Tissue management is crucial to restoring any given tooth. We know that we must isolate perfectly to produce a perfect bond, or we will generate a faulty restoration. Bleeding gingival tissue is one obstacle we must overcome as preps become more complex and difficult.
To be analytical as we proceed into this subject, we should first determine if we are dealing with a local or systemic problem. Patients with systemic bleeding tendencies may have untreated medical conditions, such as
- High blood pressure,
- Platelet deficiency,
- Hyperthyroidism.
Alternatively, their condition may be a result of medical intervention, following antiplatelet or anticoagulant therapy.
Another background contributor, sometimes unrecognized, can be habituation to high daily intake of alcohol, sugar, or cayenne.These would not be medical in origin but still a part of their presenting systemic condition, and therefore a factor in every restoration attempted.
Even if the underlying causes are systemic, bleeding nonetheless can often still be controlled by local means, only it may require more time for coagulation. As well,multiple measures may be needed, as compared to a normal patient who responds to one quick deft maneuver.
Hypertension seems to be an exception. If you suspect hypertension, use a blood pressure cuff to monitor BP. You may be the first to identify this serious condition for the patient.
When treating gingival bleeding challenge of any origin, the following hierarchy makes sense.
- The first line of defense is compression of the tissues with wedges ,or packed cotton pledglets.
- Secondly, placing cord or other gingival packing containing hemostatic agents.
- Thirdly, medication –hemostatic agents
- Fourth, excision of diseased tissue that is abnormally perfused with capillaries due to chronic irritation
- Fifth is to Quit; temporize with a well-executed ZOE temporary restoration, and reappoint after completing a tissue recovery program of at least several weeks duration, allowing time to re-epithelialize the gingival collar, and for connective tissue repair if the gingival disease is deeply rooted. The usual strategies of improved oral hygiene, bacteriostatic mouthrinses, antibiotics if necessary, and so can be followed.
COMMON SITUATIONS
- Periodontal pocket:
If there is a periodontal pocket exuding crevicular fluid, use multiple cords , filling the pocket from its base to the crest with progressively larger cords. Be sure to leave a tail of excess cord of each strand so that they can all be easily retrieved. - Floppy, sloppy tissue: If the tissue is chronically inflamed, histologically it will have fewer fibers than normal, excess vascular invagination, and, excessive numbers of granulomatous cells. When it has degenerated to this extent, hemorrhage fills the prep and blocks vision, and the normal expedients of wedging, hemostatics, and cord won’t control it. Sometimes this hypertrophic tissue will prevent effective insertion of wedges, so that the matrix cannot be properly wedged to the gingival margin of the prep.
In this type of case, excise the papilla with a bur or scalpel, or remove the pocket lining with a curette. The latter allows the papilla to collapse. This excision of granulation tissue usually placates the embrasure, brings on normal coagulation, facilitates wedging, and all is sunny skies. As in any surgical intervention, visualize the end result first. We want to leave the embrasure with the stage set for proper healing to a manageable tissue line. - Cord doesn’t quite control bleeding Local irritants-plaque, food impaction, adjacent caries, subgingival fracture, and calculus can all render an embrasure inoperable. If cord has been placed, and the site is almost under control,try cording the sulcus of the adjacent tooth in addition to the operative tooth. This will reduces capillary flow to the whole papilla, and may do the trick.
- Anxiety Patient anxiety can prolong tissue bleeding long after it should have dried up. Making eye contact with the patient and speaking in a calm and reassuring voice, and using humor if that is part of your chairside manner, can help to establish a feeling of calm in the moment. Additionally, a confident touch to the shoulder; a reassuring voice (very emotional channel); and the clinician’s own personal clarity and certainty will lower anxiety. I am not sure if anxiety forces up blood pressure, or what the operative mechanism is, but these forms of reassurance often seem to turn the tide of an anxious appointment and bring bleeding tissues to a state of rest.
- Oozing band margin When the band has been placed, but there is still some oozing into the prep from the adjacent tissue, hemostatic etch Hemostatic Etch placed inside the band (the usual liquid phosphoric acid 37% titrated with saturated aluminum chloride), may often be enough.
If not, a second technique is to place cord outside the band using a larger cord size e.g. #1, or #2, rather than the usual #0. This medicates the tissue with the epinephrine and astringent of the cord, while simultaneously compressing the tissue and adapting the band to the root. - Oozing furcation Let’s say a band has been shaped on the Bandbender to adapt to a furcated root surface, but oozing still persists. Place cord, as above, apply Hemodent. then stuff the furcation with damp cotton pledglets, making a large packing against the adjacent tooth. Go do a checkup. This will both pressurize the tissue and adapt the band to the root. Upon returning from the checkup, the tissue usually will be tidy and cooperative after this chemical cautery.
INEFFECTIVE MEASURES
Here are some measures that this writer has found quite useless.
Ferric sulphate compounds. There are a large number on the market. While effective, these compounds often leave a permanent black stain at the margin of the composite restoration. It may take six months to appear, or it may be immediate.
Visine, the eyedrop OTC pharmaceutical, has not been effective as an astringent.
35% Hydrogen Peroxide (Superoxyl) will cauterize tissues and cleanse an operative site. It has not proven itself effective as a hemostatic, however, and the preparation will have reduced dentin bonding strength , see Erdemir et al JOE 2004 and Nikaido et al, AmJ Dent 1999. Reduced dentin adhesion can be offset if treated with reducing agent, such as ascorbic acid or EDTA, see MORRIS ET AL, JOE, 2001,LAI ET AL, J DENT RES, 2001,YIU ET AL, J DENT RES, 2002,WESTON ET AL JOE, 2007:
An intrapapillary epinephrine injection, in this writers experience, is very short-lived, and is quickly followed by rebound bleeding that is worse than ever.
Electrosurgury in the deeply subgingival area that is abundantly bleeding has seldom helped, while carrying serious risk of bone necrosis and a month of pain post-op.
Diode laser on a cautery setting can be effective, provided diseased tissue is removed prior and hemorrhage has been controlled prior to lasering. Otherwise one just boils the ooze and gets nowhere.
Plain cord without epinephrine has seldom done the job.
Finally, my dental assistant wishes me to say that snapping at the assistant is not effective.
TISSUE RECOVERY PROGRAMS
Sometimes there is just no way to finish the restoration. The tissue will not behave itself. The best strategy is to temporize, exit the game, and work with the patient. Prescribe a program utilizing hygiene, chlorhexidine or Listerine rinses, waterpikking, interproximal aids, or even a periodontal antibiotic suite such as amoxillin/metronidazole, or Rovamycin.
When you return to the site, and the tissue has spent some weeks adjacent to a zinc oxide/eugenol surface under the healing effects of the program, you will have a brand new day compared to the previous War Zone.