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.

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. Copyright:

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.[1]

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.[2]

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.[3] The usage of Curcumin as topical application, subgingival irrigation, and mouthrinses following scaling and root planing significantly improves gingival and periodontal parameters.[456]

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

Patient selection

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:[7]

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.

Clinical procedure

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].

Table 1

Mean of clinical attachment level

CAL	No. of cases	Mean	Standard deviation	Standard error of mean
Prior ToPhase-I	20	3.643	0.3912	0.0875
AfterPhase-I	20	3.607	0.3979	0.0889

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

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.[8] 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.[9] The TE and color of the gingiva was recorded on a scale of 1–3. The early wound healing scale by Wachtel et al.[10] [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.[1112] 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].

Table 2

Demographic details

Age	Sex
	Male		Female		Total
	No	%	No	%	No	%
20-29	2	10	1	5	3	15
30-39	3	15	6	30	9	45
40-49	1	5	4	20	5	25
50-59	1	5	2	10	3	15
Total	7	35	13	65	20	100
Mean SD	38.3 9.82

SD – Standard deviation

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

Clinical parameters	Mean±SD		P
	Periodontal dressing group (n=20)	Curcumin group (n=20)
Tissue edema	1.355±0.53012	1.2075±0.23242	0.262
Tissue colour	1.144±0.30734	1.1325±0.23355	0.895
Wound healing	1.5±0.66886	1.4965±0.50569	0.985
MVAS	1.4525±0.46071	1.2395±0.17355	0.06
Number of analgesics taken	4.3±1.08094	3.3±0.7327	0.001

n- Number of subjects, MVAS – Modified visual analogue scale, P – P, SD – Standard deviation, Statistically no significant difference at P>0.05, Statistically significant difference at P<0.05

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.[8]

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.[13]

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.[14]

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.[15]

Curcumin (CU) exhibits properties such as anti-inflammatory, antiseptic, antioxidant, antimicrobial, immunostimulant,[16] anticarcinogenic, antiviral,[17] antifungal, and accelerated wound healing.[3]

In present study, tissue response at the surgical site was assessed by the tissue response model suggested by Sanz-Moliner et al.,[9] 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 [18] 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.[7] 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 [4] 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.[5] 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.[1917]

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.[10] 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.[11]

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.[11]

The earlier studies [471518] 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.[20]

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.[212223]

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.[24]

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.[25]

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.[9] One of the most objective methods of analyzing pain after a surgical procedure is by recording and analyzing analgesic used postsurgery.[26]

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,[20] 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.[27]

Our study results are in line with the one by Checchi and Trombelli,[26] 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.[26]

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.[5]

Anti-inflammatory properties of curcumin were studied by Satoskar et al.[28] 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.,[29] 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.

Limitations

Randomized controlled trials with large sample size may assess the benefits of curcumin over periodontal dressing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.