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Current Status of Periodontal

Accepted for publication
A comprehensive
22

Dressings
Joseph

H. A. Sachs, A. Farnoush, L. Checchi and C. E.
February 1984

review of periodontal dressings is presented. The rationale for the application of dressings, their advantages and disadvantages are described. Tissue reactions to dressings and the therapeutic and adverse effects of antimicrobial agents used in dressings are discussed. The present status and value of a surgical dressing is critically assessed in view of recent studies which indicate that the routine use of dressings in postsurgical care may be

either unnecessary

or

undesirable.

The use of periodontal dressings has been widespread for many years. Recently, however, the value of periodontal dressings and their effects on periodontal wound healing have been questioned. This paper reviews the current rationale for the use of periodontal dressings and discusses the therapeutic effects of various substances incorporated into the dressing materials to promote wound healing.

DRESSING MATERIALS Rationale for Usage. Periodontal dressings were first introduced in 1923 when Dr. A. W. Ward advocated the use of a packing material around teeth following gingival surgery.1'2 This material called Wondrpak" consisted of zinc oxide-eugenol mixed with alcohol, pine oil and asbestos fibers. Its stated purpose was to cover and protect the surgical area, splint loose teeth and soft tissues, immobilize injured areas, densensitize teeth and provide patient comfort. Box and Ham3 described the use of a zinc oxide-eugenol dressing to perform a chemical curettage in treatment of necrotizing ulcerative gingivitis (NUG). Tannic acid was included for hemostasis and astringency, while thymol was included as an antiseptic. It was claimed that this dressing destroyed 'spirillum' and 'fusiforme' bacteria present in NUG, and helped contain the infection. Orban4 described a zinc oxide-eugenol dressing with paraformaldehyde to perform gingivectomy by chemosurgery. Although pocket depth reduction was achieved, this dressing caused extensive necrosis of gingiva and bone, and was felt to promote abscess formation by the blockage of exúdate. Bernier and Kaplan5 stated that the primary purpose of a periodontal dressing was wound protection, and that constituents which may aid in healing are of secondary importance. Ariaudo and Tyrell6 recommended

dressing to position and stabilize an apically positioned flap. Blanquie7 felt that the purpose of a dressing was to control postoperative bleeding, decrease postoperative discomfort, splint loose teeth, allow for tissue healing under aseptic conditions, prevent reestablishment of pockets and desensitize cementum. Gold8 felt that a dressing could be used to splint teeth as long as it was a cement dressing that set hard. Weinreb and Shapiro'' packed zinc oxide-eugenol impregnated cords into periodontal pockets but found them less effective than a gingivectomy in reducing pocket depth. This
using
a

method was felt to be useful when surgery was not recommended either for medical reasons or because of esthetic considerations in the anterior region. Baer et al.10 stated that the primary purpose of a dressing was to provide patient comfort and protect the wound from further injury during healing. It can also be used to hold a flap in position after it has been sutured or to immobilize a gingival graft by dissipating the pull from the alveolar mucosa and lip. They pointed out that a dressing should not be used to control postoperative bleeding, which should be controlled at the termination of surgery; nor should it be used to splint teeth, which should be done prior to surgery.

Physical Properties of Dressings. The exact proportions of constituents in currently marketed dressings are trade secrets, but the general formulations are known. Various formulas of zinc oxide-eugenol dressings have been well documented." They contain about 40 to 50% eugenol, but the set material always contains some free eugenol, which increases in amounts as the zinc eugenate decomposes.12 This has been shown to cause tissue necrosis and delayed healing.13 Radden14 also found that free eugenol caused a marked inflammatory reaction, delayed healing and necrosis of the tissue. Asbestos and tannic acid have been eliminated from

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they serve to enhance the plaque accumulation. to consist of two pastes. However.19 Perio 20 Putty is another noneugenol dressing in current use which contains methyl. This may account. This is important where large areas of connective tissue are left be mandaexposed and where use of a dressing may 58 Studies tory. lung their possible detrimental systemic found to have the potential for eugenol dressings. due to dimensional changes which caused tissue irritation. After an 8-hour test culture. In addition. or desirable. These include wire ligation. The material did not set to a hard consistency as do eugenol dressings. one containing zinc oxide. comparing the tissue-irritating properties of periodontal dressings have mainly involved comparisons between eugenol-containing and noneugenol dressings. Peripac and Peripac Improved was tested. the most toxic material was Coe-Pak and the least was as or However. Periodontol.63 exposed serial .24 tested the adhesive properties of Coe-Pak.25 Watts and Combe26 compared Coe-Pak.22 The physical properties of periodontal dressings are believed to have a noticeable effect on their clinical performance. Wondrpak) and two noneugenol dressings (Coe-Pak.17 described the use of a noneugenol dressing containing zinc oxide. Gjerdet and Haugen23 measured linear dimensional changes of freshly prepared samples of Coe-Pak.49"''0-52"56 some have shown that eugenol dressings 55 Reare more irritating than noneugenol dressings.41 and foil.1016 Baer et al. the results conflict. PPC-noneugenol) on fibroblasts. Joseph to was J.18 The antimicrobial agents were reduced in amounts due to reports that they caused tissue irritation. Retention of Dressings. Farnoush. However.2832"40 the use of interproximal spiral saws with cotton thread. to protect them from deterioration. probably due to the lack of standardization of experimental conditions. regardless of whether or not it contains eugenol. a noneugenol dressing. Peripac'" and Wondrpak.and propyl-parabens for their effective bacteriocidal and fungicidal properties21 and benzocaine as a topical anesthetic.28"30 suturing the dressing with cotton tape embedded in it. When the viscosity of Coe-Pak. was recommended. and they introduce a significant amount of operator inconvenience at the end of a surgical procedure. These studies show that current dressings lack the ideal properties for clinical use even though they exhibit certain desirable characteristics such as plasticity and adhesiveness. an oil (for plasticity). Wondrpak exhibited the greatest cell toxicity and PPC-eugenol the least. and leave a bad taste in the patient's mouth.690 Sachs. Kreth et al. the need for these devices is a reflection of the inadequacy of the materials. Haugen et al. especially in regard to adaptation to the wound area. Placement of adhesive foil between a dressing and teeth with composite restorations. Checchi. On the other hand. Peripac and Peripac Improved for their effects on composite filling material and on a glass ionomer cement. such as around an isolated tooth when apically positioned tissue must be held in place. and Peripac did not have any adhesive strength at all. thickened with colophony resin (or rosin) and chlorothymol (a bacteriostatic agent). for their decreased popularity. and no dressing exhibited an adequately well defined set. bacitracin and hydrogenated fat. none of the dressings displayed sufficient adhesion for retention. and it was concluded that mechanical interlocking was necessary to hold dressings in place. 1984 dressings due effects.44 However. The main disadvantage of eugenol dressings is that they set hard. Further research is needed to improve " Coe-Pak". was shown to be more irritating than Wondrpak. Rivera-Hidalgo et al.15 Tannic acid was found to cause potential liver damage if absorbed systemically. a gum (for cohesiveness) and lorothidol (a fungicide). Similar results have been reported by others.61 tested four periodontal dressings on HeLa cell cultures.31 a variety of Stents and splints which fit over the teeth and gingiva. Peripac expanded while the other dressings contracted.53 cently. materials such Telfa" PPC-noneugenol. as in the protection of a donor site of a free gingival graft or a bone graft area. Asbestos cancer and mesothelioma. This was felt to be a clinical disadvantage. a popular dressing in current use.27 none of the dressings exhibited ideal flow properties during manipulation and adaptation. in large part. it has been shown that an early irritating effect of a dressing may contribute to postoperative pain and swelling. December. EFFECTS ON WOUND HEALING Comparison of Eugenol and Noneugenol Dressings. Peripac and Wondrpak to tooth surfaces and to soft tissue.43"56 However.42 43 Such supplementary retention has also been advocated for protection of the donor sites in free gingival graft procedures.57 other fabrics5960 may be interposed between dressing and tissues to prevent such harmful effects. Various devices have been used to keep dressings from either being displaced or to reinforce them. The other paste consists of liquid coconut fatty acids. Hildebrand and DeRenzis62 tested the effect of two eugenol dressings (PPC-eugenol.57 Effects on Cell Cultures. is known the physical properties of dressings. often with sharp edges. the need for supplementary retention is sometimes unavoidable. Coe-Pak displayed somewhat better adhesion than Wondrpak. after 24 hours.56 Peripac. Implant studies provide a more controlled environment to study the irritating effects of dressings. All three caused a small amount of softening of the composite but had little effect upon the glass ionomer cement. and found two eugenol dressings (PPC" and Wondrpak) slightly inhibitory to cell growth. it was felt that the expansion of Peripac may be related to movement of the dressing over the wound site with consequent irritation of the tissues. and bacitracin was believed to aid in healing. It was felt to be a superior dressing due to the absence of tissue irritation and hard sharp edges of causing asbestosis.

A high concentration of dressing extract was found to be cytotoxic. delayed healing occurs by foreign body reaction if the material becomes embedded in the tissues or underneath a flap. they advised removal of the dressing within 7 days. Binnie and Forrest71 compared the clinical and his- However. After 1 week. Cyanoacrylates are biodegradable. and the dressing itself was cleaner than those without bacitracin. Patients experienced less odor and unpleasant taste and were more comfortable with the terramycin dressing. there was little difference between the two. A definite antimicrobial effect and accelerated healing was found. cyanoacrylate cannot dissipate the pull of the lip or immobilize a flap for the time required for it to attach to the underlying tissues. a eugenol and a noneugenol dressing on surgical wound healing. many of the cytotoxic elements would be diluted by saliva. In vitro. Peripac and Wondrpak on cultured epithelial cells. allowed faster wound healing and stimulated less granulation tissue proliferation underneath them than conventional dressings. 3) may accelerate early periodontal healing by acting as a protective barrier and 4) aids in precise positioning of a flap or a free gingival graft. and rapid polymerization upon contact with small amounts of moisture. to the United States. Baer et al.72 documented the use of cyanoacrylate Therapeutic Effect of Various Antimicrobial Agents in Dressings. 2) provides rapid hemostasis due to polymerization in the presence of moisture. . and Coe-Pak was more cytotoxic than PPC-eugenol. A dressing containing 3. Apically positioned. Heaney et al. Cyanoacrylates have also been used to splint teeth. the dressings were capable of sterilizing the base of periodontal pockets. cement conventional dressings. blood. healing was superior in the cyanoacrylate dressed areas.Volume 55 Number 12 Status of Periodontal Dressings 691 dilutions of PPC-eugenol or Coe-Pak to a population of human polymorphonuclear leukocytes. Addition of bacitracin had a definite suppressive effect on the growth of microorganisms. It was found that cyanoacrylates produced better healing.87 compared the bacterial flora in 7-day postsurgical dressing samples in 250 patients and found that antimicrobial agents used in conjunction with dressings may allow for selective inhibition of microorganisms.68 Ochstein et al. the ones with the bacitracin dressing experienced less odor and unpleasant taste.10-67'73-74 Forrest70 compared clinically cyanoacrylate dressing suturing without dressing. living tissues together and producing immediate hemostasis. Saad and Swenson85 found that the incorporation of corticosteroid (Cordan) into a dressing was of no value in wound healing. All three materials were found to have a very high degree of cytotoxicity. full thickness and split thickness flaps were performed on 16 dogs. twelve patients developed allergic reactions. the dressings exhibited an effective antibacterial effect against various Streptococci. It was concluded that cell culture experiments are of limited use in evaluating dressings. produced quick hemostasis. No significant difference found between the two was with responses.65 investigated the effect of cyanoacrylates on experimental tongue wounds in rats.10 In addition. Cyanoacrylate Dressing Material. Of 200 gingivectomy cases studied. using a split mouth approach in 30 surgical cases. Clinical and histological evaluations were made for 21 days. and act as a replacement for sutures. as ideal as it appears. with one of the three dressings applied postsurgically. mostasis. Romanow84 found that the inclusion of antibiotics in periodontal dressings encouraged the growth of Candida albicans and yeast. In vivo. reduced postoperative pain. but after 3 weeks. cyanoacrylate produced rapid he- regard to healing tological healing responses to cyanoacrylate dressings versus suturing following periodontal surgery in two beagle dogs.75 76 are eliminated in the feces and urine.000 units/ gm of bacitracin was recommended. Cyanoacrylates have been shown to be useful as a postsurgical dressing. Fraleigh82 used terramycin in dressings following gingivectomies in 50 patients.66 Bhaskar et al.69 compared the effects of a cyanoacrylate.83 proposed that most dressings have little or no antibacterial effect. Swann et al.78 79 It appears that cyanoacrylate is useful as a dressing because it 1 ) significantly reduces the time required for suturing.80 Cyanoacrylates are not currently approved for use in THERAPEUTIC EFFECTS dressings following various flap and mucogingival procedures in 725 patients and concluded that cyanoacrylate is close to an ideal dressing material. presumably because they prevented the accumulation of plaque and debris by sealing the wound site. had minimal bulk. and tested the antibacterial properties of a bacitracin containing dressing in vitro and in vivo. Linghorne and O'Connell81 performed in vitro and in vivo experiments on the antimicrobial effects of zinc-oxide eugenol dressings.86 obtained a similar result with Phenytoin.77 inhibit bacterial growth and have not been implicated as a carcinogen. tissue fluid and cellular defense components. However. Butyl cyanoacrylate showed the greatest tissue compatibility while higher homologues showed greater adverse tissue reactions. however. Bhaskar et al. as cytotoxic components are diluted in the mouth by saliva. Haugen and Hensten-Pettersen64 tested the cytotoxic effects of freshly prepared and stored samples of Coe-Pak. It was pointed out that clinically. Levin et al. Micrococcus catarrhalis and Candida albicans. Disadvantages noted were occasional difficulty in application around posterior teeth. absence of discomfort compared to sutures and better patient acceptance.67 also demonstrated that w-butyl cyanoacrylate was more tissue-tolerant than conventional periodontal dressings and found that the material was easily applied. and found that cyanoacrylates were capable of cementing moist.

Peripac the least.99 evaluated the efficacy of Chlorhexidine when used with a dressing. Chlorhexidine is well known for its antibacterial properties and inhibition of plaque growth. Persson and Thilander89 compared the antimicrobial effectiveness of Coe-Pak. The dressings were left in place for 1 week postsurgically. This difference from the previous study101 may be explained by the fact that a greater wound surface is exposed with gingivectomy making it more growth. Coe-Pak exerted the greatest antimicrobial effect and the greatest amount of tissue irritation. Addy and Douglas100 tested the antibacterial properties of a Chlorhexidine containing gel in vitro and in vivo. in another experiment. Peripac had the greatest antibacterial effect. for 5 days. Peripac.2% Chlorhexidine mouthwash dressing. less bleeding and lower Gingival Index scores than the control sides. December. there was significantly less plaque accumulation and less sulcular bleeding in areas treated utilizing no with the Chlorhexidine rinse. these studies indicate that the antimicrobial properties of dressings are minor considerations in periodontal wound healing. Patients expressed a preference for the Chlorhexidine rinse. Nobetec"*. the beneficial effects of antimicrobial additives must be weighed against the potential for allergy. However. 1984 Haugen et al. and Wondrpak. and healing was examined for up to 36 days postsurgically. as scaling and root planing changes the composition of subgingival microflora. However. The addition of antimicrobial agents to periodontal dressings is of questionable value in postoperative care. In conclusion. for the presence of supragingival microorganisms. either dry or wet.88 found that periodontal dressings exhibited differing antibacterial properties when tested in the unmixed form. It was felt that Chlorhexidine rinse did not have access to the teeth because of the presence of the dressing. a significant reduction in the amount of plaque formation was observed.2% Chlorhexidine rinse interdentally.94"97 its use with or without a dressing postsurgically may be of value. mobility and attachment levels at intervals of 1. as it inhibits plaque In contrast to painful. or after 1 or 2 days of storage. one side received a 0. Healing patterns were similar for both groups. sensitization or alteration of the oral environment with potential negative effects.98 found that a dressing containing Chlorhexidine promoted healing because it de- creased bacterial colonization of the wound. The efficacy of Chlorhexidine appears to be related to its mode of application. It was concluded that the antimicrobial property of a dressing is not a critical factor in the suitability of a dressing. The zinc oxide eugenol dressings showed a diminishing effect over time. whereas Peripac has no antimicrobial properties according to its manufacturer.692 Sachs. However.2% Chlorhexidine for 1 minute every evening. Pluss et al. which was felt to be due to its setting into nonreactive zinc eugenate. as a fresh mix. a higher concentration than normally required to inhibit plaque was necessary (up to 2%). because of diffusion of Chlorhexidine through the gel. O'Neill90 tested the antibacterial effects of five dressings (Coe-Pak. Joseph J. Asboe-Jorgensen et al. but after 1 month there was no significant difference in sulcular bleeding between the two sides. whereas the powder was in direct contact with the teeth and thus able to inhibit plaque. versus a dressing (Coe-Pak) with no Chlorhexidine. Addy and Dolby. finding it less uncomfortable than a dressing. and measurements were taken of gingival fluid flow. and Coe-Pak almost none. Following bilateral flap surgery. 2 and 4 weeks after surgery. A combination of mouthwash and dressing was suggested.91 compared dressing placement plus subgingival scaling. Periodontol. when the dressings were rolled in 15-20 mg of Chlorhexidine dihydrochloride (a relatively insoluble form of Chlorhexidine). Chlorhexidine as an Additive to Dressing. Fraleigh82 . when placed underneath a dressing. Sensitization and Allergy to Dressings. The sides treated with Chlorhexidine had less gingival exúdate.92 This may have influenced the results. tested the effect of 0. but most patients expressed a preference for the dressing on the basis that it was less painful. After 1 week. but a significant decrease in microbial flora was found when subgingival instrumentation was performed. The use of subgingival instrumentation without placement of a dressing might have allowed a better interpretation of the results. gingival bleeding. Septipac®) on 430 patients as well as in vitro against nine strains of bacteria. Zinc-oxide eugenol. Peripac. root planing and curettage to dressing placement without subgingival instrumentation. Bay and Langebaek103 reported that Coe-Pak coated with Chlorhexidine produced no additional plaque-inhibiting effect when used after gingivectomy. It was found that the total weight of accumulated plaque was not affected by the use of a dressing. following gingivectomy. Cross Pack". the above studies. Pihlstrom et al. Twenty periodontally healthy subjects had dressings placed (Peripac) and were instructed to rinse with 0. the overall results of these studies indicate that Chlorhexidine is a valuable asset in postsurgical care. Checchi. and found that methacrylate gel is a good medium for carrying Chlorhexidine to the wound area and releasing it slowly. Coe-Pak contains chlorothymol and lorothidol. However. Farnoush. Newman and Addy102 performed essentially the same experiment. No significant reduction in plaque formation was observed compared to the control. The results showed that topical Achromycin.101 using a split mouth approach. The dressings were tested in vitro against Staphylococcus aureus and C albicans. using flap surgery instead of gingivectomy. Breloff and Caffesse93 tested the effect of Achromycin® applied underneath a dressing in a single blind study involving 12 patients. had no beneficial effect on healing.

patients generally expressed a preference for no dressing. Patients reported more pain and discomfort when the dressing was used. Although the sample size was too small to reach definitive conclusions. Histological examinations of the wounds were done to look for newly formed crevicular epithelium and connective tissue. reduced postoperative plaque accumulation and surgical inflammation. and increases postoperative surgical inflammation. It was suggested that the use of a dressing postoperatively is undesirable. Heaney and Appleton"3 tested the effect of periodontal dressings when placed in periodontally healthy mouths. It was concluded that application of a dressing is a matter of individual rapid flammation than undressed areas. pocket depth. as it promotes bacterial contamination of the surgical site. compared the effects of not using a dressing versus using Coe-Pak on crevicular fluid flow. using either Coe-Pak or Wondrpak."6 who demonstrated that Chlorhexidine rinse is roughly equivalent to professional plaque control in postsurgical healing and was judged to be a viable alternative regime for plaque control. It was suggested that the sensitizing potential of a dressing was related to the leaching of their components. entrapping sutures beneath the dressing and forcing dressing material under the flap during placement. Wondrpak exhibited the strongest effect. Koch et al. This finding was felt to be of significance in medically compromised cases. the Gingival Index. gingival inflammation and postoperative discomfort. Greensmith and Wade. It was concluded that be removed within 1 week of surgery to prevent alterations in the healing pattern due to bacterial growth.104105 was able to produce allergic reactions to eugenol and rosin in both guinea pigs and humans. Jones and Cassingham"4 tested the postoperative differences between using no dressing and using CoePak in seven patients who had periodontal surgery. histological inflammation and pocket depths were compared. This is supported by the findings of Westfelt et al. PRESENT STATUS AND VALUE OF A SURGICAL DRESSING Whether or Not to Use a Dressing. 1 week after removal of the eugenol containing dressing. Gingival Index.107 Lysell108 reported a case of contact allergy to rosin in a periodontal dressing after the patient's third surgery. Stahl et al. and pocket depth. especially those with a history of rheumatic heart disease or bacterial endocarditis. they were associated with more in- dressings should noneugenol dressing (Perio Putty) on periodontal healing following modified Widman flap procedures in thirteen patients. No significant differences were found between dressed and undressed sites with regard to clinical attachment levels. Biopsies of the surgical sites were taken at regular intervals for up to 8 weeks. by contrast. Löe and Silness46 noted that in the absence of a dressing complete healing still took place and concluded that a dressing has little influence on healing provided that the surgical area is kept clean. and generally expressed a preference for no dressing. Thus. "1 found a 24% incidence of transient bacteremia in patients during postoperative dressing change. Peripac the weakest. Less plaque accumulation. following reverse bevel flap procedures. sulcular bleeding and postoperative discomfort were found in patients who used the Chlorhexidine rinse. Other disadvantages attributed to dressings were the possibility of displacing the flap. While healing appeared slightly more in the dressed segments."0 compared the healing sequence of dressed and undressed gingivectomies in 152 human subjects. ."2 in a split mouth approach. there was the strong clinical impression that routine use of periodontal dressings serve no useful purpose.Volume 55 Number 12 Status of Periodontal Dressings 693 noted allergic reactions to the presence of terramycin in a dressing. Chlorhexidine. No significant differences between the two modes of therapy were found. swelling of the dorsum of both hands and involvement of the interphalangeal joints. They found that while the dressings caused little damage to the periodontium.2% Chlorhexidine rinse following inverse bevel flap procedures in nine patients. Haugen and HenstenPettersen109 demonstrated that Coe-Pak. They speculated that repair might be improved if a dressing is not used since it accumulates plaque and irritates the healing tissues. Poulsom106 reported an anaphylactic reaction after application of Coe-Pak. but the exact components responsible for the reactions were not identified. Crevicular fluid flow. They do contribute to plaque retention and may promote bacterial proliferation at the surgical a sites. It was felt to be due to the presence of tannin in the dressing. based on recent studies it appears that periodontal dressings do not improve postoperative healing and do not provide a significantly greater degree of patient comfort. The reaction included urticaria on the abdomen. They found no significant differences in the healing of either side and concluded that the presence of inflammation at the wound site had more to do with the rate of healing than whether or not a dressing is placed. A number of reports have indicated that it may not be necessary or desirable to use a periodontal dressing in postsurgical care. Newman and Addy"5 compared a dressing plus a saline mouthrinse to 0. Wampole et al. Allen and Caffesse117 examined the clinical effects of preference. They reported no clinically significant difference between any of these parameters and found that the use of a dressing caused more pain and swelling but less sensitivity and eating difficulty than when no dressing was used. Peripac and Wondrpak were all capable of producing sensitization in guinea pigs.

Larato. On the other hand. J. 1947.: Periodontal pack on single tooth retained by At this time. E. G. 30. 1970. This may delay healing. G. Molnar. Gurney. 10. . Odanl Revy 23: 275. R... N. Watts./ Periodontal 33: 238. Br Dent J 151: 423. Experimental evidence has not fully resolved the issue./ Penadonto/ 14: 37. 1968b. 20. . Tissue reaction to various packs.: Mouth wounds. 1 I. 17. P.: Experimental studies of surgical packs. 25. Haugen. T. and Thilander. Watts. Watts. 1964. E. E./ Periodontal 28: 106. It should be noted. Furthermore. McKenzie. the degree of pain and discomfort. For example. 16.: Inharmonious cusp relation as a factor in periodontoclasia./ Oral Rehab 9: 291. Sumner. Dent Clin Am 8: 37. Baer. 1947. 4. Dyer.102'"5 "6121 and further research in this area encouraged. 2. J. 35. . 18. Castenfelt. 1970. 1952. as discussed. and Miller. and Combe. tissue management and duration of the operation may influence not only the severity of postsurgical pain and discomfort but also the healing comfort. 27.: Residual eugenol from zinc oxide-eugenol compounds. and Mjor. 1977. December.. M.. L. G. Ward. 3. A. J Dent Res 56: 1507. J Periodont Res 14: 487.: Frenum position and vestibule depth in relation to gingival health. Mclntosh. Ariaudo. L. R. F. W.694 Sachs. E. P. B."512" Chlorhexidine. that results of studies evaluating postsurgical pain and discomfort are based on patient responses and thus are not objectively evaluated because of the subjective criteria usually employed. conflicting reports exist in the literature. Hileman. Oral Surg 13: 494. 14.: Repositioning and increasing the zone of attached gingiva. . Oral Health 37: 721. J Am Dent Assoc 55: 676. P. Oliver. Colman. G: Sequelae following the use of eugenol or non-cugenol dressings after gingivectomy and subgingival curettage.. Odontal Tidskr 76: 157.: The possible adverse effects of asbestos in gingivectomy packs. However. periodontal dressings promote bacterial colonization of the surgical site. 1957. G.44 In addition.: Postoperative care in the surgical treatment of pyorrhea. There is evidence to support the use of a periodontal dressing in retention of an apically positioned flap by preventing coronal displacement.: The use of paraformaldehyde and oxygen in periodontal treatment. and Combe. L. 1980.: Chemotherapy in dental practice. CDA Council for Dental Materialsand Devices: Status report: periodontal dressings. 1960. however. T.. 33. 1977.: Adhesive properties of periodontal dressings—an in vitro study. amount of surgical trauma. 1979.: Fundamentals and technique of surgical periodontal packing.: The current status of surgical gingivectomy. C. C: Reinforcement of the periodontal pack. Gold. 29. J Can Dent Assoc 43: 501./ Am Dent Assoc 35: 697. Br Dent J 113: 112. denuded bone can be protected from further injury by a dressing during the early phase of healing which occurs by secondary intention. Munns.. and Shapiro. and Haugen. Oral Surgi: 1069. Br Dent J 113: 22.: A method for postgingivectomy pack stabilization. 1962.. M.: Retention of periodontal Packs. S. Espevik. B. 1954. G. 28. 34..: A clinical and histological investigation of the pressure pack method in periodontia. 26. G: Periodontal dressings. N. N. C: Surgical repositioning of vestibule and frenums in periodontal disease. T./ Periodontal 29: 199. 1962. C. Gjerdct. . Farnoush.: The repair of gingival tissue after surgical intervention. 23. R. 1923./ Dent Res 46: 645. appears to be a valuable asset in postsurgical care. In addition. 1967. C. 1962. as it inhibits plaque growth and bacterial colonization. M. 24. L. G: A study of some antimicrobial agents used in oral surgery. C: Adhesion of periodontal dressings to enamel in vitro. response. 1982. J. Gottsegen.: Studies on a hydrogenated fat-zinc bacitracin periodontal dressing. by contrast. 32. W. C: A materialistic look at periodontal packs. there is evidence that when good flap adaptation is achieved. Br Dent J 122: 507. 1981. J.: Sulcus deepening incorporating mucosal graft. H. D. . J Periodontal 22: 201. Smith. 6. P. E. I. 13. at least in part. Checchi. 2. and Tyrell. Radden.. NY State Dent J 33: 138. Ward. Holmes. Dent Pratt Dent Ree 21: 49. 1951. 31. Koch.. Sumner.. P. use REFERENCES 1. Y."7122 Well adapted flaps may serve as a barrier to bacteria117 and are thus more effective than any protection provided by a dressing. the use of a periodontal dressing does not add to patient comfort nor promote healing. and Kaplan.: Dimensional changes of periodontal dressings. A. Cowan. J Am Dent Assoc 10: 471. C: Rheological aspects of non-eugenol periodontal dressing materials. H. 1967. R. at least routinely. J Am Dent Assodi: 20. 8. Bernier. 1929.102 Its use should be strongly considered. 19. Br Dent J 92: 184. 1964.. W. Magnusson. J Can Dent Assoc 12: 268. 22. Box. 9. there is a great deal of debate over the value and usefulness of periodontal dressings. Persson.. J Periodontal 35: 167.: Necrotic gingivitis: its histopathology and treatment with an adherent dressing. . T.95"100 and appears to help reduce "5 postoperatively postoperative discomfort. and Nyquist. can be attributed to the nature of the surgical technique itself rather than the presence or absence of a dressing. D.: A dressing for major periodontoplastic operations. 1971.. . 1969. and thereby minimizes postoperative discomfort. F. H. H. a number of factors weigh against of a dressing. 21. there will always be a use for periodontal dressings although routine use of dressings may decrease because of better surgical techniques and the use of antibacterial mouth rinses."8 "9 With regard to the effect of a periodontal dressing on patient as previously discussed./ Clin Periodontal 7: 62. C: Effect of non-eugenol periodontal dressing materials upon the surface hardness of anterior restorative materials in vitro. K. Joseph CONCLUSION J. L. Pericdontol.. T. W. . J Periodontal36: 188. Bacr. . H. 1957. Hirschfeld. A. R. . .6 or its use to provide additional support to stabilize a free gingival graft. 12. J Am Dent Assoc 16: 635. E. 1942... 1969.: Contact allergy to medicaments and materials used in dentistry. S. and Wasserman. 1958. Dent Piaci Dent Ree 20: 263. 1965.. 1984 5. and Ham. 36. amount of osseous surgery. W.. Orban. 7./ Periodontal 33: 346. D. H. 1943. B.: Gingivectomy splint. . 1962. A. 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