Hemostasis in endodontic microsurgery

There are numerous ways to achieve hemostasis. With the abundance of hemostatic agents available and with the introduction of new products, one has to make an objective decision. A good agent achieves hemostasis within a short period of time, is easy to manipulate, is biocompatible, does not impair or retard healing, must be relatively inexpensive, is reliable, and works best for the particular surgical procedure. With these purposes in mind, the following sequence is recommended to achieve hemostasis during endodontic microsurgery. I. Presurgical: Give 2 to 3 Carpules of 1:50,000 epinephrine local anesthetic with multiple infiltration sites throughout the entire surgical field. II. Surgical: A. Remove all granulation tissue. B. Place an epinephrine pellet into the bony crypt followed by dry sterile cotton pellets. Apply pressure for 2 minutes. Remove all the cotton pellets except the first epinephrine pellet. Continue with the surgical procedure and remove the epinephrine pellet before final irrigation and closure. C. Alternatively, calcium sulfate can be mixed into a thick putty and packed against the bone cavity. Because it is a biodegradable material, calcium sulfate can be left in situ. In fact, in large bone defects and through-and-through lesions, additional calcium sulfate can be placed to fill the entire bone cavity as a barrier material. Healing is more predictable with little chance of scar tissue formation. Calcium sulfate resorbs in 2 to 4 weeks. D. Small bleeding sites in the bone can be brushed with ferric sulfate solution. III. Postsurgical: Tissue compression before and after suturing cuts down on postsurgical bleeding and swelling. Hemostasis is imperative in endodontic microsurgery for better visualization, a good environment for placement of retrograde filling material, and a more efficient surgical procedure with less blood loss.