INTRODUCTION:

Wound healing in tissues is a complex process where the cellular structures and tissue layers are restored back to the original state and is broadly divided into 3 stages viz., inflammatory, proliferative and remodeling. A well co ordinated series of events takes place within these three phases resulting in restoration of normal structure of the injured tissue. Before the first periodontal pack was introduced by Dr. AW Ward in 1923^[1],[2] surgical eradication of periodontal disease was accompanied by adverse outcomes such as pain, hemorrhage, tissue sloughing, improper wound healing.

Periodontal dressings play the role of protecting the wound from mechanical trauma and stabilizing the surgical site during the healing process, enhancing post operative patient comfort, adaptation to the underlying tissue, minimal chances of post-operative hemorrhage or infection, reduced post operative tooth hypersensitivity, protecting the clot from the forces applied during speaking or chewing, protection of denuded bone after surgery.^[3],[4]Both dressings and packs can be used interchangeably. At the beginning stages in periodontal therapy a packing material was used therapeutically to help eliminate the periodontal pocket, which was at that time termed as Pack. With the advent of newer techniques for periodontal therapy and use of a postsurgical dressing to cover the exposed wound surface the term periodontal dressing advocated by American Academy of Periodontology is more appropriate.^[5] (Linghorne et al, 1949) Periodontal dressings are broadly categorized as Eugenol based dressings and non-Eugenol dressings. Over the years, the dressings have been modified in many ways with respect to their composition so that their physical, mechanical and therapeutic properties could be improved. However, despite having numerous advantages, indications for the use of periodontal dressings are limited. Numerous Controversies regarding the rationale behind the use of most commonly available periodontal dressings and their current relevance in clinical practice exists. Evidences that advocate the use of these dressings as well as those that state there are no improved outcomes when these dressings are used still exist. There exists a lacunae when it comes to the usage of ideal material for periodontal dressings, ideal time frame etc. Numerous studies have been undertaken to compare different type of dressings but none regarding the practice and preference of dressings by periodontitsts. Hence, this survey was undertaken.

This Survey assesses the Knowledge, Attitude and Practice of placing periodontal dressings following periodontal therapy among periodontists in Chennai.

MATERIAL AND METHODS:

Clearance for the study was obtained from the institutional review board.In order to ascertain the level of knowledge, practice of placing periodontal dressings among dental practitioners, particularly Periodontists a Survey was carried out in one of the southern states (Chennai) in India. This survey was a cross sectional study done by a self- prepared questionnaire consisting of 20 questions among Periodontists in Chennai city. (Figure-1) This study included postgraduate students of periodontology, periodontists who were working in government hospitals, individual and corporate clinics. Undergraduate dental students and other dental specialists were excluded from the study. The questionnaire was distributed online among the periodontists with the purpose of the study clearly explained, with the mention that their responses would remain confidential. The questionnaire was distributed online using Google forms in order to avoid bias and error in generation and compilation of results. Their responses were generated online and the resulting data was analyzed and represented graphically.

RESULTS:

Table 1: represents the distribution of study population with accordance to sex and years of experience (demographic data)

No of Years of Experience	Male (number, %)	Female (number, %)	Total (number)
<10 years	37(63.7%)	53(57.6%)	90
10–20 years	11(18.9%)	17(18.4%)	28
>20 years	10(17.2%)	22(23.9%)	32
Total	58 (38.7%)	92 (61.3%)	150

A total of 150 periodontists undertook the survey, (38.7%) were male, (61.3%) were female. 97.6% doctors said that they place periodontal dressings after surgical Intervention, 2.4% do not place periodontal dressings. (Figure-1) Among those who place Periodontal dressings 29.3% preferred to place Eugenol Based dressings, 68.3% preferred Non Eugenol dressings, 2.4% preferred Collagen dressings and none preferred using Light Cured dressings. (Figure-2) Amongst those who place Eugenol dressings, 31% preferred Ward’s Wondrpack, 24.1% preferred Kirkland pack and others 44.8% did not have any particular preference. (Figure-3) Amongst those who place Non Eugenol dressings, majority preferred COE pack (87.2%), 7.7% preferred Perio care dressing, 2.6% preferred Perio Putty, and 2.5% preferred Peri Pack dressing.

(Figure-4) Amongst those who do not place periodontal dressings, 60% felt the dressings were messy and acted as a source of plaque and food accumulation while 30 % felt they did not offer any added advantages and said they observed good healing even otherwise and the remaining 10% felt the dressings caused irritation to the tissues and caused discomfort to the patients. Amidst those who advocated placement of dressings, 52.4% believed they played an important role in enhancing wound healing while 38.1% believed they had little effect, 7.1% answered that they did not have any role in healing and the remaining 2.4% did not know if they played a role in healing at all. (Figure-5) 57.1% felt periodontal dressings reduced Post operative hemorrhage and chances of Infection, 35.7% believed they had little effect while the rest 7.1% answered that they did not know. (Figure-6) Among the subjects, 16.7% felt the dressings are a source of plaque accumulation, thereby worsening inflammation, 16.7% felt it was untrue while the remaining 61.9% answered maybe. (Figure-7) 71.4% said their patients did not complain of any post op discomfort or difficulty in eating whereas the remaining 28.6% answered that their patients faced discomfort. (Figure-8) Among the subjects, 9.5% felt periodontal dressings were effective after non surgical therapy, 66.7 % said they were ineffective, 16.7 % felt they maybe effective while the remaining 7.1% answered that they did not know. (Figure-9) 92.9% doctors answered that their patients did not report back with any allergy to Periodontal dressing, while the remaining 7.1% answered that they had few patients report back with an allergy and that the allergy was due to a Non Eugenol based dressing and they managed the allergy by removing the dressing, irrigating with saline and also prescribed Anti histamines. (Figure-10)

Among the subjects, 76.2% answered that the dressings should be held in place for one week, 16.7% answered three days while the remaining 7.1% answered ten days. (Figure-11) 23.8% answered that the dressings should be changed every 2 to 4 days for at least 2 weeks, 52.4% answered that they should not be changed, 19% answered maybe, 4.8% answered that they did not know. (Figure-12) Among those who prefer placing dressings, 57.1% answered that they were least retentive following any Excisional Biopsy procedure, 35.7% answered that they were least retentive following any Mucogingival surgery, 4.8% answered following flap surgery, the remaining 2.4% answered that they were least retentive following gingivectomy. (Figure-13) 92.9% Doctors answered that they prescribe adjuncts such as mouth rinses after placement of periodontal dressings, 7.1% answered that they do not. (Figure-14) Only 2.4% were aware of a resorbable periodontal dressing ,though none knew the name of it whereas the remaining 92.9% were not aware of a resorbable/absorbable dressing.(Figure-15) 57.1% answered that the dressings reduced post operative hypersensitivity, 14.3% answered no, 21.4% answered maybe and remaining 7.1% answered that they did not know.(Figure-16) Among the subjects, 42.9% answered that periodontal dressings underwent dimensional changes, 31% answered no,11.9% answered maybe while the remaining 14.3% answered that they did not know.(Figure-17)

Figure-1 (Those who place periodontal dressings)

Figure-2 ( Preferred type of dressing)

Figure-3 (Preferred Eugenol dressing)

Figure-4 (Preferred Non-Eugenol dressing)

Figure-5 ( Effect on Wound Healing)

Figure-6 (Reduction in Post Op Hemorrhage and Infection)

Figure-7 (Plaque Accumulation)

Figure-8 (Post Op Discomfort)

Figure-9 ( Beneficial after Non Surgical Periodontal therapy)

Figure-10 (Allergy to Periodontal Dressings)

Figure-11 ( Duration that the dressing should be held in place)

Figure-12 (Periodic Replacement of the dressings)

Figure-13 (Retention of the dressings)

Figure-14 (Prescription of adjuncts)

Figure-15 ( Knowledge on Resorbable dressings)

Figure-16 (Reduction of post operative Hypersensitivity)

Figure-17 (Occurrence of Dimensional changes)

DISCUSSION:

The main rationale underlying the application of a periodontal dressing is based on the protection and stabilization of the blood clot. ^{[6, 7-9]} The pressure over the healing site caused by the periodontal dressing could enhance soft tissue adhesion to the root or bone surface and prevent further bacterial infiltration, thus, stabilizing the wound and improving the overall healing process, in addition.^[6,9] Significant reduction in root hyper sensitivity and plaque deposition in the wound site has been also reported as a potential advantageous property. ^[10] Ariaudo and Tyrell ^[11] observed that dressings offered Protection of wound from mechanical trauma, provided enhanced stability of the surgical site during healing process. Prichard^[12]observed more Patient comfort during healing, good adaptation to underlying gingival and bony tissue, and also stated that dressings prevented postoperative hemorrhage and infection. Studies by Wikesjo et al ^[13] and Sigusch et al ^[14] were also in favour of Periodontal dressings. Conversely, Stahl et al^[15], Jones and Cassingham ^[16], Kidd and Wade^[17], Bose et al ^[18] stated that periodontal dressings did not offer any advantage, they found higher plaque accumulation and more irritation to the soft tissues and a higher post operative discomfort among their patients. Loe and Silness^[19], Harpenau ^[20], Greensmith ^[21] stated that Dressing has little effect on healing. Scaling and root planing represents the most common and widely accepted procedure for the management of periodontitis. ^[22] Recently, several studies advocate the use of dressing to enhance non-surgical periodontal treatment outcomes offering a significant reduction of Probing Depth and gain of Clinical Attachment Level^[6,14,23]Numerous reviews have addressed the potential advantages and disadvantages of dressings.^[24,25] Zinc oxide dressings containing eugenol have reported to have additional obtundant effects for pain reduction but may also induce allergies and have a higher risk of cytotoxicity^[26,27] on the other hand, cellulose- based dressings have shown better results.^[25] A 7-day regimen of application to maintain physical and mechanical properties of the dressing is usually suggested by manufacturers. Dimensional changes generally occur in all the dressings materials potentially leading to wound distortion^[28]. Othman et al^[29] assessed the effect of varying concentrations of chlorhexidine supplementation on periodontal dressings. He stated that adjunctive use of chlorhexidine was beneficial. Eugenol-free dressings were developed to indemnify the irritant and toxic properties of eugenol. Numerous studies have outlined the resultant adverse effects of eugenol based dressing^[26],[30]. Those studies reported that the post operative pain was significantly higher after the use of Peripac than Coe-Pak and Wondrpak. Also, highest post op hypersensitivity was found after the use of Coe-Pak, and the lowest with Peripac^[17].

CONCLUSION:

In this cross sectional study, most of the doctors seemed to place periodontal dressings after surgical procedures. Some stated that dressings are more advantageous whereas others did not believe so. Having discussed the various physical, biologic and therapeutic benefits conferred by periodontal dressings as well as the disadvantages, the question of whether periodontal dressing is needed for all surgical procedures remains unanswered. The well established fact that complete healing occurs even when a dressing is not placed, provided the surgical site is kept clean supports the theory that not all areas need to be “packed” or ”dressed” ^[19]. A number of clinical trials advocating the usage of dressings as well those that contemplate usage of dressings still exist. The answer to this controversial topic, though still wide open to debate, is probably safe to say that the usage of a periodontal dressing is a matter of individual preference and the judgment of the doctor

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 10.10.2018 Modified on 07.11.2018

Research J. Pharm. and Tech 2019; 12(2):799-804.

DOI: 10.5958/0974-360X.2019.00139.2