Clinical vignette A 38-year-old man with no history comes to the emergency department with dental bleeding . He was at the dentist earlier today for a simple tooth extraction, but noticed the bleeding didn’t stop. He complains of mild pain at the extraction site and has never had bleeding problems before. Vital signs include T 37.1, RR 82, BP 130/82, RR 14, SpO2 99% in RA. On inspection of the bleeding site it appears that a right mandibular molar (Tooth #30) was extracted with visible blood clots and active exudation. His airway is patent, breath sounds are normal, and the patient appears to be well perfused. |
What is the diagnosis and your approach to bleeding control?
Dental Anatomy
Teeth can be named or numbered. For documentation, it is helpful to quickly refer to the numbering system below.
Tooth extraction:
Indications
- Severe tooth decay
- Fractured/impacted/crowded tooth
- Severe gum disease
It is often performed with a combination of anxiolysis, local anesthesia, and nerve block.
After extraction, a gelatinous material may remain in place to help eventually implant a replacement tooth.
Post-extraction bleeding (PEB) is defined as bleeding that continues beyond 8 to 12 hours after extraction. The incidence varies between 0-26%
Clinic history:
- Any use of antiplatelet or anticoagulant medications and when you last took them.
- Recent prothrombin time (INR) test level if you take warfarin.
- Personal or family history or bleeding disorders.
- Patients with hemophilia : Ask about inhibitors, the need for prophylactic factor replacement, and whether they brought their own factor replacement.
- What type of dental procedure did they undergo?
- Interventions that have already been tried to stop bleeding.
Physical exam:
Monitor for changes in vital signs that suggest worsening hypovolemic shock.
Remove the gauze and make sure the airway is clear.
Identify the extraction site and evaluate for expanding hematomas or early upper airway obstruction.
Mucosal bleeding is usually a slow exudate; anything else should raise concern for underlying vascular involvement.
Although rare, an arterio/venous malformation (AVM) in the gingivobuccal space is possible.
Interventions:
Gauze/Packaging : It is a simple and low-cost intervention.
Fold a 2x2 stack and instruct the patient to bite for at least 20 minutes.
Lidocaine with epinephrine
- 1% Lidocaine with epinephrine: Approximately 1-3 mL.
- Infiltrate the tissue until you see adequate whitening of the extraction site
- Have the patient bite down on a soaked gauze pad to create an additive effect of vasoconstriction and mechanical pressure.
- The anesthetic effect of lidocaine will make it easier for the patient to bite down on the gauze.
Tea bag
- Black tea bags contain the highest concentration of tannins .
- Tannins are hemostatic and have mild antiseptic properties.
- Place the tea bag in boiling water for 2-3 minutes, allow it to cool, and then place it on the extraction site for 5 minutes.
Tranexamic acid (TXA)
Commonly used in three different ways to achieve hemostasis.
Mouthwash
It has shown benefit for post-procedure bleeding in patients with multiple tooth extractions while on a DOAC.
It is often used before and after the procedure for prophylaxis.
Have the patient gently rinse their mouth with 5-10 ml of 5% TXA solution for 2 minutes and then spit out the solution being careful not to dislodge any clots that have formed.
TXA-soaked gauze
Soak a 2x2 or 4x4 gauze pad in a solution of the TXA IV preparation and place it over the extraction site with moderate patient biting pressure to hold it in place.
Reassess hemostasis in 10-20 minutes
Pasta
Almost non-existent literature, but it is a low-cost alternative to the IV TXA solution.
Crush three 650 mg TXA tablets and add small aliquots of approximately 0.5 mL of sterile water to a fine paste. Apply for 20-30 minutes before reassessment and removal of the paste.
Combination of topical thrombin and gelatin foam
It can be applied over the extraction site to provide the scaffolding and thrombin to initiate clot formation.
Embolization
Reserved only for the most severe and refractory bleeding when concern for hypovolemic shock and airway compromise is evident.
Rare cases of AVM causing persistent and forceful bleeding from tooth extraction.
Highlights to remember:
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