Documente Academic
Documente Profesional
Documente Cultură
Key Words
Calcium sulfate hemi-hydrate, endodontic surgery,
hemostasis
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Scarano et al.
dequate cleaning, shaping, and obturation of the root canal system are required to
achieve healing in endodontic orthograde treatment or retreatment, whereas for
periradicular surgery, proper root-end management and root-end seal are essential.
Although conventional root canal therapy is approximately 90% successful when performed by a general dentist or endodontist, there are certain instances when this is not
possible or not indicated. An adequate apical seal is a major factor for improving
endodontic success (1). The retreatment before apical surgery, even if it is not possible
to achieve full working length, leads to a significantly higher success rate in endodontic
surgery (2, 3). Surgical endodontics can be considered when conventional root canal
therapy has failed or cannot be performed. This procedure includes exposure of the
involved apex, resection of the apical end of root, preparation of class I cavity, and
insertion of a root-end filling material (2).
The root-end filling material should provide an apical seal to an otherwise unobturated root canal or improve the seal of existing root canal filling material and be
biocompatible with the periradicular tissues. An ideal material to seal the root-end cavities should prevent leakage of microorganisms and their by-products into the periradicular tissues. The presence of serous exudate or bleeding should not affect its
sealing ability. Various materials and methods are available to control moisture during
dental procedures, including cotton roll isolation, saliva ejectors, anesthetic solution
with 1:50,000 epinephrine, and ferric sulfate.
The presence of moisture (saliva, blood, pus, and serous exudate) and bleeding
could affect the sealing ability of the material. Although many materials are available, no
material has yet been found that fulfills all or most of the properties for an ideal retrograde filling material. Cements and sealers such as zinc oxideeugenol cement, intermediate restorative material, Super EBA, Cavit, zinc polycarboxylate, zinc phosphate and
glass ionomer cements, mineral trioxide aggregate (MTA), calcium phosphate cement,
and bone cement have all been used for retrofillings. Other commonly used materials
are composite resin (with and without bonding agent) (4) and gutta-percha. A large
number of bacterial penetration investigations have been performed on MTA,
comparing it with other currently used root-end filling materials (5, 6). The sealing
ability of original MTA, other types of MTA, and its new compositions has been
tested by leakage studies (dye, fluid filtration, bacteria, and bacterial by-products)
and scanning electron microscopy (SEM). Because materials used in endodontics
are frequently placed in close contact with the periodontium, they also must be biocompatible with the host tissues. In an investigation of MTA as a root-end filling material, the
material was contaminated with blood, saline solution, and saliva. The salivacontaminated samples showed significantly more bacterial leakage in comparison
with uncontaminated MTA (7). For this reason it is imperative that the retrofilling
procedure be made in a dry field. For this purpose, the bleeding inside the bony crypt
must be controlled. Hemostatic agents used during endodontic surgery are intended to
control bleeding from small blood vessels or capillaries. Witherspoon and Gutmann (8)
have written a review of methods for hemostasis during endodontic surgery. It has been
reported that some of these agents, such as bone wax and ferric sulfate, might produce
an inflammatory response if left in situ (9, 10). Probably calcium sulfate (CaS) as an
approach to hemostasis in endodontic surgery has not received enough attention.
Clinical Research
Figure 1. Apex has been removed. Note how the bleeding makes it difficult to
have a well-dried area for surgery.
Figure 2. The back of the bone cavity has been packed with CaS. Bleeding has
been controlled.
Statistical Analysis
The statistical analysis was carried out by using the c2 test according to the Statistical Package for Social Science (SPSS 8.0; SPSS Inc,
Chicago, IL). A P value <.05 was considered significant (14).
Results
In group I (CaS), control of the bleeding always happened in ideal
conditions, and in all the experiments the root-end filling materials
(Figs. 1 and 2) were successfully used. Moreover, the positioning of
the CaS always allowed a better view of the area (Figs. 35). In this
group adequate hemostasis was achieved in all 11 cases. In group II
(gauzes or cotton), in 7 cases bleeding did not allow the positioning
of root-end filling materials; this condition required that the gauzes
or cotton had to be changed frequently. Adequate hemostasis was
achieved in 3 of 10 cases. In group III (ferric sulfate), the level of
adequate hemostasis was achieved in 6 of 10 cases.
Statistical Analysis
A statistically significant difference in adequate hemostasis was
present between groups I and II and between groups I and III
Hemostasis Control in Endodontic Surgery
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Clinical Research
Figure 3. CaS in the bone cavity caused instant and very good hemostasis.
Discussion
One of the most important factors for successful endodontic treatment is the complete obliteration of the root canal system and development of a fluid-tight seal (15). When no bacteria remained, healing
occurred independently of the quality of the root filling (16, 17). In
contrast, in the root canals that could not be effectively disinfected,
there was greater correlation with nonhealing in poor-quality root fillings than in technically well-performed fillings (17, 18). Nonsurgical
endodontics attempts to eliminate the bacteria by cleaning and
shaping the root canal to remove infected dentin, disinfecting the
canal, and sealing with a root filling. If root canal therapy fails and
the tooth cannot be re-treated, surgical endodontics might be indicated
to eliminate the noxious substances from the root canal system. When
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Scarano et al.
Clinical Research
imperative to completely remove it to avoid a delay in the healing
process (20, 21), and for this purpose a curette is used under
copious irrigation. The residual presence of the CaS in the bony
cavity is not a problem. It is reasonable to think that the CaS
resorbs the blood proteins, therefore assuming a net negative
charge. This resorption might start the intrinsic coagulation pathway
(22). The resorption of Factor XII might in this case assume an important role in the biomaterial-induced clotting (23). As has been recently
shown in vitro, contact between a biomaterial and blood determines
the activation of Factor XII as well as prekallikrein. Besides its influence on the clotting-mechanism activation downfall, CaS used in the
exposure of impacted teeth carries out a hemostatic effect through
a compressive effect, insulating the tooth like a rubber dam. Moreover,
the white color of CaS greatly facilitates visibility of the surgical area to
the surgeon.
In the present study, CaS has been used with the aim of controlling
bleeding of the surgical site and for insulating the surface of the apex;
after the apical root-end filling had been set in place, the biomaterial
was completely removed. It is important to keep in mind that this biomaterial is totally resorbable and biocompatible, and no problems should
arise if some CaS particles should be left around the tooth at the end of
the surgery (2426). When carefully used, CaS facilitated the
apicectomy and retrograde root canal filling.
In conclusion, the use of CaS controlled the bleeding from inside
the crypt, producing very good hemostasis instantly. Maintaining strict
control of bleeding during endodontic surgery enhances optimal visibility and might decrease the length of surgery. Further studies are
desirable to confirm the simplicity, possibilities, and limits of the
proposed procedure.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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