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 exdate. 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

689

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Sachs, Farnoush, Checchi, Joseph

to
was

J. Periodontol.

December, 1984

dressings due

effects. Asbestos

cancer and mesothelioma.15 Tannic acid was found to cause potential liver damage if absorbed systemically.1016 Baer et al.17 described the use of a noneugenol dressing containing zinc oxide, bacitracin and hydrogenated fat. The material did not set to a hard consistency as do eugenol dressings, 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, lung

their possible detrimental systemic found to have the potential for

eugenol dressings.

to

consist of two pastes, one containing zinc oxide, an oil (for plasticity), a gum (for cohesiveness) and lorothidol (a fungicide). The other paste consists of liquid coconut fatty acids, thickened with colophony resin (or rosin) and chlorothymol (a bacteriostatic agent).18 The antimicrobial agents were reduced in amounts due to reports that they caused tissue irritation.19 Perio 20 Putty is another noneugenol dressing in current use which contains methyl- and propyl-parabens for their effective bacteriocidal and fungicidal properties21 and benzocaine as a topical anesthetic.22 The physical properties of periodontal dressings are believed to have a noticeable effect on their clinical performance, especially in regard to adaptation to the wound area. Gjerdet and Haugen23 measured linear dimensional changes of freshly prepared samples of Coe-Pak, Peripac'" and Wondrpak. Peripac expanded while the other dressings contracted; 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. Haugen et al.24 tested the adhesive properties of Coe-Pak, Peripac and Wondrpak to tooth surfaces and to soft tissue. Coe-Pak displayed somewhat better adhesion than Wondrpak, and Peripac did not have any adhesive strength at all. However, none of the dressings displayed sufficient adhesion for retention, and it was concluded that mechanical interlocking was necessary to hold dressings in place. Similar results have been reported by others.25 Watts and Combe26 compared Coe-Pak, Peripac and Peripac Improved for their effects on composite filling material and on a glass ionomer cement. All three caused a small amount of softening of the composite but had little effect upon the glass ionomer cement. Placement of adhesive foil between a dressing and teeth with composite restorations, to protect them from deterioration, was recommended. When the viscosity of Coe-Pak, Peripac and Peripac Improved was tested,27 none of the dressings exhibited ideal flow properties during manipulation and adaptation, and no dressing exhibited an adequately well defined set. This was felt to be a clinical disadvantage. 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. Further research is needed to improve
"

Coe-Pak", a popular dressing in current use, is known

the physical properties of dressings. Retention of Dressings. Various devices have been used to keep dressings from either being displaced or to reinforce them. These include wire ligation,28"30 suturing the dressing with cotton tape embedded in it,31 a variety of Stents and splints which fit over the teeth and gingiva,2832"40 the use of interproximal spiral saws with cotton thread,41 and foil.42 43 Such supplementary retention has also been advocated for protection of the donor sites in free gingival graft procedures.44 However, the need for these devices is a reflection of the inadequacy of the materials, and they introduce a significant amount of operator inconvenience at the end of a surgical procedure. In addition, they serve to enhance the plaque accumulation. On the other hand, the need for supplementary retention is sometimes unavoidable, such as around an isolated tooth when apically positioned tissue must be held in place, or desirable, as in the protection of a donor site of a free gingival graft or a bone graft area. EFFECTS ON WOUND HEALING

Comparison of Eugenol and Noneugenol Dressings. comparing the tissue-irritating properties of periodontal dressings have mainly involved comparisons between eugenol-containing and noneugenol dressings.43"56 However, the results conflict, probably due to the lack of standardization of experimental conditions. Implant studies provide a more controlled environment to study the irritating effects of dressings;49"''0-52"56 some have shown that eugenol dressings 55 Reare more irritating than noneugenol dressings.53 cently, it has been shown that an early irritating effect of a dressing may contribute to postoperative pain and swelling, regardless of whether or not it contains eugenol.56 Peripac, a noneugenol dressing, was shown to be more irritating than Wondrpak, due to dimensional changes which caused tissue irritation. This is important where large areas of connective tissue are left be mandaexposed and where use of a dressing may 58
Studies

tory.57

other fabrics5960 may be interposed between dressing and tissues to prevent such harmful effects. The main disadvantage of eugenol dressings is that they set hard, often with sharp edges, and leave a bad taste in the patient's mouth. This may account, in large part, for their decreased popularity.57 Effects on Cell Cultures. Kreth et al.61 tested four periodontal dressings on HeLa cell cultures, and found two eugenol dressings (PPC" and Wondrpak) slightly inhibitory to cell growth. Hildebrand and DeRenzis62 tested the effect of two eugenol dressings (PPC-eugenol, Wondrpak) and two noneugenol dressings (Coe-Pak, PPC-noneugenol) on fibroblasts. After an 8-hour test culture, Wondrpak exhibited the greatest cell toxicity and PPC-eugenol the least. However, after 24 hours, the most toxic material was Coe-Pak and the least was
as or

However, materials such

Telfa"

PPC-noneugenol. Rivera-Hidalgo et al.63 exposed serial

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691

dilutions of PPC-eugenol or Coe-Pak to a population of human polymorphonuclear leukocytes. A high concentration of dressing extract was found to be cytotoxic, and Coe-Pak was more cytotoxic than PPC-eugenol. It was pointed out that clinically, many of the cytotoxic elements would be diluted by saliva. Haugen and Hensten-Pettersen64 tested the cytotoxic effects of freshly prepared and stored samples of Coe-Pak, Peripac and Wondrpak on cultured epithelial cells. All three materials were found to have a very high degree of cytotoxicity. It was concluded that cell culture experiments are of limited use in evaluating dressings, as cytotoxic components are diluted in the mouth by saliva, blood, tissue fluid and cellular defense components. Cyanoacrylate Dressing Material. Cyanoacrylates have been shown to be useful as a postsurgical dressing. Bhaskar et al.65 investigated the effect of cyanoacrylates on experimental tongue wounds in rats, and found that cyanoacrylates were capable of cementing moist, living tissues together and producing immediate hemostasis. Butyl cyanoacrylate showed the greatest tissue compatibility while higher homologues showed greater adverse tissue reactions.66 Bhaskar et al.67 also demonstrated that w-butyl cyanoacrylate was more tissue-tolerant than conventional periodontal dressings and found that the material was easily applied, produced quick hemostasis, had minimal bulk, reduced postoperative pain, allowed faster wound healing and stimulated less granulation tissue proliferation underneath them than conventional dressings. Cyanoacrylates have also been used to splint teeth, cement conventional dressings, and act as a replacement for sutures.68 Ochstein et al.69 compared the effects of a cyanoacrylate, a eugenol and a noneugenol dressing on surgical wound healing. Apically positioned, full thickness and split thickness flaps were performed on 16 dogs, with one of the three dressings applied postsurgically. Clinical and histological evaluations were made for 21 days. It was found that cyanoacrylates produced better healing, presumably because they prevented the accumulation of plaque and debris by sealing the wound site.
to

the United States.

Cyanoacrylates are biodegradable,75 76 are eliminated in the feces and urine,77 inhibit bacterial growth and have not been implicated as a carcinogen.78 79 It appears that cyanoacrylate is useful as a dressing because it 1 ) significantly reduces the time required for suturing, 2) provides rapid hemostasis due to polymerization in the presence of moisture, 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.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. However, as ideal as it appears, cyanoacrylate cannot dissipate the pull of the lip or immobilize a flap for the time required for it to attach to the underlying tissues.10 In addition, delayed healing occurs by foreign body reaction if the material becomes embedded in the tissues or underneath a flap.10-67'73-74

Forrest70 compared clinically cyanoacrylate dressing suturing without dressing, using a split mouth approach in 30 surgical cases. No significant difference
found between the
two

was

with

responses.

mostasis, absence of discomfort compared to sutures and better patient acceptance. Disadvantages noted were occasional difficulty in application around posterior teeth, and rapid polymerization upon contact with small amounts of moisture. Binnie and Forrest71 compared the clinical and his-

However, cyanoacrylate produced rapid he-

regard

to

healing

tological healing responses to cyanoacrylate dressings versus suturing following periodontal surgery in two beagle dogs. After 1 week, healing was superior in the cyanoacrylate dressed areas, but after 3 weeks, there
was

little difference between the two. Levin et al.72 documented the use of

cyanoacrylate

Therapeutic Effect of Various Antimicrobial Agents in Dressings. Linghorne and O'Connell81 performed in vitro and in vivo experiments on the antimicrobial effects of zinc-oxide eugenol dressings. In vitro, the dressings exhibited an effective antibacterial effect against various Streptococci, Micrococcus catarrhalis and Candida albicans. In vivo, the dressings were capable of sterilizing the base of periodontal pockets. Fraleigh82 used terramycin in dressings following gingivectomies in 50 patients. A definite antimicrobial effect and accelerated healing was found. Patients experienced less odor and unpleasant taste and were more comfortable with the terramycin dressing; however, twelve patients developed allergic reactions. Baer et al.83 proposed that most dressings have little or no antibacterial effect, and tested the antibacterial properties of a bacitracin containing dressing in vitro and in vivo. Addition of bacitracin had a definite suppressive effect on the growth of microorganisms. Of 200 gingivectomy cases studied, the ones with the bacitracin dressing experienced less odor and unpleasant taste, and the dressing itself was cleaner than those without bacitracin. A dressing containing 3,000 units/ gm of bacitracin was recommended. Romanow84 found that the inclusion of antibiotics in periodontal dressings encouraged the growth of Candida albicans and yeast. Saad and Swenson85 found that the incorporation of corticosteroid (Cordan) into a dressing was of no value in wound healing. Swann et al.86 obtained a similar result with Phenytoin. Heaney et al.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; they advised removal of the dressing within 7 days.

692

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J. Periodontol.

December, 1984

Haugen et al.88 found that periodontal dressings exhibited differing antibacterial properties when tested in the unmixed form, as a fresh mix, or after 1 or 2 days of storage, either dry or wet. Persson and Thilander89 compared the antimicrobial effectiveness of Coe-Pak, Peripac, Nobetec"*, and Wondrpak. The dressings were tested in vitro against Staphylococcus aureus and C albicans. Coe-Pak exerted the greatest antimicrobial effect and the greatest amount of tissue irritation, Peripac the least. However, Coe-Pak contains chlorothymol and lorothidol, whereas Peripac has no antimicrobial properties according to its manufacturer. The zinc oxide eugenol dressings showed a diminishing effect over time, which was felt to be due to its setting into nonreactive zinc eugenate. It was concluded that the antimicrobial property of a dressing is not a critical factor in the suitability of a dressing. O'Neill90 tested the antibacterial effects of five dressings (Coe-Pak, Peripac, Zinc-oxide eugenol, Cross Pack", Septipac) on 430 patients as well as in vitro against nine strains of bacteria. Peripac had the greatest antibacterial effect, and Coe-Pak almost none. Pihlstrom et al.91 compared dressing placement plus subgingival scaling, root planing and curettage to dressing placement without subgingival instrumentation, for the presence of supragingival microorganisms. It was found that the total weight of accumulated plaque was not affected by the use of a dressing, 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, as scaling and root planing changes the composition of subgingival microflora.92 This may have influenced the results. Breloff and Caffesse93 tested the effect of Achromycin applied underneath a dressing in a single blind study involving 12 patients. The dressings were left in place for 1 week postsurgically, and measurements were taken of gingival fluid flow, gingival bleeding, mobility and attachment levels at intervals of 1, 2 and 4 weeks after surgery. The results showed that topical Achromycin, when placed underneath a dressing, had no beneficial effect on healing. In conclusion, these studies indicate that the antimicrobial properties of dressings are minor considerations in periodontal wound healing. The addition of antimicrobial agents to periodontal dressings is of questionable value in postoperative care; the beneficial effects of antimicrobial additives must be weighed against the potential for allergy, sensitization or alteration of the oral environment with potential negative effects. Chlorhexidine as an Additive to Dressing. Chlorhexidine is well known for its antibacterial properties and inhibition of plaque growth;94"97 its use with or without a dressing postsurgically may be of value. Asboe-Jorgensen et al.98 found that a dressing containing Chlorhexidine promoted healing because it de-

creased bacterial colonization of the wound. Following bilateral flap surgery, one side received a 0.2% Chlorhexidine rinse interdentally, and healing was examined for up to 36 days postsurgically. The sides treated with Chlorhexidine had less gingival exdate, less bleeding and lower Gingival Index scores than the control sides. The efficacy of Chlorhexidine appears to be related to its mode of application. Pluss et al.99 evaluated the efficacy of Chlorhexidine when used with a dressing. Twenty periodontally healthy subjects had dressings placed (Peripac) and were instructed to rinse with 0.2% Chlorhexidine for 1 minute every evening, for 5 days. No significant reduction in plaque formation was observed compared to the control. However, in another experiment, when the dressings were rolled in 15-20 mg of Chlorhexidine dihydrochloride (a relatively insoluble form of Chlorhexidine), a significant reduction in the amount of plaque formation was observed. It was felt that Chlorhexidine rinse did not have access to the teeth because of the presence of the dressing, whereas the powder was in direct contact with the teeth and thus able to inhibit plaque. Addy and Douglas100 tested the antibacterial properties of a Chlorhexidine containing gel in vitro and in vivo, and found that methacrylate gel is a good medium for carrying Chlorhexidine to the wound area and releasing it slowly. However, a higher concentration than normally required to inhibit plaque was necessary (up to 2%), because of diffusion of Chlorhexidine through the gel. Addy and Dolby,101 using a split mouth approach, tested the effect of 0.2% Chlorhexidine mouthwash

dressing, versus a dressing (Coe-Pak) with no Chlorhexidine, following gingivectomy. Healing patterns were similar for both groups, but most patients expressed a preference for the dressing on the basis that it was less painful. A combination of mouthwash and dressing was suggested. Newman and Addy102 performed essentially the same experiment, using flap surgery instead of gingivectomy. After 1 week, there was significantly less plaque accumulation and less sulcular bleeding in areas treated utilizing
no

with the Chlorhexidine rinse, but after 1 month there was no significant difference in sulcular bleeding between the two sides. Patients expressed a preference for the Chlorhexidine rinse, finding it less uncomfortable than a dressing. 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.

the above studies, Bay and Langebaek103 reported that Coe-Pak coated with Chlorhexidine produced no additional plaque-inhibiting effect when used after gingivectomy. However, the overall results of these studies indicate that Chlorhexidine is a valuable asset in postsurgical care, as it inhibits plaque
In
contrast to

painful.

Sensitization and Allergy

to

Dressings. Fraleigh82

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693

noted allergic reactions to the presence of terramycin in a dressing. Koch et al.104105 was able to produce allergic reactions to eugenol and rosin in both guinea pigs and humans. Poulsom106 reported an anaphylactic reaction after application of Coe-Pak, 1 week after removal of the eugenol containing dressing. It was felt to be due to the presence of tannin in the dressing.107 Lysell108 reported a case of contact allergy to rosin in a periodontal dressing after the patient's third surgery. The reaction included urticaria on the abdomen, swelling of the dorsum of both hands and involvement of the interphalangeal joints. Haugen and HenstenPettersen109 demonstrated that Coe-Pak, Peripac and Wondrpak were all capable of producing sensitization in guinea pigs. Wondrpak exhibited the strongest effect, Peripac the weakest, but the exact components responsible for the reactions were not identified. It was suggested that the sensitizing potential of a dressing was related to the leaching of their components.
PRESENT STATUS AND VALUE OF A SURGICAL DRESSING Whether or Not to Use a Dressing. A number of reports have indicated that it may not be necessary or desirable to use a periodontal dressing in postsurgical care. Le 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. Stahl et al."0 compared the healing sequence of dressed and undressed gingivectomies in 152 human subjects. Biopsies of the surgical sites were taken at regular intervals for up to 8 weeks. Histological examinations of the wounds were done to look for newly formed crevicular epithelium and connective tissue. 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. They speculated that repair might be improved if a dressing is not used since it accumulates plaque and irritates the healing tissues. Wampole et al. "1 found a 24% incidence of transient bacteremia in patients during postoperative dressing change. This finding was felt to be of significance in medically compromised cases, especially those with a history of rheumatic heart disease or bacterial endocarditis. Greensmith and Wade,"2 in a split mouth approach, compared the effects of not using a dressing versus using Coe-Pak on crevicular fluid flow, the Gingival Index, and pocket depth, following reverse bevel flap procedures. 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. While healing appeared slightly more

in the dressed segments, patients generally expressed a preference for no dressing. It was concluded that application of a dressing is a matter of individual

rapid

flammation than undressed areas. It was concluded that be removed within 1 week of surgery to prevent alterations in the healing pattern due to bacterial growth. Jones and Cassingham"4 tested the postoperative differences between using no dressing and using CoePak in seven patients who had periodontal surgery. Crevicular fluid flow, Gingival Index, histological inflammation and pocket depths were compared. No significant differences between the two modes of therapy were found. Patients reported more pain and discomfort when the dressing was used, and generally expressed a preference for no dressing. Although the sample size was too small to reach definitive conclusions, there was the strong clinical impression that routine use of periodontal dressings serve no useful purpose. Other disadvantages attributed to dressings were the possibility of displacing the flap, entrapping sutures beneath the dressing and forcing dressing material under the flap during placement. Newman and Addy"5 compared a dressing plus a saline mouthrinse to 0.2% Chlorhexidine rinse following inverse bevel flap procedures in nine patients. Less plaque accumulation, sulcular bleeding and postoperative discomfort were found in patients who used the Chlorhexidine rinse. It was suggested that the use of a dressing postoperatively is undesirable, as it promotes bacterial contamination of the surgical site, and increases postoperative surgical inflammation. Chlorhexidine, by contrast, reduced postoperative plaque accumulation and surgical inflammation. This is supported by the findings of Westfelt et al."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. Allen and Caffesse117 examined the clinical effects of

preference. Heaney and Appleton"3 tested the effect of periodontal dressings when placed in periodontally healthy mouths, using either Coe-Pak or Wondrpak. They found that while the dressings caused little damage to the periodontium, 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, pocket depth, gingival inflammation and postoperative discomfort. Thus, 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. They do contribute to plaque retention and may promote bacterial proliferation at the surgical
a

sites.

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Sachs, Farnoush, Checchi, Joseph

CONCLUSION

J. Pericdontol.

December, 1984 5. Bernier, J. L., and Kaplan, H.: The repair of gingival tissue after surgical intervention../ Am Dent Assoc 35: 697, 1947. 6. Ariaudo. . .. and Tyrell. . .: Repositioning and increasing the zone of attached gingiva../ Periodontal 28: 106, 1957. 7. Blanquie, R. H.: Fundamentals and technique of surgical periodontal packing../ Periodontal 33: 346. 1962. 8. Gold, .: The current status of surgical gingivectomy. Dent Clin Am 8: 37, 1964. 9. Weinreb. . M.. and Shapiro. S.: A clinical and histological investigation of the pressure pack method in periodontia. J Periodontal 35: 167, 1964. 10. Bacr. P. N.. Sumner. C. R., and Miller, G: Periodontal dressings. Dent Clin Am 13: 181, 1969. 1 I. Mclntosh, W. G.: Periodontal packs and their application. J Can Dent Assoc 12: 268, 1947. 12. Molnar, E. J.: Residual eugenol from zinc oxide-eugenol compounds. ./ Dent Res 46: 645, 1967. 13. Colman, G: A study of some antimicrobial agents used in oral surgery. Br Dent J 113: 22. 1962. 14. Radden. H. G.: Mouth wounds. Br Dent J 113: 112, 1962. 15. Dyer. M. R. Y.: The possible adverse effects of asbestos in gingivectomy packs. Br Dent J 122: 507, 1967. 16. CDA Council for Dental Materialsand Devices: Status report: periodontal dressings. J Can Dent Assoc 43: 501. 1977. 17. Baer. P. N.. Sumner. C. F.. and Scigliano. J.: Studies on a hydrogenated fat-zinc bacitracin periodontal dressing. Oral Surg 13: 494, 1960. 18. Smith, D. C: A materialistic look at periodontal packs. Dent Piaci Dent Ree 20: 263. 1970. 19. Persson. G. and Thilander. H.: Experimental studies of surgical packs. 2. Tissue reaction to various packs. Odontal Tidskr 76: 157. 1968b. 20. Gurney, B. F.: Chemotherapy in dental practice. J Am Dent Assodi: 20. 1969. 21. Oliver. W. M., and Heaney, T. G: Sequelae following the use of eugenol or non-cugenol dressings after gingivectomy and subgingival curettage. Dent Pratt Dent Ree 21: 49, 1970. 22. Koch. G, Magnusson. B.. and Nyquist. G.: Contact allergy to medicaments and materials used in dentistry. Odanl Revy 23: 275, 1971. 23. Gjerdct. N. R.. and Haugen, E.: Dimensional changes of periodontal dressings. J Dent Res 56: 1507. 1977. 24. Haugen. E.. Espevik. S.. and Mjor. I. .: Adhesive properties of periodontal dressingsan in vitro study. J Periodont Res 14: 487. 1979. 25. Watts. T. L. P.. and Combe, E. C: Adhesion of periodontal dressings to enamel in vitro../ Clin Periodontal 7: 62, 1980. 26. Watts. T. L. P.. and Combe. E. C: Effect of non-eugenol periodontal dressing materials upon the surface hardness of anterior restorative materials in vitro. Br Dent J 151: 423. 1981. 27. Watts. T. L. P., and Combe, E. C: Rheological aspects of non-eugenol periodontal dressing materials. ./ Oral Rehab 9: 291. 1982. 28. Hirschfeld, L., and Wasserman, B.: Retention of periodontal Packs../ Periodontal 29: 199. 1958. 29. Cowan. .: Sulcus deepening incorporating mucosal graft. J Periodontal36: 188, 1965. 30. Larato. D. C: Reinforcement of the periodontal pack. NY State Dent J 33: 138. 1967. 31. Castenfelt. T.: A dressing for major periodontoplastic operations. ./ Periodontal 33: 238, 1962. 32. McKenzie. J. S.: A method for postgingivectomy pack stabilization. J Periodontal 22: 201. 1951. 33. Munns. D.: Gingivectomy splint. Br Dent J 92: 184, 1952. 34. Gottsegen. R.: Frenum position and vestibule depth in relation to gingival health. Oral Surgi: 1069, 1954. 35. Hileman, A. C: Surgical repositioning of vestibule and frenums in periodontal disease. J Am Dent Assoc 55: 676, 1957. 36. Holmes. C. H.: Periodontal pack on single tooth retained by

At this time, there is a great deal of debate over the value and usefulness of periodontal dressings. Experimental evidence has not fully resolved the issue. There is evidence to support the use of a periodontal dressing in retention of an apically positioned flap by preventing coronal displacement,6 or its use to provide additional support to stabilize a free gingival graft.44 In addition, denuded bone can be protected from further injury by a dressing during the early phase of healing which occurs by secondary intention, and thereby minimizes postoperative discomfort. Use of a dressing may also act as a template for healing by preventing the formation of excess granulation tissue."8 "9 With regard to the effect of a periodontal dressing on patient

as previously discussed, conflicting reports exist in the literature. It should be noted, however, 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. Furthermore, the degree of pain and discomfort, at least in part, can be attributed to the nature of the surgical technique itself rather than the presence or absence of a dressing. Factors such as poor flap adaptation, amount of osseous surgery, amount of surgical trauma, tissue management and duration of the operation may influence not only the severity of postsurgical pain and discomfort but also the healing

comfort,

response.

On the other hand, a number of factors weigh against of a dressing, at least routinely. For example, periodontal dressings promote bacterial colonization of the surgical site. This may delay healing."512" Chlorhexidine, by contrast, appears to be a valuable asset in postsurgical care, as it inhibits plaque growth and bacterial colonization,95"100 and appears to help reduce "5 postoperatively postoperative discomfort.102 Its use should be strongly considered,102'"5 "6121 and further research in this area encouraged. In addition, there is evidence that when good flap adaptation is achieved, the use of a periodontal dressing does not add to patient comfort nor promote healing."7122 Well adapted flaps may serve as a barrier to bacteria117 and are thus more effective than any protection provided by a dressing. However, as discussed, 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.
use

REFERENCES
1. Ward. A. W.: Inharmonious cusp relation as a factor in periodontoclasia. J Am Dent Assoc 10: 471, 1923. 2. Ward. A. W.: Postoperative care in the surgical treatment of pyorrhea. J Am Dent Assoc 16: 635. 1929. 3. Box, H. K. and Ham, A. W.: Necrotic gingivitis: its histopathology and treatment with an adherent dressing. Oral Health 37:

721. 1942. 4. Orban, B.: The use of paraformaldehyde and oxygen in periodontal treatment. ./ Penadonto/ 14: 37. 1943.

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Send reprint requests to: A. Farnoush, DDS, Department of Periodontics, School of Dentistry, University of Southern California. University ParkMC 0641, Los Angeles, CA 90089-0641.