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The influence of hemostatic agents on dentin and enamel surfaces and dental bonding: A systematic review Karina de Oliveira Bernades, Leandro Augusto Hilgert, Ana Paula Dias Ribeiro, Fernanda Cristina Pimentel Garcia and Patrícia Nóbrega Rodrigues Pereira JADA 2014;145(11):1120-1128 10.14219/jada.2014.84 The following resources related to this article are available online at jada.ada.org (this information is current as of November 18, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/11/1120

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ORIGINAL CONTRIBUTIONS

ARTICLE 2

The influence of hemostatic agents on dentin and enamel surfaces and dental bonding A systematic review Karina de Oliveira Bernades, DDS; Leandro Augusto Hilgert, DDS, MS, PhD; Ana Paula Dias Ribeiro, DDS, MS, PhD; Fernanda Cristina Pimentel Garcia, DDS, MS, PhD; Patrícia Nóbrega Rodrigues Pereira, DDS, PhD

C

avity preparation procedures often cause gingival bleeding, which may be a result of tissue trauma or gingival inflammation.1,2 In addition, the need to control moisture and contamination is common in restorative dentistry, especially when rubber dam isolation is not feasible.3 In these cases, hemostasis becomes of utmost importance in maintaining the ideal, contaminant-free operatory field.4,5 The most common procedures used to control bleeding and decrease the flow of gingival fluid involve the use of a topical hemostatic agent.6,7 These agents are based on two categories of pharmacological action: astringents (blood coagulation factors) and vasoconstrictors (adrenergic agents).5,8 Meanwhile, the use of these agents raises doubts about whether bonding on hemostatic-contaminated dentin and enamel results in decreased bond strength. Abundant information is available regarding the local effects of hemostatic agents on the Dr. Bernades is a graduate student, Department of Dentistry, School of Health Sciences, University of Brasília, Brazil. Dr. Hilgert is a professor, Department of Dentistry, School of Health Sciences, University of Brasília, Brazil. Dr. Ribeiro is a professor, Department of Dentistry, School of Health Sciences, University of Brasília, Brazil. Dr. Garcia is a professor, Department of Dentistry, School of Health Sciences, University of Brasília, Brazil. Dr. Pereira is a professor, Department of Dentistry, School of Health Sciences, University of Brasília, Campus Darcy Ribeiro, CEP: 70910-900, Brazil, e-mail [email protected] Address correspondence to Dr. Pereira.

abstract Background. Hemostatic agents have been used clinically in dentistry for many years to control bleeding. The authors reviewed scientific publications in which researchers investigated the effects of hemostatic agents on dentin and enamel surfaces and on bonding of adhesive systems and resin cements. Types of Studies Reviewed. The authors screened PubMed and Scopus databases for studies in English published from 1980 to 2013. They read the titles and abstracts to identify literature that fulfilled the inclusion criteria. The authors included studies in which researchers evaluated the hemostatic action on the dentin and enamel surfaces or its influence on the bond strength of adhesive systems or resin cements. They used cross-referencing to identify more articles. Results. Twenty in vitro studies met the inclusion criteria. Investigators in 12 of these studies evaluated the bond strength to contaminated dentin. Investigators in 10 of these studies reported a significant decrease in bond strength. Those in two studies evaluated the influence of a hemostatic agent on the dental enamel and reported decreases in bond strength. Researchers also reported significant increases in microleakage of self-etching adhesives on contaminated dentin. Scanning electron microscopy revealed partial removal of the smear layer or an etching effect of dentin as a result of the application of hemostatic agents on dentin. Practical Implications. Adhesive procedures may be affected adversely when performed on dentin and enamel contaminated by hemostatic agents. Hemostatic agents may induce changes in the dentin surface morphology. The results of this review indicate that the bond strength of self-etching adhesive systems is affected more negatively than is that of etch-and-rinse systems. The authors found that a 60-second application of ethylenediaminetetraacetic acid followed by a water spray restored the bond strength of a self-etching adhesive to dentin; use of phosphoric acid for 15 seconds followed by a water spray also was an effective cleaning method. Direct comparison of selected studies was not possible, however, mainly because of methodological differences hampering definitive conclusions. Key Words. Bonding agents; adhesives; aluminum chloride; cementation; dental adhesives; dental bonding; hemostasis. JADA 2014;145(11):1120-1128. doi:10.14219/jada.2014.84

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ORIGINAL CONTRIBUTIONS

surrounding soft tissue,9-11 but little is known about their effect on enamel and dentin substrates on hybridization. Nevertheless, it is becoming increasingly important for clinicians to recognize changes in dental composition and microstructure that may occur after the application of hemostatic agents when they plan restorative procedures that depend on dentin and enamel bonding. The purpose of this systematic review was to assess the influence of hemostatic agents on bonding of adhesive systems and resin cements to contaminated tooth surfaces and to analyze their effect on the tooth surface morphology.

which researchers evaluated the cytotoxicity of hemostatic agents on human gingival fibroblasts. Data extraction. One of us (K.O.B.) extracted the following data from the included studies and entered them into electronic spreadsheets: authors, year of publication, hemostatic agent, contamination time, cleaning method, adhesive system or resin cement, bond strength test and any other tests used (Table 112-31). We did not perform any statistical analysis or meta-analysis owing to both methodological differences and differences in the combinations of materials used to create the experimental groups.

METHODS

RESULTS

Data sources. We based identification of studies to be considered for inclusion on a search strategy involving two electronic databases (PubMed and Scopus). We included studies published from 1980 to 2013. This period covered the time during which studies were published that had a focus on hemostatic agents and their influence on dentin and enamel substrates and on dentin and enamel bonding of adhesive systems and resin cements.

The searches yielded 574 citations. In total, we investigated 33 full-text studies, 20 of which qualified for this review (Figure 1, page 1124). We did not locate any additional articles by means of cross-referencing. All of the investigations were in vitro laboratory studies published in English. Investigators in all but two studies22,29 used extracted human teeth, and those in three of the 18 studies used primary teeth.15,18,23 We

Energy-dispersive x-ray spectroscopy data showed more aluminum and ferric remnants in the groups with contaminated dentin after the dentin surface was treated with self-etching primers than in the groups treated with phosphoric acid as part of the etch-and-rinse systems. We prepared the following search strategy according to Medical Subject Headings terms related to the research question: “hemostatic” OR “vasoconstrictor agents” OR “ferric sulfate” OR “ferric chloride” OR “aluminum chloride” in association with (AND) “dental cement” OR “dental bonding” OR “resin luting agent” OR “dental enamel” OR “dentin.” The search strategy was modified appropriately for each database. One investigator (K.O.B.) screened all titles revealed by this research strategy and searched the abstracts to identify articles that might be of relevance. The reference lists of all eligible studies also were hand-searched for additional relevant publications. The same investigator evaluated the complete articles to decide whether to include or exclude the selected studies. Inclusion and exclusion criteria. We considered four main aspects when identifying reports for inclusion: substrate, type of hemostatic agent, cleaning procedures and evaluation method. We identified the articles on the basis of the following inclusion and exclusion criteria. We included studies if the investigators evaluated the hemostatic action on the dental surface or its effect on the bond strength of adhesive systems or resin cements. We accepted permanent and primary human teeth, as well as bovine teeth, for the review. We excluded studies in which researchers evaluated hemostatic effectiveness in bleeding control or effectiveness in pulpotomy and endodontic procedures. Also excluded were studies in

assessed 16 hemostatic agents (Table 2, page 1125). These included both self-etching and total-etching systems, but researchers in only six studies reported results of comparisons between them.15,17,19,21,26,30 Researchers in only one study evaluated a self-adhesive resin cement.20 In only two studies did researchers evaluate the influence of the hemostatic agent on the dental enamel.29,31 These researchers assessed two orthodontic adhesives in their studies. We found no standardization among studies regarding the contamination methods. Researchers in some studies applied the hemostatic agent on the dentin surface by using a microbrush,22,25,27,28,30 some dripped a drop of the solution on the dentin,14,21,29,31 and others soaked the dentin specimens for days in a receptacle containing the solution.18,23 Investigators in one study placed the dentin specimens on gauze soaked in the hemostatic agent, which was sealed in a closed container,15 and those in two studies submerged the dentin specimens in the hemostatic agent for different application times.25,28 Investigators in other studies did not specify clearly the contamination methods used.16,17,19,20,24,26 In ABBREVIATION KEY. EDS: Energy-dispersive x-ray spectroscopy. EDTA: Ethylenediaminetetracetic acid. FTIR: Fourier transform infrared spectroscopy. SBS: Shear bond strength. SEM: Scanning electron microscopy.  JADA 145(11) http://jada.ada.org November 2014 1121

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ORIGINAL CONTRIBUTIONS

TABLE 1

Summary of main characteristics of studies included in the review (in order retrieved). SOURCE

HEMOSTATIC AGENT *

Land and Colleagues,12 1994

Astringedent

Land and Colleagues,13 1996

CONTAMINATION TIME

CLEANING METHOD

ADHESIVE SYSTEM OR LUTING AGENT†

BOND STRENGTH TEST

SURFACE ANALYSIS OR OTHER TEST

Five-second wash with air-water syringe, followed by 10-second spray and 15-second rinse

None

Not conducted

SEM ‡

Astringedent, 30 seconds/ Hemogin L, two minutes/fi ve Hemodent, minutes Cranberry Styptin, Gingi-Aid Astringent 25%, Orostat 8%, Visine Original, Ocuclear

Three-phase irrigation cycle in water followed by 10-second spray with multifunction syringe

None

Not conducted

SEM

Ayo-Yusuf and Colleagues,14 2005

Hemodent, Astringedent, Ultradent buffered 25% aluminum chloride

30 seconds/ one minute/two minutes/ fi ve minutes

Air-water spray for 10 seconds

None

Not conducted

SEM, EDS §

Salama,15 2005

Astringedent

48 hours

Rinse with tap water for 15 seconds

Prime & Bond NT, OptiBond Solo Plus

SBS ¶

None

Kimmes and Colleagues,16 2006

ViscoStat, ViscoStat Plus

One minute

Rinse with water spray for one minute

OptiBond Solo Plus

SBS

None

Kuphasuk and Colleagues,17 2007

Racestyptine

Two minutes

Rinse with water spray for 30 seconds

Clearfil SE Bond, Excite

Micro-SBS

SEM, EDS

Prabhakar and Bedi,18 2008

Astringedent

48 hours

Rinse with tap water for 15 seconds

Adper Prompt L- Pop, Clearfil SE Bond

SBS

None

Two minutes

Rinse with water spray for 30 seconds

ED Primer II/ Panavia F, Excite DSC/Variolink II

Micro-SBS

SEM, EDS

Harnirattisai and Racestyptine Colleagues,19 2009

30 seconds/ two minutes/fi ve minutes

* The manufacturers of the hemostatic agents are as follows: Astringedent, Ultradent Products, South Jordan, Utah; Hemogin L, Dux Dental, Oxnard, Calif.; Hemodent, Premier Dental Products, Plymouth Meeting, Pa.; Cranberry Styptin, Dux Dental; Gingi-Aid Astringent 25%, Gingi-Pak, a division of The Belport Co., Camarillo, Calif.; Orostat 8%, Gingi-Pak; Visine Original, McNeil-PPC, Lancaster, Pa.; Ocuclear, Health Care Products, Memphis, Tenn.; Ultradent buffered 25% aluminum chloride, Ultradent Products; ViscoStat, ViscoStat Plus and ViscoStat Clear, Ultradent Products; Racestyptine, Septodont, Saint-Maur-des-Fossés, France; Ferric Subsulfate Dental Gel, Beall’s Compounding Pharmacy, Puyallup, Wash.; Ankaferd Blood Stopper, Ankaferd, Istanbul; Hemostop, Dentsply International, York, Pa. † The manufacturers of the adhesive systems or luting agents are as follows: Prime & Bond NT, Dentsply, York, Pa.; OptiBond Solo Plus, Kerr, Orange, Calif.; Clearfil SE Bond, Kuraray, Tokyo; Excite, Ivoclar Vivadent, Schaan, Liechtenstein; Adper Prompt L-Pop, 3M ESPE, St. Paul, Minn.; ED Primer II and Panavia F, Kuraray; Excite DSC and Variolink II, Ivoclar Vivadent; Rely X Unicem, 3M ESPE; All Bond SE, Bisco, Schaumburg, Ill.; Solobond M, VOCO, Cuxhaven, Germany; Clearfil Tri-S Bond, Kuraray; Adper Easy One, 3M ESPE; AdheSE and AdheSE One, Ivoclar Vivadent; Tetric N-Bond, Ivoclar Vivadent; Single Bond, 3M ESPE; iBond, Heraeus Kulzer, Hanau, Germany; Transbond XT, 3M Unitek, Monrovia, Calif.; Clearfil S3 Bond, Kuraray; Light Bond, Reliance Orthodontic Products, Itasca, Ill. ‡ SEM: Scanning electron microscopy. § EDS: Energy-dispersive spectroscopy. ¶ SBS: Shear bond strength. # EDTA: Ethylenediaminetetraacetic acid.

addition, we found enormous differences in contamination periods (10 seconds to 48 hours). Overall, among the 20 included studies, investigators in 10 of them evaluated the bond strength of self-etching adhesive systems to contaminated dentin15,17-19,21,23,24,26,28,30; those in eight of these studies reported a significant decrease in bond strength.15,17,18,21,23,24,26,30 Investigators in seven studies evaluated the bond strength of etch-and-rinse adhesive systems to contaminated dentin15-17,19,21,26,30; in three of these studies, investigators

reported a significant decrease in bond strength,15,21,30 whereas in one study, investigators reported a significant increase in bond strength.17 Figure 215-21,23,24,26,28 (page 1126) shows these results in greater detail. Researchers in the one study that evaluated the bond strength of a self-adhesive resin cement to contaminated dentin also reported a significant decrease in bond strength to specimens rinsed with water only.20 However, because these researchers evaluated bond strength after dentin contamination with blood followed by application of the

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ORIGINAL CONTRIBUTIONS

TABLE 1 (continued)

SOURCE

HEMOSTATIC AGENT *

CONTAMINATION TIME

CLEANING METHOD

ADHESIVE SYSTEM OR LUTING AGENT†

BOND STRENGTH TEST

SURFACE ANALYSIS OR OTHER TEST

Chaiyabutr and Kois,20 2011

ViscoStat Clear, Ferric Subsulfate Dental Gel

Five minutes

Rinse with water spray for 20 seconds, clean with 37% phosphoric acid for 15 seconds and rinse for 10 seconds or clean with aluminum oxide abrasion and rinse using water spray

Rely X Unicem

SBS

SEM

Arslan and Colleagues, 21 2012

Ankaferd Blood Stopper

Not specified

No cleaning or use 37% phosphoric acid

Clearfil SE Bond, All Bond SE, Solobond M

SBS

SEM

Mohammadi and Colleagues, 22 2012

Hemostop

Two minutes

Rinse with water spray for 30 seconds

Clearfil Tri-S Bond

Not conducted

Microleakage

Shalan and Colleagues, 23 2012

Astringedent

48 hours

Rinse with tap water for 15 seconds

AdheSE One

SBS

SEM, Fourier transform infrared spectroscopy

Ajami and Colleagues, 24 2013

Hemostop

Two minutes

No cleaning or use highpressure water spray for fi ve minutes, 10% EDTA # solution for 60 seconds followed by water spray for 30 seconds or 35% phosphoric acid for 15 seconds followed by water spray for 30 seconds

Clearfil Tri-S Bond

SBS

SEM, EDS

Arslan and Colleagues, 25 2013

Ankaferd Blood Stopper

Not specified

No cleaning, air-dry only

Clearfil SE Bond, Adper Easy One

Not conducted

Microleakage

Ebrahimi and Colleagues, 26 2013

ViscoStat

60 seconds

Rinse with water spray for 60 seconds

AdheSE, AdheSE One, Tetric N-Bond

SBS

None

Kumar and Colleagues, 27 2012

ViscoStat

10 seconds

Air-water spray for 10 seconds

Single Bond, iBond

Not conducted

Microleakage

Kilic and Colleagues, 28 2013

Ankaferd Blood Stopper

20 seconds

Rinse with water spray for 10 seconds

ED Primer II/ Panavia F

Microtensile bond strength

None

Trakyali and Oztoprak, 29 2010

Ankaferd Blood Stopper

Not specified

No cleaning, air-dry only

Transbond XT

SBS

None

Ulusoy and Colleagues, 30 2011

Ankaferd Blood Stopper

10 seconds

Air-water spray for 15 seconds

Prime & Bond NT, Clearfil S3 Bond

Microtensile bond strength

None

Güngör and Colleagues, 31 2013

Ankaferd Blood Stopper

Not specified

No cleaning, air-dry only

Light Bond

SBS

None

hemostatic agent,20 we considered the contamination to be a consequence of both and not a result of the hemostatic contamination alone. The results of two studies in which researchers evaluated the influence of hemostatic contamination on bonding to enamel showed a significant decrease in bond strength in the contaminated group.29,31 The results of all studies in which investigators evaluated microleakage showed a significant increase in leakage of self-etching adhesives on contaminated dentin (P < .05).12,25,27 The scanning electron microscopy results

showed that each hemostatic agent had a distinct effect on the dentin surface. In addition, this adverse effect increased as a function of time.12-14 Land and colleagues13 reported that a two-minute exposure to 15.5 percent ferric sulfate resulted in severe etching comparable with a five-minute exposure to a 21.3 percent aluminum chloride agent. Similarly, Chaiyabutr and Kois20 reported that during the same length of time, dentinal tubules in groups assigned to an aluminum chloride–containing agent mainly were occluded, with partial removal of the smear layer. In the ferric sulfate groups, the dentinal  JADA 145(11) http://jada.ada.org November 2014 1123

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Records identified through PubMed database screening (n = 275)

Records identified through Scopus database screening (n = 299)

Total records screened (n = 574)

Duplicated articles (n = 25)

Included

Eligibility

Screening

Identification

ORIGINAL CONTRIBUTIONS

Full-text articles assessed for eligibility (n = 58)

Records excluded (n = 516)

Full-text articles excluded (n = 13)

Studies included in systematic review (n = 20)

Figure 1. Flow chart of the literature search process.

tubules exhibited a more pronounced etching effect. The results of other studies confirmed the effect of two nondental astringents containing tetrahydrozoline hydrochloride that are used commonly as eye drops.5,13 The authors noted that a five-minute exposure of dentin to these nondental astringents did not result in statistically significant smear layer removal or etching of the dentin surface, thus suggesting a possible use in dentistry.5 Energy-dispersive x-ray spectroscopy (EDS) data showed more aluminum and ferric remnants in the groups with contaminated dentin after the dentin surface was treated with self-etching primers than in the groups treated with phosphoric acid as part of the etch-and-rinse systems.14,17,19,24 Researchers in one study found that 4.76 percent of the aluminum remained in dentin specimens conditioned with self-etching primers compared with 0.46 percent in specimens conditioned with phosphoric acid.17 Investigators in a second study detected 2.46 percent of aluminum remnants in dentin specimens after conditioning with a self-etching system

compared with 0.46 percent in dentin specimens in the etch-and-rinse group.19 EDS analysis also showed a less dramatic reduction in calcium content when hemostatic agents were used.14 DISCUSSION

In this review, we selected studies pertaining to hemostatic effects on both dentin and enamel surfaces and dentin and enamel bonding. Because the use of hemostatic agents is routine in clinical procedures, understanding their effects on dentin morphology, as well as on the enamel surface and on bonding, is of unquestionable importance. However, owing to the lack of similarities in methodological criteria between the studies in our review, we found it difficult to draw definitive conclusions. Crossover analysis among studies was limited because of the few similarities between them; therefore, conducting a statistical analysis was not feasible. Hemostatic agents are acidic solutions, with pH values ranging from 0.7 to 2.0.12-14,17,19 Aluminum chloride and ferric sulfate were the main active ingredients in

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ORIGINAL CONTRIBUTIONS

most of the hemostatic agents studied in this review. In the presence of water, these compounds undergo hydrolysis and form hydrochloric acid and sulfuric acid, respectively. Because both are strong acids, they may cause the etching effect observed on the dentin surface.12-14,17,20 Contaminants. At the same time, contaminants, such as remaining particles of the hemostatic agent, may obstruct the flow of resin monomers into the dentinal tubules. Small contaminant particles may penetrate the dentinal tubules and, ultimately, affect the development of the hybrid layer.32 Prabhakar and Bedi18 pointed out that one possible explanation for the reduced shear bond strength associated with ferric sulfate could be the coagulation of plasma proteins in the dentinal fluid, which also might affect the surface architecture of the dentin. In addition, for the specimens in the aluminum chloride groups, the deposition of aluminum in the form of unbound minerals on the dentin surface and the formation of a layer of residue may be responsible, in part, for the decrease in bond strength.24 The study findings suggest that self-etching monomers may not remove these contaminants sufficiently, because their bonding ability depends on forming short resin tags and a relatively thin submicron hybrid layer. Self-etching monomers may not readily etch a more acid-resistant dentin surface that is contaminated with a hemostatic agent.24 As a result, self-etching adhesive systems are more susceptible to reduced bond strengths after contamination because the smear layer is used as a bonding substrate.30 However, phosphoric acid, with a pH of 0.516 and an aggressive etching effect, seems to be able to demineralize the dentin and remove virtually all of the contaminant on the dentin surface. Therefore, the phosphoric acid in etch-and-rinse systems may have acted as a cleaning agent. Support for this speculation can be found in the EDS results, which showed a similar amount of aluminum remaining on the surfaces of uncontaminated and contaminated dentin after undergoing etching with phosphoric acid. These findings differ from those in the self-etching groups, in which more aluminum remained on the contaminated dentin surfaces; thus, this may explain, in part, why these surfaces seemed to be affected more by the hemostatic agents.14,17,19,24,30 Blood versus hemostatic agent. Although study findings have shown that hemostatic agents have a negative effect on the bond strength of the majority of adhesive systems, results also have shown that in the presence of blood, use of a hemostatic agent still is necessary. Some researchers evaluated specimens in blood-contaminated groups, in blood-contaminated groups followed by hemostatic agent contamination, and in hemostatic agent–contaminated groups without blood contamination.28-31 Their findings show lower bond strength values for specimens in blood-contaminated groups. When investigators used hemostatic agents after blood

TABLE 2

Hemostatic agents tested in studies. HEMOSTATIC AGENT

MANUFACTURER

ACTIVE INGREDIENT *

Astringedent

Ultradent Products, South Jordan, Utah

15.5 percent ferric sulfate solution

Ultradent Buffered Aluminum Chloride

Ultradent Products

25 percent aluminum chloride solution

ViscoStat

Ultradent Products

20 percent ferric sulfate solution

ViscoStat Plus

Ultradent Products

22 percent ferric chloride solution

ViscoStat Clear

Ultradent Products

25 percent aluminum chloride gel

Ferric Subsulfate Dental Gel

Beall’s Compounding Pharmacy, Puyallup, Wash.

13 percent ferric sulfate gel

Hemogin L

Dux Dental, Oxnard, Calif.

25 percent aluminum chloride aqueous solution

Hemodent

Premier Dental Products, Plymouth Meeting, Pa.

21.3 percent aluminum chloride aqueous/glycol solution

Cranberry Styptin

Dux Dental

20 percent aluminum chloride buffered glycol solution

Gingi-Aid Astringent 25%

Gingi-Pak, a division of The Belport Co., Camarillo, Calif.

25 percent aluminum chloride solution

Orostat 8%

Gingi-Pak

8 percent racemic epinephrine solution

Visine Original

McNeil-PPC, Lancaster, Pa.

Tetrahydrozoline hydrochloride solution

Ocuclear

Health Care Products, Oxymetazoline Memphis, Tenn. solution

Racestyptine

Septodont, SaintMaur-des-Fossés, France

25 percent aluminum chloride solution

Hemostop

Dentsply International, York, Pa.

Aluminum chloride solution

Ankaferd Blood Stopper

Ankaferd, Istanbul

Natural plant extract (Thymus vulgaris, Vitis vinifera, Glycyrrhiza glabra, Alpina officinarum and Urtica dioica)

* Active ingredient information was obtained from the studies in the review.

contamination, bond strength values increased, but they still were lower than those in groups contaminated with hemostatic agent only. These bond strength values, in turn, were substantially lower than those in the uncontaminated groups.30 Bonding to enamel. Researchers in two studies evaluated the influence of hemostatic contamination on bonding to enamel; they pointed out that the SBS in the contaminated dentin specimens may have been lower than that in uncontaminated specimens owing to the possible prevention of contact between the tooth enamel  JADA 145(11) http://jada.ada.org November 2014 1125

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e ate ulf lorid h ic S err rric C tF en nt Fe c r Pe rce 20 2 Pe 2

50 40 30

25 Percent Aluminum Chloride

25 Percent Aluminum Chloride

20

Ankaferd Blood Stopper Ankaferd Blood Stopper

15.5 Percent Ferric Sulfate

20 Percent Ferric Sulfate

15.5 Percent Ferric Sulfate

Aluminum Chloride e

Ankaferd Blood Stopper

10

15.5 Percent Ferric Sulfate

rid nt Chlo rce Pe um 25 min nt Alu erce lfate P Su 13 rric Fe

Co lle ag ue Ki s, 2 lic 8 a 20 nd 13 Co lle ag A ue jam s, 2 i 4 a 20 nd 13 Co lle ag Sh ue ala s, 2 n 3 a 20 nd 12 Ch ai y Ko ab is 2 utr , 0 a 20 nd 11

Pr ab Be ha di ka , 18 r a 20 nd 08

Co lle Eb ag ra ue him s, 2 i 6 a 20 nd 13 Co lle K ag im ue m s, 1 es 6 a 20 nd 06

Co lle ag Ar ue sla s, 2 n 1 a 20 nd 12

5 a, 1 5 20 0 Sa la m

Co lle ag Ulu ue so s, 3 y 0 a 20 nd 11

0 Co K lle up ag ha ue su s, 1 k 7 a 20 nd 07 Co Ha lle rni ag rat ue tis s, 1 ai 9 a 20 nd 09

BOND STRENGTH IN MEGAPASCALS

ORIGINAL CONTRIBUTIONS

STUDY Etch-and Rinse Adhesives

Two-Step Self-Etch Adhesives

One-Step Self-Etch Adhesives

Self-Adhesive Cement

Uncontaminated Dentin

Uncontaminated Dentin

Uncontaminated Dentin

Uncontaminated Dentin

Contaminated Dentin

Contaminated Dentin

Contaminated Dentin

Contaminated Dentin

Figure 2. Bond strength test results of studies performed on dentin. Ankaferd Blood Stopper is manufactured by Ankaferd, Istanbul.

and the bonding agent, the obstruction of resin tags on the etched enamel surface, or both.29,31 Investigators reported varying results for specimens in the etch-and-rinse groups; some specimens exhibited an increase in bond strength after contamination with a hemostatic agent, whereas others exhibited a decrease in bond strength. These differences may be attributed to the different combinations of materials and contamination times. Investigators in three studies16,17,19 reported an increase in bond strength in contaminated specimens in the etch-and-rinse groups; two of these studies involved the use of the same adhesive system, the same hemostatic agent and the same contamination time.17,19 However, investigators in four other studies15,21,26,30 reported a decrease in bond strength in contaminated dentin specimens in the etch-and-rinse groups. Researchers in three studies used a two-day contamination time15,18,23; however, most used a two-minute contamination time.12-14,17,19,22 Investigators in some studies applied an unusual hemostatic agent, a mixture of plant extracts prepared from Alpinia officinarum, Glycyrrhiza glabra, Thymus vulgaris, Urtica dioica and Vitis vinifera with homeostatic and antibacterial effects.21,25,29-31 Finally, Ebrahimi and colleagues26 were the only researchers to report a decrease in bond strength for a one-step selfetch adhesive system that was not statistically significant. Furthermore, many researchers reported that the results of the bond strength tests varied as a consequence of different dentin substrate conditions, such as the age of the tooth and storage conditions.33,34 These variables make

it difficult for us to draw parallels between the studies, as well as impossible to point out the reasons for such substantially different results. In most cases, it appears that water alone was not sufficient to remove contamination. Researchers in only two studies assessed cleaning methods for hemostatic agents.20,24 According to Ajami and colleagues,24 application of 10 percent ethylenediaminetetraacetic acid (EDTA) for 60 seconds followed by a 30-second water spray restored the bond strength of a self-etching adhesive to dentin. However, the authors reported that phosphoric acid failed to increase the bond strength of self-etching adhesive to dentin to the level of that in the control group. They reported that a five-minute water rinse under high pressure resulted in an increase in bond strength when compared with that in the nonrinsed, nonconditioned contaminated group; however, the bond strength still was much lower than that in the control group.24 Furthermore, for some dental practices, the five-minute water rinse may be considered clinically unacceptable. Chaiyabutr and Kois20 pointed out that after hemostatic contamination with 25 percent aluminum chloride or 13 percent ferric sulfate, the cleansing protocol should include particle abrasion with low-pressure aluminum oxide or phosphoric acid etching to restore the bond strength to precontamination levels when using a self-adhesive resin cement. These authors reported that the mean bond strengths of specimens in the acidetch groups and the particle abrasion groups were not

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ORIGINAL CONTRIBUTIONS

significantly different from the mean bond strength of specimens in the control group; however, the group that underwent water rinsing alone demonstrated the lowest mean bond strength.20 Because the results reported here are limited to the materials and contamination times used in each study, a standardized study is needed in which investigators compare all cleaning methods (that is, 10 percent EDTA, particle abrasion, 37 percent phosphoric acid and water spray). In addition, it may be useful to examine the use of pumice mixed with water, a cleaning method used in dentistry, to clarify this issue. Researchers should give special attention to the possibility of using alternative adrenergic agents, such as eye drops, in dentistry.13 Land and colleagues13 conducted a study in which they used this vasoconstrictor solution as a gingival retraction agent.5 According to their study findings, a five-minute exposure to tetrahydrozoline hydrochloride (Visine Original, McNeil-PPC, Lancaster, Pa.) (pH 6.8) or oxymetazoline hydrochloride (Ocuclear, Health Care Products, Memphis, Tenn.) (pH 6.5) did not cause significant smear layer removal or etching of the dentin surface. Our review included only one study in which investigators evaluated a self-adhesive resin cement and applied blood before the hemostatic contamination. Consequently, we suggest that researchers conduct further studies of this material. On the basis of our study findings, it remains unclear if the use of different hemostatic agents can result in different bond strength values for the same adhesive or dental cement, or if the same hemostatic agent in solution or gel form can cause different effects on dentin or enamel morphology and bonding. The literature is limited with regard to evaluations of the effects of hemostatic agents on enamel. Furthermore, researchers in the two studies in our review who evaluated enamel used a nonconventional agent made from plant extracts.29,31 We found no reports regarding the effect of a hemostatic agent on enamel morphology, but, as described earlier, it is known that the bond strength is affected negatively.29,31 Because some hemostatic agents are more soluble than others, it is important to note that some cleaning methods may be efficient for one type of hemostatic agent but not for others. Further investigation is necessary to address the problems cited earlier and the effect of self-adhesive resin cements on luting properties. CONCLUSION

Within the limitations of this systematic review, our findings show that hemostatic agents can induce changes on the dentin surface and in bonding performed on dentin and enamel. Limited data suggest that the bond strength of self-etching adhesives is affected more negatively than is the bond strength of etch-and-rinse systems. However, because of considerable methodological

differences between studies, further research is required before we can make definitive conclusions. n Disclosure. None of the authors reported any disclosures. 1. Schattenberg A, Werling U, Willershausen B, Ernst CP. Two-year clinical performance of two one-step self-etching adhesives in the restoration of cervical lesions. Clin Oral Investing 2008;12(3):225-232. 2. de Carvalho Mendonça EC, Vieira SN, Kawaguchi FA, Powers J, Matos AB. Influence of blood contamination on bond strength of a selfetching system. Eur J Dent 2010;4(3):280-286. 3. Yoo HM, Oh TS, Pereira PN. Effect of saliva contamination on the microshear bond strength of one-step self-etching adhesive systems to dentin. Oper Dent 2006;31(1):127-134. 4. Fischer DE. Tissue management needs for adhesive dentistry now and in the future. Dent Clin North Am 1998;42(4):595-606, vii. 5. Nowakowska D, Saczko J, Kulbacka J, Choromanska A, Raszewski Z. Cytotoxic potential of vasoconstrictor experimental gingival retraction agents: in vitro study on primary human gingival fibroblasts. Folia Biol (Praha) 2012;58(1):37-43. 6. Bailey JH, Fischer DE. Procedural hemostasis and sulcular fluid control: a prerequisite in modern dentistry. Pract Periodontics Aesthet Dent 1995;7(4):65-75. 7. Polat NT, Ozdemir AK, Turgut M. Effects of gingival retraction materials on gingival blood flow. Int J Prosthodont 2007;20(1):57-62. 8. Felpel LP. A review of pharmacotherapeutics for prosthetic dentistry: part I. J Prosthet Dent 1997;77(3):285-292. 9. Yalçin M, Barutcigil C, Umar I, Bozkurt BS, Hakki SS. Cytotoxicity of hemostatic agents on the human gingival fibroblast. Eur Rev Med Pharmacol Sci 2013;17(17):984-988. 10. Albaker AM. Gingival retraction: techniques and materials—a review. Pak Oral Dent J 2010;30(2):545-551. 11. Nowakowska D, Saczko J, Kulbacka J, Choromanska A. Dynamic oxidoreductive potential of astringent retraction agents. Folia Biol (Praha) 2010;56(6):263-268. 12. Land MF, Rosenstiel SF, Sandrik JL. Disturbance of the dentinal smear layer by acidic hemostatic agents. J Prosthet Dent 1994;72(1):4-7. 13. Land MF, Couri CC, Johnston WM. Smear layer instability caused by hemostatic agents. J Prosthet Dent 1996;76(5):477-482. 14. Ayo-Yusuf OA, Driessen CH, Botha AJ. SEM-EDX study of prepared human dentine surfaces exposed to gingival retraction fluids. J Dent 2005;33(9):731-739. 15. Salama FS. Influence of zinc-oxide eugenol, formocresol, and ferric sulfate on bond strength of dentin adhesives to primary teeth. J Contemp Dent Pract 2005;6(3):14-21. 16. Kimmes NS, Olson TL, Shaddy RS, Latta MA. Effect of ViscoStat and ViscoStat Plus on composite shear bond strength in the presence and absence of blood. J Adhes Dent 2006;8(6):363-366. 17. Kuphasuk W, Harnirattisai C, Senawongse P, Tagami J. Bond strengths of two adhesive systems to dentin contaminated with a hemostatic agent. Oper Dent 2007;32(4):399-405. 18. Prabhakar AR, Bedi S. Effect of glutaraldehyde and ferric sulfate on shear bond strength of adhesives to primary dentin. J Indian Soc Pedod Prev Dent 2008;26(suppl 3):S109-S113. 19. Harnirattisai C, Kuphasuk W, Senawongse P, Tagami J. Bond strengths of resin cements to astringent-contaminated dentin. Oper Dent 2009;34(4):415-422. 20. Chaiyabutr Y, Kois JC. The effect of tooth-preparation cleansing protocol on the bond strength of self-adhesive resin cement to dentin contaminated with a hemostatic agent. Oper Dent 2011;36(1):18-26. 21. Arslan S, Ertaş H, Zorba YO. Influence of Ankaferd Blood Stopper on shear bond strength of bonding systems. Dent Mater J 2012;31(2): 226-231. 22. Mohammadi N, Kimyai S, Bahari M, Pournaghi-Azar F, Mozafari A. Effect of aluminum chloride hemostatic agent on microleakage of Class V composite resin restorations bonded with all-in-one adhesive. Med Oral Patol Oral Cir Bucal 2012;17(5):e841-e844. 23. Shalan H, Awad S, El-Fallal AA. Influence of pulpotomy medicaments on the ultrastructure and shear bond strength of a self-etch adhesive to primary tooth dentin. Quintessence Int 2012;43(6):517-523. 24. Ajami AA, Kahnamoii MA, Kimyai S, et al. Effect of three differ-

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ent contamination removal methods on bond strength of a self-etching adhesive to dentin contaminated with an aluminum chloride hemostatic agent. J Contemp Dent Pract 2013;14(1):26-33. 25. Arslan S, Ertaş H, Zorba YO. Effect of a plant-based hemostatic agent on microleakage of self-etching adhesives. Med Oral Patol Oral Cir Bucal 2013;18(1):e124-e129. 26. Ebrahimi SF, Shadman N, Abrishami A. Effect of ferric sulfate contamination on the bonding effectiveness of etch-and-rinse and self-etch adhesives to superficial dentin. J Conserv Dent 2013;16(2):126-130. 27. Kumar P, Shenoy A, Joshi S. The effect of various surface contaminants on the microleakage of two different generation bonding agents: a stereomicroscopic study. J Conserv Dent 2012;15(3):265-269. 28. Kilic K, Arslan S, Demetoglu GA, Zararsiz G, Kesim B. Do blood contamination and haemostatic agents affect microtensile bond strength of dual cured resin cement to dentin? J Appl Oral Sci 2013;21(1):85-91. 29. Trakyali G, Oztoprak MO. Plant extract Ankaferd Blood Stopper

effect on bond strength. Angle Orthod 2010;80(3):570-574. 30. Ulusoy AT, Bayrak S, Tunc ES, Tuzuner T. Effect of new haemostatic agent on microtensile bond strength of two adhesive systems to dentin. Mater Res Innov 2011;15(5):330-334. 31. Güngör AY, Alkis H, Turkkahraman H. Effects of contamination by either blood or a hemostatic agent on the shear bond strength of orthodontic buttons. Korean J Orthod 2013;43(2):96-100. 32. Sung EC, Tai ET, Chen T, Caputo AA. Effect of irrigation solutions on dentin bonding agents and restorative shear bond strength. J Prosthet Dent 2002;87(6):628-632. 33. Inoue S, Pereira PN, Kawamoto C, et al. Effect of depth and tubule direction on ultimate tensile strength of human coronal dentin. Dent Mater J 2003;22(1):39-47. 34. Sattabanasuk V, Shimada Y, Tagami J. The bond of resin to different dentin surface characteristics. Oper Dent 2004;29(3):333-341.

1128  JADA 145(11)  http://jada.ada.org  November 2014 Copyright © 2014 American Dental Association. All Rights Reserved.

The influence of hemostatic agents on dentin and enamel surfaces and dental bonding: a systematic review.

Hemostatic agents have been used clinically in dentistry for many years to control bleeding. The authors reviewed scientific publications in which res...
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