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Post-extraction bleeding is a common problem after the removal or extraction of a tooth. It is often seen in the Emergency Department in the late evening or night when the patient is unable to contact their Dentist. Bleeding that occurs within a few hours of the extraction is often due to the wearing off of the vasoconstrictor effect of the local anesthetic solution used for anesthesia.1 The application of direct pressure over the bleeding site by having the patient bite down on a folded piece of moist gauze almost always controls post-extraction bleeding.1 Many patients, however, will report that they have been doing this prior to coming to the Emergency Department and require additional assistance. Post-extraction bleeding can be classified depending on when it occurs (Table 212-1).
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ANATOMY AND PATHOPHYSIOLOGY
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A careful history may reveal that the patient inadvertently caused the extraction site to bleed by drinking through a straw, spitting, gargling, or smoking. All these activities will produce negative pressure within the oral cavity and remove the clot from the extraction site. Ask the patient if they are touching the extraction site with their tongue causing a mechanical disruption of the clot. Obtain information about any significant medical history, any history of bleeding, and current medications. This includes use of aspirin products, anticoagulants, broad-spectrum antibiotics, alcohol, and antineoplastic medications. These all may contribute to prolonged bleeding. Ask about the symptoms and examine for the signs of liver disease, hypertension, or hematologic disorders.2,3 Post-extraction bleeding may be a sign of an underlying coagulopathy due to anticoagulant use, clotting factor disorders, thrombocytopenia, or vascular abnormalities.1
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All post-extraction bleeding must be managed carefully and methodically. The techniques are easy to perform, simple, and straightforward.
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There are no contraindications to the management of post-extraction bleeding.
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2×2 gauze squares
Irrigating syringe
Dental mirror, optional
Local anesthetic solution containing 1:100,000 epinephrine
23 to 25 gauge, 1.5 inch needle
5 mL syringe
Silk, plain gut, or Vicryl sutures, 3–0 on a half-circle needle
Absorbable gelatin sponge (Gelfoam)
Oxidized regenerated cellulose (Surgicel)
Topical thrombin
Topical collagen
Tranexamic acid
Ankaferd Blood Stopper
Hemocoagulase (Reptilase)
Silver nitrate matchsticks
Suture set
Dental forceps
Tea bag
Bone rongeur
Bone wax (beeswax, paraffin, and a softening agent)
Headlamp
Yankauer suction catheter
Suction source and tubing
Electrocautery unit