Post extraction 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!

Management

  • 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

Who to refer

  • 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


Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 11/24/21.