A Systematic Review on the Effect of Use of Impregnated Retraction Cords on Gingiva

 

Abinaya Kannan^1*, Dr. Suresh Venugopalan²

¹Post Graduate Student, Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai.

²Reader, Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai.

 

ABSTRACT:

Introduction: For teeth requiring crowns or replacement in the form of fixed dental prosthesis, gingival retraction becomes a mandatory procedure which aids in recording the prepared and unprepared surfaces of the abutment tooth. Various methods of retraction known in the past include mechanical (copper band, retraction cord packing, rubber dam placement), chemical and chemo mechanical (retraction cords soaked in racemic epinephrine, dl – aluminium sulfate, aluminium chloride, adrenaline hydrochloride and cordless paste – expasyl and expanding polyvinyl siloxane material) , rotary (gingettage, electro rotary) and laser. Though many new techniques have come up, by far, chemo-mechanical retraction of gingiva is widely preferred. Impregnated gingival retraction cords are known to efficiently perform retraction of the gingiva along with hemostasis. Objective: This systematic review is performed to assess the effects of gingival retraction done by cords impregnated with various chemicals on gingival health. Methods: Search Strategy: The data bases of Pubmed Central and Medline were searched for the related topics. Bibliographies of randomized control trials and reviews, identified in the electronic search, were analyzed for studies published outside the electronically searched journals. Results: The systematic search yielded 4 articles and one article was rejected on the basis of irrelevance of title and abstract. One article was excluded after examination of the core data, 2 articles were handpicked and a total of 4 articles were obtained based on the inclusion criteria. Conclusion: From all the articles considered in this review, we may conclude saying that knitted cords impregnated with aluminium chloride and potassium aluminium sulphate are more preferable than the rest.

 

 

 

INTRODUCTION:

A successful replacement with fixed partial denture accounts to many factors. Marginal fit being one of the vital factors dictating the prognosis of the prosthesis, it is essential to record the prepared and unprepared surfaces of the abutment with absolute precision¹. This is facilitated by gingival retraction prior to impression making after tooth preparation.

 

After various trials and testing, the method commonly employed for gingival retraction is gingival retraction cord packing with impregnated retraction cords.

 

Retraction cords may be impregnated with medicaments such as epinephrine, adrenaline hydrochloride, aluminium chloride and aluminium sulfate^1-19.

 

Cord packing has been reported to injure the supporting tissues and impinge into the biological width. Impregnation with adrenaline and other such chemicals has been known to bring about various deleterious systemic effects^20-25. However, the effect that impregnated gingival retraction cords have on the gingival health is an area which still needs to be explored.

 

Aim:

The aim of the current review is to systematically analyze the scientific evidence of the present and the past for articles and studies showing a comparative evaluation on effects that chemicals used for impregnation of gingival retraction cords elicit on the gingival health

 

Structured Questions:

·        Does retraction with various types of impregnated gingival retraction cords show the same effect on the gingival health?

·        Is one type of impregnated retraction cord better as compared to the rest on the grounds of gingival health?

 

Null Hypothesis:

·        There is no difference in the effects elicited on the gingiva by various modes of chemo-mechanical retraction

 

Alternate Hypothesis:

·        There is a difference in the effects elicited on the gingiva by various modes of chemo-mechanical retraction

 

PICO Analysis:

·        Population – FPD Preparations

·        Intervention –Gingival Retraction

·        Comparison – Retraction Cords Impregnated In Various Chemicals.

·        Outcome – Gingival Index, Gingival Recession, Histopathologic Evidence Of Gingival Trauma.

 

MATERIALS AND METHODS:

Review of literature on studies evaluating the effect of impregnated retraction cords on gingival health that have been published was carried out without a filter on publication dates and all articles of the past were retrieved. 

 

Sources Used:

For identification of studies included or considered for this review, detailed search strategies were developed for the database searched. The MEDLINE search used the combination of controlled vocabulary and free text terms. The key words employed in this search were broadly classified into five categories describing population, intervention, comparison, outcome and the type of study.

 

Key words within each group were combined using Boolean operator OR and the searches of individual groups were combined using Boolean operator AND to retrieve articles electronically.

 

Language:

Articles in languages other than English were not included

Searched Databases:

·        PubMed

·        PubMed Advanced Search

·        MEDLINE

·        Google Scholar

 

Hand Searching:

In order to complete the search, the following journals were hand searched for articles on the subject of interest:

·        The Journal of Prosthetic Dentistry

·        Research Journal of Biological Sciences

 

Search Algorithm:

The search algorithm applied in PUBMED was as follows:

 ((((((((((((((((((((((((crown) OR crowns) OR FPD) OR FPDs) OR crown preparation) OR crown preparations) OR tooth preparation) OR tooth preparations) OR FPD preparation) OR FPD preparations) OR fixed partial denture) OR fixed partial dentures) OR fixed partial denture preparation) OR fixed partial denture preparations) OR fixed prosthesis preparation) OR fixed prosthesis preparations) OR tooth supported fpd preparation) OR tooth supported fpd preparations) OR tooth supported fixed partial denture preparation) OR tooth supported fixed partial denture preparations)) AND (((((((((((((((((((retraction) OR gingival retraction) OR cord packing) OR retraction cord) OR retraction cord packing) OR gingival retraction cord packing) OR mechanical retraction) OR mechanical retraction of the gingiva) OR plain gingival retraction cord packing) OR non impregnated gingival retraction cord packing) OR retractions) OR gingival retractions) OR mechanical gingival retraction) OR mechanical gingival retractions) OR plain gingival retraction cord) OR plain gingival retraction cords) OR non impregnated gingival retraction cord) OR non impregnated gingival retraction cords) OR tissue displacement)) AND (((((((((((((((((((((((((((((chemo mechanical retraction) OR chemo mechanical retractions) OR chemomechanical retractions) OR chemomechanical retraction) OR chemo mechanical retraction of gingiva) OR chemomechanical retraction of gingiva) OR impregnated gingival retraction cord) OR impregnated gingival retraction cords) OR gingival retraction cord impregnated in aluminium chloride) OR gingival retraction cords impregnated in aluminium chloride) OR gingival retraction cord impregnated in epinephrine) OR gingival retraction cords impregnated in epinephrine) OR gingival retraction cord impregnated in aluminium sulphate) OR gingival retraction cords impregnated in aluminium sulphate) OR gingival retraction cord impregnated in adrenaline hydrochloride) OR gingival retraction cords impregnated in adrenaline hydrochloride) OR chemical retraction) OR chemical retractions) OR chemical retraction of gingiva) OR epinephrine cord) OR epinephrine cords) OR aluminium sulfate cord) OR aluminium sulfate cords) OR mechanical chemical tissue displacement) OR mechanical chemical tissue displacement methods) OR mechanical chemical tissue displacement method) OR alum) OR hemodent) OR gingipak)) AND (((((((((((gingival index) OR hemostasis) OR gingival recession) OR periodontal index) OR bleeding on probing) OR gingival bleeding index) OR mobility) OR biological width) OR probing depth) OR crevicular fluid flow) OR gingival crevicular fluid flow)) AND ((((((((animal study) OR clinical study) OR randomized clinical trial) OR randomized controlled trial) OR randomized controlled trials) OR case control study) OR randomized control trial) OR randomized control trials)

 

Inclusion Criteria:

Criteria for Considering Studies for This Review:

Types of Studies:

1.      Clinical studies, case control studies and randomized control trials

2.      Gingival retraction via packing of different impregnated gingival retraction cords analyzed for effects on gingival health in terms of gingival inflammation, gingival trauma, gingival recession, probing depth and evaluation of histopathologic sections

 

Types of Population:

·        FPD preparations

·        Crown Preparations

 

Types of Outcome Measures:

·        Hemostasis

·        Histopathologic evaluation

·         Gingival Recession

·        Gingival Index

 

Exclusion Criteria:

The following studies were excluded

·        Case reports/ case series

·        In vitro studies

·        Review articles

 

RESULTS:

Out of the 4 articles obtained from electronic search, 1 was excluded on examination of title and abstract and 1 was excluded on the basis of core data. Two articles were handpicked and a total of 4 articles were reviewed as depicted in the flow chart below.

 

Chart 1 depicts the search methodology describing the number of articles obtained after search, the ones that were excluded and the total number of articles that were retrieved for analysis

Table 1 gives the variables of interest

Table 2 gives details about the studies that were excluded and reason for exclusion

Table 3 gives the general information of the studies included in the review

Table 4 gives outcomes of various studies consolidated together

Table 5 tabulates the CEBM level of evidence of each article included in this review

Table 6 gives the Risk of Bias – Major Criteria

Table 7 gives the Risk of Bias – Minor Criteria

 

 

CHART 1: SEARCH FLOW CHART

 

TABLE 1: VARIABLES OF INTEREST

 

TABLE 2: STUDIES EXCLUDED AND REASONS FOR EXCLUSION

S.NO.	STUDY	STUDY DESIGN	REASON
1	Jokstad et al (1999)5	RCT	Unclear grading of outcome
2	Kumbuloglu et al (2007)6	RCT	Gingival parameters were not elicited. Only, quality of impression was assessed

 

RISK OF BIAS IN INCLUDED STUDIES:

The assessments for the four main methodological quality items are shown in table. The study was assessed to have a “High risk” of bias if it did not record a “Yes” in three or more of the four main categories, “Moderate” if two out of four categories did not record a “Yes” and “Low” if randomization assessor blinding and completeness of follow – up were considered adequate.

 

 

 

 

TABLE 3: GENERAL INFORMATION OF STUDIES INCLUDED IN THE REVIEW

S.NO.	STUDY	INTERVENTION	DESIGN	SAMPLE SIZE	OUTCOME ASSESSMENT
1	Stuffken et al  (2016)1	Aluminium chloride cord (Ultra pakandHemodent)	RCT	N=12	Gingival recession
		810nm diode laser (Odyssey, Ivoclar)
2	Weir et al (1984)2	Non-medicated Cord (dry, water saturated, hemodent saturated) (Retrax No. 10)	RCT	N=120	Hemostasis
		R-Epinephrine Cord (dry, water saturated, hemodent saturated) (Racord No.10)
		Aluminium Sulfate Cord (dry, water saturated, hemodent saturated) (Pascord No.10)
3	Kazemi et al (2009)3	Knitted aluminium chloride cord (Ultrapakand Stat)	RCT	N=20	-Gingival recession -Gingival retraction -Gingival width
		Expasyl Paste
4	de Gennaro et al (1982)4	Untreated Cord	RCT	N=36	-Gingival inflammation
		Potassium Aluminium Sulfate Cord (Alum Cord)
		Aluminium Chloride Cord (Hemodent)
		8% Racemic Epinephrine Cord (Gingipak)

 

TABLE 4: OUTCOMES OF VARIOUS STUDIES

S. NO	STUDY	INTERVENTION	INFLAMMATORY GRADING		GINGIVAL RECESSION			HEMOSTASIS (NO. OF CASES THAT SHOWED NO BLEEDING / OTAL NO. OF CASES)
1	Stuffken et al (2016)1	Aluminium chloride cord	-		0.26  (0.00 to 0.72)			-
		810nm diode laser			0.27 (0.01 to 0.68)
2	Weir et al (1984)2	Dry non medicated cord	-		-			0/10
		Water saturated non medicated cord						0/10
		Hemodent saturated non medicated cord						10/20
		Dry R-Epinephrine cord						1/10
		Water saturated R- Epinephrine cord						0/10
		Hemodent saturated R – Epinephrine cord						18/20
		Dry Aluminium Sulphate Cord						1/10
		Water Saturated Aluminium Sulphate Cord						0/10
		Hemodent saturated Aluminium Sulfate cord						16/20
3	Kazemi et al (2009)3	Knitted aluminium chloride cord	-		7 DAYS	14 DAYS	28 DAYS	-
					0.15±0.06	0.27±0.06	0.14±0.07
		Expasyl Paste			0.07±0.06	0.11±0.06	0.03±0.04
4	de Gennaro et al (1982)4	Untreated Cord	24 HRS	7 DAYS	-			-
			1.89±0.93	1.33±1
		Potassium Aluminium Sulfate Cord	0.89±0.93	1.22±0.97
		Aluminium Chloride Cord	1.56±0.53	1.56±1.24
		8% Racemic Epinephrine Cord	1.44±0.88	2±0.71

 

 

 

 

TABLE 5: CEBM LEVEL OF EVIDENCE OF INCLUDED STUDIES

S.NO	STUDY	STUDY DESIGN	CEBM LEVEL OF EVIDENCE
1	Stuffken et al (2016)1	RCT	Level  1
2	Weir et al (1984)2	RCT	Level  1
3	Kazemi et al (2009)3	RCT	Level  1
4	de Gennaro et al (1982)4	RCT	Level  1

 

 

 

TABLE 6: RISK OF BIAS - MAJOR CRITERIA

Author and year	Randomization	Allocation Concealed	Assessor Blinding	Dropouts Described	Risk of  Bias
Stuffken et al (2016)1	Yes	No	No	No	High
Weir et al (1984)2	Yes	Yes	Yes	No	Low
Kazemi et al (2009)3	Yes	No	No	No	High
de Gennaro et al (1982)4	Yes	No	Yes	No	Moderate

 

TABLE 7: RISK OF BIAS - MINOR CRITERIA

Author and Year	Sample Justified	Baseline Comparison	I/E Criteria	Method Error
Stuffken et al (2016)1	No	No	Yes	No
Weir et al (1984)2	No	No	Yes	No
Kazemi et al (2009)3	No	Yes	Yes	No
de Gennaro et al (1982)4	No	No	No	Yes

 

DISCUSSION:

In a study by Stuffken et al²⁶, on evaluation of gingival recession as an effect of gingival retraction (double cord technique with cords impregnated with 5% aluminium chloride cords vs. 810nm diode laser), an average loss of gingival height of 0.26 mm for the double cord technique and 0.27mm for the laser was obtained. Various factors can affect the amount of recession, including the tissue thickness (biotype), marginal accuracy of the interim crown and amount of keratinized tissue. A thick biotype consists of more connective tissue than a thin biotype and therefore is resistant to loss of gingival height. Though the average loss of gingival height due to retraction may not seem to hold much of clinical significance; with local, systemic and other contributing factors adding up might lead to a questionable prognosis of the restoration. The author stated that further clinical investigations using larger samples and histological evaluations are necessary to compare these methods of gingival displacement and to achieve more conclusive results. Eight weeks after the cementation of definitive crowns, comparable recession was found with mechanical – chemical gingival displacement and a diode laser.

 

Weir et al²⁷ in his study evaluated the rate of hemostasis achieved with different cords used in three different ways. He used cords containing 0.60mg racemic epinephrine/inch, cords impregnated with 2.60mg aluminium sulfate/ inch and non medicated cords either in a dry form, saturated with water or saturated with hemodent. He concluded that there was no significant difference between racemic epinephrine cord and aluminium sulfate cord; both the cords were found to be more effective than non medicated ones. He stated that there was no difference between dry cord and water saturated cord and that hemorrhage control with a cord saturated in Hemodent was more effective than water saturated or dry cords. Since racemic epinephrine cord was not superior to other chemico-mechanical retraction and with its potential systemic effects it is suggested that it might be replaced with a more suitable material. Hemodent approximately doubled the hemostasis success of any cord used in this study.

In his study on assessing the gingival width, gingival inflammation and gingival recession on retraction by a cord presaturated with 15% aluminium chloride solution vs. retraction using Expasyl at 0, 7, 14 and 28 days, Kazemi et al²⁸ found that the retracted sulcus in the cord group was found to have a greater width than the expasyl group. Also the mean gingival recession was found to be significantly higher in the cord group (0.14±0.07) than in the paste group (0.03±0.04mm).  At 7 and 14 days after retraction, significant increase of gingival index was seen in cord group than in paste group. However, the gingival index was found to return to base line at day 28 indicating healing post retraction. Though the sulcular width of presaturated retraction cord was greater than Expasyl paste, the amount of retraction in both groups was effective enough. In terms of gingival recession and inflammation Expasyl paste was found to hold superior properties.

 

de Gennaro et al²⁹ in his study with untreated cords, potassium aluminium sulfate cords, aluminium chloride cords and racemic epinephrine cords packed in orthodontic patients requiring bilateral premolar extractions assessed cord packing-induced gingival inflammation via histological observation of inflammatory cells after 24 hours and after 7 days after packing. It was observed that potassium aluminium sulfate, aluminium chloride and racemic epinephrine did not demonstrate practical differences, although potassium aluminium sulfate produced fewer inflammatory changes as compared to other agents. He also stated that factors other than the chemical agents may also play a role in the amount of gingival inflammation induced and hence additional studies with a larger size and an untreated control site should be undertaken to give reliable results.

 

In his study among students and faculty, Jokstad et al³⁰ observed that clinicians were unable to detect any differences between knitted cords impregnated with aluminium sulfate and dl-epinephrine cords. With a qualitative research design, the grading used in the evaluation criteria seems to be vague and does not substantiate the superiority of one material over the other. Hence, this study was excluded from data extraction, however the results of this study are still taken into account. This study revealed that the consistency of gingival retraction cord, twined or knitted, seems to be more important than the medicament when related to preference. He reported that knitted cords were superior to twined cords in terms of hemostasis, sulcus dilation, bleeding on removal and dryness of sulci. He also said that cords containing epinephrine were comparable to aluminium sulfate cords, according to the evaluation criteria used in his study and that choice of medicament should be wisely made in such conditions where the potential risks outweigh with an apparent lack of significant improved clinical performance.

 

CONCLUSION:

From this systematic review of literature we may conclude that knitted cords impregnated with Aluminium Chloride show superior results in terms of hemostasis and gingival inflammation. Potassium Aluminium Sulphate was also known to produce minimal gingival inflammatory changes.  Though their results are comparable to that of 8% racemic epinephrine, it is preferable to use the former ones owing to the potential risk of adverse effects associated with epinephrine.

 

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Accepted on 14.03.2018          © RJPT All right reserved

Research J. Pharm. and Tech 2018; 11(5):2121-2126.