Presented by: Dr.

Pfukrolo Koza

 Dressings have no curatives properties

Assists healing by protecting tissue rather than

providing healing factors

 Pack serves the following functions: Controls postoperative bleeding To enhance patients comfort, protect against pain induced by contact of the wound with food or tongue during mastication Minimizes the livelihood of postoperative infection Provide some splinting of mobile teeth Facilitates healing by preventing surface trauma during mastication and irritation from plaque and food debris Repositions soft tissue protect sutures Protection of newly exposed root surface from temperature changes

Types of periodontal dressings

Most common types of dressing are Zinc oxide- eugenol Zinc oxide non-eugenol others ZINC OXIDE-EUGENOL PACKS: Based on the reaction of zinc oxide and eugenol Include the Wonder-Pak developed by Ward in 1923 and several modified Wards original formula Addition of accelerators, such as zinc acetate, gives a better working time

 Other substances that are added include asbestos,

used as binder and filler, and tannic acid. Mostly supplied as a liquid and a powder that are mixed before use. Some may be prepared ahead of time, wrapped in wax paper, and frozen for prolonged storage. Eugenol may induce an allergic reaction that produces reddening of area and burning pain in some patients.

ZINC OXIDE NON-EUGENOL

Coe-pak Periocare Periopac Perioputty Vocopac OTHERS

Photocuring periodontal dressing: Barricaid Collagen dressings Methyacrylic gels(tissue conditioners) Cyanoacrylate Gelatin-based dressing- Stomahesive ,excellent for use

in soft tissue augmentation procedure, material has good stability properties and dissolve in 24 to 48 hours

Coe-pak
Reaction between metallic oxide and fatty acids

is the basis for Coe-Pak. Supplied in two tubes

One tube contains: Zinc oxide an oil(for plasticity), a gum (for cohesiveness), and Lorothidol (a fungicide); Other tube contains : Liquid coconut fatty acids thickened with colophony resin (or rosin) Chlorothymol (a bacteriostatic agent)

Antibacterial Properties of Packs

Improved healing and patient comfort with less odor and taste have been obtained by incorporating antibiotics in the pack. Bacitracin, oxytetracycline (Terramycin), neomycin, and nitrofurazone have been tried, but all may produce hypersensitivity reactions. The emergence of resistant organisms and opportunistic infection has been reported.
generally recommended, particularly when long and traumatic surgeries are performed

Incorporation of tetracycline powder in Coe-Pak is

Reaction to Dressings
Contact allergy to eugenol and rosin has been reported
Allergic reactions to periodontal dressing sometimes

occur
Patients wearing dressings over a prolonged period of

time due to multiple episodes of surgery or delayed healing Sensitivity reaction is usually provoked by eugenol in the zinc oxide-eugenol type of dressings. Very rarely with non-eugenol containing dressings

 First symptom of a sensitivity reaction to dressing is

burning sensation on the buccal mucosa and on the surface of the tongue where with the dressing is in contact.
If dressing is not removed, reaction progresses from

erythema to vesicle formation and edema

If patient not treated, generalized allergic reaction

may develop, including dermatitis.

Retentions of packs
In case of edentulous areas: with the help of splints, Hawleys appliance and stents In case of dentulous areas: mechanically by interlocking in interdental spaces and joining the lingual and facial portions of the pack In case isolated teethTie dental floss or gauze loosely around the teeth and over which pack is applied

Preparation and Application of Dressing

A, Equal lengths of the two pastes are placed on a paper pad. B, Pastes are mixed with a wooden tongue depressor for 2 or 3 minutes until the paste loses its tackiness (C). D, Paste is placed in a paper cup of water at room temperature. With lubricated fingers, it is then rolled into cylinders and placed on the surgical wound.

Preparation and Application of Dressing

Zinc oxide packs are mixed with eugenol or noneugenol

liquids on a wax paper pad with a wooden tongue depressor. The powder is gradually incorporated with the liquid until a thick paste is formed.

Coe-Pak is prepared by mixing equal lengths of paste from

tubes containing the accelerator and the base until the resulting paste is a uniform colour . A capsule of tetracycline powder can be added at this time. The pack is then placed in a cup of water at room temperature . In 2 to 3 minutes the paste loses its tackiness and can be handled and moulded; it remains workable for 15 to 20 minutes.

 Working time can be shortened by adding a small amount

of zinc oxide to the accelerator (pink paste) before spatulating. The pack is then rolled into two strips approximately the length of the treated area. The end of one strip is bent into a hook shape and fitted around the distal surface of the last tooth, approaching it from the distal surface . The remainder of the strip is brought forward along the facial surface to the midline and gently pressed into place along the gingival margin and interproximally.

 The second strip is applied from the lingual surface. It

is joined to the pack at the distal surface of the last tooth, then brought forward along the gingival margin to the midline The strips are joined interproximally by applying gentle pressure on the facial and lingual surfaces of the pack For isolated teeth separated by edentulous spaces, the pack should be made continuous from tooth to tooth, covering the edentulous areas

Inserting the periodontal pack. A, Strip of pack is hooked around the last molar and pressed into place anteriorly. B, Lingual pack is joined to the facial strip at the distal surface of the last molar and fitted into place anteriorly. C, Gentle pressure on the facial and lingual surfaces joins the pack interproximally.

 Continuous pack covers the edentulous space.

 When split flaps have been performed, the area should be

covered with tin foil to protect the sutures before placing the pack The pack should cover the gingiva, but overextension onto uninvolved mucosa should be avoided. Excess pack irritates the mucobuccal fold and floor of the mouth and interferes with the tongue. Overextension also jeopardizes the remainder of the pack because the excess tends to break off, taking pack from the operated area with it. Pack that interferes with the occlusion should be trimmed away before the patient is dismissed .Failure to do this causes discomfort and jeopardizes retention of the pack.

 Periodontal pack should not interfere with the

occlusion.

 The operator should ask the patient to move the

tongue forcibly out and to each side, and the cheek and lips should be displaced in all directions to mold the pack while it is still soft. After the pack has set, it should be trimmed to eliminate all excess. the patient may develop pain from an overextended margin that irritates the vestibule, floor of the mouth, or tongue. The excess pack should be trimmed away, making sure that the new margin is not rough, before the patient is dismissed.

 If a portion of the pack is lost from the operated area

and the patient is uncomfortable, it is usually best to repack the area. The clinician should remove the remaining pack, wash the area with warm water, and apply a topical anesthetic before replacing the pack, which is then retained for 1 week. As a general rule, the pack is kept on for 1 week after surgery. This guideline is based on the usual timetable of healing and clinical experience. It is not a rigid requirement; the period may be extended, or the area may be repacked for an additional week

POSTOPERATIVE INSTRUCTIONS
After the pack is placed, printed instructions are given to

the patient to be read before he or she leaves the chair

The pack will harden in a few hours, after which it can

withstand most of the forces of chewing without breaking off. For the first 3 hours after the operation, avoid hot foods to permit the pack to harden try to chew on the nonoperated side of your mouth avoid hot liquids during the first 24 hours Do not smoke.

 Do not brush over the pack

Do not rinse on the day of pack application,

chlorhexidine oral rinses after brushing. The pack should remain in place until it is removed at the next appointment After the pack is removed, the gums most likely will bleed more than they did before the operation. This is perfectly normal in the early stage of healing and will gradually subside. Do not stop cleaning because of it.

Findings at Pack Removal

Gingivectomy : the cut surface is covered with a friable

meshwork of new epithelium, which should not be disturbed. If calculus has not been completely removed, red, beadlike protuberances of granulation tissue will persist. The granulation tissue must be removed with a curette, exposing the calculus so that it can be removed and the root can be planed. Removal of the granulation tissue without removal of calculus is followed by recurrence. After a flap operation, the areas corresponding to the incisions are epithelialized but may bleed readily when touched; they should not be disturbed. Pockets should not be probed.

 The facial and lingual mucosa may be covered with a

grayish yellow or white granular layer of food debris that has seeped under the pack. This is easily removed with a moist cotton pellet. The root surfaces may be sensitive to a probe or to thermal changes, and the teeth may be stained.
Fragments of calculus delay healing. Each root surface

should be rechecked visually to be certain that no calculus is present. Sometimes the color of the calculus is similar to that of the root. The grooves on proximal root surfaces and the furcations are areas where calculus is likely to be overlooked.

Removal of Pack and Return Visit

When the patient returns after 1 week, the periodontal

pack is taken off by inserting a surgical hoe along the margin and exerting gentle lateral pressure. Pieces of pack retained interproximally and particles adhering to the tooth surfaces are removed with scalers. Particles enmeshed in the cut surface and should be carefully picked off with fine cotton pliers. The entire area is rinsed with peroxide to remove superficial debris.

Repacking
After the pack is removed, it is usually not necessary to

replace it. However, repacking for an additional week is advised for patients with
(1) a low pain threshold who are particularly

uncomfortable when the pack is removed, (2) unusually extensive periodontal involvement, or (3) slow healing. Clinical judgment helps in deciding whether to repack the area or leave the initial pack on longer than 1 week.