Effective Hemostasis and Tissue Management

INTRODUCTION
A common clinical challenge dentists face with restorative procedures is blood contamination. There are a variety of reasons that the gingiva can bleed, including from plaque, trauma, and/or an encroached biologic width. Plaque causes gingivitis, caries, and periodontitis. Trauma that happens during the restorative procedure can cause bleeding. Wedges can press laterally and aggressively against the gingival papilla, and metal or plastic matrix bands’ sharp edges can cut healthy/inflamed tissue during the isolation of the cavity. Burs are used to excise the caries, excise inflammatory tissue, and widen the gingival sulcus. Cords are packed to deflect or retract the gingiva in attempt to expose the cavity margin. Any of these events can result in blood contaminating the restorative field, thus negatively affecting impressions, cavity preparation, restorative materials, and cementation.
      There is an association between restorative care and periodontal health. An encroachment of the biologic width happens when the restorative margins are placed too deep within the sulcus. Inadequate restorations can have ledges or areas that are not cleansable, which can contribute to plaque accumulation. Adolescents and geriatrics alike can have poor oral hygiene. New restorations are often needed because plaque control has been compromised. In addition, a high-carbohydrate (sugary, carbonated beverages) and nutrient-poor (refined foods) diet is a primary contributing factor in the patient examples presented in this article.
      To eliminate gingivitis and a periodontal condition, there must be an accurate marginal fit of the restoration. A good example is a fixed prosthodontic restoration. The fit of the restoration is related to the completeness of the impression. An inadequate impression from blood contamination creates a problem with the restoration if the impression is forwarded to the dental laboratory. The impression will produce an inaccurate die due to negative voids or positive bubbles (Figure 1).

Figure 1. (Case 1) Blood has contaminated first impression to create voids.

     If the dental laboratory technician team fabricates a restoration to an inaccurate die, the dentist receives an unacceptable restoration that will be rejected. The doctor must reappoint the patient and send a new impression back to the lab. The revenue stream is broken for all involved. The patient may have to take time off from work, the dentist has to provide additional chair time, and the dental technicians involved in the case will be expected to accommodate the process.
      When there’s a problem, we tend to blame someone else. To the dentist, it feels like a personal failure, but it is often actually a systems failure. If the system is not corrected, profits for both the dentist and laboratory are negatively impacted. The challenge is to look at the system of controlling blood and fluids in the restorative treatment site to see how the technical steps and/or materials being used can be improved.
With case examples, this article will demonstrate how one can improve the quality of one’s indirect restorative work by changing his or her technique protocol (system) to effectively control bleeding and manage the soft tissues.

HEMOSTASIS: A CHALLENGE IN THE PRESENCE OF TISSUE INFLAMMATIOn
Case 1

The system that produced the defective impression seen in Figure 1 was a standard cord soaked in a hemostatic solution and a one-step impression. The cord was placed on inflamed tissues after restorative techniques were accomplished for subgingival caries. Subgingival caries required a subgingival core buildup, which led to a subgingival crown preparation. Inflamed tissue usually bleeds, and it was unlikely that the aforementioned system would have been able to effectively control bleeding during the impression-taking procedure.
      For this patient, a new impression was necessary to optimize the accuracy of the indirect technique in the dental laboratory. To correct a faulty system, a new impression-taking protocol needed to be utilized. One change that was incorporated into the impression retake steps included the use of Traxodent (Premier Dental Products). This paste system is used prior to taking impressions for both gingival retraction and hemostasis. Traxodent contains aluminum chloride (Hemodent) that causes contraction and shrinkage of tissues, protein to precipitate, blood vessels to contract, and fluids to be removed from tissues. Aluminum chloride paste also reduces the risk of postoperative inflammation. According to the scientific literature, it is the least irritating of the retraction medicaments.1 In addition, it produces no detectable recession of the gingiva after placement into the sulcus.
      Before retaking the impression, the bleeding tissue was rinsed, and attempts were made to dry the oozing area. A straight cannula was applied to the Traxodent syringe and, in this case, the cannula was formed over a mirror handle to make a 90° bend. The bend helps placement in the posterior regions of the mouth where direct access is not possible. The Traxodent paste was then applied on top of the bleeding tissue and slowly injected above the sulcus and around the periphery of the preparation margin. It should be allowed to remain in the sulcus from 1 to 2 minutes (Figure 2). When using Traxodent paste, one first notices that the gingiva blanches, and then, any oozing blood will become brown and stagnant. These are the 2 signs of hemostasis, ensuring a successful outcome of the impression.

Figure 2. Hemostatic paste (Traxodent [Premier Dental Products) was extruded into bleeding sulcus. (It is left in place for one to 2 minutes.) Figure 3. The impression was retaken. Note the blood-free retake impression without voids as a result of using a different and improved protocol (system).

     The paste was then rinsed thoroughly with an air-water spray and dried. Once these steps were done, hemostasis was achieved and the gingival sulcus was dry. A light and medium-body impression material (Honigum [DMG America]) was used to make a one-step impression (Figure 3).
The techniques employed in this case, Traxodent with Honigum, resulted in an excellent impression without additional cord packing. (Other impression materials/techniques could be used effectively as well.) Note also that a small amount of impression material has flowed beyond the prepared margin (Figure 3), allowing the dental technician to accurately trim the gypsum die. This will permit the fabrication of a precise fitting restoration.

HEMOSTASIS AFTER ROTARY CURETTAGE
Case 2

Figure 4. (Case 2) Blood and fluid were evident in the gingival trough. Figure 5. Hemostatic paste was placed in direct contact with the bleeding tissues.
Figure 6. A retraction cap (Premier Dental Products) adds pressure for additional gingival deflection. Figure 7. The hemostatic paste was rinsed away and dried, prior to taking the impression.

The tooth in Figure 4 had an amalgam core buildup supported by pins. The tooth needed the support of a full crown. It had a healthy sulcus and sufficient attached gingiva. The full crown here required the incorporation of a ferrule in the preparation design for an improved long-term prognosis. Creating the ferrule in this case required that the tooth be prepared to the bottom of the gingival sulcus. Rotary curettage with a high-speed diamond (Curettage GCP 254.SB [Premier Dental Products]) was used to trough and quickly excise the sulcular lining adjacent to the margin. Research shows that rotary curettage has little effect on the marginal heights of gingiva if adequate keratinized gingiva is present.2 Rotary curettage was also needed to create a 0.2-mm space in the sulcus to maintain adequate thickness of polyvinyl siloxane impression material. This thickness of impression material is needed to prevent tearing and to prevent distortion upon removal from the mouth.3 The removal of the sulcular lining resulted in bleeding (Figure 4). Traditional methods would require cord placement for 4 to 10 minutes for sulcular expansion. In this case, the Traxodent paste was placed for 2 minutes to stop the bleeding created by the rotary curettage (Figure 5). Additional deflection was achieved using a retraction cap (Premier Dental Products) (Figure 6). After thoroughly rinsing the paste off with an air-water spray, only amalgam debris remained. The sulcus was dry, and hemostasis had been effectively achieved (Figure 7).

HEMOSTASIS PRIOR TO CEMENTATION
Case 3

Bleeding is sometimes an unexpected event. In this case, when the temporaries were removed, there was bleeding throughout the treatment site (Figure 8).

Figure 8. (Case 3) Bleeding obscures finish lines. Figure 9. Hemostatic paste was applied to the inflamed and lacerated tissues and left in place for 2 minutes.
Figure 10. Hemostatic paste was rinsed away to expose finish lines. Figure 11. (Case 4) Veneer preparation with a bleeding sulcus.

     Many times the operator will encounter blood in a cementation site. If blood were to intermix with cement, it would be detrimental to the physical properties of the cement. If blood were to remain on the tooth prior to cementation of a restoration, it would function like a separating medium with a resultant loss of retention. Additional problems could include pulpal inflammation with sensitivity to a stimulus such as cold, heat, or pressure. Pulpal inflammation would initially be reversible; however, the potential for irreversible pulpitis and loss of the tooth are a possibility. Sometimes, the patient is aware of bleeding near the treatment site when flossing. More often, bleeding comes from not flossing the interproximal tissue regularly to remove plaque. The tissue becomes inflamed and poorly keratinized, and it will bleed with minimal stimulation. The gingival tissue has the signs of erythema owing to the proliferation of capillaries.
      In this case, Traxodent paste was applied immediately to the sulcular area (Figure 9). After 2 minutes, it was rinsed away, and the teeth were ready to receive their cemented crowns (Figure 10). Traxodent effectively controlled the bleeding and allowed for visualization/isolation of the treatment site for an intact cementation without contamination.

AESTHETIC ZONE TREATMENT
Case 4

In anterior aesthetics, it may not be desirable to create a trough around the margin with a bur, a cord, or laser since this may be detrimental to the aesthetic outcome. Cosmetic restorations are challenging because the preparation line is in close contact with the gingiva. When the root shade is very dark, it can create a dark line in the cervical area. Patients are aware of this problem as an aesthetic concern. Cord placement could lead to ulceration or inflammation of the junctional epithelium. The problem is that it is hard to accurately control the forces used in the placement of cord. If the facial gingiva is a thin biotype, there is a chance of gingival line migration. Other trauma, such as mechanical pressure or surgical trauma, can cause an undesirable migration of the gingival line away from the margin. Like Magic FoamCord (Coltène/Whaledent), using a hemostatic paste is a less traumatic method to dry the field and to achieve mild retraction of the tissue.4

Figure 12. The hemostatic paste was extruded with the cannula aligned parallel to tooth.

Figure 13. Hemostatic paste was then rinsed away.

Figure 14. Full gingival rebound at a 3-month recall. Ceramic veneer (Root Dental Lab) fabricated of Empress (Ivoclar Vivadent). Figure 15. (Case 5) The gingiva was inadvertently lacerated during caries excavation.

     The patient in Figure 11 has high aesthetic concerns and dislikes the dark and contrasting colors along the gum line. She presented with a fractured porcelain veneer that required replacement. The tooth had already been prepared at the crest of the gingival sulcus. The veneer was removed with a high-speed diamond bur, with the location of the margin left in the same location. Inadvertent bur contact to sulcular tissue resulted in lacerated areas that bled. To prepare the tooth for the impression-taking procedure, Traxodent was placed into the sulcus and allowed to remain (Figure 12). After 1 to 2 minutes, the tooth was rinsed with air-water spray and dried (Figure 13). A one-step impression (light body on the tooth and a medium-body tray material) produced an accurate impression without bubbles or voids. The replacement veneer was cemented with a subgingival margin. At the 3-month recall, the margin level remained stable and within the aesthetic zone (Figure 14).

HEMOSTASIS WITH DIRECT RESTORATIONS
Case 5

Blood contamination during a Class II filling has the same risk as a crown and bridge procedure. It can mean lengthening of the procedure for the patient and disruption of the patient schedule for the doctor.
      In this case, the problem began with interproximal caries (Figure 15). Interproximal hemorrhage can often be associated with caries. Caries seen on the radiograph is an approximation of the depth of the caries. In the mouth, the caries is often more extensive, and its removal requires an expansion in cavity size. Other times, the subgingival preparation is used to obtain an adequate resistance and retention form for clinical crown length. With these patients, bleeding is common and upregulated if the patient is on a blood thinner such as Warfarin, aspirin, or Plavix. Bleeding begins from the inflamed interproximal gingiva if it is touched with a bur during caries excavation.

Figure 16. Hemostatic paste was applied directly to the bleeding tissue. Figure 17. The hemostatic paste was rinsed away, revealing effective hemostasis.

     Bleeding can also occur during isolation procedures when the band, wedge, or rubber dam is placed in contact with inflamed tissue (Figure 16). In this case, Traxodent was applied to the bleeding area located in the deepest part of the interproximal box and allowed to remain for the recommended time (Figure 17). Then, it was rinsed away with air-water spray, dried, and hemostasis was confirmed. Visualization of the entire cavosurface was evident. The direct filling was then placed in a routine manner.

DISCUSSION
These case reports demonstrate a hemostatic system (Traxodent paste) that effectively addressed the common problem of bleeding in the restorative treatment sites. The paste has a thixotropic property that allows entrance into restrictive sulcular spaces and then remains in position. This property is important when treating the maxillary arch or the mandibular arch because the medicament remains in the sulcus, not in the vestibule or throat. Once applied, the product remains in position, even if contact is made by the tongue or cheek. This is important to the patient because it allows a less offensive procedure.
      In general, hemostatic agents are strong astringents that create a dry, puckering feel in the mouth with a sandpapery sensation. This delivery system is important to the dentist because it allows the medicament to remain with intimate contact and at full strength in the gingival sulcus, thus preventing the need for reapplication due to dilution by saliva or gravity runoff. The paste differs from liquid hemostasis agents because it has the ability to absorb fluids in a manner similar to Expasyl (Kerr) paste.
      Treatment sites adjacent to alveolar mucosa may communicate to deeper spaces. The operator should be aware of the problems of a poor treatment site that lacks attached, keratinized tissue. One precaution would be the risk of washing hemostatics into deep spaces between tissues where the product is not intended to be applied. Traxodent paste is intended to be injected on top of tissue, not submucosally. It is also not intended to be used for the treatment of gingivitis, periodontitis, or other conditions. The operator needs to supervise its application in the dental treatment site.

CONCLUSION
Hemorrhage is a common problem that is encountered during restorative procedures. Common causes are a plaque-induced erythema from gingivitis next to the treatment site or inadvertent instrumentation that lacerates gingival tissues in the restorative procedure. Any trauma to inflamed tissue or healthy tissue results in bleeding into the restorative field. Bleeding results in distorted impressions, unbonded fillings, and contaminated cements.
It is vital to control gingival bleeding and to manage the soft tissue without additional tissue damage to produce successful restorations for the dentist and patient.


References
  1. Dental Product Spotlight. Gingival Retraction. J Am Dent Assoc. 2002;133:653.
  2. Bennani V, Schwass D, Chandler N. Gingival retraction techniques for implants versus teeth: current status. J Am Dent Assoc. 2008;139:1361.
  3. Donovan TE, Chee WW. Current concepts in gingival displacement. Dent Clin North Am. 2004;48:433-444.
  4. Beier US, Kranewitter R, Dumfahrt H. Quality of impressions after use of the Magic FoamCord gingival retraction system—a clinical study of 269 abutment teeth. Int J Prosthodont. 2009;22:143-147.

Dr. Elledge graduated in 1983 from the University of Missouri, Kansas City (UMKC) School of Dentistry. He received his master’s in prosthodontics from the University of Minnesota in 1985. He teaches in the Department of Advanced Education in General Dentistry at UMKC and practices in Kansas City. He has lectured to dental societies throughout the United States and in 18 universities. He is one of Dentistry Today’s Leaders in Continuing Education and he lectures on restorative dentistry for the difficult dentition. He can be reached via e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Elledge received an honorarium from Premier Dental Products for writing this article. He has no other financial interests in any other products or services mentioned herein.