Nano Zero-Valent Iron-Mediated Sodium Alginate/Polyacrylic Acid Composite Hydrogel: Evaluation of Hemostatic Effects on Post-Extraction Bleeding in Anticoagulated Mice

Nano Zero-Valent Iron-Mediated Sodium Alginate/Polyacrylic Acid Composite Hydrogel: Evaluation of Hemostatic Effects on Post-Extraction Bleeding in Anticoagulated Mice | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Nano Zero-Valent Iron-Mediated Sodium Alginate/Polyacrylic Acid Composite Hydrogel: Evaluation of Hemostatic Effects on Post-Extraction Bleeding in Anticoagulated Mice Fangbing Zhao, Yongkang Xu, Jingwen Zhang, Yulin Cheng, Yuanming Geng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8014153/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Apr, 2026 Read the published version in BMC Oral Health → Version 1 posted 12 You are reading this latest preprint version Abstract Objectives This study evaluated the hemostatic efficacy, biocompatibility, and wound healing promotion of a sodium alginate/polyacrylic acid composite hydrogel (SPI hydrogel) mediated by nano zero-valent iron (nZVI) in anticoagulated mice with post-extraction bleeding. Materials and Methods Primary human gingival fibroblasts were cultured in media containing different concentrations (0.05, 0.5, 1.25, 2.5–mg/ml) of SPI hydrogel extracts and tested for biocompatibility using the cck8 assay. CD-1 mice were modeled for anticoagulation using oral anticoagulants. After confirming modeling success via INR assessment, mice were divided into cotton (Control), gelatin sponge (GS), and hydrogel (SPI) groups. Experiments included tooth extraction hemostasis and tail amputation tests, alongside postoperative healing observation of extraction sockets and comparative histopathological analysis. Results The hydrogel extract at 50% concentration showed slight cytotoxicity and the remaining concentrations were biocompatible. Post-extraction bleeding volume in the SPI group (40 ± 21 mg) was lower than in the Control (265 ± 93 mg) and GS (133 ± 41 mg) groups. Following tail transection, SPI group bleeding volume (7.90 ± 5.15 mg) was lower than the control group (22.70 ± 12.86 mg), and hemostasis time (1020 ± 115.11 s) was shorter than control group (1500 ± 151.24 s). HE and Masson test of wound tissue revealed superior healing, reduced inflammation, and normal collagen formation in the SPI group. Conclusion SPI hydrogel has excellent biocompatibility, hemostatic efficacy and wound healing properties, surpassing conventional materials in treating anticoagulant-induced post-extraction bleeding. Clinical Relevance: It provides a better material option for managing anticoagulant-induced bleeding after tooth extraction clinically. Hydrogel Polyacrylic Acid༛Warfarin༛Anticoagulant༛Postextraction Hemorrhage Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Oral extraction is a routine procedure in oral and maxillofacial surgery. The incidence of bleeding complications after oral surgery in healthy patients ranges from 0.2%–3.3%. However, in patients with coagulation disorders, the complication rate significantly increases to approximately 8.6%–32.1%[ 1 ]. Traditional hemostatic materials such as gauze, cotton balls, and absorbent gelatin sponges can adsorb blood cells and platelets. However, when applied to actively bleeding sites, they have limited biocompatibility. Combined with the harsh dynamic oral environment, characterized by salivary flow, blood, oral muscle movement, and involuntary swallowing that limited biocompatibility leads to poor tissue adhesion. Consequently, prolonged pressure application with gauze or cotton balls remains clinically necessary for hemostasis[ 2 ]. In addition to this, there has been controversy over whether to discontinue warfarin in patients with coagulopathies prior to dental extractions[ 3 ]. Guidelines from the American College of Chest Physicians (ACCP) recommend that patients discontinue warfarin 5 days before any surgical procedure associated with bleeding risk, with temporary substitution of low-molecular-weight heparin (LMWH) as bridging therapy[ 4 ]. Conversely, the American Heart Association (AHA) recommends that patients achieve an international normalized ratio (INR) of 2.0–2.5 before tooth extraction, with strict INR monitoring during the procedure. Nevertheless, patients with a history of warfarin use often remain in a state of high anticoagulation, significantly increasing the risk of postoperative bleeding complications during routine invasive procedures. Therefore, it is crucial for oral health professionals to implement bleeding prevention and control measures during and after tooth extraction for patients with a history of anticoagulant use. Recent research has demonstrated that a gel powder composed of polyethyleneimine/polyacrylic acid/quaternized chitosan (PEI/PAA/QCS) can rapidly form a highly adhesive biohydrogel at the wound site within 2 seconds. This occurs through strong physical interactions between polymers that absorb moisture from the wound surface, creating a physical barrier for rapid hemostasis[ 5 ]. However, PEI exhibits significant toxicity and non-degradability, which limits its biomedical applications[ 6 ]. By contrast, PAA can be polymerized from acrylic acid (AA) to form a stable three-dimensional (3D) network structure, which exhibits excellent biocompatibility and mechanical properties[ 7 ]. Furthermore, PAA is a highly water-absorbent polymer that is water-soluble and recyclable, making it widely used in the preparation of biomaterials such as hydrogels[ 8 ]. Sodium alginate (SA), extracted from seaweeds or brown algae, is a natural linear anionic polysaccharide with abundant hydrophilic groups in its molecular structure. Sodium alginate exhibits excellent water absorption, good water solubility, and biodegradability. It remains stable in the human body and possesses favorable biocompatibility[ 9 ]. Building on this, Zhang et al. [ 10 ] introduced nano-zero-valent iron (nZVI) with advantages of high reactivity, strong reducibility and low cost as a catalyst into the synthesis of PAA/SA hydrogels (SPI). The hemostatic efficacy was validated using rat liver hemorrhage models and rabbit full-thickness skin wounds. However, the oral microenvironment differs significantly from other anatomical sites, featuring continuous mechanical stimulation, high humidity, and a diverse microbial community[ 11 ]. These factors not only elevate the risk of prolonged bleeding but also hinder the formation of stable blood clots. Thus, the hemostatic efficacy of sodium alginate-polyacrylate gel in dental extraction sockets remains unevaluated. This study building upon the SPI synthesized by Zhang et al. [ 10 ], investigated the hemostatic performance of SPI in extraction sockets of anticoagulated mouse models by comparing its hemostatic efficacy with that of traditional hemostatic materials after tooth extraction in anticoagulated mouse models. The null hypotheses of this study were: (1) There is no difference in hemostatic efficacy between the SPI and cotton balls; (2) There is no difference in hemostatic efficacy between the SPI and absorbent gelatin sponges. 2. Methods and materials 2.1 Material Preparation In this study, nZVI-mediated sodium alginate/polyacrylic acid (SA/PAA) composite hydrogel (SPI hydrogel) prepared by South China Agricultural University (SCAU) was used, and the material characterization and properties have been verified in Zhang et al [ 10 ]. The fundamental principle involves introducing nano-zero-valent iron (nZVI)[ 12 ] as a catalyst during the synthesis of PAA/SA hydrogels. By leveraging the high reactivity, strong reducibility, and low cost of nZVI, this approach enables the ultrafast synthesis of SPI at room temperature via a mild redox system (zero-valent iron-persulfate). 2.2 Collection of Human Gingival Fibroblasts Human gingival tissue was obtained from patients undergoing impacted tooth extraction at the Department of Oral and Maxillofacial Surgery, Zhujiang Hospital, Southern Medical University. All experimental protocols have been performed in accordance with the Declaration of Helsinki and must have been approved by the Institutional Human Ethics Committee of Southern Medical University Zhujiang Hospital (Ethics No.: 2022-KY-302-02). All patients were Informed written consent. Inclusion criteria: 1. Patient age 18–25 years; 2. Extracted tooth free of caries; 3. Gingiva without inflammation or hyperplasia; 4. No periodontitis; 5. No history of pericoronitis; 6. Good oral hygiene. During extraction, flap surgery was performed to remove impacted teeth. Normal gingival tissue, approximately 2.0mm × 2.0mm × 2.0mm was excised from the extraction site. Samples were collected in sterile vials containing low-glucose Dulbecco's Modified Eagle Medium (DMEM) supplemented with 10% fetal bovine serum (FBS), 100 U/mL penicillin, and 100 µg/mL streptomycin, and transported to the laboratory at 4°C within 30 minutes. 2.3 Cell Compatibility Testing Different materials were disinfected under ultraviolet light for 24 hours, then incubated in DMEM medium for 24 hours. Solutions of 0.005 (0.1%), 0.05 (1%), 0.5 (10%), 1.25 (25%), and 2.5 (50%) mg/mL SPI hydrogel extracts. Fourth-generation human gingival fibroblasts were used as the test cell line. After digestion, cells were added to DMEM medium containing 1% antibiotic-antimycotic and 10% fetal bovine serum to form a cell suspension at 4 × 10³ cells/mL. A 100µL cell suspension was incubated in a 96-well plate at 37°C, 5% CO₂, and 90% relative humidity for 24 hours[ 13 ]. After incubation, remove the supernatant and material, then wash with sterile PBS solution. Add 100 µL of DMEM solution containing 10% Cell Counting Kit 8 (CCK-8, Dojindo, Japan) to each well and incubateat 37°C in a 5% CO₂ incubator for 1 hour. After incubation, the CCK-8 solution containing cells was added to the 96-well plate, and the absorbance at 450 nm was measured using an enzyme-linked immunosorbent assay reader (ELX808, Biotek, USA). The blank group was set with only blank medium. The relative growth rate (RGR) was calculated using the following equation: $$\:RGR=\frac{{OD}_{1}-{OD}_{0}}{{OD}_{C}-{0D}_{0}}\times\:100\%$$ OD 1 indicate absorbance value of the experimental treatment group, OD 0 demonstrate the absorbance value of the CCK-8 blank group and OD c indicate the absorbance value of the control group. Cytotoxicity assessment was determined based on cell survival rate relative to the control group, calculated as[ 14 ]: No cytotoxicity: cell survival rate > 90%; Mild cytotoxicity = 60–90% cell survival rate; Moderate cytotoxicity = 30–59% cell survival rate; Severe cytotoxicity ≤ 30% cell survival rate. 2.4 Establishment of Anticoagulant Mouse Model This experiment established a CD-1 mouse anticoagulant model based on the methods of Foerch et al [ 15 ]. Male CD-1 (40 ± 5 g) with intact teeth and dentition, normal occlusion, no periodontal disease, and no dental caries were purchased from Zhuhai Bestone Biotechnology Co., Ltd. and housed in the SPF-grade animal facility of the Animal Experiment Center at Southern Medical University Zhujiang Hospital. Animal care and procedures in this study fully complied with the regulations of the Institutional Management Department at the Animal Experiment Center of Southern Medical University Zhujiang Hospital. All experimental protocols were approved by the Institutional Animal Ethics Committee of Southern Medical University Zhujiang Hospital (Ethics No. : LAEC-2022-037) and conducted in accordance with the National Research Council's Guidelines for the Care and Use of Laboratory Animals. Mice were acclimated in the Animal Experiment Center for 1 week under standard housing conditions. The experimental group (n = 6) was administered water containing dissolved warfarin tablets at a dose of 2 mg warfarin per kg body weight for 24 hours. The control group received standard bottled drinking water for 24 hours. Subsequently, mice were anesthetized via intraperitoneal injection of 1% sodium pentobarbital solution (0.2 mL–0.25 mL). Under deep anesthesia, 0.4–0.5 mL of blood was collected from the apex of the heart using a 1 mL syringe and a 25-gauge needle. An INR value was measured 24 hours after warfarin administration in CD-1 using a Roche CoaguchekXS® device (Roche, Mannheim, Germany) and compared with the control group to verify successful modeling. Roche, Mannheim, Germany) to measure the INR value of CD-1 24 hours after warfarin administration. This value was compared with that of the control group to determine whether modeling was successful[ 16 ]. 2.5 Establishment of Mouse Tooth Extraction Model Experimental mice were randomly divided into three groups (n = 12). A 1% pentobarbital solution (0.2–0.25 mL) was administered via intraperitoneal injection for anesthesia. Position mice supine and secure the maxilla, mandible, and limbs using an animal restraint device. After complete disappearance of corneal reflex, disinfect the oral cavity with povidone-iodine solution and fully expose the maxillary incisors[ 17 ], using a disposable scalpel incise the gingiva over the right maxillary central incisor. Separate the gingiva with a gingival retractor to expose the alveolar bone. Gently loosen the tooth using a curved probe and light-curing bur, carefully separating the right maxillary central incisor. Grasp the crown with curved mosquito forceps. and extract the right maxillary central incisor. Scrape the extraction socket with an oral surgical curette to ensure no tooth fragments remain. Examine the tooth outside the mouth to confirm its integrity, as shown in Fig. 1 . Following complete tooth extraction in CD-1, the extraction site was immediately packed with materials according to the following groups: Control group: Immediately pack the extraction socket with cotton balls (5 mg); GS group: Absorbent gelatin sponge (5 mg) immediately packed into the extraction socket of CD-1; SPI group: Immediately after extraction, a curette was used to deliver sodium alginate powder (5 mg) into the extraction socket of CD-1. 2.6 Establishment of Mouse Tail Amputation Model CD-1 were anesthetized via intraperitoneal injection of 1% pentobarbital (0.2 mL–0.25 mL) solution (n = 12). Following anesthesia, tails were amputated 4 mm from the base. Hemostasis was achieved at the wound site using either sodium alginate gel powder or cotton balls. Bleeding volume and time to cessation of bleeding were recorded for both groups. 2.7 Bleeding Volume Calculation Prior to tooth extraction and tail amputation in CD-1, unused sterile cotton balls from each group were weighed in EP tubes (W 1 ). 30 seconds after implanting hemostatic materials in each group, pre-weighed cotton balls were placed into the extraction sockets. and pressed the wound until no active bleeding was observed. Blood exuding from the extraction site was wiped dry, and the cotton balls were reweighed in the EP tubes (W 2 ). Blood loss was calculated based on the weight difference before and after complete hemostasis using clean cotton balls[ 18 ]. $$\:Blood\:loss={W}_{2}-{W}_{1}$$ 2.8 Hematoxylin and Eosin (HE) Staining and Masson's Trichrome (Masson) Staining 1 d, 7 d, 14 d and 28 d after implanting the SPI and GS into the mouse extraction sockets, the healing status of the mouse extraction wounds was recorded by visual observation. Subsequently, the wound tissues of mice in the three groups were excised respectively, fixed with 4% paraformaldehyde, and embedded in paraffin. Tissues were sectioned at 4-µm thickness and stained with HE and Masson. Stained sections were imaged and analyzed. 2.8 Statistical Analysis All experimental data are expressed as mean ± standard deviation (n ≥ 5). Results were analyzed using SPSS 26.0 and GraphPad Prism software. D'Agostino & Pearson tests confirmed normal distribution of the dataset ( p > 0.05 ). Intergroup comparisons were performed using t-tests, one-way ANOVA, and two-way ANOVA, followed by Tukey's post hoc analysis for multiple comparisons. Statistical significance was defined as * p < 0.05 . 3. Results 3.1 Biocompatibility of SPI Hydrogel Table 1 quantifies the biocompatibility of SPI at various concentrations with human gingival fibroblasts. Results indicate that at Day 1, cell viability in all gel-treated groups (1%, 10%, 25%, 50%) was comparable to the control group. Notably, cell viability increased in the 1%, 10%, and 25% treatment groups, demonstrating that concentrations exhibit good biocompatibility with human gingival fibroblasts and promote cell growth. On Day 2, the 50%-treated group exhibited mild cytotoxicity with a 23.59% decrease in cell viability, while the 1%, 10%, and 25% treatment groups maintained approximately 100.0% viability, retaining good compatibility. On Day 3, cell viability decreased by 11.47% and 30.60% in the 25% and 50% treatment groups, respectively, yet remained above the international standard for biomaterial cell viability (ISO 10993:2009, ≥ 70%). Cell viability in the 1% and 10% treatment groups was essentially comparable to the blank control group. Table 1 Cytotoxicity Evaluation of SPI Hydrogel Extracts at Different Concentrations (RGR ± SD, Cytotoxicity Grade) 1d 2d 3d RGR (%) SD RGR (%) SD RGR (%) SD Control 100.07 5.66 100.05 5.02 101.83 5.06 Non Non Non 1% group 106.75 2.47 99.46 4.54 100.00 4.91 Non Non Non 10% group 105.86 6.26 103.25 4.79 101.60 6.31 Non Non Non 25% group 108.39 5.37 99.01 2.19 90.14 3.08 Non Non Non 50% group 97.95 2.94 76.44 3.68 70.67 2.43 Non Slight Slight 3.2 INR Detection Results in Experimental Mouse Models INR is the ratio adjusted from prothrombin time (PT), commonly used to measure blood coagulation ability[ 19 ]. In establishing the mouse anticoagulant model, the Roche coagulation analyzer detected an INR value of 0.85 ± 0.04 in the blank control group, while the warfarin-treated group exhibited an INR value of 3.97 ± 1.20, significantly higher than the blank control group ( p < 0.05 ). This confirmed the successful establishment of the CD-1 anticoagulant model. 3.3 Hemostatic Effect of the Anticoagulant Model in CD-1 Mice Following Tooth Extraction The bleeding volume after tooth extraction in each group of CD-1 is shown in Fig. 2 . By measuring the weight difference of cotton balls before and after absorbing blood 30 seconds after implanting the hemostatic agent, the bleeding volume in the SPI group was found to be 40 ± 21 mg, lower than that in the Control group and GS group (265 ± 93 mg, 133 ± 41 mg). One-way analysis of variance (ANOVA) results showed statistically significant differences between the Control group and both the GS and SPI groups ( p < 0.05 ). Although no significant difference was observed between the GS and SPI groups, the SPI group overall exhibited a lower bleeding volume trend than the GS group, demonstrating superior hemostatic efficacy of SPI compared to GS in this experiment. 3.4 Tail Amputation Experiment Results in CD-1 Mice Anticoagulation Model In addition to the tooth extraction model, we further validated the hemostatic efficacy of SPI using the mouse tail-amputation method (Fig. 2 ). After quantifying the data from both groups and performing an independent samples t-test, SPI group demonstrated statistically significant differences ( p < 0.05) compared to the Control group in both hemostatic volume and hemostasis time. The total blood loss in the SPI group was 7.90 ± 5.15 mg, while the Control group recorded 22.70 ± 12.86 mg. Compared to the Control group, the SPI group exhibited a 65.20% reduction in blood loss, as shown in Fig. 2 g. The mean hemostasis time in the SPI group was 1020.00 ± 115.11 s. The mean hemostasis time in the Control group was 1500.00 ± 151.24 s. The SPI group showed a reduction of 480 s in mean hemostasis time compared to the Control group, representing a 32.00% decrease, as shown in Fig. 2 h. 3.5 Macroscopic Observation of Tooth Extraction Wound Healing in CD-1 The healing and repair effects of SPI and GS hemostatic materials on extraction sites were evaluated by observing the surface healing status, gingival probing bleeding, gingival color, material retention, and infection status in CD-1 anticoagulant mice after tooth extraction. As shown in Fig. 3 , at 1 day postoperatively, the extraction sites in both groups remained open. The GS group exhibited hematoma formation at the extraction site, with visible GS filling material. By contrast, the SPI group showed a relatively flat extraction site with gingival adhesion closure, and no SPI filling material was observed on the wound surface. At 7 days post-extraction, the GS group wounds remained open with extensive granulation tissue proliferation, presenting a soft texture and marked depression. However, the SPI group wounds were largely closed without granulation tissue proliferation, showing slight depression of the alveolar socket. By 14 days post-extraction, both groups exhibited near-complete wound closure with pronounced depression at the extraction sites and deep hematoma within the extraction sockets. The SPI group exhibited fuller wounds with firmer gingiva and visible coverage by new epithelial tissue compared to the GS group. By postoperative day 28, wounds in both groups were completely closed and full, with normal gingival coloration. Gingiva in both groups appeared pink, showed no obvious abnormalities, and exhibited no bleeding on probing. Mice in both groups maintained normal feeding habits, and no infections occurred during the study period. 3.6 Analysis of HE-stained and Masson-stained tissue sections HE stained tissue sections of the wound sites at different time points after tooth extraction are shown in Fig. 4 a. At 1 day postoperative, the Control group exhibited marked inflammatory reactions around the wound site, including inflammatory cell infiltration, vascular dilation, and congestion. The GS group similarly showed inflammatory cell infiltration and neutrophil exudation around the wound. In contrast, the SPI group demonstrated relatively mild inflammatory reactions, with less pronounced inflammatory cell infiltration and vascular dilation. At 7 days postoperative, inflammatory cell infiltration persisted in the Control group, with nuclear disappearance and leukocyte appearance. The GS group exhibited scar tissue formation, gradual reduction in neutrophils, and increased numbers of lymphocytes and monocytes. The SPI group showed increased lymphocyte and monocyte counts alongside elevated fibroblast and collagen fiber levels. At 14 days postoperative, the Control group exhibited hyperemia and leukocyte exudation. The GS group showed increased density and strength of scar tissue, along with elevated numbers of fibroblasts and macrophages. The SPI group began to demonstrate increased density and number of neovascularization, while inflammatory cell infiltration decreased. At 28 days postoperative, the Control group exhibited cellular hypertrophy, poor fibrous architecture, localized abscess necrosis within the scab layer, and poor tissue healing. The GS group showed mild cellular hypertrophy, poor fibrous architecture, and distinct scar tissue. The SPI group demonstrated relatively ideal healing with fibrous architecture tending toward normalization. Prepared Masson-stained sections and analyzed collagen area (blue) in the images to better understand changes in collagen content during wound healing. The Masson staining results shown in Fig. 4 b indicate that over time, collagen fibers in the Control group gradually deposited and distributed in an increasingly organized manner, reflecting a natural repair process accompanied by fibrosis. The GS group exhibited distinct collagen dynamics compared to the control, with the material altering the rhythm of collagen deposition and tissue remodeling patterns, resulting in unique structural repair characteristics in the later stages. The SPI group exhibited a distinct collagen growth pattern starting at 7 days, with extensive collagen coverage at 28 days but differing distribution morphology. Its fibrosis and structural remodeling characteristics differed from the previous two groups. Comparison reveals that gelatin sponges and hydrogels exert distinct effects on tissue collagen metabolism and repair processes, with hydrogels potentially offering greater potential for regulating optimal collagen deposition. 4. Discussion Building upon the studies by Zhang et al. [ 10 ], this research further validates the efficacy of SPI in extraction sockets, offering a novel approach for hemostasis in oral and maxillofacial surgery. Through hemostasis experiments in tooth extraction and tail amputation models using anticoagulated CD-1, we demonstrated that SPI outperforms traditional cotton balls and gelatin sponges in oral and maxillofacial hemostasis. Consequently, both null hypotheses were rejected. In this study, the compatibility evaluation of human gingival fibroblasts using the CCK-8 assay indicated that SPI extracts at concentrations ranging from 1% to 25% exhibited no cytotoxicity over a 3-day period and even promoted the proliferation of human gingival fibroblasts as early as the first day. The enhanced biocompatibility of SPI may be attributed to SA providing abundant hydroxyl and carboxyl groups that improve cell adhesion. However, it is noteworthy that the 50% concentration extract exhibited mild cytotoxicity on day 3, with a cell survival rate of 70.67%. This is consistent with findings by Sjogren et al .[ 14 ], who suggested that high concentrations of polymer extracts may disrupt cellular metabolism by altering the osmotic pressure of the culture environment. Therefore, clinical applications necessitate controlled SPI dosing to mitigate potential risks from localized high concentrations. In recent years, studies utilizing mouse models of tooth extraction wounds have increased[ 20 , 21 ]. This experiment established an anticoagulant mouse model by dissolving warfarin tablets in drinking water. According to the World Health Organization (WHO) guidelines for the acceptable INR range when using oral anticoagulants, the INR value for preventing arterial thrombosis is 3.0–4.0, and the INR value for patients after artificial valve surgery is also 3.0–4.0. It can be seen that the INR values detected in the mice in this experiment reached the therapeutic range for human anticoagulant drug use[ 16 ]. This indicates that the animal model established by this method effectively enhances anticoagulant performance in mice. In observing wound healing in the anticoagulant mouse tooth extraction model, we found that SPI significantly promoted healing of extraction sockets in anticoagulant CD-1. 1 day postoperative, the SPI group exhibited markedly better wound healing than the GS group, with visible wound closure and no apparent filling material within the wound. By postoperative day 7, the extraction sockets in the SPI group were largely closed, whereas the GS group still exhibited noticeable depressions and granulation tissue proliferation. This aligns with findings from Peng et al. [ 5 ], who demonstrated that hydrogel materials can modulate inflammatory responses and accelerate the transition from the inflammatory to proliferative phase of wound healing. HE staining revealed milder inflammatory cell infiltration in the SPI group on postoperative day 1 and increased neovascularization by day 14, indicating SPI's potential to promote angiogenesis. Additionally, Masson staining demonstrated more regular collagen fiber arrangement in the SPI group by postoperative day 28, whereas the GS group exhibited marked scar tissue formation. This further confirms SPI ability to enhance wound healing quality. The tail-amputation hemostasis experiment further validated the hemostatic advantage of SPI. Compared to cotton ball hemostasis, the SPI demonstrated significantly reduced blood loss and shorter hemostasis time. Within just 10 seconds, the gel absorbs blood to form a hydrogel, achieving immediate hemostasis. Interestingly, after absorbing blood exuded from the severed mouse tail, the SPI adheres to the wound cross-section, with the powdered gel forming a hydrogel upon absorbing exudate. During experiments, the gel rapidly formed a gel-film structure at the amputation site with excellent adhesion and stretchability[ 22 ], enveloping the wound to achieve rapid hemostasis and shield against external stimuli. In contrast, while cotton ball groups demonstrated some hemostatic effect, they suffered from issues like loose adhesion and displacement, limiting their efficacy in dynamic wound environments. The limitations of this study are as follows: First, the oral cavity is a dynamic environment where the biocompatibility of medical biomaterials is influenced by various factors such as saliva flow rate, composition, oral temperature, and pH levels[ 23 ]. Second, the oral mucosa contains mucin and keratin layers, which provide greater resistance to toxic substances than cultured cells in vitro; this protective barrier may alter the results of cytotoxicity assays[ 24 ]. Finally, this study did not investigate the long-term biodegradation process of SPI in vivo , leaving its potential impact on surrounding tissues to be clarified. Future research should further explore aspects such as simulating the oral environment, investigating long-term stability, and evaluating clinical application efficacy. In summary, the SPI exhibits excellent biocompatibility, hemostatic efficacy, and wound healing promotion capabilities. Compared to traditional hemostatic materials, including cotton balls and absorbable gelatin sponges, it demonstrated significant advantages in an anticoagulant mouse model, particularly in reducing blood loss and accelerating tissue repair. This study not only provides a new option for treating post-extraction bleeding in patients with coagulation disorders but also enriches the research on PAA-SA composite hydrogels. 5. Conclusion By comparing the hemostatic efficacy of SPI with traditional hemostatic materials in anticoagulated CD-1, this study concludes that: SPI exhibits excellent stability and swelling properties, rapidly forming a physical barrier on oral wound surfaces and achieving swift hemostasis upon expansion. SPI exhibits good biocompatibility and relative cell proliferation rates. SPI effectively reduces wound bleeding volume and shortens bleeding duration, demonstrating superior repair effects on wound healing. Declarations Not applicable Author Contribution Fangbing Zhao: Conceptualization, Methodology, Investigation, Validation, Formal analysis, Writing–original draft. Yongkang Xu: Software, Formal analysis, Visualization, Writing–review & editing. Jingwen Zhang: Software, Investigation, Formal analysis, Data processing.Yulin Cheng: Conceptualization, Methodology, Data curation, Writing–review & editing. Yuanming Geng: Writing–review & editing, Visualization, Resources, Investigation. Xiaoqing Shen: Conceptualization, Methodology, Investigation, Resources, Formal analysis, Writing–review & editing, Supervision. Acknowledgement The authors thank the team of Prof Jiang Gangbiao at South China Agricultural University for providing nZVI-mediated sodium alginate/polyacrylic acid (SA/PAA) composite hydrogel (SPI hydrogel). Data Availability declaration Not applicable Competing Interest declaration No Funding Declaration Not applicable Clinical trial number Not applicable Ethics, Consent to Participate, and Consent to Publish declarations not applicable References Roemer P, Heimes D, Pabst A, Becker P, Thiem DGE, Kaemmerer PW. Bleeding disorders in implant dentistry: a narrative review and a treatment guide. Int J Implant Dent. 2022;8(1):20. https://doi.org/10.1186/s40729-022-00418-2 . Hickman DA, Pawlowski CL, Sekhon UDS, Marks J, Sen Gupta A. Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding. Adv Mater. 2018;30(4). https://doi.org/10.1002/adma.201700859 . Caliskan M, Tukel H-C, Benlidayi M-E, Deniz A. Is it necessary to alter anticoagulation therapy for tooth extraction in patients taking direct oral anticoagulants? Med Oral Patol Oral Cir Bucal. 2017;22(6):E767–73. https://doi.org/10.4317/medoral.21942 . Snipelisky D, Kusumoto F. Current strategies to minimize the bleeding risk of warfarin. J Blood Med. 2013;4:89–99. https://doi.org/10.2147/jbm.S41404 . Peng X, Xu X, Deng Y, Xie X, Xu L, Xu X. Ultrafast Self-Gelling and Wet Adhesive Powder for Acute Hemostasis and Wound Healing. Adv Funct Mater. 2021;31(33). https://doi.org/10.1002/adfm.202102583 . Tsai L-R, Chen M-H, Chien C-T, Chen MK, Lin FS, Lin KM. A single-monomer derived linear-like PEI-co-PEG for siRNA delivery and silencing. Biomaterials. 2011;32(14):3647–53. https://doi.org/10.1016/j.biomaterials.2011.01.059 . Micutz M, Lungu RM, Circu V, lis M, Staicu T. Hydrogels Obtained via γ-Irradiation Based on Poly(Acrylic Acid) and Its Copolymers with 2-Hydroxyethyl Methacrylate. Appl Sci. 2020;10(14):4960. https://doi.org/10.3390/app10144960 . Gulyuz U, Okay O. Self-healing polyacrylic acid hydrogels. Soft Matter. 2013;9(43):10287–93. https://doi.org/10.1039/c3sm52015c . Saltz A, Kandalam U. Mesenchymal stem cells and alginate microcarriers for craniofacial bone tissue engineering: A review. J Biomed Mater Res A. 2016;104(5):1276–84. https://doi.org/10.1002/jbm.a.35647 . Zhang HY, Liu JW, Hu XL, Yang Y, Zhu S, Liu BN. Nano zero-valent iron driven sodium alginate/poly (acrylic acid) composite hydrogel powder for rapid hemostasis and wound healing. Int J Biol Macromol. 2025;306(Pt 3):141659. https://doi.org/10.1016/j.ijbiomac.2025.141659 . Sedghi L, DiMassa V, Harrington A, Lynch SV, Kapila YL. The oral microbiome: Role of key organisms and complex networks in oral health and disease. Periodontol 2000. 2021;87(1):107–31. https://doi.org/10.1111/prd.12393 . Diao ZH, Xu XR, Jiang D, Kong LJ, Sun YX, Hu YX. Bentonite-supported nanoscale zero-valent iron/persulfate system for the simultaneous removal of Cr(VI) and phenol from aqueous solutions. Chem Eng J. 2016;302:213–22. https://doi.org/10.1016/j.cej.2016.05.062 . Peng S, Niu S, Gao Q, Song R, Wang Z, Luo Z. Hydroxypropyl chitosan/ε-poly-L-lysine based injectable and self-healing hydrogels with antimicrobial and hemostatic activity for wound repair. Carbohydr Polym. 2024;357:123496. https://doi.org/10.1016/j.carbpol.2024.122135 . Sjogren G, Sletten G, Dahl JE. Cytotoxicity of dental alloys, metals, and ceramics assessed by millipore filter, agar overlay, and MTT tests. J Prosthet Dent. 2000;84(2):229–36. https://doi.org/10.1067/mpr.2000.107227 . Foerch C, You Z, Wang H, Lo EH, Whalen MJ. Traumatic Brain Injury during Warfarin Anticoagulation: An Experimental Study in Mice. J Neurotrauma. 2012;29(6):1150–5. https://doi.org/10.1089/neu.2011.2104 . Illanes S, Zhou W, Heiland S, Markus Z, Veltkamp R. Kinetics of hematoma expansion in murine warfarin-associated intracerebral hemorrhage. Brain Res. 2010;1320:135–42. https://doi.org/10.1016/j.brainres.2010.01.015 . Takagi T, Yamamoto M, Sugano A, Kanehira C, Kitamura K, Katayama M. Alteration of Oral and Perioral Soft Tissue in Mice following Incisor Tooth Extraction. Int J Mol Sci. 2022;23(6):2987. https://doi.org/10.3390/ijms23062987 . Barrachina B, Lopez-Picado A, Albinarrate A, Iriarte I, Remón M, Basora M. Analysis of the estimation of bleeding using several proposed haematometric equations. Ir J Med Sci. 2023;192(1):327–33. https://doi.org/10.1007/s11845-022-02946-7 . Stern R, Karlis V, Kinney L, Glickman R. Using the international normalized ratio to standardize prothrombin time. J Am Dent Assoc. 1997;128(8):1121–2. https://doi.org/10.14219/jada.archive.1997.0369 . Soma T, Iwasaki R, Sato Y, Kobayashi T, Nakamura S, Kaneko Y. Tooth extraction in mice administered zoledronate increases inflammatory cytokine levels and promotes osteonecrosis of the jaw. J Bone Min Metab. 2021;39(3):372–84. https://doi.org/10.1007/s00774-020-01174-2 . Soma T, Iwasaki R, Sato Y, Kobayashi T, Ito E, Matsumoto T. Osteonecrosis development by tooth extraction in zoledronate treated mice is inhibited by active vitamin D analogues, anti-inflammatory agents or antibiotics. Sci Rep. 2022;12(1):19. https://doi.org/10.1038/s41598-021-03966-6 . Feng J, Wang J, Wang H, Cao X, Ma X, Rao Y. Multistage Anticoagulant Surfaces: A Synergistic Combination of Protein Resistance, Fibrinolysis, and Endothelialization. ACS Appl Mater Interfaces. 2023;15(30):35860–71. https://doi.org/10.1021/acsami.3c05145 . de Gomes PS, Figueiral MH, Fernandes MHR, Scully C. Cytotoxicity of denture adhesives. Clin Oral Investig. 2011;15(6):885–93. https://doi.org/10.1007/s00784-010-0464-0 . Lima Chaves CA, Machado AL, Vergani CE, de Souza RF, Giampaolo ET. Cytotoxicity of denture base and hard chairside reline materials: a systematic review. J Prosthet Dent. 2012;107(2):114–27. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Apr, 2026 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 22 Dec, 2025 Reviews received at journal 17 Dec, 2025 Reviews received at journal 15 Dec, 2025 Reviews received at journal 15 Dec, 2025 Reviewers agreed at journal 11 Dec, 2025 Reviewers agreed at journal 06 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers invited by journal 05 Dec, 2025 Editor assigned by journal 01 Dec, 2025 Submission checks completed at journal 01 Dec, 2025 First submitted to journal 29 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8014153","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":556496442,"identity":"5e73de38-10b4-4f76-af3f-5d02a6162d97","order_by":0,"name":"Fangbing Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYBAC+4bDBw4k8EjI8bM3EKnFgPFY4oMPMjbGkj0HiNXCfMbYcIZNWuKGGQlEajFnO2MmzZNzOHGD5OONNxhqbKIJarHsOVYmzXPmsPF26bRiC4ZjabkNBPXcOLxNmrfnsOzO2TlmEowNh4nQcv+BmTTvv8OMG26eIVKLwYEjQO/zpCluuMFDpBbJBlAg84ACGeiXBGL8ws8Aj8rDG298qLEhwi/IjpRIIEU5RAupOkbBKBgFo2BkAAB/F0ZfyYVgPwAAAABJRU5ErkJggg==","orcid":"","institution":"Zhujiang Hospital","correspondingAuthor":true,"prefix":"","firstName":"Fangbing","middleName":"","lastName":"Zhao","suffix":""},{"id":556496443,"identity":"38717fe3-27f3-4143-b960-195b9bc6a475","order_by":1,"name":"Yongkang Xu","email":"","orcid":"","institution":"Zhujiang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yongkang","middleName":"","lastName":"Xu","suffix":""},{"id":556496444,"identity":"23685641-dd2f-42e5-ac94-df1bf40def87","order_by":2,"name":"Jingwen Zhang","email":"","orcid":"","institution":"Zhujiang 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14:14:08","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":212203,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/99d3f94be5987fe6e82b4efb.jpeg"},{"id":97895761,"identity":"fa5d3066-b192-457f-8a11-c05841f37051","added_by":"auto","created_at":"2025-12-10 15:34:53","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1217908,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/9709d4673e9a37b43a75e093.jpeg"},{"id":97713661,"identity":"c95df0ae-e56a-4c02-ab83-a9156ad0624f","added_by":"auto","created_at":"2025-12-08 14:14:08","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88057,"visible":true,"origin":"","legend":"","description":"","filename":"7f845c9d5aab4c379f049bf4a670734d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/ff5c1263a21c646d71a2535a.xml"},{"id":97894256,"identity":"7476b05f-dc0b-4a9e-99e1-fe00406dbe46","added_by":"auto","created_at":"2025-12-10 15:32:08","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96701,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/ef950a0772b2e487dc437e58.html"},{"id":97713651,"identity":"a4acaf3b-219c-48d0-8f2c-a5a0b2b857aa","added_by":"auto","created_at":"2025-12-08 14:14:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":94397,"visible":true,"origin":"","legend":"\u003cp\u003eTooth extraction procedure in CD-1. (a) Holding the crown with curved mosquito forceps; (b) Extracting the right maxillary incisor; (c) Scraping the alveolar socket to verify complete extraction; (d) Maxillary incisor of CD-1 mouse.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/75fb575309a3febf0b397b89.png"},{"id":97713653,"identity":"a9bb1681-63b1-4654-a773-6d3ec1d461b9","added_by":"auto","created_at":"2025-12-08 14:14:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":134934,"visible":true,"origin":"","legend":"\u003cp\u003eHemostasis status after extraction and tail amputation in anticoagulated mouse models. (a) Cotton ball, (b) gelatin sponge, and (c) gel powder packed into the extraction site; (d) Box plot quantifying hemostatic efficacy among the three groups; (e)Tail amputation at 4 mm from the base; (f)SPI absorbing blood and forming a hydrogel within 10 seconds; (g)Box plots quantifying blood loss in both groups; (h)Box plots quantifying blood coagulation time in both groups (significance level: *\u003cem\u003ep \u0026lt; 0.05\u003c/em\u003e).\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/461e50df895b78882c954077.png"},{"id":97894264,"identity":"bd938f21-2196-4390-9e08-0b6d4f6088ff","added_by":"auto","created_at":"2025-12-10 15:32:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":138617,"visible":true,"origin":"","legend":"\u003cp\u003eAnalysis of gel tissue repair function by observing alveolar socket healing at different time points after tooth extraction in anticoagulated CD-1.\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/8ad404ae64634843aaee2d5e.png"},{"id":97895259,"identity":"a4d2dc84-80ec-4822-aef3-40055ba2bca8","added_by":"auto","created_at":"2025-12-10 15:33:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":790165,"visible":true,"origin":"","legend":"\u003cp\u003eHE (a) and Masson (b) staining of wound tissue from tooth extraction sites in mice treated with different materials at different time points (days).\u003c/p\u003e","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/7133cdf940c5acab12d1b93a.png"},{"id":107350856,"identity":"91b36cbb-0125-498d-8291-be5857757ee1","added_by":"auto","created_at":"2026-04-20 16:05:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1759453,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8014153/v1/53874155-5877-4131-a904-d65039b9ae95.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nano Zero-Valent Iron-Mediated Sodium Alginate/Polyacrylic Acid Composite Hydrogel: Evaluation of Hemostatic Effects on Post-Extraction Bleeding in Anticoagulated Mice","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eOral extraction is a routine procedure in oral and maxillofacial surgery. The incidence of bleeding complications after oral surgery in healthy patients ranges from 0.2%\u0026ndash;3.3%. However, in patients with coagulation disorders, the complication rate significantly increases to approximately 8.6%\u0026ndash;32.1%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Traditional hemostatic materials such as gauze, cotton balls, and absorbent gelatin sponges can adsorb blood cells and platelets. However, when applied to actively bleeding sites, they have limited biocompatibility. Combined with the harsh dynamic oral environment, characterized by salivary flow, blood, oral muscle movement, and involuntary swallowing that limited biocompatibility leads to poor tissue adhesion. Consequently, prolonged pressure application with gauze or cotton balls remains clinically necessary for hemostasis[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition to this, there has been controversy over whether to discontinue warfarin in patients with coagulopathies prior to dental extractions[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Guidelines from the American College of Chest Physicians (ACCP) recommend that patients discontinue warfarin 5 days before any surgical procedure associated with bleeding risk, with temporary substitution of low-molecular-weight heparin (LMWH) as bridging therapy[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Conversely, the American Heart Association (AHA) recommends that patients achieve an international normalized ratio (INR) of 2.0\u0026ndash;2.5 before tooth extraction, with strict INR monitoring during the procedure. Nevertheless, patients with a history of warfarin use often remain in a state of high anticoagulation, significantly increasing the risk of postoperative bleeding complications during routine invasive procedures. Therefore, it is crucial for oral health professionals to implement bleeding prevention and control measures during and after tooth extraction for patients with a history of anticoagulant use.\u003c/p\u003e\u003cp\u003eRecent research has demonstrated that a gel powder composed of polyethyleneimine/polyacrylic acid/quaternized chitosan (PEI/PAA/QCS) can rapidly form a highly adhesive biohydrogel at the wound site within 2 seconds. This occurs through strong physical interactions between polymers that absorb moisture from the wound surface, creating a physical barrier for rapid hemostasis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, PEI exhibits significant toxicity and non-degradability, which limits its biomedical applications[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. By contrast, PAA can be polymerized from acrylic acid (AA) to form a stable three-dimensional (3D) network structure, which exhibits excellent biocompatibility and mechanical properties[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, PAA is a highly water-absorbent polymer that is water-soluble and recyclable, making it widely used in the preparation of biomaterials such as hydrogels[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSodium alginate (SA), extracted from seaweeds or brown algae, is a natural linear anionic polysaccharide with abundant hydrophilic groups in its molecular structure. Sodium alginate exhibits excellent water absorption, good water solubility, and biodegradability. It remains stable in the human body and possesses favorable biocompatibility[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBuilding on this, Zhang \u003cem\u003eet al.\u003c/em\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] introduced nano-zero-valent iron (nZVI) with advantages of high reactivity, strong reducibility and low cost as a catalyst into the synthesis of PAA/SA hydrogels (SPI). The hemostatic efficacy was validated using rat liver hemorrhage models and rabbit full-thickness skin wounds. However, the oral microenvironment differs significantly from other anatomical sites, featuring continuous mechanical stimulation, high humidity, and a diverse microbial community[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These factors not only elevate the risk of prolonged bleeding but also hinder the formation of stable blood clots. Thus, the hemostatic efficacy of sodium alginate-polyacrylate gel in dental extraction sockets remains unevaluated.\u003c/p\u003e\u003cp\u003eThis study building upon the SPI synthesized by Zhang \u003cem\u003eet al.\u003c/em\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], investigated the hemostatic performance of SPI in extraction sockets of anticoagulated mouse models by comparing its hemostatic efficacy with that of traditional hemostatic materials after tooth extraction in anticoagulated mouse models. The null hypotheses of this study were: (1) There is no difference in hemostatic efficacy between the SPI and cotton balls; (2) There is no difference in hemostatic efficacy between the SPI and absorbent gelatin sponges.\u003c/p\u003e"},{"header":"2. Methods and materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Material Preparation\u003c/h2\u003e\u003cp\u003eIn this study, nZVI-mediated sodium alginate/polyacrylic acid (SA/PAA) composite hydrogel (SPI hydrogel) prepared by South China Agricultural University (SCAU) was used, and the material characterization and properties have been verified in Zhang \u003cem\u003eet al\u003c/em\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The fundamental principle involves introducing nano-zero-valent iron (nZVI)[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] as a catalyst during the synthesis of PAA/SA hydrogels. By leveraging the high reactivity, strong reducibility, and low cost of nZVI, this approach enables the ultrafast synthesis of SPI at room temperature via a mild redox system (zero-valent iron-persulfate).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Collection of Human Gingival Fibroblasts\u003c/h2\u003e\u003cp\u003eHuman gingival tissue was obtained from patients undergoing impacted tooth extraction at the Department of Oral and Maxillofacial Surgery, Zhujiang Hospital, Southern Medical University. All experimental protocols have been performed in accordance with the Declaration of Helsinki and must have been approved by the Institutional Human Ethics Committee of Southern Medical University Zhujiang Hospital (Ethics No.: 2022-KY-302-02). All patients were Informed written consent. Inclusion criteria: 1. Patient age 18\u0026ndash;25 years; 2. Extracted tooth free of caries; 3. Gingiva without inflammation or hyperplasia; 4. No periodontitis; 5. No history of pericoronitis; 6. Good oral hygiene. During extraction, flap surgery was performed to remove impacted teeth. Normal gingival tissue, approximately 2.0mm \u0026times; 2.0mm \u0026times; 2.0mm was excised from the extraction site. Samples were collected in sterile vials containing low-glucose Dulbecco's Modified Eagle Medium (DMEM) supplemented with 10% fetal bovine serum (FBS), 100 U/mL penicillin, and 100 \u0026micro;g/mL streptomycin, and transported to the laboratory at 4\u0026deg;C within 30 minutes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Cell Compatibility Testing\u003c/h2\u003e\u003cp\u003eDifferent materials were disinfected under ultraviolet light for 24 hours, then incubated in DMEM medium for 24 hours. Solutions of 0.005 (0.1%), 0.05 (1%), 0.5 (10%), 1.25 (25%), and 2.5 (50%) mg/mL SPI hydrogel extracts. Fourth-generation human gingival fibroblasts were used as the test cell line. After digestion, cells were added to DMEM medium containing 1% antibiotic-antimycotic and 10% fetal bovine serum to form a cell suspension at 4 \u0026times; 10\u0026sup3; cells/mL. A 100\u0026micro;L cell suspension was incubated in a 96-well plate at 37\u0026deg;C, 5% CO₂, and 90% relative humidity for 24 hours[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. After incubation, remove the supernatant and material, then wash with sterile PBS solution. Add 100 \u0026micro;L of DMEM solution containing 10% Cell Counting Kit 8 (CCK-8, Dojindo, Japan) to each well and incubateat 37\u0026deg;C in a 5% CO₂ incubator for 1 hour. After incubation, the CCK-8 solution containing cells was added to the 96-well plate, and the absorbance at 450 nm was measured using an enzyme-linked immunosorbent assay reader (ELX808, Biotek, USA). The blank group was set with only blank medium. The relative growth rate (RGR) was calculated using the following equation:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:RGR=\\frac{{OD}_{1}-{OD}_{0}}{{OD}_{C}-{0D}_{0}}\\times\\:100\\%$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOD\u003csub\u003e1\u003c/sub\u003e indicate absorbance value of the experimental treatment group, OD\u003csub\u003e0\u003c/sub\u003e demonstrate the absorbance value of the CCK-8 blank group and OD\u003csub\u003ec\u003c/sub\u003e indicate the absorbance value of the control group.\u003c/p\u003e\u003cp\u003eCytotoxicity assessment was determined based on cell survival rate relative to the control group, calculated as[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]:\u003c/p\u003e\u003cp\u003eNo cytotoxicity: cell survival rate\u0026thinsp;\u0026gt;\u0026thinsp;90%;\u003c/p\u003e\u003cp\u003eMild cytotoxicity\u0026thinsp;=\u0026thinsp;60\u0026ndash;90% cell survival rate;\u003c/p\u003e\u003cp\u003eModerate cytotoxicity\u0026thinsp;=\u0026thinsp;30\u0026ndash;59% cell survival rate;\u003c/p\u003e\u003cp\u003eSevere cytotoxicity\u0026thinsp;\u0026le;\u0026thinsp;30% cell survival rate.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Establishment of Anticoagulant Mouse Model\u003c/h2\u003e\u003cp\u003eThis experiment established a CD-1 mouse anticoagulant model based on the methods of Foerch \u003cem\u003eet al\u003c/em\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Male CD-1 (40\u0026thinsp;\u0026plusmn;\u0026thinsp;5 g) with intact teeth and dentition, normal occlusion, no periodontal disease, and no dental caries were purchased from Zhuhai Bestone Biotechnology Co., Ltd. and housed in the SPF-grade animal facility of the Animal Experiment Center at Southern Medical University Zhujiang Hospital. Animal care and procedures in this study fully complied with the regulations of the Institutional Management Department at the Animal Experiment Center of Southern Medical University Zhujiang Hospital. All experimental protocols were approved by the Institutional Animal Ethics Committee of Southern Medical University Zhujiang Hospital (Ethics No. : LAEC-2022-037) and conducted in accordance with the National Research Council's Guidelines for the Care and Use of Laboratory Animals. Mice were acclimated in the Animal Experiment Center for 1 week under standard housing conditions.\u003c/p\u003e\u003cp\u003eThe experimental group (n\u0026thinsp;=\u0026thinsp;6) was administered water containing dissolved warfarin tablets at a dose of 2 mg warfarin per kg body weight for 24 hours. The control group received standard bottled drinking water for 24 hours. Subsequently, mice were anesthetized via intraperitoneal injection of 1% sodium pentobarbital solution (0.2 mL\u0026ndash;0.25 mL). Under deep anesthesia, 0.4\u0026ndash;0.5 mL of blood was collected from the apex of the heart using a 1 mL syringe and a 25-gauge needle. An INR value was measured 24 hours after warfarin administration in CD-1 using a Roche CoaguchekXS\u0026reg; device (Roche, Mannheim, Germany) and compared with the control group to verify successful modeling. Roche, Mannheim, Germany) to measure the INR value of CD-1 24 hours after warfarin administration. This value was compared with that of the control group to determine whether modeling was successful[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Establishment of Mouse Tooth Extraction Model\u003c/h2\u003e\u003cp\u003eExperimental mice were randomly divided into three groups (n\u0026thinsp;=\u0026thinsp;12). A 1% pentobarbital solution (0.2\u0026ndash;0.25 mL) was administered via intraperitoneal injection for anesthesia. Position mice supine and secure the maxilla, mandible, and limbs using an animal restraint device. After complete disappearance of corneal reflex, disinfect the oral cavity with povidone-iodine solution and fully expose the maxillary incisors[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], using a disposable scalpel incise the gingiva over the right maxillary central incisor. Separate the gingiva with a gingival retractor to expose the alveolar bone. Gently loosen the tooth using a curved probe and light-curing bur, carefully separating the right maxillary central incisor. Grasp the crown with curved mosquito forceps. and extract the right maxillary central incisor. Scrape the extraction socket with an oral surgical curette to ensure no tooth fragments remain. Examine the tooth outside the mouth to confirm its integrity, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eFollowing complete tooth extraction in CD-1, the extraction site was immediately packed with materials according to the following groups:\u003c/p\u003e\u003cp\u003eControl group: Immediately pack the extraction socket with cotton balls (5 mg);\u003c/p\u003e\u003cp\u003eGS group: Absorbent gelatin sponge (5 mg) immediately packed into the extraction socket of CD-1;\u003c/p\u003e\u003cp\u003eSPI group: Immediately after extraction, a curette was used to deliver sodium alginate powder (5 mg) into the extraction socket of CD-1.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Establishment of Mouse Tail Amputation Model\u003c/h2\u003e\u003cp\u003eCD-1 were anesthetized via intraperitoneal injection of 1% pentobarbital (0.2 mL\u0026ndash;0.25 mL) solution (n\u0026thinsp;=\u0026thinsp;12). Following anesthesia, tails were amputated 4 mm from the base. Hemostasis was achieved at the wound site using either sodium alginate gel powder or cotton balls. Bleeding volume and time to cessation of bleeding were recorded for both groups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.7 Bleeding Volume Calculation\u003c/h2\u003e\u003cp\u003ePrior to tooth extraction and tail amputation in CD-1, unused sterile cotton balls from each group were weighed in EP tubes (W\u003csub\u003e1\u003c/sub\u003e). 30 seconds after implanting hemostatic materials in each group, pre-weighed cotton balls were placed into the extraction sockets. and pressed the wound until no active bleeding was observed. Blood exuding from the extraction site was wiped dry, and the cotton balls were reweighed in the EP tubes (W\u003csub\u003e2\u003c/sub\u003e). Blood loss was calculated based on the weight difference before and after complete hemostasis using clean cotton balls[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:Blood\\:loss={W}_{2}-{W}_{1}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e\u003cem\u003e2.8 Hematoxylin and Eosin (HE) Staining and Masson's Trichrome (Masson) Staining\u003c/em\u003e\u003c/h2\u003e\u003cp\u003e1 d, 7 d, 14 d and 28 d after implanting the SPI and GS into the mouse extraction sockets, the healing status of the mouse extraction wounds was recorded by visual observation. Subsequently, the wound tissues of mice in the three groups were excised respectively, fixed with 4% paraformaldehyde, and embedded in paraffin. Tissues were sectioned at 4-\u0026micro;m thickness and stained with HE and Masson. Stained sections were imaged and analyzed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.8 Statistical Analysis\u003c/h2\u003e\u003cp\u003eAll experimental data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (n\u0026thinsp;\u0026ge;\u0026thinsp;5). Results were analyzed using SPSS 26.0 and GraphPad Prism software. D'Agostino \u0026amp; Pearson tests confirmed normal distribution of the dataset (\u003cem\u003ep\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/em\u003e). Intergroup comparisons were performed using t-tests, one-way ANOVA, and two-way ANOVA, followed by Tukey's post hoc analysis for multiple comparisons. Statistical significance was defined as *\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Biocompatibility of SPI Hydrogel\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e quantifies the biocompatibility of SPI at various concentrations with human gingival fibroblasts. Results indicate that at Day 1, cell viability in all gel-treated groups (1%, 10%, 25%, 50%) was comparable to the control group. Notably, cell viability increased in the 1%, 10%, and 25% treatment groups, demonstrating that concentrations exhibit good biocompatibility with human gingival fibroblasts and promote cell growth. On Day 2, the 50%-treated group exhibited mild cytotoxicity with a 23.59% decrease in cell viability, while the 1%, 10%, and 25% treatment groups maintained approximately 100.0% viability, retaining good compatibility. On Day 3, cell viability decreased by 11.47% and 30.60% in the 25% and 50% treatment groups, respectively, yet remained above the international standard for biomaterial cell viability (ISO 10993:2009, \u0026ge;\u0026thinsp;70%). Cell viability in the 1% and 10% treatment groups was essentially comparable to the blank control group.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCytotoxicity Evaluation of SPI Hydrogel Extracts at Different Concentrations (RGR\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, Cytotoxicity Grade)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e1d\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e2d\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e3d\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRGR (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRGR (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRGR (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e101.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e5.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1% group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e99.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e100.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e4.91\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10% group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e103.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e101.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e6.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25% group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e108.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e99.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e90.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50% group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e97.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSlight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSlight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.2 INR Detection Results in Experimental Mouse Models\u003c/h2\u003e\u003cp\u003eINR is the ratio adjusted from prothrombin time (PT), commonly used to measure blood coagulation ability[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In establishing the mouse anticoagulant model, the Roche coagulation analyzer detected an INR value of 0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04 in the blank control group, while the warfarin-treated group exhibited an INR value of 3.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20, significantly higher than the blank control group (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e). This confirmed the successful establishment of the CD-1 anticoagulant model.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Hemostatic Effect of the Anticoagulant Model in CD-1 Mice Following Tooth Extraction\u003c/h2\u003e\u003cp\u003eThe bleeding volume after tooth extraction in each group of CD-1 is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. By measuring the weight difference of cotton balls before and after absorbing blood 30 seconds after implanting the hemostatic agent, the bleeding volume in the SPI group was found to be 40\u0026thinsp;\u0026plusmn;\u0026thinsp;21 mg, lower than that in the Control group and GS group (265\u0026thinsp;\u0026plusmn;\u0026thinsp;93 mg, 133\u0026thinsp;\u0026plusmn;\u0026thinsp;41 mg). One-way analysis of variance (ANOVA) results showed statistically significant differences between the Control group and both the GS and SPI groups (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e). Although no significant difference was observed between the GS and SPI groups, the SPI group overall exhibited a lower bleeding volume trend than the GS group, demonstrating superior hemostatic efficacy of SPI compared to GS in this experiment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Tail Amputation Experiment Results in CD-1 Mice Anticoagulation Model\u003c/h2\u003e\u003cp\u003eIn addition to the tooth extraction model, we further validated the hemostatic efficacy of SPI using the mouse tail-amputation method (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After quantifying the data from both groups and performing an independent samples t-test, SPI group demonstrated statistically significant differences (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) compared to the Control group in both hemostatic volume and hemostasis time. The total blood loss in the SPI group was 7.90\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15 mg, while the Control group recorded 22.70\u0026thinsp;\u0026plusmn;\u0026thinsp;12.86 mg. Compared to the Control group, the SPI group exhibited a 65.20% reduction in blood loss, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eg. The mean hemostasis time in the SPI group was 1020.00\u0026thinsp;\u0026plusmn;\u0026thinsp;115.11 s. The mean hemostasis time in the Control group was 1500.00\u0026thinsp;\u0026plusmn;\u0026thinsp;151.24 s. The SPI group showed a reduction of 480 s in mean hemostasis time compared to the Control group, representing a 32.00% decrease, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eh.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Macroscopic Observation of Tooth Extraction Wound Healing in CD-1\u003c/h2\u003e\u003cp\u003eThe healing and repair effects of SPI and GS hemostatic materials on extraction sites were evaluated by observing the surface healing status, gingival probing bleeding, gingival color, material retention, and infection status in CD-1 anticoagulant mice after tooth extraction.\u003c/p\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, at 1 day postoperatively, the extraction sites in both groups remained open. The GS group exhibited hematoma formation at the extraction site, with visible GS filling material. By contrast, the SPI group showed a relatively flat extraction site with gingival adhesion closure, and no SPI filling material was observed on the wound surface. At 7 days post-extraction, the GS group wounds remained open with extensive granulation tissue proliferation, presenting a soft texture and marked depression. However, the SPI group wounds were largely closed without granulation tissue proliferation, showing slight depression of the alveolar socket. By 14 days post-extraction, both groups exhibited near-complete wound closure with pronounced depression at the extraction sites and deep hematoma within the extraction sockets. The SPI group exhibited fuller wounds with firmer gingiva and visible coverage by new epithelial tissue compared to the GS group. By postoperative day 28, wounds in both groups were completely closed and full, with normal gingival coloration. Gingiva in both groups appeared pink, showed no obvious abnormalities, and exhibited no bleeding on probing. Mice in both groups maintained normal feeding habits, and no infections occurred during the study period.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Analysis of HE-stained and Masson-stained tissue sections\u003c/h2\u003e\u003cp\u003eHE stained tissue sections of the wound sites at different time points after tooth extraction are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea. At 1 day postoperative, the Control group exhibited marked inflammatory reactions around the wound site, including inflammatory cell infiltration, vascular dilation, and congestion. The GS group similarly showed inflammatory cell infiltration and neutrophil exudation around the wound. In contrast, the SPI group demonstrated relatively mild inflammatory reactions, with less pronounced inflammatory cell infiltration and vascular dilation. At 7 days postoperative, inflammatory cell infiltration persisted in the Control group, with nuclear disappearance and leukocyte appearance. The GS group exhibited scar tissue formation, gradual reduction in neutrophils, and increased numbers of lymphocytes and monocytes. The SPI group showed increased lymphocyte and monocyte counts alongside elevated fibroblast and collagen fiber levels. At 14 days postoperative, the Control group exhibited hyperemia and leukocyte exudation. The GS group showed increased density and strength of scar tissue, along with elevated numbers of fibroblasts and macrophages. The SPI group began to demonstrate increased density and number of neovascularization, while inflammatory cell infiltration decreased. At 28 days postoperative, the Control group exhibited cellular hypertrophy, poor fibrous architecture, localized abscess necrosis within the scab layer, and poor tissue healing. The GS group showed mild cellular hypertrophy, poor fibrous architecture, and distinct scar tissue. The SPI group demonstrated relatively ideal healing with fibrous architecture tending toward normalization.\u003c/p\u003e\u003cp\u003ePrepared Masson-stained sections and analyzed collagen area (blue) in the images to better understand changes in collagen content during wound healing. The Masson staining results shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eb indicate that over time, collagen fibers in the Control group gradually deposited and distributed in an increasingly organized manner, reflecting a natural repair process accompanied by fibrosis. The GS group exhibited distinct collagen dynamics compared to the control, with the material altering the rhythm of collagen deposition and tissue remodeling patterns, resulting in unique structural repair characteristics in the later stages. The SPI group exhibited a distinct collagen growth pattern starting at 7 days, with extensive collagen coverage at 28 days but differing distribution morphology. Its fibrosis and structural remodeling characteristics differed from the previous two groups. Comparison reveals that gelatin sponges and hydrogels exert distinct effects on tissue collagen metabolism and repair processes, with hydrogels potentially offering greater potential for regulating optimal collagen deposition.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eBuilding upon the studies by Zhang \u003cem\u003eet al.\u003c/em\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], this research further validates the efficacy of SPI in extraction sockets, offering a novel approach for hemostasis in oral and maxillofacial surgery. Through hemostasis experiments in tooth extraction and tail amputation models using anticoagulated CD-1, we demonstrated that SPI outperforms traditional cotton balls and gelatin sponges in oral and maxillofacial hemostasis. Consequently, both null hypotheses were rejected.\u003c/p\u003e\u003cp\u003eIn this study, the compatibility evaluation of human gingival fibroblasts using the CCK-8 assay indicated that SPI extracts at concentrations ranging from 1% to 25% exhibited no cytotoxicity over a 3-day period and even promoted the proliferation of human gingival fibroblasts as early as the first day. The enhanced biocompatibility of SPI may be attributed to SA providing abundant hydroxyl and carboxyl groups that improve cell adhesion. However, it is noteworthy that the 50% concentration extract exhibited mild cytotoxicity on day 3, with a cell survival rate of 70.67%. This is consistent with findings by Sjogren \u003cem\u003eet al\u003c/em\u003e.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], who suggested that high concentrations of polymer extracts may disrupt cellular metabolism by altering the osmotic pressure of the culture environment. Therefore, clinical applications necessitate controlled SPI dosing to mitigate potential risks from localized high concentrations.\u003c/p\u003e\u003cp\u003eIn recent years, studies utilizing mouse models of tooth extraction wounds have increased[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This experiment established an anticoagulant mouse model by dissolving warfarin tablets in drinking water. According to the World Health Organization (WHO) guidelines for the acceptable INR range when using oral anticoagulants, the INR value for preventing arterial thrombosis is 3.0\u0026ndash;4.0, and the INR value for patients after artificial valve surgery is also 3.0\u0026ndash;4.0. It can be seen that the INR values detected in the mice in this experiment reached the therapeutic range for human anticoagulant drug use[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This indicates that the animal model established by this method effectively enhances anticoagulant performance in mice.\u003c/p\u003e\u003cp\u003eIn observing wound healing in the anticoagulant mouse tooth extraction model, we found that SPI significantly promoted healing of extraction sockets in anticoagulant CD-1. 1 day postoperative, the SPI group exhibited markedly better wound healing than the GS group, with visible wound closure and no apparent filling material within the wound. By postoperative day 7, the extraction sockets in the SPI group were largely closed, whereas the GS group still exhibited noticeable depressions and granulation tissue proliferation. This aligns with findings from Peng \u003cem\u003eet al.\u003c/em\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], who demonstrated that hydrogel materials can modulate inflammatory responses and accelerate the transition from the inflammatory to proliferative phase of wound healing. HE staining revealed milder inflammatory cell infiltration in the SPI group on postoperative day 1 and increased neovascularization by day 14, indicating SPI's potential to promote angiogenesis. Additionally, Masson staining demonstrated more regular collagen fiber arrangement in the SPI group by postoperative day 28, whereas the GS group exhibited marked scar tissue formation. This further confirms SPI ability to enhance wound healing quality.\u003c/p\u003e\u003cp\u003eThe tail-amputation hemostasis experiment further validated the hemostatic advantage of SPI. Compared to cotton ball hemostasis, the SPI demonstrated significantly reduced blood loss and shorter hemostasis time. Within just 10 seconds, the gel absorbs blood to form a hydrogel, achieving immediate hemostasis. Interestingly, after absorbing blood exuded from the severed mouse tail, the SPI adheres to the wound cross-section, with the powdered gel forming a hydrogel upon absorbing exudate. During experiments, the gel rapidly formed a gel-film structure at the amputation site with excellent adhesion and stretchability[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], enveloping the wound to achieve rapid hemostasis and shield against external stimuli. In contrast, while cotton ball groups demonstrated some hemostatic effect, they suffered from issues like loose adhesion and displacement, limiting their efficacy in dynamic wound environments.\u003c/p\u003e\u003cp\u003eThe limitations of this study are as follows: First, the oral cavity is a dynamic environment where the biocompatibility of medical biomaterials is influenced by various factors such as saliva flow rate, composition, oral temperature, and pH levels[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Second, the oral mucosa contains mucin and keratin layers, which provide greater resistance to toxic substances than cultured cells in vitro; this protective barrier may alter the results of cytotoxicity assays[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Finally, this study did not investigate the long-term biodegradation process of SPI \u003cem\u003ein vivo\u003c/em\u003e, leaving its potential impact on surrounding tissues to be clarified. Future research should further explore aspects such as simulating the oral environment, investigating long-term stability, and evaluating clinical application efficacy.\u003c/p\u003e\u003cp\u003eIn summary, the SPI exhibits excellent biocompatibility, hemostatic efficacy, and wound healing promotion capabilities. Compared to traditional hemostatic materials, including cotton balls and absorbable gelatin sponges, it demonstrated significant advantages in an anticoagulant mouse model, particularly in reducing blood loss and accelerating tissue repair. This study not only provides a new option for treating post-extraction bleeding in patients with coagulation disorders but also enriches the research on PAA-SA composite hydrogels.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eBy comparing the hemostatic efficacy of SPI with traditional hemostatic materials in anticoagulated CD-1, this study concludes that:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSPI exhibits excellent stability and swelling properties, rapidly forming a physical barrier on oral wound surfaces and achieving swift hemostasis upon expansion.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSPI exhibits good biocompatibility and relative cell proliferation rates.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSPI effectively reduces wound bleeding volume and shortens bleeding duration, demonstrating superior repair effects on wound healing.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFangbing Zhao: Conceptualization, Methodology, Investigation, Validation, Formal analysis, Writing\u0026ndash;original draft. Yongkang Xu: Software, Formal analysis, Visualization, Writing\u0026ndash;review \u0026amp; editing. Jingwen Zhang: Software, Investigation, Formal analysis, Data processing.Yulin Cheng: Conceptualization, Methodology, Data curation, Writing\u0026ndash;review \u0026amp; editing. Yuanming Geng: Writing\u0026ndash;review \u0026amp; editing, Visualization, Resources, Investigation. Xiaoqing Shen: Conceptualization, Methodology, Investigation, Resources, Formal analysis, Writing\u0026ndash;review \u0026amp; editing, Supervision.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the team of Prof Jiang Gangbiao at South China Agricultural University for providing nZVI-mediated sodium alginate/polyacrylic acid (SA/PAA) composite hydrogel (SPI hydrogel).\u003c/p\u003e\u003ch2\u003eData Availability declaration\u003c/h2\u003e\u003cp\u003e Not applicable\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting Interest declaration\u003c/strong\u003e\u003cp\u003e\u003cb\u003e\u003c/b\u003eNo\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics, Consent to Participate, and Consent to Publish declarations\u003c/strong\u003e\u003cp\u003enot applicable\u003c/p\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRoemer P, Heimes D, Pabst A, Becker P, Thiem DGE, Kaemmerer PW. Bleeding disorders in implant dentistry: a narrative review and a treatment guide. Int J Implant Dent. 2022;8(1):20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s40729-022-00418-2\u003c/span\u003e\u003cspan address=\"10.1186/s40729-022-00418-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHickman DA, Pawlowski CL, Sekhon UDS, Marks J, Sen Gupta A. Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding. Adv Mater. 2018;30(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/adma.201700859\u003c/span\u003e\u003cspan address=\"10.1002/adma.201700859\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCaliskan M, Tukel H-C, Benlidayi M-E, Deniz A. Is it necessary to alter anticoagulation therapy for tooth extraction in patients taking direct oral anticoagulants? Med Oral Patol Oral Cir Bucal. 2017;22(6):E767\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4317/medoral.21942\u003c/span\u003e\u003cspan address=\"10.4317/medoral.21942\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSnipelisky D, Kusumoto F. Current strategies to minimize the bleeding risk of warfarin. J Blood Med. 2013;4:89\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/jbm.S41404\u003c/span\u003e\u003cspan address=\"10.2147/jbm.S41404\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeng X, Xu X, Deng Y, Xie X, Xu L, Xu X. Ultrafast Self-Gelling and Wet Adhesive Powder for Acute Hemostasis and Wound Healing. Adv Funct Mater. 2021;31(33). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/adfm.202102583\u003c/span\u003e\u003cspan address=\"10.1002/adfm.202102583\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsai L-R, Chen M-H, Chien C-T, Chen MK, Lin FS, Lin KM. A single-monomer derived linear-like PEI-co-PEG for siRNA delivery and silencing. Biomaterials. 2011;32(14):3647\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.biomaterials.2011.01.059\u003c/span\u003e\u003cspan address=\"10.1016/j.biomaterials.2011.01.059\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMicutz M, Lungu RM, Circu V, lis M, Staicu T. Hydrogels Obtained via γ-Irradiation Based on Poly(Acrylic Acid) and Its Copolymers with 2-Hydroxyethyl Methacrylate. Appl Sci. 2020;10(14):4960. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/app10144960\u003c/span\u003e\u003cspan address=\"10.3390/app10144960\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGulyuz U, Okay O. Self-healing polyacrylic acid hydrogels. Soft Matter. 2013;9(43):10287\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1039/c3sm52015c\u003c/span\u003e\u003cspan address=\"10.1039/c3sm52015c\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaltz A, Kandalam U. Mesenchymal stem cells and alginate microcarriers for craniofacial bone tissue engineering: A review. J Biomed Mater Res A. 2016;104(5):1276\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/jbm.a.35647\u003c/span\u003e\u003cspan address=\"10.1002/jbm.a.35647\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang HY, Liu JW, Hu XL, Yang Y, Zhu S, Liu BN. Nano zero-valent iron driven sodium alginate/poly (acrylic acid) composite hydrogel powder for rapid hemostasis and wound healing. Int J Biol Macromol. 2025;306(Pt 3):141659. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijbiomac.2025.141659\u003c/span\u003e\u003cspan address=\"10.1016/j.ijbiomac.2025.141659\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSedghi L, DiMassa V, Harrington A, Lynch SV, Kapila YL. The oral microbiome: Role of key organisms and complex networks in oral health and disease. Periodontol 2000. 2021;87(1):107\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/prd.12393\u003c/span\u003e\u003cspan address=\"10.1111/prd.12393\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiao ZH, Xu XR, Jiang D, Kong LJ, Sun YX, Hu YX. Bentonite-supported nanoscale zero-valent iron/persulfate system for the simultaneous removal of Cr(VI) and phenol from aqueous solutions. Chem Eng J. 2016;302:213\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cej.2016.05.062\u003c/span\u003e\u003cspan address=\"10.1016/j.cej.2016.05.062\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeng S, Niu S, Gao Q, Song R, Wang Z, Luo Z. Hydroxypropyl chitosan/ε-poly-L-lysine based injectable and self-healing hydrogels with antimicrobial and hemostatic activity for wound repair. Carbohydr Polym. 2024;357:123496. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.carbpol.2024.122135\u003c/span\u003e\u003cspan address=\"10.1016/j.carbpol.2024.122135\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSjogren G, Sletten G, Dahl JE. Cytotoxicity of dental alloys, metals, and ceramics assessed by millipore filter, agar overlay, and MTT tests. J Prosthet Dent. 2000;84(2):229\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1067/mpr.2000.107227\u003c/span\u003e\u003cspan address=\"10.1067/mpr.2000.107227\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFoerch C, You Z, Wang H, Lo EH, Whalen MJ. Traumatic Brain Injury during Warfarin Anticoagulation: An Experimental Study in Mice. J Neurotrauma. 2012;29(6):1150\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/neu.2011.2104\u003c/span\u003e\u003cspan address=\"10.1089/neu.2011.2104\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIllanes S, Zhou W, Heiland S, Markus Z, Veltkamp R. Kinetics of hematoma expansion in murine warfarin-associated intracerebral hemorrhage. Brain Res. 2010;1320:135\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.brainres.2010.01.015\u003c/span\u003e\u003cspan address=\"10.1016/j.brainres.2010.01.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTakagi T, Yamamoto M, Sugano A, Kanehira C, Kitamura K, Katayama M. Alteration of Oral and Perioral Soft Tissue in Mice following Incisor Tooth Extraction. Int J Mol Sci. 2022;23(6):2987. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijms23062987\u003c/span\u003e\u003cspan address=\"10.3390/ijms23062987\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarrachina B, Lopez-Picado A, Albinarrate A, Iriarte I, Rem\u0026oacute;n M, Basora M. Analysis of the estimation of bleeding using several proposed haematometric equations. Ir J Med Sci. 2023;192(1):327\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11845-022-02946-7\u003c/span\u003e\u003cspan address=\"10.1007/s11845-022-02946-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStern R, Karlis V, Kinney L, Glickman R. Using the international normalized ratio to standardize prothrombin time. J Am Dent Assoc. 1997;128(8):1121\u0026ndash;2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.14219/jada.archive.1997.0369\u003c/span\u003e\u003cspan address=\"10.14219/jada.archive.1997.0369\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSoma T, Iwasaki R, Sato Y, Kobayashi T, Nakamura S, Kaneko Y. Tooth extraction in mice administered zoledronate increases inflammatory cytokine levels and promotes osteonecrosis of the jaw. J Bone Min Metab. 2021;39(3):372\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00774-020-01174-2\u003c/span\u003e\u003cspan address=\"10.1007/s00774-020-01174-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSoma T, Iwasaki R, Sato Y, Kobayashi T, Ito E, Matsumoto T. Osteonecrosis development by tooth extraction in zoledronate treated mice is inhibited by active vitamin D analogues, anti-inflammatory agents or antibiotics. Sci Rep. 2022;12(1):19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-021-03966-6\u003c/span\u003e\u003cspan address=\"10.1038/s41598-021-03966-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeng J, Wang J, Wang H, Cao X, Ma X, Rao Y. Multistage Anticoagulant Surfaces: A Synergistic Combination of Protein Resistance, Fibrinolysis, and Endothelialization. ACS Appl Mater Interfaces. 2023;15(30):35860\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1021/acsami.3c05145\u003c/span\u003e\u003cspan address=\"10.1021/acsami.3c05145\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede Gomes PS, Figueiral MH, Fernandes MHR, Scully C. Cytotoxicity of denture adhesives. Clin Oral Investig. 2011;15(6):885\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00784-010-0464-0\u003c/span\u003e\u003cspan address=\"10.1007/s00784-010-0464-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLima Chaves CA, Machado AL, Vergani CE, de Souza RF, Giampaolo ET. Cytotoxicity of denture base and hard chairside reline materials: a systematic review. J Prosthet Dent. 2012;107(2):114\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hydrogel, Polyacrylic Acid༛Warfarin༛Anticoagulant༛Postextraction Hemorrhage","lastPublishedDoi":"10.21203/rs.3.rs-8014153/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8014153/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eThis study evaluated the hemostatic efficacy, biocompatibility, and wound healing promotion of a sodium alginate/polyacrylic acid composite hydrogel (SPI hydrogel) mediated by nano zero-valent iron (nZVI) in anticoagulated mice with post-extraction bleeding.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e\u003cp\u003ePrimary human gingival fibroblasts were cultured in media containing different concentrations (0.05, 0.5, 1.25, 2.5\u0026ndash;mg/ml) of SPI hydrogel extracts and tested for biocompatibility using the cck8 assay. CD-1 mice were modeled for anticoagulation using oral anticoagulants. After confirming modeling success via INR assessment, mice were divided into cotton (Control), gelatin sponge (GS), and hydrogel (SPI) groups. Experiments included tooth extraction hemostasis and tail amputation tests, alongside postoperative healing observation of extraction sockets and comparative histopathological analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe hydrogel extract at 50% concentration showed slight cytotoxicity and the remaining concentrations were biocompatible. Post-extraction bleeding volume in the SPI group (40\u0026thinsp;\u0026plusmn;\u0026thinsp;21 mg) was lower than in the Control (265\u0026thinsp;\u0026plusmn;\u0026thinsp;93 mg) and GS (133\u0026thinsp;\u0026plusmn;\u0026thinsp;41 mg) groups. Following tail transection, SPI group bleeding volume (7.90\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15 mg) was lower than the control group (22.70\u0026thinsp;\u0026plusmn;\u0026thinsp;12.86 mg), and hemostasis time (1020\u0026thinsp;\u0026plusmn;\u0026thinsp;115.11 s) was shorter than control group (1500\u0026thinsp;\u0026plusmn;\u0026thinsp;151.24 s). HE and Masson test of wound tissue revealed superior healing, reduced inflammation, and normal collagen formation in the SPI group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eSPI hydrogel has excellent biocompatibility, hemostatic efficacy and wound healing properties, surpassing conventional materials in treating anticoagulant-induced post-extraction bleeding.\u003c/p\u003e\u003ch2\u003eClinical Relevance:\u003c/h2\u003e\u003cp\u003eIt provides a better material option for managing anticoagulant-induced bleeding after tooth extraction clinically.\u003c/p\u003e","manuscriptTitle":"Nano Zero-Valent Iron-Mediated Sodium Alginate/Polyacrylic Acid Composite Hydrogel: Evaluation of Hemostatic Effects on Post-Extraction Bleeding in Anticoagulated Mice","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 14:14:03","doi":"10.21203/rs.3.rs-8014153/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-22T07:38:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T13:55:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-15T22:21:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-15T18:37:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32155496316951936544526168853589758732","date":"2025-12-11T16:40:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246853414096595085693424447021865541539","date":"2025-12-06T10:20:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46531932314127794133348301296027752011","date":"2025-12-05T19:04:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182447917956792314834736985140192759951","date":"2025-12-05T15:47:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-05T06:20:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-01T08:49:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-01T06:28:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-11-30T02:42:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e68e290e-4074-4950-b02a-1e415bcfc7ef","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:03:13+00:00","versionOfRecord":{"articleIdentity":"rs-8014153","link":"https://doi.org/10.1186/s12903-026-08305-7","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2026-04-16 15:58:55","publishedOnDateReadable":"April 16th, 2026"},"versionCreatedAt":"2025-12-08 14:14:03","video":"","vorDoi":"10.1186/s12903-026-08305-7","vorDoiUrl":"https://doi.org/10.1186/s12903-026-08305-7","workflowStages":[]},"version":"v1","identity":"rs-8014153","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8014153","identity":"rs-8014153","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}