Moisture is generally not a dentist’s friend — and this is especially true during oral surgery. Mentor examines the various methods clinicians use to manage excess blood and saliva during dental procedures
By Rebecca Stone
Most sales pros are familiar with the fact that many of today’s dental materials just don’t mix well with moisture. This is the ultimate irony, as a healthy oral cavity is, by nature, moist. Yet saliva, the beneficial fluid that bathes, protects and nurtures the oral cavity, and blood, a normal byproduct of dental therapies, can cause treatments to fail due to materials that are incompatible with moisture. Further, these fluids may also obscure the field of operation and, if sprayed or spattered, pose cross-contamination risks.
If left unchecked, these problems can take a serious bite out of office efficiency — not to mention safety — and can jeopardize a wide range of dental procedures. For instance, David Hornbrook, DDS, FAACD, a cosmetic and restorative practitioner in La Mesa, California, and an international lecturer on esthetic and restorative dentistry, explains that for restorative dentists, the biggest challenges can come when isolating for an adhesively bonded restoration. “This is especially true,” he says, “when using a total-etch technique, where any saliva contamination can lead to microleakage and post-operative sensitivity. And the degree of difficulty and importance is that much greater when treating a second molar, especially one with pre-existing subgingival margins, where saliva control as well as hemostasis and sulcular fluid control come into play.”
It is in oral surgery (involving the cutting of soft tissue), however, that moisture management can be particularly challenging. But in such scenarios, moisture control can be a double-edged sword. “Any time the tissues dry, that causes cells to die,” notes Peter Nordland, DMD, whose Nordland Oral Microsurgical Institute is based in La Jolla, California. “Cells dying on a wound margin can lead to scar formation and slowed healing,” he explains, adding that to address this problem, an idea is being floated among a small group of oral surgeons to perform oral surgery with a layer of water covering the surgical site, although how this would be accomplished on living patients remains to be seen. “It’s tricky,” he admits. “But that idea has been proposed.”
For the time being, though, Nordland says that one of the primary ways in which he deals with bleeding is to head it off at the pass by instructing his patients to forego taking aspirin, fat-soluble vitamins and fish oils a week before a procedure. In the case of patients who take blood thinners, he works with their physicians to moderate dosages prior to oral surgery.
But given that the oral cavity is a virtual minefield of salivary glands, you would think clinicians are fighting a losing battle. Fortunately, there are scores of tried-and-true methods — as well as some newer strategies — for managing moisture during oral surgery and other kinds of dental procedures. Sales reps who would like to keep their clients — and patients — from drowning should be familiar with the various techniques.
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There are several methods of moisture control that can be used in operative dentistry and oral surgery. Dental dams serve to isolate teeth during restorative procedures, but they are not as widely used as the various types of absorbent materials that are now available. These include gauze and dry angles (triangular absorbent pads that block salivary flow from the parotid gland). Additionally, cotton rolls, available for use with cotton roll holders, help to enhance patient comfort and provide a degree of isolation, as well as tongue and cheek retraction. Formerly made of cotton, these products are now made of new synthetic materials, which allows them to be much more absorbent without shedding or tearing.
Many of these procedural adjuncts can be used to control both saliva and blood. Michael Sonick, DMD, who operates a practice specializing in implants and periodontics in Fairfield, Connecticut, reports, “The most frequently used method of hemostasis is pressure. This is usually performed by moistening a piece of gauze and holding it on top of the area of bleeding for two to five minutes.”
Nordland is a fan of using dry angles, which also help with retraction. “When I’m placing implants, I’ll want to have a nice sterile field — and if the implant is bathed in saliva, it’s going to be contaminated,” he says. “You certainly don’t want a sterile implant to be contaminated on its way into the prepped hole in the jawbone.”
Other products are designed specifically for hemostasis. In fact, according to Hornbrook, moisture control and hemostasis are really two separate issues. “Hemostasis,” he says, “should include sulcular fluid control, since both of these are imperative in capturing accurate impressions for indirect dentistry and for cementation of any type of restoration. Traditional retraction cord, the use of lasers and electrosurgery, and putty retraction pastes and gels are all effective in managing this problem.”
Sonick stresses the importance of hemostasis, especially at the conclusion of a surgical procedure. “In the case of gingival grafting, bleeding could cause the graft to lift off the surface of the tooth, leading to a ‘dead space’ and loss of the graft,” notes Sonick. “It is also important to control bleeding before a patient leaves the operatory so that he or she will have a comfortable post-operative experience.”
As effective as moisture-control and hemostatic products are, they do not prevent contamination or debris from accumulating. And while saliva ejectors are certainly familiar clinical fixtures, when it comes to more invasive procedures such as soft-tissue surgery, it’s time to haul out the big guns. High-volume evacuators (HVE) are vacuum systems that allow faster and more powerful suction than ejectors. Capable of removing solid debris, they are typically preferred for use in conjunction with high-speed handpieces, which require a cooling spray and a way to contain aerosolized bacteria. Often featuring surgical suction tips made of stainless steel, they can also double as retraction aids.
David Hornbrook, DDS, FAACD, an international lecturer on esthetic and restorative dentistry who operates a cosmetic and restorative practice in La Mesa, California, explains that new devices are now available that remove excess saliva, while at the same time retracting the tongue and acting as a bite block to hold the arches apart. “These are all excellent when a rubber dam can’t be used,” he observes.
Some HVE devices also offer illumination via reflective surfaces. While clinicians operating with magnification having its own light source may not find the reflective properties that beneficial, these systems are reportedly helpful for those operating without dental assistants.
JUST SAY YES
Chemical agents provide yet another means of moisture control. Local anesthetics are often laced with a vasoconstrictor, such as epinephrine. When injected into the soft tissue, it constricts blood vessels, which reduces bleeding. Nordland, like other clinicians, often uses an anesthetic with epinephrine for added hemostasis, especially in tissue surgery. But he points out that in addition, he typically sedates his patients, and says that the narcotics themselves have a drying effect.
Other agents used in hemostasis include topical solutions, such as those containing sodium hypochlorite, ferric sulfate or aluminum chloride, and hemostatic astringent agents, such as racemic epinephrine, aluminum potassium sulfate and aluminum sulfate. These are available in gel or paste forms and in impregnated retraction cord. It has also been found that a bleaching agent containing 30% hydrogen peroxide quickly helps eliminate bleeding when applied to soft tissues. Sonick says that one of his favorite hemostatic agents is a ferric sulfate product. “The results are immediate upon application to the site, and it is very easy to use, whether during impression-taking, dental and implant surgeries, tissue grafts or other applications,” he tells Mentor.
Sonick notes that in addition, agents such as hemostatic collagen, gelatin, bone wax and cellulose are frequently used at the end of surgery for hemostasis. “They are usually placed at the site of bleeding and serve as a nidus for initial clotting,” he says.
Nordland points out that impregnated retraction cord acts like an astringent to stop bleeding, but he cautions that it can also injure tissue, causing it to recede. “Any time we’re treating the tissue with a chemical that causes the blood vessels to close down,” he notes, “there’s a risk this will be traumatic to the tissue.”
In contrast, Hornbrook reports there are several new kaolin clay putty retraction pastes that are atraumatic and easily used as retraction mediums. “The aluminum chloride in these pastes provides hemostasis, while the clay-based putty expands into the sulcus, retracting the tissue,” he explains. “They can be used prior to taking vinyl or digital impressions, or prior to cementation.”
Studies and collective experience show that the type of cutting instrument used influences the amount of bleeding that occurs during a procedure. For this reason, many clinicians who perform oral surgery advocate the use of lasers or electrosurgical units over blades as a way to control bleeding. “Surgical blades result in the most bleeding,” explains Sonick. “Electrosurgical units and lasers cause coagulation as they cut, leading to little or no bleeding.”
In Hornbrook’s estimation, the laser is the most effective cutting instrument in this respect. “The use of a surgical blade causes the most bleeding because it provides no hemostasis,” he notes. “The electrosurgical unit will help with retraction and hemostasis, but since it provides this by heating and cauterizing the tissue, healing is not as predictable as when a laser is used. This can be a huge concern in the esthetic zone where isolation, hemostasis and retraction are desired.”
A diode laser, Nd:Yag laser and CO2 laser, designed to cut soft tissue, are reported to cause the least bleeding while offering razor-sharp precision. In fact, it is said that soft-tissue lasers cut and seal at the same time. This is particularly true in the case of the diode laser, which is said to lay down a layer of carbon upon hitting tissue, which serves as a sort of surgical dressing to maintain sterility and promote healing.1
“The diode laser provides excellent retraction and hemostasis,” says Hornbrook, who notes the once prohibitively expensive devices have now come down in price, making them reasonable alternatives to electrosurgical units. “In my opinion,” he adds, “the diode laser is a must-have in every dental practice.”
Nonetheless, Nordland prefers a blade, saying, “A laser cauterizes as it burns away tissue, and that’s a benefit. I will use a laser on occasion, but it’s not my go-to instrument with every surgery. I’ll use microsurgical blades to keep the incision as small as possible. In my experience, if incisions are less traumatic, patients experience less bleeding and faster healing. I have used electrosurgical units and they work nicely — but I use those devices and lasers more for fine tuning.”
There’s no doubt that challenges in moisture management remain — but the innovations are sure to keep coming. And with the variety of strategies available, salespeople have their hands full in not only keeping up with developments, but also in determining each client’s preferred approach. By doing that, account reps can help clinicians keep the flood under control amidst a rising sea of product change.
- Tolle SL, Sirois M. Laser therapy basics. Dimensions of Dental Hygiene. 2011; 9(1): 50–53.