|Year : 2020 | Volume
| Issue : 3 | Page : 186-188
The hemostatic properties of chitosan in oral surgery
Rocco Franco1, Francesco Gianfreda2, Michele Miranda2, Alberta Barlattani3, Patrizio Bollero2
1 Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
2 Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
3 Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
|Date of Submission||21-Mar-2020|
|Date of Acceptance||07-Apr-2020|
|Date of Web Publication||12-Sep-2020|
Dr. Rocco Franco
Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Via Montpellier, 100133 Rome, Italy. University Hospital of Rome “Tor Vergata”, Dental Clinic, Viale Oxford, 81, Rome
Source of Support: None, Conflict of Interest: None
Chitosan (CS) belongs to the natural linear aminopolysaccharide family. It is formed by a repetition of D-glucosamine units (deacetylated units) and a smaller number of N-acetyl-D-glucosamine units. Their distribution is casual. It derives from chitin which is a naturally occurring polysaccharide in the arthropod exoskeleton. CS is a biocompatible material and for this reason it is used in medicine, especially in dentistry. It also has anti-inflammatory and regenerative properties. It is used in conservative dentistry, periodontology, especially in oral surgery. Its antibacterial and hemostatic properties are useful in the surgical treatment of patients on anticoagulant/antiplatelet therapy. The purpose of this work is to analyze through a systematic review of the literature on the use of CS as a local hemostatic.
Keywords: Chitosan, hemostasis, oral surgery
|How to cite this article:|
Franco R, Gianfreda F, Miranda M, Barlattani A, Bollero P. The hemostatic properties of chitosan in oral surgery. Biomed Biotechnol Res J 2020;4:186-8
|How to cite this URL:|
Franco R, Gianfreda F, Miranda M, Barlattani A, Bollero P. The hemostatic properties of chitosan in oral surgery. Biomed Biotechnol Res J [serial online] 2020 [cited 2021 Jan 17];4:186-8. Available from: https://www.bmbtrj.org/text.asp?2020/4/3/186/294855
| Introduction|| |
Chitosan (CS) belongs to the natural linear aminopolysaccharide family. It is formed by a repetition of D-glucosamine units (deacetylated units) and a smaller number of N-acetyl-D-glucosamine units. Their distribution is casual. It derives from chitin, which is a naturally occurring polysaccharide in the arthropod exoskeleton. CS is produced from chitine through an N-deacetylation process, which leads to the breaking of the bonds and the removal of the acetyl group. However, this deacetylation never occurs completely on the whole chitin chain. Bacterial and fungal enzymes are used to perform deacetylation. CS has several beneficial properties for humans. Among the various biological activities are listed: hemostatic effects, promotion of wound healing, increases the activity of the immune system, antibacterial activity, and promotes bone formation. CS finds various applications in medicine; it also has a marked biocompatibility with human tissues. Specifically, in humans, they have the ability to attract macrophages and neutrophils and can stimulate fibroblasts to produce type IV collagen. It also stimulates leukocytes to produce cytokines and angiogenetic factors. It has a chemical similarity to cellulose and is not degradable by the human body. It is a polysaccharide of natural origin, nontoxic, highly biocompatible, and biodegradable and has strong antibacterial properties. It also has the ability to form a film and gel, which is very useful in conservative dentistry for the prevention of caries. Its use is also in endodontics for its strong antibacterial qualities. In fact, it acts against the most resistant bacterial species in the root canals. CS interacts with the negative charges of bacterial cells and causes the loss of intracellular components. Its use is also in periodontology. It works by preventing the loss of periodontal tissues and helping their regeneration. Many scientists agree on the possible use of CS to regenerate the lost periodontal tissues. Furthermore, given its regenerative properties, it forms scaffolds on which osteoblasts produce bone matrix. In conclusion, CS can be used in various branches of dentistry. Its multiple properties make it an excellent material. However, we focus attention on the use of CS as a local hemostatic agent in patients with clotting problems.
CS is used to promote wound healing as a local hemostatic or bone regeneration agent. The purpose of this work is to carry out a systematic review of the use of CS as a local hemostatic agent. Indeed, the further aim of the study is to evaluate the application of this material in the postextraction cavities of patients on antiplatelet or anticoagulant therapy.
| Materials and Methods|| |
The study was conducted utilizing the main scientific databases (PUBMED, MEDLINE, and WEB of SCIENCE). The time window considered for the electronic search was from March 1, 2007, to March 1, 2020. The term “melatonin” was first combined with “periodontal disease” and then independently with “salivary concentration” using the connector “AND.” The web search was assisted using Medical Subject Headings. The criteria for this review are described in the PRISMA flow diagram. The purpose of this review is to answer to the following questions using a PICO method (P: patient problem/population; I: intervention; C: comparison; and O: outcome): (1) Can CS help as a hemostatic in oral surgery, especially in patients on anticoagulant/antiplatelet therapy?
The following inclusion criterion was used: articles in English, human studies, and clinical trials. Two independent people search with the same keywords all articles and select the article founding. The risk of bias in this phase is solved by an independent author that conducts the same search. The phase of the screening is carried out by the two independent research that excluded the article duplicated, review, and animal study. The articles found in this phase are 30. Ten articles are excluded because they are duplicates and they do not respect the topic proposed in this review.
The phase of eligibility is conducted by other two reviewers. These authors compare the article founding and select the article that asked the PICO. Articles which did not contain data regarding CS, oral surgery, and hemostatic agents are excluded from the study. The authors read first the abstract of all articles excluded, which did not respect the inclusion criteria, after reading the complete test of the remaining articles. In this phase, 15 articles are excluded.
In this phase, the risk of bias is solved by an independent author, completely external, and unknown to the authors. The number of articles remaining in this phase is five. One article is excluded because they did not use the periodontal index and treats only of oral health.
The synthesis of data is carried out by the authors. All data were extracted. The author reads first the abstract of all articles after reading the complete test of the articles. All the reviewers extract the data regarding the CS, time of bleeding. Articles which do not contain the data and the previous keywords were excluded. All doubts, regarding the included articles, are solved by contacting the author [Table 1].
| Results|| |
Two independent scientists searched the previously mentioned keywords, read the titles, and summarized the abstracts of articles. During an initial reading, they excluded the articles that did not respect the topic. Therefore, articles that responded to the key characteristics were selected. These remaining articles were read, and one of them was excluded because it did not conform to the inclusion criteria established. The complete text of the three remaining articles was read, and all were found to respect the inclusion criteria. In conclusion, three articles were included in the present review. The scientists extrapolated the following data: bleeding time, number of patients, mean age, sex, and type of drugs. Data, regarding the bleeding time in patients with CS, were taken into account and extrapolated. The study of Sarkar compares the effects of PRP and CS on the healing of the sockets in patients with antiplatelet therapy. It also assessed the hemostatic effects of the two materials. Sixty patients on oral antiplatelet therapy who required dental extractions were enrolled. The patients were divided into two groups: the first group of 30 patients was treated with platelet-rich fibrin (PRF), and the second group of 30 patients were treated with CS hydrogel. Bleeding time was assessed for each of the two groups. Furthermore, the following parameters were detected in the 1st-, 3rd-, and 7th-day postextraction: secondary pain/bleeding/scarring/soft-tissue dehiscence/alveolar osteitis. Bleeding time was shorter in the CS group (2.64 min) than in the PRF group (1.182 min) with a P < 0.001. Postoperative pain was less in the PRF group (3.2, 1.4, and 0.37 on 1st, 3rd, and 7th day, respectively) than in the study group (3.4, 1.67, and 0.53 on 1st, 3rd, and 7th day, respectively) with a P = 0.001.
The study of Kumar found the effects of CS on hemostasis in patients with oral anticoagulant therapy. Thirty patients between 18 and 90 years were enrolled. Seafood allergy patients were excluded. The study was structured as a split mouth. Patients on oral anticoagulant therapy with international normalized ratio (INR) <4 were also enrolled. Therapy was not altered during surgery. The collected data were subjected to statistical analysis using unpaired t-tests. The sites treated with CS coagulated in 1.49 min, while the control sites coagulated in 4.06 min (P < 0.001). As for pain, the treated sites showed a reduction (1.87 and 1.27, respectively, on the 1st and 3rd day) compared to the control sites (4.0 and 1.87, respectively, on the 1st and 3rd day) P value (0.001 and 0.001, respectively). In addition, the sites treated with CS had better healing both on the 1st and 3rd postoperative day (P < 0.0001).
The study of Efeoǧlu evaluates the effects of CS and surgicel, a topical hemostatic, in patients with cirrhosis. Fifty patients with cirrhosis were enrolled. A randomized, double-blind study was performed. Patients were divided according to the type of cirrhosis. The bleeding time, the trauma score, and the correct bleeding time (during postoperative reviews) were calculated in the two groups. The patients were contacted by phone after 5 h, 10 h, and for another 5 days twice a day, and a telephone test was performed to evaluate bleeding or any complications. The two groups underwent an equal number of extractions (40 teeth each). No statistically significant differences were observed, especially regarding bleeding time, as well as for the other parameters.
| Conclusion|| |
CS is a natural linear aminopolysaccharide. Its structure is based on repetitive units of D-glucosamine (deacetylated units) and less randomly distributed N-acetyl-D-glucosamine units (acetylated units), connected by β-(1–4) bond. It forms the crystalline microfibers of arthropod and cell wall exoskeletons. CS derives from the N-deacetylation of chitin. CS has anti-inflammatory properties and high biocompatibility. CS has numerous applications in the medical field. In fact, among its main properties are regenerative ones. CS stimulates the activity of macrophages, fibroblasts to produce collagen VI, and stimulates cells to produce growth factors useful for regeneration. For this, the CS promotes the healing of wounds or traumatic events. Furthermore, thanks to its conformation, it is used as a scaffold for bone formation. CS is widely used in oral surgery because of its regenerative abilities. Specifically, it inhibits bleeding, promotes the formation of granulation tissue, and promotes a scaffold for bone regeneration. In fact, in this review, we have analyzed the hemostatic properties of CS. We evaluated the hemostatic properties of CS in patients on anticoagulant or antiplatelet therapy. The increase in heart and cardiovascular diseases caused an increase in the use of these drugs. Therefore, in dentistry, it is useful to know how to manage this category of patients. The current guidelines for antiplatelet drugs do not suspend them, as they would cause an increased thromboembolic risk. Obviously, in the case of extractions up to three dental elements, as for oral anticoagulants, the current guidelines provide not to stop the oral anticoagulant drug if we are faced with an INR of <3.5. Therefore, the discovery of new hemostatic materials, including CS, becomes particularly useful. The purpose of this review was the analysis of the hemostatic properties of CS in groups of patients receiving anticoagulant and antiplatelet therapy. In addition, regenerative and healing properties were evaluated. Although there are few studies in the literature.,, All the studies affirm the hemostatic and regenerative properties of CS. All the studies structured the studies either split mouth or randomized clinical trial, in which only sutures were applied in the control group.,, Only one study evaluated the efficacy of CS in comparison with another local hemostatic widely used; in fact, in this case, the results showed an equal hemostatic efficacy. In the remaining studies, however, both primary and secondary hemostatic capacity was statistically significant. Hence, we can conclude that CS can be used in oral surgery in complete safety and efficacy, especially in those categories of patients on anticoagulant/antiplatelet therapy. In fact, the use of this material can prevent the patient from stopping the drug and subjecting it to thromboembolic risk. Numerous clinical trials will be needed to confirm the effectiveness of this material.
I thank Prof. Tiberti for the help in the data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Muxika A, Etxabide A, Uranga J, Guerrero P, de la Caba K. Chitosan as a bioactive polymer: Processing, properties and applications. Int J Biol Macromol 2017;105:1358-68.
Wieckiewicz M, Boening KW, Grychowska N, Paradowska-Stolarz A. Clinical application of chitosan in dental specialities. Mini Rev Med Chem 2017;17:401-9.
Younes I, Rinaudo M. Chitin and chitosan preparation from marine sources. Structure, properties and applications. Mar Drugs 2015;13:1133-74.
Ribeiro JCV, Vieira RS, Melo IM, Araújo VMA, Lima V. Versatility of chitosan-based biomaterials and their use as scaffolds for tissue regeneration. ScientificWorldJournal 2017;2017:8639898.
Sarkar S, Prashanth NT, Shobha ES, Rangan V, Nikhila G. Efficacy of platelet rich fibrin versus chitosan as a hemostatic agent following dental extraction in patients on antiplatelet therapy. J Oral Biol Craniofac Res 2019;9:336-9.
Kumar KR, Kumar J, Sarvagna J, Gadde P, Chikkaboriah S. Hemostasis and post-operative care of oral surgical wounds by Hemcon dental dressing in patients on oral anticoagulant therapy: A split mouth randomized controlled clinical trial. J Clin Diagn Res 2016;10:ZC37-40.
Efeoǧlu C, Sipahi Çalış A, Karasu Z, Koca H, Boyacıoǧlu H. Prospective randomized single-blind study of post-operative bleeding after minor oral surgery in patients with cirrhosis. Turk J Gastroenterol 2019;30:171-6.
Miranda M, Martinez LS, Franco R, Forte V, Barlattani A Jr, Bollero P. Differences between warfarin and new oral anticoagulants in dental clinical practice. Oral Implantol (Rome) 2016;9:151-6.
Gupta A, Rattan V, Rai S. Efficacy of chitosan in promoting wound healing in extraction socket: A prospective study. J Oral Biol Craniofac Res 2019;9:91-5.
Chang SH, Wu CH, Tsai GJ. Effects of chitosan molecular weight on its antioxidant and antimutagenic properties. Carbohydr Polym 2018;181:1026-32.
Cheung RC, Ng TB, Wong JH, Chan WY. Chitosan: An update on potential biomedical and pharmaceutical applications. Mar Drugs 2015;13:5156-86.
Machado AHS, Garcia IM, Motta ASD, Leitune VCB, Collares FM. Triclosan-loaded chitosan as antibacterial agent for adhesive resin. J Dent 2019;83:33-9.
Pavez L, Tobar N, Chacón C, Arancibia R, Martínez C, Tapia C, et al
. Chitosan-triclosan particles modulate inflammatory signaling in gingival fibroblasts. J Periodontal Res 2018;53:232-9.
Franco R, Miranda M, Di Renzo L, De Lorenzo A, Barlattani A, Bollero P. Glanzmann's thrombastenia: The role of tranexamic acid in oral surgery. Case Rep Dent 2018;2018:9370212.
Ye Y, Pang Y, Zhang Z, Wu C, Jin J, Su M, et al
. Decellularized periosteum-covered chitosan globule composite for bone regeneration in rabbit femur condyle bone defects. Macromol Biosci 2018;18:e1700424.