Review of Hemostatic Agents Used in Dentistry

					        Article published in Dentistry Today
        March 2005, pages 62 – 65
        (with permission of authors)

        Review of Hemostatic Agents Used in Dentistry
                                                              During oral surgical procedures,
        Dentists perform a variety of surgical        persistent minor oozing of blood is
procedures frequently requiring the need for a        common, although occasionally a bleeding
hemostatic agent. Exodontia, tissue biopsies,         episode prevents the continuation of the
placement of endosseous implants, and                 procedure and requires immediate
periodontal surgery are just some examples            attention. The usual sources for this
where hemostatic agents may be beneficial. Not        intraoperative complication are incision
only are these agents useful for specific             into an area of granulomatous tissue,
procedures, but they also are valuable for            vessels in the periosteum or mucosa, or
certain patient groups, specifically those with       encountering nutrient arteries in the
coagulation defects. These defects may be             alveolar bone. Identification of the source
genetic or acquired (Table). A comprehensive          of the bleeding requires good illumination,       Figure 1. Coagulation cascade. (Reprinted
review of this topic is beyond the scope of this      adequate retraction, and thorough                 from Handbook for Anesthesia and Co-
article. Nevertheless, dentists performing            suctioning. Once identified, the bleeding         Existing Disease, Vol 1, Robert K. Stoelting,
surgery should be familiar with these defects         site should be packed, clamped,                   MD, and Stephen F. Dierdorf, MD, page 256,
and their clinical manifestations. Figure 1                                                             1993, with permission from Elsevier.)
                                                      cauterized, burnished, debrided, and/or
demonstrates a schematic diagram of the               sutured for control. Topical hemostatic
cascade of events leading to the formation of a       agents should be available, and if             aggregation of platelets, which bind in large
fibrin clot. These steps are initially divided into   necessary, applied.                            numbers to the collagen fibrils.
intrinsic and extrinsic pathways, leading into a              The dentist should be familiar with             The aggregated platelets degranulate,
common pathway of coagulation.                        the range of methods, techniques,              releasing factors such as thromboxane A22 that
         This article is a review of perioperative    materials, and their application during        assist in the formation of a clot. The sponge also
hemorrhage, certain available hemostatic              different types of bleeding episodes.          provides a 3-D matrix for strengthening the blood
agents, and an introduction to a new agent with       Having a broad knowledge of the                clot.3
good potential for application in the oral cavity.    management approaches will allow the                    As with most hemostatic agents, collagens
                                                      clinician to know when to apply a              are not to be used in infected or contaminated
                                                      particular approach. Unfortunately, some       wounds. The agents may serve as a nidus for
    PERIOPERATIVE HEMORRHAGE                          of the most useful preventive measures         abscess formation and may potentiate bacterial
                                                      and management techniques are not              growth. Possible adverse reactions are formation
         The best management of perioperative         utilized because of a lack of understanding    of adhesions, allergic reactions, foreign body
hemorrhage is prevention. This includes a             of the coagulation process and/or the          reactions, and subgaleal seroma formation3
thorough preoperative patient history, necessary      approaches and materials that are              (subgaleal seroma is an accumulation of blood
medical consults, familiarity with managing           available.                                     serum beneath the scalp). In an animal model,
patients with possible bleeding diathesis,                    One of the more common methods         incision sites inoculated with Staphylococcus
meticulous intra-operative technique, and             of intraoperative hemorrhage control           aureus demonstrated more infection when collagen
appropriate post-operative instructions, care,        involves the use of a topical hemostatic       was used as compared to a control.3 Such results
and follow-up. Although these are easily listed,      agent. This article reviews some of the        are similar to what has been reported for other
application in practice can be challenging.           more common hemostatic agents and              hemostatic agents.3
Multiple      obstacles    may      prevent     the   introduces ActCel (MedSpring Group), a                  Besides sponges and plugs, these products
implementation of the management steps listed.        hemostatic agent that has recently become      are available in microfibrillar form. This form is
Some of these hurdles include treating patients       available.                                     generally less useful for oral surgical procedures.
with an undisclosed or undiagnosed medical
condition, improper information retrieval, or          TOPICAL HEMOSTATIC AGENTS                                           Gelatin
difficult surgical conditions. Poor patient
compliance with medication or postoperative                  Hemostatic Collagen                                        (eg, Gelfoam)
instructions also are factors to be considered.
         If an intraoperative bleeding episode is             These products (eg, CollaPlug,                  Gelfoam (Pharmacia) is one of the more
encountered, the clinician should consider            CollaTape,     and      Helistat    [Integra   commonly employed agents for the control of
several steps. A quick mental review of the           LifeSciences]) are soft, white, pliable,       minor bleeding, It is a porous, pliable sponge made
patient's medical history is first. If the            nonfriable,     coherent,        sponge-like   from dried and sterilized porcine skin gelatin.
hemorrhagic episode is difficult to manage,           structures. They are fabricated from           Gelfoam's mode of action is not completely
injection of 1/50,000 solution of epinephrine         bovine collagen (usually from deep flexor      understood, but unlike collagen, it is believed to be
into the area may be needed. This will likely         tendons)    and     are    nontoxic      and   related to formation of a mechanical matrix that
provide temporary reduction of bleeding as a          nonpyrogenic. The products are highly          facilitates clotting4-7 rather than affecting the
result of local vasoconstriction. The site may        absorbent and able to hold many times          blood-clotting mechanism. This agent can retain in
need to be packed, and the clinician will need to     their own weight of fluid. Their               its interstices 45 times its weight in blood.8
consider the seriousness of the event. If very        indications are for wound protection and       Gelfoam liquefies in one week and is completely
serious, a call to an emergency service (911)         for control of oozing or bleeding from         resorbed in 4 to 6 weeks.
may be necessary. Further, if the dentist is          clean oral wounds. As for application,                  Its use is not associated with excessive scar
properly, trained starting an intravenous line to     these products should be held in place for     formation.8-12 Reported adverse reactions are giant
initiate fluid resuscitation may be advisable.        approximately 2 to 5 minutes to achieve        cell granuloma and hematoma formation, foreign
The process of immediate delivery of the              hemostasis and then may be removed,            body reactions, excessive fibrosis, toxic shock
patient to a medical facility for possible            replaced, or left in situ. All of these        syndrome, fever, and failure of absorption.13
transfusions, anticoagulant reversal, and general     collagen materials are completely
life support measures can be initiated.               resorbed within 14 to 56 days.1
However, a careful clinician will rarely                      In addition to serving as a                                 Bone Wax
encounter such an event in an outpatient office       mechanical obstruction to bleeding, these
setting. More commonly, dentists confront             materials affect the coagulation process.              Bone Wax (Ethicon) is a sterile mixture of
patients with inconvenient, nonemergent               In contact with blood, collagen causes
bleeding events that require a response.
                                                                                                                                                                 evaluate      the    extrinsic
                                                                                                                                                                 pathway.       These      tests
                                                                                                                                                                 measure different phases of
                                                                                                                                                                 early aspects of the
                                                                                                                                                                 coagulation            process
                                                                                                                                                                 (intrinsic and extrinsic
                                                                                                                                                                 pathways), but all measure
                                                                                                                                                                 the common pathway and
                                                                                          Figure 5. Preoperative         Figure 6. In the process of             formation         of       end
                                                                                          radiograph of tooth No. 32-    removing bone with a bur on the         products.25 Research has
                                                                                          a partial bony impaction.      disto-buccal aspect of this tooth
                                                                                          The patient is a 32-year-old   (see x-ray in Figure 5), a nutrient     demonstrated that in vitro,
                                                                                          male and is healthy with no    canal (artery) was cut. Some            PTT is decreased (resulting
       Figures 2a and 2b. Left: A 1 x 1-inch piece of hemostatic gauze.                   known bleeding problems.       spurting of blood ensued. The
       Right: The same piece of gauze that has been placed for a few                                                     vessel was localized by the use of      in enhanced clotting) with
       seconds into water. Upon saturation with water or blood, the gauze                                                suction, and bone surrounding the       the presence of ActCel in
       starts to convert to a resorbable, gel-like state. In a fresh                                                     bleeding source was compressed
       extraction socket, it serves to promote hemostasis and stabilize a                                                into the site with a periosteal
                                                                                                                                                                 the       wound.24        (The
       blood clot.                                                                                                       elevator. Bleeding lessened but still   procedure       consists     of
                                                                                                                         continued. The next step was to
                                                                                                                         burnish Bone Wax into the bleeding
                                                                                                                                                                 placing defined weight, or a
                                                                                                                         bony orifice. Again, the magnitude      surface area equivalent, of
                                                                                                                         of bleeding diminished but did not
                                                                                                                         stop. Note the amount of blood
                                                                                                                                                                 test material in contact with
                                                                                                                         collected on 4 x 4-inch gauze           citrated plasma, incubation,
                                                                                                                         sponges during this period of time.
                                                                                                                                                                 and then adding a PTT
                                                                                                                                                                 reagent      and       calcium
                                                                                                                                                                 chloride. Time required for
                                                                                    organisms, and it does not                                                   clotting is then determined
                                                                                    enhance infection under                          After an injury,
                                                                                                                            platelets are activated,             for the test sample and the
                                                                                    experimental conditions.16-                                                  control, which has no
                                                                                        Nevertheless, it is still           changing from a discoid to
                                                                                                                            spherical       shape       and      device contact. A minimum
       Figure 3. The cotton plier is            Figure 4. The gauze is placed in    recommended to avoid its                                                     of 6 tests were performed,
       grasping a 1 x 1-inch piece of           and out of the socket until it is                                           extending        pseudopodia.
       hemostatic gauze. It is ready to be      totally saturated with blood.
                                                                                    use      in     contaminated                                                 averaged, and statistically
       placed in a lower third molar socket.
                                                When saturated, it can be left in   wounds where persistent                 Platelets release factors
       The purpose of the gauze is to help
                                                the socket, since it readily                                                such as thromboxane A22              analyzed using analysis of
       stabilize the clot and prevent a dry
                                                converts to glucose and saline
                                                                                    drainage       is     desired.                                               variance.)      These      data
       socket. It has been lightly coated                                                                                   that      stimulate        other
       with tetracycline. (Approximately 20     within 1 to 2 weeks. One or         Encapsulation of fluid and                                                   support the role of ActCel
       1 x 1-inch pieces of the gauze were      more sutures can then be placed     foreign body reactions have             platelets      to      activate.
       placed in a sterile container to which   superiorly to close the wound.
                                                                                                                            Platelets have receptors that        in modifying the intrinsic
       the contents of one 250-mg capsule                                           been reported,20-22 and a                                                    pathway.
       of tetracycline was added. The                                                                                       promote their adhesion to
       container was then shaken to coat                                            burning sensation has been                                                            Additionally, many
       each piece uniformly with a small
                                                                                    noted when the product is               blood       vessel      linings,
       amount of tetracycline powder.) As
                                                                                                                            collagen,       and        other     of       the       previously
       the gauze enters the socket, it is                                           placed in unanesthetized                                                     mentioned            enzyme-
       easily controlled and manipulated
       with the cotton pliers.                                                      nasal passages. 15                      platelets.2 It has been
                                                                                                                            demonstrated         that    the     mediated reactions within
                                                                                             ActCel is a new                                                     the clotting cascade are
                                                                                    topical hemostatic agent                fabric-like and solid texture
                                                                                                                            of ActCel slows blood flow           calcium dependent. One
beeswax, paraffin, and                                                              that is made from treated                                                    study has demonstrated that
isopropyl palmitate (a                                                              and sterilized cellulose and            and reduces the time for
                                                          Cellulose                                                                                              ActCel adheres to calcium
softening agent) that is                                                            available in similar fabric             thrombin to be released
                                                    (eg, Surgicel, ActCel)
                                                                                                                            into the wound.24 This               ions,23 making calcium
packaged in individual foil                                                         meshwork as Surgicel,                                                        more available for the
envelopes. It is useful when                                                        although it is slightly more            increases platelet adhesion
                                                         Surgicel (Johnson                                                                                       clotting cascade. Further,
bleeding     is      from      a                                                    friable. It is an FDA-                  (similar       to       platelet
                                                & Johnson) is a resorbable                                                                                       since the material's surface
visualized local vascular                                                           approved              material          aggregation at a damaged
                                                oxidized cellulose material                                                                                      area increases as it
channel      within      bone,                                                      indicated for the control of            blood vessel wall or at
                                                and is an expensive but                                                                                          dissolves, the area available
commonly referred to as a                                                           bleeding from open wounds               exposed collagen), thereby
                                                useful option in oral                                                                                            for the coagulation process
"bone bleeder," at the                                                              and body cavities (eg,                  reducing the time to
                                                surgery. It is prepared as a                                                                                     also increases.
surgical site. This occurs                                                          mouth, ears, nose, throat,              establish the clot.
                                                sterile fabric meshwork. Its                                                                                              Another        special
commonly        during      the                                                     and vagina). The material                        Subsequently,
                                                mechanism of action is not                                                                                       characteristic      of     this
extraction of mandibular                                                            does not contain chemical               coagulation          progresses
                                                completely understood, but                                                                                       material is its bacteriostatic
third molars, and if not                                                            additives, thrombin, or                 through a cascade of events
                                                appears to be physical                                                                                           properties.24
                                                                                                                                                                                    This      is
adequately           addressed                                                      collagen, and is hypo-                  with the relatively unstable
                                                rather than involve an                                                                                           especially important in
during surgery can be a                                                             allergenic. In contact with             platelet plug being replaced
                                                alteration of the clotting                                                                                       contaminated wounds or in
reason for postoperative                                                            blood, it expands to 3 to 4             with a stronger, more
                                                mechanism. After it is fully                                                                                     body cavities in which it is
bleeding. The wax is                                                                times its original size and is          resilient clot. This cascade
                                                absorbed with blood, it                                                                                          difficult or impossible to
pliable enough to be placed                                                         almost            immediately           involves a series of
                                                swells           into        a                                                                                   maintain a sterile field.
within a vascular channel,                                                          converted      to    a     gel.         interdependent,        enzyme-
                                                brownish/black gelatinous
immediately tamponading                                                             Complete dissolution of the             mediated reactions that are
                                                mass that aids in clotting.                                                                                        Dry Socket Prevention
the vascular source.                                                                product takes place within              initiated         by         the
                                                Excessive amounts of the
        Bone       Wax        is                                                    1 to 2 weeks.23 Because of              degranulation of platelets
                                                material should be removed                                                                                                Localized alveolar
nonresorbable, and due to                                                           its purity and the fact that it         or the release of activated
                                                if possible to prevent                                                                                           osteitis is the most common
its possible adverse effect                                                         degrades      rapidly      into         tissue thromboplastin from
                                                delayed healing.                                                                                                 complication in extractions,
on osteogenesis,14 caution                                                          biocompatible end products              damaged blood vessels.
                                                         Specific       dental                                                                                   with a prevalence of 1.9%
should bee used where                                                               (glucose, water), it does               The fundamental reaction is
                                                indications include use as                                                                                       to      31.2%       following
regeneration of bone is                                                             not adversely affect wound              the generation of thrombin
                                                an adjunct to control                                                                                            removal of mandibular
expected (eg, a future                                                              healing.             ActCel's           and         fibrin         from
                                                bleeding in exodontia and                                                                                        third molar teeth.26-28 A
implant       site).      Mild                                                      mechanisms of action are                prothrombin                 and
                                                other       oral      surgical                                                                                   variety of theories exist as
inflammatory          reactions                                                     multiple, enhancing the                 fibrinogen,       respectively.
                                                procedures.15 This material                                                                                      to its etiology, although it
have been reported in                                                               coagulation           process           Clinically, the blood tests
                                                may be more useful in soft-                                                                                      certainly      involves    an
tissues adjacent to the site                                                        biochemically                by         performed         to      detect
                                                tissue procedures due to its                                                                                     interruption       of     the
of         Bone           Wax                                                       enhancing              platelet         abnormalities within this
                                                shape, consistency, and                                                                                          healing process.         This
implantation,14 and this                                                            aggregation and physically              series of events are partial
                                                interference             with                                                                                    condition is a significant
agent may prevent the                                                               by 3-D clot stabilization               thromboplastin time (PTT)
                                                osteogenesis.                                                                                                    problem for both the
clearing of bacteria from                                                           (Figure 2).                             to assess the intrinsic
                                                         Surgicel has been                                                                                       clinician & the patient, as
infected sites.1                                                                                                            pathway or prothrombin
                                                found to be bacteriocidal in                                                                                     45% of patients who
                                                                                                                            time (PT) and international
                                                vitro      against      many                                                                                     develop alveolar
                                                                                                                            normalized ratio (INR) to
osteitis require at least 4 additional
postoperative     visits.29    Several                 Table. Categories Of
methods have been found to reduce                      Coagulation Disorders
the incidence of alveolar osteitis,
including the use of both topical30-32                 Hereditary
and      systemic      agents.    33-35                ------------------------------------------
Preliminary results examining the                      hemophilia A
use of ActCel and tetracycline in
                                                       hemophilia B
mandibular impacted extraction
sites have reduced alveolar osteitis                   von Willebrand's disease
(personal                observation).
Randomized controlled trials are                       afibrinogenemia
                                                                                                                           Figure 7. Since bleeding was not       Figure 8. The immediate
needed to substantiate these                                                                                               yet completely controlled              postextraction socket of tooth No. 5
observations.                                          factor V deficiency                                                 (continued from Figures 5 and 6),      in an 82-year-old woman who was
                                                                                                                           1 x 1-inch pieces of hemostatic        taking Coumadin. She had an INR of
         Indications for the use of                    factor XIII deficiency                                              gauze were placed in the socket        3.0. Preoperatively, her physician was
                                                                                                                           one-by-one until the bleeding          consulted over the phone. It was
ActCel are the control of bleeding                                                                                         totally stopped. A total of 8 pieces   decided that with her stroke history
                                                       hereditary hemorrhagic                                              were placed. After a few minutes,      and the limited nature of the oral
or protection of a wound in the oral                   telangiectasia                                                      3 sutures were tied to                 surgery, it would be best to use local
cavity. This includes minor oozing                                                                                         approximate soft tissue over the       measures to control expected
that may require additional                            protein C deficiency                                                socket. This helped contain the        intraoperative and possible
hemostatic assistance, routine use                                                                                         gauze and protect it from              postoperative hemorrhage. At the
                                                                                                                           dislodgement. After 30 minutes of      surgery appointment, the tooth was
in     mandibular       third  molar                   antithrombin III deficiency
                                                                                                                           observation, the patient was           removed atraumatically. Following the
extraction sites to decrease the                                                                                           allowed to leave the office.           extraction, one 1 x 1-inch piece of
occurrence of alveolar osteitis, or                                                                                                                               hemostatic gauze was placed in the
as an adjunct for control of arterial                  Acquired                                                                                                   socket. A figure-8 suture was tied
                                                       ------------------------------------------                                                                 over the socket to better approximate
bleeding (first stopping the arterial                                                                                                                             buccal and lingual gingival and to
                                                       vitamin K deficiency                                                                                       prevent hemostatic gauze
bleed with other methods and then
                                                                                                                                                                  dislodgement. As a precaution, food
assisting in stabilizing the clot by                   drug induced hemorrhage                                                                                    was limited to a liquid diet that day.
placement of ActCel). ActCel, as                                                                                                                                  Food was chewed on the other side of
previously noted, should not be                        massive blood transfusion                                                                                  the mouth for the following few days.
placed in areas that are not in
communication with the external                        postcardiopulmonary bypass
environment or placed in infected
sites (Figures 3 to 8).                                disseminated intravascular
                                                                                                           23. Zhang Qin shang Xu Qing zhong. Application
          CONCLUSION                                                                                       of S 99 soluble styptic gauze to wounds. Beijing
                                                       drug induced platelet dysfunction                   Xuan Wu Hospital, Departments of Pathology and
                                                                                                           Stomatology. Beijing, China. December 31, 1982:
         Hemostatic agents are used                    idiopathic thrombocytopenic                         personal communication.
in dentistry for hemorrhage control                    purpura                                             24. Data on file. Nelson Laboratories, Inc; Salt
and wound protection. This                                                                                 Lake City, Utah; Telephone: (801) 963 2600.
         article     has     reviewed                  catheter induced
different hemostatic agents, their                     thrombocytopenia                                    25. Hematologic problem. In: Barker LR, Burton
                                                                                                           JR, Zieve PD eds. Principles of Ambulatory             William L. McBee, DDS
mechanisms of action, and their                                                                            Medicine 5th ed. Baltimore, W. Williams &
                                                                                                           Wilkins; 1999:641.                                     Dr. McBee is an oral and maxillofacial
clinical         indications      and                                                                                                                             surgeon who graduated from dental
contraindications. ActCel, a new                                                                                                                                  school at the University of Tennessee
hemostatic agent, was reviewed.                                                                            26. Berge 71, Boe OE. Predictor evaluation of          and then completed his residency at
                                                      12. Rarig HR. Successful use of gelatin foam         postoperative morbidity after surgical removal of      the University of Minnesota. He
                                                      sponge in surgical restoration of fertility. Am J    mandibular third molars. Acts Odontol Scand.           currently practices oral and
          References                                  Obstet Gynecol. 1963;86:136.                         1994;52:162 169.                                       maxillofacial surgery in Provo, Utah,
1. Ogle OE. Perioperative hemorrhage. In: Dym                                                                                                                     and can be reached at (801) 375-4707
H, Ogle OE. Atlas of Minor Oral Surgery.              13. Gelfoam [package insert]. Kalamazoo, Mich:       27. Swanson AE. Prevention of dry socket: an           or
Philadelphia, Pa: WB Saunders; 2000:62 63.            Pharmacia; 1999.                                     overview. Oral Surg Oral Med Oral Pathol.
                                                                                                           1990;70:131 136.
                                                                                                                                                                  Disclosure: Dr McBee is a member of
2. Platelets and primary hemostasis. In: Andreoli     14. ETHICON Bone Wax [package insert).
                                                      Somerville, NJ: Ethicon Inc; 1997.                   28. Krekmanov L. Alveolitis after operative            the MedSpring Group Medical Advisory
TE, Bennett JC, Carpenter CCJ, et al. Cecil                                                                                                                       Board. He does not receive financial
Essentials of Medicine 4th ed. Philadelphia, Pa:                                                           removal of third molars in the mandible. Int J
                                                      15. Surgicel Fibrillar Hemostat [package insert].    Oral Surg. 1981:10:173 179.                            remuneration for any product
WB Saunders; 1997:403.
                                                      Somerville, NJ: Ethicon Inc; 1998. 16. Dineen P                                                             mentioned in this article.
3. CollaPlug [package insert]. Plainsboro, NJ:        Antibacterial activity of oxidized regenerated       29. Osborn TP, Frederickson G Jr, Small IA, et al.
Integra LifeSciences Corp; 2001.                      cellulose. Surg Gynecol Obstet. 1976;142:481         A prospective study of complications related to
                                                      486.                                                 mandibular third molar surgery. J Oral Maxillofac
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                                                      cellulose on experimental intravascular Infection.   30. Quinley JF, Royer RQ, Gores RJ. "Dry
5. Jenkins HP, Janda R, Clarke J. Clinical and        Surgery. 1977;82:576 579.                            socket" after mandibular odontectomy and use of
experimental observations on the use of gelatin                                                            soluble tetracycline hydrochloride. Oral Surg Oral
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                                                      cellulose on experimental infected infected
6. Jenkins HP, Janda R. Studies on the use of         splenotomies J Surg Res. 1977;23:114-125             31. Goldman DR, Kilgore DS, Panzer JD, et al.
gelatin sponge or foam as a hemostatic agent in                                                            Prevention of dry socket by local application of
experimental liver resections and injuries to large   19. Kuchta N. Dineen P. Effects of hemostats on      lincomycin In Gelfoam. Oral Surg Oral Med Oral
veins. Ann Surg. 1946;124:952 961.                    intraabdominal sepsis. Infections in Surgery.        Pathol. 1973;35:472 474.
                                                      1983;2:441 445.                                                                                             Karl R. Koerner, DDS, MS
7. Correll JT Prentice HR, Wise EC. Biologic                                                               32. Julius LL, Hungerford RW, Nelson WJ, et all.
investigations of a now absorbable sponge. Surg       20. Ibrahim MF, Ape C. Young CP. A foreign           Prevention of dry socket with local application of     Dr. Koerner has taught more than 500
Gynecol Obstet. 1945;181:585 589.                     body reaction to Surgical mimicking an abscess       Terra Cortril in gelfoam. J Maxillofac Surg.           didactic and hands-on courses to
                                                      following cardiac surgery [letter). Eur J            1982;40:285 286.                                       dentists in the United States and
8. Council on Pharmacy and Chemistry.                 Cardiothorac Surg. 2002;22:489 490.                                                                         abroad. He has contributed to 2
Absorbable gelatin sponge: new and nonofficial                                                             33. Rood JP, Murgatroyd J. Metronidazole in the        volumes of Dental Clinics of North
remedies. JAMA. 1947;135:921.                         21. Krishnan LK, Mohanty M, Umashankar PR,           prevention of 'dry socket'. Br J Oral Surg.            America. Since 2002, he has been a
                                                      et al. Comparative evaluation of absorbable          1979;17:62 70.                                         clinician and lecturer for Clinical
9. Jenkins HP, Senz EH, Owen H, et at. Present        hemostats: advantages of fibrin based sheets.                                                               Research Associates in Provo, Utah.
status of gelatin sponge for control of               Biomaterials. 2004;25:5557 5563.                     34. Krekmanov L, Nordenram A. Postoperative            He is past president of the Utah
hemorrhage. JAMA. 1946; 132:614619.                                                                        complications after surgical removal of                Dental Association and Utah Academy
                                                      22. Kothbeuer KF, Jallo GI, Siffert J, et al.        mandibular third molars: effects of penicillin V       of General Dentistry. He is a general
10. Treves N. Prophylaxis of post mammectomy          Foreign body reaction to hemostatic materials        and chlorhexidine. Int J Oral Maxillofac Surg.         dentist and practices in Salt Lake City,
lymphederna by the use of GELFOAM laminated           mimicking recurrent brain tumor report of three      1986; 15:25 29.                                        Utah, and can be reached at (801)
rolls. Cancer. 1952;5:73 83.                          cases. J Neurosurg. 2001;95:503 506.                                                                        502-8585 or
                                                                                                           35. Mitchell DA. A controlled clinical trial of
                                                                                                           prophylactic tinidazole for chernoproaxis in third
11. Barnes AC. The use of gelatin foam sponges                                                                                                                    Disclosure: Dr Koerner is a member of
in obstetrics and gynecology. Am J Obstet                                                                  molar surgery. Br Dent J. 1986;160:284 286.
                                                                                                                                                                  the MedSpring Group Medical Advisory
Gynecol. 1963;86:105 107.                                                                                                                                         Board. He does not receive financial
                                                                                                                                                                  remuneration for any product
                                                                                                                                                                  mentioned in this article.

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