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Symptomatic foreign body reaction to haemostatic alginate
Symptomatic foreign body reaction to haemostatic alginate E. W. Odell, P. Oades, T. Lombardi Department of Oral Medicine and Pathology, UMDS, Guy’s Hospital, London, UK, and Department of Oral and Maxillofucial Surgery, Oldchurch Hospital, Romford, UK
SUIMMARY. Kaltostat, a haemostatic wound dressing made from non-woven sodium calcium alginate fibres is becoming more frequently and widely used by practitioners. We report a florid foreign body giant cell reaction elicited by Kaltostat which had been used to obtain haemostasis in an apicectomy cavity on an upper lateral incisor approximately 7 months earlier. The case demonstrates that alginate fibres left in situ may elicit a long-lasting and symptomatic adverse foreign body reaction. This material should be reserved for problematic haemorrhage and be removed from the tooth socket soon after haemostasis.
sulcus prompted treatment with Augmentin. Two months post-apicectomy a granulomatous swelling was apparent in the buccal sulcus, the tooth was extracted and granulation tissue was curetted via the socket. Healing progressed slowly and 5 months post-apicectomy a sinus was present necessitating recurettage of the area. Healing was finally complete 26 weeks after the apicectomy. Histological examination of the socket curettings revealed fibrous and granulation tissue containing abundant closely packed foreign body giant cells, a light patchy lymphocytic infiltrate and occasional neutrophils (Fig. 1). Between the giant cells were numerous homogeneous non-birefringent PASpositive fibres, some with a small central void, identical to Kaltostat fibres (Fig. 2). There was no evidence of any degradation or breakdown of the fibres, bacterial infection or retrograde root filling material.
INTRODUCTION Haemostatic agents are widely used in surgery of the maxillofacial region both to maintain a dry surgical field and to control bleeding from tooth sockets. Kaltostat (Britcair, Aldershot, UK) is a haemostatic gauze of non-woven calcium-sodium alginate fibres initially developed as a wound dressing for superficial wounds1,2 but which has also been used for dental purposes since the late 1940s. Alginate fibres form a viscous hydrophilic gel on contact with blood and release calcium ions which promote platelet activation and coagulation.3 Its low cost, ease of use and effectiveness have resulted in widespread use for apicectomy and post-extraction bleeding despite the fact that few experimental studies have been performed to analyse the biocompatibility of alginatebased haemostatic agents in these situations4x5 Investigations have shown a variety of tissue responses, including foreign body reactions and delayed bone healing but most have considered that alginate fibres do not persist in the tissues for significant amounts of time and are generally adequately tolerated.4,s We report the occurrence of a florid symptomatic foreign body giant cell reaction following an apicectomy in which haemostasis had been obtained by Kaltostat placed 26 weeks earlier. This case demonstrates that alginate fibres may persist in human tissues for much longer periods than have been shown in animal models, and that the resulting reaction may necessitate surgical intervention.
DISCUSSION Early studies using alginate-based material as a haemostatic dressing for extraction sockets produced
Case report A 62-year-old female patient had an apicectomy cavity lightly and partially packed with Kaltostat following removal of an apical granuloma on an upper lateral incisor and placement of an amalgam retrograde root filling. The semilunar incision was closed normally and healing was initially uneventful but 1 month later swelling in the buccal
Fig. 1 - PhotomicrographshowingKaltostat fibreswhichappear aspale greyhomogeneousspaceslying in granulationtissue containingnumerousforeign body giant cells.Haematoxylinand eosin, magnification x 310. 178
Symptomatic
foreign
body
reaction
to haemostatic
alginate
119
of these agents.’ We would agree with Matthew et aL5 that this and other haemostatic materials should be removed from sockets soon after haemostasis and also suggest that they should be avoided in closed bony cavities. References
Fig. 2 - Photomicrograph showing Kaltostat as variably sized fibres sometimes with a small central lumen and pointed ends. The outer layer is more strongly PAS-positive. Periodic acid Schiff, magnification x 3 10.
favourable results6 This was despite the fact that the alginate, which was considered to be resorbable, was left in the sockets. More recently poor healing of third molar flaps was reported7 after large quantities of Kaltostat were inserted in the sockets and this was ascribed to the marked expansion which occurs when alginate absorbs fluid. Few studies have been carried out to determine the biocompatibility of alginatebased haemostatic agents in tooth sockets. Mat&on et a1.4 studied the biocompatibility of another alginate-based haemostatic agent Astroplast in bony cavities within rabbit mandibles, a situation analogous to an apicectomy cavity. They found that this material provoked an adverse foreign body reaction which was more severe than that produced by bone wax and which persisted for at least 8 weeks. They also observed a marked delay in bone healing but considered that the tissue reaction was acceptable in view of the clinical advantages. Matthew et al5 recently evaluated the tissue response to Kaltostat up to 24 weeks in healing tooth sockets in dogs. They demonstrated delayed wound healing in the first 4 weeks associated with a foreign body reaction and also showed that alginate fibres persisted for as long as 12 weeks in the sockets. This report illustrates that alginate fibres left in situ in human tissues are relatively resistant to degradation and may persist for more than 6 months, much longer than the maximum of 12 weeks seen in dogs.5 The resulting foreign body reaction was symptomatic and necessitated curettage on two occasions, a reflection of the difficulty of the subsequent removal
1. Thomas S. Alginates in wound management and dressings. In: Wound management and dressings. 1st ed. London: Pharmaceutical Press, 1990: 43-49. 2. Gensheimer D. A review of calcium alginates. Ostomy Wound Management 1993; 39: 34-8,4333. 3. Blair SD, Blackhouse CM, Harper R, Matthews J, McCollum CN. Comparison of absorbable materials for surgical haemostasis. Br J Surg 1988; 75: 9699971. 4. Mattsson T, Anderssen K, Koendell P-A, Lindskog S. A longitudinal comparative histometric study of the biocompatibility of three local hemostatic agents. Int J Oral Maxillofac Surg 1990; 19: 47-50. 5. Matthew IR, Browne RM, Frame GW, Millar BG. Tissue response to a haemostatic alginate wound dressing in tooth extraction sockets. Br J Oral Maxillofac Surg 1993: 31: 1655169. 6. Rumble JFS. Twenty-five dental cases treated with absorbable aleinate wool. Br Dent J 1949: 86: 203-205. I. Speculand B, Down K, Hunter J, Smith IM. Calcium alginate gauze as a haemostatic dressing in lower third molar surgery. J Dent Res 1990; 69: 1007. 8. Ibarrola JL, Bjorenson JE, Austin BP, Gerstein H. Osseous reactions to three hemostatic agents. J Endodont 1985; 11: 75-83.
The Authors E.W. Odell BDS, FDS, MSc, PhD Lecturer T. Lombardi MD, Dr Med Dent Postdoctoral Research Fellow Department of Oral Medicine and Pathology UMDS Guy’s Hospital St Thomas’ Street London UK P. Oades BDS SHO Department of Oral and Maxillofacial Surgery Oldchurch Hospital Romford Essex UK Correspondence
and requests
for offprints
Dr T. Lombardi is recipient of a grant from Research Foundation (c.a. nr.823A-33423) Paper received 29 July 1993 Accepted 2 September 1993
to Dr E. Ode11 the Swiss National
SUIMMARY. Kaltostat, a haemostatic wound dressing made from non-woven sodium calcium alginate fibres is becoming more frequently and widely used by practitioners. We report a florid foreign body giant cell reaction elicited by Kaltostat which had been used to obtain haemostasis in an apicectomy cavity on an upper lateral incisor approximately 7 months earlier. The case demonstrates that alginate fibres left in situ may elicit a long-lasting and symptomatic adverse foreign body reaction. This material should be reserved for problematic haemorrhage and be removed from the tooth socket soon after haemostasis.
sulcus prompted treatment with Augmentin. Two months post-apicectomy a granulomatous swelling was apparent in the buccal sulcus, the tooth was extracted and granulation tissue was curetted via the socket. Healing progressed slowly and 5 months post-apicectomy a sinus was present necessitating recurettage of the area. Healing was finally complete 26 weeks after the apicectomy. Histological examination of the socket curettings revealed fibrous and granulation tissue containing abundant closely packed foreign body giant cells, a light patchy lymphocytic infiltrate and occasional neutrophils (Fig. 1). Between the giant cells were numerous homogeneous non-birefringent PASpositive fibres, some with a small central void, identical to Kaltostat fibres (Fig. 2). There was no evidence of any degradation or breakdown of the fibres, bacterial infection or retrograde root filling material.
INTRODUCTION Haemostatic agents are widely used in surgery of the maxillofacial region both to maintain a dry surgical field and to control bleeding from tooth sockets. Kaltostat (Britcair, Aldershot, UK) is a haemostatic gauze of non-woven calcium-sodium alginate fibres initially developed as a wound dressing for superficial wounds1,2 but which has also been used for dental purposes since the late 1940s. Alginate fibres form a viscous hydrophilic gel on contact with blood and release calcium ions which promote platelet activation and coagulation.3 Its low cost, ease of use and effectiveness have resulted in widespread use for apicectomy and post-extraction bleeding despite the fact that few experimental studies have been performed to analyse the biocompatibility of alginatebased haemostatic agents in these situations4x5 Investigations have shown a variety of tissue responses, including foreign body reactions and delayed bone healing but most have considered that alginate fibres do not persist in the tissues for significant amounts of time and are generally adequately tolerated.4,s We report the occurrence of a florid symptomatic foreign body giant cell reaction following an apicectomy in which haemostasis had been obtained by Kaltostat placed 26 weeks earlier. This case demonstrates that alginate fibres may persist in human tissues for much longer periods than have been shown in animal models, and that the resulting reaction may necessitate surgical intervention.
DISCUSSION Early studies using alginate-based material as a haemostatic dressing for extraction sockets produced
Case report A 62-year-old female patient had an apicectomy cavity lightly and partially packed with Kaltostat following removal of an apical granuloma on an upper lateral incisor and placement of an amalgam retrograde root filling. The semilunar incision was closed normally and healing was initially uneventful but 1 month later swelling in the buccal
Fig. 1 - PhotomicrographshowingKaltostat fibreswhichappear aspale greyhomogeneousspaceslying in granulationtissue containingnumerousforeign body giant cells.Haematoxylinand eosin, magnification x 310. 178
Symptomatic
foreign
body
reaction
to haemostatic
alginate
119
of these agents.’ We would agree with Matthew et aL5 that this and other haemostatic materials should be removed from sockets soon after haemostasis and also suggest that they should be avoided in closed bony cavities. References
Fig. 2 - Photomicrograph showing Kaltostat as variably sized fibres sometimes with a small central lumen and pointed ends. The outer layer is more strongly PAS-positive. Periodic acid Schiff, magnification x 3 10.
favourable results6 This was despite the fact that the alginate, which was considered to be resorbable, was left in the sockets. More recently poor healing of third molar flaps was reported7 after large quantities of Kaltostat were inserted in the sockets and this was ascribed to the marked expansion which occurs when alginate absorbs fluid. Few studies have been carried out to determine the biocompatibility of alginatebased haemostatic agents in tooth sockets. Mat&on et a1.4 studied the biocompatibility of another alginate-based haemostatic agent Astroplast in bony cavities within rabbit mandibles, a situation analogous to an apicectomy cavity. They found that this material provoked an adverse foreign body reaction which was more severe than that produced by bone wax and which persisted for at least 8 weeks. They also observed a marked delay in bone healing but considered that the tissue reaction was acceptable in view of the clinical advantages. Matthew et al5 recently evaluated the tissue response to Kaltostat up to 24 weeks in healing tooth sockets in dogs. They demonstrated delayed wound healing in the first 4 weeks associated with a foreign body reaction and also showed that alginate fibres persisted for as long as 12 weeks in the sockets. This report illustrates that alginate fibres left in situ in human tissues are relatively resistant to degradation and may persist for more than 6 months, much longer than the maximum of 12 weeks seen in dogs.5 The resulting foreign body reaction was symptomatic and necessitated curettage on two occasions, a reflection of the difficulty of the subsequent removal
1. Thomas S. Alginates in wound management and dressings. In: Wound management and dressings. 1st ed. London: Pharmaceutical Press, 1990: 43-49. 2. Gensheimer D. A review of calcium alginates. Ostomy Wound Management 1993; 39: 34-8,4333. 3. Blair SD, Blackhouse CM, Harper R, Matthews J, McCollum CN. Comparison of absorbable materials for surgical haemostasis. Br J Surg 1988; 75: 9699971. 4. Mattsson T, Anderssen K, Koendell P-A, Lindskog S. A longitudinal comparative histometric study of the biocompatibility of three local hemostatic agents. Int J Oral Maxillofac Surg 1990; 19: 47-50. 5. Matthew IR, Browne RM, Frame GW, Millar BG. Tissue response to a haemostatic alginate wound dressing in tooth extraction sockets. Br J Oral Maxillofac Surg 1993: 31: 1655169. 6. Rumble JFS. Twenty-five dental cases treated with absorbable aleinate wool. Br Dent J 1949: 86: 203-205. I. Speculand B, Down K, Hunter J, Smith IM. Calcium alginate gauze as a haemostatic dressing in lower third molar surgery. J Dent Res 1990; 69: 1007. 8. Ibarrola JL, Bjorenson JE, Austin BP, Gerstein H. Osseous reactions to three hemostatic agents. J Endodont 1985; 11: 75-83.
The Authors E.W. Odell BDS, FDS, MSc, PhD Lecturer T. Lombardi MD, Dr Med Dent Postdoctoral Research Fellow Department of Oral Medicine and Pathology UMDS Guy’s Hospital St Thomas’ Street London UK P. Oades BDS SHO Department of Oral and Maxillofacial Surgery Oldchurch Hospital Romford Essex UK Correspondence
and requests
for offprints
Dr T. Lombardi is recipient of a grant from Research Foundation (c.a. nr.823A-33423) Paper received 29 July 1993 Accepted 2 September 1993
to Dr E. Ode11 the Swiss National