Al-Rafidain University

College
Dentistry Department
‫ﺻوره‬
‫اﻟطﺎﻟب‬
‫اﻟﺷﺧﺻﯾﮫ‬ Oral sergury

How you can manage patient with

hemorrhage from socket after tooth
extraction

Student Name: ‫اﺣﺴﺎن ﻋﺒﺪاﻟﺮﺣﯿﻢ ذﻧﻮن‬

Grade: ‫اﻟﺜﺎﻟﺜﺔ‬
Group: B4
Evaluation score: -----

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 Introduction

Post-extraction bleeding (PEB) is a recognised, frequently encountered

complication in dental practice, which is defined as bleeding that continues
beyond 8 to 12 hours after dental extraction. The incidence of post-extraction
bleeding varies from 0% to 26%. If post- extraction bleeding is not managed,
complications can range from soft tissue haematomas to severe blood loss.
Local causes of bleeding include soft tissue and bone bleeding. Systemic
causes include platelet problems, coagulation disorders or excessive
fibrinolysis, and inherited or acquired problems (medication induced). There
is a wide array of techniques suggested for the treatment of post-extraction
bleeding, which include interventions aimed at both local and systemic
cuases.

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Due to the high vascularization, bleeding is a normal and expected part
of the extraction process, Immediately after extraction, blood flowing
from alveolar bone and gingiva begins to clot,The clot acts as a
mechanical barrier; protects the underlying bone; and acts as a
scaffold.

high vascularization - both friend and foe to the dental surgeon,

Accelerates healing as well as poses risk for uncontrolled hemorrhage ,
Open wound left to heal through secondary intention ,Frequent irritants
and disruptive forces tri bleeding.

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Prevention of Post Operative Bleeding

• Obtain a history of bleeding

• Use the atraumatic surgical technique
• Obtain good hemostasis at surgery
• Provide excellent patient instructions.

Post Extraction Tooth Socket Care

• The socket should be debrided only if necessary. , If neither a

periapical lesion nor debris is present, the socket should not be
curetted The remnants of the periodontal ligament and the
blleeding bony walls are in the best condition to provide for rapid
healing.

• Patient should be instructed NOT TO: , Spit, suck or smoke for

few days ,Take hot foods , Touch the empty socket space with
tongue Exercise or work too vigorously for few days

• The expanded buccolingual plates should be compressed (not

compressed if implant is planned) , This helps prevent bony
undercuts , Initial control of hemorrhage is achieved by use of
a moistened 2 x 2 inch gauze placed over the extraction socket.
Patient should bite firmly on this damp gauze sponge for at
least 30 minutes.

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 Types of Hemorrhage (Based on type of vessel)

• Primary Hemorrhage at the time of injury

• Reactionary hemorrhage – within 24 hours of surgery
• Intermediate hemorrhage - within 8 hours after stoppage of
primary bleeding
• Secondary hemorrhage – after 24 hours to several days

Types of Hemorrhage (Based on time)

• Primary Hemorrhage – at the time of injury.

• Reactionary hemorrhage – within 24 hours of surgery
• Intermediate hemorrhage – within 8 hours after stoppage of
primary bleeding
• Secondary hemorrhage – after 24 hours to several days

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 Management of Post- operative Bleeding of
Extraction Socket

Use of hemostats to catch bleeding points if any ,Sutures and

Ligation ,Direct pressure by biting moistened Gauze piece for
half an hour.

After extraction of a single tooth, a small space exists where the

crown of the tooth was located,Pressure Pack should be applied
for achieving primary hemostasis.

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If the gauze is simply placed on the occlusal table, the pressure
applied to the bleeding socket is insufficient to achieve adequate
hemostasis

The gauze should be positioned such that when the patient closes
his or her teeth together, it fits into the space previously occupied
by the crown of the tooth.

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Other ways

1-Prevention and Treatment of Psychogenic Shock

this type of shock due to fear , so its prevention depends to a

great extent on a dentist behaviour and his calm attitude when he
receives the patient ,by allaying patient apprehension and
assuring him that this condition will be controlled , after that the
patient should be placed in a position facilitated cerebral
circulation and this produce quick recovery.

2-Diagnosis and looking for the Cause of Hemorrhage

The actual cause of bleeding should be discovered, look for

tendency of the blood to clot, if the blood have a tendency to clot
so the blood clotting mechanism is normal and the bleeding is
due to local factors and coukd be managed as following. ,Clear
the patient mouth from accumulated blood ,Examine the bleeding
area to find out if the bleeding is coming out from lacerated soft
tissues or it is coming from the bony socket ,In cases of bony
socket bleeding the socket should be carefully examined to fined
out if bleeding is due to severed inferior dental vessel , a nutrient
canal or it is simply due to interference of the patient to the blood
clot

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3-Treatment of the cause Hemorrhage

If bleeding is due to soft tissue laceration should be suture,

If bleeding is due to interference by the patient to the formed
clot,
it is controlled by the use of pressure packs and proper post-
operative instruction,
If bleeding is due to the presence of nutrient canal this could be
controlled either by bone wax to occlude the canal or by crushing
of some spongy bone into the bleeding point by the tip of a blunt
instrument ,
If hemorrhage is due to severed inferior dental vessels a local
haemostatic such as thrombin , oxidized cellulose, fibrin foam or
gelatin foam ,
If hemorrhage is due to systemic disease , the treatment is
directed to mange the underlying systemic problem and by doing
the required investigations. Using local haemostasis by suturing
or using local haemostatic measure,

If still bleeding is not controlled

• Investigations for any coagulopathies should be done Bleeding

Time - prolonged in thrombocytopenia, Von Willebrand Disease
(VWD) and platelet dysfunction Platelet count - if (50000-
100000 per cu. mm, transfusion of platelet rich plasma is needed
and 5% tranexamic acid mouthwash for 3 days)

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References

1-BMJ 2017:357:j1217 doi:

10.1136/bmj.j1217 (Published 2017 April 03)
2-Bleeding after dental extractions in
patients taking warfarin, S. Salam a, H.
Yusuf b, A. Milosevic c,+, British Journal of
Oral and Maxillofacial Surgery 45 (2007)
463–466
3-Scully's Medical Problems in Dentistry, 7th
Edition.
4-ORAL AND MAXILLOFACIAL
SURGERY JAMES R. HUPP EDWARD
ELLIS III MYRON R. TUCKER
5-Complications of Extractions A Pee
Reviewed Publication wimen by Donald
Testa. DOS and Michael Horman. DOs

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