In vitro kinetic study of absorbency of retraction cords

Ferenc Csempesz, DMD,a János Vág, DMD,b and Árpád Fazekas, DMD, PhD, DScc
Faculty of Dentistry, Semmelweis University, Budapest, Hungary
Statement of problem. The soaking time required for liquid uptake by retraction cords is a crucial factor in
the successful gingival retraction procedure.
Purpose. The aim of this investigation was to determine the optimal soaking time for 3 retraction cords of
different thickness to ensure adequate uptake of the hemostatic solution.
Material and methods. Braided ULTRAPAC retraction cords of 3 different thicknesses (No. 00, No. 0, and
No. 1) with identical lengths (35 mm) were used. The capability of the cords to absorb liquids was measured by
a gravimetric method. Different sulcus retraction solutions (epinephrine, aluminum chloride, and ferric sulfate)
were tested, with physiological saline solution used as the control. The cords were soaked for various time
intervals (2 seconds; 1, 5, and 60 minutes; and 24 hours) in the medicament solutions at room temperature.
Immediately before immersion, air inclusions that may have inhibited the inner moistening of the cords were
manually pressed out. In each of the 4 treatment groups, 75 pieces of cord were tested by determining the grams
of fluid absorbed by grams of dry cord (gram/gram). Before the cord was weighed, excess fluid accumulating on
the outer surface of the cord was removed by filter paper saturated in the corresponding test solution. The data
were analyzed by F test analysis, and P⬍.05 was regarded as significant.
Results. In each group, regardless of the cord type (No. 00, No. 0, or No. 1) or medicament solutions tested,
the amount of fluid absorbed increased with the soaking time, but to different extents. A logarithmic relationship
in a linear plot between the amount of fluid absorbed and the soaking time was demonstrated. The relationship
established offered an exact determination of both the rate and the saturation level of liquid uptake. The rate of
liquid uptake calculated from the saturation equations exhibited significant correlation with the cord thickness
(P⬍.05). The saturation levels of the solutions did not show correlation with the cord thickness (P⬎.30).
Conclusion. Within the limitations of this study, the results indicated that 20 minutes of soaking time was
necessary for saturation of the cords before use, provided that air trapped within the cords was removed. In
addition to the soaking time, the saturation of the cords with the solutions largely depended on the wetting of the
cords. (J Prosthet Dent 2003;89:45-9.)

CLINICAL IMPLICATIONS
This in vitro study suggests that prior to retraction procedures, (1) an optimal soaking time
should be ensured for the retraction cord immersed in the preferred medicament solution and (2)
care should be taken to remove all air inclusions from the cord.

T he vertical and horizontal expansion of the gingival

sulcus is a generally recognized prerequisite for taking
accurate dental impressions. This technique becomes
especially important when the level of the crown margin
is in or close to the crevice because of caries, esthetic
considerations, or retention purposes. In addition to
surgical techniques, mechanical and mechanical-chemi-
cal gingival retraction methods have been described.1,2
Of the known gingival retraction techniques, that in
which the retraction cord is immersed in or pre-impreg-
nated with hemostatic solutions is the most widely used
and causes the least tissue injury. As a result of short-
term treatment, the gingiva remains unaltered, whereas
This work was supported by the National Science Foundation (OTKA
T-023601) and the Ministry of Health (ETT-30/2000).
a
PhD student, Department of Conservative Dentistry.
b
PhD student, Department of Conservative Dentistry.
c
Professor and Director, Department of Conservative Dentistry.
a contact time beyond 30 minutes produces injury to the
sulcular epithelium, with regeneration occurring after
more than 10 days.3-5 A basic requirement is that the
medicaments be effective and do not cause irreversible
tissue injury or harmful systemic side effects.
In addition to the expansive action of the sulcus, the
medicament-impregnated retraction cords should have
a proper hemostatic action to minimize gingival hemor-
rhage resulting from accidental tissue injury associated
with the preparation. The cords should also inhibit the
formation of the crevicular fluid or absorb it if already
present.
Many different medicaments have been used for im-
pregnation of the retraction cords. These include alumi-
num chloride (AlCl3), aluminum sulfate, epinephrine,
and zinc chloride, among others.4 It has been demon-
strated that retraction cords with no medicaments were
less suitable for hemostatic purposes than those impreg-

JANUARY 2003 THE JOURNAL OF PROSTHETIC DENTISTRY 45

THE JOURNAL OF PROSTHETIC DENTISTRY
nated with aluminum sulfate or epinephrine.6 Soaking
the retraction cord in an AlCl3 solution before placing it
in gingival sulci provides hemostasis but does not lessen
the cord’s ability to absorb crevicular fluid.7 Whereas de
Camargo et al8 observed that hemostatic solutions ab-
sorbed by retraction cords did not alter the polymeriza-
tion and accuracy of dental impression materials, other
investigators have found that some retraction cord me-
dicaments (AlCl3, ferric sulfate [Fe2(SO4)3], ferric sub-
sulfate/ferric sulfate) can modify the surface detail re-
production. Therefore careful removal of all traces of
these medicaments before recording the vinyl polysilox-
ane impression has been recommended.9 With the use of
aluminum oxide or aluminum sulfate solutions, no sys-
temic action was observed,5,10 whereas epinephrine elic-
ited systemic responses.11 In retraction cords of differing
materials and diameters with lengths of 2.5 cm, the es-
timated uptake from an epinephrine solution (1 mg/
mL) varied from 0.2 to 1 mg/cord, an amount much
greater than the maximum dose for healthy subjects.3
Kellam et al12 have shown that after 5 to 15 minutes’
contact time, 64% to 94% of the epinephrine content of
the impregnated retraction cords was lost while in the
sulcus.
It is evident that the amount of medicament solution
absorbed by cords during soaking is of importance to
achieve a proper hemostatic action. In addition to the
length, thickness, structure, and moistening properties
of the cord, the amount of medicament absorbed also
depends on the length of soaking time. With a given
cord size, the strengths of the responses in gingival mi-
crocirculation are expected to depend on the amount of
medicament crossing the sulcus epithelium; therefore
standardization of the conditions during the soaking
procedure is critical. Little attention has been paid in the
literature to the kinetics of fluid absorption of retraction
cords. The purpose of this study was to evaluate the time
course of absorption of hemostatic solutions by retrac-
tion cords of various thickness. Determining the optimal
soaking time of retraction cords could help practicing
dentists to perform successful retraction procedures.
MATERIAL AND METHODS
Braided ULTRAPAC retraction cords (No. 00, No.
0, and No. 1; Ultradent Products, South Jordan, Utah)
were used. The cords were cut into pieces of identical
length (35 mm) and incubated for various time intervals
in different test solutions at room temperature. The
amount of the absorbed fluid was determined by
gravimetry with an electronic analytical balance (Mettler
AE-200; Mettler-Toledo AG, Greifensee, Switzerland)
by subtracting the weight of the cord measured before
incubation from the weight value measured at the end of
incubation.
46
CSEMPESZ, VÁG, AND FAZEKAS
The solutions tested as retraction medicaments were
as follows: 0.1% epinephrine (TONOGEN injection
1 mg/mL; Richter Gedeon Rt, Budapest, Hungary),
25% AlCl3 solution, and 15.5% Fe2(SO4)3 solution (Ul-
tradent Products); and physiological saline solution was
used as the control. In each of the 4 treatment groups,
75 pieces of cord were tested. Within each treatment
group, 15 subgroups were constructed with 5 cords to
be tested in each. The time course study included gravi-
metric measurements at 2 seconds; 1, 5, and 60 minutes;
and 24 hours with each type of cord (No. 00, No. 0, and
No. 1).
Conditions for the fluid absorption study were stan-
dardized. Immediately before immersion, air inclusions
that may have inhibited the inner moistening of the
cords were manually pressed out. In earlier pilot exam-
inations, the omission of this step yielded a lower accu-
racy in fluid uptake measurements, and the data were
not reproducible. To characterize the effect of manual
pressing, 2 series of preliminary examinations with 72
tests were performed with and without pressing, respec-
tively. In each test 5 cords were used. The SDs of liquid
absorbency for the pressed cords were significantly lower
than those for the nonpressed specimens. For the 36
tests performed with pressed cords, the SD was 0.0014,
and for the 36 nonpressed cords, the SD was 0.0025.
These results confirmed that this maneuver was neces-
sary to perform adequate and reproducible measure-
ments of liquid uptake.
The excess fluid accumulating on the outer surface of
cords was removed by filter paper saturated in the cor-
responding test solution, and the cord was weighed
promptly. The amount of absorbed fluid was calculated
by subtracting the weight of the cord before incubation
from the weight value measured at termination of the
incubation. This was expressed as gram/gram unit of
cord. Values for fluid uptake of cords of various thick-
ness and incubated in different test solutions were plot-
ted in a linear coordinate system as a function of time,
and the best-fit line was constructed (y ⫽ k ⫹ k⬘ 䡠 log x).
The maximum amount of fluid absorbed by the cords
with each test solution was calculated on the basis of the
Michaelis-Menten equation.13 Accordingly, the recipro-
cal of time was plotted against the reciprocal of grams of
fluid absorbed. The intercept of the best-fit line with the
y-axis gave the reciprocal of the saturation; therefore this
procedure determined the saturation (yt) for a given
cord and medicament solution, respectively. The satura-
tion time (xt) corresponding to saturation (yt) was eval-
uated by using the original plot. The rate of fluid uptake
was obtained from the slope of the original plot
(y ⫽ k ⫹ k⬘ 䡠 log x). Relationships between cord
thickness and saturation and the slope, respectively,
were tested by regression analysis determining the
Spearman r coefficient.
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CSEMPESZ, VÁG, AND FAZEKAS THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Liquid uptake of retraction cord type No. 00 in terms of gram fluid absorbed per gram cord from solutions of various
medicaments as a function of incubation time. Equations of best-fit lines and regression coefficients for various medicaments
tested are as follows (n⫽100): in physiological saline solution (sodium chloride [NaCl]), y ⫽ 1.99 ⫹ 0.94 log x (r⫽0.92,
P⬍.001); in Fe2(SO4)3 solution, y ⫽ 3.39 ⫹ 0.96 log x (r⫽0.90, P⬍.001); in AlCl3 solution, y ⫽ 2.04 ⫹ 1.06 log x (r⫽0.95,
P⬍.001); and in epinephrine solution, y ⫽ 1.7 ⫹ 0.78 log x (r⫽0.86, P⬍.001).

The data were analyzed by F test analysis, and P⬍.05 DISCUSSION

was regarded as significant.
RESULTS
The results of the kinetic investigations obtained for
different cords are presented in Figures 1 through 3.
The absorption capacity of the cords for the 3 medica-
ments and the incubation time corresponding to the
saturation level are illustrated by the curves.
In each group, regardless of the cord type (No. 00,
No. 0, or No. 1) or medicament solution [physiological
saline solution, Fe2(SO4)3, AlCl3, or epinephrine]
tested, a relationship existed between incubation time
and the amount of fluid absorbed. The dynamic of fluid
absorption exhibited a logarithmic relationship in a lin-
ear plot. The equations of the best-fit lines for the vari-
ous medicaments tested are shown in the figure legends.
Calculated maximum amounts of fluid absorbed, ac-
tual amounts of fluid absorbed, and saturation times for
cords of various thickness are presented in Table I. The
saturation levels of the 4 medicament solutions calcu-
lated for 3 cords did not demonstrate a correlation with
cord thickness (r⫽0.33, P⬎.30). On the other hand, the
slopes (k⬘) calculated from the 4 saturation equations
(y ⫽ k ⫹ k⬘ 䡠 log x) for the 3 cords exhibited significant
correlation with cord thickness (r⫽0.68, P⬍.05). With
increased cord thickness, slopes indicating the rate of
fluid absorption declined.
The gingival retraction technique applied before dental
impression procedures should be chosen such that the gin-
gival sulcus is properly retracted and that hemostatic action
and elimination of tissue fluid (crevicular fluid) are en-
sured. The agent used and the proper pore size for the
appropriately moistened retraction cord ensure the re-
quired actions during the mechanical-chemical retraction
procedures. This study was designed to simulate clinical
practice as closely as possible. Soaking the cords in the
medicament solutions ensured fluid uptake. The condi-
tions for this step were standardized for reproduction in
everyday practice. The proposed protocol allows reproduc-
ible estimation of the saturation times of cords with a given
thickness immersed in medicament solutions.
In a preliminary study, it was observed that air inclu-
sions trapped in pores substantially hindered the moist-
ening of the cords. Therefore the air inclusions were
manually pressed out from the inner pores and surface of
the cords before soaking. An examiner pulled the cord
against a piece of clean filter paper held between the
thumb and index finger. This technique also avoids the
antimoistening action due to a possible hydrophobic
contamination. It was observed that omission of this
step resulted in a large spread of the measured values;
sometimes the deviations were an order of magnitude
higher. The aforementioned protocol is useful in the
clinical practice of in situ application of retraction cords
saturated with the medicament.

JANUARY 2003 47
THE JOURNAL OF PROSTHETIC DENTISTRY CSEMPESZ, VÁG, AND FAZEKAS

Fig. 2. Liquid uptake of retraction cord type No. 0 in terms of gram fluid absorbed per gram cord from solutions of various
medicaments as a function of incubation time. Equations of best-fit lines and regression coefficients for various medicaments
tested are as follows (n⫽100): in physiological saline solution (sodium chloride [NaCl]), y ⫽ 2.99 ⫹ 0.98 log x (r⫽0.94,
P⬍.001); in Fe2(SO4)3 solution, y ⫽ 4.36 ⫹ 0.68 log x (r⫽0.92, P⬍.001); in AlCl3 solution, y ⫽ 2.86 ⫹ 0.98 log x (r⫽0.96,
P⬍.001); in epinephrine solution, y ⫽ 2.81 ⫹ 0.76 log x (r⫽0.92, P⬍.001).

Fig. 3. Liquid uptake of retraction cord type No. 1 in terms of gram fluid absorbed per gram cord from solutions of various
medicaments as a function of incubation time. Equations of best-fit lines and regression coefficients for various medicaments
tested are as follows (n⫽100): in physiological saline solution (sodium chloride [NaCl]), y ⫽ 1.83 ⫹ 0.60 log x (r⫽0.80,
P⬍.001); in Fe2(SO4)3 solution, y ⫽ 2.89 ⫹ 0.67 log x (r⫽0.91, P⬍.001); in AlCl3 solution, y ⫽ 1.94 ⫹ 0.83 log x (r⫽0.94,
P⬍.001); in epinephrine solution, y ⫽ 1.55 ⫹ 0.68 log x (r⫽0.89, P⬍.001).

The results obtained in the fluid absorbency kinetic
study support that, in an aqueous environment, the fluid
absorption of medicament test solutions by cords depends
on soaking time, but the properties of the medicament
solutions also have an influence. Long-term storage of
cords in the medicament solutions may cause some prob-
lems; thus, on the basis of these data, it is recommended
that cords cut to the proper size be incubated in the medi-
cament solution for 20 minutes before use. A shorter in-
cubation time generally does not ensure even impregna-
tion of the cords, whereas long-term storage yields only an
insignificant increase in the amount of fluid absorbed.

48 VOLUME 89 NUMBER 1
CSEMPESZ, VÁG, AND FAZEKAS THE JOURNAL OF PROSTHETIC DENTISTRY

Table I. Characteristics of fluid absorbency of retraction cords

Amount of Amount of
fluid medicament
Cord absorbed Saturation absorbed
type Medicament solution tested (g/g cord) time (s) (␮g/cm)

00 Physiological saline solution 4.39 361 —

Epinephrine solution 3.59 220 3
AlCl3 solution 4.95 542 116
Fe2(SO4)3 solution 6.02 579 88
0 Physiological saline solution 5.05 1048 —
Epinephrine solution 5.11 1108 6
AlCl3 solution 5.75 912 182
Fe2(SO4)3 solution 6.53 1509 128
1 Physiological saline solution 3.68 790 —
Epinephrine solution 3.29 377 5
AlCl3 solution 4.08 370 165
Fe2(SO4)3 solution 4.68 499 117

The results of this study also suggest that an inverse
relationship between fluid absorption rate and cord
thickness exists. Thus cords with smaller diameters ex-
hibit faster absorption rates than thicker cords. Never-
theless, these values do not lead to conclusions regard-
ing saturation time, as this parameter also depends on
the maximum of fluid absorption capacity but does not
have a relationship to cord thickness. This can possibly
be explained by the differences among cords in pore
structure, moistening of inner surfaces, and swelling of
threads.
CONCLUSIONS
The soaking time ensured for the liquid uptake of
retraction cords was a crucial factor in the successful
gingival retraction procedure. The results of this study
indicated that prior to clinical use, 20 minutes of soaking
in the medicament solution was necessary when air bub-
bles were removed from the cords before soaking.
The rate of liquid uptake depended on the thickness
of the cords as well. The thinner cords exhibited faster
absorption rates than the thicker cords. The saturation
time, however, did not correlate with the thickness of
cords, as the time also depended on the maximum of the
fluid absorption capacity.
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Reprint requests to:
DR FERENC CSEMPESZ
DEPARTMENT OF CONSERVATIVE DENTISTRY
SEMMELWEIS UNIVERSITY
H-1088 BUDAPEST
MIKSZÁTH TÉR 5
HUNGARY
FAX: 36-1-317-1122
E-MAIL: csempesz@konfog.sote.hu
Copyright © 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 ⫹ 0
doi:10.1067/mpr.2003.61

JANUARY 2003 49