HAEMOSTASIS IN ENDODONTICS

Dr.Suneetha
3rd year post graduate
CONTENTS

• Introduction
• Terminology
• Types of bleeding/classification of Haemorrhage
• Adverse effects of surgical bleeding
• Factors influencing surgical bleeding
• Mechanism of Haemostasis/Biology of Haemostasis
• Phases of Haemostasis
• Patient evaluation before surgery
• Laboratory tests for screening
• Characteristics of ideal Haemostatic agent
• Methods of Haemostasis
• Recent advances
• Conclusion
• References 
INTRODUCTION

In endodontics the procedures involved with bleeding

 Pulpotomy or pulpectomy
 Hemisection
 Bi cuspidization
 Curretage
 Perforation repair
 Intentional replantation
Endodontic surgery --

• Blood loss during endodontic surgical procedures - 10 ml

to less than 50 ml. Do not need to be concerned about
intravenous fluid or whole blood replacement, even
following prolonged endodontic surgery.
• Persistent minor oozing of blood is common, although
occasionally a bleeding episode prevents the continuation
of the procedure and requires immediate attention.
TERMINOLOGY

 Blood-It is a connective tissue in fluid form.

 Haemorrhage-It is defined as escape of blood from the

blood vessel to the exterior due to damage or injury to
the vasculature.

 Haemotoma- Accumulation of blood with in the tissues.

 Haemostasis- hemo=blood stasis=arresting

Complex and physiological process that stops
bleeding.
 Thrombosis-It is a kind of blood clot inside a blood
vessel, obstructing the flow of blood.

 Coagulants-A substance that causes clotting or

coagulation of blood.

 Anti-coagulants- A substance that prevents the blood

from clotting by suppressing the synthesis and function
of various clotting factors. Ex-heparin , warfarin.
Procoagulant- a substances that promote the conversion
inactive protein prothrombin to the clotting enzyme
thrombin.

 Haemostatic agent -a substance that promotes

haemostasis.
CLASSIFICATION OF HEAMORRHAGE
Based on nature of bleeding

Venous
Capillary
Haemorrhag
Arterial Haemorrhage:
e: Dark in
Heamorrhage Blood oozing.No
colour and
- Pulsative , bleeding point. Not
blood flows in
brisk, bright severe and is easily
a even stream.
red in colour. controlled by
Relatively
simple pressure
more flow
with gauze pads.
from veins.
Depending upon timing of haemorrhage

Primary bleeding: Occurs at the time of injury. Haemostatic

mechanisms in the body attempt to stop the bleeding by
formation of clot.

 Secondary bleeding: bleeding in the wound starts after 24

hours to several days.
It may be due to: (a) dislodgement of clot or
(b) secondary trauma to the wound,
(c) infection.
Intermediate bleeding/ Reactionary bleeding: within
8hr after stoppage of primary bleeding.
Loose foreign body like calculus, broken bone piece, and
preexisting extensive granulation tissues in the surgical
site .

Spontaneous Bleeding: without any provocation, e.g. in

acquired (patients with decreased platelets count) and
hereditary coagulopathies.
Based on source of bleeding

Internal Bleeding:
Bleeding that is confined within the body cavity and is not
apparent on the surface - concealed bleeding.

 External Bleeding:
Blood escaping through a wound in the skin - external
bleeding.
Based on volume of blood loss

i) Mild Hemorrhage: Blood loss ≤ 500 mL.

ii) Moderate Hemorrhage: Blood loss 500 – 1000 mL.

iii) Severe Hemorrhage: Blood loss ≥ 1 L.

Depending upon speed of blood loss:

 i) Acute Hemorrhage: Massive bleeding in short span of

time.

ii) Chronic Hemorrhage: Slow bleeding small in quantity

for long time.
ADVERSE EFFECTS OF SURGICAL BLEEDING

 Visual obstruction of the surgical field

 Reduction in core temperature

 Thrombocytopenia

 Hypovolemic shock
 
--Need for blood transfusions-volume loss
FACTORS INFLUENCING SURGICAL BLEEDING

Procedural factors- Patient factors-

1. Type of procedure 1. Specific anatomical
2. Patient position considerations
3. Surgical incisions 2. Medications (eg.
4. Exposed bone- Large Anticoagulants)
surfaces of exposed 3. Coagulopathies
capillaries 4. Platelet dysfunction or
5. Unseen sources of deficiency
bleeding 5. Fibrinolytic activity
6. Tissues that cannot be 6. Coagulation factor
sutured. deficiencies.
MECHANISM OF HAEMOSTASIS/BIOLOGY OF HAEMOSTASIS
PATIENT EVALUATION BEFORE SURGERY

o A careful physical examination should be done.

o Skin and mucosal surface.

o Petechia to large areas of ecchymosis is usually

characteristic of abnormalities of the vessels or the
platelets.

o Haemorrhage into synovial joints is virtually diagnostic of a

severe hereditary coagulation disorder .
• Family history –

 Vessels and platelets --are acquired

Ehlers-danlos syndrome
Vit-c deficiency
Hemangiomas
thrombocytopenia
polcythemia vera
Iron deficiency
thrombocytopathy
Serious coagulation disorders -hereditary-
90% males.

Hemophilia A ,B,C-bleeding from large vessels

Von willebrand disease.

 Vit-k deficiency
 Liver diseases
• History of surgery, major injury, or even multiple tooth
extractions with abnormal bleeding .

• Profuse and often life threatening hemorrhage following

trauma or surgical procedures .
• Conformed with diagnostic test.Physician.
LABORATORY TESTS FOR SCREENING

 Clotting Time –
Time taken to coagulate - 5-11min
increases in hemophilia, Liver Diseases
decreases in Typhoid, splenectomy.

 Bleeding Time - time required for stoppage of bleeding

after deep needle puncture.1-4min
-assess platelet function and capillary integrity.
-prolonged -DIC.thrombocytopenia,asprin,cyclooxygenase
inhibitors,purpura.
-reduced - thrombocytosis Asprin should stopped
7dys before surgery
 Capillary Resistance Test -capillaries to resist the pressure.

 Thrombin Time – 12-14sec

- time taken for a clot to form in plasma of a blood sample
containing anticoagulant.
-indicates abnormality in conversion of fibrinogen to fibrin.
- coagulation disorders-vit k def.liver disease.
 Partial Thromboplastin Time
-Checks the efficacy of Intrinsic system & common pathways.
- aPTT- 15-30sec.- factors 125891o 11 12

 Prothrombin Time/ INR – extrinisic pathway-

-Normal range:11-16 sec.
-Monitor anti coagulant thearapy-125710

 Platelet Count - 150,000-400,000/mm3 .

Decrease in- leukemia,viral infections,pernnicious anemia.
Increase in-bone marrow cancers.after splenectomy

 
 CHARACTERISTICS OF IDEAL HEMOSTATIC AGENT

No mixing simplicity
Capability to
Non irritant
stop bleeding

Long shelf life

Short period
Light weight
and durable
safe
visible

sterile
Cost effective
HEAMOSTASTIC AGENTS
HISTORICAL BACKGROUND

• Hippocrates used caustics to achieve hemostasis.

• 18th-Carnot introduced gelatin.

• Ferric sulphate-monsels -1857

• Bonewax-1892-horsley
• Oxidized cellulose(OC) - 1942

• Gelatin foam(GF) - 1945

• Oxidized Regenerated Cellulose - 1960

• Microfibrillar collagen (MFC)- 1970 by Hait

• Chitosan based agents - approved by FDA at 2003 .

• A Plant extract agents was registered in Turkey in 2007.

Sequence to achieve hemostasis during endodontic surgery.

2 to 3 Carpules of 1:50,000
I.Pre surgical epinephrine.
 multiple infiltration sites .

C.calcium sulfate - packed

A.Remove all granulation
against tissue.
the bone cavity.
II. Surgical
B. Epinephrine
D. Small pellet intosites
bleeding the bony
-
cryptbrushed
+ dry sterile
withcotton
ferric pellets-
sulfate 2
min. solution.

Text book of endodontics -Anil Kohli

 Tissue compression before
and after suturing.
Dressing of surgical site
III. Postsurgical
Cold pack
Reduce stress on suture line
 EPINEPHRINE

Local anesthesia has two distinct purposes: anesthesia and

haemostasis.
• Kim and Rethnam -epinephrine-cotton pellet technique
--most efficient in the bony crypt.

• Grossman first suggested the use of cotton pellets

saturated with 1:100 epinephrine .

• Ingle recommended packing the bony cavity with 2%

racemic epinephrine for 4 min.
• Sommer et al- epinephrine 1:500 or 1:1000, phenylephrine
1:100, or nordefrin 1:200 on saturated gauze packs.

• Racellets containing 1.5% racemic epinephrine

hydrochloride.

• May be effective-but leaving fibers.

CLASSIFICATION OF HEAMOSTATIC AGENTS

A. Heamostatic agents by mechanism of action

 MECHANICAL AGENTS-Bone wax

 CHEMICALAGENTS- Vasoconstrictors-
ephinephrine, Ferric sulfate
 BIOLOGICAL AGENTS- Thrombin
 RESORBABLE AGENTS- Calcium sulfate, gelfoam
Absorbable collagen
Microfibrillar collagen- Surgicel.

Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review.

Journal of Endodontics. 2006 Jul 1;32(7):601-23.
B.Depending on the site of action

1. Agents acting locally –

Ex-Thrombin , thromboplastin, fibrin, gelfoam,
oxycel , avitene.
1a..Astringent- Agents which precipitates superficial
proteins ,but do not penetrate cells -diminish the
excretion of superficial cells.

EX- tannic acid 1-5%, zinc chlorides,

ferric chlorides,zinc sulfate.
• 1b..Styptics-local heamostatics-are substances used to
stop bleeding from a local and approachable site-
effective on oozing surfaces.

EX- Gelatin foam,

Oxidized cellulose(as strips,absorbed in 1-4 weeks)
Thrombin-dry powder or solution
2. Systemically adimistered
• Fresh frozen plasma-octaplas
• Vit-K- 2,7,9,10
• Protamine Sulfate –heparin

Antifibrinolytics:
1. Aprotinin-(inhibits fibrinolysis.),
2.Epsilon amino caproic acid-iv inj –post op bleeding.
3.Tranexamic acid-antifibrinolytics
C. Classification by Ronald Hoffman

a.Physical agents-
-Bone wax and alkylene oxide copolymers (ostene).

b. Absorbable agents
-Gelatin foams -animal products 
- Oxidized cellulose -wood pulp
- Microfibrillar collagen - bovine components .

 
c.Biologic agents
-Plasma-derived thrombin.
- Recombinant forms of human thrombin.

d. Synthetic agents
- Octyl-2-cyanoacrylate - closing small wounds or
incisions and provides good cosmetic results.

-Polyethylene glycol hydrogel -sprayed onto tissues.

-Glutaraldehyde cross-linked bovine albumin .
METHODS OF HAEMOSTASIS
 Rebound phenomenon
Rebound vasodilatory effect
Reactive hyperemia

Tissue conce.vasopressor
Leads to post op bleeding
Interferes with wound
Restricted blood flow---returns
healing to normal
Impossible to re-establish
haemostasis
Rapidly increases far beyond normal

Not the result of beta receptor activity

Localized tissue hypoxia,acidosis caused by prolonged

vasoconstriction
 Direct pressure
MECHANICAL Fabric pads/sponges/gauzes
METHODS Sutures/staples/ligating clips
Hemostats-mosquito artery

• 1.Electro surgery –
 Monopolar
THERMAL  Bipolar
METHODS  Bipolar vessel sealing device
 Argon enhanced coagulation
• 2.Ultrasonic devices
• 3.lasers
 Epinephrine
pharmocological Vitamin k
Protamine
methods
Desmopressin
Lysine analogues
Ethamsylate
CHEMICAL
METHODS

A.Passive agents-
Collagen based
Topical methods Gelatin
Others-flowables and
Polysaccharide spheres
sealants
B.Active agents-
Thrombin products
 MECHANICAL METHODS

-- Compression of blood vessels.

A. Direct pressure
 Surgeon’s first choice.
 Simplest & fastest .
 Arterial bleeding > venous.

Disadvantage- Not recommended in major arteries.

B.Fabric pads/gauzes/sponges

 Application of direct pressure

 Packaging of body cavity
 No. of sponges used .
 Temporary measure.
• Disadvantage-only pressure is not sufficient to arrest
bleeding.
C.Sutures/staples/ligating clips
 Sutures and ties - tie off blood vessels .
1-stick tie and 2.regular tie.
 Staples- stapling device required –titanium staples.
 Ligating clips – quick & easy to apply
Disadvantages -1. Chances of tissue reaction, injury &
allergic reactions .
2. Site of application should be clearly
visible and accessible to apply clip.
D.Hemostat- forceps
5inches
Serrated
Small vessels
 THERMAL/ENERGY BASED METHODS

1. Electro-surgery or electro cautery

High frequency alternating current for cutting,
coagulating and vaporizing tissues .

A. Monopolar – current flows through the patient from

electrode to electrode- frequently used.

B. Bipolar – better on delicate tissues/small anatomical

structures .
• Current only passes through the tissue, not the patient’s
entire body.
C. Bipolar vessel sealing device
- Applies heat with high compression.
-Sealing and transecting vessels upto 7 mm dia.
D . Argon enhanced coagulation technology –A stream of
non combustible argon gas.
-Tip of coagulator is held 1cm from the tissues.
-Clears the surgical site - focused directly on the tissues.

Disadvantages - Patient injuries, user injuries.

2.Ultrasonic devices
 Electrical energy into mechanical energy-vibration .
 Cuts & coagulates .
 Less thermal damage to tissues.
 No current through body.

Harmonic ultrasonic
scalpal
3. Lasers

 Laser energy delivered to target site can be reflected,

scattered, transmitted or absorbed.
 Blood less field.
 Coagulated small vessels - incisions.

Soft-tissue ablative dental
lasers.
Eribium ,co2,ND:YAG
4.Cryosurgery- Extreme cold -20degree to -180.

• Disadvantage-small arterioles undergo cryogenic

necrosis-caused by dehydration and denaturation of
lipid molecules. -liquide nitrogen
 CHEMICAL METHODS

pharmacological agents

- Epinephrine
Vasoconstriction.
Topical or injected.
- Vitamin K
 Pre-operatively - reverse effects of warfarin.
 IV infusion
 2,7,9,10
-Protamine
• Reverse heparin anticoagulation.
• Anaphylais..

-Desmopressin
• Release of von Willebrand factor (vWF) & enhances
primary haemostasis.
• Reduces the perioperative bleeding.
-Lysine analogues.
• Aminocaproic acid, tranexamic acid.

• Antifibrinolytic and competitively inhibit activation of

plasminogen.-prevents prolonged post op bleeding

-Ethamsylate-
• Reduces capillary bleeding.
• Restoration of capillary endothelial resistance
• Increases platelet aggregation.
Topical haemostatic agents

1.Passive haemostatic agents- 
Accelerating the coagulation process.

physical, latticelike matrix

activates the extrinsic clotting pathway

platform for platelets to aggregate

form a clot. 
 2 to 5 minutes
Soft, white, pliable,
resorbed within 14 to 56
nonfriable, coherent,
days.
spongelike

Bovine Collagen -
deep flexor
tendons(OraPlug,
OraTape)
 

nontoxic,
nonpyrogenic, oozing or bleeding
Absorbent
purifying bovine attracts
collagen and platelets-trigger powder form
processing it platelet Spray-best.
into aggregation.
microcrystals

Microfibrillar
collagen

Avitene-1970
instat

Adhere to
instrumnts,gloves.
expensive.
 stabilize the clot
Promotes healing

are soft, white,

Hemostatic pliable, nonfriable,
Collagen- coherent, sponge-
like

CollaPlug, CollaTape,
Nontoxic and non and Helistat
pyrogenic.

to fill tissue voids-

are highly
extractions, biopsy
absorbent
procedures, periodontal
defects
 Resorbable alpha-
sterile fabric meshwork oxidized cellulose-poly
-mecanically-forms anhydroglucuronic acid
artificial coagulum

Cellulose Surgicel-
(Johnson & Johnson)
Ph-3

Exodontia .Removed
it swells into a –foreign body re.
brownish/black
gelatinous mass
.

affordable
Formation of
and
thrombin
Fibrin readily
strands accessible.
infiltration

dried and Gelatin Water

sterilized common insoluble
animal skin

porous,
pliable Resorbed
1940s as
sponge in 4 to 6
Gel foam
40 times weeks
spongostan

Swollen soft gelatinous mass-difficult to put pressure-may

displace-leads to bleeding
 converted to a gel that
Calcium provides moisture to the
alginatefibers-1978 wound bed-pot surgical
dressings

soft non-woven fibers

calcium salts of seaweed

biodegradable,
hydrophilic, non-
adherent, and highly
absorbent

contact with wound

exudate- soluble sodium pads ropes, or ribbons.
salt
Algiderm
Algisite
Algisorb, Algosteril
 HEMCON-97%

chitosan- derived from arthropod skeletons.

dual-sided 4 x 4 inch rectangular bandage

flexible and can break

active side which must be placed

HemCon was more difficult than other agents –not adherent

 Not
“Bone bleeder” recommended-
Non resorbable periradicular
surgery
88%Beeswax, Soft, malleable,
12%isopropyl nonbrittle wax-
palmitate, and no effect on
almond oil clotting mech.
Bone wax- Sir
Removed-delayed Victor Horsley-
healing. foreign 1892
body reaction
 Time consuming-
forms ferric ion- difficulty to crown and bridge
protein remove from impression,
complex(agglutinate marrow spaces pulpotomy, and
d protein complex) periradicular surgery.

20% solution
-Monsel’s solution Ferric sulfate 1–3 min
 Relatively
Biocompatible inexpensive
Resorbable
2-4w
Calcium
sulfate-
POP
Mechanical
Bony defects barrier-
GTR-barrier plug the
furcation vessel
repair
Powder
and liquid-
paste
 2.Active topical haemostatic
Agents have biological activity and directly participate at
the end of the coagulation cascade to induce a clot at the
site of bleeding.

Thrombin – Bovine thrombin

Only topical Human thrombin
In the late 1970s
application Recombinant
FDA

interaction with the

difficult to handle
Not recommended fibrinogen in the
and to deliver .
in peri. patient’s blood -
expensive.
fibrin clot.
3.Flowable Hemostat agents-

D-Stat® Flowable Hemostat
• Comprised of collagen, thrombin .
• Facilitates haemostasis by initiating the body’s own
clotting mechanisms.
• SURGIFLO-
 Haemostatic Matrix with thrombin.
 provides a matrix for platelet adherence.
 accelerating platelet plug.
 fibrin clot formation.

FLOSEAL - Gelatin Matrix granules+ Thrombin Component.

 Thrombin must be added to the
 Gelatin Matrix prior to use.
 Biocompatible
4.Fibrin sealant

• It is a two-component material consisting of fibrinogen

and thrombin.
• Bergel used fibrin first as a hemostat in 1909.
• Young and Medawar used it as an adhesive in 1940.

EVICEL-
Airless Spray Accessory is designed to deliver a rapid,
adherent.
TISSEEL

•To seal or glue tissue.

•Is made from human plasma- transmitting infectious

agents, e.g., viruses,

EVARREST- Fibrin Sealant Patch

-2inX4in

-Compression for 3 minutes

RECENT ADVANCES

TOPICAL APPLICATION AGENT: QUICKCLOT

o Frank Hursey
o Approved by FDA - 2002
o Contain kaolin(inorganic mineral)-accelerate natural
clotting .
o Faster and efficient.
o Mineral sponge that rapidly absorbs.
o Easy to use.
 SYSTEMICALLY USED AGENT: NOVOSEVEN

• It is recombinant factor VIIa for I.V-for hemophiliac

patients to control.
• Production of thrombin- formation of a stable clot.
• Not most commonly used.
 THERMAL AGENT: WATERLASE

• Revolutionary Er, Cr: YSGG Hydrokinetic laser.

• Its uses a unique Er, Cr: YSGG laser to energize
atomized water.
• It effectively cuts and coagulates soft tissues with no
effect on target organs.

Saquib I, sureshchandra B. Blood-less operating field–an endodontist’s enigma hemostasis in periradicular

surgery–a review.
CollaCote

• CollaCote saturated with 2.25% racemic epinephrine

provides excellent hemostasis with no evident changes in
blood pressure or pulse rate.
• Bleeding from periapex-difficult to obdurate-used as
apical stop.
ActCel-
2x2 ,4x4.
• Sterilized cellulose - Surgicel- slightly more friable.
• Form a gel –expands-pressure.
• Degrades- into glucose, water.-water soluble.

• Platelet aggregation and physically

by 3-D clot stabilization.
• Calcium availability.
Synthetic Bone Hemostat Material (Ostene )

• 2004 by the FDA.

• Mixture of water-soluble alkaline oxide copolymers .
• Dissolves in 48 hours.
•  Sterile peel pouches and is applied in a manner similar
to bone wax without the associated disadvantages.
 • Expasyl- (Aluminium chloride)

• It is a recent hemostatic agent in periapical surgery .

• No clinical studies have been published on the efficacy
and adverse reactions of this material.
• Foreign body reactions .- avoided by freshening the
bone crypt with rotary instruments and irrigation before
suturing.

Clé-ovejero A, valmaseda-castellón E. Haemostatic agents in apical surgery. A systematic review.

Medicina oral, patologia oral y cirugia bucal. 2016 sep;21(5):e652.
CONCLUSION-

Coagulation cascade –congenital diseases-unwanted

situation . Topical haemostatic agents may improve
blood conservation, avoid potential adverse events of
systemic haemostatic medications, reduce overall
procedure time, and contribute to faster patient recovery
times.

Familiarity with the products. Appropriate and

correct use of these products has the potential to
improve outcome.
REFERENCES-

• Human physiology-AK JAIN

• Review of Medical Physiology-W.E.Ganong.

• Essentials of Medical Physiology-A.Sembulingum.

• Endodontics 6-ingle.
• Pathways of the pulp-cohen
• Hemostasis basic principles and practice –7th edition by
Ronald Hoffman
• Consultative hemostasis and thrombosis-3rd edition by
Nicholas

• Avoiding complications in oral implantology-Randolph.

• Maestre ferrín l, peñarrocha diago m. Hemostatic

agents used in apical surgery: A review.
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endodontist’s enigma hemostasis in periradicular surgery–a
review.

• Jackson MR. Fibrin sealants in surgical practice: an

overview. The American journal of surgery. 2001 Aug
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practice: a review. Journal of endodontics. 2006 jul
1;32(7):601-23.
• Samudrala S. Topical hemostatic agents in surgery: a
surgeon's perspective. AORN journal. 2008 Sep
1;88(3):S2-11.

• Khoshmohabat H, Paydar S, Kazemi HM, Dalfardi B.

Overview of agents used for emergency hemostasis.
Trauma monthly. 2016 Feb;21(1).

• Sauveur G, Roth F, Sobel M, Boucher Y. The control of

haemorrhage at the operative site during periradicular
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