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The influence of hemostatic agents on dentin

and enamel surfaces and dental bonding: A
systematic review
Karina de Oliveira Bernades, Leandro Augusto
Hilgert, Ana Paula Dias Ribeiro, Fernanda
Cristina Pimentel Garcia and Patrcia Nbrega
Rodrigues Pereira
JADA 2014;145(11):1120-1128
10.14219/jada.2014.84
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ORIGINAL CONTRIBUTIONS

ARTICLE 2

The influence of hemostatic agents

on dentin and enamel surfaces
and dental bonding
A systematic review
Karina de Oliveira Bernades, DDS;
Leandro Augusto Hilgert, DDS, MS, PhD;
Ana Paula Dias Ribeiro, DDS, MS, PhD;
Fernanda Cristina Pimentel Garcia, DDS, MS, PhD;
Patrcia Nbrega Rodrigues Pereira, DDS, PhD

avity preparation procedures often

cause gingival bleeding, which may be
a result of tissue trauma or gingival inflammation.1,2 In addition, the need to
control moisture and contamination is common
in restorative dentistry, especially when rubber
dam isolation is not feasible.3 In these cases,
hemostasis becomes of utmost importance in
maintaining the ideal, contaminant-free operatory field.4,5
The most common procedures used to control bleeding and decrease the flow of gingival
fluid involve the use of a topical hemostatic
agent.6,7 These agents are based on two categories of pharmacological action: astringents
(blood coagulation factors) and vasoconstrictors (adrenergic agents).5,8 Meanwhile, the use
of these agents raises doubts about whether
bonding on hemostatic-contaminated dentin
and enamel results in decreased bond strength.
Abundant information is available regarding the local effects of hemostatic agents on the
Dr. Bernades is a graduate student, Department of Dentistry,
School of Health Sciences, University of Braslia, Brazil.
Dr. Hilgert is a professor, Department of Dentistry, School of
Health Sciences, University of Braslia, Brazil.
Dr. Ribeiro is a professor, Department of Dentistry, School of
Health Sciences, University of Braslia, Brazil.
Dr. Garcia is a professor, Department of Dentistry, School of
Health Sciences, University of Braslia, Brazil.
Dr. Pereira is a professor, Department of Dentistry, School
of Health Sciences, University of Braslia, Campus Darcy
Ribeiro, CEP: 70910-900, Brazil, e-mail patriciap@unb.br.
Address correspondence to Dr. Pereira.

abstract
Background. Hemostatic agents have been used clinically in
dentistry for many years to control bleeding. The authors reviewed
scientific publications in which researchers investigated the effects of
hemostatic agents on dentin and enamel surfaces and on bonding of
adhesive systems and resin cements.
Types of Studies Reviewed. The authors screened PubMed
and Scopus databases for studies in English published from 1980
to 2013. They read the titles and abstracts to identify literature that
fulfilled the inclusion criteria. The authors included studies in which
researchers evaluated the hemostatic action on the dentin and enamel
surfaces or its influence on the bond strength of adhesive systems or
resin cements. They used cross-referencing to identify more articles.
Results. Twenty in vitro studies met the inclusion criteria. Investigators in 12 of these studies evaluated the bond strength to contaminated dentin. Investigators in 10 of these studies reported a significant decrease in bond strength. Those in two studies evaluated the
influence of a hemostatic agent on the dental enamel and reported
decreases in bond strength. Researchers also reported significant
increases in microleakage of self-etching adhesives on contaminated
dentin. Scanning electron microscopy revealed partial removal of the
smear layer or an etching effect of dentin as a result of the application
of hemostatic agents on dentin.
Practical Implications. Adhesive procedures may be affected
adversely when performed on dentin and enamel contaminated by
hemostatic agents. Hemostatic agents may induce changes in the
dentin surface morphology. The results of this review indicate that
the bond strength of self-etching adhesive systems is affected more
negatively than is that of etch-and-rinse systems. The authors found
that a 60-second application of ethylenediaminetetraacetic acid followed by a water spray restored the bond strength of a self-etching
adhesive to dentin; use of phosphoric acid for 15 seconds followed by
a water spray also was an effective cleaning method. Direct comparison of selected studies was not possible, however, mainly because of
methodological differences hampering definitive conclusions.
Key Words. Bonding agents; adhesives; aluminum chloride; cementation; dental adhesives; dental bonding; hemostasis.
JADA 2014;145(11):1120-1128.
doi:10.14219/jada.2014.84

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ORIGINAL CONTRIBUTIONS

surrounding soft tissue,9-11 but little is known about their

effect on enamel and dentin substrates on hybridization.
Nevertheless, it is becoming increasingly important for
clinicians to recognize changes in dental composition and
microstructure that may occur after the application of
hemostatic agents when they plan restorative procedures
that depend on dentin and enamel bonding. The purpose
of this systematic review was to assess the influence of hemostatic agents on bonding of adhesive systems and resin
cements to contaminated tooth surfaces and to analyze
their effect on the tooth surface morphology.

which researchers evaluated the cytotoxicity of hemostatic agents on human gingival fibroblasts.
Data extraction. One of us (K.O.B.) extracted the following data from the included studies and entered them
into electronic spreadsheets: authors, year of publication,
hemostatic agent, contamination time, cleaning method,
adhesive system or resin cement, bond strength test and
any other tests used (Table 112-31). We did not perform any
statistical analysis or meta-analysis owing to both methodological differences and differences in the combinations of
materials used to create the experimental groups.

METHODS

RESULTS

Data sources. We based identification of studies to be

considered for inclusion on a search strategy involving
two electronic databases (PubMed and Scopus). We included studies published from 1980 to 2013. This period
covered the time during which studies were published
that had a focus on hemostatic agents and their influence on dentin and enamel substrates and on dentin and
enamel bonding of adhesive systems and resin cements.

The searches yielded 574 citations. In total, we investigated 33 full-text studies, 20 of which qualified for this
review (Figure 1, page 1124). We did not locate any additional articles by means of cross-referencing.
All of the investigations were in vitro laboratory
studies published in English. Investigators in all but
two studies22,29 used extracted human teeth, and those
in three of the 18 studies used primary teeth.15,18,23 We

Energy-dispersive x-ray spectroscopy data showed more

aluminum and ferric remnants in the groups with contaminated dentin
after the dentin surface was treated with self-etching primers
than in the groups treated with phosphoric acid as part of the
etch-and-rinse systems.
We prepared the following search strategy according to
Medical Subject Headings terms related to the research
question: hemostatic OR vasoconstrictor agents
OR ferric sulfate OR ferric chloride OR aluminum
chloride in association with (AND) dental cement
OR dental bonding OR resin luting agent OR dental
enamel OR dentin. The search strategy was modified
appropriately for each database. One investigator (K.O.B.)
screened all titles revealed by this research strategy and
searched the abstracts to identify articles that might be
of relevance. The reference lists of all eligible studies also
were hand-searched for additional relevant publications.
The same investigator evaluated the complete articles to
decide whether to include or exclude the selected studies.
Inclusion and exclusion criteria. We considered four
main aspects when identifying reports for inclusion:
substrate, type of hemostatic agent, cleaning procedures
and evaluation method. We identified the articles on the
basis of the following inclusion and exclusion criteria.
We included studies if the investigators evaluated the
hemostatic action on the dental surface or its effect on
the bond strength of adhesive systems or resin cements.
We accepted permanent and primary human teeth, as
well as bovine teeth, for the review. We excluded studies
in which researchers evaluated hemostatic effectiveness
in bleeding control or effectiveness in pulpotomy and
endodontic procedures. Also excluded were studies in

assessed 16 hemostatic agents (Table 2, page 1125). These

included both self-etching and total-etching systems,
but researchers in only six studies reported results of
comparisons between them.15,17,19,21,26,30 Researchers in
only one study evaluated a self-adhesive resin cement.20
In only two studies did researchers evaluate the influence
of the hemostatic agent on the dental enamel.29,31 These
researchers assessed two orthodontic adhesives in their
studies.
We found no standardization among studies regarding the contamination methods. Researchers in some
studies applied the hemostatic agent on the dentin
surface by using a microbrush,22,25,27,28,30 some dripped
a drop of the solution on the dentin,14,21,29,31 and others
soaked the dentin specimens for days in a receptacle
containing the solution.18,23 Investigators in one study
placed the dentin specimens on gauze soaked in the hemostatic agent, which was sealed in a closed container,15
and those in two studies submerged the dentin specimens in the hemostatic agent for different application
times.25,28 Investigators in other studies did not specify
clearly the contamination methods used.16,17,19,20,24,26 In
ABBREVIATION KEY. EDS: Energy-dispersive x-ray
spectroscopy. EDTA: Ethylenediaminetetracetic acid. FTIR:
Fourier transform infrared spectroscopy. SBS: Shear bond
strength. SEM: Scanning electron microscopy.
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ORIGINAL CONTRIBUTIONS

TABLE 1

Summary of main characteristics of studies included in the review

(in order retrieved).
SOURCE

HEMOSTATIC
AGENT *

Land and
Colleagues,12
1994

Astringedent

Land and
Colleagues,13
1996

CONTAMINATION
TIME

CLEANING
METHOD

ADHESIVE
SYSTEM
OR
LUTING AGENT

BOND
STRENGTH
TEST

SURFACE
ANALYSIS OR
OTHER TEST

Five-second wash with

air-water syringe, followed
by 10-second spray and
15-second rinse

None

Not
conducted

SEM

Astringedent,
30 seconds/
Hemogin L,
two minutes/fi ve
Hemodent,
minutes
Cranberry Styptin,
Gingi-Aid
Astringent 25%,
Orostat 8%, Visine
Original, Ocuclear

Three-phase irrigation cycle in

water followed by 10-second
spray with multifunction
syringe

None

Not
conducted

SEM

Ayo-Yusuf and
Colleagues,14
2005

Hemodent,
Astringedent,
Ultradent buffered
25% aluminum
chloride

30 seconds/
one minute/two
minutes/
fi ve minutes

Air-water spray
for 10 seconds

None

Not
conducted

SEM, EDS

Salama,15 2005

Astringedent

48 hours

Rinse with tap water for 15

seconds

Prime & Bond NT,

OptiBond Solo
Plus

SBS

None

Kimmes and
Colleagues,16
2006

ViscoStat,
ViscoStat Plus

One minute

Rinse with water spray for one

minute

OptiBond Solo
Plus

SBS

None

Kuphasuk and
Colleagues,17
2007

Racestyptine

Two minutes

Rinse with water spray for 30

seconds

Clearfil SE Bond,
Excite

Micro-SBS

SEM, EDS

Prabhakar and
Bedi,18 2008

Astringedent

48 hours

Rinse with tap water for 15

seconds

Adper Prompt
L- Pop, Clearfil SE
Bond

SBS

None

Two minutes

Rinse with water spray for 30

seconds

ED Primer II/
Panavia F, Excite
DSC/Variolink II

Micro-SBS

SEM, EDS

Harnirattisai and Racestyptine

Colleagues,19
2009

30 seconds/
two minutes/fi ve
minutes

* The manufacturers of the hemostatic agents are as follows: Astringedent, Ultradent Products, South Jordan, Utah; Hemogin L, Dux Dental, Oxnard,
Calif.; Hemodent, Premier Dental Products, Plymouth Meeting, Pa.; Cranberry Styptin, Dux Dental; Gingi-Aid Astringent 25%, Gingi-Pak, a division
of The Belport Co., Camarillo, Calif.; Orostat 8%, Gingi-Pak; Visine Original, McNeil-PPC, Lancaster, Pa.; Ocuclear, Health Care Products, Memphis,
Tenn.; Ultradent buffered 25% aluminum chloride, Ultradent Products; ViscoStat, ViscoStat Plus and ViscoStat Clear, Ultradent Products; Racestyptine,
Septodont, Saint-Maur-des-Fosss, France; Ferric Subsulfate Dental Gel, Bealls Compounding Pharmacy, Puyallup, Wash.; Ankaferd Blood Stopper,
Ankaferd, Istanbul; Hemostop, Dentsply International, York, Pa.
The manufacturers of the adhesive systems or luting agents are as follows: Prime & Bond NT, Dentsply, York, Pa.; OptiBond Solo Plus, Kerr, Orange,
Calif.; Clearfil SE Bond, Kuraray, Tokyo; Excite, Ivoclar Vivadent, Schaan, Liechtenstein; Adper Prompt L-Pop, 3M ESPE, St. Paul, Minn.; ED Primer II
and Panavia F, Kuraray; Excite DSC and Variolink II, Ivoclar Vivadent; Rely X Unicem, 3M ESPE; All Bond SE, Bisco, Schaumburg, Ill.; Solobond M,
VOCO, Cuxhaven, Germany; Clearfil Tri-S Bond, Kuraray; Adper Easy One, 3M ESPE; AdheSE and AdheSE One, Ivoclar Vivadent; Tetric N-Bond, Ivoclar
Vivadent; Single Bond, 3M ESPE; iBond, Heraeus Kulzer, Hanau, Germany; Transbond XT, 3M Unitek, Monrovia, Calif.; Clearfil S3 Bond, Kuraray; Light
Bond, Reliance Orthodontic Products, Itasca, Ill.
SEM: Scanning electron microscopy.
EDS: Energy-dispersive spectroscopy.
SBS: Shear bond strength.
# EDTA: Ethylenediaminetetraacetic acid.

addition, we found enormous differences in contamination

periods (10 seconds to 48 hours).
Overall, among the 20 included studies, investigators in
10 of them evaluated the bond strength of self-etching adhesive systems to contaminated dentin15,17-19,21,23,24,26,28,30;
those in eight of these studies reported a significant decrease in bond strength.15,17,18,21,23,24,26,30 Investigators
in seven studies evaluated the bond strength of
etch-and-rinse adhesive systems to contaminated
dentin15-17,19,21,26,30; in three of these studies, investigators

reported a significant decrease in bond strength,15,21,30

whereas in one study, investigators reported a significant
increase in bond strength.17 Figure 215-21,23,24,26,28 (page
1126) shows these results in greater detail. Researchers in the one study that evaluated the bond strength
of a self-adhesive resin cement to contaminated dentin
also reported a significant decrease in bond strength to
specimens rinsed with water only.20 However, because
these researchers evaluated bond strength after dentin
contamination with blood followed by application of the

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ORIGINAL CONTRIBUTIONS

TABLE 1 (continued)

SOURCE

HEMOSTATIC
AGENT *

CONTAMINATION
TIME

CLEANING
METHOD

ADHESIVE
SYSTEM
OR
LUTING AGENT

BOND
STRENGTH
TEST

SURFACE
ANALYSIS OR
OTHER TEST

Chaiyabutr and
Kois,20 2011

ViscoStat Clear,
Ferric Subsulfate
Dental Gel

Five minutes

Rinse with water spray for

20 seconds, clean with
37% phosphoric acid for
15 seconds and rinse for
10 seconds or clean with
aluminum oxide abrasion and
rinse using water spray

Rely X Unicem

SBS

SEM

Arslan and
Colleagues, 21
2012

Ankaferd Blood
Stopper

Not specified

No cleaning or use 37%

phosphoric acid

Clearfil SE Bond,
All Bond SE,
Solobond M

SBS

SEM

Mohammadi and
Colleagues, 22
2012

Hemostop

Two minutes

Rinse with water spray for 30

seconds

Clearfil Tri-S Bond

Not conducted

Microleakage

Shalan and
Colleagues, 23
2012

Astringedent

48 hours

Rinse with tap water for 15

seconds

AdheSE One

SBS

SEM, Fourier
transform
infrared
spectroscopy

Ajami and
Colleagues, 24
2013

Hemostop

Two minutes

No cleaning or use highpressure water spray for fi ve

minutes, 10% EDTA # solution
for 60 seconds followed by
water spray for 30 seconds or
35% phosphoric acid for 15
seconds followed by water
spray for 30 seconds

Clearfil Tri-S Bond

SBS

SEM, EDS

Arslan and
Colleagues, 25
2013

Ankaferd Blood
Stopper

Not specified

No cleaning, air-dry only

Clearfil SE Bond,
Adper Easy One

Not conducted

Microleakage

Ebrahimi and
Colleagues, 26
2013

ViscoStat

60 seconds

Rinse with water spray for 60

seconds

AdheSE, AdheSE
One,
Tetric N-Bond

SBS

None

Kumar and
Colleagues, 27
2012

ViscoStat

10 seconds

Air-water spray for 10 seconds

Single Bond,
iBond

Not conducted

Microleakage

Kilic and
Colleagues, 28
2013

Ankaferd Blood
Stopper

20 seconds

Rinse with water spray for 10

seconds

ED Primer II/
Panavia F

Microtensile
bond strength

None

Trakyali and
Oztoprak, 29 2010

Ankaferd Blood
Stopper

Not specified

No cleaning, air-dry only

Transbond XT

SBS

None

Ulusoy and
Colleagues, 30
2011

Ankaferd Blood
Stopper

10 seconds

Air-water spray for 15 seconds

Prime & Bond NT,

Clearfil S3 Bond

Microtensile
bond strength

None

Gngr and
Colleagues, 31
2013

Ankaferd Blood
Stopper

Not specified

No cleaning, air-dry only

Light Bond

SBS

None

hemostatic agent,20 we considered the contamination to

be a consequence of both and not a result of the hemostatic contamination alone.
The results of two studies in which researchers evaluated the influence of hemostatic contamination on bonding to enamel showed a significant decrease in bond
strength in the contaminated group.29,31
The results of all studies in which investigators
evaluated microleakage showed a significant increase in
leakage of self-etching adhesives on contaminated dentin
(P < .05).12,25,27 The scanning electron microscopy results

showed that each hemostatic agent had a distinct effect

on the dentin surface. In addition, this adverse effect
increased as a function of time.12-14 Land and colleagues13
reported that a two-minute exposure to 15.5 percent
ferric sulfate resulted in severe etching comparable
with a five-minute exposure to a 21.3 percent aluminum
chloride agent. Similarly, Chaiyabutr and Kois20 reported
that during the same length of time, dentinal tubules in
groups assigned to an aluminum chloridecontaining
agent mainly were occluded, with partial removal of the
smear layer. In the ferric sulfate groups, the dentinal
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Records identified through

PubMed database screening
(n = 275)

Records identified through

Scopus database screening
(n = 299)

Total records screened

(n = 574)

Duplicated articles
(n = 25)

Included

Eligibility

Screening

Identification

ORIGINAL CONTRIBUTIONS

Full-text articles
assessed for eligibility
(n = 58)

Records excluded
(n = 516)

Full-text articles excluded

(n = 13)

Studies included in
systematic review
(n = 20)

Figure 1. Flow chart of the literature search process.

tubules exhibited a more pronounced etching effect.

The results of other studies confirmed the effect of
two nondental astringents containing tetrahydrozoline
hydrochloride that are used commonly as eye drops.5,13
The authors noted that a five-minute exposure of dentin
to these nondental astringents did not result in statistically significant smear layer removal or etching of the
dentin surface, thus suggesting a possible use in
dentistry.5
Energy-dispersive x-ray spectroscopy (EDS) data
showed more aluminum and ferric remnants in the
groups with contaminated dentin after the dentin
surface was treated with self-etching primers than in
the groups treated with phosphoric acid as part of the
etch-and-rinse systems.14,17,19,24 Researchers in one study
found that 4.76 percent of the aluminum remained in
dentin specimens conditioned with self-etching primers
compared with 0.46 percent in specimens conditioned
with phosphoric acid.17 Investigators in a second study
detected 2.46 percent of aluminum remnants in dentin
specimens after conditioning with a self-etching system

compared with 0.46 percent in dentin specimens in the

etch-and-rinse group.19 EDS analysis also showed a less
dramatic reduction in calcium content when hemostatic
agents were used.14
DISCUSSION

In this review, we selected studies pertaining to hemostatic effects on both dentin and enamel surfaces and
dentin and enamel bonding. Because the use of hemostatic agents is routine in clinical procedures, understanding their effects on dentin morphology, as well as
on the enamel surface and on bonding, is of unquestionable importance. However, owing to the lack of similarities in methodological criteria between the studies in our
review, we found it difficult to draw definitive conclusions. Crossover analysis among studies was limited
because of the few similarities between them; therefore,
conducting a statistical analysis was not feasible.
Hemostatic agents are acidic solutions, with pH values ranging from 0.7 to 2.0.12-14,17,19 Aluminum chloride
and ferric sulfate were the main active ingredients in

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ORIGINAL CONTRIBUTIONS

most of the hemostatic agents studied in this review. In

the presence of water, these compounds undergo hydrolysis and form hydrochloric acid and sulfuric acid, respectively. Because both are strong acids, they may cause the
etching effect observed on the dentin surface.12-14,17,20
Contaminants. At the same time, contaminants,
such as remaining particles of the hemostatic agent, may
obstruct the flow of resin monomers into the dentinal
tubules. Small contaminant particles may penetrate the
dentinal tubules and, ultimately, affect the development
of the hybrid layer.32 Prabhakar and Bedi18 pointed out
that one possible explanation for the reduced shear bond
strength associated with ferric sulfate could be the coagulation of plasma proteins in the dentinal fluid, which
also might affect the surface architecture of the dentin.
In addition, for the specimens in the aluminum chloride
groups, the deposition of aluminum in the form of unbound minerals on the dentin surface and the formation
of a layer of residue may be responsible, in part, for the
decrease in bond strength.24
The study findings suggest that self-etching monomers may not remove these contaminants sufficiently,
because their bonding ability depends on forming short
resin tags and a relatively thin submicron hybrid layer.
Self-etching monomers may not readily etch a more
acid-resistant dentin surface that is contaminated with
a hemostatic agent.24 As a result, self-etching adhesive
systems are more susceptible to reduced bond strengths
after contamination because the smear layer is used as
a bonding substrate.30 However, phosphoric acid, with
a pH of 0.516 and an aggressive etching effect, seems to
be able to demineralize the dentin and remove virtually
all of the contaminant on the dentin surface. Therefore,
the phosphoric acid in etch-and-rinse systems may have
acted as a cleaning agent.
Support for this speculation can be found in the EDS
results, which showed a similar amount of aluminum remaining on the surfaces of uncontaminated and contaminated dentin after undergoing etching with phosphoric
acid. These findings differ from those in the self-etching
groups, in which more aluminum remained on the
contaminated dentin surfaces; thus, this may explain, in
part, why these surfaces seemed to be affected more by
the hemostatic agents.14,17,19,24,30
Blood versus hemostatic agent. Although study findings have shown that hemostatic agents have a negative
effect on the bond strength of the majority of adhesive
systems, results also have shown that in the presence of
blood, use of a hemostatic agent still is necessary. Some
researchers evaluated specimens in blood-contaminated
groups, in blood-contaminated groups followed by
hemostatic agent contamination, and in hemostatic
agentcontaminated groups without blood contamination.28-31 Their findings show lower bond strength
values for specimens in blood-contaminated groups.
When investigators used hemostatic agents after blood

TABLE 2

Hemostatic agents tested in studies.

HEMOSTATIC AGENT

MANUFACTURER

ACTIVE
INGREDIENT *

Astringedent

Ultradent Products,
South Jordan, Utah

15.5 percent ferric

sulfate solution

Ultradent Buffered
Aluminum Chloride

Ultradent Products

25 percent aluminum
chloride solution

ViscoStat

Ultradent Products

20 percent ferric
sulfate solution

ViscoStat Plus

Ultradent Products

22 percent ferric
chloride solution

ViscoStat Clear

Ultradent Products

25 percent aluminum
chloride gel

Ferric Subsulfate
Dental Gel

Bealls Compounding
Pharmacy, Puyallup,
Wash.

13 percent ferric
sulfate gel

Hemogin L

Dux Dental, Oxnard,

Calif.

25 percent aluminum
chloride aqueous
solution

Hemodent

Premier Dental
Products, Plymouth
Meeting, Pa.

21.3 percent
aluminum chloride
aqueous/glycol
solution

Cranberry Styptin

Dux Dental

20 percent aluminum
chloride buffered
glycol solution

Gingi-Aid
Astringent 25%

Gingi-Pak, a division
of The Belport Co.,
Camarillo, Calif.

25 percent aluminum
chloride solution

Orostat 8%

Gingi-Pak

8 percent racemic
epinephrine solution

Visine Original

McNeil-PPC,
Lancaster, Pa.

Tetrahydrozoline
hydrochloride
solution

Ocuclear

Health Care Products, Oxymetazoline

Memphis, Tenn.
solution

Racestyptine

Septodont, SaintMaur-des-Fosss,
France

25 percent aluminum
chloride solution

Hemostop

Dentsply
International, York,
Pa.

Aluminum chloride
solution

Ankaferd Blood
Stopper

Ankaferd, Istanbul

Natural plant extract

(Thymus vulgaris,
Vitis vinifera,
Glycyrrhiza glabra,
Alpina officinarum
and Urtica dioica)

* Active ingredient information was obtained from the studies in the

review.

contamination, bond strength values increased, but they

still were lower than those in groups contaminated with
hemostatic agent only. These bond strength values, in
turn, were substantially lower than those in the uncontaminated groups.30
Bonding to enamel. Researchers in two studies
evaluated the influence of hemostatic contamination on
bonding to enamel; they pointed out that the SBS in the
contaminated dentin specimens may have been lower
than that in uncontaminated specimens owing to the
possible prevention of contact between the tooth enamel
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e
ate
ulf lorid
h
ic S
err rric C
tF
en nt Fe
c
r
Pe
rce
20 2 Pe
2

50
40
30

25 Percent
Aluminum Chloride

25 Percent
Aluminum Chloride

20

Ankaferd
Blood Stopper
Ankaferd
Blood Stopper

15.5 Percent
Ferric Sulfate

20 Percent
Ferric Sulfate

15.5 Percent
Ferric Sulfate

Aluminum Chloride
e

Ankaferd
Blood Stopper

10

15.5 Percent
Ferric Sulfate

rid
nt Chlo
rce
Pe um
25 min nt
Alu erce lfate
P Su
13 rric
Fe

Co
lle
ag
ue Ki
s, 2 lic
8
a
20 nd
13
Co
lle
ag A
ue jam
s, 2 i
4
a
20 nd
13
Co
lle
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BOND STRENGTH IN MEGAPASCALS

ORIGINAL CONTRIBUTIONS

STUDY
Etch-and Rinse Adhesives

Two-Step Self-Etch Adhesives

One-Step Self-Etch Adhesives

Self-Adhesive Cement

Uncontaminated Dentin

Uncontaminated Dentin

Uncontaminated Dentin

Uncontaminated Dentin

Contaminated Dentin

Contaminated Dentin

Contaminated Dentin

Contaminated Dentin

Figure 2. Bond strength test results of studies performed on dentin. Ankaferd Blood Stopper is manufactured by Ankaferd, Istanbul.

and the bonding agent, the obstruction of resin tags on

the etched enamel surface, or both.29,31
Investigators reported varying results for specimens
in the etch-and-rinse groups; some specimens exhibited
an increase in bond strength after contamination with a
hemostatic agent, whereas others exhibited a decrease in
bond strength. These differences may be attributed to the
different combinations of materials and contamination
times. Investigators in three studies16,17,19 reported an
increase in bond strength in contaminated specimens in
the etch-and-rinse groups; two of these studies involved
the use of the same adhesive system, the same hemostatic
agent and the same contamination time.17,19 However,
investigators in four other studies15,21,26,30 reported a
decrease in bond strength in contaminated dentin specimens in the etch-and-rinse groups.
Researchers in three studies used a two-day contamination time15,18,23; however, most used a two-minute contamination time.12-14,17,19,22 Investigators in some studies
applied an unusual hemostatic agent, a mixture of plant
extracts prepared from Alpinia officinarum, Glycyrrhiza
glabra, Thymus vulgaris, Urtica dioica and Vitis vinifera
with homeostatic and antibacterial effects.21,25,29-31 Finally, Ebrahimi and colleagues26 were the only researchers
to report a decrease in bond strength for a one-step selfetch adhesive system that was not statistically significant.
Furthermore, many researchers reported that the results
of the bond strength tests varied as a consequence of different dentin substrate conditions, such as the age of the
tooth and storage conditions.33,34 These variables make

it difficult for us to draw parallels between the studies,

as well as impossible to point out the reasons for such
substantially different results.
In most cases, it appears that water alone was not
sufficient to remove contamination. Researchers in
only two studies assessed cleaning methods for hemostatic agents.20,24 According to Ajami and colleagues,24
application of 10 percent ethylenediaminetetraacetic
acid (EDTA) for 60 seconds followed by a 30-second
water spray restored the bond strength of a self-etching
adhesive to dentin. However, the authors reported that
phosphoric acid failed to increase the bond strength of
self-etching adhesive to dentin to the level of that in the
control group. They reported that a five-minute water
rinse under high pressure resulted in an increase in bond
strength when compared with that in the nonrinsed,
nonconditioned contaminated group; however, the bond
strength still was much lower than that in the control
group.24 Furthermore, for some dental practices, the
five-minute water rinse may be considered clinically
unacceptable.
Chaiyabutr and Kois20 pointed out that after hemostatic contamination with 25 percent aluminum chloride
or 13 percent ferric sulfate, the cleansing protocol should
include particle abrasion with low-pressure aluminum oxide or phosphoric acid etching to restore the
bond strength to precontamination levels when using
a self-adhesive resin cement. These authors reported
that the mean bond strengths of specimens in the acidetch groups and the particle abrasion groups were not

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ORIGINAL CONTRIBUTIONS

significantly different from the mean bond strength of

specimens in the control group; however, the group that
underwent water rinsing alone demonstrated the lowest
mean bond strength.20
Because the results reported here are limited to the
materials and contamination times used in each study,
a standardized study is needed in which investigators
compare all cleaning methods (that is, 10 percent EDTA,
particle abrasion, 37 percent phosphoric acid and water
spray). In addition, it may be useful to examine the use
of pumice mixed with water, a cleaning method used in
dentistry, to clarify this issue.
Researchers should give special attention to the possibility of using alternative adrenergic agents, such as eye
drops, in dentistry.13 Land and colleagues13 conducted a
study in which they used this vasoconstrictor solution
as a gingival retraction agent.5 According to their study
findings, a five-minute exposure to tetrahydrozoline
hydrochloride (Visine Original, McNeil-PPC, Lancaster,
Pa.) (pH 6.8) or oxymetazoline hydrochloride (Ocuclear,
Health Care Products, Memphis, Tenn.) (pH 6.5) did not
cause significant smear layer removal or etching of the
dentin surface.
Our review included only one study in which investigators evaluated a self-adhesive resin cement and applied
blood before the hemostatic contamination. Consequently, we suggest that researchers conduct further
studies of this material.
On the basis of our study findings, it remains unclear
if the use of different hemostatic agents can result in
different bond strength values for the same adhesive or
dental cement, or if the same hemostatic agent in solution or gel form can cause different effects on dentin
or enamel morphology and bonding. The literature is
limited with regard to evaluations of the effects of hemostatic agents on enamel. Furthermore, researchers in
the two studies in our review who evaluated enamel used
a nonconventional agent made from plant extracts.29,31
We found no reports regarding the effect of a hemostatic
agent on enamel morphology, but, as described earlier, it
is known that the bond strength is affected negatively.29,31
Because some hemostatic agents are more soluble
than others, it is important to note that some cleaning
methods may be efficient for one type of hemostatic
agent but not for others. Further investigation is necessary to address the problems cited earlier and the effect
of self-adhesive resin cements on luting properties.
CONCLUSION

Within the limitations of this systematic review, our

findings show that hemostatic agents can induce changes
on the dentin surface and in bonding performed on
dentin and enamel. Limited data suggest that the bond
strength of self-etching adhesives is affected more negatively than is the bond strength of etch-and-rinse systems. However, because of considerable methodological

differences between studies, further research is required

before we can make definitive conclusions. n
Disclosure. None of the authors reported any disclosures.
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