Chapter 179. Post-Extraction Bleeding Management

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. 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. Many patients, however, will report that they have been doing this prior to coming to the Emergency Department and require additional assistance.

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.1,2 Post-extraction bleeding may be a sign of an underlying and undiagnosed coagulopathy.

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

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

• 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 or plain gut sutures, 4-0 or 5-0
• Absorbable gelatin sponge (Gelfoam)
• Oxidized regenerated cellulose (Surgicel)
• Topical thrombin
• Suture set
• Dental forceps
• Tea bag
• Bone rongeur
• Bone wax
• Headlamp
• Yankauer suction catheter
• Suction source and tubing
• Silver nitrate matchsticks
• Electrocautery unit

Explain the risks, benefits, potential complications, and aftercare to the patient and/or their representative. Document this discussion in the medical record. A signed consent form is usually not required for these procedures. Consider obtaining a radiograph of the affected area to rule out a retained root or a bony spur.

Position the patient to visualize the extraction site. Place the patient in a multipositional dental chair, if available, or on a gurney. Do not place the patient in a chair as they may become presyncopal and require being placed supine to prevent injury. An overhead light source or a headlamp is ideal to illuminate the field. Suction any blood and oral secretions from the mouth. Visualize the extraction site for any signs of bleeding. Thoroughly irrigate the site with warm saline and remove all clots with the aid of suction. It may be necessary to perform a dental block if the patient complains of pain upon irrigation. Refer to Chapter 176 for the complete details regarding dental anesthesia and analgesia.

The management of post-extraction bleeding is simple. Numerous methods to control the bleeding have been described and tested (Table 179-1). These techniques are often performed in a sequential manner as described below. The techniques may, of course, be performed in any order, depending on the physical examination and physician preference.

Mechanical Pressure

Place saline-moistened 2 × 2 gauze squares over the socket. Instruct the patient to apply firm pressure by biting down on the gauze for 20 minutes. Instruct the patient to maintain pressure for 20 minutes despite initial bleeding. Place the suction catheter, intermittently, into the vestibule of the mouth to remove any blood and secretions. The application of pressure will control most post-extraction bleeding. It may be necessary to perform a dental block, if not performed during the irrigation phase, if the patient cannot bite down due to pain.

Tea Bag Application

Place a saline-moistened tea bag in the socket if mechanical pressure does not control the bleeding. The tannins in the tea leaves will assist with the coagulation process. Instruct the patient to bite down on the tea bag for 15 minutes.

Absorbable Dressings

The two most commonly used absorbable dressings are Gelfoam and Surgicel. Gelfoam is an absorbable gelatin sponge that is readily available and inexpensive. It forms a scaffold for the formation of a blood clot. Surgicel is composed of oxidized and regenerated cellulose. It promotes coagulation better than Gelfoam and can be packed into the socket under pressure. Unfortunately, Surgicel results in delayed healing of the socket and its use should be reserved for persistent bleeding or when Gelfoam is not available.

Place an absorbable dressing (Gelfoam or Surgicel) in the socket if the extraction site continues to bleed.1–3 The author prefers to use Gelfoam because it is easier to manipulate and it is absorbed more rapidly than Surgicel. Work the Gelfoam in your fingers until it resembles the shape of the socket. Insert the Gelfoam into the socket and compact it with a dental forceps. Insert additional pieces of Gelfoam into the socket, as necessary, to obtain a solid mass of Gelfoam filling the socket. An alternative is to pack the socket with Surgicel. Once the socket is packed, apply a 2 × 2 gauze square over the socket. Instruct the patient to bite down for approximately 20 to 30 minutes. The author prefers to place a figure-of-eight stitch using 4-0 or 5-0 silk suture or plain gut suture over the socket (Figure 179-1). The suture applies pressure over the socket and ensures that the Gelfoam or Surgicel will not prematurely fall out of the socket. This technique will usually stop most post-extraction bleeding.

Two additional absorbable dressings are topical thrombin and collagen. They are expensive, not usually available in the Emergency Department, and their use should be limited to circumstances where other hemostasis methods have failed. Topical thrombin is made from bovine thrombin. Place a piece of Gelfoam or Surgicel saturated with thrombin into the socket. Thrombin converts fibrinogen to fibrin, bypassing the coagulation cascade, to form a clot within the socket. Collagen is available in multiple forms from a variety of sources. It promotes platelet aggregation and forms a scaffold for the formation of a clot. Pack the socket with collagen and cover it with a piece of Gelfoam. Place a figure-of-eight suture over the thrombin or collagen-filled socket to secure it in place.

The use of chitosan bandages to control battlefield and prehospital hemorrhage has crossed over into the dental realm. Chitosan dental bandages (HemCon Medical Technologies, Portland, OR) have been designed to control post-extraction hemorrhage. Chitosan is a naturally occurring polysaccharide derived from shellfish. It attracts red blood cells. When placed over the bleeding extraction site, the red blood cells attach to the bandage to form a clot and tamponade the bleeding.

Local Anesthetic Infiltration

Infiltrate the soft tissue surrounding the socket with local anesthetic solution containing epinephrine if the bleeding is not controlled by the above methods. The most commonly used local anesthetic solutions are lidocaine and bupivacaine. Infiltrate the soft tissues surrounding the socket with the local anesthetic solution until the tissue blanches. This usually requires 2 to 3 mL of the local anesthetic solution. Irrigate the socket. Apply a piece of moist gauze over the socket. Instruct the patient to bite down and to exert pressure on the socket. The patient is often able to bite down much harder on the tissues after the infiltration of the local anesthetic solution.

The effect of mechanical pressure combined with the vasoconstrictive effects of epinephrine control the bleeding. Occasionally, after the vasoconstrictive effect of epinephrine wears off, there is a rebound effect and the persistence of bleeding. This may be prevented by routinely placing Gelfoam or Surgicel into the socket after the bleeding is controlled.

Miscellaneous Techniques

Reexamine the extraction site if the bleeding is not controlled by the above methods. The source of bleeding may be new granulation tissue, gingival tears, a bone spur, or a partially transected vessel. Cauterization of granulation tissue with silver nitrate or electrocautery will control the bleeding. Handheld, disposable, single-patient use electrocautery units work well but require the patient to be anesthetized. Use a blunt instrument to feel for the presence of a bone spur. This may be a source of significant bleeding. Remove the bone spur with a rongeur or cover it with bone wax to control the bleeding. An exposed and bleeding arteriole or venule can be controlled with cauterization (silver nitrate or electrocautery) or the application of a plain gut suture through the vessel. Suture any tears in the gingiva.

Observe the patient for 30 to 60 minutes after the bleeding has terminated. Do not give the patient anything by mouth (NPO). Reevaluate the socket for signs of bleeding. Continued bleeding requires further attempts at termination.

Discharge the patient home after the bleeding has been terminated and a brief observation period. Instruct the patient to avoid any liquids or solids for 2 hours. Stress the importance of not spitting, gargling, drinking through a straw, smoking, using aspirin-containing products, or playing with the site with their tongue. Instruct the patient to apply gauze squares and bite down for 20 minutes if the bleeding returns. They should return promptly to the Emergency Department if the bleeding continues after 20 minutes. Additional instructions should include a soft diet, avoidance of extremely hot or cold substances, avoidance of chewing gum, and avoidance of other such “sticky” foods. Arrange follow-up as soon as possible with the Dentist or Oral Surgeon who performed the extraction.

There are no documented complications associated with the termination of post-extraction bleeding. The complications are associated with the bleeding itself. Obtain screening labs (e.g., PT, PTT, platelet count, and bleeding times) if hemostasis is not achieved by any of the aforementioned methods. Early consultation with a Dentist or Oral Surgeon and a Hematologist should be considered if the patient is coagulopathic or has a bleeding disorder.

A careful history and physical examination will often provide the reasons for most post-extraction bleeding that presents to the Emergency Department. Most patients without complicating medical conditions will be easily managed in a simple and systematic manner with a minimal amount of equipment. All patients should follow-up with their Dentist or Oral Surgeon after the bleeding is terminated.