ENDODONTOLOGY BLOOD-LESS OPERATING FIELD AN ENDODONTIST S ENIGMA HEMOSTASIS IN PERIRADICULAR SURGERY A REVIEW

Transcription

1 AN ENDODONTIST S ENIGMA HEMOSTASIS IN PERIRADICULAR SURGERY A REVIEW Inamdar Saquib * Sureshchandra B. ** ABSTRACT It is indeed a very true saying that necessesity is the mother of all inventions. How true it is if we correlate this with the truly noble Medical & Dental fraternity. Researchers are working so hard as to provide humanity with the ultimate in dental care. This review article focuses on how to obtain a blood less field during endodontic peri-radicular surgery with special emphasis on the historical background and the latest in hemostyptic preparations. Effective hemostasis is critically important during endodontic microsurgery because uncontrolled bleeding in the surgical site obscures the anatomical landmarks guiding the surgeon, and it is therefore not surprising that one of the most frequently asked questions about endodontic microsurgery, is how to effectively manage bleeding in the osteotomy site and inside the bony crypt? Effective hemostasis is a pre-requisite for endodontic microsurgery and successful hemostasis begins with effective local anesthesia. Normally profound anesthesia with an agent containing 1: 50,000 parts epinephrine is adequate to achieve a blood free field. Lidocaine (2%) with 1: 50,000 epinephrine is the anesthetic of choice. Both buccal and lingual or palatal injections are required to achieve profound anesthesia and effective hemostasis In many cases, however, it is necessary to employ additional hemostatic preparations such as ferric sulfate solution, cotton pellets soaked with epinephrine, Bonewax, Gelfoam, Surgicel. Epinephrine pellets (Racellets) used alone or in conjunction with a ferric sulfate soaked pellet are effective topical hemostats when applied in the bony crypt with light pressure. True epinephrine allergy is extremely rare. Attempts to improve hemostasis by injection into soft or osseous tissues after the incision has been made are ineffectual because powerful vasodilators at the incision site over ride the effect of the vasoconstrictors. Surgeons must understand the normal clotting mechanism and normal clotting time of human blood; it takes several minutes for the blood to begin clotting. FOUR IMPORTANT STEPS INVOLVED IN HEMOSTASIS The injured blood vessel, in an attempt to reduce blood flow undergoes constriction due to spasm in the vessel wall Activation of platelets and formation of platelet plug. (Primary hemostasis). Activation of clotting mechanism and formation of clot leading to completion of secondary hemostasis. Fibrous organization of the clot or retraction of clot. * Senior lecturer, Dept. of Conservative Dentistry / Endodontics, Dayananda Sagar College of Dental Sciences Bangalore ** Principal, Prof. & Head of the Department Dept. of Conservative Dentistry & Endodontics, A. J. Institute of Dental Sciences, Mangalore 42

2 CLINICAL MANAGEMENT OF HAEM- ORRHAGE IN A NORMAL PATIENT 1. INCISION PLANNING 2. USE OF HEMOSTATS 3. HEMOSTASIS THROUGH APPLICATION OF PRESSURE 4. HEMOSTATIC AGENTS 5. HYPOTENSIVE ANESTHESIA & VASOCON STRICTORS THE USE OF HEMOSTATIC AGENTS IN PERIRADICULAR SURGERY (Reference Outline of oral surgery Kelley & Kay and Colour atlas of microsurgery in endodontics: Syngcuk Kim) MECHANICAL METHODS 1. PRESSURE 2. USE OF HEMOSTATS 3. SUTURES AND LIGATION THERMAL AGENTS 1. CAUTERY 2. ELECTROSURGERY 3. CRYOSURGERY 4. ARGON-BEAM 5. LASERS COAGULATOR Certain oragan, diode, Nd:YAG, Ho:YAG, Er, Cr: YSGG, Er: YAG and CO 2 lasers F.D.A approved. CHEMICAL METHODS LOCAL AGENTS 1. ASTRINGENTS AND STYPTICS (EXAMPLE: a. FERRIC SULFATE b. CALCIUM SULFATE c. TANNIC ACID 2. BONE WAX 3. THROMBIN 4. GELFOAM 5. OXYCEL 6. SURGICEL 7. FIBRIN GLUE 8. ADRENALINE SYSTEMIC AGENTS 1. WHOLE BLOOD 2. PLATELET RICH PLASMA 3. FRESH FROZEN PLASMA 4. CRYOPRECIPITATE 5. ADRENOCHROME MONO SEMICARBAZON AND ETHAMSYLATE CLASSIFICATION OF TOPICAL HEMOSTATIC AGENTS - (Reference: Colour Atlas of Microsurgery in endodontics: Syngcuk Kim) MECHANICAL - BONEWAX (Ethicon), CALCIUM SULFATE CHEMICAL - EPINEPHRINE, FERRIC SULFATE BIOLOGICAL - THROMBIN (Thrombostat Thrombogen) ABSORBABLE AGENTS INTRINSIC ACTION GELGOAM (Uphohn Co), ABSORBABLE COLLAGEN, MICROFIBRILLAR COLLAGEN HEMOSTATS EXTRINSIC ACTION SURGICEL (Johnson & Johnson) MECHANICAL ACTION CALCIUM SULFATE SURGIPLAST (Class Implant) NEWER APPROACHES FOR OBTAINING HEMOSTASIS 1. TOPICAL APPLICATION AGENT: QUICKCLOT Developed by Frank Hursey Approved by FDA in May 2002 Consists of mineral sponge that rapidly absorbs all but the blood s clotting factors. It is effective safe and easy to use 2. SYSTEMICALLY USED AGENT: NOVOSEVEN It is recombinant factor VII a for I.V. administration only Can be used in normal individuals but is of great importance when used in hemophiliac patients. This agents leads to enhanced production of thrombin, which brings about formation of a stable clot. 3. THERMAL AGENT: WATERLASE Revolutionary Er, Cr: YSGG Hydrokinetic laser for hard and soft tissues. This waterlase s patented hydrokinetic technology uses a unique Er, Cr: YSGG laser to energize atomized water. It effectively cuts and coagulates soft tissues with no effect on target organs. 43

3 A careful evaluation of the medical history of the person undergoing periradicular surgery is mandatory to rule out any systemic condition or bleeding diathesis Diseases, which can be encountered prior to endodontic surgery are 1. Diseases with defection coagulation a) Hemophilia b) Christmas disease 2. Conditions in which there is a hypoprothrombinemia 3. Thrombocytopenia 4. Abnormalities of capillaries a. Purpura b. Ehler Danlos Syndrome c. von Willebrand s disease d. Osler Weber Rendu disease e. Acute leukemias 5. Patients on antiplatelet and anticoagulant therapy. MANDATORY INVESTIGATIONS PRIOR TO SURGERY 1. Bleeding time 2. Clotting time 3. Prothrombin time 4. Thrombin time 5. Partial thromboplastin time 6. Activated partial thromboplastin time 7. Reptilase test SUMMARY AND CONCLUSION: Obtaining adequate hemostasis is of immense importance both intra operatively and post operatively. A proper diagnosis, detailed history and hematological examination are mandatory before planning an endodontic surgery. Management of bleeding reduce intra-operative and post-operative problems to a great extent. Moreover adequate visualization is necessary during surgery and this is possible if there is excellent hemostasis. The dentist should be well competent to manage any hemorrhage occurring during surgery. Hemostatic agents should be present during the time of surgery. The diseases already mentioned should be taken care off and physicians consent obtained before going ahead with the surgery. This will save a lot of trouble to the dentist and discomfort to the patient. Hemorrhagic diathesis can be fatal. Adequate post-operative instructions have to be given to the patient after surgery and he should be able to contact the dentist in case of any problems. The endodontist should be in town after he has performed the surgery to follow up the case and in case of unavoidable circumstances, he should give the patient under the care of a colleague in case he has to go out of station. All surgery patients should be recalled after 24 hours for follow-up. With the introduction of latest methods and materials to control bleeding life has become easier for the endodontist while performing periradicular surgery. REFERENCES: 1. Donald J. Coluzzi An overview of laser wavelengths used in dentistry- Dental clinics of North America 2000; 44(4): From the Internet ( 3. Kelley & Kay Outline of oral surgery Part II, Rudolf Beer, et al Colour atlas of dental medicine Endodontology, Syngcuk Kim, et al Colour Atlas of microsurgery in endodontics, Syngcuk Kim, et al Hemostasis in endodontic microsurgery. Dental clinics of North America 1997; 41(3): Witherspoon D.E. & Gutmann J.L. Haemostasis in periradicular Surgery. International endodontic journal 1996; 29:

4

5