Abstract
Purpose
The aim of this scoping review was to evaluate the wound healing indices available in literature and propose a new intra-oral wound healing index to assess the healing of palatal mucosa.
Materials and Methods
A PubMed database search was conducted to identify relevant studies using the search strategy: (‘Oral Wound healing’) OR (‘Palatal tissue healing’) OR (‘Healing indices in Oral and Maxillofacial Surgery’) OR (‘Palatal wound healing’) OR (‘Complications in wound healing’). A qualitative and quantitative synthesis of the results was done and data was presented following the PRISMA-ScR guidelines.
Results
The search resulted in 9 articles published between 2019 and 2022, which were eligible for inclusion in the study. The data revealed that the indices currently available for the assessment of intra-oral healing were limited and primarily concerned with the assessment of gingival and periodontal tissues.
Conclusion
The healing indices devised for gingival and periodontal tissues cannot be applied to palatal healing due to the differences in clinical and histological aspects. Therefore, a new index to monitor the healing response specifically for the soft tissues in the palate has been proposed. This maybe particularly useful in cleft palate repair and other procedures performed over the palatal tissues.
Keywords: Wound repair, Palatal mucosa, Healing indices, Complications
Introduction
Monitoring of wound healing following any surgery plays an important role in the successful outcome of the surgery [1]. The integral step in most oral surgical procedures is the reflection of the flap [2]. Following flap reflection, the tissue margins should be approximated and the wound-healing process ensues. The wound-healing response to any tissue injury is extremely important. Primitive body defense mechanism aims at repairing tissue integrity. The initial post-operative weeks are of primordial importance in maintaining the stability of the wound. The factors influencing the quality of healing responses are the nature of the tissue disruption and the circumstances encompassing wound closure. Wound healing is a complex phenomenon; the operating surgeon must have a thorough knowledge of the science and mechanism of the repair of normal tissue and thus can intervene in the event of any complication, to facilitate favorable outcome. For this reason, wound healing monitoring scales would be useful [2].
Wound Healing Concept: A wound occurs as a result of disruption in the continuity of skin, mucosa or organ tissue. Following tissue injury, several sequential yet overlapping intra and extracellular pathways are activated aimed at restoring the integrity of the tissue. Any deviation or alteration from this sequence may lead to dysfunctional wound repair [3].
The wound healing process is arbitrarily divided into the following phases: (a) coagulation and hemostasis; (b) inflammation; (c) proliferation; and (d) wound Remodeling with scar tissue formation [4]. Immediately after tissue injury, coagulation and hemostasis take place in the wound. The principal aim of these mechanisms is to prevent exsanguination and to protect the vascular system and in the long term provide a provisional matrix bed for invading cells that are needed in the later phases of wound healing. The next phase is the inflammatory phase which usually lasts for several days after injury [5]. Following the inflammatory phase, but before its complete resolution, the proliferative stage begins 4 days after injury and may continue up to 2 weeks. In this step, epithelisation, angiogenesis, and granulation tissue formation occur which are fundamental steps in wound building [6].
The inflammatory stage is followed by the maturation phase. This is the longest phase of wound healing which begins 8 days after injury and may last up to almost 1 year or even more. During this stage, the previously randomly laid collagen is destroyed and replaced by new collagen fibers which are oriented better to resist tensile forces on the wound. However intra-oral wound differs from the extra-oral in that they show accelerated healing and lesser scarring [5, 6].
Both functionally and anatomically considered, the palate is a complex structure comprising bone, mucosa and muscle. The palate anteriorly consists of transverse ridges, rugae present on either side of the midline and the palatal structure has thin bone, covered on either side by mucosa, posteriorly the rigid hard palate becomes a dynamic soft palate due to the musculature of the soft palate. Palatal mucosa is firm, resilient and attached closely to the bone via periosteum. The mucoperiosteum over the hard palate is highly vascularised is supplied by the greater palatine artery and has an enormous capacity to heal with epithelization and leaving no donor site deformity. Any trauma and scarring of the soft palate mucosa may lead to altered speech, tethering and hamper speech and deglutition [7, 8].
According to Larson et al. (2010), unlike adults, the inflammatory phase is absent in fetal wound healing. The wound healing process by Broughton et al. (2006) and Larjava (2012) in the palate concluded that due to absence of healthy underlying bone makes the healing process difficult in palatal surgeries. In such cases, wound healing might be accompanied by perforation to the nose and antrum or by serious scarring. This can lead to the narrowing of the transversal width of the maxilla if the patient is in their growing phase, as is observed in cleft patients who have surgery on the palate. Surgical closure of the palatal clefts creates an area of palate denuded of mucosa which is allowed to heal by secondary intention [8, 9].
All the indices proposed in the field of oral and maxillofacial surgery literature are used to assess the healing status of gingival and periodontal soft tissue only. Unfortunately, so far there is no literature/indices discovered especially for palatal mucosa following any surgical procedures. This current paper proposes a new, novel, easy and simple index for palatal mucosa healing based on the nature of Mucosal Tear, Wound dehiscence, Blanching, Erythema, Flap Instability and infection after reviewing the existing literature.
Aim and Objectives
This study aims to review the wound healing indices available in the Maxillofacial region and put forward an index that would be useful for monitoring healing following surgery involving palatal mucosa. The Objectives of the study were
To review the wound healing indices available in the literature of oral and Maxillofacial surgery.
To Propose the New Wound Healing Index for Palatal Mucosa.
Materials and Methods
A thorough literature search for relevant articles was done. The search was conducted in PubMed and MEDLINE. Articles were searched using the terms 'wound healing', 'palatal wound healing', 'complications in wound healing', and 'healing index in OMFS'. Articles published between the years 1975 and 2021 were selected. Studies were included based on the availability of full-text articles, original articles, human trials, randomised control trials, non-randomised control trials, and studies conducted in the assessment of wound healing of the oral mucosa. Articles that made use of the same healing indices from previous studies, studies that were conducted on animal subjects, and healing assessments on areas other than oral mucosa were excluded. Each obtained article was reviewed and analyzed by 2 independent readers and if the articles were considered relevant by both the readers they were included. In the event of a disagreement, the articles were re-read and discussed among the authors and a decision was made whether or not to include the article.
The PubMed and MEDLINE search revealed 393 articles related to wound healing, out of which 79 potentially relevant full-text articles were selected and reviewed. Following the screening of the full-text articles, a total of 9 articles were included. Full-length articles were obtained and their references were searched for additional articles (Fig. 1).
Fig. 1.
Wound healing concept
All the literature indices were tabulated based on year, commonly cited, tissue Color, Response to palpation, Granulation tissue, Incision margins, Suppuration, bleeding, erythema, and flap dehiscence. Existing indices are enlisted in Tables 1 and 2.
Table 1.
Assessment Scales for Wound Healing-I
| Assessment scale | Year | Assessment parameters | Score | Inference |
|---|---|---|---|---|
| Landry’s wound healing index | 1988 | Tissue Color | 1–5 | 1—very poor |
| 2—poor | ||||
| Response to palpation | 3—good | |||
| Granulation tissue | 4—very good | |||
| 5—excellent | ||||
| Incision margins | ||||
| Suppuration | ||||
| Early Wound Healing Index (Watchtel et al.) | 2003 | 1. Complete flap closure—no fibrin line in the interproximal area | 1 | 1—Good wound healing |
| 2. Complete flap closure—fine fibrin line in the interproximal | 2 | 5—Poor wound healing | ||
| 3. Complete flap closure—fibrin clot in the interproximal area | 3 | |||
| 4. Incomplete flap closure—partial necrosis of the interproximal | 4 | |||
| 5. Incomplete flap closure—complete necrosis of the interproximal tissue | 5 | |||
| Wound healing index (Lien-Hui Huang) | 2005 | Gingival edema | 1–3 | 1—uneventful healing |
| Erythema | 2—uneventful healing with mild symptoms | |||
| Patient discomfort | ||||
| 3—poor healing | ||||
| Flap dehiscence | ||||
| Suppuration | ||||
| Modified Landry’s wound healing index (Mozzati et al.) | 2014 | Tissue color | 1–3 | 4—excellent healing |
| Color and consistency of the healing tissue | 1–3 | 12—severely impaired healing | ||
| Suppuration | 1–3 | |||
| Bleeding | 1–3 |
Table 2.
Assessment scale for wound healing-II
| Assessment scale | Year | Assessment parameters | Score | Inference |
|---|---|---|---|---|
| Modified Landry’s wound healing index (Paneerselvam et al.) | 2016 | Tissue Color | 1–5 | 1—Very poor |
| Response to palpation | 2—Poor | |||
| Granulation tissue | 3—Good | |||
| Suppuration | 4—Very good | |||
| Presence of alveolar osteitis | 5—Excellent | |||
| Modified Landry’s wound healing index (Pippi et al.) | 2017 | Inspection | ||
| Gingival color | 0/1 | Equal/Worse compared to the control site | ||
| Granulation tissue | 0/1 | |||
| Epithelization degree | 0/1 | |||
| Swelling | 0/1 | |||
| Palpation | ||||
| Bleeding | 0/1 | |||
| Pain | 0/1 | |||
| Suppuration | 0/1 | |||
| Early Wound Healing score (EWHS) (Lorenzo Marini) | 2019 | CSR- clinical signs of re-epithelialization | Maximum Score—10 | |
| Merged incison margins | 6 | 0—Worst possible healing | ||
| Incision margins in contact | 3 | |||
| Visible between incision margin | 0 | |||
| CSH—clinical signs of hemostasis | 10—Ideal Wound healing | |||
| Absence of fibrin on the incision margins | 2 | |||
| Presence of fibrin on the incision margins | 1 | |||
| Bleeding at the incision margins | 0 | |||
| CSI—clinical signs of inflammation | ||||
| Absence of redness along the incision length | 2 | |||
| Redness involving < 50% of the incision length | 1 | |||
| Redness involving > 50% of the incision length and/or pronounced swelling | 0 | |||
| IPR Wound Healing Scale | 2021 | Inflammatory phase (3–5 days) | 0/1 | 0–4—Poor healing |
| Bleeding, spontaneously or | ||||
| on palpation | 5–10—Acceptable healing | |||
| Granulation tissue | ||||
| Hematoma | 11–16—excellent healing | |||
| Tissue color | ||||
| Incision margin | ||||
| Suppuration | ||||
| Edema | ||||
| Pain | ||||
| Proliferative phase (14 days) | ||||
| Re epithelization | ||||
| Tissue color | ||||
| Scar | ||||
| Suppuration | ||||
| Pain | ||||
| Remodeling (6 weeks) | ||||
| Scar | ||||
| Tissue color | ||||
| Pain |
New Index and Its Rationale
The wound healing indices devised for the gingival and periodontal tissues cannot be used to assess palatal healing because they differ both in clinical and histological aspects. Monitoring of wounds following any surgery plays a vital role in the early diagnosis of any pathology or deformity. A method for assessing palatal wound healing may facilitate the monitoring and assessment of postoperative wound healing and helps in identifying any early signs of infection. Thus, we have formulated a scale to monitor the healing response of the soft tissues in the palate. We feel this wound healing scale will be more applicable for assessing post-surgical healing of the palate and any dental or oral surgeon can be trained to utilize the index.
The parameter for our study includes: (1) Immediate: (a) Mucosal Tear at the site of suture, (b) Erythema, (c) Blanching- Immediate, (d) Pus or Wound infection. (2) Delayed: (e) Wound dehiscence, (f) Flap Instability, (g) Blanching-Late, (h) Suture Loosening, (i) Pus or Wound infection. (3) Late: (j) Fistulae and (k) Scar. The overall score of our scale ranges from 0 to 16. A total score that ranges from 0 to 4 indicates excellent healing, 5–8 indicates acceptable/satisfactory healing, 9–12 indicates fair healing, and 13–16 indicates poor healing (Table 3).
Table 3.
Author’s Palatal Mucosa wound healing index
| S. No | Parameter | Description | Clinical Finding | Score | Assessment method |
|---|---|---|---|---|---|
| I. Immediate(1st, 3rd and 7th Postop day) | |||||
| (a) | Mucosal Tear at the site of suture | Discontinuity of the mucosa at the sutured site due to pull or tension | Absent | 0 | Clinical/Visual assessment |
| Present | 1 | ||||
| (b) | Erythema | Presence of redness around the wound edges | At one point | 0 | Clinical/Visual assessment |
| At more than one point | 1 | ||||
| Along the suture | 2 | ||||
| (c) | Blanching—Immediate | White or pale region around the wound site | Absent | 0 | Clinical/Visual assessment |
| Present | 1 | ||||
| (d) | Pus or Wound infection | White or yellowish exudate at the surgical site | No infection | 0 | Clinical/Visual assessment |
| At one point | 1 | ||||
| Along the wound | 2 | ||||
| Delayed (10th, 14th & 21st Postop day) | |||||
| (e) | Wound dehiscence | Separation of wound edges due to poor wound healing | Minor separation at any point along the suture | 0 | Clinical/Visual assessment |
| Medium [Single or Multiple] separations | 1 | ||||
| Major [Single or Multiple] separations | 2 | ||||
| (f) | Flap Instability | Improper flap approximation at the site of surgery | Stable | 0 | Clinical/Visual assessment |
| Unstable | 1 | ||||
| (g) | Blanching—Late | White or pale region around the wound site | Absent | 0 | Clinical/Visual assessment |
| Present | 1 | ||||
| (h) | Suture Loosening (Suture seen outside) | Loosening of suture at the surgical site | Suture intact | 0 | Clinical/Visual assessment |
| Suture Loosened | 1 | ||||
| (i) | Pus or Wound infection | White or yellowish exudate at the surgical site | No infection | 0 | Clinical/Visual assessment |
| At one point | 1 | ||||
| Along the wound | 2 | ||||
| Late (3rd and 6th Month) | |||||
| (j) | Fistulae | An abnormal communication between the oral cavity and the nasal floor | Absent | 0 | Clinical/Visual assessment |
| Small [1-2 mm] | 1 | ||||
| Medium [3-5 mm] | 2 | ||||
| Large [> 5 mm] | 3 | ||||
| (k) | Scar (absence of rugae or fibrotic bands) | Structural alteration in the wound site | Absent | 0 | Clinical/Visual assessment |
| Present | 1 | ||||
Overall Score = 0–17; 0–4 = Excellent Healing; 5–8 = Acceptable/satisfactory healing; 9–12 = Fair Healing; 13–17 = Poor Healing
Review of Literature
One of the earliest developed healing indices was devised by Landry et al. in the year 1988. This index was widely used to assess healing following various oral and maxillofacial procedures. Five clinical parameters were assessed in this index i.e., Tissue color, response to palpation, granulation tissue, incision margin, and suppuration. Score 1—indicated very poor healing, 2—poor healing, 3—good healing, 4—very good and 5—excellent healing. Many clinicians modified this index to assess healing following surgery [10–13] (Table 1).
Wachtel et al., in 2003 used Early Wound healing Index (EHI) to assess post-operative healing following flap surgery. The index had 5 different scores for different degrees of healing. 1: complete flap closure and no fibrin line in the interproximal area, 2: complete flap closure fine fibrin line in the interproximal area, 3: complete flap closure and fibrin clot in the interproximal area, 4: incomplete flap closure and partial necrosis of the interproximal tissue, 5: incomplete flap closure and complete necrosis of the interproximal tissue. An EHI score of ≤ 3 was considered primary healing and an EHI score of ≥ 4 as secondary healing [10] (Table 1).
Lien-Hui Huang articulated the Wound Healing Index (WHI) in the year 2005 which estimated the clinical parameters like gingival odema, erythema, suppuration, patient discomfort, or flap dehiscence. A score of 1 indicated uneventful healing with no gingival odema, erythema, suppuration, patient discomfort, or flap dehiscence; a score of 2 = uneventful healing with slight gingival odema, erythema, patient discomfort, or flap dehiscence, but no suppuration; and score 3 = poor wound healing with significant gingival odema, erythema, patient discomfort, flap dehiscence, or any suppuration [11, 12] (Table 1).
Mozzati et al., in the year 2014 used the Landry wound healing index but modified his study. The clinical parameters considered were bleeding, suppuration, tissue color, and consistency each of which was scored from 1 up to 3. The total scores ranged from 4 to 12 wherein a score of 4 corresponds to excellent healing and 12 corresponds to severely impaired healing [2, 13] (Table 1).
In a study conducted by Paneerselvam et al. (2016) wound healing following therapeutic extraction was assessed using modified Landry's wound healing index wherein alveolar osteitis was included in the place of the incision margin [14] (Table 2). Pippi et al., In the year 2015 healing of the socket following dental extraction using Landry's wound healing index which was modified according to the needs of the study. A dichotomic score (0/1) was applied to the clinical parameters: Tissue color, presence or absence of granulation tissue, presence or absence of suppuration, and presence or absence of swelling to assess the healing in the test and the control site [2, 15] (Table 2).
Marenzi et al. in the year 2015 conducted a study to assess the influence of Leukocytes and Platelet Rich Fibrin in post-operative healing of extraction sockets, where they modified Landry's wound healing Index by Mozzati [13]. Lorenzo Marini along with his group introduced the Early Wound Healing score (EHS) in the year 2019. This index is intended to evaluate Clinical signs of Re-epithelization (CSR), Hemostasis (CSH), and Inflammation (CSI) from the first postoperative day of surgery onwards. CSR scores: 0—the visible distance between incision margins, 3—contact between incision margins, 6—merged incision margins. CSH scores: 0—Bleeding at the incision margins, 1—the presence of fibrin on the incision margins, 2—an absence of fibrin at the incision margins. CSI scores: 0—redness involving more than 50% of the incision length and/or pronounced swelling, 1—redness involving less than 50% of the incision length, 2—an absence of redness along the incision length. The cumulative sum of the individual scores of each parameter renders the EHS which ranges between 0 and 10 with 0 being the worst possible wound healing and 10 suggesting ideal wound healing. An EHS score of 0 was given if there was suppuration present irrespective of the individual scores of each clinical parameter [16, 17] (Table 2).
Yafit Hamzani et al. introduced the IPR wound healing scale (I = Inflammatory, P = Proliferative, R = Remodeling) where different parameters were evaluated during different phases of wound healing. Parameters assessed in the inflammatory phase (from 3 to 5 days) included bleeding spontaneously or on palpation, granulation tissue, hematoma, tissue color, incision margins, suppuration, odema, and pain. Proliferative phase (14 days) Re-epithelization, Tissue color, scar, suppuration, and pain were assessed. In the Remodeling phase (6 weeks) the parameters of scar, tissue color, and pain were assessed. A score of 0 or 1 was given depending upon the features expressed The overall score of the IPR scale ranges from 0 to 16. A total score that ranges from 0 to 4 indicates poor healing, 5–10 indicates acceptable healing and 11–16 indicates excellent healing [2, 18] (Table 2).
Discussion
Wound healing is a complex process with the wound environment dynamic with the health status of the individual. A thorough knowledge of the basics of the physiology of wound healing is a must to implement the principles of chronic wound care [1, 2].
In Oral and Maxillofacial Surgical practice, wound healing monitoring plays a crucial role. Several animal and human studies have been conducted in the past to review all the knowledge in uncomplicated wound healing. The primary function of wound healing is to return the form and function of the tissue. Since wound healing is a complex process and its complexity necessitates interruption at many levels to check and avoid complications. Several local and systemic factors influence the effect of wound healing. The local factors may include infection, ischemia, wound contamination, foreign bodies etc. Systemic factors include Diabetes Mellitus, hypothyroidism, age, sepsis, etc. [1, 15].
The initial post-operative weeks play an important role in the maintenance of wound stability. Surgical wound dehiscence is the most common postoperative complication. Other complications include erythema, blanching, flap instability, pus or infection. The operating surgeon can identify the early signs and symptoms of complications in the soft tissue. Thus may intervene, if necessary to ensure favorable progression of wound repair and surgical outcome. A wound healing scale will be useful for this purpose [15, 19, 20].
The review conducted by Violeta Malpartida et al. reviewed 31 articles aimed to present a comprehensive review of outcome measures related to palatal wound healing and postoperative morbidity and concluded that tissue color match, bleeding evaluation, hydrogen peroxide test and visual inspection, discomfort sensation, Pain perception, analgesic consumption, burning sensation, and changes in feeling habits are the most commonly used outcome measurements related to postoperative palatal wound healing and patient-reported morbidity [21, 22]. In this new proposed index, we have included new parameters for wound healing after assessing other ten clinical scales which have their clinical inferences and importance which will be useful for assessing wound healing in palatal mucosa.
Liat Chaushu et al. conducted an animal experimental study in a rat model to assess the histology and histomorphometry of palatal wound healing. After the incision was made on the maxillary palate, palatally a full-thickness flap was raised and repositioned and sutured. The parameters assessed were epithelial gap, vascular fraction, inflammatory infiltration, myofibroblasts expression and stem cell markers within the oral epithelium and stromal cells. He concluded that palatal wound healing with primary intent in rat model heals within 14 days. Surgical trauma decreases the cytokeratin (CK) 14 and cytokeratin 15 which returned to normal after 14 days. He also found that epithelization and epithelial cell differentiation are upregulated by connective tissue SOX2 [23].
Molnár et al. [24] conducted an observational clinical case series for the assessment of palatal mucosal healing by laser speckle contrast imaging. Laser speckle contrast imaging is a two-dimensional contrast-based surface visualization method that was recently used in the evaluation of palatal wound healing and acts as a mandatory feature for complex flap and wound monitoring. The drawback of this method would be the availability of the instrument, it is technique sensitive [24]. The author's proposed healing index for palatal mucosa is a clinical scale, easy to follow, not technique sensitive and no invasive instruments are required.
This review of literature on 7 to 8 commonly used indices described in this article are all designed to evaluate and monitor the healing of wounds and respective tissue responses. Each of these scales emphasizes various parameters which evaluated in different phases in the wound healing process. All healing indices available in Oral and Maxillofacial literature available are only about the healing of gingival and periodontal soft tissues. There is no literature available, to assess the healing, especially for palatal mucosa following any surgical procedure. The healing indices devised for the gingival and periodontal tissues cannot be used to assess palatal healing because they differ both in clinical and histological aspects. The features that have commonly been observed during wound healing following a palatal surgery are Mucosal tear, Wound dehiscence, Flap instability, Erythema, Blanching, Suture Loosening, Pus or wound infection, Fistulae and Scar.
Conclusion
Wound monitoring following any surgery plays an important role in the early diagnosis of any pathology or deformity. We recommend that this palatal wound healing index can be used generalized to all the cases involving palatal mucosa and can further facilitate the monitoring and assessment of postoperative wound healing and helps in identifying any early signs of wound dehiscence and infection.
Future clinical studies are needed to evaluate the Author's PMWHI for wider applications in palatal mucosal surgery so that clinicians will be able to identify the wound healing process, and signs and symptoms of early infection that may promote or inhibit the healing process following surgical procedures.
Acknowledgements
The authors would like to thank the Meenakshi Academy of Higher Education (MAHER) and Research, Chennai, Tamil Nadu, India for constant support to carry out our research project. The authors would like to thank Dr Veerabhahu M, MDS- Oral and Maxillofacial Surgeon and Dr Mustafa Khader, MDS- Oral and Maxillofacial Surgeon for validation of the author's healing score.
Funding
No funding was procured for this work.
Declarations
Conflict of interest
All authors declare that they have no conflict of interest.
Ethical approval
Not required.
Patient consent
Not required.
Footnotes
Publisher's Note
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