Clinical Applications of Ferric Sulfate in Dentistry:

A Narrative Review
Journal of conservative dentistry Year : 2017 / Volume : 20 / Issue : 4
 Keywords

• Ferric sulfate
• Hemostasis
Hemostasis is the process by which the bleeding is arrested. It is the first stage of wound
healing.

Hemostasis has three major steps

1) Vasoconstriction
2) platelet plug formation
3) Blood coagulation / the formation of a fibrin clot.
 1) Vasoconstriction

• It is produced by vascular
smooth muscle cells.
• first response to injury

Damage of blood vessel > immediate reflex( initiated by local

sympathetic pain receptors )> causes vasoconstriction.

reduces the amount of blood flow and limits the amount of

blood loss.
2) Platelet plug
formation
(primary
hemostasis)

• Collagen is exposed at the site of injury

• Platelets binds to collagen (Mediated by Von Willebrand factor)
• After binding Platelets change in shape
• also release cytoplasmic granules, containing serotonin, ADP and
thromboxane A2.
Serotonin > vasoconstrictor
Adenosine diphosphate (ADP) > attracts more platelets
thromboxane A2 > assists in platelet aggregation, vasoconstriction
and degranulation.
 Platelet Activation
• Platelets are in normal, unactivated state >> when
circulating through healthy endothelium (Maintained by
prostacyclin release from endothelium)
• Damage in endothelium >> Platelet encounters ,the
molecules that trigger its activation.
• Ie collagen,thrombin,thromboxane A2, ADP
 Activated Platelets
• Release of granules.
• Change in shape to a more amorphous form with projecting
fingers.
Receptors present on activated platelets
• glycoprotein 2b/3a receptors > binds to fibrinogen.
two platelets adhere to each other.
• VWF receptors. > Adherence of platelet to collagen under
the broken endothelium.

Hence> Platelets adhere to each another and to collagen under

the endothelium, forming a platelet plug.
Normal amorphous form

platelet plug
 3) Clot formation

• clotting factors are proteins

present in plasma in
inactive/zymogen form

• After platelet plug formation

clotting factors are activated in
a sequence > its called
'coagulation cascade'

• it leads to the formation of

Fibrin from inactive fibrinogen.

Thus, a Fibrin mesh is produced around the platelet plug and this
step is called "Secondary Hemostasis".
 clotting factors

*Most of clotting factors are proteins present in plasma in inactive/zymogen

form
Mechanism of coagulation

Fibrinogen Fibrin
Thrombin

Xa

Pro thrombin

Xa is produced by two path ways

> Intrinsic path
> Extrinsic path
Intrinsic pathway
Trigger is> Contact of factor XII with subendothelium

XII XIIa Extrinsic pathway

Trigger > damaged endothelium
XI XIa releases Tissue factor (TF).. A
Lipoprotien
IX IXa
In presence of VIIIa, Ca++, PL Tissue factor
X Xa
VII VIIa

X Xa
In presence of Va, Ca++, PL

Xa
Prothrombin thrombin

Fibrinogen Fibrin
Common
pathway XIIIa

stable Fibrin
PL> phospho lipid
 Tertiary hemostasis / fibrinolysis

• Injured tissues and vascular endothelium after clot formation

and stoppage of bleeding release powerful activator tPA
(tissue plasminogen activator)
• tPA converts plasminogen to plasmin >removes the
unnecessary blood clot
• Many small blood vessels in which blood flow has been
blocked are reopened by this mechanism
 Hemostatic agents ( KD Tripathi)

1) Vitamin K
2) Fibrinogen
3) Antihaemophilic factor
4) Ethamsylate
• Vitamin K >> Act as co factor in synthesis of coagulation factors
(liver)
Prothrombin, Factors VII,IX,X
• Vit k causes gamma carboxylation of glutamate residues in
Clotting factors and this gives capacity to bind to calcium and PL
>which is essential for coagulation
• Use > prophylaxis and treatment of bleeding due to deficiency of
clotting factors
• Fibrinogen (factor I)

• fibrinogen concentrate of human plasma is used.

0.5g Iv is given
• used to control bleeding in
hemophilia,antihaemophilic globulin deficiency

Mechanism of action
• bridges the activated platelets, key substrate for
thrombin for Fibrin production

• Brand Name : RiaSTAP

• Antihaemophilic factor (factor VIII) >
• it is concentrated antihaemophilic globulin
prepared from human plasma.
• Used in hemophilia,antihaemophilic
globulin deficiency
• Brand Name: Advate
• Dosage (IV)> 1750 IU
• Ethamsylate > reduces capillary bleeding when platelets are
adequate. Improves capillary wall stability.
• Ethamsylate acts on the first step of hemostasis by improving
platelet adhesiveness and restoring capillary resistance.
• Ethamsylate Inhibit of PgI2 (Prostacyclin) synthesis//
(Prostacyclin inhibit platelet activation)
• Used for prevention of capillary bleeding (example after tooth
extraction)
 Haemostatics in dentistry ( KD Tripathi)

• Styptics ( local haemostatics)>Stops bleeding from local

approachable sites.
• Particularly effective on oozing surfaces ( tooth surface,
abrasions)

• Absorbable materials >1-4 weeks//

1.Fibrin >prepared from human plasma and dryed as sheet or
foam
 2.Gelatin foam >
Gel foam is a porous, pressed form of
gelatin sponge used in conjunction with
thrombin to control oozing of blood from
surface wounds.

Gel foam is usually moistened with sterile.

isotonic saline before use.

It is completely absorbed within 4to 6 weeks

Gel foam is available as cones, packs, sponges

and powder.
 3. Oxidized cellulose > as strips which can be cut and placed
in socket

Oxycel is surgical gauze treated with

nitrogen dioxide

Oxycel, when wet with tissue fluid,

becomes sticky and gummy and exerts its
haemostatic effect by mechanical
blockage, which stimulates an artificial
clot over the surface of the wound.

Oxycel is usually absorbed completely

within 2 to 10 days.
4. Thrombin from bovine plasma applied as dry powder or solution in to
bleeding surface in hemophiliacs

Thrombin therapy is restricted to local application in oozing of

blood.

If given intravenously, thrombin causes extensive thrombosis and

death. Topically applied thrombin operates as a hemostatic.
5. When vasoconstriction is inadequate > vasoconstrictors like
1% adrenaline is soaked in cotton gauze and packed in bleeding
socket

6.Astringents like tannic acid are used in bleeding gums etc

common hemostatic agents > Common hemostatic agents used in dentistry are ferric
(ferrous) sulfate and AlCl3.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4163818/table/T1/
 FS/ Ferric sulfate
• Ferric sulfate was first introduced in the
field of dermatology as Monsel’s solution in
1856.
• In dentistry, 15%–20% FS is used as an
astringent and styptic.
• Hemostatic action > agglutination of blood
proteins (due to reaction of blood with
ferric and sulfate ions in acidic pH.)
• The agglutinated proteins form plugs that
occlude the capillary orifices.
 FS is available in two chemical forms.

• Ferric subsulfate (Monsel’s solution)

• Ferric sulfate
 Ferric subsulfate (Monsel’s solution)
• Monsel’s solution, 20% FsS, >effective
styptic agent in skin and mucosal biopsies
• Can cause staining of the teeth due to its
high acidity (pH <1).
• The postoperative complications like
delayed reepithelialization and
dyspigmentationcan occur.
• It also causes reactive and degenerative
changes.

AstrinGyn - Thickened Monsel's Solution, gel consistency ..

Ease of application

Applcation > wound is then wiped with gauze, the Monsel's solution applied, and the
tension maintained for about 15 s.
 Ferric sulfate
• FS (15.5% solution) > coagulative and hemostatic agent, forms
ferric ion-protein complex on contact with blood.
• It seals the damaged vessels mechanically, the capillary
orifices are occluded by the agglutinated protein complex,
which prevents blood clot formation.
• It causes a local and reversible inflammatory response to the
oral soft tissues.

Application > should be placed directly against

the damaged tissue for 1–3 min

Solutions of FS above 15% are highly acidic

and may cause considerable tissue irritation
and postoperative root sensitivity.
Commercial forms of FS
 Applications of FS in dentistry
• Pulpotomy medicament
• Antibacterial agent
• During restorative procedure
• Gingival displacement in prosthodontics
• Management of post extraction hemorrhage
• Hemostatic agent in periradicular and endodontic surgery
 Pulpotomy medicament

• Used to control pulpal bleeding in vital pulp therapy since

three decades.
• 15.5% solution is used >apply using cotton pellets to pulp for
10-15 sec.
• hemostasis is by >> forming a sealing membrane at the
damaged vessels of pulpal tissue by agglutinating the blood
proteins with ferric and sulfate ions
• The nonaldehyde form of FS is most preferred as a pulpotomy
agent due to its mechanism of controlling hemorrhage
(believed to be associated with physiological clot formation.)
 Antibacterial agent

• FS also has antimicrobial activity.

• Similar to 0.2% chlorhexidine digluconate
• This might be due to its acidic pH and cytotoxicity.
• In addition, the occlusion of capillary orifices by agglutinated
proteins prevents the ingress of bacteria.
During restorative procedures

• One of most commonly used chemical hemostatic reagents

• Impregnated into retraction cords in chemomechanical
gingival retraction technique
• 15%–25% conc. Of FS is used for 3–10 min

Dis advantages
> Causes internal discoloration of the dentin.

> Removes Smear layer and affects the bonding mechanism of

self etching adhesives
gingival displacement in prosthodontics

• Used during crown and bridge impressions.

• It is used for tissue displacement.
• Cause Stain in the gingival tissue (Yellow-brown to black)
• Irrigation with water for at least 10 s eliminates the staining and
discoloration effect of ferric compounds
 Management of postextraction hemorrhage

• FS can be used in mucosal tears or uncontrolled

postextraction hemorrhage in gingival tissues.
Use in periradicular and endodontic surgery

Epinephrine pellets alone or in combination with a

FS-soaked pellet are effective topical hemostats when
applied in the bony crypt under light pressure.

Aluminum chloride alone or in combination with FS

(Stasis®) appeared to be the most efficient hemostatic
agent to control the bleeding during periapical surgery

Adequate curettage and irrigation is required> else FS can cause

persistent inflammation and delay in osseous repair.

20% FS (Viscostat®) for 5 s >> used for

hemostasis during endodontic surgeries
(root-end resection, root-end preparation, and
root-end filling)
Merits & demerits of FS
 FS toxicity
• FS is highly biocompatible, no concerns about toxic or harmful
effects have been reported in the dental literature till date
conclusion