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Microsoft word - 3 - therapeutic properties of periodontal cement packs.docThe Therapeutic Properties of Periodontal Cement by W J. LINGHORNE, D.D.S., Department of Physiology D. C. O'CONNELL, M.S.A., Banting and Best Department of Medical Research, experiments that may be of interest to the Ipa cks have been increasingly used in the clinician are reported in this paper. treatment of periodontal disease. Aided by a grant to Dr. H. K. Box, Research Professor together to form a paste. In the presence of University of Toronto, from the Associate moisture the paste sets, forming fairly hard cement. Three formulae (see Appendix I), National Research Council, an investigation were selected as suitable for the various of the therapeutic properties of periodontal 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 Research, University of Toronto. It is hoped through this study will result in a more powders-zinc oxide, tannic acid, asbestos, intelligent and effective clinical use of 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 of this method of therapy to the various sensitivity tests.1 (See Appendix II). The tests were carried out against staphylococcus application of the packing procedure to such conditions as necrotic gingivitis, necrotic of the test of the various ingredients in the asbestos as a binder. The incubation period rather than to attempt to describe any exact clinical techniques based on the results of the investigation, with the hope that the specific information will be helpful to the reader in evaluating and developing his own materials. However, the three methods de- scribed in the in- vivo studies were found to be adequate in meeting most of the packing problems encountered in periodontal case was omitted but. asbestos was again used as results when eugenol alone was used as the then, upon further diffusion, may have been subsequently killed. Accordingly, after two days at room temperature following the initial 24' Asbestos + Zinc Oxide + Eugenol. …………. 8 hours incubation at 37° C, five plates and one control were re-inoculated with staphylococcus aureus and re-incubated. No growth occurred in any portion of any plate except the control plate. Evidently diffusion had continued through-out 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 the bacteriostatic action, the following studies sweet almond oil and the same amount with Asbestos + Zinc Oxide + Liquid . …………. 21 eugenol and thymol were placed on swab sticks, (see Appendix IV), and dropped into 5 c.c. of After one half-hour in the first tube the pack had set and was transferred from tube to Asbestos + Sweet Almond Oil gave an inhibition eugenol and thymol (98 parts eugenol and 2 - staphylococcus aureus and incubated at 37 Co for 24 and 28 hours. No growth occurred in any The next question was whether the result Asbestos + Zinc Oxide + liquid …….27 obtained was due to an agent on the surface or to actual diffusion from the core of the pack. Therefore in the next test, after the pack had been allowed to harden in the first tube for 1/2 hour, it 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 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. coccus aureus had been killed or its growth one of the half hour tubes in the dif-fusion series and incubated at 37° C for 48 hours. No growth occurred in any tube indicating that the determine how long the pack would continue to diffuse the active agent. It was carried out in duplicate according to the method described 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 procedure was continued each day. Day by day the tubes from which the pack had been removed were seeded with staphylococcus organisms and incubated for 24 hours. Up to the 35th day, no growth occurred in either the 1 hour or the 24 hour tubes. This same pack in broth was set aside in the laboratory for one year, during which time the broth had evaporated to dryness. When the 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 made against candida albicans, the micro- organism concerned in thrush. The zone of 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 technique (see Appendix III) the effect of the Studies were carried out to investigate the crococcus catarrhalis, staphylococcus aureus, effect of packing periodontal pockets in humans streptococcus viridans and streptococcus 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 drying, the smears were examined under oil, at least 30 fields being considered in thin 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 suitably shaped and lightly scraped along the For practical purposes the microscopic findings were divided into three groupings. Those smears 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 for various lengths of time and after the pocket had been packed several times. Only those series considered to have a bearing on clinical determined by means of a probe graduated in 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 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 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 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 lightly tamped until the, pocket was three longer than 48 hours it was often loosened or quarters filled. The y pocket was then overfilled 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 into place using finger pressure and instruments, a mix of Formula II, which would flow under 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 pocket thinness, viscosity of the pocket fluids 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 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 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 such a way that the soft tissue wall is retracted to the base, or that the pocket be filled to the base 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. In order to meet the various requirements in formulae, varying mainly in the physical mix, are suggested. The mix of Formula I is thick and creamy and might be described as a paint. It is sticky and adheres well to the teeth and mucous membrane. The mix of Formula II is 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 softer and less brittle than the mix of either of the (3) Diffusion of the bacteriostatic agent from the pack into the surrounding media will continue for a far longer time than is required in perio- appears to be largely due to the eugenol and thymol. The addition of thymol seems to increase (4) The periodontal pack acts as a stimulant and the bacteriostatic effect. - Sweet almond oil 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 (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 painful surfaces, the patient experiences almost immediate relief, also, there is a marked beneficial effect on the tissues observed clinically within 24 hours of the application of The pack is fairly insoluble in water but dissolves readily in alcohol. This fact is made The addition of 5% sulphathiazole or penicillin (5000 units to 5 grams of pack) does not appear to enhance the bacteriostatic effects of the pack The in vitro test against candida albicans, the fungus concerned in thrush, suggests that the This technique consists of cutting a well in the centre of a poured agar plate which has been previously inoculated with the test organism and then filling the well with the plate is incubated at 37° C for 24 to 48 hours. The inhibition produced is the width of the annulus obtained, measured in millimetres (distance from edge of well to bacterial growth just beyond zone of no growth). Beyond the zone of inhibition, the test organism should grow well and there by provide a control for the test. tested by this technique and duplica-tion requires 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 narrow trough or gutter through the centre of a poured agar plate and then filling this cut with batch of pack (5 gms.) and placing it around the 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 inoculation the plates are incubated at 37° C for The pack will harden in about one hour in 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. close together, one organism may be streaked the tubed and treated medium may be inoculated several times on one plate or several organisms may be streaked on the same plate, thereby (1) Fleming, A. 1929. Brit. J. Exp. Path. 10-226. (2) Box, Harold Keith. D.D.S. Ph.D. Necrotic Gingivitis, (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 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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