|Year : 2020 | Volume
| Issue : 1 | Page : 54-59
Comparison of effect of curcumin gel and noneugenol periodontal dressing in tissue response, early wound healing, and pain assessment following periodontal flap surgery in chronic periodontitis patients
M Venkata Sai Meghana, Jeevanand Deshmukh, MV Devarathanamma, K Asif, L Jyothi, H Sindhura
Department of Periodontology, Navodaya Dental College and Hospital, Raichur, Karnataka, India
|Date of Submission||20-Feb-2019|
|Date of Decision||29-Jul-2019|
|Date of Acceptance||16-Aug-2019|
|Date of Web Publication||02-Jan-2020|
Dr Jeevanand Deshmukh
Department of Periodontology, Navodaya Dental College and Hospital, Raichur - 584 103, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The study was designed taking into consideration the drawbacks of periodontal dressing and healing properties of curcumin. The aim was to assess and compare the effect of Curcumin gel (Curenext) and noneugenol periodontal dressing (Coe pak) on tissue response, wound healing in the early stages, and pain post periodontal flap surgery in patients diagnosed with chronic periodontitis. Materials and Methods: Twenty patients requiring periodontal flap surgery were allotted to two groups at random, one receiving periodontal dressing and the other receiving curcumin for this cross over split-mouth study. Flap surgeries were performed on 2 quadrants with 3 weeks' interval. After suture removal, postoperative sites were assessed for tissue response (tissue color [TC] and tissue edema [TE]) and early wound healing as primary outcomes of the study. The secondary outcome was pain assessment and the number of analgesics taken by the individuals. Results: The two groups showed no significant differences with respect to tissue response, early wound healing, and pain perception. Curcumin group consumed lesser number of analgesics as compared to the one with periodontal dressing. Conclusion: It was confirmed that periodontal dressing and curcumin are effective in reducing the TE, normalizing the TC, enhancing the wound healing and reducing the pain perception. Curcumin can thus be used as an alternative to periodontal dressing.
Keywords: Curcumin, edema, flap surgery, pain assessment, wound healing
|How to cite this article:|
Meghana M V, Deshmukh J, Devarathanamma M V, Asif K, Jyothi L, Sindhura H. Comparison of effect of curcumin gel and noneugenol periodontal dressing in tissue response, early wound healing, and pain assessment following periodontal flap surgery in chronic periodontitis patients. J Indian Soc Periodontol 2020;24:54-9
|How to cite this URL:|
Meghana M V, Deshmukh J, Devarathanamma M V, Asif K, Jyothi L, Sindhura H. Comparison of effect of curcumin gel and noneugenol periodontal dressing in tissue response, early wound healing, and pain assessment following periodontal flap surgery in chronic periodontitis patients. J Indian Soc Periodontol [serial online] 2020 [cited 2020 Sep 26];24:54-9. Available from: http://www.jisponline.com/text.asp?2020/24/1/54/274556
| Introduction|| |
It is of utmost importance that following any periodontal surgery, the wound should be protected from mechanical trauma, and the surgical site should be stable to encourage the healing process as well as the comfort of the patient. This is enabled by the use of periodontal dressing.
Recently, the use of periodontal dressing following periodontal surgical procedures has become questionable. Its usage possesses few drawbacks such as patients' experiencing postoperative pain and discomfort.
This has led interest to consider curcumin as an alternative to periodontal dressing. Used commonly as a topical application and possessing wound healing properties, curcumin also serves as an anti-inflammatory, antimicrobial, antiviral, antifungal, antioxidant as well as a chemosensitizing agent. The usage of Curcumin as topical application, subgingival irrigation, and mouthrinses following scaling and root planing significantly improves gingival and periodontal parameters.,,
Considering the disadvantages of periodontal dressing and considerable healing potentials of curcumin, we hypothesized that the effect of curcumin gel may be better in terms of tissue response, pain, and wound healing in the early stages and can be an alternative to periodontal dressing in patients diagnosed with chronic periodontitis.
| Materials and Methods|| |
A sample of twenty individuals (forty quadrants), 20–60 years of age, having chronic generalized moderate periodontitis (AAP 1999) were selected from those reporting to outpatient department to take part in this crossover split-mouth randomized study.
The sample size was analyzed using the following formula:
Where d– Difference of mean, σ – Pooled standard deviation (SD), – 95% confidence interval, Zβ – 80% power interval, and n – minimum sample size.
Patients were explained about the nature, need, and outcome of the study, followed by which a verbal and written consent was obtained. Ethical clearance was obtained from the ethical committee.
Each patient complete medical and dental history along with the periodontal clinical parameters using University of North Carolina probe (UNC-15) probe Clinical attachment level and periodontal probing pocket depth from six sites on each tooth were recorded following laboratory investigations red blood cell count, white blood cell count, Bleeding Time (BT), Clotting Time (CT) and Hemoglobin % (HB%) were recorded. Orthopantamograph was taken to assess extent of bone loss. Patients with any systemic conditions, pregnancy and lactating women, smokers, and alcoholics were excluded from the study.
A total of twenty patients requiring periodontal flap surgery [Table 1] in at least minimum of two quadrants were randomly allotted to either periodontal dressing group or curcumin group by “toss-of-the-coin” method, and a split-mouth study design was followed [Figure 1].
|Figure 1: Consort flowchart of the study. n – Sample size; CAL – Clinical attachment level; PPD – Periodontal pocket depth; EWH – Early wound healing; MVAS – Modified visual analog scale|
Click here to view
Standard clinical and surgical procedures were maintained throughout for better comparison. The same clinician performed all forty surgeries. The anesthetic techniques and volume of anesthetic used were standardized. To obtain surgical anesthesia, 2% lignocaine in the required amount was used along with 1:200,000 adrenaline. Periodontal flap surgery was done in both maxilla and mandible. The split-mouth study design allowed each study individual to act as their own control.
Modified Widman flap surgery was performed. Approximation of the mucoperiosteal flaps was done with interrupted direct loop sutures using 4–0 black silk suture. Bias elimination was done by randomly allocating individuals to the respective interventions. For periodontal dressing group, COE pack (COE-PAK™ AUTOMIX-Surgical Dressing and Periodontal Pack) was mixed and applied, using sufficient amount of vaseline on gloves according to manufacturer instructions. The required contouring was done after pushing the material into the embrasure spaces. For curcumin group, patients were asked to apply curenext oral gel (Curenext Oral Gel) gently on the operated site from the next 24 h of surgery twice daily for 1 week. Postoperative instructions were given.
The patients were prescribed with ibuprofen 600 mg preoperatively followed by 1 tablet every 8 h for first 24 h and SOS ('Si Opus Sit') thereafter for a period of 1 week as pain medication. Self-reported postoperative pain was measured on a daily basis using a customized chart provided to the individuals, which contained the modified visual analog scale, and an entry for the number of tablets consumed. These outcomes were considered secondary. The primary outcomes were tissue edema (TE) and color (TC), recorded under the heading of tissue response and early wound healing recorded using early wound healing index (EHI).
The patients were recalled 1-week postoperatively for suture removal. On the same day, the primary outcomes were assessed clinically, and secondary outcomes were assessed by using patient's subjective response. Tissue response was assessed according to Sanz-Moliner et al. The TE and color of the gingiva was recorded on a scale of 1–3. The early wound healing scale by Wachtel et al. [EHI] was used to measure and record wound healing on a scale representing 5 different degrees.
The standard 10 cm line was used to integrate the patient's subjective assessment in the Modified visual analog scale., The mean number of analgesics taken for the next 7 days of surgery was calculated.
The time period between first and second surgeries was at least 3 weeks.
Statistical analysis and methods
Data were collected using a structured pro forma. Data entered in MS excel sheet and the statistical analysis were done using EPI info version 7.0 (Karnataka, India). Qualitative data were expressed in percentage and frequency. Quantitative data were expressed in terms of mean and SD. Comparison of mean and SD between two groups was done using independent sample t-test. Descriptive and inferential statistical analyses were carried out in the present study. P < 0.05 was considered as statistically significant whereas P < 0.001 was considered as highly significant.
| Results|| |
The present study included total of twenty patients (female = 13 and male = 7) with age group ranges of 20–60 years (38.3 ± 9.82) [Table 2] having chronic generalized moderate periodontitis [Table 1].
No statistical significant (P > 0.001) difference in tissue response Tissue colour and tissue edema though curcumin group showed better results [Table 3].
|Table 3: Measurements (mean values and standard deviation) of tissue edema, tissue color, wound healing, modified visual analog scale, and number of analgesics taken|
Click here to view
Curcumin group showed better wound healing, with no statistical significance (P = 0.985) [Table 3].
Statistically, no significant reduction of pain reported in periodontal dressing group compared to curcumin group. With respect to intake of analgesics, a highly significant difference was noted (P < 0.001) with the curcumin group requiring less consumption of analgesics than the periodontal dressing group [Table 3].
| Discussion|| |
The modified Widman flap procedure was used in the present study. The advantage of using this method is that along with the pocket epithelium removal, it enables direct approximation of the connective tissue with the surface of the tooth. When compared to closed curettage, this procedure offers less mechanical trauma paired with other perks such as minimal removal of bone, maximal periodontal tissue conservation, and better maintenance of oral hygiene, reduced root exposure, and sensitivity.
The time period between first and second surgeries was at least 3 weeks. This time interval between two surgeries is necessary to achieve the maximum tensile strength of tooth-gingival flap interface following periodontal surgery.
Periodontal dressings accelerate the healing process and also mechanically protect the site of surgery. Periodontal dressing prevents the flap detachment from root surface and protects the coagulum during chewing and talking.
When the flap was left open without a dressing, drawbacks such as plaque accumulation on the sutures, chances of infection, discomfort for patient while eating, and mild postprocedural oozing of blood were observed.
Curcumin (CU) exhibits properties such as anti-inflammatory, antiseptic, antioxidant, antimicrobial, immunostimulant, anticarcinogenic, antiviral, antifungal, and accelerated wound healing.
In present study, tissue response at the surgical site was assessed by the tissue response model suggested by Sanz-Moliner et al., and it was evaluated based on mean scores of TE and TC of each tooth.
In our study, TE and TC in curcumin group showed better results than periodontal dressing group; but, the results were was statistically not significant (>0.05).
Jones and Cassingham  conducted a study to compare healing with and without periodontal dressing postperiodontal surgery. It was concluded that for the sites with dressings, the inflammatory indices were slightly higher, although no statistically significant difference was noted. However, in their study, Soheilifar et al. found that the response of gingival tissues to treatment with periodontal dressing was normal and comparable to the findings of our study.
Allen and Caffesse  measured the clinical parameters of gingival inflammation before and after periodontal surgery. The mean difference in gingival inflammation between dressed and undressed sites at 1-week interval suggested very mild inflammation with no color change. The findings of this study are almost in similarity with our study.
Curcumin was compared with 0.2% chlorhexidine for subgingival irrigation by Suhag et al. Sites irrigated by curcumin resulted in the improvement of the clinical parameters which was statistically significant.
Curcumin exhibits its anti-inflammatory effect by increasing cortisone production by adrenal glands and by decreasing histamine levels and also by inhibiting the synthesis of prostaglandins and neutrophil function. It also inhibits the pro-inflammatory cytokines' production and represses the activation of activator protein 1 and nuclear factor kappa β.,
In the current study, curcumin was equally effective compared with periodontal dressing in reducing the TE and normalizing the TC.
In the present study, early wound healing index was used to assess the wound healing of after periodontal flap surgery. Curcumin group showed better wound healing when compared with periodontal dressing with no statistical significance (>0.05).
The healing of any surgical site is determined by the oral hygiene of the patient and the presence of periodontopathic bacteria. However, studies done in the past have not assessed early phase of healing response.
Hence, in this study, events associated with early wound healing have been clinically assessed. The degrees of exposure are differentiated by EHI along with the amount of fibrin formation at the time of compete closure.
The earlier studies ,,, assessed the wound healing by evaluating, facial swelling, swelling of soft tissue, color of gingiva and gingival fluid flow, but not clinically differentiated wound healing as done in this study which is critical in early tissue response in wound healing.
In a 7-day trial by Greensmith and Wade, it was noted that the healing of the dressed surgical site was rapid as compared to the uncovered site. In spite of the initial inflammation, dressing leads to improved healing than the sites without periodontal dressing.
Curcumin possess wound healing and anti-inflammatory property, thereby reducing edema and vascular engorgement of connective tissue. Curcumin increases collagen deposition, angiogenesis, and the density of fibroblasts.,,
According to the study done by Muhammad and Ghani, wounds were created surgically in rabbits to test the topical application of curcumin. Sites treated with curcumin showed significantly better response in wound healing compared to control sites.
Curcumin has also been tested in vivo in rats and guinea pigs by Sidhu et al. When treated with curcumin, punch wounds closed faster than the untreated counterparts.
Our study was the first to compare the impact of periodontal dressing and curcumin on the differentiated healing response in an early wound. On the index of early wound healing, both periodontal dressing group and curcumin group were equal. However, curcumin fared slightly better than periodontal dressing.
Pain, though not commonly associated with periodontal diseases, may be a part of the treatment for the same. One of the most objective methods of analyzing pain after a surgical procedure is by recording and analyzing analgesic used postsurgery.
In our study, the modified visual analog scale of curcumin group showed better results than periodontal group, but without any statistical significance (>0.05). Curcumin group consumed less number of tablets compared to periodontal dressing group with results showing statistically significant difference (<0.01).
In a study by Greensmith and Wade, modified Widman flap surgery was carried out, following which the pain experienced in patients with and without periodontal dressing was compared. Patient's experience of pain was equal or more on the dressed sites than on the nondressed sites. Increase in inflammation on dressed sites could have contributed to this.
Newman and Addy also demonstrated that more pain was experienced on periodontal dressing area than nondressing sites.
Our study results are in line with the one by Checchi and Trombelli, who in a similar study found the mean pain scores ranging from mild pain to no pain.
Periodontal dressing provides a closely approximating, impermeable barrier, thus preventing salivary leakage and inhibiting bacterial growth along with patient comfort. Moreover, in the early phases of healing, periodontal dressings protect exposed tissues from further injury.
The action of curcumin is similar to that of aspirin, wherein it diminishes the inflammatory mediators of arachidonic acid metabolism. However, unlike aspirin, curcumin does not affect synthesis of prostacyclin and selectively inhibits synthesis of prostaglandin E2 and thromboxane.
Anti-inflammatory properties of curcumin were studied by Satoskar et al. It was found to affectively alleviate clinical signs of postoperative inflammation such as pain tenderness and edema. Curcumin was also shown to possess analgesic and antioxidative stress effects in their study by Bulboacă et al., who compared curcumin with indomethacin and propranolol treatments. Curcumin fared superiorly than the comparative counterparts.
In our study, the mean analgesic consumption by the individuals advised curcumin, when compared to the periodontal dressing group was significantly less. However, the consumption in terms of number of tablets differed by only one. Probably slight discomfort with foreign body nature and direct mechanical irritation of periodontal dressing may have influenced the patients to consume more number of analgesics.
The present study was the first study to compare postoperative results following application of periodontal dressing versus curcumin as topical application after periodontal flap surgery. Curcumin was marginally better than periodontal dressing in exhibiting anti-inflammatory effect and was very effective in reduction of postoperative pain.
| Conclusion|| |
The present study concluded that periodontal dressing and curcumin are effective in reducing the TE, normalizing the TC, effective in enhancing the wound healing, and effective in reducing the pain perception.
Thus, periodontal dressing and curcumin have the positive effect on wound healing and pain control after periodontal flap surgery. However, topical application of curcumin can be used as a safe alternative when the patient is not willing for periodontal dressing.
Randomized controlled trials with large sample size may assess the benefits of curcumin over periodontal dressing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baghani Z, Kadkhodazadeh M. Periodontal dressing: A review article. J Dent Res Dent Clin Dent Prospects 2013;7:183-91.
Cheshire PD, Griffiths GS, Griffiths BM, Newman HN. Evaluation of the healing response following placement of coe-pak and an experimental pack after periodontal flap surgery. J Clin Periodontol 1996;23:188-93.
Grover HS, Deswal H, Bhardwaj A. Curcumin: A medicinal plant and its effects in medicine and dentistry. Int J Contemp Dent Med Rev 2015;2015:1-4.
Allen DR, Caffesse RG. Comparison of results following modified widman flap surgery with and without surgical dressing. J Periodontol 1983;54:470-5.
Suhag A, Dixit J, Dhan P. Role of curcumin as a subgingival irrigant: A pilot study. PERIO 2007;1:115-21.
Muglikar S, Patil KC, Shivswami S, Hegde R. Efficacy of curcumin in the treatment of chronic gingivitis: A pilot study. Oral Health Prev Dent 2013;11:81-6.
Soheilifar S, Bidgoli M, Faradmal J, Soheilifar S. Effect of periodontal dressing on wound healing and patient satisfaction following periodontal flap surgery. J Dent (Tehran) 2015;12:151-6.
Kirmani M, Saima S, Behal R, Jan SM, Yousuf A, Shah AF. Comparing the efficacy of scaling with root planing and modified widman flap in patients with chronic periodontitis. IAIM 2016;3:168-74.
Sanz-Moliner JD, Nart J, Cohen RE, Ciancio SG. The effect of an 810-nm diode laser on postoperative pain and tissue response after modified widman flap surgery: A pilot study in humans. J Periodontol 2013;84:152-8.
Wachtel H, Schenk G, Böhm S, Weng D, Zuhr O, Hürzeler MB, et al.
Microsurgical access flap and enamel matrix derivative for the treatment of periodontal intrabony defects: A controlled clinical study. J Clin Periodontol 2003;30:496-504.
López A, Nart J, Santos A, Alcázar J, Freixa O. Assessment of morbidity after periodontal resective surgery. J Periodontol 2011;82:1563-9.
Ahuja S, Yadav S, Joshi N, Chaudhary S, Madhu SV. Efficacy of caudal fentanyl and ketamine on post-operative pain and neuroendocrine stress response in children undergoing infraumbilical and perineal surgery: A pilot study. J Anaesthesiol Clin Pharmacol 2015;31:104-9.
] [Full text]
Lang NP, Lindhe J. Clinical Periodontology and Implant Dentistry. 6th
ed. UK: John Wiley and Sons; 2015. p. 526-8.
Ghanbari H, Forouzanfar A, Fatemi K, Mokhtari MR, Abrishami M, Ebrahiminik Z, et al
. Modified widman flap procedure: With or without periodontal dressing? Open J Stomatol 2012;2:170-2.
Bose S, Gundannavar G, Chatterjee A, Mohan RR, Viswanath RA, Shetty S. Comparison of the early wound healing following periodontal flap surgery in periodontitis patients with and without periodontal dressing. Indian J Dent Sci 2013;5:25-9.
Behal R, Mali AM, Gilda SS, Paradkar AR. Evaluation of local drug-delivery system containing 2% whole turmeric gel used as an adjunct to scaling and root planing in chronic periodontitis: A clinical and microbiological study. J Indian Soc Periodontol 2011;15:35-8.
] [Full text]
Nagasri M, Madhulatha M, Musalaiah SV, Kumar PA, Krishna CH, Kumar PM, et al.
Efficacy of curcumin as an adjunct to scaling and root planning in chronic periodontitis patients: A clinical and microbiological study. J Pharm Bioallied Sci 2015;7:S554-8.
Jones TM, Cassingham RJ. Comparison of healing following periodontal surgery with and without dressings in humans. J Periodontol 1979;50:387-93.
Anuradha BR, Bai YD, Sailaja S, Sudhakar J, Priyanka M, Deepika V, et al.
Evaluation of anti-inflammatory effects of curcumin gel as an adjunct to scaling and root planing: A Clinical study. J Int Oral Health 2015;7:90-3.
Greensmith AL, Wade AB. Dressing after reverse bevel flap procedures. J Clin Periodontol 1974;1:97-106.
Nagpal M, Sood S. Role of curcumin in systemic and oral health: An overview. J Nat Sci Biol Med 2013;4:3-7.
Mathur V, Tijare M, Desai A, Gupta S, Kallianpur S. Curcumin oral cure from the Indian curry. Inter J Pharmacother 2014;4:137-40.
Chan MM, Huang HI, Fenton MR, Fong D.In vivo
inhibition of nitric oxide synthase gene expression by curcumin, a cancer preventive natural product with anti-inflammatory properties. Biochem Pharmacol 1998;55:1955-62.
Muhammad NH, Ghani BA. Histological evaluation of the effect of topical application of curcumin powder and essential oil on skin wound healing. J Baghdad Coll Dent 2015;27:58-63.
Sidhu GS, Singh AK, Thaloor D, Banaudha KK, Patnaik GK, Srimal RC, et al.
Enhancement of wound healing by curcumin in animals. Wound Repair Regen 1998;6:167-77.
Checchi L, Trombelli L. Postoperative pain and discomfort with and without periodontal dressing in conjunction with 0.2% chlorhexidine mouthwash after apically positioned flap procedure. J Periodontol 1993;64:1238-42.
Newman PS, Addy M. Comparison of hypertonic saline and chlorhexidine mouthrinses after the inverse bevel flap procedure. J Periodontol 1982;53:315-8.
Satoskar RR, Shah SJ, Shenoy SG. Evaluation of anti-inflammatory property of curcumin (diferuloyl methane) in patients with postoperative inflammation. Int J Clin Pharmacol Ther Toxicol 1986;24:651-4.
Bulboacă AE, Bolboacă SD, Stănescu IC, Sfrângeu CA, Bulboacă AC. Preemptive analgesic and antioxidative effect of curcumin for experimental migraine. Biomed Res Int 2017;2017:4754701.
[Table 1], [Table 2], [Table 3]