatory, antimicrobial, antiviral, antifungal, antioxidant as well as a chemosensitizing agent.¹⁹ Effect of curcumin gel and non-eugenol periodontal dressing (Coe-pak) after periodontal flap surgery was evaluated for wound healing and post-operative pain. It was reported that Curcumin was marginally better than periodontal dressing in exhibiting anti‑inflammatory effect and was very effective in reduction of postoperative pain.²⁰

Advantages:

• Anti- inflammatory and anti- bacterial property

Disadvantages:

• Retention of gel is difficult

• Duration of action is not clear

• Depends on patient compliance

Amniotic Membrane Dressing

Amniotic Membrane is the most internal layer of the placenta, which consists of three layers: an epithelial monolayer, a thick basement membrane, and a collagenrich underlying stroma. It has no nerves, muscles or lymphatic vessels, and can be easily separated from the underlying chorion. The amniotic membrane (AM) is a biological dressing with many therapeutic effects.²¹ A growing interest to use this material for periodontal tissue repair is noted in recent years.

Studies have shown that AM induces re-epithelialization and angiogenesis and decreases the inflammatory response. It also has antibacterial properties and contains growth factors such as tumor growth factor-alpha and fibroblast growth factor-beta as well as mesenchymal stem cells with different differentiation potential.²² It has anti-inflammatory properties, protects the wound and decreases scar tissue formation. It decreases the level of pain and inflammation and risk of infection since its stromal surface adheres to the wound surface, covers the exposed free nerve endings in the wound area, protects the wound surface from trauma and external stimuli, and minimizes the protein and fluid loss from the wound.²³ A study assessed the effect of lyophilized AM, as a biological dressing, applied on palatal donor site in free gingival graft surgery. The results show that use of AM as a biological dressing can prevent the complications of free gingival graft (such as pain and bleeding) and may accelerate healing.²³

Propolis Extract

Propolis is a resin which is known to be non-toxic and exists in the form of paste with a pleasant smell. As it has strong composition of phenolic compounds it has a strong antioxidant property. It increases antibody production and activates the T and B-lymphocytes. Propolis can serve as an anti-inflammatory agent since it contains flavonoids and cinnamic acid derivatives, which regulate prostaglandin and leukotriene production and activity of myeloperoxidase, NADPH-oxidase, ornithine decarboxylase, tyrosine-kinase and hyaluronidase.²⁴

Propolis possesses properties required for wound healing, which occurs by decreasing the activity of free radicals thereby enhancing the healing of wound matrix. By its effects on metabolism of collagen in the healing phase, Propolis can increase the tissue content of collagen types 1 and 3, thus play role in regeneration of cell matrix and formation of granulation tissue.²⁴

Askari et al assessed the efficacy of application of propolis extract in combination with eugenol-free dressing (Coe-Pak) for enhancement of wound healing after crown lengthening surgery.²⁴ The results of this study showed no difference in pain score and healing process after the crown lengthening surgery between the use of Coe-Pak dressing alone or in combination with propolis extract. Authors have suggested that methods enabling addition of higher concentrations of propolis to Coe-Pak or industrial production of propolis as an oral dressing may result in higher effective dose of propolis at the surgical site and its subsequently higher efficacy.

Bluem® oral

Bluem® oral gel is a newer formula developed for dental professionals as a local drug delivery system. Wound healing improves significantly due to intensified levels of oxygen which can be delivered to periodontal pockets and oral wounds.²⁵

Advantages:

• Easy to apply

Disadvantages:

• Relies on patient compliance

• High cost

Laser bandage

It is a biologic bandage/ char layer created with patient’s own tissues. By using laser in non-contact mode at extremely low power it aids in denaturation of proteins present in surface layer of lesions. Evidences suggest that this process results in immediate relief of pain and healing time is significantly reduced.²⁶

Controversies on periodontal dressing

Although biological and therapeutic benefits of periodontal dressings are documented in literature, there is still a debate on whether to use periodontal dressings or not. It is observed at several instances that, healing after periodontal surgeries occurred even without the use of a periodontal dressing. However, good flap adaptation and patient’s meticulous oral hygiene maintenance play a vital role in healing. Studies have shown that there is no difference in healing between dressed and undressed wounds. Also, studies have shown that not all periodontal dressings are biocompatible. This has called for a notion that not all surgical wounds need to be dressed.

Patient preferences of periodontal dressing have been evaluated. Conflicting reports are found in literature. However, most of the studies have employed subjective measures to evaluate the patient reported outcomes. Patients experienced more discomfort with use of periodontal dressing, and difficulty in eating. When compared with mouthwash or periodontal dressings as post- operative measures, patients have preferred mouthwash. On the contrary, patients have also reported that having periodontal dressing over the surgical area gave a psychological sense of protection.

Table 2&3 summarises the studies that favour and those do not favour periodontal dressing.

Conclusion

The search for ideal and better periodontal dressing shall continue. There is a need to explore biologic/ biomaterial based periodontal dressings which is highly biocompatible, non-immunogenic, aids in healing process, stabilizes the wound tissues, reduces pain and discomfort, easy for application and economical. Good quality randomized controlled trials are lacking in the literature on the use of periodontal dressings. Most of the literature belongs to previous decades and there is a need to update the literature with studies having better study designs and broadened objectives. Patient centred outcome measures have to be given importance in further studies. Literature shows no clear consensus on the use of periodontal dressing and the question of ‘to pack or not to pack’ still prevails. It is left to the decision of the clinician to choose what is best for the particular patient. Further improvements in biomaterials may lead to proper consensus on the use of periodontal dressings. Studies should concentrate on improving clinical outcomes and better patient reported outcome measures.

Conflict of Interest

Authors declare no conflict of interest.