|Year : 2021 | Volume
| Issue : 2 | Page : 98-102
Zinc oxide eugenol paste as a dressing material on surgical raw wounds after wide excision of oral potentially malignant disorders: A prospective controlled clinical trial
Vishal1, Tanya Khaitan2, VK Prajapati1
1 Department of Oral and Maxillofacial Surgery, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
2 Department of Oral Medicine and Radiology, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
|Date of Submission||26-Sep-2020|
|Date of Decision||16-Oct-2020|
|Date of Acceptance||19-Dec-2020|
|Date of Web Publication||22-Mar-2021|
Department of Oral Medicine and Radiology, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi - 834 009, Jharkhand
Source of Support: None, Conflict of Interest: None
Introduction: Oral potentially malignant disorders (PMDs) have a high risk to develop oral squamous cell carcinomas which are responsible for approximately 270,000 patients annually worldwide. When surgical excision of PMD is done, a raw denuded area is formed, which is required to be addressed. The present study was done to determine the effectiveness of zinc oxide (ZnO) eugenol paste as a dressing material of such surgical raw wounds and to assess its usefulness. Materials and Methods: A total of thirty patients with oral PMDs underwent wide surgical excision under local anesthesia. ZnO eugenol paste with preformed sterile gauge piece was applied in denuded area as dressing and sutured. Intraoperative evaluation was done on the following criteria: handling of ZnO eugenol paste and hemostasis achieved; postoperative evaluation included pain, adherence, granulation, epithelialization, reactivity to the ZnO eugenol. and overall usefulness as an intraoral dressing material. Results: Good hemostasis was obtained in 24 cases (80%). The mean score of pain was recorded as 3.5. Twenty-three cases (76%) showed granulation and epithelialization was rated as good. ZnO eugenol paste with the help of sutures showed good adherence in 29 cases (96.6%). No allergic reaction was noted. ZnO eugenol dressing was proved to be very effective in 28 cases (93.3%), effective in 2 cases (6.7%), and ineffective in 0 cases (0%). Conclusion: The chemical, physiological, and biological properties of ZnO eugenol have proved to be useful as a dressing material in cases of raw wound formed after excision of oral PMDs It is not a replacement for skin graft or collagen biodegradable membrane, but it can be one of the armamentaria for the oral surgeon in such cases.
Keywords: Dressing, excision, leukoplakia, zinc oxide eugenol
|How to cite this article:|
Vishal, Khaitan T, Prajapati V K. Zinc oxide eugenol paste as a dressing material on surgical raw wounds after wide excision of oral potentially malignant disorders: A prospective controlled clinical trial. Indian J Dent Sci 2021;13:98-102
|How to cite this URL:|
Vishal, Khaitan T, Prajapati V K. Zinc oxide eugenol paste as a dressing material on surgical raw wounds after wide excision of oral potentially malignant disorders: A prospective controlled clinical trial. Indian J Dent Sci [serial online] 2021 [cited 2021 Apr 20];13:98-102. Available from: http://www.ijds.in/text.asp?2021/13/2/98/311680
| Introduction|| |
Oral potentially malignant disorders (PMDs) often puzzle the oral physician and surgeon in regard to the best possible treatment modality. It is noteworthy that many oral squamous cell carcinomas develop from PMDs. Oral squamous cell carcinoma includes 92%–95% of all oral cancers which are responsible for approximately 3% of all malignancies and found in 270,000 patients annually worldwide. In the oral cavity, buccal mucosa is the most common site followed by tongue, gingiva, alveolus, and lips. Most of the PMDs are treated conservatively by long-term observation alone or prescribing medication for its regression which includes the use of naturally or synthetically fabricated compounds such as retinoids, epidermal growth factor receptor inhibitors/antagonists, cyclooxygenase-2 inhibitors, p53 modulators, and topical bleomycin. Antioxidants, corticosteroids (systemic or local), placentrex, hyaluronidase, or various combination of lozenges have also been tried.
In cases where the lesion does not resolve with medical treatment, visual increase in size, or psychological fear of the patient, surgical treatment is advised. Surgical treatment modalities include traditional excision, cryosurgery, and carbon dioxide laser ablation. Sometimes, the surgical site is covered with a graft usually an autologous skin graft, local flap rotation, and free mucosal grafts. Whenever wide surgical excision of the lesion is planned, it is not possible to primarily close the lesion due to loss of tissue at the site and taking a graft is not always advisable. In such cases, either the surgical site is left raw or covered by a dressing material like Coe-Pack or natural collagen.,
Zinc is well known for its wound healing capacity and eugenol as antiseptic and anesthetic agent., Zinc oxide (ZnO) eugenol has various use in dentistry such as a temporary restorative material, impression making, and medication in cases of dry socket. Literature reveals meager usage of ZnO eugenol as a dressing material on a raw wound after wide excision of oral PMDs. Considering the above background, the present study was undertaken to determine the effectiveness of ZnO eugenol paste as a dressing material on such surgical raw wounds in the management of oral PMDs and evaluating its usefulness.
| Materials and Methods|| |
The present study is a prospective, controlled clinical trial done in the Department of Oral and Maxillofacial Surgery, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi. The study was initiated after approval from institutional ethical committee. A total of 30 patients ranging in the age group of 20–60 years were included in the study. Relevant personal history was taken from the patients and careful oral examination was done. The importance of the study was explained to all individuals and informed consent was taken. Subjects selected for the study were in good health; none of them presented with evidence of malignant lesion which was confirmed through incisional biopsy. Patients with diabetes, on steroidal therapy, present-day smokers, tobacco chewers, and alcoholics were excluded from the study. However, patients who previously had the habit of smoking and chewing tobacco or consuming alcohol and ceased the habit were included. Intraoral sites selected were categorized as buccal mucosa, labial mucosa, gingivoalveolar mucosa, buccal mucosa with gingivoalveolar mucosa, and labial mucosa with gingivoalveolar mucosa.
Preoperative radiographs (orthopantomograms) were taken for every patient to rule out any bony involvement. Surgical excision of PMDs was carried out under local anesthesia resulting in raw denuded areas. ZnO eugenol paste after mixing was applied and held in place with preformed sterilized gauge pieces and 3-0 silk suture. Dental Product of India ZnO eugenol paste used in the present study contained two tubes: base paste (ZnO – 87%, olive oil – 13%) and accelerator paste (oil of clove – 12%, polymerized resin – 50%, fillers – 20%, lanolin – 3%, resinous balsam – 10%, acceleration solution – 5%) was used. A four-layered gauge piece was preformed to slightly excess of the size of the denuded area. ZnO eugenol paste was mixed in a glass plate with cement spatula, applied over the area, mended in the place with gauge, and sutured to the edges of the wound or interdental suturing by the use of silk sutures. ZnO eugenol dressing was removed at the end of 14 days; any remnant ZnO eugenol was removed with gentle saline irrigation.[Figure 1] All the patients were advised to apply metronidazole gel on the neogranularized area thrice daily for a further period of 15 days.
|Figure 1: (a) Preoperative image of the oral lesion (Homogenous leukoplakia), (b) Intraoperative image showing complete wide excision, (c) Postoperative image showing granulation after 14 days|
Click here to view
Results were evaluated on the following parameters:
On the day of surgery
- Handling of the ZnO eugenol paste, i.e., suppleness, resiliency, and dressing ability
- Hemostasis achieved after dressing assessed on the day of surgery and immediate postoperatively.
In the postoperative period, the following parameters were considered.
- Reactivity to the ZnO eugenol
- Overall usefulness as an intraoral dressing material.
The scoring criterion for hemostatic effects, pain relief, granulation, epithelialization, and adherence of ZnO eugenol paste to the wound was mentioned as good – 2, fair – 1, and poor – 0. Effectives (E) was assessed by adding up the scores and the value ranging between 8 and 10 was considered very effective, 5–7 as effective, and 0–2 as ineffective. All the parameters were calculated in terms of frequency and presented as percentage. Chi-square test was performed to evaluate the overall effectiveness of ZnO eugenol paste. Statistical analysis was done using SPSS 16.01 (Statistical Package for the Social Sciences) software IBM, Chicago, USA. Significance was considered at P < 0.01.
| Results|| |
A total of 30 patients (25 males and 5 females) with the mean age of 39 years were enrolled in the study. The frequency of intraoral site involvement was buccal mucosa 8 cases (26.6%), buccal mucosa plus gingivoalveolar mucosa 7 (23.3%), labial mucosa plus gingivoalveolar mucosa 10 (33.3%), gingivoalveolar mucosa 5 (16.7%), and labial mucosa 0 (0%). PMDs diagnosed in our study were leukoplakia (21 cases), erythroplakia (4), erosive lichen planus (4), and chronic hyperplastic candidiasis (1). All lesions were confirmed histopathologically through incisional biopsy.
All the patients were comfortable with the intraoral placement of ZnO eugenol paste. None of them complained about any sensation of a foreign body or any odor. Good hemostasis was obtained in 24 cases (80%). Pain was recorded in visual analog scale (VAS) and the mean score was 3.5. 22 cases (73.3%) reported good pain control and 8 cases (26.7%) fair. In 23 cases (76%), granulation and epithelialization were rated as good. The results were directly related to the depth of the wound, healing being better in shallow wounds.
ZnO eugenol paste showed good adherence in 29 cases (96.6%) with the help of sutures, where it stayed intact until day 14. Only in one case, sutures became loose and dressing had to be repeated. ZnO eugenol dressing was proved to be very effective in 28 cases (93.3%), effective in 2 cases (6.7%), and ineffective in 0 cases (0%).
None of the cases showed any adverse reaction to the ZnO eugenol paste, thus proving its safety as an intraoral dressing. It was regarded as very useful in 28 cases (93.3%), useful in 2 cases (6.7%), and useless in no cases (0%).[Table 1] Chi-square test was done to evaluate the usefulness of ZnO eugenol dressing and was found statistically significant with P < 0.01.
|Table 1: Scoring criteria for evaluation of zinc oxide eugenol paste as a dressing material|
Click here to view
| Discussion|| |
PMDs are defined as morphologically atypical tissue, which appears abnormal when viewed under the microscope and more likely progress to cancer than normal tissue. PMDs encountered during our study included leukoplakia, erythroplakia, erosive lichen planus, and chronic hyperplastic candidiasis. Mostly, PMDs in the oral cavity are associated with consumption of smokeless tobacco, presence of sharp tooth/teeth, or sometimes can be idiopathic. There is no definitive panacea for the complete diminution of oral PMDs. Surgical intervention is not the first line of treatment; rather, a more conservative approach is used to treat or hoping spontaneous remission of the lesion.
Cases unresponsive to medical management, increase in size of the lesion or patient's willingness to get rid of the lesion are some of the factors where role of oral and maxillofacial surgeons come into play. Usually, these procedures are performed under local anesthesia, but cases should be chosen wisely and planned accordingly either under local or general anesthesia to avoid complications such as chances of profuse bleeding, which can happen due to rupture of buccal vessels, mental vessels, or even facial vessels. In case of minor bleeding, it can be controlled by electrocautery and surgical pressure dressing, but if facial vessels are damaged, bleeding can be bothersome. Identification and ligation of facial vessel intraorally under local anesthesia is challenging if not impossible. Occasionally, a lesion can be superimposed on existing oral submucous fibrosis characterized by reduced mouth opening, in which incisional biopsy itself can be difficult. We had carefully chosen patients for this study and the procedure was properly planned; thus, none of the abovementioned complications were encountered by us.
Raw wounds of the oral cavity, like any other body wounds, heal by epithelialization and granulation. However, in the oral cavity, the healing of raw wounds is delayed as the environment is constantly moist due to contamination with salivary secretion and food ingestion increases the risk of infection. Constant movement of the cheek and tongue, masticatory forces, and oral hygiene may further interfere with adherence and acceptance of mucosal or skin graft.
Bioresorbable materials such as collagen have been used in the past as a intraoral surgical dressing material for raw wound and proven good results., Coe-Pak, a periodontal dressing material, is also used and shown good results. Literature reveals limited studies with the use of ZnO eugenol paste as a dressing material on a raw wound. ZnO eugenol is widely used in multidisciplinary dentistry due to its favorable chemical, physiological, and biological properties., In conservative dentistry and endodontics, it is used as a temporary restorative material and root canal sealant, in prosthodontics as a secondary impression material, as periodontal dressing in periodontology, and as medication of alveolar osteitis in oral surgery.,, ZnO eugenol is inexpensive and costs just a fraction in comparison to other materials used for dressing raw intraoral wounds and easily affordable by the patients of the low- and middle-income countries.
When zinc-based paste and eugenol accelerator paste are mixed, a setting reaction occurs and a fine consistent mix is obtained. It has the setting time of 2–3 min, but due to its low tensile strength, it cannot withstand the force of overlying sutures. Reinforcing it with a layer of sterile gauge piece above the ZnO eugenol paste produces the desired strength. ZnO eugenol dressing remained adhered in the place in 29 patients for the time period of 14 days in the present study. During removal, the dressing can be easily removed and remnants could be washed with normal saline irrigation.
Pain relief was achieved due to anesthetic properties of the eugenol and the average VAS score of all the patients was 3.4 after a day of surgery. While standard antibiotics and analgesics had been prescribed to the patients, the VAS score was less compared to the magnitude of the procedure performed. Twenty-four patients did not report any bleeding, and 6 patients had slight bleeding, but no intervention was required as bleeding completely stopped during the next day of follow-up without prescribing any hemostatic.
Granulation and epithelialization were rated as good in 23 (76.6%) cases at the end of the 3rd week and 4th week, respectively. Rastogi et al. and Ramwala and Jha conducted similar studies with bioresorbable dressing materials such as collagen resulting in marginal better granulation and epithelialization. However, in these studies, epithelialization was recorded after the end of 1 month., Likewise in our study, the appearance of raw areas was restored to normal texture in about 4–5 weeks [Table 2].
|Table 2: Comparison of various dressing materials for oral raw surgical areas|
Click here to view
In the present study, no allergic reaction was observed due to ZnO eugenol and it proved to be very useful in 93.3% of cases and useful in all the remaining cases. ZnO eugenol paste can be advocated as a temporary non-biological dressing material for raw wounds after wide excision of PMDs in the oral cavity because of its simple chairside application and good tolerance by oral tissues.
| Conclusion|| |
ZnO eugenol dressing is not a replacement of skin graft or collagen biodegradable membrane for the use in the raw surgical areas, but it can be one of the armamentaria for the oral and maxillofacial surgeon in treating cases of oral PMDs where resources and equipment are limited. Further studies should be done on a larger scale to determine the effectiveness of ZnO eugenol paste as a dressing material in raw oral surgical wounds.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mortazavi H, Baharvand M, Mehdipour M. Oral potentially malignant disorders: An overview of more than 20 entities. J Dent Res Dent Clin Dent Prospects 2014;8:6-14.
Awadallah M, Idle M, Patel K, Kademani D. Management update of potentially premalignant oral epithelial lesions. Oral Surg Oral Med Oral Pathol Oral Radiol 2018;125:628-36.
Sciubba JJ. Oral leukoplakia. Crit Rev Oral Biol Med 1995;6:147-60.
Schramm VL Jr., Johnson JT, Myers EN. Skin grafts and flaps in oral cavity reconstruction. Arch Otolaryngol 1983;109:175-7.
Sowjanya NP, Rao N, Bhushan NV, Krishnan G. Versitality of the use of collagen membrane in oral cavity. J Clin Diagn Res 2016;10:ZC30-3.
Kathariya R, Jain H, Jadhav T. To pack or not to pack: The current status of periodontal dressings. J Appl Biomater Funct Mater 2015;13:e73-86.
Sood KS, Garnick A. Zinc and wound healing: A review of Zinc physiology and clinical applications. Comp Clin Res Prac 2017;29:102-6.
Markowitz K, Moynihan M, Liu M, Kim S. Biologic properties of eugenol and zinc oxide-eugenol. A clinically oriented review. Oral Surg Oral Med Oral Pathol 1992;73:729-37.
Myers GE, Peyton FA. Physical properties of the zinc oxide--eugenol impression pastes. J Dent Res 1961;40:39-48.
Bessho K, Murakami K, Iizuka T. The use of a new bilayer artificial dermis for vestibular extension. Br J Oral Maxillofac Surg 1998;36:457-9.
Yardimci G, Kutlubay Z, Engin B, Tuzun Y. Precancerous lesions of oral mucosa. World J Clin Cases 2014;2:866-72.
Rastogi S, Modi M, Sathian B. The efficacy of collagen membrane as a biodegradable wound dressing material for surgical defects of oral mucosa: A prospective study. J Oral Maxillofac Surg 2009;67:1600-6.
Ramwala V, Jha L. Surgical excision of premalignant lesion oral leukoplakia followed by guided tissue regeneration (GTR) membrane grafting – A study of 10 cases. IOSR J Dent Med Sci 2016;15:1-4.
Cheshire PD, Griffiths GS, Griffiths BM, Newman HN. Valuation of the healing response following placement of Coe-pzpx'[/b jtrSYAak and an experimental pack after periodontal flap surgery. J Clin Perio 1996;23:188-93.
Klein IE, Broner AS. Complete denture secondary impression technique to minimize distortion of ridge and border tissues. J Prosthet Dent 1985;54:660-4.
Bloomer CR. Alveolar osteitis prevention by immediate placement of medicated packing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:282-4.
Pathak H, Mohanty S, Urs AB, Dabas J. Treatment of oral mucosal lesions by scalpel excision and platelet-rich fibrin membrane grafting: A review of 26 sites. J Oral Maxillofac Surg 2015;73:1865-74.
[Table 1], [Table 2]