CHAPTER 43
Bleeding after Dental Surgery
Presentation
The patient who had an extraction or other dental surgery performed earlier in the day now has excessive bleeding at the site and is unable to visit the dentist. The patient may also be using aspirin, Coumadin, Plavix, or other anticoagulant medications.
What To Do:
Ask the patient what procedure was done and estimate how much bleeding has occurred. Inquire about ingestion of antiplatelet drugs (aspirin, Coumadin, Plavix, or Pradaxa), underlying coagulopathies, and previous experiences with unusual bleeding.
Using suction and saline irrigation, clear any packing and blood from the bleeding site.
Roll a 2 × 2–inch gauze pad, insert it over the bleeding site, and have the patient apply constant pressure on it (biting down usually suffices) for 30 to 45 minutes.
If the site is still bleeding after 30 to 45 minutes of gauze pressure, infiltrate the extraction area and inject a local anesthetic and vasoconstrictor, such as 2% lidocaine with 1:100,000 or 1:200,000 epinephrine, into the socket and surrounding gingiva until the tissue blanches. Again, have the patient bite on a gauze pad for 45 minutes. The anesthetic allows the patient to bite down harder, and the epinephrine helps restrict the bleeding.
If this injection does not stop the bleeding, pack the bleeding site with Gelfoam, Surgicel, or gauze soaked in topical thrombin. Then place the gauze pad on top, and apply pressure again. Alternatively, HemCon dental gauze (HemCon Medical Technologies, Portland, Ore.) can be applied. Place the HemCon dental dressing into the extraction wound. The dressing is most effective when in contact with blood from the wound, which wets the dressing. The top of the dressing should be flush with the gingival margin. Place sterile gauze over the HemCon dental dressing, and have the patient bite down, applying gentle pressure for 1 to 2 minutes. Visualize the site to confirm proper placement of the dressing, and replace the gauze on top. The HemCon dressing dissolves in 48 hours to 7 days and does not need to be removed. The patient may irrigate the wound site at 7 days to ensure removal of any residual material.
Another approach to the bleeding is to saturate the gauze sponge with tranexamic acid (Cyklokapron) injectable solution, 100 mg/mL at a dose of 25 mg/kg (which can be swallowed), and have the patient bite down hard for another 30 to 45 minutes.
An arterial bleeder resistant to all the aforementioned treatments may require ligation with a figure-eight stitch.
Assess any possible large blood loss by obtaining orthostatic vital signs.
When the bleeding stops, remove the overlying gauze and instruct the patient to leave the site alone for a day and see her dentist for follow-up.
What Not To Do:
Do not routinely obtain laboratory clotting studies or hematocrit levels, unless there is reason to suspect a bleeding disorder such as hemophilia A or von Willebrand disease, overmedication with warfarin (Coumadin), or severe blood loss.
Do not allow a patient to intermittently remove the gauze. It is the constant, prolonged pressure that is most likely to provide successful hemostasis.
Discussion
Serious hemorrhage is rare even in the presence of a bleeding diathesis or anticoagulant therapy. Most patients are merely annoyed by the continued bleeding and often only need to stop dabbing the area and apply constant pressure to get the bleeding to stop.
Occasionally this problem can be handled with telephone consultation alone. Some say a moistened tea bag, which contains the hemostatic effects of tannic acid, works even better than a gauze pad when constant pressure is applied.
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