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1. Introduction
Soil is an integral part of the environment that is involved in many ecosystem services. However, decline in the actual and/or potential productivity of soils due to poor land management practices has become a major challenge to sustainable agriculture and environmental quality [1], thus threatening the food security of many countries of the world. According to Truong [2], some of these poor land management practices often lead to soil erosion and agro-chemical contamination from agricultural practices, urban wastes and industrial operations, which adversely reduces soil’s potential for sustainable food production, consequently affecting plants, animals and human lives.
In Truong [2], soil conservation methods such as contour banks, earthen bunds and concrete structures employed to rehabilitate lands with low soil quality are expensive, short-lived and sometimes impossible to execute. He finally reported that vegetative methods, such as the use of grasses, are an effective erosion and sediment control technology which are practicable and economical for the rehabilitation of lands for agricultural production. Vetiver grass (Vetiveria zizanioides L.) has been reported to be effective in erosion control [3] and remediation of contaminated soils [4]. According to Rao [5], due to their efficiency and low-cost, vetiver systems are more profitable than both engineering structures and other vegetative barriers. In Ref. [6], vetiver was reported to be highly tolerant to extreme soil conditions including heavy metal contaminations. In comparison with other grasses for rehabilitation of lands with adverse soil conditions, vetiver grass was reported to be superior to Bermuda grass (Cynodon dactylon) which has been recommended as a suitable species for acid mine rehabilitation [7]. Also, in an attempt to revegetate a highly saline land, Truong [8] reported superior performance of vetiver grass over Rhodes (Chloris guyana) and saltwater couch (Paspalum vaginatum), as it was able to survive and resume growth under very high saline conditions. This is due to its unique morphological and physiological characteristics which enables it to survive where other plants cannot [9].
2. Brief description of vetiver grass
Vetiver grass (V. zizanioides L.) is a perennial tufted plant that is native to India (Figure 1). It is described as a coarse Asian plant [10]. Although V. zizanioides is also commonly found in West Africa, an African counterpart, V. nigritana, has been reported to be far more common [10]. Table 1 shows some countries where vetiver grass is known to exist. According to Truong [11], vetiver grass possesses a root system that is abundant, complex, extensive and vertical in nature. According to National Research Council [10], the root grows almost straight down with few lateral surface roots, thus not interfering with the growth of other crops which could result in loss of yield. In Hengchaovanich [12], it was explained that the root system of vetiver grass can reach 3–4 m in the first year of planting, while [13] reported that it attains a total length of 7 m after 36 months. The roots are very strong with a mean tensile strength of between 75 and 85 MPa [14]. The leaves are thin and have sharp edges [10], while the shoots can grow up to 2 m. The mature foliage is tough and coarse, which enables it to stay in place for years [10]. They further reported that this attribute is important as an erosion control crop provided it is to work effectively. Its growth occurs from the crown, which rises relative to soil build-up [9]. The crown of the plant occurs slightly below the soil surface and as such no lasting damage can be done on it by grazing or trampling animals [10].
Figure 1.
Vetiver (Vetiveria zizanioides L.) grass strips at the University of Ibadan, Nigeria.
2.1. Vetiver grass technology
Vetiver grass has been reported to be very effective in trapping both fine and coarse sediments in runoff water [10]. These sediments constitute bulk of the fertile layer (topsoils) of most agricultural lands, which is critical for crop cultivation. In addition, vetiver grass has been reported to have high tolerance for extreme adverse conditions, including heavy metal toxicity [15], hence making it suitable for the remediation of heavy metal-contaminated soils. This could be due to some of its special attributes which makes it an ideal species for environmental protection and sustainable agriculture. Some of these characteristics include massive, fine-structured root system [16]; high resistance to pests, diseases and fire [17]; high efficiency in absorbing dissolved N, P, Hg, Cd and Pb in polluted water [18]; and good and fast recovery rate after being affected by the previously listed adverse conditions [19].
2.2. Applications of vetiver grass
The application of vetiver grass as a technology for soil and water conservation was first developed in India by the World Bank in the 1980s [2]. Some of the applications of vetiver grass technology, which could sum up to the enhancement of sustainable agricultural development, include its use for soil erosion and sediment control on sloping farmlands and floodplains [20–24]; rehabilitation of saline and acid sulphate soils [6]; bioremediation of agro-chemicals [25, 26]; biological pest control [24]; and on- and off-site heavy metal pollution control [6, 26] amongst others.
2.2.1. Erosion and sediment control
Erosion, which is simply the washing away of soils by ‘agents’ such as water and wind, is a phenomenon that has ravaged so many lands, resulting in soil degradation and consequently low crop yield. According to National Research Council [10], it is among the most devastating environmental disaster for many developing countries and it results in loss of huge amounts of valuable soils which are key to agricultural production. Management methods could be expensive and sometimes less effective. However, Truong [27] reported that both research and field results in Australia, Asia, Africa and South America show that in comparison with conventional cultivation practices, surface runoff and soil loss from fields treated with vetiver grass were significantly lower and crop yield was much improved. Figure 2 illustrates the processes of erosion and sediment control under conventional cultivation practice and vetiver grass system. V. zizanioides has been reported to reduce soil loss from 11 to 3 t ha−1 [10]. They explained that vetiver is suitable for erosion and sediment control because it slows runoff and gives the rainfall a better chance of soaking into the soil instead of rushing off the slope. According to Truong and Loch [9], when vetiver grass is planted in single or multiple rows on the contour, it forms a protective barrier across the slope, which slows the runoff water, thereby causing sediment to be deposited. They further explained that since the barriers only filter the runoff and do not convey it, water seeps through the hedge, reaching the bottom of the slope at lower velocity without causing any erosion or without being concentrated in any particular area.
Figure 2.
Comparison between conventional terrace/contour system and Vetiver system in soil and water conservation (adapted from Ref. [9]).
According to Refs. [21–23, 26, 28–30], results over the last 10 years have showed vetiver grass to be very successful in reducing flood velocity and limiting soil movement, with very little erosion in fallow strips. In Rao et al. [31], relative to control plots, average reductions of 69% in runoff and 76% in soil loss were recorded from vetiver plots. In Nigeria, Babalola et al. [3] demonstrated the usefulness of vetiver grass as a soil and water conservation measure in the Nigerian environment. They established vetiver strips on 6% slopes for three growing seasons. The results of the study showed that vetiver grass ameliorated soil physical and chemical conditions, reduced soil and nutrient losses, and increased soil moisture storage by a range of 1.9–50.1% at various soil depths for a distance of 20 m. Other research studies that have been conducted on the use of vetiver grass for soil and water conservation in Nigeria include Refs. [21–23, 26, 32, 33]. Table 2 shows a summary of the effects of vetiver grass and conventional systems in soil loss and runoff control.
Africa
America
Asia
Caribbean
Pacific
Others
Algeria
Argentina
Bangladesh
Antigua
American Samoa
France
Angola
Brazil
Burma
Barbados
Cook Islands
Italy
Burundi
Colombia
China
Cuba
Fiji
Spain
Comoro
Costa Rica
India
DR
New Caledonia
USA
CAR
FG
Indonesia
Haiti
New Guinea
USSR
Ethiopia
Guatemala
Japan
Jamaica
Tonga
Gabon
Guyana
Malaysia
Martinique
Western Samoa
Ghana
Honduras
Nepal
Puerto Rico
Kenya
Paraguay
Pakistan
St. Lucia
Madagascar
Suriname
Philippines
St. Vincent
Malawi
Singapore
Trinidad
Mauritius
Sri Lanka
Virgin Islands
Nigeria
Thailand
Rwanda
Reunion
Seychelles
Somalia
South Africa
Tanzania
Tunisia
Uganda
Zaire
Zambia
Zimbabwe
Table 1.
Some countries where vetiver is known to exist.
Note: CAR, Central African Republic; FG, French Guiana; DR, Dominican Republic (source: Ref. [10]).
2.2.2. Rehabilitation of saline and acid sulphate soils
Salinity, which is the amount of dissolved salt content of a soil or water body, is a major challenge confronting agricultural production especially in semi-arid regions of the world with respect to crop. According to Truong and Baker [35], vetiver grass that could cope with saline soils has been successfully employed in the rehabilitation of salt-affected lands. This may be due to its high tolerance to salt-affected soils. In Truong [36], it was reported that with a salinity threshold level at ECse = 8 d Sm−1, vetiver grass compares favourably with some of the most salt-tolerant crops and pasture species (such as Bermuda grass (C. dactylon) with threshold at 6.9 d Sm−1; Rhodes grass (C. guyana) at 7.0 d Sm−1; Wheat grass (Thynopyron elongatum) at 7.5 d Sm−1; and barley (Hordeum vulgare) at 7.7 d Sm−1) grown in Australia.
On the other hand, acid soils which constitute a major part of arable lands in Africa and Asia are highly erodible and difficult to stabilize and rehabilitate [27]. However, vetiver has been successfully used to stabilize and rehabilitate a highly erodible acid sulphate soil, where the actual soil pH was about 3.5 and oxidized pH was as low as 2.8 [4, 37]. When planted on saline and/or acid sulphate soils, vetiver grass can effectively absorb plant available sodium and metals that contribute to soil salinity or acidity, thereby rehabilitating these soils [35]. Also, the tensile strength of its root system can also contribute to increasing soil strength against runoff and erosion, thus stabilizing the soil slope.
2.2.3. Bioremediation of agro-chemicals
Agro-chemicals (pesticides, herbicides, and even fertilizers) have been reported to adversely affect soil properties and water quality. This adverse effect is finally expressed in the quality of crop produced. According to Truong [27], vetiver has played an important role in the decontamination of agro-chemicals due to its ability to retain them within its system, thereby preventing them from contaminating and accumulating in soils and crops. Table 3 shows the threshold levels of heavy metals to vetiver grass. According to Refs. [18, 25], research conducted in cabbage crops grown on steep slope (60%) in Thailand indicated that vetiver hedges had an important role in the process of captivity and decontamination of agro-chemicals, especially pesticides such as carbofuran, monocrotophos and anachlor. According to Truong et al. [15], planting vetiver grass across drainage lines could serve as a living filter for capturing unwanted foreign chemicals or contaminants before they reach non-polluted soil and downstream areas.
Heavy metals
Threshold levels in soil (mg kg−1)
Threshold levels in plant (mg kg−1)
Vetiver
Other plants
Vetiver
Other plants
Arsenic
100–250
2.0
21–72
1–10
Cadmium
20–60
1.5
45–48
5–20
Copper
50–100
NA
13–15
15
Chromium
200–600
NA
5–18
0.02–0.20
Lead
>1500
NA
>78
NA
Mercury
>6
NA
>0.12
NA
Nickel
100
7–10
347
10–30
Selenium
>74
2–14
>11
NA
Zinc
>750
NA
880
NA
Table 3.
Tolerance levels of vetiver grass and other plants to heavy metals.
Insects and pests are two of the most destructive biological pests known to cause damage to agricultural crops and consequently leading to reduction in crop yield. The use of agro-chemicals in controlling most of these pests results in adverse effects on both soils and crops. Results of the research carried out in Guangxi University, China, after subjecting vetiver grass to insect attack, showed that of the 79 species of insect found on vetiver rows, only four attacked young vetiver leaves [24]. He explained that due to few insects that could attack vetiver grass, the damage was minimal. Also, the potential of vetiver extract as a natural pre-emergent weed killer was obtained when methanol extracts of its ground stem and root were found to be very effective in preventing the germination of a number of both monocotyledonous and dicotyledonous weed species [38].
2.3. Management of wastewater
Large volume of waste or contaminated water emanating from industrial or domestic discharges could be difficult or expensive to control, especially when released into the environment. In Truong [36], wastewaters can be managed either by disposal (i.e. total elimination or reduction in volume) or treatment (i.e. improving its quality).
2.3.1. Disposal of wastewater
According to Truong [36], vegetative methods are the only feasible and practicable method available for the disposal of wastewater. Vetiver grass has been reported to be more effective than trees and pasture species in the disposal of domestic and industrial effluent. This is because vetiver grass possesses some unique characteristics suitable for environmental protection purposes [39]. Apart from absorbing toxic elements in wastewater, vetiver grass can also absorb large quantities of water, thus reducing the volume of these waters from the environment. Thus, according to Truong [20], the problem of wastewater disposal can be solved by using such water as irrigation water for growing vetiver grass, where it can be absorbed. Effluent discharge was reduced by sub-surface irrigating vetiver grass rows [15]. This could also reduce potential ponding situations which are not usually favourable for most arable crops. It was reported in Truong and Smeal [40] that in producing a massive growth of biomass (>100 t ha−1), vetiver grass consumes a large volume of water.
According to Truong [36], in quantifying the water use rate of vetiver, a good correlation between water use and dry matter yield of vetiver was obtained. He explained that from this correlation, it was estimated that for a kilogram of dry shoot biomass, vetiver grass would use 6.8 L day−1. Also, Truong and Smeal [40] explained that if the biomass of 12-week-old vetiver, at the peak of its growth cycle, was 40.7 t ha−1, a hectare of vetiver grass would potentially use 279 kL ha−1 day−1. According to Truong [36], data from a landfill leachate site showed that vetiver grass can dispose up to 3.8 L m−2 day−1. It was reported in Truong and Hart [41] that where other plants such as fast growing tropical grasses and trees, and other crops such as sugar cane and banana have failed, vetiver grass survived. Vetiver grass of about 100 vetiver stands in an area less than 50 m2 completely dried up the effluent discharge from a toilet block. In addition, Percy et al. [42] reported that 4 and 2 mL of highly contaminated landfill leachate were effectively disposed in a month in summer and in winter by 3.5 ha planting of vetiver, respectively, while Smeal et al. [43] reported that most industries in Queensland are upgrading their treatment process of wastewater by adopting vetiver grass system as a sustainable means of disposing wastewater.
2.3.1.1. Treatment of wastewater
Vegetative method is generally the most efficient and common method for water quality improvement [36]. He reported that the attributes of vetiver grass indicate that it is highly suitable for treating polluted wastewater from industries as well as domestic discharges. Some of these attributes include its tolerance to elevated and sometimes toxic levels of salinity, acidity, sodicity, and heavy metals. Vetiver can be used to improve wastewater quality either by absorbing pollutants and heavy metals or by trapping debris, sediment and agro-chemicals in agricultural lands. In Truong [20], it was reported that growing vetiver grass on effluent is one of the effective low-cost technologies of treating wastewater. According to Truong and Hart [41], planting 100 vetiver grass in an area less than 50 m2 completely dried up effluent discharge from a septic tank. An earlier research by Wagner et al. [44] showed the exceptional ability of vetiver grass in absorbing and to tolerate extreme levels of nutrients, Truong et al. [15] stated that nutrients (N, P, Ca, etc.), herbicides (diuron, trifluralin, fluometuron, etc.) and pesticides (α, β and sulphate endosulfan and chlorpyrifos, parathion and profenofos) could be restrained on site if vetiver grass hedges were established across drainage lines (Figure 3).
Figure 3.
Herbicide concentration in soil-deposited upstream and downstream of vetiver filter strips (source: Ref. [32]).
In China, research showed that vetiver grass can reduce soluble P up to 99% after 3 weeks and 74% of soluble N after 5 weeks [27]. Vetiver grass has also been used to control algal growth. For example, Refs. [45, 46] reported that vetiver grass could remove dissolved nutrients and reduce algal growth within 2 days under experimental condition. In addition, Truong [27] explained that vetiver grass can be used very effectively to control algal growth in water infested with blue-green algae by planting vetiver grass strips at the edges of the streams or in the shallow parts of the lakes where usually high concentrations of soluble N and P occur. The thick culms of vetiver that is just above the soil surface also collected debris and soil particles carried along watercourse [47], while Liao et al. [48] reported that with proper planning, vetiver grass technology has the potential of removing up to 102 t of N and 54 t of P yr−1 ha−1 of vetiver planting.
Furthermore, in the purification of wastewater from a pig farm which contained very high N, P, Cu and Zn, vetiver grass showed a very strong purifying ability, with its ratio of uptake and purification of Cu and Zn (>90%), As and N (>75%), Pb (between 30 and 71%), and P (between 15 and 58%) [48]. Concentrations of some toxic elements (Al, Fe, and SO4) in vetiver grass planted on an acid sulphate soil was found to increase as the plant matures, thus reducing contamination of canal water [49]. Thus, the efficiency of wastewater treatment increases with an increase in the age of vetiver plant [47]. Table 4 presents effluent water quality prior to and after vetiver treatment. This could be highly beneficial to agriculture especially in the area of irrigation where available water for crop cultivation is fast diminishing as a result of climate change impact and competition from other users.
The improvement of agricultural crop yield is one of the resultant benefits of the effects of vetiver grass technology on soil and water conservation. This could be beneficial to farmers, especially those farming on sloppy lands that are usually prone to erosion. It was reported by National Research Council [10] that vetiver grass improves crop harvest by reducing crop failure against the dry spell. They also reported that vetiver grass enhances soil moisture for plant use. In Nigeria, Babalola et al. [3] reported an increase in crop yields by a range of 11–26% for cowpea and by about 50% for maize following the application of vetiver grass strips at 20-m intervals against non-vetiver plots on a 6% slope. They attributed the higher grain yield to higher nutrient use efficiency under vetiver grass strips relative to no vetiver strip.
Also, Oshunsanya et al. [32] reported an increase in maize grain yield (13.5–26.6%), and cassava tuber weight (7.9–11.2%) in a maize/cassava intercrop under vetiver grass strips spaced at 5-, 10- and 20-m surface intervals. Another report by Babalola et al. [50] showed that grain yields on plots treated with 4 and 6 t ha−1 vetiver grass mulch were 4 and 47.4% higher than plots treated with vetiver grass strips, respectively. In addition, Laing [51] finally reported that the full potentials of vetiver grass could be harnessed by combining vetiver grass mulch with vetiver grass strips such that vetiver grass strips would reduce soil water erosion, while mulch materials would decompose to improve the nutrient status of the farmland.
2.5. Other uses of vetiver grass
Apart from its unique physiological characteristics, which give it an edge over other grasses as a plant with diverse environmental applications, vetiver grass has also been found useful in a number of ways. Apart from being a soil and water conservation technology, this grass of great utility has been reported to be legally accepted for use as property lines in certain parts of India. Also, in Nigeria the surveyor general has in past permitted vetiver grass hedges as a legal boundary marker. This is because its bases expand so little [10]. It grows so densely that it can block the spread of weeds. For instance, in Zimbabwe and Mauritius, farmers plant vetiver grass around their fields to keep Kikuyu grass and Bermuda grass from invading their fields, respectively [10].
Furthermore, National Research Council [10] reported that for several centuries, vetiver grass has been commercially cultivated for its scented oil that can be distilled from its roots. They also reported that it is a treasured ingredient in some of the world’s best-known perfumes and soaps, and largely because of its potential as an export commodity. However, only a handful of countries produce vetiver oil commercially. Although reliable statistics are unavailable, the world production of vetiver oil is estimated to be about 250 tons a year [10]. The annual consumption is estimated in Table 5. Other products that could be derived from the vetiver grass include mats, baskets, fans, sachets, window coverings, wall hangings, thatch roofs, lampshades and ornaments which are usually weaved from its roots or stems [10].
Vetiver grass technology has been applied globally for controlling soil erosion, stabilizing land and water resources and remediating contaminated lands in order to improve crop growth and yields. It is used as fodder for animal feed, mulch for improving soil moisture and fertility, and fibrous root system for holding soils in place could guarantee food production on a sustainable basis owing to the fact that this grass can withstand adverse environmental and climatic conditions, coupled with quick regeneration after pruning. Thus, when vetiver grass is applied appropriately, it could be a low-cost, simple and easily applicable multi-purpose soil and water conservation tool for sustainable agriculture. It is also a grass of great utility that could provide other means of revenue for local farmers.
\n',keywords:"soil conservation, bioremediation, soil amendment, crop productivity, soil stabilization",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/55730.pdf",chapterXML:"https://mts.intechopen.com/source/xml/55730.xml",downloadPdfUrl:"/chapter/pdf-download/55730",previewPdfUrl:"/chapter/pdf-preview/55730",totalDownloads:2230,totalViews:2293,totalCrossrefCites:2,totalDimensionsCites:5,hasAltmetrics:0,dateSubmitted:"October 19th 2016",dateReviewed:"April 19th 2017",datePrePublished:null,datePublished:"September 6th 2017",dateFinished:"May 31st 2017",readingETA:"0",abstract:"Vetiver grass is a densely tufted bunch grass which can be easily established in both tropics and temperate regions of the world. It plays a vital role in watershed protection by slowing down and spreading runoff harmlessly on the farmland, recharging ground water, reducing siltation of drainage systems and water bodies, reducing agro-chemicals loading into water bodies and for rehabilitation of degraded soils. Vetiver grass could tolerate extremely high levels of heavy metals. It could be used as biological pest control. The use of vetiver grass has been regarded as a low-cost technology for soil and water conservation; on- and off-farm land and water sources stabilization and remediation of polluted soils; and enhancement of water quality for irrigation purposes when compared with other soil conservation technologies. It could be a dynamic tool for mitigating environmental and agricultural problems, thereby enhancing crop yield and supporting all-year round agricultural cultivation. Recently, vetiver grass has been used to raise animals of different kinds. Thus, this chapter in the book explores several applications of vetiver grass, its impacts and resultant benefits as a technology that could enhance sustainable agricultural development.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/55730",risUrl:"/chapter/ris/55730",book:{slug:"grasses-benefits-diversities-and-functional-roles"},signatures:"Suarau O. Oshunsanya and OrevaOghene Aliku",authors:[{id:"175778",title:"Dr.",name:"Suarau",middleName:null,surname:"Oshunsanya",fullName:"Suarau Oshunsanya",slug:"suarau-oshunsanya",email:"soshunsanya@yahoo.com",position:null,institution:{name:"University of Ibadan",institutionURL:null,country:{name:"Nigeria"}}},{id:"176082",title:"Mr.",name:"OrevaOghene",middleName:null,surname:"Aliku",fullName:"OrevaOghene Aliku",slug:"orevaoghene-aliku",email:"orevaoghenealiku@gmail.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Brief description of vetiver grass",level:"1"},{id:"sec_2_2",title:"2.1. Vetiver grass technology",level:"2"},{id:"sec_3_2",title:"2.2. Applications of vetiver grass",level:"2"},{id:"sec_3_3",title:"Table 1.",level:"3"},{id:"sec_4_3",title:"2.2.2. Rehabilitation of saline and acid sulphate soils",level:"3"},{id:"sec_5_3",title:"Table 3.",level:"3"},{id:"sec_6_3",title:"2.2.4. Biological pest control",level:"3"},{id:"sec_8_2",title:"2.3. Management of wastewater",level:"2"},{id:"sec_8_3",title:"Table 4.",level:"3"},{id:"sec_8_4",title:"Table 4.",level:"4"},{id:"sec_11_2",title:"2.4. Crop yield",level:"2"},{id:"sec_12_2",title:"2.5. Other uses of vetiver grass",level:"2"},{id:"sec_14",title:"3. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'Lal R. Tillage effects on soil degradation, soil resilience, soil quality, and sustainability. Soil and Tillage Research. 1993;27(1):1-8'},{id:"B2",body:'Truong P. Vetiver grass for mine site rehabilitation and reclamation. In: Proceedings of Remade Lands International Conference, Fremantle, Australia; November 2000; pp. 85-86'},{id:"B3",body:'Babalola O, Jimba JC, Maduakolam O, Dada OA. Use of Vetiver grass for soil and water conservation in Nigeria. In: Proceedings of Third International Conference on Vetiver and Exhibition Guangzhou, China; October 2003; pp. 293-309'},{id:"B4",body:'Loch R, Truong P, Smirk D, Fulton I. Vetiver grass for land management and reclamation. In: Proceedings of the Third AMEEF Innovation Conference; Brisbane, Australia; August 2000; pp. 116-122'},{id:"B5",body:'Rao DV. Vetiver Information Network. Newsletter No. 10. ASTAG. Washington D.C.: The World Bank; 1993'},{id:"B6",body:'Truong PN, Baker, D. Vetiver grass system for environmental protection. Technical Bulletin No. 1998/1998; Pacific Rim Vetiver Network. Office of the Royal Development Projects Board, Bangkok, Thailand'},{id:"B7",body:'Taylor KW, Ibabuchi IO, Sulford P. Growth and accumulation of forage grasses at various clipping dates on acid mine spoils. Journal of Environmental Science and Health. 1989;24:195-204'},{id:"B8",body:'Truong PN. Vetiver grass for land rehabilitation. In: First International Conference on Vetiver. Bangkok: Office of the Royal Development Projects Board; 1996. pp. 49-56'},{id:"B9",body:'Truong PNV, Loch R. Vetiver system for erosion and sediment control. In: ISCO 2004—13th International Soil Conservation Organisation Conference; Brisbane; 2004; No. 247. p. 6'},{id:"B10",body:'National Research Council. Vetiver Grass: A Thin Green Line against Erosion. Washington, D.C.: National Academy Press; 1993. p. 169'},{id:"B11",body:'Truong PN. Vetiver Grass Technology. In: Maffei, M, editor. “Vetiveria” the Genus Vetiveria. London and New York: Taylor & Francis; 2002. pp. 114-132'},{id:"B12",body:'Hengchaovanich D. Vetiver grass for slope stabilization and erosion control. Tech. Bulletin’ 1998; No. 1998/2, PRVN/Office of the Royal Development Project Board, Bangkok, Thailand'},{id:"B13",body:'Lavania UC, Lavania S, Vimala Y. Vetiver system ecotechnology for water quality improvement and environmental enhancement. Current Science. 2004;86:11-14'},{id:"B14",body:'Cheng H, Yang X, Liu A, Fu H, Wan M. A study on the performance and mechanism of soil-reinforcement by herb root system. In: Truong P, Xiu HP, editors. Proceedings of the Third International Conference on Vetiver and Exhibition; Guangzhou, China; 2003. pp. 411-414'},{id:"B15",body:'Truong PN, Mason F, Waters D, Moody P. Application of Vetiver grass technology in off-site pollution control. I. Trapping agrochemicals and nutrients in agricultural lands. In: Proceedings of Second International Vetiver Conference, Thailand; January 2000'},{id:"B16",body:'Hengchaovanich D. Fifteen years of bioengineering in the wet tropics from A (Acacia auriculiformis) to V (Vetiveria zizanioides). In: Proceedings of Ground and Water Bioengineering for Erosion Control and Slope Stabilization; Manila; April 1999'},{id:"B17",body:'West L, Sterling G, Truong PN. Resistance of Vetiver grass to infection by root-knot nematodes (Meloidogyne spp.), 1996. Vetiver Newsletter (20): 20-22.'},{id:"B18",body:'Sripen S, Komkris T, Techapinyawat S, Chantawat S, Masuthon S, Rungsuk M. Growth potential of Vetiver grass in relation to nutrients in wastewater of Changwat Phetchaburi. Paper presented at ICV-1. In: Abstracts of Papers Presented at First International Conference on Vetiver. Office of the Royal Development Projects Board, Bangkok; 1996. p. 44'},{id:"B19",body:'Truong P, Baker DE, Christiansen I. Stiffgrass barrier with Vetiver grass. A new approach to erosion and sediment control. In: Proceedings of The Third Annual Conference on Soil & Water Management for Urban Development, Sydney; 1995. pp. 214-222'},{id:"B20",body:'Truong P. Report on the International Vetiver Grass Field Workshop, Kuala Lumpur. Australian Journal of Soil and Water Conservation. 1993;6:23-26'},{id:"B21",body:'Oshunsanya SO. Surface soil properties and maize yields in runoff plots planted with vetiver grass (Vetiveria nigritana Stapf) hedges. Soil Science. 2013;178(4):205-213'},{id:"B22",body:'Oshunsanya SO, Are K, Fagbenro JA. The use of vetiver grass (Vetiveria nigritana Stapf) strips in checking soil loss and improving yields of maize-cassava-cowpea intercropping systems in Southwest Nigeria. Journal of Applied Agricultural Research. 2014;6(1):237-244'},{id:"B23",body:'Oshunsanya SO. Crop yields as influenced by land preparation methods established within vetiver grass alleys for sustainable agriculture in Southwest Nigeria. Agroecology and Sustainable Food Systems. 2013;37(5):578-591'},{id:"B24",body:'Chen SW. Insect on Vetiver hedges. Assumption University Journal of Technology. 1999;3:38-41'},{id:"B25",body:'Pinthong J, Impithuksa S, Ramlee A. The capability of Vetiver hedgerows on the decontamination of agro chemical residues. In: Proceedings of the First International Conference on Vetiver. Office of the Royal Development Projects Board; Bangkok; 1998. pp. 91-98'},{id:"B26",body:'Oshunsanya SO, Ewetola EA. Production of hygienic Amaranthus cruentus on soils remediated with vetiver grass species in Ibadan, Nigeria. Journal of Science Research. 2011;10(2):212-220'},{id:"B27",body:'Truong PNV. The global impact of vetiver grass technology on the environment. In: Proceedings of the Second International Vetiver Conference, Thailand; 2000. pp. 46-57'},{id:"B28",body:'Dalton PA, Smith RJ, Truong PNV. Hydraulic characteristics of vetiver hedges: An engineering design approach to flood mitigation on cropped floodplain. In: Proceedings of the First International Vetiver Conference; Chiang Rai, Thailand; October, 1996, 1996a. pp. 65-73'},{id:"B29",body:'Dalton PA, Smith RJ, Truong PNV. Vetiver grass hedges for erosion control on a cropped flood plain: Hedge hydraulics. Agricultural Water Management. 1996b;31:91-104'},{id:"B30",body:'Truong P, Van TT, Pinners E. The Vetiver system for agriculture. The First National Indian Vetiver Workshop. The Vetiver Network International Publication; 2008, Kochi, India.'},{id:"B31",body:'Rao KPC, Cogle AL, Srivastava KL. ICPdSAT Annual Report. Andhra Pradesh, India; 1992'},{id:"B32",body:'Oshunsanya SO, Are KS, Babalola O. Soil sediment accumulation and crop yields as affected by Vetiver buffer strip spacing in Southwest Nigeria. In: Proceedings of the 34th Annual Conference of Soil Science Society of Nigeria, Institute of Agricultural Research and Training, Ibadan, Nigeria; 2010. pp. 224-231'},{id:"B33",body:'Oshunsanya SO. Spacing effects of vetiver grass (Vetiveria nigritana Stapf) hedgerows on soil accumulation and yields of maize-cassava intercropping system in Southwest Nigeria. Catena. 2013;104:120-126'},{id:"B34",body:'Rodriguez OD. Vetiver grass technology for soil conservation on steep agricultural land. In: Proceedings of the International Workshop on Soil Erosion Processes on Steep Lands; Merida, Venezuela; 1993'},{id:"B35",body:'Truong PN, Baker D. The role of vetiver grass in the rehabilitation of toxic and contaminated lands in Australia. In: International Vetiver Workshop, Fuzhou, China; October 1997'},{id:"B36",body:'Truong, P. Vetiver system for prevention and treatment of contaminated land and water. In: Proceeding of the Fourth International Vetiver Conference, Caracas, Venezuela, 2006; p. 16'},{id:"B37",body:'Truong PN, Baker D. Vetiver grass for the stabilization and rehabilitation of acid sulphate soils. In: Proceedings of the 2nd National Conference on Acid Sulphate Soils, Coffs Harbour, Australia; 1996. pp. 196-198'},{id:"B38",body:'Techapinyawat S, Sripen K, Komkriss T. Allelopathic effects of vetiver grass on weeds. In: Abstracts of Papers Presented at ICV-1, ORDPB, Bangkok; 1996. p. 45'},{id:"B39",body:'Truong PNV. Vetiver grass technology for mine tailings rehabilitation. In: Barker D, Watson A, Sompatpanit S, Northcut B, Maglinao A. Ground and Water Bioengineering for Erosion Control and Slope Stabilisation. NH, USA: Science Publishers Inc.; 2004'},{id:"B40",body:'Truong P, Smeal C. Research, development and implementation of Vetiver system for wastewater treatment: GELITA Australia. Technical Bulletin No. 2003/3. Pacific Rim Vetiver Network. Bangkok, Thailand: Office of the Royal Development Projects Board; 2003'},{id:"B41",body:'Truong PN, Hart B. Vetiver system for wastewater treatment. Technical Bulletin No. 2001/2. Pacific Rim Vetiver Network. Bangkok, Thailand: Office of the Royal Development Projects Board; 2001'},{id:"B42",body:'Percy I, Truong P. Landfill leachate disposal with irrigated Vetiver grass. In: Proceedings of Landfill 2005. National Conference on Landfill; Brisbane, Australia; September 2005'},{id:"B43",body:'Smeal C, Hackett M, Truong P. Vetiver system for industrial wastewater treatment in Queensland, Australia. In: Proceedings of the Third International Vetiver Conference; Guangzhou, China, October 2003'},{id:"B44",body:'Wagner S, Truong P, Vieritz A, Smeal C. Response of vetiver grass to extreme nitrogen and phosphorus supply. In: Proceedings of the Third International Vetiver Conference; Guangzhou, China; October 2003'},{id:"B45",body:'Xia HP, Ao HX, Lui SZ, He DQ. A preliminary study on vetiver’s purification for garbage leachate. In: Paper Presented at the International Vetiver Workshop; Fuzhou China; October 1997'},{id:"B46",body:'Zheng CR, Tu C, Chen HM. Preliminary experiment on purification of eutrophic water with vetiver. In: Paper Presented at the International Vetiver Workshop; Fuzhou, China; October 1997'},{id:"B47",body:'Chomchalow N. Review and update of the Vetiver system R&D in Thailand. In: Proceedings of the Regional Vetiver Conference; Cantho, Vietnam; 2006'},{id:"B48",body:'Liao X, Shiming L, Yinbao W, Zhisan W. Studies on the abilities of Vetiveria zizanioides and Cyperus alternifolius for pig farm wastewater treatment. In: Proceedings of the Third International Vetiver Conference; Guangzhou, China; October 2003'},{id:"B49",body:'Le Van Du, Truong, P. Vetiver system for erosion control on severe acid sulfate soil in Southern Vietnam. In: Proceedings of the Third International Vetiver Conference; Guangzhou, China; October 2003'},{id:"B50",body:'Babalola O, Oshunsanya SO, Are K. Effects of vetiver grass (Vetiveria nigritana) strips, vetiver grass mulch and an organomineral fertilizer on soil, water and nutrient losses and maize (Zea mays L.) yields. Soil and Tillage Research. 2007;96:6-18'},{id:"B51",body:'Laing DR. Vetiver trials at the International Centre for Tropical Agriculture (CIAT), Columbia. Vetiver Newsletter. 1992;8:13-15'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Suarau O. Oshunsanya",address:"soshunsanya@yahoo.com",affiliation:'
Department of Agronomy, University of Ibadan, Ibadan, Nigeria
Department of Agronomy, University of Ibadan, Ibadan, Nigeria
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\n
1. Introduction
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All surgical procedures, including dental surgery, present risk of complications, which may include pain, nerve injury, swelling, infections, and hemorrhage. Dental surgery is defined as any dental intervention including an incision in the oral mucosa or gingiva, including anything from a simple dental extraction to alveoloplasties [1]. Bleeding control is an important step during dental surgery procedures [2] because excessive bleeding complicates surgery and increases the risk of morbidity. To avoid such complications when long-lasting bleeding occurs, despite the proper use of traditional techniques for hemorrhage control, a broad range of hemostatic agents are available, as adjunctive measures to enhance hemostasis in the course of dental surgeries [3]. Despite the expressive rise in the amount and types of topical hemostats in the past decade, high-level evidence regarding the management of these agents during bleeding in dental surgery is still lacking.
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The periprocedual management of patients receiving therapeutic anticoagulation represents a challenge for dental practitioners, as the risk of bleeding must be counterbalanced against the risk of systemic or local thromboembolic phenomena. Recommendations for dental interventions in individuals receiving anticoagulation therapy remain quite unclear, in spite of practice guidelines from both dental [4] and medical [5] fields.
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This chapter aims to discuss the effective ways of managing bleeding complications in dental surgery, mainly in high-risk patients. The role of biosurgical materials to prevent or solve these complications, during and after dental surgery procedures, will also be addressed, as well as their modes of action, practical applications, adverse effects, and effectiveness.
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2. Normal hemostasis
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The physiological mechanism that prevents and hinders bleeding at the area of an injury while preserving regular blood flow everywhere else in the circulation is called hemostasis [6]. The hemostasis process has two major components. Primary hemostasis initiates promptly after vascular injury, and it can be divided into four consecutive and superposed stages: (A) vasoconstriction, (B) platelet adhesion, (C) platelet activation, and (D) platelet aggregation [7, 8, 9, 10]. Primary hemostasis results in the formation of a platelet plug [10]. Secondary hemostasis comprises a sequence of serine protease zymogens and their cofactors, which interact successively on phospholipid surfaces (damaged endothelial cells or platelets), leading to the development of covalently cross-linked fibrin [10, 11, 12]. This cross-linked fibrin mesh is then incorporated into and around the platelet plug. It strengthens and stabilizes the blood clot. These two processes are intertwined and occur at the same time [6]. These systems are regulated by multiple anticoagulant mechanisms, which are responsible for maintaining blood fluidity in the absence of injury, generating a clot that is consistent with the trauma. Hemostasis and the avoidance of bleeding or thrombosis are directly related to the adequate balance between procoagulant and anticoagulant systems [6].
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3. Bleeding diathesis in dental surgery: acquired, autoimmune, or genetic
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Hemorrhage in dental surgery can be categorized as:
Primary hemorrhage: bleeding occurs during surgery
Reactionary hemorrhage: bleeding occurs 2–3 hours after surgery
Secondary hemorrhage: bleeding occurs until 14 days after surgery, probably due to an infection
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Hemorrhage can also be categorized according to the area injured: vascular, bone, and soft tissue [13, 14]. Bleeding diathesis is an unusual susceptibility to bleeding and may be genetic, autoimmune, or acquired (Table 1) [15, 17]. Selected bleeding disorders will be covered in this chapter.
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Table 1.
Hemorrhagic diatheses–adapted from Vezeau [15] and Goswami et al. [16].
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3.1 von Willebrand disease and hemophilia
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The most prevalent hereditary bleeding disorders are von Willebrand disease and hemophilia, affecting 1% of the population and 20,000 people in the USA, respectively [18, 19, 20, 21, 22]. Dental patients presenting inherited bleeding present a significantly higher risk of perioperative bleeding. The frequency and severity of bleeding are related to disease-related factors, such as the severity of the hemophilia. Factors related to the patient include the level of periodontal disease, vasculopathy or platelet dysfunction, and procedure-related factors (teeth extracted—type and the number—or the size of the wound area) [23].
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3.2 Immune thrombocytopenia
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One example of autoimmune bleeding diathesis is the immune thrombocytopenic purpura (ITP), an idiopathic thrombocytopenic purpura condition, characterized by isolated thrombocytopenia without a clinically apparent cause [24].
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3.3 Common hemostasis-altering medications
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The most common acquired bleeding diathesis is the one related to hemostasis-altering medications. Anticoagulant agents are among the most prescribed medications in the USA [25]. For decades, anticoagulants have been prescribed to prevent arterial and venous thromboembolism [1]. Prolonged bleeding and bruising are some of the adverse events related with these medications [4]. The most frequently used drugs are therapeutic platelet inhibitors, vitamin K antagonists, or direct oral anticoagulants. Patients susceptible to hemorrhage may present severe bleeding resulting from dental surgery procedures. The use of biosurgical hemostatic agents to decrease or control bleeding may be beneficial for patients at risk for bleeding diathesis.
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4. Biosurgical topical hemostatic agents in dental surgery
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Bleeding complications can occur either in healthy or systemically compromised patients. Some patients tend to bleed excessively during or after dental surgery, due to different factors, such as anticoagulant therapy, inherited bleeding disorders, uncontrolled hypertension, extreme trauma to soft tissues, and non-compliance to postoperative recommendations. In these cases, the use of an effective hemostatic agent enhances hemostasis, providing a wide spectrum of benefits, such as superior management of the anticoagulated patient, shorter operation time, as well as smaller wound exposure and shorter recovery time.
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The ideal topical hemostatic agent should be biocompatible, affordable, and effective [14, 26, 27]. In recent years, the number of different topical hemostatic agents has increased significantly (Table 2). Knowledge and familiarity with the wide range of topical hemostatic agents available are essential for dental practitioners, including their effectiveness, mode of action, and adverse effects. A well-informed professional will be able to opt for the most effective and practical agent for each situation. In relation to the use of local hemostatic in dental procedures, available scientific data is not homogenous. Most publications use one or more local hemostatic agents to compensate for the anticoagulant effect and prevent postoperative bleeding [29]. The most common local biosurgical hemostatic agents used in dentistry and approved by the Food and Drug Administration (FDA) are listed in Table 2.
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Table 2.
Types and trade name of some biosurgical agents–adapted from Pereira et al. [28].
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Local biosurgical hemostatic agents can be classified into (A) passive or mechanical, (B) active, and (C) flowables [30].
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4.1 Passive or mechanical agents
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Considered as the most effective agents for small amounts of bleeding, passive or mechanical agents provide platelet activation and aggregation. This results in a matrix formation in the bleeding area that works as a barrier to stop bleeding, by activating the extrinsic clotting pathway and providing a surface that will allow coagulation to occur faster [30]. As these agents are biologically inactive, they rely on the individual’s own fibrin production to attain hemostasis. Passive hemostats are only indicated for individuals with an unscathed coagulation cascade [27]. They are generally applied as frontline agents, since they are readily available, do not require special storage or handling, and are relatively affordable [14, 27, 31].
Gelatin is a hydrocolloid derived from acid partial hydrolysis of purified animal collagen. It is presented as a gelatin sponge, powder (mixed to form a paste), or film. Gelatin can be placed dry or after moistening it with saline [14, 28, 32, 33]. Gelatin-based products adapt effortlessly to wounds making it appropriate for application into irregular surfaces [27]. Although their mode of action is not completely understood, gelatin-based products likely act more physically than chemically in the coagulation cascade [28, 34]. Affordability, ease of use and good hemostatic activity make topical hemostats with gelatin matrix a popular tool for reducing the morbidity caused by hemorrhage [27, 28] after dental extractions and periodontal surgeries.
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The most popular absorbable gelatin sponge in dentistry is Gelfoam®. It is a hemostatic compressed sponge obtained from purified porcine skin gelatin. Gelfoam® is capable of absorbing many times its weight of whole blood [35]. Generally, when applied in soft tissues, its complete absorption occurs within 4–6 weeks.
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4.1.2 Collagen (Helistat®, Instat®, Helitene®)
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Collagen absorbable products are nontoxic and non-pyrogenic. They are sourced from either bovine dermal collagen or bovine tendon. Collagen hemostats provide a matrix for clot formation and consolidation. These products also improve clotting factor release and platelet aggregation and degranulation, thereby breaking up clot formation. Their presentation in sheets and flours allows for easy adaptation and adhesion to irregular surfaces. Although they are commercialized at a higher price than gelatin-based hemostats, hemostasis can usually be accomplished relatively quicker (1–5 min). Collagen absorbable products are easily removed, reducing the risks of rebleeding and the need for various applications. They are absorbed in 8–10 weeks if remained in place. Adverse effects linked to bovine collagen products might include swelling and allergic reaction [30].
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Helistat® is a collagen-based product originated from purified and freeze-dried bovine flexor tendon and is available as a spongelike structure [14, 27]. Helistat® can hold many times its own weight of fluid, as it is highly absorbent. Collagen induces platelet agglomeration when in contact with blood. In order to achieve hemostasis, Helistat® must be kept at the site (approximately 2–5 minutes). Subsequently, it can be removed, replaced, or left in place. It is easily manipulated, and it must be handled dry, and any excess must be removed. Complete reabsorption occurs within 14–56 days [14, 27, 36]. Helistat® may foster bacterial growth, acting as a nidus for abscess formation [14, 27, 37]; therefore, it should not be placed in wounds with any kind of contamination or infection. Possible adverse reactions of Helistat® or similar products are allergic reaction, foreign body reaction, and adhesion formation [27, 38].
Simple oxidized cellulose was first introduced in the early 1940s in the USA. In the 1960s, a new topical hemostatic-oxidized regenerated cellulose (ORC) was launched as a meshwork made from treated and sterilized cellulose—Surgicel®. ORC products are originated from vegetal-based alpha cellulose, available in absorbable knitted fabrics (low or high density), and prepared as sterile fabric meshworks. They are ready-to-use products that may be kept at room temperature and absorb 7–10 times its own weight [27, 30]. ORC cause contact activation and platelet activation, and, when absorbed, a gelatinous mass is created, assisting in the establishment of the clot formation [30]. Thrombin is ineffective with these agents due to low-pH factors. ORC are utilized in the management of capillary, venous, and small arterial bleeding, and they require dry application, without addition of saline or thrombin [27, 39] and are absorbed within 4–8 weeks, depending on the volume applied, the tissue bed, and the magnitude of blood saturation [27, 40, 41, 42]. To prevent delayed healing, excessive volumes should be removed [27]. ORC should not be used in osseous defects as it may intervene with bone regeneration [14, 27, 31]. Adverse effects also include reactions related to the acidic nature of ORC. This characteristic may induce necrosis and inflammation of the surrounding tissue and makes thrombin inefficient with these agents. When left in the wound, they may lead to fluid encapsulation and foreign body reaction [14, 27].
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The most common commercial products in this category are Surgicel®, Oxycel®, and Surgicel Nu-Knit®. Surgicel® and Surgicel Nu-Knit® come in knit, solid fiber form, whereas Oxycel® comes in knit, hollow fiber form; however, they function basically in a similar manner [30].
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4.1.3.2 Oxidized cellulose (ActCel®, Gelita-Cel®)
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Oxidized cellulose (OC) agents are produced from sterilized and treated cellulose, presented as a meshwork. In the presence of blood, they present a three- to fourfold increase in volume and are converted into gel. OC dissolve completely in 1–2 weeks into biodegradable end products glucose and water, and they do not interfere with wound healing [14, 27].
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ActCel® binds to calcium ions, resulting in more calcium available for the coagulation cascade [14, 27, 37]. Biochemically, it intensifies the coagulation process by increasing platelet aggregation and physically by 3D clot stabilization. ActCel® is especially indicated in third molar extractions, to avoid the occurrence of dry sockets, and in orthognathic and periodontal surgeries [27]. ActCel® is hypoallergenic, as it does not contain collagen, thrombin, or chemical additives. It also has important bacteriostatic properties [27, 43], which are particularity relevant in infected wounds [27].
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Gelita-Cel® is a relatively quick acting, oxidized resorbable cellulose hemostatic gauze of natural origin. It presents a decreased risk for encapsulation, as it resorbs as fast as 96 hours [14, 27, 37].
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4.1.4 Polysaccharide hemospheres (Arista™AH)
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Polysaccharide hemospheres are a fairly new class of topical biosurgical hemostatic agents, produced from vegetable starch, and they contain no animal or human elements. They are commercially presented in powder form. Polysaccharide hemospheres increase barrier formation by creating a hydrophilic effect, dehydrating the blood, and concentrating its solid components [14, 27]. Due to their 3D scaffold, they are devised to enhance clot formation and organization, even in the absence of intrinsic coagulation activity [14, 44, 45]. Polysaccharide hemospheres should be used with caution in diabetic patients, as they consist of sugars [27].
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Arista™AH is the only FDA-approved product in the polysaccharide hemosphere category. It is used in dental surgery as an adjunctive hemostatic agent, when conventional mechanical procedures, such as pressure and ligature, are not effective or practical.
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4.1.5 Adhesives (BioGlue®)
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Hemostatic adhesives are often used as adjuncts to standard hemostatic procedures to control bleeding from surgical areas [30]. One of the most well-known products in this category is BioGlue®. It consists of a solution of 10% glutaraldehyde and 45% bovine albumin solution purified by precipitation, heat, and chromatography radiation [28, 46]. BioGlue® has been extensively used for its sealants and hemostatic characteristics. The risk of leaking through the suture tracks is the main disadvantage of BiolGue® [27]. In the search for newly created adhesives with the chemical features and the safe reabsorptive profile required to benefit dental surgery patients, several clinical trials are currently in process.
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4.2 Active agents
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Active hemostatic agents are biologically active, as they play a direct role in the coagulation cascade, inducing the formation of a fibrin clot [26, 27].
Thrombin is key to hemostasis, as well as to the inflammatory and cell signaling processes. It is the base of the fibrin clot, fostering the transformation of fibrinogen to fibrin [28]. Topical thrombin hemostats are originated from either bovine or human plasma, and they can also be produced through recombinant DNA techniques [14, 27]. In the past, the only thrombin hemostat available was composed of bovine plasma (Thrombin-JMI). Although it has proven to be efficient in terminating bleeding, bovine thrombin induces an important immune response [28, 47]. Individuals on hemodialysis, with increased levels of antibodies against topical bovine thrombin, had higher incidence of vascular access thrombosis, severe coagulopathy, and bleeding after exposure to bovine thrombin [28, 48]. As an attempt to avoid these hazardous effects, thrombin derived from human plasma (Evithrom®) and recombinant human thrombin (Recothrom®) were developed. In 2010, Browman et al. [49] demonstrated, in a comparative study between recombinant human thrombin and bovine thrombin, that human recombinant thrombin showed the same efficacy in surgical hemostasis, a comparable safety profile, and a remarkably lower immune response than bovine thrombin. Thrombin may be applied topically, as a solution combined with gelatin sponges mixed with a gelatin matrix, as a dry powder, or as a spray [14, 27]. It is commonly used in conjunction with Gelfoam® to stop moderate to severe bleeding.
Fibrin sealant or fibrin glue originates from bovine and/or human blood components and simulates the last phases of the coagulation cascade, generating a fibrin clot [30]. These agents control local, as well as diffuse, bleeding from the surgical area. Nevertheless, they are ineffective in controlling intense bleeding. Its use in dentistry includes tooth extraction sites, bone grafting, and periodontal surgery [14].
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Tisseel® was the first fibrin sealant approved by the FDA. It has in its composition human thrombin and fibrinogen, intermixed with aprotinin and CaCl2. Because aprotinin is a bovine protein, it is a potential allergen. Multiple exposures may cause allergic reactions, as well as anaphylactic reaction approaching lethality [30, 50]. As for its ideal application, a dry operating field is required; Tisseel® is particularly effective when applied prior to bleeding. In this situation, fibrinogen may polymerize before blood pressure increases local microcirculation flow. When used after the onset of bleeding, one should apply local pressure over the wound to allow polymerization [28, 51]. Tisseel® is available in a pre-filled syringe, allowing for effective application using the EasySpray and DuploSpray MIS systems.
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Another option for fibrin sealants, Evicel®, originates from pooled human plasma. It is available as two separate vials of fibrinogen and human thrombin. Prior to use, the two deep frozen solutions must be thawed and mixed after defrosting and heating up (20–30°C) [30].
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Crosseal™ is a virally inactivated, second-generation surgical sealant. It is produced from concentrated human clottable proteins, namely, biological active component (BAC), which contains the active component fibrinogen, and human α-thrombin (1000 IU/ml) [52]. This fibrin sealant is applied using an application device which drips/sprays Crosseal™ onto the bleeding site.
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4.3 Flowables (Surgiflo®, Floseal®)
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There are two main categories of flowable biosurgicals: products containing porcine gelatin, which can be combined with thrombins (bovine, human-pooled plasma thrombin, or rhThrombin), and bovine collagen-based agents, packed with human-pooled plasma thrombin. The flowable agents are deemed the most effective of all the local hemostatic agents [30, 53].
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Surgiflo® is an absorbable, sterile, hemostatic porcine gelatin matrix, combined with Thrombin-JMI, a topical bovine-derived thrombin. It should be placed directly to the bleeding areas to activate the hemostatic process [30]. A compression period is required for polymerization of the sealant components [28].
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Floseal® consists of a bovine gelatin matrix, plasma-extracted human thrombin, and CaCl2. Its gelatin granules expand (10–20%), as it comes in contact with blood, producing a seal when the product is applied to a bleeding area [27, 30]. The thrombin fraction of the product triggers the regular pathway of the coagulation cascade, converting fibrinogen to a fibrin polymer and creating a clot around the firm matrix [27], which is reabsorbed within the expected period of standard wound healing (6–8 weeks) [14, 27, 33, 42, 54]. A distinctive feature of Floseal® is the need for the presence of blood for activation [30, 55]. Neither compression, nor a dry surgical field is required for its application [28].
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Because of this biosurgical flowability, they can easily adapt to irregular wounds. Flowables have been utilized as frontline topical hemostats in major dental surgeries, in patients where conventional procedures are ineffective. They can be utilized as an adjunct to hemostasis in practically all dental surgical interventions. Flowables are effective on both hard and soft tissues [27, 30]. They have a risk of transmitting infectious agents and are contraindicated in patients who are allergic to materials of bovine origin [27].
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5. Effectiveness of different biosurgical hemostatic agents in dentistry
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Although traditional methods, such as ligature and manual pressure, can promote hemostasis, they are not an effective approach of bleeding control in less accessible sites and complex injuries. Furthermore, bleeding control is especially challenging in patients presenting acquired or congenital coagulation disorders.
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Topical biosurgical hemostatic agents comprise a wide range of products aiming at minimizing the risk of bleeding. In recent years, several clinical trials have analyzed the effectiveness, advantages, and limitations of biosurgicals, as well as performed comparisons among the different types of biosurgicals and other non-biologic agents. Despite the beneficial effect of these local hemostatic agents in preventing bleeding in dental surgery, available data comparing their effectiveness and efficiency is still scarce and inconclusive. Methodological heterogeneities, such as the lack of a standard therapy and comparable treatment regimens, are noticeable among studies, as well as the reduced number of randomized controlled trials [2, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70].
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In summary, local hemostatic agents are very distinct products with diverse indications. Presently, there is no definite evidence-based approach to guide the dental practitioner when selecting a local hemostatic agent. They must be aware of the characteristics of each single hemostatic agent, to elect the most suitable product for every particular clinical situation. In addition, current available data shows that no topical agent can be regarded as superior or more effective than the others [2]. Further experimental research and controlled clinical trials are warranted to define the most cost-effective biosurgical hemostatic agents in dentistry.
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6. Preoperative assessment and risk of bleeding
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The dental practitioner should assess the bleeding risk of the patient, as well as the bleeding risk of the surgical intervention, preoperatively. After assessing both bleeding risks, the professional can then conceive an intraoperative and postoperative plan. The international normalized ratio (INR) must be evaluated in patients reporting an elevated risk of bleeding. While a standard parameter of coagulation has an INR of 1 [71], the therapeutic range runs from 2.0 to 3.5. In this case, it is recommended to use local hemostatic measures independently or in combination with conventional methods. These agents can be used before, during, and after dental surgeries.
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6.1 Preoperative assessment
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Comprehensive medical history, including all medications in the patient’s regimen, to identify potential bleeding issues prior to the surgery [26].
In order to decrease surgical bleeding, patients receiving anticoagulant therapy may need to break up exodontia into multiple appointments [26, 72].
Laboratory values such as platelet count, INR, and prothrombin time are of critical value in medically compromised patients [26].
Demographic risk factors (female sex and older age) [73].
Supplemental patient-related risk determinants: diabetes mellitus, hypertension, obesity, hemostatic disorders, renal impairment, and other major organ system failures [73, 74, 75].
Timing of the appointment: early morning visits allowing patients to return to the dental office in case of postsurgical hemorrhage [26].
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6.2 Identifying patients at risk of bleeding
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Patients at a higher bleeding risk are those reporting family history of bleeding and previous bleeding problems after dental surgery or trauma and individuals using medications, such as aspirin, anticoagulants, and/or long-term antibiotics. Any illnesses associated with bleeding problems, such as leukemia, congenital heart disease, liver disease, or hemophilia, present a higher risk of bleeding. The dental professional needs to be aware and prepared for any intercurrence, during or after a surgical procedure. Individuals presenting advanced periodontal disease are also considered as having a higher risk of perioperative bleeding. In such cases, the surgical plan should include a preoperative phase, consisting of scaling and root planning and a proper chlorhexidine gluconate mouth rinse regimen, 2 weeks before an elective procedure [26].
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The risk of bleeding of a dental intervention may be ranked as high, moderate, and low [25, 76, 77, 78]. In most patients, antithrombotic therapy is not interrupted before dental interventions with low bleeding risk, due to the disastrous complications of thrombosis (Table 3) [25, 76, 77, 78]. Moderate and high bleeding potential interventions might need the temporary discontinuation of the antithrombotic therapy [25, 76, 77, 78].
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Table 3.
Dental interventions that do not require anticoagulation therapy interruption*–adapted from Kaplovitch and Dounaevskaia [25].
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7. Bleeding in dental surgery: clinical implications
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Dental surgical interventions are considered by most recommendations, as minor procedures presenting self-limited blood loss and low bleeding risk. Bleeding, in most cases, can be managed with local hemostatic agents [79, 80].
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7.1 Should anticoagulants, antiplatelets, or direct oral anticoagulants be discontinued for minor dental surgeries?
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The dental care of individuals receiving therapeutic anticoagulation becomes critical when invasive procedures are needed. At this time, the clinician must decide either to maintain the anticoagulation therapy and risk bleeding complications or withdraw the anticoagulation medication and risk developing systemic thrombosis [1]. After decades of controversial data, there is currently a nearly unanimous consensus that anticoagulation therapy, for most dental surgeries, should not be discontinued. The higher risk of bleeding complications is compensated by the elevated risk of developing thromboembolic complications [1, 81, 82, 83, 84].
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National dental and medical group statements and multiple evidence-based clinical guidelines have considered the issue independently and support the maintenance, for most dental patients, of anticoagulation therapy (American Dental Association; American Academy of Dental Sleep Medicine; American Heart Association; American College of Cardiology; American Academy of Neurology; American Society of Anesthesiologists; Society for Neuroscience in Anesthesiology and Critical Care; American College of Chest Physicians (ACCP)) [1]. In a 2012 statement [76], the ACCP recommended continuing anticoagulation therapy with warfarin, with the additional utilization of a local hemostatic. The ACCP advised a 2–3-day anticoagulation therapy suspension, in order to lower the INR levels to a range of 1.6 and 1.9 [76, 85].
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Lately, the dental care of patients receiving anticoagulant treatment has been the focus of expressive scientific interest, in both dental and medical fields. A recent literature review showed that only 31 (0.6%) of more than 5400 patients receiving over 11,300 dental surgical interventions while continuing to take vitamin K antagonist anticoagulants (warfarin in most cases) demanded more than local maneuvers for hemostasis. No cases of fatal hemorrhage were reported. In over 2600 individuals whose anticoagulation was discontinued for dental interventions, 22 thromboembolic complications (0.8% of medication withheld), including 6 fatal events (0.2% of medication withheld), were observed [83]. Similar results have been shown in a literature review of dental surgery and antiplatelet medications. Of more than 1200 patients receiving over 2300 dental surgical procedures while continuing their antiplatelet medications (aspirin in most cases), only 2 (0.2%) needed more than local measures for hemostasis. Conversely, in over 320 individuals undergoing 370 antiplatelet interruptions for dental procedures, 17 (5.3%) suffered thromboembolic complications [86].
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Available data shows that the majority of dental interventions can be safely conducted in patients receiving anticoagulation treatment, when considering older medications [4]. However, there are fewer studies reporting the provision of dental care in individuals using newer direct oral anticoagulants. The clinical implications of these newer anticoagulant and antiplatelet therapies have only been recently investigated [80, 87]. The protocol followed by the dental practitioner when managing these patients varies significantly and shows inconsistencies reflecting the lack of large-scale studies and evidence-based clinical guidelines [80, 88, 89]. The risk of postoperative bleeding after invasive periodontal treatment in individuals using different anticoagulation therapies was assessed, retrospectively, in 456 individuals receiving an antiplatelet and/or anticoagulant therapy [90]. Data was collected after 484 invasive periodontal interventions, with 99.6% of patients continuing their medications during the procedures. Postoperative bleeding was reported only following three interventions (0.35%), and it was controlled with local hemostatic maneuvers. Although the authors did not specify which type of local hemostatic procedure was used, this retrospective study showed a very low risk of bleeding in patients receiving an invasive periodontal intervention while using an anticoagulant or antiplatelet medication [90]. These results support the recommendation that such medications do not need to be discontinued in anticipation to invasive periodontal interventions.
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Extended inter- or postoperative bleeding following dental surgery is infrequent, seldom demanding anything more than the use of local hemostatic biosurgicals. The judgment of whether or not to interrupt anticoagulation treatment can be both intricate and dynamic, and it should be based on the indication for pharmacological therapy, as well as previous thromboembolic history. The discontinuation of anticoagulant therapy may be required in dental interventions with moderate and high bleeding risk [25, 76, 77, 78]. Currently, most clinicians dealing with anticoagulant management tend to personalize the periprocedural management of the bleeding potential, according to the individual risk of each procedure—low, moderate, or high—following the current clinical practice recommendations based on best evidence and maintaining the anticoagulant therapy. Thereby, the patient anticoagulant regimen should be continued in specific low-risk dental procedures, without consultation or fear of disproportionate bleeding demanding additional intervention (Table 3) [25].
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7.2 Common anticoagulants and potential interactions with dental medications
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Undoubtedly, anticoagulant agents are effective in preventing thromboembolism. Nevertheless, their potential for critical adverse effects cannot be ignored. The use of antithrombotic medications is the most frequent cause of an adverse drug event requiring individuals to seek out emergency care [25, 91]. The majority of drug interactions with anticoagulants lead to elevated risk of bleeding. The nature of the interactions cannot be predicted, as they are expressed through both pharmacodynamic mechanisms and pharmacokinetic properties [25].
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Regarding patient safety, potential risk for interaction, as well as knowledge of appropriate prescribing and monitoring, is crucial. Equally decisive is selecting the appropriate anticoagulant agent and monitoring the potential for drug–drug interaction [10, 11, 12, 13, 14, 15, 17, 25]. Common anticoagulants and their interaction with the most common medications prescribed for dental patients are described in Table 4 [25, 92, 93, 94, 95, 96, 97, 98].
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Table 4.
Common anticoagulants and potential interactions with dental medications–adapted from Kaplovitch and Dounaevskaia [25].
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7.3 What is the difference in the risk of bleeding between patients ongoing anticoagulant therapy and patients not treated?
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Most studies evaluating the occurrence of peri- and postoperative bleeding show anticoagulation therapy can be maintained when adequate local hemostatic maneuvers are used.
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As an example, a controlled clinical trial compared the occurrence of bleeding following dental extractions in individuals receiving oral anticoagulants (experimental group) versus patients that had never received oral anticoagulant therapy (control group). Tooth extractions were performed, and a piece of oxidized cellulose was placed only into the sockets in the experimental group. The wound borders were sutured, and a gauze saturated with tranexamic for 30–60 minutes was applied with pressure in the wound. Both groups presented similar bleeding complications [99]. In a similar clinical trial [100], 161 tooth extractions were performed in patients undertaking warfarin. After tooth extraction, an oxidized cellulose gauze was placed in the socket, and the wound was sutured. Patients were assigned to four groups, according to their INR range (INR was 1.5–1.99 in group 1; 2.0–2.49 in group 2; 2.5–2.99 in group 3; and 3.0–3.7 in group 4). No significant differences were found in the postoperative bleeding among groups.
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8. Conclusions
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Based on the latest evidence and clinical practice recommendations on the perioperative management of dental patients receiving direct oral anticoagulants, on single or dual antiplatelet therapy or vitamin K antagonists, as well as on the current scientific knowledge on biosurgical hemostatic agents, the following conclusions can be made:
The majority of dental procedures can be securely executed without the withholding of anticoagulants, using only local hemostatic therapy. In fact, current recommendations and consensus support the continuation of antiplatelet or anticoagulant therapy. Discontinuing these drugs can increase the risk of thromboembolism, at the cost of minor bleeding, which can be restrained without difficulty. The appropriate use of local hemostatic measures, such as topical biosurgical hemostatic agents, should always be considered whenever indicated.
In order to safely treat a patient receiving anticoagulant therapy, familiarity with anticoagulants and with the potential for drug–drug interactions is required, in addition to knowledge about the topical hemostatic options available.
Topical biosurgical hemostatic agents are diverse agents with distinct indications. The dental practitioner must be aware of the properties of each single agent, in order to properly select the product needed in each different clinical condition.
Based on current available data, no topical hemostatic agent can be regarded as superior or more effective than the others. Further experimental research and controlled clinical trials are warranted to define the most cost-effective biosurgical hemostatic agents in dentistry.
A definite protocol for excessive bleeding is still required for dental surgery in patients with hemorrhagic diathesis. The most effective local hemostatic agent with lesser complications should be determined in future research, considering their availability and cost-effectiveness.
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Acknowledgments
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The authors are grateful to Kisa Iqbal BSc Hons, DDS Candidate c/o 2020, New York University College of Dentistry, for editing this article.
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Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"bleeding, antiplatelet, hemostasis, biosurgical agents, topical agents, dental surgery",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/69934.pdf",chapterXML:"https://mts.intechopen.com/source/xml/69934.xml",downloadPdfUrl:"/chapter/pdf-download/69934",previewPdfUrl:"/chapter/pdf-preview/69934",totalDownloads:696,totalViews:0,totalCrossrefCites:2,dateSubmitted:"May 28th 2019",dateReviewed:"October 1st 2019",datePrePublished:"November 6th 2019",datePublished:null,dateFinished:"November 6th 2019",readingETA:"0",abstract:"Excessive bleeding complicates surgery and may result in a higher risk of morbidity in dentistry. Although multiple evidence-based clinical guidelines regard dental interventions as minor procedures, with low risk of bleeding, patients on anticoagulation therapy are at elevated risk of bleeding complications, during and following dental surgeries. In many instances, discontinuation or altering of anticoagulation can be avoided through the use of local hemostatic agents during or after the procedure (or both), while patients are therapeutically continued on their prescribed anticoagulant doses. In addition, patients with diagnosis of hereditary bleeding disorders, such as von Willebrand disease and hemophilia, and individuals without any history of bleeding complications can present the need for the use of topical hemostatic agents. In this chapter, we discuss the mechanisms of action, practical applications, effectiveness, and potential negative effects of biosurgical topical hemostatic agents, such as gelatin sponges, collagen, oxidized regenerated cellulose (ORC) and oxidized cellulose, fibrin sealants, flowables, adhesives, and topical thrombin in dental surgery.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/69934",risUrl:"/chapter/ris/69934",signatures:"Natália de Campos, Flávia Furlaneto and Yvonne De Paiva Buischi",book:{id:"10606",title:"Contemporary Applications of Biologic Hemostatic Agents across Surgical Specialties - Volume 2",subtitle:null,fullTitle:"Contemporary Applications of Biologic Hemostatic Agents across Surgical Specialties - Volume 2",slug:null,publishedDate:null,bookSignature:" Michael S. Firstenberg and Dr. Stanislaw P. Stawicki",coverURL:"https://cdn.intechopen.com/books/images_new/10606.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-83968-892-8",printIsbn:"978-1-83968-891-1",pdfIsbn:"978-1-83968-893-5",editors:[{id:"64343",title:null,name:"Michael S.",middleName:null,surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Normal hemostasis",level:"1"},{id:"sec_3",title:"3. Bleeding diathesis in dental surgery: acquired, autoimmune, or genetic",level:"1"},{id:"sec_3_2",title:"3.1 von Willebrand disease and hemophilia",level:"2"},{id:"sec_4_2",title:"3.2 Immune thrombocytopenia",level:"2"},{id:"sec_5_2",title:"3.3 Common hemostasis-altering medications",level:"2"},{id:"sec_7",title:"4. Biosurgical topical hemostatic agents in dental surgery",level:"1"},{id:"sec_7_2",title:"4.1 Passive or mechanical agents",level:"2"},{id:"sec_7_3",title:"4.1.1 Gelatin (Gelfoam®, Surgifoam®, Gelfilm®, Gelita-Spon®, Geli Putty®)",level:"3"},{id:"sec_8_3",title:"4.1.2 Collagen (Helistat®, Instat®, Helitene®)",level:"3"},{id:"sec_9_3",title:"4.1.3 Cellulose-based products",level:"3"},{id:"sec_9_4",title:"4.1.3.1 Oxidized regenerated cellulose (Surgicel®, Oxycel®, Surgicel Nu-Knit®, Surgicel Original®, Surgicel Fibrillar®, Interceed®, Gelita-Cel®)",level:"4"},{id:"sec_10_4",title:"4.1.3.2 Oxidized cellulose (ActCel®, Gelita-Cel®)",level:"4"},{id:"sec_12_3",title:"4.1.4 Polysaccharide hemospheres (Arista™AH)",level:"3"},{id:"sec_13_3",title:"4.1.5 Adhesives (BioGlue®)",level:"3"},{id:"sec_15_2",title:"4.2 Active agents",level:"2"},{id:"sec_15_3",title:"4.2.1 Topical thrombin (Thrombin-JMI®, Evithrom®, Recothrom®)",level:"3"},{id:"sec_16_3",title:"4.2.2 Fibrin sealants (Tisseel®, Evicel®, Crosseal™)",level:"3"},{id:"sec_18_2",title:"4.3 Flowables (Surgiflo®, Floseal®)",level:"2"},{id:"sec_20",title:"5. Effectiveness of different biosurgical hemostatic agents in dentistry",level:"1"},{id:"sec_21",title:"6. Preoperative assessment and risk of bleeding",level:"1"},{id:"sec_21_2",title:"6.1 Preoperative assessment",level:"2"},{id:"sec_22_2",title:"6.2 Identifying patients at risk of bleeding",level:"2"},{id:"sec_24",title:"7. Bleeding in dental surgery: clinical implications",level:"1"},{id:"sec_24_2",title:"7.1 Should anticoagulants, antiplatelets, or direct oral anticoagulants be discontinued for minor dental surgeries?",level:"2"},{id:"sec_25_2",title:"7.2 Common anticoagulants and potential interactions with dental medications",level:"2"},{id:"sec_26_2",title:"7.3 What is the difference in the risk of bleeding between patients ongoing anticoagulant therapy and patients not treated?",level:"2"},{id:"sec_28",title:"8. Conclusions",level:"1"},{id:"sec_29",title:"Acknowledgments",level:"1"},{id:"sec_32",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Wahl MJ. 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Journal of Pharmacy Practice. 2018;31:202-207. DOI: 10.1177/0897190017707126\n'},{id:"B85",body:'Kunz R, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Response [letter]. Chest. 2013;144:1424-1426. DOI: 10.1378/chest.13-1728\n'},{id:"B86",body:'Wahl MJ. Dental surgery and antiplatelet agents: Bleed or die. The American Journal of Medicine. 2014;127:260-267. DOI: 10.1016/j.amjmed.2013.11.013\n'},{id:"B87",body:'Constantinides F, Rizzo R, Pascazio L, Maglione M. Managing patients taking novel oral anticoagulants (NOAs) in dentistry: A discussion paper on clinical implications. BMC Oral Health. 2016;16:5. DOI: 10.1186/s12903-016-0170-7\n'},{id:"B88",body:'Johnston S. A study of the management of patients taking novel oral antiplatelet or direct oral anticoagulant medication undergoing dental surgery in a rural setting. Dentistry Journal. 2015;3:102-110. DOI: 10.3390/dj3040102\n'},{id:"B89",body:'Sivolella S, De Biagi M, Brunello G, et al. Managing dentoalveolar surgical procedures in patients taking new oral anticoagulants. Odontology. 2015;103:258-263. DOI: 10.1007/s10266-015-0195-4\n'},{id:"B90",body:'Rubino RT, Dawson DR 3rd, Kryscio RJ, Al-Sabbagh M, Miller CS. Postoperative bleeding associated with antiplatelet and anticoagulant drugs: A retrospective study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology. 2019;128:243-249. DOI: 10.1016/j.oooo.2019.04.005\n'},{id:"B91",body:'Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US emergency department visits for outpatient adverse drug events, 2013-2014. Journal of the American Medical Association. 2016;316:2115-2125. DOI: 10.1001/jama.2016.16201\n'},{id:"B92",body:'Baillargeon J, Holmes HM, Lin YL, Raji MA, Sharma G, Kuo YF. Concurrent use of warfarin and antibiotics and the risk of bleeding in older adults. The American Journal of Medicine. 2012;125:183-189. DOI: 10.1016/j.amjmed.2011.08.014\n'},{id:"B93",body:'Rice PJ, Perry RJ, Afzal Z, Stockley IH. Antibacterial prescribing and warfarin: A review. British Dental Journal. 2003;194:411-415\n'},{id:"B94",body:'Jaffer A, Bragg L. Practical tips for warfarin dosing and monitoring. Cleveland Clinic Journal of Medicine. 2003;70:361-371\n'},{id:"B95",body:'Battistella M, Mamdami MM, Juurlink DN, Rabeneck L, Laupacis A. Risk of upper gastrointestinal hemorrhage in warfarin users treated with nonselective NSAIDs or COX-2 inhibitors. Archives of Internal Medicine. 2005;165:189-192\n'},{id:"B96",body:'Shorr RI, Ray WA, Daugherty JR, Griffin MR. Concurrent use of nonsteroidal anti-inflammatory drugs and oral anticoagulants places elderly persons at high risk for hemorrhagic peptic ulcer disease. Archives of Internal Medicine. 1993;153:1665-1670\n'},{id:"B97",body:'Burnett AE, Mahan CE, Vazquez SR, Oertel LB, Garcia DA, Ansell J. Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. Journal of Thrombosis and Thrombolysis. 2016;41:206-232. DOI: 10.1007/s11239-015-1310-7\n'},{id:"B98",body:'Macie C, Forbes L, Foster GA, Douketis JD. Dosing practices and risk factors for bleeding in patients receiving enoxaparin for the treatment of an acute coronary syndrome. Chest. 2004;125:1616-1621\n'},{id:"B99",body:'Zanon E, Martinelli F, Bacci C, Cordioli G, Girolami A. Safety of dental extraction among consecutive patients on oral anticoagulant treatment managed using a specific dental management protocol. Blood Coagulation and Fibrinolysis. 2003;14:27-30\n'},{id:"B100",body:'Morimoto Y, Niwa H, Minematsu K. Hemostatic management of tooth extractions in patients on oral antithrombotic therapy. Journal of Oral and Maxillofacial Surgery. 2008;66:51-57\n'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Natália de Campos",address:null,affiliation:'
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Openness - We communicate honestly and transparently. We are open to constructive criticism and committed to learning from it.
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IntechOpen is a dynamic, vibrant company, where exceptional people are achieving great things. We offer a creative, dedicated, committed, and passionate environment but never lose sight of the fact that science and discovery is exciting and rewarding. We constantly strive to ensure that members of our community can work, travel, meet world-renowned researchers and grow their own career and develop their own experiences.
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If this sounds like a place that you would like to work, whether you are at the beginning of your career or are an experienced professional, we invite you to drop us a line and tell us why you could be the right person for IntechOpen.
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