Haemostatic agent used in dentistry to control bleeding

HAEMOSTATS USED IN DENTISTRY

1. HAEMOSTATIC AGENT USED IN DENTISTRY TO CONTROL BLEEDING AVISHEK PANDA INTERNEE

2. UNDER NORMAL CONDITION BLOOD CIRCULATE THROUGH INTACT VASCULATURE WITHOUT THROMBUS FORMATION. HEMOSTASIS STATE OF FLUID EQUILIBRIUM IN THE VESSEL VESSELS COAGULATION PROTEIN FIBRINOLYSIS INHIBITOR PLATELET

3. HEMOSTASIS A PROCESS WHICH CAUSES BLEEDING TO STOP PHASES OF HEMOSTASIS PRIMARY HEMOSTASIS ARTERIOLES CONSTRICTION FORMATION OF PLATELET PLUG SECONDARY HEMOSTASIS ACTIVATION OF COAGULATION CASCADE FORMATION OF PERMANENT PLUG

4. VESSEL CONSTRICTION THERE ARE TWO MECHANISMS LOCAL SMOOTH MUSCLE CONTRACTILE RESPONSE THROMBOXANE A2 RELEASE FROM EPITHELIUM FORMATION OF PLATELET PLUG EXPOSURE OF SUBEPITHELUAL LAYER CAUSE PLATELET TO ADHERE THEY RELEASE ADP &TxA2 WHICH FURTHER CAUSES PLATELET AGGREGATION &ACTIVATION ADHESION REQUIRE VON WILLBRAND FACTOR FROM SUB ENDOTHELIAL LAYER

5. COAGULATION FACTOR Factor I Fibrinogen Factor II Prothrombin Factor III Tissue Thromboplastin Factor IV Calcium Ions Factor V Labile Factor, Proaccelerin Factor VII Stable Factor, Proconvertin Factor VIII Antihemophilic Factor Factor IX Christmas Factor Factor X Stuart- Prower Factor Factor XI Plasma Thromboplastin Antecedent Factor XII Hageman Factor Factor XIII Fibrin Stabilizing Factor All coagulation factors are made in the liver, except for vWF

6. COAGULATION CASCADE

7. NATURAL INHIBITOR OF COAGULATION CASCADE THOMBOMODULIN ANTITHROMBIN III TISSUE FACTOR PATHWAY INHIBITOR PROTEIN C PROTEIN S

8. Visual obstruction of the surgical field Need for blood transfusions Reduction in core temperature Thrombocytopenia Hypovolemic shock Economic consequences Adverse effects of Surgical bleeding

9. Factors influencing Surgical bleeding

10. Why Use Hemostatic Agents Minimize blood loss Improve visualization Save operative time Reduce or avoid transfusion Manage anticoagulated patient Avoid conversion of lap procedures Prevent leakage of non-bloody fluids Decrease post-op drainage and infection Decrease hospital length of stay

11. Characteristics of an Ideal hemostatic agents for clinical use : (1) capability to stop large vessel arterial and venous bleeding within minutes of application when applied to an actively bleeding wound through a pool of blood; (2) no requirement for mixing or pre-application preparation; (3) simplicity of application (4) light weight and durable; (5) long shelf life in extreme environments; (6) safe to use with no risk of injury to tissues or transmission of infection; (7) cost-effective

12. Methods of Hemostasis

13. Mechanical methods

14. Thermal/energy based method

15. Chemical methods – pharmacological agents

16. Topical Agents – Passive Provides a physical, lattice like matrix that adheres to bleeding site Matrix activates the extrinsic clotting pathway Platelets aggregate and form a clot Passive agents rely on fibrin production and hence can be used only in a patient with intact coagulation cascade Passive agents can absorb several times its weight in fluid. However, this expansion of the agent can cause complications like compression of surrounding tissues .

17. Activated on contact with bleeding. Provide stable matrix for clot formation, enhance platelet aggregation, degranulation and release of clotting factors Collagen Based Products

18. Topical agents – active Have biological activity Participate directly at the end of coagulation cascade Stimulate fibrinogen at the bleeding site to produce a clot Thrombin acts at the end of the clotting cascade, action of agent is not affected by clotting factor deficiencies or platelets malfunction. Can also be given to patients receiving anti-platelets/anti-coagulation Active topical agents provide hemostasis within 10 minutes and they are more effective in controlling bleeding than passive agents

19. Thrombin products

20. Combine passive and active hemostatic agents into a single application product Work by blocking blood flow & actively converting fibrinogen into fibrin Two types of products: Absorbable bovine gelatin + pooled human thrombin Absorbable porcine gelatin + either of the 3 thrombin types Both the products do not contain fibrinogen. Hence direct contact with blood is necessary Both products are indicated for all types of surgeries except ophthalmic surgeries AEs: anemia, arrhythmia, arterial thrombosis, atelectasis, atrial fibrillation, hemorrhage, infection, pleural effusion, right heart failure Flowable hemostatic agents

21. Sealants Sealants work by forming a barrier that is impervious to the flow of most liquids

22. Polyethylene glycol polymers

23. Contains 10% glutaraldehyde sol and 45% bovine serum albumin Glutaraldehyde cross-links the residual proteins in albumin to cell proteins at wound site and forms a tough scaffold to which clot can adhere Commonly used for sealing holes around suture or staple lines in complex CV procedures and in peripheral vascular procedures AEs: tissue injury, muscle necrosis, emboli, delayed pseudoaneurysm formation, sensitivity to glutaraldehyde Albumin- Glutaraldehyde

24. Consists of 2 cyanoacrylate monomers 2-octyl cyanoacrylate Butyl lactoyl cyanoacrylate Product to be used as a sealant and not as a substitute for sutures, staples, or other methods of mechanical closure Cyano -acrylates

25. Rapidly and effectively control bleeding Effectively contact the bleeding surface Work reliably Be handled easily Be prepared easily Be available in multiple delivery options Be compatible with patient’s physiology Be safely used Be cost effective Key considerations in the selection of topical agent

26. Reference : TEXTBOOK OF PATHOLOGY 6 TH ED.-HARSH MOHAN TEXTBOOK OF PATHOLOGY -ROBBINS DENTAL MANAGEMENT OF MEDICALLY COMPROMISED PATIENT -FALACE TEXTBOOK OF PHARMACOLOGY –K.D.TRIPATHY

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