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The Therapeutic Properties of Periodontal Cement

Packs
by W J. LINGHORNE, D.D.S., Department of Physiology
and
D. C. O'CONNELL, M.S.A., Banting and Best Department of Medical Research,
University of Toronto

I N RECENT years. periodontal cement


packs have been increasingly used in the
treatment of periodontal disease. Aided by
experiments that may be of interest to the
clinician are reported in this paper.
Periodontal cement packs consist of
a grant to Dr. H. K. Box, Research Professor a powder and- a liquid which are mixed
of Periodontia, Faculty of Dentistry, together to form a paste. In the presence of
University of Toronto, from the Associate moisture the paste sets, forming fairly hard
Committee on Dental Research of the cement. Three formulae (see Appendix I),
National Research Council, an investigation were selected as suitable for the various
of the therapeutic properties of periodontal purposes and conditions encountered in
cement packs and their use in the treatment periodontal case management. The products
of periodontal disease has been conducted in differed mainly in the physical character of
the Banting and Best Department of Medical the mix.
Research, University of Toronto. It is hoped IN VITRO STUDIES
that the additional knowledge obtained The materials studied were:
through this study will result in a more powders-zinc oxide, tannic acid, asbestos,
intelligent and effective clinical use of resin; and liquids-eugenol, thymol, and
periodontal packs. sweet almond oil. The bacteriostatic
This paper primarily deals with the properties of each were studied singly and in
therapeutic properties of periodontal cement combination using the agar - plate - with -
packs and does not discuss the relationship gutter technique as used in penicillin
of this method of therapy to the various sensitivity tests.1 (See Appendix II). The
forms of periodontal disease. The tests were carried out against staphylococcus
application of the packing procedure to such aureus.
conditions as necrotic gingivitis, necrotic The following chart gives the result
and simplex periodontitis is beyond the of the test of the various ingredients in the
scope of this paper. powders using water as the liquid and
It has been considered preferable to asbestos as a binder. The incubation period
present the pertinent experimental data was 24 hours.
rather than to attempt to describe any exact Compound Zone of inhibition
clinical techniques based on the results of of growth in mm.
the investigation, with the hope that the Asbestos + H2O .......................................... 0
specific information will be helpful to the Asbestos + Zinc Oxide + H20 ...... 1
reader in evaluating and developing his own Asbestos + Resin + H2O .............................
clinical procedures when using these 0
materials. However, the three methods de- Asbestos + Tannic Acid + H20 .... 5
scribed in the in- vivo studies were found to Asbestos + Zinc Oxide + Tannic
be adequate in meeting most of the packing Acid + H2O ...................... 2
problems encountered in periodontal case In testing the liquid, water of course
management. Both in vivo and in vitro was omitted but. asbestos was again used as
studies were carried out. Only those a binder. The following chart gives the
results when eugenol alone was used as the liquid; incubation period 24 hours.
Compound Zone of inhibition then, upon further diffusion, may have been
. of growth in mm. subsequently killed. Accordingly, after two days
Asbestos and Eugenol ..................................... 14 at room temperature following the initial 24'
Asbestos + Zinc Oxide + Eugenol.. ………….. 8 hours incubation at 37° C, five plates and one
Asbestos + Zinc Oxide + Resin control were re-inoculated with staphylococcus
+ Eugenol ............................................ 21 aureus and re-incubated. No growth occurred in
Asbestos + Zinc Oxide + Tannic any portion of any plate except the control plate.
Acid + Eugenol ...:...... …………….... 12 Evidently diffusion had continued through-out
Asbestos + Zinc Oxide + Tannic the whole plate.
Acid + Resin + Eugenol …………….. 13 In order to ascertain for what length of
The next chart gives results using eugenol time the active agent continued to diffuse from
15 parts and sweet almond oil 25 parts as. the the pack, and whether the setting interfered with
liquid; incubation period 24 hours. the bacteriostatic action, the following studies
Compound , Zone of inhibition were carried out.
of growth in mm. Five grams of pack with eugenol and
Asbestos + Liquid ............. ....................... 14 sweet almond oil and the same amount with
Asbestos + Zinc Oxide + Liquid . …………... 21 eugenol and thymol were placed on swab sticks,
Asbestos + Zinc Oxide + Resin (see Appendix IV), and dropped into 5 c.c. of
+ Liquid ............................................... 24 beef extract broth.
Asbestos + Zinc Oxide + Tannic After one half-hour in the first tube the
Acid + Liquid ...................................... 10 pack had set and was transferred from tube to
Asbestos + Zinc Oxide + Tannic tube at intervals.
1
Acid + Resin + Liquid ........... 12 Tube 1 /2 hour
1
Asbestos + Sweet Almond Oil gave an inhibition .. Tube 2 . /2 “
of 5 mm. Tube 3 1 “
The next chart gives the results when Tube 4 1 “
eugenol and thymol (98 parts eugenol and 2 - Tube 5 24 “
parts thymol) were mixed as the liquid; All tubes were then seeded with
incubation period 24 hours. . staphylococcus aureus and incubated at 37 Co for
Compound Zone of inhibition 24 and 28 hours. No growth occurred in any
of growth in mm culture tube.
Asbestos + liquid .......................................... 22 The next question was whether the result
Asbestos + Zinc Oxide + liquid ……..27 obtained was due to an agent on the surface or to
Asbestos + Zinc oxide + Resin actual diffusion from the core of the pack.
+ liquid ................................................ 25 Therefore in the next test, after the pack had been
Asbestos + Zinc oxide + Resin allowed to harden in the first tube for 1/2 hour, it
+Tannic acid + liquid .......................... 12 was carried through a series of six washes in one
In all the plates showing inhibition there hour, ten minutes in each tube and then carried
seemed to be two processes going on at the same through two 1/2 hour tubes, two 1 hour tubes and
time, namely the diffusion of the bacteriostatic one 24 hour tube. No growth appeared in any
agent through the agar and the growth of the tube after 24 hours incubation. On 72 hours
organisms. Thus the question arose whether the incubation, only the last four of the six wash
organisms which had grown before the tubes showed evidence of growth. It appears,
bacteriostatic agent had diffused in the area and then, that time for diffusion is necessary since a
10 minute interval is not always sufficient time inhibited only, four tubes of fresh sterile broth
to ensure a bacteriostatic concentration. were seeded from
To determine whether the staphylo-
coccus aureus had been killed or its growth
one of the half hour tubes in the dif-fusion series (3) Pack + penicillin (5000 units in 5
and incubated at 37° C for 48 hours. No growth grams of pack)
occurred in any tube indicating that the
organisms had been killed.
The next study was carried out to
determine how long the pack would continue to Test Organisms Zone of Inhibition
diffuse the active agent. It was carried out in

pack+ penicillin
sulphathiazole
duplicate according to the method described
above, with the swab stick.
The pack was placed in broth, and

pack+
Pack
incubated for 24 hours, then removed and placed
in the next broth tube and incubated for 1 hour.
Following this, it was transferred to another tube Micrococcus
and incubated for another 24 hours. The cataruhalis 7, 7, 14, 9, 7, 8,
procedure was continued each day. Day by day Streptococcus
the tubes from which the pack had been removed viridans 10, 10, 10, 10, 11, 10,
were seeded with staphylococcus organisms and Streptococcus
incubated for 24 hours. Up to the 35th day, no hemolyticus . 7, 7, 7, 8, 10,11,
growth occurred in either the 1 hour or the 24 Staphylococcus
hour tubes. This same pack in broth was set aside aureus 16, 17, 8, 10, 16, 14,
in the laboratory for one year, during which time Psuedomonas
the broth had evaporated to dryness. When the aeruginosa 2, 1, 1, 2, 1, 2,
pack was placed in broth for 1 hour, once again In addition to the tests carried out against
sufficient of the bacteriostatic agent had diffused the above pathogenic bacteria, a similar test was
from the pack to prevent the growth of made against candida albicans, the micro-
staphylococcus aureus. organism concerned in thrush. The zone of
The following studies were made of the inhibition produced against C, albicans was 20
bacteriostatic effect of the pack against other mm, indicating that the pack has considerable
organisms. Using the agar-plate-with-well fungicidal properties.
technique (see Appendix III) the effect of the IN VIVO STUDIES
pack against pseudomonas aeruginosa, mi- Studies were carried out to investigate the
crococcus catarrhalis, staphylococcus aureus, effect of packing periodontal pockets in humans
streptococcus viridans and streptococcus and dogs.
hemolyticus, was determined. Procedure
In addition, a comparison of the bac- Material taken from the depths of the
teriostatic effect of the pack with that of pack + periodontal pockets was placed on slides, care
sulphathiazole and pack + penicillin was made. being taken to prevent maceration of the
The following chart gives the results of organisms and it was allowed to dry in air. After
the testing of the pack alone, pack + drying, the smears were examined under oil, at
sulphathiazole and pack + penicillin. least 30 fields being considered in thin
Test materials: preparation.
(1) Pack Three methods for removing the material
(2) Pack + 5% sulphathiazole powder from the pocket were investigated: (1) using a
suitably shaped wooden toothpick, (2) a metal
probe and (3) a capillary tube pipette. The first pack. The pack was again removed in 24 or 48
was the method selected and used throughout hours. In a limited number of cases the pack was
these experiments. In each case the pocket area allowed to remain in place for 4 to 7 days.
was isolated with cotton rolls, excess moisture
re-moved by blast of air, the toothpick was Method II
suitably shaped and lightly scraped along the Where the pocket was narrow, tor-
base of the pocket.
For practical purposes the microscopic findings
were divided into three groupings. Those smears
in which no

organisms of the fuso-spirochetal group were


found were called clinically sterile; those
showing one or two organisms per field were
called almost clinically sterile; and those smears
showing any of the group organisms in fair
numbers were called clinically septic. (See
photomicrograph 1, 2; and 3.) Smears were taken
before packing, after the pack had been in place FIG. 1. Septic
for various lengths of time and after the pocket
had been packed several times. Only those series
considered to have a bearing on clinical
procedure are reported in this paper.
Pockets from 4 to 8 mm. in depth as
determined by means of a probe graduated in
millimetres, were selected. A number of
techniques for applying the pack were tried. .
Three were selected and used according to the
depth and course of the pocket and the nature of
the soft tissue wall.
Method I FIG., 2. Almost Sterile
Where it was possible to retract the soft
tissue wall to the base, Method I was used. A
mix of Formula 3 (See Appendix I) was made
about the consistency of putty and was
introduced, a portion at a time, gradually, over-
filling the pocket. Each portion of pack was
sealed to the tooth and to the pack already
inserted, avoiding direct pressure on the soft
tissues. Finger pressure was used to mould the
overfilled portion to the tooth and to seal the
pocket. Only half of the mouth was packed at
one time and the patient was requested to avoid
chewing food where the teeth were packed. The FIG. 3. Sterile
pack was removed in 24-48 hours, at which time tuous, deep (over 6 mm.) or where the soft tissue
the pocket wall was often retracted to the base. was dense and fibrous, Method II was used. A
Where considered necessary the pocket was thin creamy mix of Formula I was made into
repacked, this operation being greatly facilitated which shreds of -absorbent cotton were mixed.
by the opening up of the pocket by the preceding
Then, with a suitable instrument, this saturated
"# $ % #
cotton was introduced into the pocket and very
% "# $ ## % &

Leaving the pack in place longer than 24


hours at a time made little difference. When the
pack was left
lightly tamped until the, pocket was three longer than 48 hours it was often loosened or
quarters filled. The y pocket was then overfilled displaced.
with a stiffer mix of formula III which was The following table gives the results of
moulded around the tooth using finger pressure packing experimentally produced periodontal
to seal the pocket. pockets in dogs using Method II.
Method III
Where it was possible to flow the pack
into place using finger pressure and instruments,
a mix of Formula II, which would flow under
finger pressure, was used.
The purpose in packing was to bring the
active agent in the pack into close contact with, && & &
the bacteria at the base of the pocket. Box, in his
paper "Necrotic Gingivitis''2' pointed out that
All pockets were clinically septic before,
taking into account the questions of extreme
packing.
pocket thinness, viscosity of the pocket fluids
DISCUSSION
and the presence of calcific deposits which, serve
The in vivo studies indicated 'that the cement
to interfere with great mass movements through
packs selected are highly effective in combating
constrictions etc., it wcu1d appear that
the organisms of the periodontal pocket. The an
convection currents have little bearing on the
vitro studies show that the pack is bacteriostatic
oxygen distribution in the pocket. Constrictions
against a number of known pathogenic
would slow the rate of penetration of the pocket
organisms and that under certain conditions this
by diffusion also. Thus in order to permit the
effect is maintained for a far longer time than is
diffusion through-out the pocket of the, active
required clinically in pocket therapy. Thus the
agent in, the pack, either the soft tissue wall must
pocket can be kept clinically sterile for at least a
be retracted to the base, or the pocket must be
week if desired in treatment.
filled to the base with the pack.
However, as pointed out before in this paper, in
The following table gives the results of
order that the active agent be brought into
packing periodontal pockets in humans. Only,
contact with all the organisms in sufficient
those cases where the pack remained firmly in
concentration for the required time, it appears
place were included. All pockets were found to
necessary that either the pocket be packed in
be clinically septic before packing.
such a way that the soft tissue wall is retracted to
the base, or that the pocket be filled to the base
with the pack. Thus, in the dogs, where
conditions were such that the pockets could be
packed to the base, all were found to be clinically
sterile in 24 hours. Also, in human periodontal
pockets a much higher percentage was found to
be clinically sterile following second packing
! ! ! than when only one pack was used. This is to be
expected as the opening up of the pocket by the
first pack greatly facilitated the, second packing. SUGGESTIONS FOR USE CLINICALLY
In order to meet the various requirements in
management of periodontal cases, three (1) In pocket therapy.
formulae, varying mainly in the physical (2) In the treatment of coronitis.
characteristics of the (3) Pre-operative to the extraction of
periodontally affected teeth.
(4) Pre-operative and post-operative to
mix, are suggested. The mix of Formula I is thick gingivectomy.
and creamy and might be described as a paint. It (5) On infected surfaces in the mouth.
is sticky and adheres well to the teeth and
mucous membrane. The mix of Formula II is CONCLUSIONS
stiffer and more fibrous but will flow under
finger pressure. It is less sticky than that of (1) In vitro studies indicate that the periodontal
Formula I. The mix of Formula III might be packing material studied is an effective
compared to the consistency of putty. When bacteriostatic agent against staphylococcus
applied it will displace the tissues and hold them aureus, streptococcus viridans, streptococcus
displaced until setting of the pack occurs. It is hemolyticus, and micrococcus catarrhalis.
not sticky but can be made to adhere to the tooth (2) In vivo studies indicate that the pack is an
and to other portions of pack. When set it is effective agent in pocket therapy.
softer and less brittle than the mix of either of the (3) Diffusion of the bacteriostatic agent from the
other two formulae. pack into the surrounding media will continue
The bacteriostatic effect of the pack for a far longer time than is required in perio-
appears to be largely due to the eugenol and dontal case management.
thymol. The addition of thymol seems to increase (4) The periodontal pack acts as a stimulant and
the bacteriostatic effect. - Sweet almond oil a local analgesic.
slows the setting time and reduces stickiness. It (5) The addition of 5% sulphathiazole or of
is omitted in Formula I and I as stickiness and penicillin (5000 units to 5 grams of pack) does
quick setting are desirable properties when used not seem to increase the bacteriostatic
by the technique described. effectiveness of the pack.
Besides being bacteriostatic, both (6) The pack is an effective fungicide against
eugenol and thymol are stimulants and local candida albicans, the organism concerned in
analgesics. When the pack is applied to tender or thrush.
painful surfaces, the patient experiences almost APPENDIX I
immediate relief, also, there is a marked FORMULA I
beneficial effect on the tissues observed Zinc Oxide Wt. per 100 gms. 39.2 mgs.
clinically within 24 hours of the application of Powdered Resin - 49.5
the pack. Tannic Acid 7.9
The pack is fairly insoluble in water but Kayalone 3.4
dissolves readily in alcohol. This fact is made (Hydrated Aluminium Silicate)
use of when cleaning mixing slabs or
instruments. Liquid
The addition of 5% sulphathiazole or penicillin Eugenol 98 parts
(5000 units to 5 grams of pack) does not appear Thymol (crystal, readily
to enhance the bacteriostatic effects of the pack soluble in eugenol) 2 parts
against the test organisms.
The in vitro test against candida albicans, the FORMULA II
fungus concerned in thrush, suggests that the Zinc oxide Wt. per 100 gms. 36.9
pack is an effective fungicide.. Powdered Resin 46.5
Tannic Acid 7.4 This technique consists of cutting a well
Kayolone 3.3 in the centre of a poured agar plate which has
Asbestos 5.9 been previously inoculated with the test
Liquid organism and then filling the well with the
Eugenol 98 parts material being tested.
Thymol 2 Immediately after filling the well, the
plate is incubated at 37° C for 24 to 48 hours.
FORMULA III The inhibition produced is the width of the
Powdered Resin 38.5 gms. annulus obtained, measured in millimetres
Tannic Acid 5.0 (distance from edge of well to bacterial growth
Zinc Oxide 38.5 just beyond zone of no growth). Beyond the zone
Asbestos 18.0 of inhibition, the test organism should grow well
Liquid and there by provide a control for the test.
Eugenol 75 parts Only one organism at a time may be
Sweet Almond Oil 25 tested by this technique and duplica-tion requires
the use of other plates.
APPENDIX II
Agar-plate-with-gutter technique for the APPENDIX IV
determination of inhibition produced by cement Swab stick technique for the determination of the
or paste-like materials against bacteria. effects of setting and time for diffusion on the
This technique consists of cutting a bacteriostatic action of cement pack.
narrow trough or gutter through the centre of a This technique consists of making up a
poured agar plate and then filling this cut with batch of pack (5 gms.) and placing it around the
the material being tested. end of a medium sized swab stick, and then
The test organisms are then streak-ed up placing it in a culture tube containing 5 c.c. of a
to, but not across the edge of the gutter. After suitable liquid culture medium.
inoculation the plates are incubated at 37° C for The pack will harden in about one hour in
24 to 48 hours. liquid and will continue to dif-fuse the active
. The inhibition produced is the distance in ingredient for considerable lengths of time. Once
millimetres measured from the edge of the the pack has hardened on the stick it may be
trough out to the first pin point colonies growing transferred from tube to tube as required, making
along the line of inoculation. Beyond the zone of it possible to study rates of diffusion of the active
inhibition the test organism should grow well agent from the pack into the surrounding culture
and by so doing provides a control for the test. medium.
By making only narrow streaks quite After removal of swab stick with pack,
close together, one organism may be streaked the tubed and treated medium may be inoculated
several times on one plate or several organisms with test organisms and incubated.
may be streaked on the same plate, thereby
giving duplication or comparison. REFERENCES
(1) Fleming, A. 1929. Brit. J. Exp. Path. 10-226.
APPENDIX III (2) Box, Harold Keith. D.D.S. Ph.D. Necrotic Gingivitis,
University of Toronto Press. 1930.
Agar-plate-with-well technique for the (3) Zinsser, H. and Bayne-Jones, S. Text book of
determination of inhibition produced by cement Bacteriology Chapter LXXIII. 8th ed. 1989.
or paste-like materials against a single
organism3.
FOOTNOTE
This work was initiated am a result of the conception of the pathogenesis of periodontal disease
recently presented by Dr. S. K. Box, in which the importance of pocket therapy even in the early
stages of periodontal disease, is emphasized. The authors owe a debt of gratitude to Dr. Box for
valuable Information on this problem an it relates to periodontal disease.
The authors also wish to acknowledge their Indebtedness to Dr. C. H. Best and to Dr, C. C. Lucas
for helpful suggestions and advice on certain phases of the problem.

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