Local Hemostatic Agents

There are many familiar hemostatic agents such as gelatin, cellulose, hemostatic collagen, and some less familiar like fibrin, and thrombin sealant patch available for use in local hemostatic control.

Gelatin products are manufactured as purified, porcine skin gelatin. Gelatin products are affordable, easily accessible, and dental providers are apt to use them because of ease of placement. However, in terms of efficacy, cellulose products are a first line recommendation for patients with bleeding disorders. Cellulose products are commonly used in oral surgery, resorbable, and found to be very effective with the appropriate suture technique. They are available as thin pieces of gauze and can be placed over a surgical site to aid in the clotting process.

Most dental providers are familiar with collagen plugs, available in mediums such as tape or membrane. Collagen plugs are often used as a bone graft material, having the ability to adhere to mucosal tissues, consequently stabilizing clot formation. It’s this property that makes it a favorable option for use in patients with bleeding disorders as well.

Aminocaproic acid, is accessible, and easy to place. It is manufactured as an oral rinse and in tablet form. When considering the use of aminocaproic acid, the dentist should consult with the patient’s hematologist/HTC prior to the appointment. If the patient’s hematologist/HTC prescribes aminocaproic acid in advance, the dentist should confirm the patient has the aminocaproic acid product with them prior to initiating treatment. Dental providers should keep in mind and advise patients that aminocaproic acid can cause gastric upset and the liquid has an unpleasant taste. A simple and practical tip for the use of aminocaproic acid is for the dental provider create a poultice. The methodology to create a poultice is to crush a 500mg tablet into 10mL of sterile saline, soak a piece of gauze in the hemostatic solution and apply mechanical pressure (or have the patient bite down if applicable) at the surgical site, to aid in clotting formation.

Another important hemostatic agent is tranexamic acid, a synthetic derivative of lysine. Tranexamic acid is approved in the United States in intravenous form for dental extractions and significantly reduces mean blood loss. It’s also extremely effective as a mouthwash or poultice. Tranexamic acid is also available as a syrup for pediatric use. To prepare for an appointment in which tranexamic acid is indicated, the dentist should consult with the patient’s hematologist/HTC to request a prescription beforehand. The patient should be instructed patient to bring the tranexamic acid prescription with them for use during the dental appointment and the provider should visibly confirm prior to initiating treatment. To prepare tranexamic acid to use as a poultice, the provider should crush a 650mg tablet into 10mL of sterile saline, soak a piece of gauze in the hemostatic solution and apply mechanical pressure (or have the patient bite down if applicable) at the surgical site, to aid in clotting formation. Tranexamic acid has a longer half life than aminocaproic acid and is often tolerated better by patients.

Desmopressin, which stimulates the release of endogenous von Willebrand factor and FVIII from the endothelial cells, is a helpful therapy for patients with mild or moderate hemophilia A or vWD. Desmopressin is administered IV and would require an infusion center for administration or may be given in a hematology office or HTC. Recently, there was an intranasal form of desmopressin, but the manufacturer discontinued its production in 2020 with no plans on resuming production. The currently available desmopressin nasal sprays lack sufficient dosing to treat hemophilia/von Willebrand and are used to treat central diabetes insipidus instead. Specially compounded intranasal form may be possible, but its availability is reduced compared to the prior commercial preparation.

For mechanical hemostasis, use long lasting resorbable sutures. Stents, as mentioned previously, can be loaded with hemostatic agents and are a highly therapeutic and inexpensive means to assist with clotting after more invasive procedures such as scaling and root planing. If the dental provider has the ability to fabricate stents, this is often ideal as it will allow the patient the opportunity to self-treat/manage if bleeding occurs after hours. The patient should be shown how to pre-treat gauze by saturating with the local hemostatic agent of choice, proper placement of the pre-treated gauze into the stent and advised on the proper amount of mechanical pressure to apply.