Post-Tooth Extraction Bleeding

Aka: Post-Tooth Extraction Bleeding, Post Extraction Bleeding, Hemorrhage Following Tooth Extraction, Bleeding After Dental Extraction

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II. History

  1. Procedure performed
    1. Time and Date of procedure
    2. Name of dentist or orofacial surgeon
    3. Locations of teeth extracted
    4. Complications from procedure
  2. Other Trauma
    1. Spitting or gargling
    2. Drinking through a straw
    3. Tobacco use
    4. Manipulating extraction site (with Tongue or finger)
  3. Medical history contributing to bleeding risk
    1. Bleeding Disorders (e.g. Hemophilia, Von Willebrand Disease)
    2. Anticoagulants (e.g. Warfarin, Factor Xa Inhibitor or DOAC)
    3. Antiplatelet Agents (e.g. Aspirin, Clopidogrel)
    4. Broad spectrum Antibiotics
    5. Chemotherapy
    6. Heavy Alcohol use or liver disease
    7. Severe Hypertension

III. Exam

  1. Ensure adequate lighting (head lamp or spot light)
  2. Identify bleeding sites
    1. May be challenging (use suction, pressure on suspected bleeding sources)
  3. Observe for bleeding causes
    1. New granulation tissue
    2. Gingival Lacerations or tears
    3. Bones spurs
    4. Injured vessel

IV. Labs

  1. Not needed in most cases
  2. Consider in refractory cases with heavy bleeding
    1. Complete Blood Count with Platelet Count
    2. Coagulation studies (INR, PTT)

V. Management: General

  1. ABC Management
  2. Maintain NPO status until Hemorrhage is controlled
  3. Intermittent suction with yanker suction catheter or similar
  4. Irrigate the socket as needed

VI. Management: Hemorrhage Control

  1. Apply Local Pressure (first-line)
    1. Hold pressure continuously for at least 5 minutes before releasing pressure to evaluate bleeding
    2. Apply direct pressure to area by biting on gauze or tea bag for at least 20 minutes (tannins promote coagulation)
    3. Apply gauze soaked in Tranexamic Acid (TXA) and held in position (typically with biting) for at least 20 minutes
      1. Consider soaking gauze in Topical Thrombin instead of TXA (esp. if patient taking Warfarin)
      2. May alternatively moisten with Normal Saline if TXA and Thrombin are unavailable
  2. Absorbable Dressing (refractory cases)
    1. Pack socket with absorbable dressing in layers (may soak in TXA or Thrombin)
      1. Gelfoam (absorbable gelatin sponge)
        1. Preferred for ease of use and absorption
      2. Surgicel (oxidized and regenerated cellulose)
        1. Risk of delayed tooth socket healing
      3. Chitosan Dental Bandage (e.g. HemCon)
        1. Not widely available in Emergency Departments
    2. Secure packing
      1. Gauze (2x2) placed over socket and patient bites on gauze (or direct pressure with finger) for 20 minutes OR
      2. Oversew the socket with figure of eight to hold the absorbable dressing in place (preferred)
        1. Use 4-0 or 5-0 Absorbable Suture (e.g. plain gut)
        2. Anesthetize area if not already performed
        3. Suture a figure of 8, with entry and exits along each side of the tooth and crossing over the center
  3. Other measures in refractory cases
    1. Suture Gingival tears
    2. Injection of Epinephrine in Local Anesthetic
    3. Cauterization
      1. Electrical cautery
      2. Silver Nitrate
      3. Monsel's Solution (Ferric Subsulfate Solution)

VII. Management: Disposition

  1. Observe patient for 30 to 60 minutes after bleeding has stopped
  2. Home Instructions
    1. Avoid liquids or solids for 2 hours after discharge
    2. Avoid spitting or gargling
    3. Avoid drinking through a straw
    4. Avoid Tobacco
    5. Avoid chewing gum or other sticky foods
    6. Maintain soft diet or liquid diet
    7. Avoid very hot or very cold foods or liquids
    8. Hold antiplatelet agents (e.g. Aspirin), Anticoagulants for 1-2 days (if not contraindicated)
  3. Recurrent Bleeding at Home
    1. Apply direct pressure to area by biting on gauze or tea bag for at least 20 minutes (tannins promote coagulation)
    2. Return if bleeding persists despite pressure
  4. Follow-up
    1. Dentist or orofacial surgeon who performed Tooth Extraction (call when office opens)

VIII. Resources

  1. Nisi (2022) Appl Sci 12(11017)
    1. https://www.mdpi.com/2076-3417/12/21/11017/pdf
  2. Chapter 179. Post-Extraction Bleeding Management. In: Reichman EF. eds. Emergency Medicine Procedures, 2e. McGraw Hill; 2013. Accessed January 30, 2023
    1. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343828

IX. References

  1. Warrington (2024) Crit Dec Emerg Med 38(4): 18-9

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