Clinical Research

Hemostasis Control in Endodontic Surgery: A Comparative

Study of Calcium Sulfate versus Gauzes and
versus Ferric Sulfate
Antonio Scarano, DDS, MD, MS,* Luciano Artese, MD,* Adriano Piattelli, MD, DDS,*
Francesco Carinci, MD, Carlo Mancino, DDS,* and Giovanna Iezzi, DDS, PhD*
Abstract
Introduction: Calcium sulfate (CaS) is a simple,
biocompatible material with a long history of safe use
in different fields of medicine. CaS is a rapidly resorbing
material that leaves behind a calcium phosphate lattice,
which promotes bone regeneration and hemostasis. The
aim of this study was a clinical evaluation of the hemostatic effect of CaS hemi-hydrate (CaSO4), commonly
known as plaster of Paris, in endodontic surgery.
Methods: Twenty-four patients with 31 periradicular
lesions were enrolled in this study. The apical roots
were exposed, and the bleeding would have made it difficult to correctly fill the root-end cavities. To avoid such an
inconvenience, the teeth were divided into 3 groups.
Hemostasis was attempted by using CaS in 11 teeth
(group I), gauze tamponade in another 10 teeth (group
II), or 20% ferric sulfate in the last 10 teeth (group III).
Results: Control of the bleeding was achieved in all teeth
of group I, whereas in group II adequate hemostasis was
achieved in 3 of 10 cases and in group III in 6 of 10 cases.
Conclusions: The use of CaS completely eliminated the
bleeding, with a very good level of hemostasis. (J Endod
2012;38:2023)

Key Words
Calcium sulfate hemi-hydrate, endodontic surgery,
hemostasis

From the *Dental School, University of Chieti-Pescara,

Chieti, and Department of Maxillofacial Surgery, University
of Ferrara, Ferrara, Italy.
Supported by the Ministry of Education, University and
Research (MIUR), Rome, Italy.
Address requests for reprints to Dr Antonio Scarano, Via dei
Frentani 98/B, 66100 Chieti, CH, Italy. E-mail address:
ascarano@unich.it
0099-2399/$ - see front matter
Copyright 2012 American Association of Endodontists.
doi:10.1016/j.joen.2011.09.019

20

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.

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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.

The aim of the present article was to describe a comparative study

of hemostasis obtained with the use of CaS versus gauze tamponade and
versus ferric sulfate during endodontic surgical procedures.

attempted by using CaS in 11 teeth (group I), gauze tamponade in

another 10 teeth (group II), or 20% ferric sulfate in the last 10 teeth
(group III) (Viscostat; Ultradent, South Jordan, UT) applied with pellet.
After positioning CaS in layers (P30; Ghimas, Casalecchio Di Reno,
Bologna, Italy), a solution of potassium chloride (4%) was used to buffer
the surface of the mold to get strengthening and hardening of the CaS
itself. The extra CaS was then removed by using dry gauze. After such
operations (3-4 minutes), at the end of which the CaS was completely
hardened, the CaS excess was removed by using an excavator. This operation was performed in such a way that the cement could be positioned in
place without blood or other biological fluids interfering with the hardening of the root-end filling materials; afterwards, all the CaS was
removed. The root-end cavities were filled with MTA (ProRoot MTA;
Dentsply, Tulsa, OK). The CaS was then removed because it was contaminated. The adequacy of hemostasis was determined by the surgical operator, according to written guidelines, and recorded as adequate or
inadequate. Adequate hemostasis was defined as the root-end preparation being dry and hemorrhage-free during root-end filling procedures.
Inadequate hemostasis was defined as the inability to keep the root-end
preparation dry and hemorrhage-free during root-end filling procedures.

Materials and Methods

Thirty-one teeth (12 mandibular teeth, 19 maxillary teeth) in
24 healthy patients (16 women and 8 men) with a mean age of 44.6
years (13.2 years) were included in the study. The protocol of the
study was approved by the Ethics Committee of the University of
Chieti-Pescara.
Criteria for inclusion were the following: presence of a periradicular lesion that could not be treated by a nonsurgical procedure and no
periodontal defects. Criteria for exclusion were the following: patients
with severe systemic diseases (diabetes mellitus, uncontrolled hypertension grade III, hepatic/renal disease, systemic bleeding disorders);
acute inflammation (abscess) at the time of surgery; surgical retreatments; and postoperative complications (infection, wound dehiscence
with exposure of the underlying bone).
No patients were taking medications that could have effects on
bleeding and coagulation.
A 14-day therapy by using daily rinses with a rinsing solution containing chlorhexidine gluconate 0.12% (Dentaton; Casalecchio di Reno,
Bologna, Italy) was prescribed. Surgery was performed under local
anesthesia with the use of articaine with adrenaline 1:100,000 infiltrated under the periosteum. Local hygiene treatment and antibiotics
(amoxicillin + clavulanic acid, 1 gm twice per day; Neo-Duplamox;
Procter & Gamble, Rome, Italy) were added for 5 days, starting from
12 hours before surgery (11, 12). Extraradicular infection lodged
separate from the root is possible but rare, unlike biofilms that have
been discovered on the outer root surface at the apex (13).
All surgical phases were performed under an operative microscope with manual zoom, objectives 4-25, focal distance 200 mm
(Karl Kaps GmbH e Co, Asslar, Germany).
After the reflection of a full mucoperiosteal flap, osteotomies,
prepared with an ultrasonic surgery device (NSK Variosurgery Dentalica,
Milan, Italy) with a diameter of approximately 4-6 mm, were performed
to locate the apex. The roots were resected with an ultrasonic surgery
device at approximately 80 to the axis of the tooth, and 2-3 mm of
the root end was removed. The pathologic soft tissue was thoroughly debrided and sent for histopathologic investigation. A 2- to 3-mm root-end
cavity was prepared ultrasonically by means of diamond-coated retrotips
(NSK Variosurgery Dentalica). At this point, the bleeding present would
have made it difficult to correctly fill the root-end cavities. Hemostasis was
JOE Volume 38, Number 1, January 2012

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.

Figure 5. Level of hemostasis was adequate without use of hemostatic agent.

(CaS versus gauzes or cotton and CaS versus ferric sulfate) (P =

.0056). No statistically significant differences were found between
groups II and III.

surgical endodontics is indicated, it is desirable that a root filling has

been inserted beforehand to improve the chances of success.
One of the most common causes for root canal failure is recurrent infection at the apex of the root. This might be due to small accessory canals. Accessory canals usually cannot be seen on dental
radiographs and often cannot be treated by conventional root canal
therapy. Persistent bacterial infection in the surrounding apical tissue
or bone at the root tip can also cause recurrent infection (2, 3).
Another common cause is fracture of the tooth root. There might
be a very fine fracture in the root of the tooth that might not show
up on dental radiograph. Root fractures can be difficult to
diagnose. If a root fracture is present, nothing can save the tooth; it
must be extracted. Many factors influence the success of endodontic
surgery. Hemostasis during surgical procedures is important for
successful case management. Excessive bleeding not only obscures
visualization of the surgical field but also creates difficulties in
maintaining a dry field for placement of a technique-sensitive rootend filling material (18, 19). It is imperative that the retrofilling
procedure be made in a dry field. For this purpose, the bleeding
inside the bony crypt must be totally eliminated. In fact, one of the
most common problems of the endodontic procedure is the
bleeding, which greatly compromises apicectomy and retrograde
root canal filling. Failures can arise as a result of blood and saliva
contamination, even with an otherwise good bonding technique.
This is a significant factor in patients who produce seemingly
copious amounts of bleeding. The dental assistant uses a small
suction tip and follows the entire procedure by using the assistant
scope. The assistant will help to maintain a dry field and good
visibility for the surgeon. If the suction is not enough to keep the
blood away from the beveled root surface, a few drops of anesthetic
solution with 1:50,000 epinephrine are placed on a sterile gauze
and then pushed against the walls of the bony crypt for a few
minutes. Another method to control the bleeding from inside the
crypt is the use of ferric sulfate, which causes very good hemostasis
instantly, because it has an extremely low pH (0.21) and causes
rapid intravascular coagulation. Ferric sulfate has not been used in
contact with important anatomic structures such as mandibular or
mental nerve, maxillary sinus, or floor of the nose. Its use is also to
be avoided on the cortical bone and on soft tissues. When the
retrofilling procedure is completed and before suturing, it is also

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

Figure 4. CaS excess was removed by using an excavator.

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Scarano et al.

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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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