Topical Hemostatic Agents

Many topical hemostatic agents are available (as listed above under �?Armamentariumâ), with differences in origin, action, ability to control bleeding, and effect on healing. No one topical hemostatic agent is ideal; each has disadvantages.

Epinephrine pellets

Epinephrine pellets applied to the bone crypt produce an immediate local vasoconstriction with only minimal absorption into the systemic circulation. First a cotton pellet is applied against the palatal bone walls and left there until the end of surgery, when is removed before final irrigation. It can be substituted by Collacote saturated with 10 drops of 2.25% racepineph-rine inhalation solution33 that is biocompatible and does not interfere with wound healing.

Ferric sulfate

With a very low pH, it acts to produce agglutination of blood proteins that form plugs that occlude the capillary orifices. The immediate dark coagulum produced is useful for identifying the source of persistent bleeders. Because ferric sulfate is cytotoxic, it can cause tissue necrosis, foreign body reaction and abscess formation, and delay healing when left in place. It should be completely removed from the surgical area before suturing.

Calcium sulfate

Calcium sulfate acts by blocking mechanically open vessels: the tampon effect. It is used when filling the bone crypt and carving away the excess to expose the root. After surgery it can be left in place because it does not inhibit bone formation37 and it acts as a scaffold for osteoblasts and a barrier against faster growing soft tissue. It is totally absorbed by the body within 3 weeks.

Surgical wax

Surgical wax contains beeswax (88%) and isopropyl palmitate (12%) and acts by a the tampon effect - blocking all vascular exists with moderate pressure. Because it has to be completely removed from the surgical area before suturing, it should not be used in surgery that involves perforation of the maxillary sinus in view of the risk of it being pushed into the sinus. Bone wax retards bone healing, predisposes the surgical site to infection38 by producing a chronic inflammatory foreign body reaction39 and impairing the clearance of bacteria40, so it can no longer be recommended.

Thrombin

Thrombin is a bovine prothrombin that coagulates the blood fibrinogen to form the blood clot.

Gelfoam

Gelfoam is a gelatine sponge made from animal skin, insoluble in water and biologically resorbable, that acts intrinsically by promoting platelet disintegration and thromboplastin release41. The initial reaction to Gelfoam in the surgical site is a decrease in the rate of healing. However, this effect is transitory and does not appear to impair long-term bone healing.

Surgicel

Surgicel is an oxicellulose that acts mechanically by blocking the open vessels by the tampon effect. It does not enhance the clotting cascade through adhesion or aggregation of platelets. It is retained in the surgical wound and healing is retarded.

Collagen

Collagen stimulates and aggregates platelets, which release coagulation factors. Collagen shows minimal interference in the wound healing process, it does not increase the incidence of infection, and only slightly delays early bone repair without a foreign body reaction.

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