Dental haemorrhage

Background

Low level oozing from a tooth socket in the first 12-24 hours after extraction is normal
Reactionary haemorrhage, usually two to three hours post extraction due to wearing off of the vasoconstrictor effect of the local anaesthetic adrenaline
Active bleeding beyond this point (infection) requires investigations and treatment (antibiotics)
Advise patients (post tooth extraction) to avoid rinsing their mouth, exploring the socket with tongue or fingers!

Significant active haemorrhage (A, B, C) addressed first
STOP THE BLEEDing (below), then IV access x-match etc
Beware bleed Hx (anticoagulated, bleeding/bruising Hx, FHx coagulopathy)
Beware some meds (e.g. methotrexate, antiplatelet agents) that patient may not associate with bleeding
Labs as indicated by Hx / Exam
Locate the bleeding site - tooth socket, gum or bone (Hx of a difficult extraction)
- Sit patient up, good light, suction away and "liver clots" (assoc. with secondary haemorrhage and infection) ±saline syringe to see base of socket
- Any visible arterial bleed / gum tear?
- Any signs infection (including trismus)?
- Any palpable fracture, mobile bony socket or mal-occlusion (fracture)?
- Beware vomit (irritant blood in stomach)
Stop bleeding with direct pressure - damp gauze in socket & bite down for 5 minutes
If bleeding continues, saline wash out the socket, soak new gauze in 10% Tranexamic acid and get patient to bite down for 30 min (alternatively, bite on tea bag as tannin is a procoagulant)
If local measures are unsuccessful call the Max Fax - Dental SHO. Management options then include:
- Placement of local anaesthetic with a vasoconstrictor
- Bleeding from the soft tissues is usually arrested by placing a horizontal mattress suture across the socket
- Bleeding from the base of the socket, from bone, is usually arrested using a pack such as 'Surgical' or in some instances soaking ribbon gauze in Whitehead's varnish and packing the socket full

Haemodynamically unstable patients - Max Fax referral
Haemorrhage from gum tear, fracture or arterial - Max Fax
Haemorrhage in anticoagulated or medicaltion related bleeding - reverse the anticoagulation, Max fax and Haematology referrals