Hemostasis
Good hemostasis for restorative dentistry takes time. Subgingival restorative margins quite often have very inflamed gingiva assocaited due to the bacterial buildup that has caused the caries. especially if there is cavitated caries, there may also be gingival ingrowth into the cavity that can be difficult to manage.
-If there is excess gingiva you must decide whether a gingivectomy or crown lengthening is required. This is dependant on the level of the crestal bone. A gingivectomy can be done with specially designed rotary burs without water (ceratip, gingiburs), high speed diamond burs, slow speed burs, scalpel, electrosurgery or Laser. Gingivectomy burs, Laser, electrosurgery also have the added benefit of causing coagulation which will assist with hemostasis after the gingivectomy.
-Cord or teflon can be packed in the sulcus for retraction and hemostasis. Retraction cord can carry a hemostatic agent but the amount of retraction iasn't as great and it can allow gingival crevicular fluid and blood to seep through to the margin. Teflon cord will provide greater retraction and is waterproof.
-Local anaesthetic containing adrenaline can be used in the tissues around the cavity to provide local vasodilation and assist in hemostasis. It will also allow you to pack cord or teflon comfortably.
-A hemostatic agent can be used on the gingiva to stop any excess bleeding. you Must ensure it is washed off completely afterwards before bonding as it will hinder the bonding and cause stain to accumulate. A cotton pellet soaked in hemostatic agent can be compacted into the cavity to apply pressure to assist in hemostasis.
-You have to allow time for hemostasis to occur. If there is frank oozing into the cavity this is unlikely to occur with the measures you have undertaken and you may need to apply more teflon or pressure rom cotton pellets. Leave the tooth alone for 5-10 minutes and work on another tooth or let the patient and yourself have a rest while the bleeding stops. If you keep taking the cotton out early to check if the bleeding has stopped you will irritate the tissues and the bleeding will start again. Very messy bleeding can look very favourable if given enough time.
-Rubber dam is always beneficial as it provides tissue retraction and stops ingress of fluid. teflon retraction before or after rubber dam placement can assist with retraction to expose the margins
-If there is excess gingiva you must decide whether a gingivectomy or crown lengthening is required. This is dependant on the level of the crestal bone. A gingivectomy can be done with specially designed rotary burs without water (ceratip, gingiburs), high speed diamond burs, slow speed burs, scalpel, electrosurgery or Laser. Gingivectomy burs, Laser, electrosurgery also have the added benefit of causing coagulation which will assist with hemostasis after the gingivectomy.
-Cord or teflon can be packed in the sulcus for retraction and hemostasis. Retraction cord can carry a hemostatic agent but the amount of retraction iasn't as great and it can allow gingival crevicular fluid and blood to seep through to the margin. Teflon cord will provide greater retraction and is waterproof.
-Local anaesthetic containing adrenaline can be used in the tissues around the cavity to provide local vasodilation and assist in hemostasis. It will also allow you to pack cord or teflon comfortably.
-A hemostatic agent can be used on the gingiva to stop any excess bleeding. you Must ensure it is washed off completely afterwards before bonding as it will hinder the bonding and cause stain to accumulate. A cotton pellet soaked in hemostatic agent can be compacted into the cavity to apply pressure to assist in hemostasis.
-You have to allow time for hemostasis to occur. If there is frank oozing into the cavity this is unlikely to occur with the measures you have undertaken and you may need to apply more teflon or pressure rom cotton pellets. Leave the tooth alone for 5-10 minutes and work on another tooth or let the patient and yourself have a rest while the bleeding stops. If you keep taking the cotton out early to check if the bleeding has stopped you will irritate the tissues and the bleeding will start again. Very messy bleeding can look very favourable if given enough time.
-Rubber dam is always beneficial as it provides tissue retraction and stops ingress of fluid. teflon retraction before or after rubber dam placement can assist with retraction to expose the margins
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