Int. J. Oral Surg.

1984: 13: 406-410

(Key words: SlIrgery, oral; hemosraries; gelmin sponge; oxidized, regenerated cel/lI[ose)

A comparison between 2 absorbable

hemostatic agents: gelatin sponge
(Spongostan®) and oxidized regenerated
cellulose (Surgicel®)
JENS K0LSEN PETERSEN, JENS KROGSGAARD, KAREN MARIE NIELSEN AND
ERLING B. N0RGAARD

Department of Oral and Maxillo/acial Surgery, The Royal Dental College, Aarhus, Denmark

ABSTRACT - Oxidized, regenerated cellulose (Surgicel®) and gelatin sponge

(Spongostanrll» were packed in the sockets of upper third molars after
surgical removal in 10 and 11 patients, respectively. The other side in each
patient functioned as control. The study revealed that more pain was
apparent on the sides, where the materials were packed, especially in the
gelatin sponge group, although more patients preferred this material to
oxidized, regenerated cellulose. The 2 materials did not differ with regard
to swelling or bleeding. No complications were encountered. Use of these
materials in post-extraction sockets did not seem to impair closure of the
wound as estimated by epithelial cover of the sockets, although healing was
slightly delayed in the gelatin group.

(Received/or publication 20 January 1983, accepted 2 February 1984)

Post-operative bleeding in oral surgery is a
well-known but always troublesome compli-
cation. In some cases, simple compression at
the site of hemorrhage will suffice in 0 btain-
ing hemostasis. In other cases, more time-
consuming procedures are necessary. The
use of hemostatic agents is popular, especi-
ally the absorbable ones, which can be
packed into the alveolar socket or left in the
soft tissues 2 - s . Different materials have been
tried, and the interest today is focused upon
gelatin sponge, oxidized cellulose, and
oxidized regenerated cellulose 6 - 8 . They all
have in common that they will be absorbed
after some time, when implanted into living
tissues 2 • 3 • 1O • Most reports on the tissue reac-
tion have shown some degree of inflamma-
tion and foreign body reaction during the
first 4-5 weeks, but thereafter no trace of the
absorbable hemostatic agent is found 1 •9 - 11 .
A few reports, however, mention that some
patients seem to experience more discomfort
and pain after packing an extraction
alveolus with an absorbable agent 6 •1l . As
this finding, too, has been our clinical im-
pression, we decided to undertake a study in
order to compare the effect of gelatin
sponge (Spongostan®) and oxidized regen-
 SPONGOSTANI]ll AND SURGICEL@
erated cellulose (Surgicel®) on pain, bleed-
ing, swelling, and healing after surgical re-
moval or extraction of upper third molars.
Material and methods
21 patients, all dental students (16 female, average
age 21.4 years, and 5 male, average age 22.4 years)
were scheduled for extraction or surgical removal
of 2 identically positioned upper third molars in
the same sitting and by the same operator. Fol-
lowing randomization, the test material, i.e. gela-
tin sponge or oxidized regenerated cellulose, was
placed in one socket according to the instructions
given by the manufacturer, while the contralateral
socket functioned as control. The side of the test
material was switched every other time in order to
eliminate bias due to side preference by the
surgeon. The test material was packed lightly in a
dry condition, using one piece of standard dental
dimensions, Le., for Spongostan®, a cube measur-
ing 10 x 10 x 10 mm, and for Surgicell]ll, a mesh
12 x 50 mm.
Spongostan®*
This is an absorbable material made on a gelatin
basis, I.e., collagen, which has been treated with
formaldehyde. It is dispensed in a sponge-form of
different sizes, being quite tough and porous. The
latter quality enables the material to absorb blood
45 times its own weight. The hemostatic effect is
stated to be due to the uniform porosity of the
gelatin sponge, making the platelets adhere to the
network and break down, thus leading to the
release of thrombokinase. The pH of Spongostan
is neutral, so it can be moistened with thrombin
or antibiotic solutions without destroying them.
Surgicel®t
This material is oxidized regenerated cellulose,
made from alpha-cellulose. The basic element is
polyanhydroglucuronic acid, spun into threads
and woven in a gauze-like material. The pH is 3,
which will destroy e.g., thrombin ifthe two agents
are mixed. Surgicel will swell in contact with
blood, adhere to wound edges and vessels. It
actually forms an artificial coagulum and secures
hemostasis in 2-3 min s.9 •
'" Manufactured by Ferrosan, Copenhagen.
t Manufactured by Johnson & Johnson.
407
When the 2 products are implanted into the
organism, they are completely absorbed in 3-4
weeks without causing notable scar formation1. 6 ,
First, there will be a moderate leukocytic, later a
macrophage and giant cell reaction followed by
invasion of connective tissue into the hemostatic
material. In the event of a more pronounced
inflammatory reaction, in operations on infected
tissue, the absorption of the gelatin sponge will be
enhanced due to the presence of proteolytic
enzymes.
In all cases, 4-0 silk sutures were placed on each
side as one cross or X-suture, in order to retain
the material in place. For local analgesia, 1.8 m1
of 2% Xylocain with adrenaline 1 : 80,000 was
injected on each side, In case of impaction, the
tooth was removed throuh a straight line incision.
Only patients with identically positioned upper
third molars entered the study. The degree of
surgical trauma was registered after the operation
as I: slight trauma, II: moderate trauma, and III:
severe trauma. Grouping in degrees of surgical
trauma depended on the actual duration of oper-
ation and bone removal, if any. Postoperatively,
the patients were given 20 tablets of paracetamol
0.5 g.to take in case of pain, 2 tablets up to 4 times
daily.
The patients were handed a take-home card
upon which to register bleeding, pain, and swel-
ling postoperatively. On the day of operation,
registration took place 1 h, 2, 3, 6, and 9 h
following the procedure. On each ofthe following
7 postoperative days, the patients were asked to
record the mentioned parameters at 7 a.m. and at
7 p.m.
The parameters were defined as follows:
bleeding: 0: no bleeding
1: oozing
2: severe bleeding
pain: 0: no pain
1: slight pain, not requiring analgesic
2: severe pain, requiring analgesic.
swelling: 0: no swelling
1: slight swelling intra- or extra-
orally or hematoma
2: severe swelling intra- or extra-
orally or hematoma
The patients were checked by one of the investiga-
tors on days 7, 14, 21, and 28 postoperatively,
with regard to bleeding, pain, swelling, hema-
toma, infection, alveoli tis sicca ("dry socket"),
epithelial cover of the extraction site, and finally
the patients' preference between test side and
control side. With regard to these findings, only a
408 PETERSEN ET AL.

Table I. Distribution of patients in groups of surgical trauma and average duration of operation time in
minutes: I: slight operative trauma; II: moderate degree of operative trauma; III: severe degree of
operative trauma

Test side Control side

Group Group Group Group Group Group

Degree of trauma I II III I II III

Surgicel@
no. of patients 6 4 o 6 4 o
average duration of operation (min) 2.8 2.8
Spongostan®
no. of patients 5 5 5 5

average duration of operation (min) 4.3 3.9

yes or no score was recorded. The investigators lysis of paired comparisons between test side
controlling the patients postoperatively were not and control side in each patient revealed a
aware of the location of the test material. The statistically significant higher pain score in
Student t-test for paired comparisons was used
for evaluation of the results. the gelatin group (0.02 <p < 0.05) than in
the cellulose group (O.05<p<0.1), Table 3.
Averaging the total bleeding scores for the
patients in the two groups demonstrated
Results slightly less bleeding in the cellulose group,
Analysis of degree of surgical trauma but no difference between the two sides in
showed no difference between the gelatin the gelatin group (Table 2). Analysis of
sponge and the oxidized regenerated cellu- paired comparisons between test side and
lose groups or between test sides and control control side in each patient showed no
sides (Table 1). statistically significant difference between
Averaging the total swelling scores for the the two sides in the two groups (Table 3).
patients in the gelatin group and in the With regard to preference between test
cellulose group showed that there was side and control side, there was no dif-
slightly less swelling in the gelatin group ference in choice selection for the gelatin
than in the cellulose group (Table 2). Analy-
sis of paired comparisons between test side
and control side in each patient showed no Table 2. Average of total parameter scores in the
statistically significant difference in swelling Surgicel® and Spongostan® groups (vertical
between the two sides in the two groups, analysis)
although the t-value was in favor of the Surgicel® Spongostan@
gelatin group (Table 3). test control test control
Averaging the total pain scores for the side side side side
patients in the gelatin and the cellulose
groups showed that there was considerably swelling 6.0 5.7 3.9 5.5
pain 7.2 2.9 7.7 3.5
more pain on the test side than on the bleeding 1.4 2.5 3.1 3.6
coptrol side for both agents (Table 2). Ana-
 SPONGOSTAN@ AND SURGICEL'1l
Table 3. Paired comparisons between test side and control side in each patient (horisontal analysis)
Surgicel$
(n= 10, d.f. =9)
swelling 1=0.167, p>50
pain 1=1.91, 0.05<p<0.1
bleeding 1=1.95, 0.05<p<0.1
group, but more patients in the cellulose
group preferred the control side compared
to the test side (Table 4). However, a X2
analysis demonstrated no statistically sig-
nificant difference (x= 3.2,f= 1, p> 0.05).
Epithelial cover of the socket. Control of
the extraction sites on days 7, 14,21, and 28
revealed that most of the sockets were
covered by epithelium on day 14, indepen-
dent of test side or control side. However, it
is, noted that more patients in the gelatin
group had a more protacted course of heal-
ing than in the cellulose group. (Table 5).
Discussion
The experimental material is rather small,
but as each patient functioned as his own
control, and as the two experimental groups
are comparable, some careful observations
can be made. It should, however, be pointed
out that bias might exist, as the probands
being dental students would tend to focus
on the test side.
In this investigation, both products dis-
Table 4. Patient preference of operated side
(cross-over analysis): test side: alveolar socket
packed with test material; control side: no
packing
No. of patients
test control no pre-
side side ference total
Surgicel$ 1 7 2 10
Spongostall<!l> 5 4 2 11
409
Spongostanll\l
(n= 11, d.f. = 10)
1=1.39, 0.1<p<0.2
1=2.38, 0.02<p<O.05
1=0.276, p> 50
played more pain on the test side than on
the control side. There was a higher pain
score difference between test and control
sides in the gelatin group than in the cellu-
lose group. The reason for this finding is not
clear, as more patients in the gelatin group
actually preferred the test side to the control
side. If pain alone had been a decisive
factor, the preference should certainly have
been reversed. Perhaps the swelling factor is
more important in making a choice of pre-
ference, as fewer patients in the gelatin
group apparently experienced swelling. This
difference, however, is not statistically
significant
In other experiments, addition of penicil-
lin or an antiseptic solution has lessened the
pain 9 ,10. The local use of penicillin cannot
be recommended due to the risk of allergy
and development of resistant micro-
organisms.
As far as healing is concerned, neither
material seems to impair the cover of the
alveolus with ingrowing epithelium, at least
not to any clinical significance, although a
slight delay in the final alveolar coverage is
noted in the gelatin group in some patients.
A few patients in the gelatin group com-
plained of a sweet, almost unpleasant taste
from the sockets.
Registration of bleeding post-operatively
revealed slightly less hemorrhage in the
cellulose group compaired to the gelatin
group, but the difference was not statisti-
cally significant. This parameter does not
contribute much, as both materials are in-
dicated for severe, profuse bleeding from the
410 PETERSEN ET AL.

Table 5. Epithelial cover of extraction sites at

post-operative control on days 7, 14, 21 and 28
References
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Surgicel<l!l Spongostan® 2. GEORGIADE, N., MITCHELL, T., LEMLER, J. &
test control test control HEID, H.: Use of a new improved hemostatic
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liikar Tidskr. 1948: 41: 287-289.
Conclusions 9. SILVERMANN, L. M.: An investigation of gela-
The use of oxidized, regenerated cellulose tin sponge with thrombin and penicillin in the
(Surgicel®) and gelatin sponge (Spongos- treatment of oral surgical wounds. Oral Surg.
tan®) in normal extraction sockets of upper 1949: 2: 260-288.
to. TROTTER, P.: A new post-operative dental
third molars without profuse bleeding seems dressing. Lancet ]956: I: 1042-1043.
to give rise to more pain in the sockets which 11. TUCKER, H. A. (ed.): Absorbable gelatin
are packed with these materials compared to sponge (Gelfoam). Charles C. Thomas,
control sides without packing. This dif- Springfields, Ill. J 965.
ference is statistically significant for gelatin
sponge. Healing of the sockets, estimated as
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not seem to be impaired by the two
materials to any clinical extent, although it
Address:
is slightly delayed in the gelatin group.
Except for the difference in pain score, there J. Kolsen Petersen
Department of Oral and Maxillofadal Surgery
are no significant differences between the Royal Dental College
two agents or between test side and control 8000 Arhus C
side. Denmark