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Review Article

Clinical applications of ferric sulfate in dentistry:

A narrative review
Madhuri Bandi, Sreekanth Kumar Mallineni, Sivakumar Nuvvula
Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Abstract
Ferric sulfate (FS) has been commonly used as a local hemostatic agent for more than three decades in dentistry. Even though
the hemostatic mechanism of FS is questioned, it seems that agglutination of blood proteins occurs due to the reaction of blood
with ferric and sulfate ions in acidic pH. FS has gained widespread importance as a pulpotomy medicament in contemporary
dentistry; nevertheless, it has several applications in different fields of dentistry which was paid little attention. Hence, the
purpose of this paper is to review the various applications of FS in dentistry, along with restorative dentistry and endodontics.
Keywords: Applications; dentistry; ferric sulfate; hemostasis

INTRODUCTION injurious to the soft, as well as hard tissues, causing

subsequent staining of the teeth due to its high
Ferric sulfate or FS [Fe2(SO4)3] is a sulfate of trivalent iron. acidity (pH <1).[4,7] The postoperative complications
It is yellow in color with a rhombic crystalline salt and is associated with the soft tissues are delayed
soluble in water at room temperature. It is produced on a reepithelialization and dyspigmentation.[8,9] It also
large scale by the reaction of sulfuric acid, a hot solution causes reactive and degenerative changes.[1,10] Armstrong
of ferrous sulfate, with an oxidizing agent. It was first et  al.[9] observed inflammation, higher incidence of
introduced in the field of dermatology as Monsel’s solution wound infection, and delayed reepithelialization rate in
in 1856.[1] In dentistry, 15%–20% FS is used as an astringent the punch biopsy wounds treated by Monsel’s solution
and styptic.[2,3] Hemostatic action of FS is due to the compared to collagen matrix at 4 weeks.
agglutination of blood proteins resulting from the reaction
of blood with ferric and sulfate ions in acidic pH.[4] The Ferric sulfate [Fe2(SO4)3]
agglutinated proteins form plugs that occlude the capillary As a 15.5% solution, FS is a coagulative and hemostatic
orifices.[5] agent which forms ferric ion‑protein complex on contact
with blood. It seals the damaged vessels mechanically,
FS is available in two chemical forms. thus producing hemostasis, and the capillary orifices are
occluded by the agglutinated protein complex, which
Ferric subsulfate [Fe4(OH)2(SO4)5] (Monsel’s prevents blood clot formation.[1] It causes a local and
solution) reversible inflammatory response to the oral soft tissues.[11]
Monsel’s solution, 20% FS, is used as an effective The recommended application time is 1–3 min and should
styptic agent in skin and mucosal biopsies.[1,4,6] be placed directly against the damaged tissue due to its
However, the ferric and ferrous salts are corrosive and quick action. Solutions of FS above 15% are highly acidic and
may cause considerable tissue irritation and postoperative
Address for correspondence: root sensitivity.
Dr. Sivakumar Nuvvula, Department of Paedodontics and
Preventive Dentistry, Narayana Dental College and Hospital, FS is available commercially with different
Nellore, Andhra Pradesh, India. E‑mail: [email protected] names [Table 1].[2,12‑15]
Date of submission : 20.07.2016
Review completed : 22.11.2016 This is an open access article distributed under the terms of the Creative
Date of acceptance : 23.10.2017 Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the work non‑commercially,
Access this article online as long as the author is credited and the new creations are licensed under
Quick Response Code: the identical terms.
Website:
www.jcd.org.in For reprints contact: [email protected]

How to cite this article: Bandi M, Mallineni SK, Nuvvula S.

DOI: Clinical applications of ferric sulfate in dentistry: A narrative
10.4103/JCD.JCD_259_16
review. J Conserv Dent 2017;20:278-81.

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Bandi, et al.: Clinical applications of ferric sulfate in dentistry

Table 1: Commercial forms of ferric sulfate available mutans, Streptococcus sobrinus, and Aggregatibacter
and their concentration actinomycetemcomitans under in vitro condition.[20] This
Commercial form Concentration of ferric might be due to its acidic pH[4] and cytotoxicity.[5] In
sulfate (%) addition, the occlusion of capillary orifices by agglutinated
ViscoStat® (Ultradent products, Inc, 20 proteins prevents the ingress of bacteria.[20]
South Jordan, UT)[2]
Astringedent® (Ultradent products, Inc., 15.5
Salt Lake City, UT)[12‑14] During restorative procedures
Astringedent® X (Ultradent products, Inc, 12.7 FS in a concentration of 15.5%–20%[21] is one of the most
South Jordan, UT) common chemical hemostatic reagents used in the
Stasis® (Belport Co, Camarillo, CA, 21
USA)[15] restorative dentistry.[22‑24] It is chemically impregnated into
retraction cords in chemomechanical gingival retraction
technique in which FS is used in 15%–25% concentration
APPLICATIONS OF FERRIC SULFATE IN for 3–10 min[24] and offers greater sulcus displacement due
DENTISTRY to combined physical and chemical effect.[21] Nevertheless,
high acidity of gingival retraction fluids and the high
Pulpotomy medicament affinity of ferric ions for hard tooth structures results in the
FS has been commonly used as a pulpotomy medicament interaction with bacterial byproducts and precipitation of
to control pulpal bleeding in vital pulp therapy since insoluble ferric sulfide in the porous demineralized dentin.
three decades. It induces hemostasis by forming a sealing This is the reason for internal discoloration of the dentin.
membrane at the damaged vessels of pulpal tissue by Conrad and Holtan[25] observed that use of FS gingival
agglutinating the blood proteins with ferric and sulfate retraction fluid in combination with translucent porcelain
ions.[12] restorations resulted in black internal discoloration of the
dentin under porcelain crowns.
The nonaldehyde form of FS is most preferred as a
pulpotomy agent due to its mechanism of controlling Dentinal exposure to such highly acidic solutions of
hemorrhage, believed to be associated with physiological FS (pH range of 0.7–2.0), for 30 s, results in rapid removal
clot formation. This might minimize the chances of of superficial smear layer and peritubular dentin was
inflammation and internal resorption when placed on the also lost after prolonged exposure.[26] Furthermore,
amputated pulp tissue for 5 min.[16,17] removal of smear layer by hemostatic agents has been
suggested to negatively affect the bonding mechanism
The most important form of FS is minimal devitalization of self‑etching adhesive,[25,27] which may further promote
and preservation of the pulp tissue.[13] The metal‑protein marginal microleakage and discoloration.[28] Hence, cavity
clot at the surface of the amputated pulp stumps may disinfection‑associated resin composite restorations is
probably act as a barrier to the irritative components of the material specific.[29] Cohesive failures were observed in
sub‑base and functions exclusively in a passive manner.[18] primary dentin bonded with self‑etch adhesive systems
FS showed superior quality of minimizing inflammation after application of FS.[30] Ebrahimi et  al.[31] observed
and internal resorption compared to calcium hydroxide that dentin surfaces contaminated with ViscoStat® for
because of physiological clot formation by the agglutinated 60 s before applying adhesives showed reduced shear
proteins.[5,16] bond strength of adhesive to dentin. Most of the failures
observed were adhesive.
Landau and Johnsen[19] reported the application of FS as
a pulpotomy medicament in monkey teeth. Fei et al.[12] To achieve better outcomes during impression making
published the first human clinical trial using FS with 100% or application of bonding agents, the hemostatic agents
clinical success, compared to formocresol (77%) with applied before or during etching should be rinsed off
1‑year follow‑up. Similarly, Fuks et  al.[13] reported a study properly to create a dentin smear layer. However, rinsing
employing FS showing high radiographic success rate of alone cannot eliminate surfaces contamination and thus
74.5%. the remnant FS interfered with diffusion of adhesive in
dentinal tubules.[31,32] Because of the weak acidity of the
Antibacterial agent primer in self‑etch adhesives, they could not dissolve the
FS not only exhibited hemostatic action but also has contamination by ViscoStat®;[33] hence, it is impossible to
antimicrobial activity. Antibacterial efficacy of FS is penetrate deeper into dentin.[32] The suggested mechanism
similar to 0.2% chlorhexidine digluconate but better than was that hemostatic agent causes derangement in bonding
Ankaferd blood stopper® on oral microorganisms such procedure because of dentinal tubules obturation and
as Staphylococcus  aureus, Enterococcus faecalis, Candida dentinal surface was demineralized in different values.[28]
albicans, Candida albicans, Porphyromonas gingivalis, It is preferably recommended that FS should be used with
Lactobacillus acidophilus, Lactobacillus salivarius, Streptococcus etch‑and‑rinse adhesive systems only.[24] Use of self‑etching

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Bandi, et al.: Clinical applications of ferric sulfate in dentistry

adhesive significantly lowered the bond strength of dentin Table 2: Merits and demerits of ferric sulphate
contaminated with the hemostatic agent compared to Merits Demerits
normal dentin. Kuphasuck et al.[28] found that the hemostatic Adequate hemostasis Tissue discoloration
agent does not have any effect on dentin bond strength of Reversible inflammatory Acidic taste
response in oral soft tissues Risk of sulcus contamination
the total‑etching adhesive.
Cost effective and less time Inhibits set of polyvinyl siloxane and
consuming polyether Impressions
For gingival displacement in prosthodontics Stops bleeding in seconds, Reduces the bond strength of
Fischer (1987) first used FS as a coagulative and hemostatic saving chair time adhesives
Decrease costly impression Causes microleakage under
agent during crown and bridge impressions.[4] It is used for remakes restorations
tissue displacement and it would be maintained for at least Effective and easy to use for
30 min.[4,14] Nonetheless, its use for gingival displacement control of bleeding, tissue
management, and pulpotomies
in implantology is not clearly understood as a result of its
ability to interrupt the setting reaction of polyether and
polyvinyl siloxane impression materials.[25,34] Owing to its An intense inflammatory response including foreign
iron content, FS stains the gingival tissue yellow‑brown body reaction and delayed osseous healing was
to black color for a few days after its application. It has documented histologically after 18 and 46 days, when
been shown to interfere with surface details of impression FS was left in situ for maximum exposure.[5] However,
materials, as well as discolor dentin by precipitating when adequately curetted and irrigated from the
ferric sulfide in an anaerobic environment.[25] Irrigation surgical site before closure, FS neither causes persistent
with water for at least 10 s eliminates the staining and inflammation nor delays osseous repair.[41] Adequate
discoloration effect of ferric compounds on gingiva and hemostasis can be achieved following the application
esthetic restorations. Furthermore, two studies reported of 20% FS (Viscostat®) for 5 s during the endodontic
that chlorhexidine gluconate helps achieve hemostasis surgeries such as root‑end resection, root‑end
in a shorter time due to its surfactant effect.[34,35] Shaw preparation, and root‑end filling.[2]
et  al.[36] observed reversible damage to the connective
tissue adjacent to the sulcular gingiva after application Merits and demerits
of FS. Nevertheless, when used within the gingival sulcus FS has several merits and a few demerits, which are shown
for <10 min, they cause minimal tissue damage.[21‑23] in Table 2.[4,8,9,12,25,28,31]

Management of postextraction hemorrhage Toxicity

FS is not widely used to control postextraction hemorrhage; As FS is highly biocompatible, no concerns about toxic or
however, it may offer assistance with mucosal tears or harmful effects have been reported in the dental literature
till date.[1,11,14]
uncontrolled postextraction hemorrhage in gingival
tissues.[37]
CONCLUSION
As hemostatic agent used in periradicular and
The FS has been equally beneficial as a local hemostatic
endodontic surgery
agent compared to other chemical hemostatic agents. FS
Control of bleeding during any surgical procedure is
is a commonly used astringent solution (15.5%) that has
imperative and can be achieved by practical and effective
multiple uses in dentistry. It is widely used in dentistry
systemic or topical approaches. Epinephrine pellets used
as hemostatic agent. The use in restorative dentistry and
either alone or in combination with a FS‑soaked pellet
endodontics, pediatric dentistry, prosthodontics, and oral
are effective topical hemostats when applied in the bony
surgery has not been clearly documented. Hence, further
crypt under light pressure.[38] Aluminum chloride alone or
research is needed regarding the effective application of FS
in combination with FS (Stasis®) appeared to be the most in the various fields of the dentistry.
efficient hemostatic agent to control the bleeding during
periapical surgery.[15,39]
Financial support and sponsorship
Nil.
Vickers et al.[2] reported that in one-third of the cases where
FS was used some oozing of blood occurred in the bony
Conflicts of interest
crypt and suction was required to maintain the dryness
There are no conflicts of interest.
of the root-end preparation. However, FS was found to
be less effective than aluminum chloride in controlling
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