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INTRODUCTION

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).

TABLE 212-1Types of Post-Extraction Hemorrhage

ANATOMY AND PATHOPHYSIOLOGY

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

INDICATIONS

All post-extraction bleeding must be managed carefully and methodically. The techniques are easy to perform, simple, and straightforward.

CONTRAINDICATIONS

There are no contraindications to the management of post-extraction bleeding.

EQUIPMENT

  • 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

PATIENT PREPARATION

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