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Year : 2020  |  Volume : 31  |  Issue : 4  |  Page : 585-588
Effects of haemostatic agents on bond strength – An In Vitro study

1 Department of Orthodontics, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, India
2 Department of Orthodontics, Faculty of Dental Sciences, Sri Ramachandra University, Porur, Chennai, India

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Date of Submission30-Jul-2012
Date of Decision02-Jan-2019
Date of Acceptance03-Jun-2019
Date of Web Publication16-Oct-2020


Aim: To evaluate and compare the effect of contamination with haemostatic agents like Tranexamic Acid (TA) and Ethamsylate, on the shear bond strength. Materials and Methods: There are about 100 extracted human premolars randomly segregated into four groups each consisting of 25 samples. Group I was bonded with Transbond, Group II was bonded with Transbond after blood contamination, while groups III and IV were bonded with Transbond after contamination with Tranexamic acid and the shear bond strength was measured. The data were compared by One- way ANOVA and Tukey (HSD) tests. Results: Group I had the highest shear bond strength (SBS) while Group II, where the teeth were contaminated with blood showed the least SBS values ANOVA indicated significant differences between the four groups (P <.05). Tukey HSD revealed that contamination with TA (Group III) had a statistically higher SBS that contamination with Ethamsylate (Group IV) (P <.05). Conclusion: Since tranexamic acid and ethamsylate reduces the bleeding when used during surgery, these haemostatic agents may be considered in bonding situations where blood contamination is anticipated.

Keywords: Bond strength, ethamsylate, haemostatic agents, tranexamic acid (TA)

How to cite this article:
Krishnan V G, Kailasam V, Chitharanjan AB. Effects of haemostatic agents on bond strength – An In Vitro study. Indian J Dent Res 2020;31:585-8

How to cite this URL:
Krishnan V G, Kailasam V, Chitharanjan AB. Effects of haemostatic agents on bond strength – An In Vitro study. Indian J Dent Res [serial online] 2020 [cited 2022 Oct 7];31:585-8. Available from:

   Introduction Top

The fixed appliance treatment requires brackets and tubes to be accurately positioned, and have minimal rate of bond failure.[1] While, avoiding saliva and blood contamination is the critical factor in ensuring successful bonding,[2] there are situations where such circumstances are unavoidable. One such is in the surgical exposure and subsequent orthodontic alignment of unerupted or impacted teeth where it is difficult to bond under ideal contamination free conditions.[3] Bonding during this procedure has a high risk of fluid contamination.

Hemostatic agents are routinely used to prevent or reduce blood flow at the site of bonding. While several hemostats have been assessed for their influence on bond strength the effect of these agents on bond strength remains questionable.[4]

To control blood loss during surgery, reduction of fibrinolytic activity with fibrinolytic inhibitors has been considered fibrinolytic inhibitors like aprotinin, epsilon-amino caproic acid (EACA), a synthetic derivative of lysine, and a relatively potent Tranexamic acid (TA).[5] Hence, the aim of this study was to evaluate and compare, in vitro, the effects of TA and Ethamsylate contamination during a bracket bonding procedure.

   Materials and Methods Top

There are about 100 human premolars, therapeutically extracted for orthodontic treatment, were collected. The criteria for tooth to be selected for thisin vitro study were buccal enamel to be intact, no cracks caused by the extraction procedure, no caries or white spot lesion and no attrition or abrasion. The teeth were washed and stored in a solution of 0.1% (wt/vol) thymol to prevent dehydration and bacterial growth. These selected teeth were fixed in blocks made of self-cure acrylic with the roots into the acrylic up to the cementoenamel junction leaving the crowns of the tooth exposed. The self cured acrylic blocks were randomly segregated into four groups namely group I, group II, group III, and group IV, each consisting of 25 samples. These blocks were then color coded.

The labial surface of the teeth were cleaned using pumice and rubber cups and etched with 37 percent phosphoric acid for 30 seconds and bonded using the following protocol. Group I: Transbond XT was used to bond the tooth surface as per manufacturer's instructions (control). Group II: Transbond XT composite resin used to bond the teeth surface which was contaminated with fresh male donor human blood; the blood was brushed on the labial surface ensuring complete contamination.

This was done within five minutes of drawing blood. This surface was then air-dried. Group III: Transbond XT composite resin used to bond the teeth surface which was contaminated with Tranexamic acid (TA) at 1 gram in 100 ml. One drop Tranexamic acid solution was smeared on the conditioned enamel and dried with air. Group IV: Transbond XT composite resin used to bond the teeth surface which was contaminated with Ethamsylate at (1 gm in 100 ml) One drop of Ethamsylate solution was applied directly on the conditioned enamel surface and air dried.

Premolar brackets (Gemini series, 0.022 × 0.028 slot, 80-gauge mesh, 3 M Unitek, Monrovia, California, USA) were routinely bonded to the labial surface of the teeth. These teeth were primed with Transbond XT primer and brackets were bonded with Transbond XT adhesive. Any resin excess was removed. Subsequently, the samples were light-cured for 40 seconds with halogen light cure system, with intensity of 480 nm. The bonded teeth were stored in distilled water which was maintained at room temperature for 24 hours before bond strength testing.

A Universal testing machine (Instron UTM, Model no 4301, Canton, Mass, USA), was used to measure the shear bond strength. The force was applied parallel to the surface of the tooth, with the rod at the bracket tooth interface with a cross head speed of 3 mm per minute.

The above procedure was repeated for all the samples. The mean and standard deviation for the samples for each study group was tabulated and assessed by One- way ANOVA (Analysis of variance). The Tukey (HSD) post hoc test was performed to compare between groups.

   Results Top

Group I, that is the control group in which Transbond XT was used to bond the teeth surface, had the highest shear bond strength (SBS) while Group II, where the teeth were contaminated with blood showed the least SBS values [Table 1]. The results of the ANOVA (F = 313.71) indicated significant differences between the four groups (P <.05, [Table 2] and [Table 3]). The Tukey HSD test revealed that contamination with TA (Group III) had a higher SBS that contamination with Ethamsylate (Group IV) and this was statistically significant (P <.05).
Table 1: Comparison of the mean shear bond strengths (in MPa) of the various groups (n=25)

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Table 2: One way analysis of variance (ANOVA) between groups and within groups (Significant at 0.05 levels)

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Table 3: Multiple comparisons between the groups with Tukey HSD (Significant at 0.05 levels)

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   Discussion Top

The semi-permanent nature of the attachment is one the difficulties in orthodontic bonding.[6] The bond strength should be sufficiently high to resist accidental debonding during treatment, but low enough so that excessive force need not be applied during debonding at the end of the treatment. Clinical Shear Bond Strength requirement (SBS) for steel attachments should be ideally around 6 – 8 MPa, because bond strength around these values can withstand both masticatory and forces from orthodontic appliances.[7]

Bonding for surgical procedures have undergone modifications since less of the impacted crown requires exposure, etch and bonding agents have undergone improvements by being less sensitive to contamination at the surgical site.[8] However, blood contamination into the surgically exposed site during the bonding procedure may result in bond failure since contamination with blood significantly decreases the bond strength. During surgical procedures, a dry surface where the bracket will be placed is required to reduce the chance of bond failure.[9]

Because of their hydrophobic properties, conventional resin composites require both completely dry and isolated field of bonding to ensure a complete bond.[10] To address this problem, hydrophilic bonding materials have been considered. Moisture insensitive primers offer similar strength when they have been evaluated in wet and dry conditions.[10],[11],[12],[13] Self-etch primers have a clinical advantage because etching and priming is done in a single step. Reaction products need not be rinsed out since they are polymerized and incorporated into the bonding. Bond strength values are conflicting as reported in the literature. Although hydrophilic, specific recommendations during moisture, blood or salivary contaminated situations are unavailable. When bonded on blood-contaminated enamel, the bond strength values were on the lower side.[3],[11],[13],[14]

The results of the presentin vitro study indicated that the highest SBS was obtained in Group I which was the control group where Transbond XT was used to bond to the tooth surface as per manufacturer's instructions. This was followed by Group III (TA contamination), Group IV (Ethamsylate contamination) and Group II (Blood contamination) [Table 1]. A statistically significant difference was observed for the SBS values between the four groups. This showed that contamination with TA and Ethamsylate produced significantly lower SBS than the group I (control) with TA contamination having a statistically significant greater SBS than Ethamsylate [Table 2] and [Table 3].

In the present study, specimens in group II, where the teeth were contaminated with blood during bonding had the lowest SBS values. Similar findings have been reported by other studies.[3],[9],[11],[13],[14],[15] SBS values after contamination with blood suggests that blood appears to be a physical barrier which would reduce the adhesive - etched tooth mechanical retention.[11] This accounts for the increased bond failure observed while bonding orthodontic attachments after exposure with a surgical procedure. Hemostatic agents may also contaminate and lead to decreased SBS.[16] Saliva could also be a contamination during bonding, but in this study contamination was restricted to blood and two topical hemostatic, namely TA and Ethamsylate.

This study showed that non contaminated enamel surfaces had the highest bond strengths for conventional composite when used as per manufacturer's instructions and this was in consonance with Bishara et al.[16] Grandhi et al.[17] Webster et al.[12] Cacciafesta et al.[3],[10] Sfondrini et al.[14] Sfondrini et al.[14] also reported that enamel surfaces had greater bond strengths for Transbond XT and Transbond Plus SEP. Both primers showed lesser shear bond strengths in a blood-contaminated environment. These findings do not agree with those reported by Hobson et al.[18] who reported Transbond MIP to be acceptable for bonding in contaminated environments.

Oonsambat et al.[13] showed that a reduction in bond strength between etched enamel which was dry, and water or human blood contaminated etched surface. This finding was in consonance with the results of this study. All the bond strength values reported in this study were slightly above or within the optimum bond strength values reported by Reynolds[7] except for Group II (for blood contamination).

During surgical exposure and bonding of the impacted canine, conditions at surgical field are not conducive to acid etching and bonding. Blood flow and thus contamination of the bonding area is always a risk for subsequent bond failure.[9] While elevating the flap, tissue damages occurs resulting rupturing of vessels, thus activating the haemostatic mechanism: vessels begin to contract, platelet plugs are formed, and coagulation procedure starts, thus ending in a stabilized network of fibrin. Simultaneously, the fibrinolytic system gets activated. This fibrinolysis is the innate physiological mechanism which ensures that clot gets dissolved, allows patency of the vessels, and more importantly activates remolding of the tissue which has been damaged.[5]

Topical Dose for TA is 500 mg diluted in 5 ml saline solution while for Ethamsylate is available in 500 mg in 5 ml ampoule and hence this dosage was used in this study. TA is hydrophilic and works by engaging to the lysine- binding location sites of the plasmin and plasminogen. Saturation of these sites subsequently removes the plasminogen from its fibrin surface, which results in fibrinolysis inhibition.[5]

Plasminogen activation to the serine protease plasmin is the critical step. Plasminogen binds to the fibrin molecules via specific lysines. The most important physiological activator of plasminogen is the tissue Type plasminogen activator (tPA), which is the activator of plasminogen has a specific affinity to fibrin binds to fibrin and subsequent co localization facilitates fibrinolysis at the location of fibrin clot.[5]

Ethamsylate is a synthetic material having a multiple location action. It balances coagulants and anti-coagulants. Ethamsylate enhances platelet plug formation by enabling more aggregation and platelet adhesiveness. Ethamsylate increases formation of fibrin, by greater thromboplastin generation and is able to hasten blood clotting. Ethamsylate has an inhibitory effect on prostacyclin synthase, which vasodilates and minimizes of aggregation of platelets. Thus ethamsylate works by helping in vascular constriction, formation of platelet plug and in the formation of the blood clot.[19]

Even with a hydrophilic bond system, blood reduces SBS and is followed (in interference intensity) by saliva and water. The specific blood components involved in this mechanism are yet to be completely elucidated or understood and hence blood contamination interfering with bonding more than saliva or water cannot be fully explained.[20]

There are no published data concerning haemostatic agents including adrenaline and their effect onin vivo bond strength. Further, the mechanism by which these hemostatic agents affect bond strength when contaminated in anin vivo environment has to be established since Araújo et al.[21] have shown in light-cured resin cement, hemostatic agent contamination affects the bond strength, degree of conversion, and color stability.

   Conclusion Top

Tranexamic acid and Ethamsylate reduces bleeding when used during surgery. Hence, these haemostatic agents may be considered during bonding situations where blood contamination is anticipated. However, their effects onin vivo bond strengths have to be evaluated.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Roelofs T, Merken N, Roelofs J, Bronkhorst E, Breuning H. A retrospective survey of the causes of bracket-and tube-bonding failures. Angle Orthod 2016;87:111-7.  Back to cited text no. 1
Kesar N, Madan M, Dua P, Saini S, Mangla R, Kumar A. Comparative evaluation of shear bond strength of two adhesive systems before and after contamination with oral fluids: AnIn vitro study. Ind J Dent Sci 2017;9:189.  Back to cited text no. 2
Cacciafesta V, Sfrondrini MF, Scribante A, De Angelis M, Klersy C. Effect of blood contamination on the shear bond strengths of conventional and hydrophilic primers. Am J Orthod Dentofacial Orthop 2004;126:207-12.  Back to cited text no. 3
Akdeniz BS, Oz AA, Arici N, Demir O, Arici S. Using hemostatic agents during orthodontic bonding: Anin vitro study. Turk J Orthod 2015;28:38-43.  Back to cited text no. 4
Tengborn L. Fibrinolytic inhibitors in the management of bleeding disorders. World Federation of Hemohphilia, Treatment of Hemophilia series. 2007;42:1-2.  Back to cited text no. 5
Reynolds IR, von Fraunhofer JA. Direct bonding in orthodontic attachments to teeth: The relation of adhesive bond strength to gauze mesh size. Br J Orthod 1975;3:91-5.  Back to cited text no. 6
Reynolds IR. A review of direct orthodontic bonding. Br J Orthod 1975;2:171-8.  Back to cited text no. 7
Holmes A, Nashed RR. Radiographic localization of canines in general dental practice. Dent Update 1990;17;29-34.  Back to cited text no. 8
Trakyali G, Oztaprak MO. Plant extract Ankaferd blood stopper effect on bond strength. Angle Orthod 2010;80:570-4.  Back to cited text no. 9
Cacciafesta V, Sfondrini MF, Angelis MD, Scribante A, Klersy C. Effect of water and saliva contamination on shear bond strength of brackets bonded with conventional, hydrophilic, and self-etching primers. Am J Orthod Dentofacial Orthop 2003;123:633-40.  Back to cited text no. 10
Faltermeier A, Behr M, Rosentritt M, Reicheneder C, Mubig D. Anin vitro comparative assessment of different enamel contaminants during bracket bonding. Eur J Orthod 2007;29:559-63.  Back to cited text no. 11
Webster MJ, Nanda RS, Duncanson MG Jr, Khajotia SS, Sinha PK. The effect of saliva on shear bond strengths of hydrophilic bonding systems. Am J Orthod Dentofacial Orthop 2001;119:54-8.  Back to cited text no. 12
Oonsambat C, Bishara SE, Ajlouni R. The effect of blood contamination on the shear bond of orthodontic brackets with the use of a new self etch primer. Am J Orthod Dentofacial Orthop 2003;123:623-40.  Back to cited text no. 13
Sfondrini M, Cacciafesta V, Scribanta A, Angelis MD, Klersy C. Effect of blood contamination on shear bond strength of brackets bonded with conventional and self-etching primers. Am J Orthod Dentofacial Orthop 2004;125:357-60.  Back to cited text no. 14
Oztoprak MOU, Isik F, Sayınsu K, Arun T, Aydemir B. Effect of blood and saliva contamination on shear bond strength of brackets bonded with 4 adhesives. Am J Orthod Dentofacial Orthop 2007;131:238-42.  Back to cited text no. 15
Bishara SE, Von Wald L, Laffoon JF, Warren JJ. Effect of self etch primer/adhesive on the shear bond strength of orthodontic brackets. Am J Orthod Dentofacial Orthop 2001;119:621-24.  Back to cited text no. 16
Grandhi RK, Combe EC, Speidel TM. Shear bond strength of stainless steel orthodontic brackets with a moisture-insensitive primer. Am J Orthod Dentofacial Orthop 2001;119:251-5.  Back to cited text no. 17
Hobson RS, McCabe JF. Relationship between enamel etches characteristics and resin-enamel bond strength. Br Dent J 2002;192:463-8.  Back to cited text no. 18
Garay RP, Chiavaroli C, Hannaert P. Therapeutic effects and mechanism of action of Ethamsylate, a long standing hemostatic agent. Am J Therap 2006;13:236-47.  Back to cited text no. 19
Prasad M, Mohamed S, Nayak K, Shetty SK, Talapaneni AK. Effect of moisture, saliva, and blood contamination on the shear bond strength of brackets bonded with a conventional bonding system and self-etched bonding system. J Nat Sc Biol Med 2014;5:123-9.  Back to cited text no. 20
[PUBMED]  [Full text]  
Araújo IS, Prado CJ, Raposo LH, Soares CJ, Zanatta RF, Torres CR, et al. Influence of hemostatic solution on bond strength and physicochemical properties of resin cement. Braz Dent J 2017;28:624-31.  Back to cited text no. 21

Correspondence Address:
Dr. V Gokula Krishnan
Department of Orthodontics, Sri Ramachandra Institute of Higher Education and Research, Sri Ramachandra University, Porur - 600 116, Chennai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_559_12

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