Topical Thrombin and l?owderred Ge~foam
`An Efficient Hemostatic Treatment for Surgery
`
`David Krill, D.M.D.
`Ervin G. Savord, D.D.S.
`
`Introduction
`
`Bleeding is perhaps one of the most
`frequent and significant complications
`encountered by the average dentist.
`The effort needed to control it wastes
`valuable chair time as well as causing
`undue emotional strain for both the
`patient and doctor. Absorbable gelatin
`sponge material and topical thrombin
`are both commonly used to control
`hemorrhage. The usc of these
`substances
`in combination has
`received attention the the recent
`medical litcrature 1
`·' but is little
`2
`3
`•
`•
`reported in dentistr/. The purpose
`of thr;: following article is to present a
`technique in which powdered gelfoam
`and topical thrombin are combined to
`form a paste which can be utilized to
`create rapid hemostasis at the donor
`site of free soft tissue autograft.
`
`Technique
`
`The formulation of the hemostatic
`paste requires a relatively simple
`armanentarium (Figure 1). Topical
`thrombin available in dosage of 1000
`units*, is reconstituted in its vial to a
`liquid state by adding lee of sterile
`
`''Hlpical Thrombin -
`Plains, NJ
`
`Park Davis, Morris
`
`Dr. Krill is a Senior l\esident at the U.TC.II.S.
`College of Dentistry in Memphis, 'Icnnessee.
`Dr. Savord is Director of Periodontal Training
`at the V.A.M.C. in Memphis, 'Icnncsscc and
`Assistant Professor at the U.T.C.II.S. College of
`Dentistry.
`
`2()
`
`(
`
`Dr. David Krill
`water (Figure 2). Powered gelfoam* *
`is placed in a sterile dappen dish in the
`amount which gives a level fill (Figure
`3). The reconstituted thrombin is then
`withdrawn from the vial and added
`to the powdered gelfoam (Figure 4).
`The agents are then gently mixed
`using a Woodsen number 7 wax
`spatula***. The result is a soft, adhe(cid:173)
`sive paste which will cling to the
`spatula (Figure 5). Palatal donor tissue
`for use as a free soft tissue autograft
`is obtained by standard technique. 2
`x 2 gauze saturated with sterile saline
`is placed at the donor site and held
`with firm finger pressure for a few
`seconds. The 2 x 2 gauze is then
`removed and the hemostatic paste is
`carried to the donor site with the
`spatula (Figure 6). Hemostasis
`is
`achieved in approximately 10 seconds.
`
`''Gel foam - Upjohn Co., Kalamazoo, MI
`'''Spatula - Hu Fricdy, Chicago, IL
`
`Dr. Ervin Savord
`In cases of persistent hemorrhage, the
`2 x 2 gauze may be held firmly in
`place over the hemostatic paste for
`approximately one minute. However,
`the authors have found this to be
`necessary in very few instances. A
`periodontal pack, vacu-form surgical
`stent, or resorbable covering is then
`placed over the surgical site for the
`protection of the patient. Healing
`progresses uneventfully.
`
`Discussion
`
`Brasher0 states that post operative
`hemorrhage is a common complica(cid:173)
`tion encountered when performing
`free soft tissue autografts. The most
`common method for local hemorrhage
`control is direct pressure with a cotton
`gauze square until bleeding stops.
`Unfortunately,
`this requires direct
`active pressure on the part of the
`dentist or assistant which occupies
`
`This material was copcied
`at the N LM and may b,e
`~ubject USCopcyright Laws
`
`]oumal of Tennessee Dental Association (i(i-2
`
`ETHICON EXHIBIT 1009
`
`

`

`Figure I
`
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`Figure 2
`
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`
`Figure 3
`
`Figure 4
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`j
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`'t
`
`; /
`
`';
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`l j
`
`Figure 5
`
`Figure 6
`
`!'re-Ap plica tirm
`
`l'ost-Applicatio11
`
`time and precious operating space in
`the mouth. Further, it has been shown
`in studies on pulpal
`tissue that
`disturbing the absorbant material by
`replacing the gauze disrupts the clot
`and allows fresh bleeding to ensue5
`•
`Thrombin is a protein supplied as
`a freeze dried sterile powder that
`reconstitutes with sterile water or
`saline to an active state. It requires no
`intermediate physiologic agent for its
`action as it clots the fibrinogen of the
`blood directly. Gclfoam is a sterile
`non-antigenic material supplied as a
`sponge or powder. It is used by the
`authors as a
`transport medium
`
`although.it has been reported to have
`some clotting properties in its own
`right'. Powdered gelfoam was
`selected over the sponge form because
`it can be added to at the surgical site
`for additional hemostasis or to
`conform to irregular areas without
`disruption of the existing partial clot.
`Absorbable gelatin and
`topical
`thrombin have both been reported as
`not retarding bone healing"'.
`~7
`
`The vietcs represented arc those of the
`authors and arc not necessarily the views of the
`Veteran~ Administration.
`
`HEFEHENCES
`
`1. Hengachary, S. and r..Lmguo~lu, A.: Control of bleeding
`dn ring
`doward proceth1re, J. Neurosurg. 52:13S-13D, IDHO.
`2. l,e(me Jr., C.: (;t·lfoam-thrombin d.wryocystorhinostomy
`'il<'nl, AnH'r. J. Opth. 0-1:-112--113, IDS2.
`:3. Cohd<'n, H.; Thrasht>r, E. amlllarris, \V.: 'lOpical hemostatic
`agenb to n•duct• blt>edin)!; from canct"llous bone, J. Bone &
`Joint Surg. :lH-A:70-7:l, 1970.
`·1. llarri~. \\',; CruiiH'r~. 0.; Moven, B.; Bounw, H.: lhpical
`ht·mn~talie .agenh for bmw hh:edin).!; in humans, J. Bone &
`Joint Surg. GO-A:·15-t--tSO. ID78.
`.'5. Shoaf. II.; P.l~hle~·. E.; Myer...-. D. ;md Pilshl<•y, D: Quantita(cid:173)
`tion ;1n<l control of pulpal hkl'ding, Pediatric Dentistry,
`I(:Ji,I77-IHI, 1!17!1.
`fi. BrmlH'r, \\'.; Het•s, T. and Boyce, \V.: Complications of free
`grafh of ma~tieatory nHJco:-.a, J. Perio., 40:1-33, 1D75.
`
`G6-l 1bpical Thmmhi11 a11d l'oicdcrcd Gclfoam: J[HiSJ!Jf'itflfi~f"f~rn?i!J:~·lfRtic 1/'call!lclll for Surgery
`at the·'N LM and may be
`~ubje;:t USCo~yright Laws
`
`27
`
`