OralSurgery

Neal J McCormick

Undrell J Moore and John G Meechan

Haemostasis Part 1: The

Management of Post-Extraction
Haemorrhage
Abstract: The management of bleeding complications following a dental extraction is an essential skill for the dental practitioner.
Extractions are often carried out on patients with complex medical histories and a long list of medications. This paper aims to help the
clinician manage post-extraction haemorrhage. A review of the management of patients on anti-thrombotic medications will be covered in
a subsequent paper.
Clinical Relevance: This article reviews the management of haemorrhage following tooth extraction; from the risk assessment of any
underlying medical conditions and medications, to the clinical techniques used to control bleeding following an extraction.
Dent Update 2014; 41: 290296

Haemostasis at the site of a dental extraction increasing health awareness and the success Vasoconstriction vascular spasm in
is considered to be a prerequisite before of medical treatments. The concept of smooth muscle in the walls of blood
the patient leaves the clinic. Failure of polypharmacy management requires dental vessels;
haemostasis could occur in any patient; clinicians to have an increased knowledge of Platelet plug formation adhesion,
however, a number of different medical the drugs that may affect dental treatment interaction and aggregation of platelets;
conditions and medications may interfere and their potential for drug interactions. Coagulation cascade/network clotting
with this process. Some drug therapies can increase the factors in the extrinsic, intrinsic and
The most recent Adult Dental potential for bleeding post-operatively. common pathways lead to the formation
Survey (2009) has shown a growing number Risk assessment prior to of fibrin.
of our patients are remaining dentate.1 embarking on a tooth extraction can allow Clot formation is a dynamic
People are living longer as a result of the operator to foresee complications process, involving a balance between
such as a haemorrhage. This involves the haemostatic and the fibrinolytic
careful planning and a thorough analysis systems. The involvement of numerous
of the medical history.2 Table 1 shows the cells, chemicals and plasma proteins are
Neal J McCormick, BDS(Lpool), MFDS haemorrhage risk factors surrounding a all required for successful haemostasis.
RCPS(Glasg), General Professional dental extraction. Fibrinolysis occurs when the plasma
Trainee (GPT), Health Education North enzyme plasminogen activates plasmin,
East, Undrell J Moore, BDS, PhD, Overview of haemostasis which digests the fibrin threads in the clot.
FDS RCS(Eng), Senior Lecturer in Oral A sound knowledge of the In health, this will occur once the site is
Surgery and John G Meechan, BSc, physiology of haemostasis is important repaired. Figure 1 outlines the timeline of
BDS, PhD, FDS RCS(Eng), FDS RCS(Ed), in understanding how haemorrhage may clot formation.
FDS RCPS, Honorary Consultant/Senior occur. A full description of the process is Consideration of the normal
Lecturer in Oral Surgery, Newcastle outside the remit of this paper; however, mechanism allows the clinician to interpret
Dental Hospital, Richardson Road, several key points are worth noting. which patients may be at high risk of
Newcastle Upon Tyne, NE2 4AZ, UK. The process of haemostasis poor haemostasis. This may be the result
involves: of underactive clotting or overactive
290 DentalUpdate May 2014
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fibrinolysis. Systemic disease may interfere clinician is to ensure that his/her surgery is haemorrhage, therefore enabling quick and
with clotting. The majority of clotting adequately equipped to deal with commonly effective management.
factors are produced by the liver, whereas occurring scenarios. Haemostatic agents
platelets are produced in red bone marrow. and equipment have a wide range of uses
Problems relating to clotting factors and beyond post-extraction haemorrhage. Immediate post-extraction
platelets may be congenital or acquired.3 Several invasive procedures, such as non- management
An example of a congenital deficiency of surgical periodontal therapy, periodontal Once a tooth has been removed,
clotting factors is Haemophilia A (Factor surgery, pulpotomy5 and the preparations of pressure should be placed on the buccal
VIII deficiency). Acquired liver disease may teeth for indirect restorations6 may all require and lingual/palatal surfaces of the alveolus
reduce production of clotting factors. Table 2 the use of appropriate haemostatic agents. around the socket. Extraction of a tooth
outlines the conditions that may give rise to All dental practices should be prepared via the intra-alveolar approach causes
a higher risk of post-extraction haemorrhage. to deal with the initial management of a expansion of the alveolus around the
haemorrhage, even if onward referral is root(s) of the tooth. The immediate bucco-
Types of post-extraction needed for definitive treatment. Table 3 lingual pressure reduces the dead space
haemorrhage shows a list of equipment that is useful of the wound and is the first step to help
in dealing with a post-extraction gain haemostasis. This should be done
The classification of a haemorrhage
haemorrhage. The appropriate use of immediately following the extraction of
is important as it has direct clinical implications.
each will be described. a tooth with intact apices, usually termed
Post-extraction haemorrhage may be
When faced with a post- digital pressure. A piece of sterile gauze may
categorized in relation to timing:4
extraction haemorrhage the dentist then be rolled up so that it is big enough
Primary haemorrhage the bleeding occurs
should remain calm and ensure that the to cover the socket. This can be placed
at the time of the surgery;
area can be well visualized. This will allow directly over the socket area and the patient
Reactionary haemorrhage 23 hours
the best opportunity to make the correct asked to bite down to apply the necessary
after the procedure as a result of cessation of
diagnosis, identifying the type of post- pressure. It is important to note that, if an
vasoconstriction;
extraction haemorrhage and the site of the edentulous area opposes the extraction
Secondary haemorrhage up to 14 days
after the surgery. The most likely cause of
this is infection.
The haemorrhage may also be Timing Risk Factor
classified according to the site affected: Before Medical complications (Table 2)
Soft tissue;
Anticoagulant/Antiplatelet medication
Bone;
Vascular. During Traumatic extraction
The diagnosis informs the Soft tissue laceration/tear
management as described below. Large vessel damage
Oro-antral communication
Armamentarium for dealing After Infection
with post-extraction
haemorrhage Physical trauma to socket dissociating the clot
A key responsibility for a Failure to follow post-operative instruction
Table 1. Risk assessment for haemorrhage in dental extractions.

Figure 1. Timeline of clot formation.

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site, biting together may not apply enough Clotting Factor Deficiencies
firm pressure. It is advisable in this case to
Haemophilia A (Factor VIII)
use finger pressure on the gauze for several
minutes. Haemophilia B (Factor IX)
In many cases, this firm pressure Von Willebrands Disease (vWF Factor)
will allow initial haemostasis to be achieved. Vitamin K Deficiency (Factor II, VII, IX and X)
The clot should begin at the base of the
Acquired liver disease hepatitis/cirrhosis
socket. It is a good idea to check that the
clot is not removed with the gauze. A Platelet Deficiency (Thrombocytopenia)
second piece of gauze can be placed in the Idiopathic
same way. This time removal should show Drug Induced (Antiplatelet therapy)
no fresh bleeding.
Anticoagulant Therapy
Whilst waiting for haemostasis
to occur, or once haemostasis is confirmed, Vascular Anomalies
the patient should be given clear Atriovenous malformation
instructions on his/her post-operative Hereditary haemorrhagic telangiectasia
management of the socket. This stage
Collagen disorders
must not be overlooked, as failure to care
for the area appropriately may cause a Table 2. Patients at high risk of post-extraction haemorrhage.
secondary haemorrhage. The instructions
should be given verbally by the clinician Sterile gauze (pressure pack)
who carried out the procedure. This will
bleeding may be prolonged as a result of Suction
allow the provision of the core instructions,
as well as any tailored instructions that are inflamed tissues or a mucosal tear. A local Suture kit
suitable to a particular patient (eg high risk anaesthetic containing a vasoconstrictor Needle holders
of haemorrhage or a tobacco smoker). An may minimize the bleed initially. A large
Tissue forceps
extraction can be a traumatic event for some area of infection causes granulation tissue
to form at the base of the socket. This may Suture material and needle
patients. These patients may not be able to
recall a long list of instructions immediately impair clotting and bleed profusely. Any Haemostatic gauze
afterwards. It is therefore advisable to unattached clots should be cleaned from Bone wax
provide a concise instruction leaflet that the mouth and an assessment made. If
Astringent solution, eg ferric sulphate
the patient can refer to in his/her own time the diagnosis is a soft tissue haemorrhage,
the correct equipment should be used to 5% Tranexamic acid mouthwash
(Table 4). However, providing the leaflet
without comprehensive verbal instructions is achieve haemostasis. Cautery
unacceptable. Systemic monitoring equipment
Patients having treatment Suturing equipment blood pressure, heart rate and pulse
under IV or inhalation sedation may have Sutures will aid socket closure oximeter
their ability to retain information reduced and help bring the tissues together. Table 3. Armamentarium for post-extraction
significantly in the immediate post-operative They are available in different sizes and haemorrhage.
period. The clinician must allow for this, materials.7 Suture materials may be
giving the aftercare instructions at the classified into:
previous appointment or pre-operatively. Braided or monofilament;
The patients chaperone must have adequate Resorbable or non-resorbable; braided and resorbable material made of
information to ensure the aftercare is safe Synthetic or natural. polygactin) is recommended. This will offer
and appropriate. These can then be placed with between 710 days of support before being
As mentioned above, if various techniques and using needles of resorbed, enough for sufficient healing
immediate pressure to the socket does not different sizes and shapes. Each classification to have taken place. A simple interrupted
control bleeding, a diagnosis needs to be of material has its advantages and suture is the most commonly placed,9
made regarding the aetiology. disadvantages, the most notable being that however, a horizontal mattress suture may
non-resorbable sutures require removal provide suitable socket closure.
after a suitable healing period, whereas
Soft tissue haemorrhage
resorbable sutures will break down over Chemical haemostatic agents
The intra-oral soft tissues are
time. Several agents that may help
highly vascularized and may be the site of
A 3.0 suture (Figure 2) on a haemostasis are available to the dental
substantial haemorrhage. Diagnosis is made
circle curved needle is a very useful practitioner. These include:
using good visualization, requiring good
suture for intra-oral wounds. A resorbable Tranexamic acid;
lighting and appropriate suction. Soft tissue
material, such as vicryl 3.08 (a synthetic, Ferric sulphate;
292 DentalUpdate May 2014
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Do Not: a
Rinse your mouth out today (may dislodge clot if fibrin stabilization has not
occurred).*
Drink alcohol or hot drinks today (may increase blood pressure or induce
hyperaemia).
Smoke or use tobacco products for at least 24 hours (causes vasoconstriction and
possible increase in dry socket).
Chew food for 4 hours, avoid hard foods for 24 hours (may disturb clot, possible
self harm if area still anaesthetized).
b
Carry out any physical activity today (increasing blood pressure).
Do:
Sip lukewarm drinks carefully (helps avoid clot removal by washing out socket).
Bite on gauze or clean, damp handkerchief for 10 minutes if area bleeds,
preferably sitting upright in a chair.
Rinse mouth gently with hot salt mouthwash or Chlorhexidine (0.2%)
mouthwash after 24 hours. Continue regular mouthwash use over the following
week, especially after meals.
Figure 2. 3.0 Vicryl suture with suturing
Clean teeth as normal, avoiding area of surgery for 24 hours. equipment.
Include contact details for advice and treatment for out of hours care

Table 4. Post-operative instruction leaflet for aftercare following a dental extraction. * In brackets:
rationale for the suggestion.

Figure 3. 95% Silver nitrate pencil.

Silver nitrate. Silver nitrate
Silver nitrate is included in this
section for completeness. It is available a
Tranexamic acid in the form of a pencil (Figure 3) which
Tranexamic acid can be effective contains 95% silver nitrate. It may be used
in the control of post-operative bleeding.10,11 to aid haemostasis in areas where suturing
The British Committee for Standards in or finger pressure is not possible. A typical
Haematology advise that patients on oral indication would be after a mucosal biopsy
anticoagulants requiring dental surgery is taken from an area such as the hard palate
can be prescribed 5% tranexamic acid or retromolar pad. Silver nitrate is a powerful
mouthwash, to be used as a rinse, four times chemical cauterizing agent; the pencil tip
daily, for two days post-operatively.12 It is can be pressed directly on the bleeding area.
worth noting that tranexamic acid is not b
After a few minutes, the silver nitrate should
readily available in the primary care setting. be de-activated by gently swabbing the
It is not first line management for soft tissue area with saline solution to avoid damage to
haemorrhage, suturing and haemostatic surrounding structures.
gauze being the preferred option.

Ferric sulphate Bleeding from the socket

Ferric sulphate is a commonly
used astringent solution (15.5%) that Bony haemorrhage Figure 4. Surgicel, which is oxidized regenerated
has multiple uses in dentistry. It may Bleeding from a bony origin may cellulose.
be employed as part of a gingival occur following any dental extraction. This
retraction technique for impressions in can be deep in an exposed socket, with the
crown/bridge work. It is also used as a blood flow, making it difficult to visualize.
haemostatic agent during pulpotomy. In most cases, bleeding from within the Haemostatic gauze
It is not widely used primarily to control socket can be arrested by inserting a pack. The availability of resorbable
post-extraction haemorrhage, however, it Cancellous bone can be burnished with a haemostatic dressing materials means that,
may offer assistance with mucosal tears or flat plastic instrument or a Mitchells trimmer in many instances, the clinician will choose
uncontrolled bleeding in gingival tissues. to help compress the bone in the area. to pack the socket with a dressing and
294 DentalUpdate May 2014
 OralSurgery

should always be aware of the local References

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Figure 6 summarizes the
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May 2014 DentalUpdate 295

OralSurgery

Tooth is extracted with apices intact.

Bucco-lingual/palatal pressure applied to socket.
Sterile gauze applied to socket with firm pressure for
several minutes.
Socket assessed with good lighting.

Has haemostasis been achieved?

Yes No

Give appropriate written and verbal post- Apply further pressure to area.
operative aftercare instructions. Ensure the patient Reassess after 23 minutes.
is fit to leave the surgery.

If patients return with reactionary (later that day) If bleeding persists assess the aetiology
or secondary (within 214 days) haemorrhage. of bleed.

Vascular Soft Tissue Bone

Localize vessel Haemostatic gauze Identify site of
Apply pressure Suture haemorrhage
May require electocautery Chemical agents if Usually place
or ligating appropriate haemostatic gauze and
suture
Haemostatic gauze
Burnish if possible and/
Suture
or insert bone wax, pack
and suture

Figure 6. Management of post-extraction haemorrhage.

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